Know Your ABCs
So there you are, taking a sip of your much needed caffeine requirement for the day when all of the sudden someone comes running into the treatment area with a lifeless animal. What do you do? If you answered “Um…panic?” please exit the veterinary hospital immediately. J Just kidding, everyone usually panics for the first 5 seconds as your brain processes the severity of the situation; once that is over with you can focus on your crashing patient.
Every technician should know his or her ABCs.
- AIRWAY: Establishing an airway is the first thing you need to do if the patient is non-responsive. If you are the first technician to get to the patient, assess the throat to see if there is any possible obstruction, if not get a properly-sized E-tube in immediately. You should be skilled enough to be able to do this in lateral recumbency, and not rely on a laryngoscope (so be sure to practice this skill in non-emergency situations, such as your normal surgery days). Remember to check for correct e-tube placement; reference our article “The Color Purple”. While you are doing this any other technicians nearby should be trying to place catheters, front or back legs, as long as it gets in.
- BREATHING: Are they breathing? If so, then turn on the oxygen to 1-2 liters/min and connect to the anesthesia machine with the proper breathing apparatus (again reference “The Color Purple”); continue to monitor breathing and bag inflation as normal. If not breathing, or breathing but color is poor and CRT is slower than 1.5 seconds, you must now ventilate the patient. Fill your breathing bag with oxygen to about ¾ full, close the pop-off valve and squeeze the bag slowly to no more than 20 mm pressure on your pressure valve (or a normal chest excursion). Quickly and completely release the bag after each squeeze. Repeat this at least 4 times, then open your pop-off valve. Monitor for breathing, mucous membrane color and CRT. If your patient is still not breathing, or color is still poor, you must commence continued ventilation until your patient is breathing and color is pink. Follow this rule: Ventilation is at 10 breaths/minute with tidal volume of 10ml/kg (if measured). Inspiratory time of 1 second.It has been found that over-ventilation can actually cause decreased survival rates. Other technicians should be monitoring all other vitals and alerting you and any doctors present to the status of the patient.
- CIRCULATION: Establish whether the patient has a pulse and heartbeat. If there is no heartbeat and no pulse you must resort to CPR. Of course, this assessment is made concurrently with the assessment of breathing
- CPR: Cardiopulmonary resuscitation (chest compression) is used when there is no heartbeat or pulse. Some hospitals do compressions with the patient in lateral recumbency, while others perform their compressions with the animal on its back. The most current recommendations offered by the Reassessment Campaign on Veterinary Resuscitation or RECOVER*** (which attempts to provide a consensus of clinical guidelines that is evidence-based) include the following:
- In general, chest compressions should be done in lateral recumbency
- In large/giant breed dogs – compress over the widest part of the thorax
- In keel-chested dogs – compress directly over the heart
- In barrel-chested dogs – consider compression in dorsal recumbency (on their back)
- Compress 1/3 to ½ the width of the thorax
- Compress at a rate of 100-120 compressions per minute.
- Allow for full recoil of the chest to allow optimal return of blood flow to the heart (so don’t lean on the chest!)
- Evaluate your patient every 2 minutes
- Consider commencing chest compressions initially when arrest is diagnosed and then proceed to intubate without interrupting chest compressions (so – you do need to be able to intubate in lateral recumbency and sometimes even standing on your head!)
The size/physical shape of the patient will determine the amount of muscle and what technique you will use for the compressions. For a cat or small breed dog, usually using the palm of one hand on the chest with the animal in lateral recumbency works well. Also a two-handed approach with one hand compressing and the other hand supporting the back of the patient can also be used. For bigger patients you may need to climb up on the treatment table (if you are 5’ 3” and under), or use a step stool so you can get some much needed leverage while compressing. A hand over hand technique will give you the most control and power for this; keep your elbows locked and your power coming from your shoulders. Teamwork plays a big role while performing CPR. 100-120 compressions per minute with full recoil is very fast and your arms will tire quickly; take turns approximately every 2 minutes if people are available and always communicate with each other what you are doing!
Notes: As focused as you will be on the task at hand and your patient, take care to always listen to directions from doctors, what others are administering to the patient, vitals being conveyed to the doctor, and certainly when to stop. You will lose a patient someday, and although it is a tremendously difficult thing to wrap your head around, you must persevere and be confident you did all that you could with mind, body, and soul to rescue that patient from the grips of death. You did good.
***For more information on RECOVER guidelines, including a CPR algorithm chart and chart of CPR emergency drugs and dosages, see http://acvecc-recover.org/