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Cardiopulmonary-Cerebral Resuscitation (CPCR) & Kit Suggestions
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I. Foals at Risk for Arrest
- Significant Hypoxemia
- Dystocia
- C-Section
- Umbilical cord torsion
- Shock
- Septic
- Hypovolemic
- Obstructive
- Cardiogenic
- Severe Metabolic Disorders
- Marked acidosis
- Hyperkalemia >6 mEq/L
Two main causes of arrest in foals
- Peripartum asphyxia - HYPOXEMIA
Focus: oxygenate and ventilate
Prognosis good if intervention is early - 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
- Asystole
- Ventricullar fibrillation or pulseless ventricular tachycardia
- Pulseless electrical activity (electromechanical dissociation)
- Cardiovascular collapse (excessive vasodilation)
Duration of Resuscitation Attempts
- No survival reported in human patients after 30 minutes
- 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
- Establish Airway
- Clean nasal and oral cavities, remove foreign objects (mucus, straw, blood, meconium)
- Place 8-9 mm endotracheal tube
- Nasotracheal
- Orotracheal
- Breathing
- Attach self-inflating AMBU bag with oxygen attached
- Start with 20 breaths per minutes with oxygen
- Vary 10-40 depending response or end tidal CO2
- 2 breaths/10 chest compressions if using compression
- DO NOT USE: demand valve (barotrauma)
- DO NOT ELEVATE HEAD (decreased cerebral perfusion)
- Circulation
- Fluids: 20 ml/kg boluses (less in immediate newborn) (Plamalyte 148, Normosol R, Lactated Ringers, Colloids; see Fluid and Electrolyte Balance)
- Begin chest compressions if asystole or if the heart rate is less than 60 bpm within 30s of ventilation
- Lateral recumbency with back toward you
- Check for rib fractues first (fractured ribs to be on down side if present)
- 80 compressions per minute
- Allow time for diastole between compressions.
Editor's Comment - good luck - Effectiveness should be evaluated (peripheral pulse, mucous membrane color, pupil size, Endtidal CO2 (goal >15 mmHg,)
- If no evidence of blood flow, then change the compression technique (hand position, force, longer intervals between compressions
- Rotate people every 2 minutes
- Drugs
Pharmaceuticals (consider if asystole or heart rate <60 BPM afer 30 seconds of ventilation and chest compressions).
Epinephrine
- First line of drug for CPR
- Potent alpha and beta adrenoreceptor agonist
- Generates the greatest coronary and cerebral blood flow
- Associated with the best resuscitation rates
- Traditional low dose is 0.01 mg/kg (1:1000; 0.5-1 ml/50 kg)
- Intravenous, intraosseal, intratracheal
- Intracardiac is not recommended (myocardial laceration, ventricular tachycardia, coronary vessel thrombosis)
- Dose can be repeated every 3-5 minutes
Vasopressin (ADH)
- Synthetic arginine vasopressin indicated after 2-3 attempts of failed epinephrine
- Long half life, use only once
- Dose: 0.2-0.6 U/kg (10-30 U/foal; 0.5-1.5 ml IV)
Other Drugs - Limited Indications
- Bradyarrhythmias, bronchoconstriction
- Atropine (0.01-0.02 mg/kg)
- Glycopyrrolate (0.001-0.002 mg/kg)
- Electrolytes (Editor's Comment - Controversial)
- Calcium (1-10 mg/kg) may improve cardiac contractility
- Sodium bicarbonate (1-2 mEq/kg) if severe acidosis present
- Magnesium sulfate (14-28 mg/kg) may be useful in cases of ventricular or junctional tachyarrhythmias
- Glucose (3-5 mg/kg/min) if severe hypoglycemia (<50 mg/dl; 2.8 mmol/l) present - avoid hyperglycemia
- Corticosteroids in septic, anaphylatic shock or in suspected adrenal insufficiency
- Prednisolone Na-succinate 1-2.5 mg/kg,
- Dexamethasone Na-phosphate 0.05-0.2 mg/kg)
Editor's Comment - Controversial
- Class III antiarrhythmic drugs severe ventricular tachyarrhythmias unresponsive to lidocaine and magnesium sulfate
- Amiodarone 5 mg/kg
- 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)
- Instruments
- Endotracheal Tube
- 7 -12 mm (internal diameter) Bivona®, 45-50 cm length. For naso-tracheal intubation
- Variable for minis (3-5 mm)
- AMBU bag
- 1 Liter reservoir bag
- Face mask
- Bain circuit
- IV sets (infusion)
- Blood glucose chemistry sticks
- IV catheters
- O2 regulator - Pressure gauge and flow rate gauge on O2 tank (make sure it’s full)
- Long bladed laryngoscope
- Miscellaneous
- Superglue, 2-0 (00) nonabsorbable suture material with needle
- Tape -3" Elasticon® and white adhesive 1/2 inch
- Shaver, Betadine soap and solution
- Small surgery set
- Stomach tube - Harris flush or enema tubes (intra-esophageal) 24 French 60 inch
- Drugs and fluids
- Epinephrine -1:1000
- Polyionic fluids (Plasmalyte 148, Normosol R, Lactated Ringers) and colloids (Hetastarch, Oxyglobin, Dextran, Pentastarch)
- Vasopressin (20 U/ml)
- 5% NaHCO3
- Atropine injectable (0.5 mg/ml)
- Glycopyrrolate (0.2 mg/ml)
- Lidocaine (20 mg/ml)
- Calcium borogluconate 23%
- Magnesium sulfate (500 mg/ml)
- 1% Dextrose
- Amiodarone (50 mg/ml)
- O2 nasal catheter
- 14 French 40 cm. Oxygen Catheter (0-airlife-Amer. Hosp. Supply)
- Defibrillator
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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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Affiliation of the authors at the time of publication
School of Veterinary Medicine, University of California-Davis, CA, USA.
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