Cardiopulmonary-Cerebral Resuscitation (CPCR) & Kit Suggestions

I. Foals at Risk for Arrest

1. Significant Hypoxemia

• Dystocia
• C-Section
• Umbilical cord torsion

2. Shock

• Septic
• Hypovolemic
• Obstructive
• Cardiogenic

3. Severe Metabolic Disorders

• Marked acidosis
• Hyperkalemia >6 mEq/L

Two main causes of arrest in foals

1. Peripartum asphyxia - HYPOXEMIA
   Focus: oxygenate and ventilate
   Prognosis good if intervention is early
2. Secondary to metabolic derangements/septic causes
   Focus: traditional ABC approach
   Prognosis poor (severely ill foal)

These are managed slightly differently, and carry different prognoses

Signs of Imprending Arrest

Bradycardia or asystole
   <40-60 bpm or irregular
Irregular to absent RR
   < 10 bpm, gasping
Mydriasis
   Sluggish or nonresponsive
Marked hypotension
   No pulse pressure
   Mean ≤ 40 mmHg

Forms of Cardiovascular Arrest

1. Asystole
2. Ventricullar fibrillation or pulseless ventricular tachycardia
3. Pulseless electrical activity (electromechanical dissociation)
4. Cardiovascular collapse (excessive vasodilation)

Duration of Resuscitation Attempts

1. No survival reported in human patients after 30 minutes
2. 10 minutes is appropriate

II. How To Do It: 40-50 kg foal example

Step one: Preparation for (ideal is 3-5 people for the procedure)

• #1 intubate and ventilate
• #2 external chest compressions
• #3 introduce IV catheter and start fluids
• #4 attach ECG and prepare medications
• #5 record

III. CPR Steps

• A = Airway
• B = Breathing
• C = Circulation
• D = Drugs and Fluids

1. Establish Airway

1. Clean nasal and oral cavities, remove foreign objects (mucus, straw, blood, meconium)
2. Place 8-9 mm endotracheal tube

1. Nasotracheal
2. Orotracheal

2. Breathing

1. Attach self-inflating AMBU bag with oxygen attached
2. Start with 20 breaths per minutes with oxygen

1. Vary 10-40 depending response or end tidal CO2
2. 2 breaths/10 chest compressions if using compression
3. DO NOT USE: demand valve (barotrauma)
4. DO NOT ELEVATE HEAD (decreased cerebral perfusion)

3. Circulation

1. Fluids: 20 ml/kg boluses (less in immediate newborn) (Plamalyte 148, Normosol R, Lactated Ringers, Colloids; see Fluid and Electrolyte Balance)
2. Begin chest compressions if asystole or if the heart rate is less than 60 bpm within 30s of ventilation

1. Lateral recumbency with back toward you
2. Check for rib fractues first (fractured ribs to be on down side if present)
3. 80 compressions per minute
4. Allow time for diastole between compressions.
   Editor's Comment - good luck
5. Effectiveness should be evaluated (peripheral pulse, mucous membrane color, pupil size, Endtidal CO2 (goal >15 mmHg,)
6. If no evidence of blood flow, then change the compression technique (hand position, force, longer intervals between compressions
7. Rotate people every 2 minutes

4. Drugs
   Pharmaceuticals (consider if asystole or heart rate <60 BPM afer 30 seconds of ventilation and chest compressions).
   
   Epinephrine

1. First line of drug for CPR
2. Potent alpha and beta adrenoreceptor agonist
3. Generates the greatest coronary and cerebral blood flow
4. Associated with the best resuscitation rates
5. Traditional low dose is 0.01 mg/kg (1:1000; 0.5-1 ml/50 kg)
6. Intravenous, intraosseal, intratracheal
7. Intracardiac is not recommended (myocardial laceration, ventricular tachycardia, coronary vessel thrombosis)
8. Dose can be repeated every 3-5 minutes

Vasopressin (ADH)

1. Synthetic arginine vasopressin indicated after 2-3 attempts of failed epinephrine
2. Long half life, use only once
3. Dose: 0.2-0.6 U/kg (10-30 U/foal; 0.5-1.5 ml IV)

Other Drugs - Limited Indications

1. Bradyarrhythmias, bronchoconstriction

1. Atropine (0.01-0.02 mg/kg)
2. Glycopyrrolate (0.001-0.002 mg/kg)

2. Electrolytes (Editor's Comment - Controversial)

1. Calcium (1-10 mg/kg) may improve cardiac contractility
2. Sodium bicarbonate (1-2 mEq/kg) if severe acidosis present
3. Magnesium sulfate (14-28 mg/kg) may be useful in cases of ventricular or junctional tachyarrhythmias

3. Glucose (3-5 mg/kg/min) if severe hypoglycemia (<50 mg/dl; 2.8 mmol/l) present - avoid hyperglycemia
4. Corticosteroids in septic, anaphylatic shock or in suspected adrenal insufficiency

1. Prednisolone Na-succinate 1-2.5 mg/kg,
2. Dexamethasone Na-phosphate 0.05-0.2 mg/kg)
   Editor's Comment - Controversial

5. Class III antiarrhythmic drugs severe ventricular tachyarrhythmias unresponsive to lidocaine and magnesium sulfate

1. Amiodarone 5 mg/kg
2. Bretylium 5 mg/kg,
   IF CPCR fails thus far:

Epinephrine: 1 mg (1 cc of 1:1000) doses, 0.01-0.02 mg/kg

Vasopressin if epinephrine fails after 2-3 doses: 1 cc (20 units)

If not due to dystocia/c–section/ prolonged delivery
Can try atropine 0.02 mg/kg
Stagger with epi
If prolonged (>5 min) use sodium bicarbonate (0.5 mEq/kg, slow)

5. Instruments

1. Endotracheal Tube

1. 7 -12 mm (internal diameter) Bivona®, 45-50 cm length. For naso-tracheal intubation
2. Variable for minis (3-5 mm)

2. AMBU bag
3. 1 Liter reservoir bag
4. Face mask
5. Bain circuit
6. IV sets (infusion)
7. Blood glucose chemistry sticks
8. IV catheters
9. O2 regulator - Pressure gauge and flow rate gauge on O2 tank (make sure it’s full)
10. Long bladed laryngoscope
11. Miscellaneous

1. Superglue, 2-0 (00) nonabsorbable suture material with needle
2. Tape -3" Elasticon® and white adhesive 1/2 inch
3. Shaver, Betadine soap and solution

12. Small surgery set
13. Stomach tube - Harris flush or enema tubes (intra-esophageal) 24 French 60 inch
14. Drugs and fluids

1. Epinephrine -1:1000
2. Polyionic fluids (Plasmalyte 148, Normosol R, Lactated Ringers) and colloids (Hetastarch, Oxyglobin, Dextran, Pentastarch)
3. Vasopressin (20 U/ml)
4. 5% NaHCO3
5. Atropine injectable (0.5 mg/ml)
6. Glycopyrrolate (0.2 mg/ml)
7. Lidocaine (20 mg/ml)
8. Calcium borogluconate 23%
9. Magnesium sulfate (500 mg/ml)
10. 1% Dextrose
11. Amiodarone (50 mg/ml)
12. O2 nasal catheter

1. 14 French 40 cm. Oxygen Catheter (0-airlife-Amer. Hosp. Supply)

15. Defibrillator