While veterinary teams in general practice may go months without performing CPR, they must be ready to perform in the event of a crisis. Whether it’s a patient that crashes under anesthesia or an unstable emergency walking through the door, all members of the veterinary team should have a basic understanding of how they should respond and where essential equipment and medications are located.

CPR guidelines for veterinary teams

The Reassessment Campaign on Veterinary Resuscitation (RECOVER) was created in 2010 with goals to review available literature, develop a consensus CPR guideline for veterinary medicine, and provide education and training on these guidelines.

The guidelines were published in a special edition of the Journal of Veterinary Emergency and Critical Care in June 2012 and are available open access. RECOVER will be releasing newly revised guidelines this year.

“We are on a mission to ‘empower people to provide lifesaving care to animals through education, science, and community,’ and will be publishing the revised evidence-based guidelines on CPR in early 2024 to further that mission,” said RECOVER Initiative Program Director Kenichiro Yagi, MS, RVT, VTS (ECC) (SAIM).

“We look forward to continuing to share the knowledge and provide standardized CPR training to create competent, confident, and connected veterinary professionals across the globe,” Yagi said. “While the best way to help patients is to prevent cardiopulmonary arrest from occurring to begin with, we have the responsibility to know how to perform CPR to give our patients the best possible chance to survive.”

Veterinary professionals can receive certification in both Basic Life Support (BLS) and Advanced Life Support (ALS) through online modules developed by the RECOVER initiative. These modules are RACE-approved.

Additional in-person training is available to become a certified BLS or ALS Rescuer. These trainings are usually held at regional or national conferences and events. Recertification is required every two years to maintain certification.

When planning your team’s CE in 2024, consider including CPR training. Here are some of the basics from the RECOVER initiative.

Know the signs of cardiopulmonary arrest

• Delayed initiation of CPR reduces success rates.
• Before ever being presented with a situation of cardiopulmonary arrest, it is essential for veterinary team members to be aware of how to recognize cardiopulmonary arrest and where to obtain the necessary equipment and supplies.
• All members of the team should be trained to take basic vitals and be given guidelines for when to alert the attending veterinarian of the potential for a problem.

Keep a well-stocked crash cart

• At minimum, a crash cart should be prepared with:
  • Intubation supplies
  • Intravenous catheters
  • Syringes
  • Fluids
  • Emergency medications¹

• The crash cart should be reserved for emergency use and should not be used as an extra source of supplies.
• All team members should know where the crash cart is.
  • For a small hospital, a single crash cart could be created out of a toolbox. For larger hospitals, multiple crash carts may be needed.
• The crash cart(s) should be placed in an area that is close to the most likely location for an emergency, such as the surgical suite or treatment area.
• Additionally, visual aids, such as CPR algorithms and emergency drug dosage charts should be clearly visible and placed in similar areas, including having a copy with the crash cart.
• Consider placing a piece of tape across the opening of the cabinet or box that is dated for the last time the box was checked. If the tape is disturbed, it’s a signal to check the stock.
• A team member should be assigned to audit the crash cart periodically—and after every use—to ensure it is fully stocked and drugs have not expired.

Run mock CPR scenarios

• Teams should run mock scenarios at least every six months to help all team members rehearse the process.²
• This training should include both a didactic review as well as hands-on simulations.
• Consistent training will ensure that team members are able to refresh their memory on important steps, review the location of the crash cart, and practice clear communication.
• It also allows teams time to debrief and review individual and team performance.

Team roles and responsibilities in CPR

Successful CPR requires a team approach. There are several designated roles that should be defined, each with their own responsibilities.

1. Leader: This role may be filled by a veterinarian or credentialed veterinary technician. This person should oversee the CPR process and assign roles to other team members.
2. Scribe/Timekeeper: This individual should keep a record of what is happening with the patient and time cycles of CPR (two minutes each).
   • This individual may also be responsible for drawing up drugs depending on the number of team members present.
   • A CPR record template is available on the RECOVER website.
   • The phone app “RECOVER CPR Coach” is also available on the Apple and Android stores with useful features like timekeeping, metronome, breath reminders, and record keeping.
3. Compressor: This role should be completed by multiple people on rotations. This individual is responsible for administering uninterrupted chest compressions for the entirety of a two-minute cycle. Compressors should be rotated every cycle to prevent fatigue.
4. Ventilator: This individual is responsible for delivering breaths to the patient during each cycle. As this is a less physically demanding job, it does not need to rotate.
5. Runner/Floater: Additional individuals will be responsible for attaching monitoring equipment, drawing up and administering drugs as instructed by the leader, and being in rotation with the compressor.

Clear communication between all team members is essential. When the team leader directs an individual to perform a task, the individual should repeat back the order to create a closed loop of communication, ensure accuracy, and allow the scribe to record information.

Performing CPR: The basics

• CPR is divided into two levels: Basic Life Support (BLS) and Advanced Life Support (ALS).
• As soon as cardiopulmonary arrest is suspected, basic life support should be initiated.
  • This includes:
    • Delivery of high-quality chest compressions,
    • Obtaining control of the airway, and
    • Managing ventilation.²
  • The benefits of rapidly initiating basic life support outweighs the risk that a patient would be harmed if they are not truly in a state of cardiopulmonary arrest.

Positioning for CPR and chest compressions

• For most dogs and cats, the preferred positioning is lateral recumbency, though chest compressions for some of the more barrel-chested dogs may be better delivered in dorsal recumbency.²
• Chest compressions should be delivered at a rate of 100–120 compressions per minute, with the chest being compressed between 1/3 and 1/2 of its width.²

Intubation or mouth-to-snout breaths

• Intubation and manual ventilation is preferred, though mouth-to-snout breaths can be administered until intubation is achieved.²
• Patients should receive 10 breaths per minute with a tidal volume of 10 mL/kg.²
• Manual ventilation can be performed simultaneously with chest compressions.
• If mouth-to-snout breaths are being utilized, one breath should be given after every 30 compressions, requiring a brief break in the delivery of chest compressions.²

Advanced life support

• Advanced life support encompasses everything beyond chest compressions and ventilation, including:
  • Administration of fluids
  • Administration of medications
  • Defibrilation
• Close monitoring of patients with ECG and end tidal CO2 should be performed throughout CPR and in the post-arrest period if return of spontaneous circulation (ROSC) is achieved.

CPR success rates

While 35–55% of animals will have ROSC, only 6–19% will survive to hospital discharge.³ Patients achieving ROSC should ideally be transferred to a 24-hour hospital for continued care and monitoring.

“It is easy to dismiss the value of CPR training when reported survival to discharge rate is 6%–19%,” Yagi said. “It’s important to realize, however, that the survival chance of the patient is highly dependent on the cause of arrest (reversible vs irreversible), general health status of the patient, how quickly the team acts, and how competently CPR is performed. Reported survival rate for anesthetic arrests, for example, is 42% in cats and 47% in dogs.”

And the best outcomes require that the team is prepared.

“If a 6-month-old dog goes into cardiopulmonary arrest under anesthesia, there is no excuse to not give the best effort to save them, and without proper training, a team is not equipped to give the best effort. Saving one life, will save that family’s world,” Yagi said.

The last essential step of CPR: A team debrief

Regardless of the patient outcome, teams should take time to debrief following CPR. This time allows team members to discuss what went well and what could be changed in the future. It also allows time to process the emotions and stress surrounding cases requiring CPR and provides essential support for team members who may be struggling with the case outcome.

Further reading

RECOVER website
https://recoverinitiative.org

CPR record template
https://recoverinitiative.org/cpr-guidelines/cpr-record-sheet/

RECOVER CPR Coach mobile app
https://recoverinitiative.org/cprapp

References

1. Plummer P. Crash carts: Preparedness and maintenance. Published June 10, 2016. Available at https://todaysveterinarynurse.com/emergency-medicine-critical-care/crash-carts-preparation-and-maintenance/. Accessed October 11, 2023.
2. Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. JVECCS 2012;22(s1):S102-131. https://doi.org/10.1111/j.1476-4431.2012.00757.x
3. Peberdy et al., Resuscitation 2003. Hofmeister et al., JAVMA 2009. Hoehne et al., Frontiers, 2019.

Photo courtesy of RECOVER

Disclaimer: The views expressed, and topics discussed, in any NEWStat column or article are intended to inform, educate, or entertain, and do not represent an official position by the American Animal Hospital Association (AAHA) or its Board of Directors.