Resuscitation-Pt .1

For Quick Emergency Needs See Drug Doses on Inside Cover - Chapter 77 Has CPCR Step By Step

 Also see Resuscitation Part 2- Evaluation of Cardiovascular Status for Cardiac Arrest (Chapter 17).

Introduction

In general, there are two different resuscitation situations in equine neonates. The first occurs immediately post birth and the second occurs more commonly in somewhat older foals suffering from anaphylaxis, traumatic, or infectious conditions. In each of these conditions differentiation of the state of asphyxia should be determined if possible. This section is a bit of background and some methods. CPCR step wise approach, drugs, etc. are detailed in Chapter 77 - Cardiopulmonary Cerebral Resuscitation.

Forms of Apnea

Primary Apnea

• May be preceded by exaggerated breathing efforts.
• Pale or blue mucous membranes.
• Some muscle tone.
• Heart rate 60-100 beats/minute.
• In this stage providing a patent airway will often allow the foal to breathe.
• See Initial Resuscitation.

Terminal Apnea

• Pale or blue mucous membrane.
• Flaccid muscles.
• Heart rate less than 40.
• Nonresponsive.
• This stage requires intubation and ventilation and may require external cardiac massage. See Intensive Resuscitation.

Initial Resuscitation Plan newborn foal (primary apnea)^1-5

Establish Patent Airway

• Clear and remove amniotic membranes from nostrils.
• Provide head-down postural drainage.
• Strip fluids gently from nostrils with fingers.
• Provide thoracic coupage (gentle).
• Suction fluids (gently) from oropharynx.
  • Provide mild suction via a tube in the pharynx on a suction device or the end of a 60 cc syringe.

Stimulation of Foal

• Rub body briskly with towels.
• Nasal tickling with straw.
• Flex limbs (stretch receptors).
• Put into sternal position.

Record Vital Signs 

Make special note of changes in values over a time.

• Heart rate - normal >60 beats/min - 1 minute after foaling; 1-2 hours of age 80-120/min.
• Respiratory rate - normal >60 breaths/minute 1-5 minutes post foaling; 30-40/min 1-2 hours of age.
• Reflexes - sternal positioning is normal.
• Mucous membranes
  • Color
  • Capillary refill
• Initiate O₂ Therapy
  • Nasal insufflation - 3-10 liters/min (100% O2) - use if foal is ventilating. If foal is not making strong ventilation attempts intubate and ventilate (intensive resuscitation).
  • Ambu Bag - initiating "first breath" may be all that is required to establish respiration.
  • When foal does not respond with spontaneous respirations and increasing heart rate by 1-2 minutes, begin intensive resuscitation measures.

Intensive Resuscitation Procedure^1-5

Terminal Apnea

If foal is not making strong ventilation attempts establish an open and unobstructed airway by endotracheal intubation.

Nasal (Preferred) or Oro-Tracheal Intubation

• Briefly and rapidly suction nose, mouth and oropharynx.
• Use 7 or 9 mm Bivona nasotracheal tube. Once in place, ask is the foal moving a satisfactory tidal volume? If an open airway does not reestablish effective ventilation in the face of vigorous patient attempts, first check position of tube, auscultate, percuss the chest and perform rapid thoracic ultrasound and rule in or out a pleural space disorder, fluid in chest or pneumothorax.

Connect Ambu bag with O2 line attached

(do not use Bain circuit in foals >50 kg).

• Hook up O₂ supply line to Ambu bag or Bain circuit
• Connect O2 line to flow regulator from 100% O₂ tank.
• Attach 2 liter reservoir bag to Bain tubing.
• Adjust flow rate to 10 liter/min minimum. This flow rate is inadequate for Bain tubing circuits in foals 50 Kg or more.

Begin Manual Intermittent Positive Pressure

• Rate - 20-30/min.
• Volume delivered is approximately 500 ml/breath = 1/2 reservoir of a one liter bag.
• Note slight chest expansion.
  • Do not use excessive pressure; should be no greater than 20-30 cm H2O.
• Check periodically for spontaneous respiration.
• Once effective movement of air has been established, evaluate adequacy of oxygenation.

If heartrate is below 60 Beats/Minute 

See Chapter 17 - Resuscitation-Pt. 2 Evaluation of Cardiovascular Status: Bradycardia or (if absent) Cardiac Arrest

Provide Intermittent Postural Drainage From Nasotracheal Tube

Use gentle coupage.

Place Foal On A Warm Pad to prevent hypothermia.

Place Sterile IV Catheter 

Surgically prep skin See fluid guidelines and drugs in Chapter 17 - Resuscitation-Pt. 2 Evaluation of Cardiovascular Status.

Re-evaluate Heart and Lungs

Obtain Blood Gas (Preferably Arterial)

• Immediate acid-base determination via venous blood if cannot obtain arterial sample.
• Use pulse oximetry to measure oxygenation

Hypothermia Management - [99-102°F (37.2-39°C) Normal]

• Heat lamps-be careful fire hazard- burn hazard
• Warm fluids.
• Sweaters.
• Temperature controlled room.
• Bear hugger warm air device.

Obtain Blood Cultures

Provide antibiotics with gram-negative spectrum if any suspicion of sepsis. Don't wait for culture results.

Obtain Thoracic Radiograph

Evaluate Electrolytes, blood gas and acid-base

Make corrections in oxygen and fluid administration.

Emergency Drugs and Their Doses, Etc.

Supportive Therapy Post-Resuscitation

• Foals That Lack A Strong Suck Reflex should receive colostrum and milk feeding by nasogastric tube. Never oral feed any foal that is lying on its side or lacks a good sucking reflex (aspiration pneumonia can result). Always hold the bottle slightly lower than level of pharynx.
• Nasogastric Tube should be placed proximal to the cardia of the stomach and sutured to the nostril. Open end should be "capped" when not feeding. Use gravity flow or "slight" pressure with syringe. Check for reflux at each feeding.
• Heating Lights and Pads Should Be Provided. Monitor rectal temperature.
• Keep in Sternal Position As Much As Possible.
• Monitor Blood Gases and Acid Base Status.
  • Need arterial blood for respiratory and ventilation evaluation (O₂ and CO₂).
• Be Clean, Wash Hands.
• Steroid Supplementation
  • Premature foal (50-100 mg hydrocortisone equivalent) See Chapter 12 -
    Assessment of Maturity - Prematurity.
• Monitor for Failure of Passive Transfer
  • Minimum is 400 mg/dl serum IgG.
  • Plasma administration when indicated.
• Decide if Chemical Stimulation of Ventilation or Mechanical Ventilation is Needed.
  • Auxiliary exams when indicated.
    • Ultrasound
    • ECG
    • Special radiographic studies.
• Treatment of Navel
  • Dip in chlorhexidine (0.5%) solution q 6 hr for 24 hrs.
• Complete Daily Monitoring Checklist.