My guess is that there is not a single person out there who hasn’t been in a situation where they were caught unprepared. It feels bad, really bad. It’s never a bad idea to periodically take a step back and access how prepared your practice is in the event of an emergency. Things change fast these days. Ideas and protocols evolve as new information is discovered and learned. “We’ve always done it this way” is said to be the most dangerous phrase in our language. And I am sure that many people reading this, regardless of what industry you have worked in, can relate.
Charles Darwin once said, “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” When the healthcare team in veterinary medicine is willing to explore new innovation, education, new ideas, evidence-based medicine and not fear change, they will survive and prosper. The human nursing profession has survived for 100 years or more because of the ability of early leaders like Florence Nightingale and the profession itself, to embrace the ability to adapt to change. Challenging the status quo can be a good thing. It’s okay to color outside of the lines sometimes. So, let’s take a look at some ways you might be able to update or add some things to make your practice more prepared in case of an emergency.
Let’s keep this pretty basic and simple without trying to turn a giant ship around in one turn. These are just a few of many things that you can add to your practice to make yourselves more prepared. First, is your staff trained in evidenced based RECOVER CPR? Yes! Fabulous! Good on you and your practice for being progressive and forward thinking. Provide refresher training with simulations every 6 months to keep the training fresh. RESPOND CPR for the Veterinary Team can help you set up a regular schedule for refresher courses. www.respondcprveterinaryteam.com
No, well then here is the opportunity to embrace change and get your staff certified in RECOVER CPR. It is an investment in patient’s lives, client’s beloved family members, the education and growth of your team and profession and getting the team all on the same page working together. Classes are available by contactingwww.respondcprveterinaryteam.com
1. Whenever a patient is admitted to your hospital the owner should sign an informed consent form as to the pet’s CPR status: Red-Do Not Resuscitate, Yellow-Basic Life Support and Green- Advanced Life Support (Open Chest CPR). Many practices shy away from getting this information because they don’t want to scare an owner by having to talk about an uncomfortable topic. Honestly, I think most people expect to be asked this information, particularly if they have ever had their pet treated at an emergency hospital. Secondly, they themselves are asked similar types of questions about their code status if they are admitted to the hospital. If people understand that the discussion needs to take place about CPR status, not because something bad is going to happen but because your practice is striving to be prepared in the rare event that something was to happen, they get it. How it is presented is key. Many practices include this information on the informed consent form that owners sign when the pet is admitted. As for the kennel cards, you can pre-make these cards and reuse them. The card should have a green dot ALS, Yellow dot BLS, Red dot Do Not Resuscitate. Some practices use colored 3x5 cards instead of sticker dots on white cards. Be creative, just make sure it is easy to see from across the room when it is on a kennel. Keep the cards in a file and place the card on each patient’s kennel once they are admitted. Some practices will use color coded charts or colored patient ID collars, with the ultimate goal of all of these ideas being to reduce confusion about code status in the event of an emergency.
2. Do you have a designated area in your practice that you treat emergencies? If you already do, great. Kudos to you! Well done. If the answer is no, here is a place to begin. Choose a place in the practice that is centrally located and fully stocked with items needed to treat an emergency or cardiopulmonary arrest.
b. Have a suction machine ready to turn on, that works, is easily accessible, with tubing and suction catheter attached (often a Yankauer). Also have red rubber catheters available as well. All staff members should know how to set up suction and turn it on.
c. IV pole and Slam Bag. All staff members should know how to use a slam bag.
d. ECG, multiparameter monitor is fine. ECG cables and clips with electrode gel, not alcohol, in case of defibrillation. Defibrillation plus alcohol can cause a fire!
e. Capnometer! Can be part of a multiparameter monitor or portable. Extremely useful in CPR and for anesthetic procedures. A capnometer is one of the most valuable, indispensable, non-invasive techniques we use to monitor patients during an arrest. It can tell us if we have intubated the trachea or the esophagus. It can tell us how effective are heart compressions are during CPR and if we are creating blood flow and lung perfusion. It can tell us when the first sign of return to spontaneous circulation occurs during CPR. It is also a tool that can be used in the practice for anesthesia/sedation cases to provide valuable monitoring information and help the practice provide safer anesthesia practices.
f. Defibrillator. All emergency practices should have a defibrillator; however, most general practices do not have them. The use of a biphasic defibrillator has been shown to be more effective than monophasic current, but monophasic would be better than none. Defibrillators are an expensive piece of equipment for many general practices that only see the occasional emergency case. But, also know that you can purchase a refurbished defibrillator for under $1,000. In the event of cardiopulmonary arrest (CPA) in one of your patients that has a shockable rhythm, you will stand between a rock and a hard place. Certain arrhythmias need defibrillation. Precordial thump can be tried but is less effective than defibrillation.
g. Oxygen. The area you designate for emergencies should have oxygen readily available. If the oxygen is coming from a portable tank and the tank is not always on, make sure there is a key readily available to turn the tank on.
h. Posted charts of CPR Emergency Drugs and Doses and the RECOVER CPR Algorithm. These charts are invaluable. Both charts can be purchased from http://veccs.org/product-category/posters/
i. Stocked and regularly maintained crash cart or crash box. Crash carts can be full of lots of items or pretty basic. I will list the basics here and each practice can customize to their wishes. Just remember that everything you put in the crash cart has to be kept updated and inventoried every shift or daily. So not overloading the crash cart is important.
j. Insure that team members are familiar with and know how to utilize a standardized crash cart or use the equipment in pre-stocked arrest stations. Create a training protocol that each team member completes on how to properly use and maintain equipment.
k. Clipboard with CPR Record Sheet on the crash cart. All CPR codes should be recorded on the record sheet, with the recorder keeping track of drugs given, times, rhythms, etc. This information is important during a code in case someone asks when a drug was last given or how long has it been since a pulse was checked, etc.
l. Crash Cart Shift Checklist: check that all items on the list are stocked in appropriate amounts, expiration dates are current, laryngoscope bulbs and batteries work, unplug defibrillator to test for functioning, check that tracing paper is loaded into defibrillator, inspect cables for any cracks or damage, plug defibrillator into wall plug once tested. Check suction machine, power on, check suction strength. Inspect all items in cart for availability and in working condition. The crash cart should be restocked after any use. The time and date of when the Crash Cart was checked should be visible on the cart.
Crash Cart Checklist (Example) _Endotracheal tubes sizes: 2.5_ 3.5_ 4_ 5_ 6_ 8_ 10_
_ET tube stylet
_Laryngoscope with working light bulb and batteries
_ET tube ties
_Bag Valve Mask (AMBU-bag)
_Thoracentesis Kit (1) Exp. Date
_Syringes for cuff inflation 6 and 12 ml
_3-way stopcock (2)
_Light source
IV catheter Supplies
_IV catheters (24-14 gauge) (12)
_White tape (3)
_Pre-drawn syringes of saline flush, dated (10)
_T-ports and male adaptors (12)
_EDTA tubes, Serum Separator tubes, Citrate tubes, Green top tubes
_Scalpel blades #11,#15 and 2-O nylon suture for venous cutdowns (5)
_Crystalloid fluids (3) 1000ML LRS (3) NORM-R 1000ML
_Hypertonic Saline (1)
_Sterile Saline (1)
_50% Glucose (1)
_Drugs Expiration date current _Epinephrine 1 mg/mL
_Atropine
_Lidocaine 2% 100mL
_Naloxone
_Flumazenil
_Atipamezole
And so on…
Crash Cart Organization
The organization of the cart should make logical sense and make items easy to find.
Airway Equipment
Endotracheal tubes in various sizes
ET tube stylet (polypropylene u-caths can be used as airway stylets)
Laryngoscope with working light bulb and batteries
Extra bulb for laryngoscope
ET tube ties
Bag valve mask (AMBU bag)
Syringes for cuff inflation
Light source
Venous Access Equipment
IV catheters (24-16 g)
T-ports and male adaptors
White tape
Pre-drawn syringes of saline flush, dated (heparin not necessary)
18g 1 ½ in. needles for intraosseous access
Optional but most ideal: EZ-IO Intraosseous Infusion Driver and needles https://www.milainternational.com/MILA_MEDIA/EZIO_Brochure.pdf
Cutdown catheter supplies:
#11 Scalpel blades and 2-0 nylon suture
Sterile curved mosquito hemostat
Sterile needle driver
Crystalloid fluids: LRS and Norm-R
Hypertonic SalineSterile Saline
IV fluid sets
Syringes 1-12mlNeedles 25g-18g
Medications
Vasopressor therapy: Epinephrine 1 mg/mL (1:1000) common concentration
Parasympatholytics therapy: Atropine
Anti-arrhythmic agents: Lidocaine 2%, Optional: amiodarone
Reversal agents: naloxone, flumazenil, atipamezole
Glucose (50% dextrose)
1mL and 3mL syringes (open with 18g needles attached)
Pre-drawn 3mL and 12mL saline flushes (heparin is not needed)
Beyond Basic:
Vasopressin
Dopamine
Norepinephrine
Furosemide
Dobutamine
Diazepam/Midazolam (controlled)
Calcium gluconate
Sodium Bicarbonate
Mannitol (usually in an incubator) and filter
Surgical packs
Thoracotomy pack for open chest CPR
Thoracentesis kit
Pericardiocentesis kit
Minor pack for tracheostomy
Tracheostomy tubes-various sizes
Sterile gauze squares
Internal paddles for defibrillator for open chest CPR
Electric clippers
Sterile gloves
Red rubber catheters for intratracheal drug administration (NAVEL: Naloxone Atropine Vasopressin Epinephrine Lidocaine-drugs that can be administered via endotracheal tube with red rubber)
m. Emergency Drug Calculators on computers in the designated Emergency Area and on phones. Here are some links to some emergency calculator resources or you can create your own calculator on Excel:
https://apps.apple.com/us/app/vetpda-calcs/id356519283 VetPDA Calcs UC Davis
n. Last but not least here is a Surgical Safety Checklist for Anesthesia cases. The intent of the checklist is to increase the team’s preparedness in case of an emergency:
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This checklist is an adaptation of the World Health Organizations Surgical Safety Checklist. The goals of the list are to improve patient safety and team preparedness as listed below.
The team will operate on the correct patient at the correct site.
The team will use methods known to prevent harm from anesthetic administration, while protecting the patient from pain.
The team will recognize and effectively prepare for life-threatening loss of airway or respiratory function.
The team will recognize and effectively prepare for risk of high blood loss.
The team will avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient.
The team will consistently use methods known to minimize risk of surgical site infection.
The team will prevent inadvertent retention of instruments or sponges in surgical wounds.
The team will secure and accurately identify all surgical specimens.
The team will effectively communicate and exchange critical patient information for the safe conduct of the operation.
Hospitals and public health systems will establish routine surveillance of surgical capacity, volume and results. 1
1. World Health Organization. WHO Guidelines for Safe Surgery 2009. Geneva: WHO; 2009.
Thanks for reading this long blog! I’d love to hear from readers as to what other topics they would like to hear about!
Toodles, until next time!
“Remember: When disaster strikes, the time to prepare has passed.” Steven Cyros