Proceeding of the LAVECCS

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1 Close this window to return to IVIS Proceeding of the LAVECCS Congreso Latinoamericano de Emergencia y Cuidados Intensivos Jun. 3-, 21 Buenos Aires, Argentina Reprinted in IVIS with the permission of the LAVECCS

2 CPCR - How to Set Up a Ready Area Jennifer J. Devey, DVM, Diplomate ACVECC jendevey@aol.com Minutes count when patients present in extremis and close to a pulmonary arrest or cardiac arrest and seconds count when a patient actually arrests. A triage or ready area and trained staff are vital to ensuring the best possible outcome in both situations. This lecture will discuss how to set up a ready area and what equipment and supplies should be available. A central location (treatment room, surgical prep area etc.) in the hospital should be designated as the ready area. Oxygen, fluids ready to be administered, and a crash cart containing all the supplies needed to deal with a life-threatening emergency should be present in the ready area. The hospital must have the capability to perform stat lab work and radiographic assessment. An operating room should always be set up in case emergency surgery is indicated. All personnel must know how to set up and use all resuscitative equipment, and must possess the skills to perform resuscitative procedures, and the knowledge to recognize potentially life-threatening problems. Staff training is vital if critical patients are to survive and cannot be overemphasized. Training should take to form of didactic sessions as well as mock emergency situations using a stuffed toy dog. Written and or posted protocols are recommended highly because during the panic of the true emergency it is easy to forget things. Protocols minimize the chance of making mistakes of omission. These protocols should be easy to understand and follow and should be regularly reviewed and revised as needed. Exam gloves should be worn in emergency situations. This will help decrease the likelihood of transmission of diseases from the pet to the staff and from the staff to the pet. The blood on an animal presenting to the emergency room may be from the owner and not the dog. Both hepatitis and HIV are not uncommon diseases and, although it is rare, the staff may be exposed to those diseases when handling emergency patients. Many nosocomial infections come from the hands of the professional staff; therefore, by wearing gloves, nosocomial infection rates should be reduced. The ready area requires good lighting, similar to that required in the operating room. Dual lights that can be directed at divergent angles are especially important for the care of the seriously injured patient. These patients frequently require emergency surgical procedures that demand this availability of good illumination, e.g., venous cutdown and slash tracheostomy. A focusing high-intensity cool beam light and a wider beam reflecting dish light for general full-body illumination are recommended. Oxygen and Ventilation An oxygen source must be available and an AMBU bag should be kept connected to the oxygen source. An AMBU bag can be connected using piped-in oxygen or an anesthetic machine. If an anesthetic machine is being used a Y connector should be inserted between the oxygen outflow and the anesthetic circuit. One arm of the Y is connected to the AMBU bag. Ideally 2 to 3 different sizes of AMBU bag should be available to accommodate the needs of both small and larger patients and the AMBU bag should be fitted with a positive end expiratory pressure valve. In busy ICU or emergency practices where patients are ventilated on a frequent basis the availability of a mechanical ventilator will ensure the patient receives proper ventilatory support Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21

3 and will help free up a set of hands. The ventilator should be completely assembled, plugged in, and ready to be started on a moment s notice. Fluids A bag of buffered balanced electrolyte fluids such as Normosol-R or Plasmalyte-A should be connected to a macrodrip set and placed in a pressure infusor bag ( slam bag ) ready for immediate use. If there are concerns that this bag is not going to be used very frequently two options are available. The bag can be spiked with the administration set and then if it is not used within 24 to 48 hours it can be used for surgical fluids or subcutaneous fluids so the bag does not need to be discarded. Alternatively the bag can be loaded into the pressure infusor but not spiked. The administration set is hung on the hook with the fluids ready for immediate use when the need arises. Crash Cart A multi-drawer tool cart makes an excellent crash cart. The crash cart should be mobile (on wheels or transportable) in order to be able to take the equipment and supplies to the patient, no matter where the emergency takes place. In busy hospitals it may be necessary to have more than one crash cart. The crash cart should be checked once to 3 times daily (depending on the hospital situation) to ensure all necessary supplies are present and all equipment is in working order. The crash cart should have a piece of tape placed across the front in a diagonal fashion from top to bottom. The tape should be initialed and dated by the person checking the cart. Once something is removed form the cart the tape is left off. This serves to tell everyone in the hospital that the cart needs to be restocked. The cart should be used for emergency use only and material should not be removed unless a code is being run or emergency resuscitation is being performed. Supplies that may be used routinely such as laryngoscopes, catheters or certain drugs such as furosemide should be stocked in a general use area as well as in the crash cart. Emergency resuscitation can be unsuccessful simply because someone borrowed something for another patient and forgot to return it. Airway and Breathing The first drawer of the crash cart should contain airway equipment. The drawer is lined with foam and sections are cut out of the foam to hold the supplies. This serves to keep the drawer organized and easily identifies missing items. The airway drawer should contain a laryngoscope with a small and large Miller blade. The batteries should be checked daily to ensure the light source is bright. A variety of sizes of cuffed clear endotracheal tubes should be present from mm to 12 mm. Each tube should have gauze or IV tubing attached to it so once the patient is intubated the tube can be secured immediately in place. Each tube should also have a syringe attached to it primed to inflate the cuff once the patient is intubated. A stylet should be available for help in intubating smaller patients. Forrester sponge forceps and Velsellum forceps should be available to remove foreign material from the mouth and oropharynx. A #1 scalpel blade and a pair of sharp Mayo scissors should be present to perform a tracheotomy and open chest CPR if necessary. Alternatively each endotracheal tube with its tie and syringe can be placed in a small clear plastic bag to prevent entanglement. Circulation The second drawer should contain emergency drugs. Again the drawer should be lined with foam and sections should be cut out of the foam to hold each bottle. Each cut out section should be labeled with the drug that belongs in that location so that it is easy to determine the location of each drug. Drugs present should include epinephrine, lidocaine, sodium bicarbonate, Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21

4 atropine, dexamethasone sodium phosphate or methylprednisolone sodium succinate, and furosemide. Other drugs to consider include topical nitroglycerin, mannitol, magnesium sulfate, dopamine, dobutamine, calcium gluconate, and doxapram. If the hospital uses a CPCR protocol that uses high dose epinephrine, multiple bottles may need to be stocked since one 2 ml bottle can be used rapidly. It may be more appropriate to keep mannitol in an incubator if one is available to decrease the likelihood of drug crystallization. Both 3 cc and 12 cc syringes with needles attached should be present alongside the drugs. The 3 cc syringes should have 18 or 2g needles attached and the 12 cc syringes should have 18g needles attached. A stiff (polypropylene) long Fr urinary catheter or red rubber tube should be available for instilling drugs via the endotracheal tube. The third drawer should contain hypodermic needles (14g to 27g), and intravenous catheters of various sizes and lengths including over the needle catheters from 24 g to 14 g in size and 19 to mm in length, several sizes of central catheters, 2 or 3 sizes of butterfly catheter (19 to 23g), and larger 13 cm 14g and 16g catheters for pericardiocentesis and diagnostic peritoneal lavage. Number 1 scalpel blades should be available for making side holes in catheters being used for diagnostic peritoneal lavage or for adding holes to chest tubes. A 6 cc syringe with an extension set and 3-way stopcock connected should be present for performing rapid thoracentesis. Additional syringes 6 cc to 6 cc (several of each size) should be stocked. Rolls of 1 inch tape for securing catheters should be tabbed ready for easy use. Long 14g needles or a teat cannula should be available for transabdominal gastric decompression in the case of gastric dilatation and volvulus. All equipment should be compartmentalized in order to visualize and retrieve the appropriate equipment rapidly. Instead of compartmentalization certain supplies can be placed in labeled zip lock bags. The fourth drawer should contain fluids and administration sets. Fluids should include buffered balanced electrolyte solutions (i.e.plasmalyte-a, Normosol R),.9% saline and % dextrose in water, and colloids such as hydroxyethyl starch or dextran-7. One-litre bags of the balanced electrolyte solutions and saline should be available and smaller bags (, 1 or 2 ml) bags of saline and dextrose in water should be available for constant rate infusions of medications. Both macrodrip and microdrip infusion sets as well as extension sets, t-ports and male catheter plugs should be present. Buretrols are useful for making up smaller volumes of fluids with additives. Blood transfusion sets and filters should be available. Tubes Remaining drawers should contain additional catheters and tubes, basic bandaging supplies, and surgical supplies. The amount of equipment present will depend on the size of the crash cart and the caseload seen by the hospital. Additional catheters include a variety of sizes of red rubber or clear feeding tubes from Fr to 12 Fr to be used for delivering nasal oxygen, for crossclamping the aorta during open chest CPR, for nasoesophageal or nasogastric tubes, for urinary catheters, and for unblocking male cats. The larger tubes (greater than Fr) should be 1 cm or 42 inches in length. Any tube being used as a nasogastric tube will require angiographic wire or some other atraumatic stylet to ensure rapid accurate placement. Multi-holed chest tubes ranging in size from 8 Fr to 3 Fr should be stocked along with 2 Heimlich valves. Christmas tree adaptors or tube connectors of various sizes and 3-way stopcocks should be present. Tuberculin syringes also make good tubing adaptors. To make the syringe into a tubing connector remove the plunger form the barrel. Cut the distal end of the barrel off leaving the end that normally attaches to the needle intact. This piece of syringe will now connect many types of tubes. Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21

5 Tracheostomy A variety of sizes of tracheostomy tubes should be available. Tracheostomy tubes can be commercially designed or created from regular endotracheal tubes. To make a tracheostomy tube, choose a size 1 to mm smaller than what would be used for orotracheal intubation. Premeasure the tube. A tracheostomy tube should reach from the mid cervical region (site of the tracheostomy) to the thoracic inlet. Remove the plastic airway adaptor. Cut 2 parallel incisions 18 degrees apart down the length of the tube to the premeasured mark, being careful not to cut the cuff-inflating mechanism. Reinsert the plastic tube adaptor. Cut the ends of the butterfly flanges as needed to shorten, and place a hole in the end of each flange. Use gauze, umbilical tape, or intravenous fluid line tubing through the holes to tie around the neck. Surgical Supplies and Bandaging Surgical supplies should include surgical gloves in sizes to fit all professional staff, sterile gauze squares and sterile instruments. A minor pack should include a minimum of a scalpel handle, 3 curved hemostats, a pair of curved Metzenbaum scissors, a pair of tissue forceps and a pair of suture scissors. If resuscitative thoracotomies are performed then it may be appropriate to have additional vascular clamps, self-retaining retractors, hemostats, forceps, scissors etc. in a separate pack. Sterile bandaging supplies should be placed on wounds whenever possible to help decrease the likelihood of nosocomial infection. Sterile gauze squares, laparotomy pads, and towels are used to help protect wounds and control hemorrhage (external and internal). Larger towels should be available for placement of external abdominal counterpressure wraps. Sterile individual packages of water-soluble lubricant should be available for placing into wounds to keep them moist. Autotransfusion An autotransfusion set can be commercially purchased or can be made from an intravenous fluid bag or feeding bag and a blood transfusion set. The feeding bags are more versatile since they have a large capped port in the top of the bag, which permits easy filling. To use an intravenous fluid bag first empty the fluids from the bag. Cut a hole approximately to 8 cm (2-3 inches) in the top of the bag so that when the bag is hung on a hook the hole opens enough to be able to pour blood into it. Connect the transfusion set to the bag and sterilize the unit. Monitoring Equipment, Defibrillator, Suction The top and side of the crash cart should hold larger equipment necessary for resuscitation. The top of the crash cart should hold an electrocardiogram machine and electrocardiogram paste. The electrocardiogram machine should be plugged in. Alcohol should be avoided in emergency situations if there is any possibility the patient might need defibrillating. Electrocardiogram leads must be attached to the machine. A defibrillator should be on the top of the cart or in the bottom drawer. Both external and internal paddles should be present. A Doppler blood pressure monitor, ultrasound gel, at least 3 sizes of blood pressure cuff, and duct tape also should be on top of the cart. The Doppler unit must be charged and a probe left attached at all times. If available a pulse oximeter and end-tidal capnometer should be present. Probes should be attached the monitors and the machine should be plugged in or fully charged (if portable). Capnometry is one of the most effective means of assessing ventilation as well as pulmonary blood flow in the arrested patient. An emergency drug chart should be posted on the cart, and ideally on the wall in the ready area, so that it can be determined immediately how much medication the patient needs during CPCR. Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21

6 Either a commercial suction unit (plugged in) or a Mityvac (brake line suction unit) (Neward Enterprises, Cucamonga, CA) should be present and a Yankauer suction tip should be attached to the suction unit. An emergency drug chart should be posted on the cart, and ideally on the wall in the ready area, so that it can be determined immediately how much medication the patient needs during CPR. Medications Other medications that should be kept stocked include broad-spectrum antibiotics, other medications for dealing with specific emergencies (congestive heart failure, arrhythmias, asthma, etc.), antidotes for common toxins and drugs, antiepileptic drugs, and injectable opioids for pain management. A refrigerator should be in the ready area. This should contain important drugs such as glucose, regular insulin, and neuromuscular blockers for inducing paralysis for intubation and ventilation. Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21

7 EMERGENCY DRUG CHART Dose in millilitres given intravenously Double dose for intratracheal Epinephrin e 1:1 1 mg/ml Atropine. mg/ml Lidocaine 2 mg/ml Na Bicarb 1 meq/ml DEX SP 4 mg/ml Ca Gluc 1 mg/ml Countersho ck EXT Countersho ck INT DOSE lb mg/lb.2 mg/kg.2 mg/lb. mg/kg 1 mg/lb 2 mg/kg. meq/lb meq/ kg 2 mg/lb 4 mg/kg mg/lb 1 mg/kg 1-1 ws/lb 2-2ws/kg.- 1ws/lb 1-2 ws/kg k g Proceedings of the Congreso Latinoamericano de Emergencia y Cuidados Intensivos LAVECCS - 21