CPR READINESS: IS YOUR CLINIC PREPARED?
Andrea M. Steele, MSc, RVT, VTS(ECC)
CPR should never be an afterthought, but instead the possibility of CPR should always be on our minds. The clinic and staff should always be prepared for an eventual emergency. Oftentimes, this desire to become “ready” occurs after a CPR has occurred in the clinic, and the realization that the clinic and staff were unprepared. Why not instead do a readiness assessment BEFORE this happens? It will eventually happen to us all, cardiopulmonary arrest does not only happen in emergency and referral hospitals!
What does CPR readiness entail? There are two considerations: the clinic — which involves equipment, space, etc; and the people — which involves training, policy development and keeping the clinic area prepared and stocked. Ensuring readiness in both of these areas is essential for efficient CPR.
Each clinic should have an area where CPR is likely to take place. Often this is a treatment area, which will already have an anesthetic machine, oxygen supply, and a table. This is a great start! Add a stepstool (to allow people of varying heights to participate in compressions), an emergency drug chart and CPR algorithm (RECOVER CPR chart information is found at the end of this article), and a “crash kit”, and you are ready to go.
The “Crash Kit”
A well stocked emergency cart or kit is essential. Searching for supplies during an arrest is only going to delay CPR. This kit can simply be a tackle box or tool chest. Find one with pull out drawers that can be adjusted to arrange endotracheal tubes, drugs, needles and syringes and other items needed for an arrest in an orderly fashion. Avoid tackle boxes with containers that need to be opened individually, or telescoping boxes as they can tip over. An inexpensive rolling set of plastic drawers can also serve as a crash kit. Be creative with what fits in your space.
The crash kit must be well organized. Ensure that items for intubation are all in the same area, and all medication and syringes etc. are in another. Using a labeler will clearly identify where items are. Keep it simple and generalize the labels as “Airway” or “Intubation Supplies”, “Medications” and “Syringes”.
You do not need to have an entire hospital in the box. Consider only those items which will save you time and effort in the event of an arrest. For example, just have a selection of ET tubes, such as only even sizes, or whole sizes (not the 0.5mm sizes). These will generally be sufficient for any patient and can be changed out later for a more appropriate size. A laryngoscope is a must! Intubating without a laryngoscope is dangerous… you have one opportunity to get the tube in and must ensure you have visualized the tube going between the laryngeal folds. Consider purchasing disposable laryngoscopes to reduce cost, these run about $10-20 each, and can be reused until the battery or bulb wears out.
If you are in a large referral or emergency type hospital, consider making a few of these kits that can be kept in main areas. One for the emergency/treatment area, one for surgery, and one for your ICU (if you have one). The kits should be prepared identically so staff are familiar regardless of what area they may be in when an arrest occurs. All staff and volunteers should know where to find the kits.
See Table 1 for a Crash Kit supply list that would work in most hospitals.
Following an arrest, there needs to be a system in place to go through the crash cart/arrest area supplies to ensure you are ready for the next arrest. This can easily be performed by an assistant or technician, but there should be a checklist of all supplies and a person assigned to ensure the area is ready. The checklist should also have periodic checking of expiration date on the drugs.
Having a well prepared clinic means nothing if the people in the clinic do not know where to find things, or use the items in the kit. The best way to learn CPR, is to DO CPR, and unless you do a lot of CPR in your clinic, the the only way to learn, is to perform practice scenarios. Role playing is rarely something that RVT’s enjoy, however it is the best way to train the body to perform in an actual emergency. A CPR mannequin is not required, instead, buy a life-sized stuffed animal and use that. It won’t be quite the same, but it works fine. Initiate a “code” when its least expected… a slow day, over the lunch hour, etc. Practice teamwork, communication and using the RECOVER guidelines. Consider charging each RVT with devising and implementing a scenario on a monthly basis. Keep it fun!
After the code, have a debriefing session over pizza. Discuss how the code went, what went well, and what could have been done better. Think of different scenarios… different species, trauma vs anesthesia, etc. Involve everyone in the clinic and don’t forget to include kennel staff, volunteers, etc. If they happen to be in the clinic when an arrest happens, they can be a useful set of hands, and will be much more valuable if they understand what is happening.
The hospital should have a CPR policy for every patient that is being hospitalized, for whatever reason. Accident’s happen, even to the healthiest patient. Having this information on the admit sheet will ensure that the question is asked and answered every time the patient is hospitalized, as the answer may differ depending on the reason for hospitalization. Develop a coloured card or sticker system on the patient’s flow sheet or cage. The colour should provide staff with the information needed. Consider GREEN for Advanced Life Support, YELLOW for Basic Life Support only and RED for Do Not Resuscitate as a simple system.
Unfortunately, CPR has very long odds when it comes to success…RECOVER identified that survival to discharge rates for dogs and cats was only 2-10%, despite a 35-45% short term survival for non-anesthetic arrests. Anesthetic arrests carried better odds with a 47% survival to discharge, generally because the patients are being closely monitored and are already intubated and on oxygen, and have an IV catheter. Preparation, as discussed in this article is key in minimizing the time before CPR is initiated, while maximizing the quality of CPR performed.
|*Laryngoscope (ideally with a large and small blade)||1 (1-2 blades)|
|Lidocaine Laryngeal Spray||1|
|Air Syringe (5 ml)||1|
|Tube Tie (length of IV tubing, gauze or premade ties)||1-2|
|**Assortment of ET tubes||1 each|
|Manual Resuscitator “Ambubag” (keep with crash kit, or in an accessible area of clinic)||(1 Adult, 1 Child ideal)|
|Anesthetic machine (always prepared with rebreathing bag and tubes)||In area|
|DRUGS (and drug administration)|
|Atropine (varying strengths depending on manufacturer, 0.5-0.6 mg/ml fits with emergency charts)||1-multidose, or 5-ampoules|
|Epinephrine 1:1000||1-multidose, or 5-ampoules|
|Lidocaine 2 mg/ml (20%)||1-multidose vial|
|Reversal Agents: Naloxone, Atipamezole||1 vial each|
|“Ready”syringes prepared with 20G x 1” needles attached||5-1ml, 5-3ml, 5-6ml, 2-12ml|
|IV catheterization supplies||Small selection of catheters, injection caps, tape|
|0.9% Saline 10 ml vials or 100 ml bags||2-vials or 1 bag|
|Urinary catheters (to administer intratracheal medications when IV or IO is not available)||1-5 Fr, 1-8 Fr|
|Optional: will depend on your practice|
|Vasopressin 20U/ml||1-2 vials|
|***Epinephrine 1:10000 (hard to find, can dilute 1:1000 at time of CPR if needed)||1-multidose if available|
Table 1: A crash kit supply list.
* Consider disposable laryngoscope handle and blades to reduce cost
** use only even ET tubes (4, 6, 8, 10, 12) or do not include ½ sizes to save space
*** Epinephrine 1:10000 (low dose epinephrine) can be made using 1 ml of 1:1000 into 9 ml of sterile 0.9% NaCl. The dose needed can be drawn from this mixture. The solution should not be made in advance, and is only necessary for smaller patients.
The RECOVER Initiative
REassessment Campaign On VEterinary Resuscitation
Article #7 has the most relevant information on the new guidelines.
RECOVER CPR Charts
Sold by the Veterinary Emergency and Critical Care Society (VECCS). https://goo.gl/7bUOpj