Quick action save lives
Effective CPR demands immediate application, rapid compression
By John C.Cargill, MA, MBA, MS
Statistician and retired Marine officer John Cargill wears many hats, among them that on an Akita breeder. He is presently involved with the Osler Institute in continuing medical education. The institute is in Terre Haute, IN; the Akitas live in Bonsall, CA.
Those of us who breed dogs whelp litters. While a time of joy and anticipation, the process of whelping may not be roses and sunshine. There is a down side, a dark side of anxiety to the process. When we breed, we bet our bitches'lives on their ability to whelp normally without complications. We also bet puppies'lives on the ability of the bitch as a mother to stimulate them immediately after following birth and to tend to afterward. Then we cross our fingers, hoping that nothing will go wrong.
Long ago I gave up trying to keeping everything sterile. I gave up on surgical thread for tying of the umbelical cord and the scissors for cutting between those ties. I gave up on the iodine as a dip for the umbelical cord - it didn't seem to make much of a difference anyway. Maybe it would help to mention that the breed I have whelped most often has been the Akita, and sometimes it is just not worth the effort to compete with Mama when she is determined to chew the umbilical cord. This special tender and emotional moment is not the time for a contest of strong wills. I have learned that crushing the cord between teeth bruises it and causes it to swell rapidly and self seal quite nicely. Not such swelling occurs with a cut from sharp shissors. About the only thing I have been able to do better than Mama has been to work with a weack puppy.
A few litters ago (about three years past), while helping whelp a fall litter of Akita puppies from a sturdy, healthy, sassy bitch, I was called to the house by the ringing of a telephone. Upon returning to the whelping box in the barn, I found a cold, damp and uncleaned puppy pushed off to the side; the count nof puppies was two more than when I had left.
Although I had been gone no longer than 10 to 15 minutes, it was apparent that two puppies had been born one right after the other. I have no idea wich was the first, but I do know which one the bitch was cleaning. It sure was not the one I was looking at that had been pushed off to the site. I do not know about the rest of you, but as ahobby kennel we do not often get the kind opportunity with compatible pedigrees offered by this litter. We could not afford to lose a single puppy. I was not yet distraught, but I was anxiuous. In this state of mind and certain emotion, I approached this wet, soggy, half dead - half alive, pushed aside puppy. The elements were all there. Those who raise livestock, have many children, serve in the military or work in the veterinary medical or police professions know that not every newborn lives. For all I knew, this might be one of those that would not make it, but I hoped this would not be the case.
Conventional cardiopulmonary resuscitation is incredibly ineffective as as an artificial means of providing blood flow during cardiac arrest. "Studies in animals show that conventional manual CPR provides very low levels of myocardial and cerebral blood , on the order of 5% - to 10 % of baseline values."(1) Hear also the not-so-conforting words of Ditchey, et al., in the title of their paper: "Relative lack of coronary blood flow during closed chest resuscitation in dogs.)(2) Doing CPR is little better than doing nothis in most cases. The reality of the situation is that without drugs (epinephrine or other heart stimulant) and defibrillation equipment, there is a strong probability that once the heart has stopped you won’t get it going again. If the lungs are fluid – filled, or the airway is blocked and the heart is still going, you have a significantly better chance of improving the situation. The American Heart Association defines basic life support (BLS) as that phase of emergiency cardiac care that " 1. prevents respiratory or circulatory arrest or insufficiency through prompt recognition and intervention or 2. supports the ventilation of a victim of cardiac arrest with cardiopulmonary resuscitation (CPR)." (3) The point I will make several time in this article is that prompt administration of BLS is key to a successful outcome. Since is not within the capabilities of most dog owners to progress to more definitive medical treatment, (i.e. advanced cardiac life support [ACLS]), success or failureusually hinges directly upon prompt and proper administration of BLS.
"The major objective of performing rescue breathing, or CPR, is to provide oxygen to the brain and heart" until normal heart and ventilatory action can be restored. (4) In weack newborn puppies the probem may just be a simple respiratory arrest, or failure to start breathing once out of the sac. "In respiratory arrest, the survival rate may be very high if airway control and rescue breathing are started promptly." (5) When a dog stops breathing, the hearth and lungs can continue to function and to provide oxigenation for the blood for several minutes. Thus oxygen will continue to circulate to the brain and other vital organs. (6)
While this sound very optimistic, those precious few minutes go by very quickly when you are attempting to re-establish breathing. Common causes of resoiratory arrest in a puppy include: drowning, drug overdose, electrocution and foreign body airway obstrucion.
Rescue breathing with mouth to nose – and – mouth is a quick and effective way to provide oxigen to the victim. With a small dog or a puppy, a human rescuer has adequate volumes of air for all the victims. The oxygen concentration in human exaled air is approximately 17 percent, but it is adequate to meet the victim's needs. (7,8) Expecially if the heart is functioning, a little bit of air may be all the animal needs to begin breathing on its own.
More specifically, previously I had seen sluggish puppies respond to BLS/CPR, more from the stimulation than the assistance in ventilation or circulation. Twenty-five years ago (1968), I performed CPR on a Chinese Army officer we shot up in Laos. He lived. A few months ago, while on the way to help host an anesthesiology board review course, I performed a CPR on an apparent hearth attack victim on the side of the road outside Lowell, MA. He died. The difference between success and failure seems to be how soon you start rescue breathing and compressing after the victim stops on his own.
The previous thaught CPR techniques of slower compression just do not work as well as the current American Heart Association thinking of 80 to 100 compressions per minute in the human. As the anesthesiology course I listened to Dr. Astride Seiffen's class on CPR. Seiffen is a professor of anesthesiology at the University of Arkansas. Note frome Swenson, et al., grafs in Figures 1 and 2, the increased amount of blood moved with the rapid chest compression rate. They report: "The high impulse method (of CPR) was the only tecnique tested that significantly elevated both aortic peack pressure and the coronary perfusion gradient during cariac arrest &ldots; high impulse chest compression method augments aortic pressure over levels achieved during conventional CPR methods." (9)
The same holds true in dogs and puppies. Note that it is extremely difficult for one person to keep up an 80 to 120 compressions per minute rate. It is not easy to keep up 60 compressions per minute, but review the charts herein and you will never doubt that more is better. In fact, Swenson suggest that 120 compressions per minute is better than 100 compressions per minute.
The lesson here is very clear. The new standards of CPR, just published in the October 28, 1992, issue of the Journal of the American Association support the requirement to move a lot of blood and to sustain life until heart and lung functions continue on their own. One does not have a professional engineer with a certification in hydraulics to grasp quickly that blood must circulate and it must to be oxygenated, and that those two functions are dependent upon the mechanical actions of a pump and pushing air and blood past on the opposite sides of a semipermeable membrane, the lungs.
If not enough blood flows, you are waisting your time. Note that no manual method of artificial resuscitation are enterely satisfactory, as they fall to move enough air and enough blood. Compressing the heart as a substitute for it contracting on its own is relatively inefficient. To make up for the inefficiency there must be a significant increase in compression over the normal number of heart beats per the same unit of time.
Just half out of the sac, this one-pound Akita neonate presented a dismal prospect. It was cold and had no signs of breathing. Puppy hearts are difficult to hear without a stethoscope, but I did no matter since there was no stethoscope present. , and I could not feel a pulse in the groin. I set the stopwatch function on my watch. I did not know the hour, I only knew that I had precious little time to get this rascal going. I knew that it was now past time to have started BLS/CPR.
We keep a suction bulb syringe handy at the whelping box. I suctioned one nostril, then the other, then the mouth. This may have been a waste of time as little mucous was removed, but I did not take much more time to clear these airways than just to check them for blockage. The pup still was not breathing. For those of you who served in the military, the concept for saving lives of "stop the bleeding; start the breathing; treat for shock" (BBS) remains valid. For hose of you more oriented toward civilian pursuitsit is "airway, breathing, circulation" (ABC). So what to do? How long to do it? As best with humans, as with dogs, CPR is effective in probability no more than 5 percent of the cases without following with ACLS. We will get back to that statistic later.
Remembering the woman who sold me my first Akita in 1968 and who falled one time to exercise due diligence and caution, I removed the puppy from the dam. I strongly recommend that whatever you must do to a puppy, you do it of "striking distance" of the bitch who is whelping. Canines cannot count. Bitches do not notice the removal of one puppy from a sizable litter. This particular woman - a dog person of significant repute – however, proceeded to perform mouth to nose-and-mouth resuscitation at the whelping box. As the puppy came to consciousness, it mustered a healthy, frightened, puppy protest of a scream. The bitch lunged out of the whelping box, snapped once on the neck and throat of the woman performing the resuscitation procedure, grabbed the puppy, returned to the whelping box, lay down and wagged her tail. No problems? Wrong! That one snap, if memory serves right, resulted in 93 stitches. Fortunately, the jugular vein and carotid artery were not involved. The damage was cosmetic but expensive, and could have very esily been fatal. This is why I do not recommend that you crawl into the whelping box for work on a puppy.
By now I had the mucous wiped away from the puppy’s face. Some breeders and vets recommend "slinging" the puppy. Slinging is simply supporting the puppy with both hands, paying special attention to supporting the neck. Then raise your arms at least shoulders level and bring them down quickly in an arcing motion. This serves to move fluid out of lungs, vomitus out of airways, etc. Do not think that if slinging a puppy a little bit is good, slinging the puppy a lot is better. Do it gently and firmly, but not violently. And if it does not work immediately, do something else. So, I slung the puppy, but there was no response. Time for BLS/CPR.
The technique I used was to place my lips over the puppy’s nose and mouth, making sure that my breath could not escape from the corners of the puppy’s mouth. Them I breathed out hard enough to see the rib cage expand significantly. Next, I squeezed gently on the sides of the ribs with the flat of my hand to expel the air, and then rather more vigorously with four to five chest compressions at rate of approximately 10 breaths and 60 to 80 compressions per minute.
Becouse I felt the puppy move, I stopped on three occasions, only to find that the puppy still did not breathe on its own. It was not until a full 20 minutes of huffing and puffing and compressing that this puppy started screaming and protesting the treatment and was able to be returned to his mother. He suckled greedly and went on to become one of the more active in the litter. His problem was that just had a slow start.
You can never go wrong stimulating sluggish puppies at birth. If the rest of the litter is in good shape, you can have the dam clean and reclean the puppy until it is moving as vigourously as the others.
Following are some dos and do’ts for CPR in dogs. The standard disclaimer is made that you should check with your veterinarian for contrary or similar instructions before you attempt CPR on your dogs and with your physician for contrary or similar instructions before you attempt to save a human life. Be forewarned that there is tremendous variance in medical opinion.
Do: Check and clear the airways for obstructions, fluid and mucous before breathing into the animal. There is no sense in blowing fluid or a foreign object into the lungs.
Do: Immediately start BLS/CPR as soon as you notice a cessation of breathing or the hearth beat stopping. If you wait, you may be too late. Very short periods of indecision can make the difference between success and failure,
Do: Make sure that your breath is not leaking out around the mouth. If you have a big dog, it is going to take a lot of breath to support him.
Do: Keep the chest compression rate above 80 to 100 if at all possible.
Don’t: Do CPR on a puppy in a whelping box in front of the mother. You too could have a neck full of 93 stitches.
Don’t: : Breathe too hard, expecially on a puppy. The concept is not to blow the puppy like a baloon and then squash it flat, but to expand the ribs trough inflating lungs without rupturing them, gently forcing the aor out and firmly and rapidly compressing the chest.
Dont’t: Give up until 30 minutes have passed.
One final Do: After using CPR on a puppy, whatever the outcome, have a cup of coffee (preferably Colombian Supremo with a splash of cream and a dash of Amaretto Di Saronno), put your feet up and rejoice in the living in the litter. If there is one more alive than would have otherwise, be expecially thankful. If you did not get the puppy going, recognize that there may have been other insurmontable prolems and that some puppies live and some die. While my experience with CPR and puppies have been positive, there are many who have lost puppies in litters. If you find yourself in such a position, recognize that you are not being punished for past sins, but that less than complete puppies die, and is all there is to it.
Research continues to improve CPR methods. Some methods with a humble beginning may be perfect and adopted for general use. One such potential improvement in technique is that of "active compression-decompression," which had been suggested from an anectodal report of successful cardiac resuscitation using a household drain plunger (the familiar plumber's helper) applied to the anterior chest wall as reported by Lurie, et al. (10)
Epilogue: The neurosurgeon who bought the dog pup I named "Rescue" purchased a bitch he named "Serchan." It was his hobby to go hiking with dogs. The command for recall was "Serchan, Rescue."
References
1. Luce, J.M.; Ross, B.K.; O'Quin, R.J.; Culver, B.H.; Sirarajan, M.; Amory, D.W.; Niskanen, R.A.; Alferness, C.A.; Kirk, W.L.; Pierson, L.B.; Butler,J., "Regional blood flow during cardiopulmanary resuscitation in dogs using simultaneous and non-simultaneous compression and ventilation," Circulation 1983, 67:258.
2. Ditchey, R.W.; Winkler, J.V.; Rhodes, C.A.: "Relative lack of coronary blood flow during closed-chest resuscitation in dogs," Circulation 1982, 66:297.
3. Emergency Cardiac Care Committee and Subcommitteess, American Hearth Association. Guidelines for cardiopulmonary resuscitation and emergency cardiac care, JAMA, 1992, 268:2184.
4. Ibid, p.2184.
5. Gordon, A.S.; Frye,C.W.; Gittelson, L.; Sadove, M.S.; Beattie, E.J.Jr.: "Mouth-to-mouth versus manual artificial respiration for children and adults" JAMA, 1958, 167:320-328.
6. Mackenzie, G.J.; Taylor , S.H.; Mc Donald, A.C.; Donald, K.W.: "Hemodynamic effects of external cardiac compression" Lancet, 1964, 1:1342-1345.
7. Elam,J.O.; Greene, D.G.: "Mission accomplished: successful mouth-to mouth resuscitation" Anesth Analg., 1961, 40:578-580.
8. American Hearth Association, Textbook of Advanced Cardiac Life Support, 2nd Ed., 1987, p.36.
9. Swenson, R.D.; Weaver, W.D.; Niskanen, R.A.; Martin,J.;Dahlberg, S., "Hemodynamics in Humans During Conventional and Experimental Methods of Cardiopulmonary Resuscitation," Circulation 1988, 78:630.
10. Lurie, K.G.; Lindo,C.; Chin,J., "CPR: the P stamds for plumber's helper," JAMA, 1990, 264:1661.