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  4. Cardiopulmonary-Cerebral Resuscitation (CPCR) & Kit Suggestions
Manual of Equine Neonatal Medicine
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Cardiopulmonary-Cerebral Resuscitation (CPCR) & Kit Suggestions

Author(s):
Madigan J.E. and
Toth B.
In: Manual of Equine Neonatal Medicine by Madigan J.E.
Updated:
SEP 30, 2017
Languages:
  • EN
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    Read

    I. Foals at Risk for Arrest

    1. Significant Hypoxemia
    • Dystocia
    • C-Section
    • Umbilical cord torsion
    1. Shock
    • Septic
    • Hypovolemic
    • Obstructive
    • Cardiogenic
    1. 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
    1. 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)
    1. 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
    1. 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)
    1. 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
    1. Glucose (3-5 mg/kg/min) if severe hypoglycemia (<50 mg/dl; 2.8 mmol/l) present - avoid hyperglycemia
    2. 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
    1. 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)

    1. 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)
    1. AMBU bag
    2. 1 Liter reservoir bag
    3. Face mask
    4. Bain circuit
    5. IV sets (infusion)
    6. Blood glucose chemistry sticks
    7. IV catheters
    8. O2 regulator - Pressure gauge and flow rate gauge on O2 tank (make sure it’s full)
    9. Long bladed laryngoscope
    10. 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
    1. Small surgery set
    2. Stomach tube - Harris flush or enema tubes (intra-esophageal) 24 French 60 inch
    3. 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)
    1. Defibrillator
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    References

    1. Magdesian KG. CPCR. Personal communication, 2012.

    2. Fielding CL, Magdesian KG. Cardiopulmonary cerebral resuscitation in Neonatal foals. Clinical techniques in Equine Practice. Vol.2. No.1. pp 9-19, 2003.

    ...
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    About

    How to reference this publication (Harvard system)?

    Madigan, J. E. and Toth, B. (2017) “Cardiopulmonary-Cerebral Resuscitation (CPCR) & Kit Suggestions”, Manual of Equine Neonatal Medicine. Available at: https://www.ivis.org/library/manual-of-equine-neonatal-medicine/cardiopulmonary-cerebral-resuscitation-cpcr-kit-suggestions (Accessed: 05 June 2023).

    Affiliation of the authors at the time of publication

    School of Veterinary Medicine, University of California-Davis, CA, USA.

    Author(s)

    • John Madigan

      Madigan J.E.

      Professor of Medicine and Epidemiology
      MS DVM Dipl. ACVIM ACAW
      Department of Medicine and Epidemiology, School of Veterinary Medicine, University of California
      Read more about this author
    • Toth Balazs

      Toth B.

      DVM Dipl. ACVIM, MS, MSc
      Equi-Med Kft.,
      Read more about this author

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