RECOVER CPR for Veterinary Nurses PDF

Veterinary Nursing Journal ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: https://www.tandfonline.com/loi/tvnj20 RECOVER CPR for veterinary nurses Courtney Waxman To cite this article: Courtney Waxman (2019) RECOVER CPR for veterinary nurses, Veterinary Nursing Journal, 34:8,...

Veterinary Nursing Journal ISSN: 1741-5349 (Print) 2045-0648 (Online) Journal homepage: https://www.tandfonline.com/loi/tvnj20 RECOVER CPR for veterinary nurses Courtney Waxman To cite this article: Courtney Waxman (2019) RECOVER CPR for veterinary nurses, Veterinary Nursing Journal, 34:8, 207-212, DOI: 10.1080/17415349.2019.1616640 To link to this article: https://doi.org/10.1080/17415349.2019.1616640 Published online: 23 Jul 2019. Submit your article to this journal Article views: 825 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=tvnj20  Clinical RECOVER CPR for veterinary nurses Courtney Waxman BAS, CVT, RVT, VTS (ECC) Department of Veterinary Administration, Instructional Technologist–Veterinary Nursing Program, Purdue University, West Lafayette, IN, USA ABSTRACT: This article outlines the Reassessment Campaign on Veterinary Resuscitation (RECOVER) initiative. It will review the established evidence-based guidelines for veterinary CPR, which are internationally recognised and endorsed Courtney Waxman, BAS, CVT, RVT, VTS (ECC) by the American College of Veterinary Emergency and Critical Care (ACVECC) and Veterinary Emergency and Critical Care Society (VECCS). After reading this Courtney graduated in 2008 with article, participants should be able to prepare for and recognise cardiopulmonary her degree in Veterinary Technology arrest (CPA), initiate basic life support, provide advanced life support, monitor the and became a Certified Veterinary CPA patient and provide post-CPA care. Participants will also have access on the Technician. She has spent over 13 years different RECOVER certifications available and certification process. working in emergency/critical care medicine and gained the VTS (ECC) Keywords: Cardiopulmonary arrest (CPA); CPR; RECOVER; BLS; ALS; veterinary qualification in 2017. In 2018, she nurse became a RECOVER Certified BLS and ALS Rescuer and a RECOVER Certified The Reassessment Campaign on Veterinary training improves cognitive skills and Instructor. Courtney currently works at Resuscitation (RECOVER) was established teaches staff how CPR is correctly per- Purdue University as an Instructor for in 2012 by a group of over 100 veterinary formed. Hands-on training allows for the the Veterinary Nursing Program. specialists. Their goal was to evaluate development of psychomotor skills so that Email: [email protected]; evidence-based medicine and form chest compressions and ventilation are ­[email protected] consensus guidelines for CPR in canine and provided effectively. Hands-on training feline patients. The result was refined can be achieved by practising CPR drills recommendations that the veterinary with team members to evaluate CPR community could adopt and follow. The performance. Regular refresher train- RECOVER guidelines are considered open ing for both instructive and hands-on is access (www.veccs.org/recover-cpr) and are recommended at least every six months to available to all veterinary professionals. prevent loss of knowledge and psychomo- tor skills. RECOVER initiative Each hospital should have a designated The initiative aimed to address five critical emergency area with a centrally located, aspects surrounding cardiopulmonary fully stocked crash cart (Figure 1 and arrest (CPA) for the veterinary team: Table 1). The crash cart should be organ- preparedness and prevention, basic life ised, routinely audited (ideally daily) to support (BLS), advanced life support ensure no supplies are missing, and have (ALS), monitoring, and post-­ its location and content standardised cardiopulmonary arrest care. (location doesn’t change, content organi- sation doesn’t change). Preparedness and prevention It’s beneficial to have a multi-parameter Preparation includes having both the monitor in the vicinity of the crash cart veterinary team and hospital be trained to as well as cognitive aids readily accessible provide cardiopulmonary resuscitation (Figure 2). Cognitive aids should have (CPR) in an organised and efficient manner. clear visibility and training on the use of them, as they have been shown to improve Being prepared first means provid- compliance of RECOVER guidelines. ing CPR training for all staff members RECOVER created three essential cogni- ­(veterinarians, nurses, assistants and client tive aids: CPR Algorithm, CPR Emergency service representatives). This includes an Drugs and Doses, and Post-Cardiac Arrest instructive component as well as hands-on Care Algorithm. These aids are available practise. Instructive training involves in the published RECOVER guidelines providing in-house or online education available on the RECOVER website (www. DOI: 10.1080/17415349.2019.1616640 to teach key concepts of CPR. Instructive recoverinitiative.org). © 2019 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal VOL 34 August 2019 Page 207 Clinical A final consideration in preparedness is Signs of impending arrest are sum- also found that it is more detrimental to having an advanced directive status for marised in Table 2. If CPA is suspected, delay starting chest compressions on a CPA each patient in the hospital. Knowing the rapid assessment of the patient (less than patient than performing chest compressions owner’s wishes for their pet ahead of time 10–15 seconds) should be done to deter- in an animal that is not in CPA. eliminates confusion and delay in provid- mine if the animal is responsive and if ing CPR efforts. they’re breathing. If the answer is no, a call With the RECOVER initiative, the ABCs for help should be shouted and BLS should (airway, breathing, circulation) was be initiated. It is important to note that eval- updated to CAB (circulation, airway, Basic life support uation of the patient’s circulation status (i.e. breathing), due to an updated statement in Basic life support (BLS) encompasses heartbeat, pulse) is not performed during 2010 from the American Heart Association recognition of cardiopulmonary arrest this rapid assessment. This is because taking (AHA). While there are no studies in (CPA), initiation of chest compressions, the extra time to auscultate for a heartbeat human or veterinary medicine that directly establishing an airway, and delivering or palpate a pulse is time taken away from look at whether chest compressions or breaths to provide ventilation. initiating life-saving chest compressions. intubation/ventilation should be initiated Additionally, the RECOVER research found first, what is certain is that chest compres- Prompt recognition and immediate that there is considerable inaccuracy in a sions are necessary for blood flow and to response to CPA are essential to improve rescuer’s ability to correctly determine if improve the chances of return of sponta- outcome and chances of patient survival. a pulse is present or absent. The research neous circulation (ROSC). It is also known that the process of intubating and provid- ing breaths is longer, when providing chest compressions can start immediately. By focusing on compressions first, there is less delay in starting CPR efforts. Chest compressions have two main goals, to restore cardiac/pulmonary tissue circulation and deliver ventilation to oxygenate tissues and restore organ function. There are two theories on how chest compressions return blood flow during CPR and where the compression point should be. The cardiac pump theory states that blood flow is gen- erated from direct compression of the heart through the thoracic wall, which simulates the systolic phase of a normal heartbeat. This compression point is directly over the heart and is ideal for narrow- or keel-chested dogs, small dogs, cats and paediatric dogs and cats. Using your thumb over the compression point is an alternative to using a hand-over- hand technique when following the cardiac pump theory (Figure 3). The thoracic pump theory states that blood flow is generated from increased intrathoracic pressures during compressions, which drive blood through the heart chambers (Figure 4). This a Figure 1. Example of a centralized crash a Figure 2. Example of a RECOVER compression point is over the widest aspect cart in ICU. cognitive aid located with a centralized of the chest and is ideal for flat-chested crash cart. dogs. Round-chested dogs are unique in a Table 1. Summary of essential supplies needed in a crash cart. that the compression point is directly over Crash cart essentials their sternum when in dorsal recumbency. Airway Venous access High-quality chest compressions should Endotracheal (ET) tubes IV catheters be delivered in lateral recumbency at a rate Laryngoscope T-ports ET tube ties 1-ml syringes ET tube cuff inflator syringe 3-ml syringes a Table 2. Summary of clinical signs of impending Multiple needle sizes cardiopulmonary arrest. Multiple saline/heparinised flushes Signs of impending CPA Breathing Drug administration Changes in mentation Red rubber catheters Epinephrine Alterations in respiratory rate/pattern Suction equipment/supplies Atropine Uncontrollable ventricular tachycardia (V-tach) Manual resuscitator (i.e. AMBU bag, Vaspopressin Bradycardia anaesthetic reservoir bag) Norepinephrine Collapse Anti-arrhythmics (lidocaine, amiodarone) Equipment Weakening pulse quality Reversal agents (naloxone, flumazenil, Defibrillator Prolonged hypotension antipamezole) ECG monitor Prolonged hypothermia Capnograph Acute decline of ETCO2 (under anaesthesia) Page 208 VOL 34 August 2019 Veterinary Nursing Journal © 2019 British Veterinary Nursing Association (BVNA)  Clinical Advanced life support Advanced life support (ALS) encompasses aspects of CPR performed after initiation of BLS and until ROSC or cessation of CPR efforts occurs. This includes venous access, emergency drug administration, monitoring equipment and defibrillation if warranted. Venous access is the preferred route to administer emergency drugs. Obtaining venous access should not impede BLS procedures. In the event venous access cannot be achieved, alternative routes of drug administration include intraosseous (IO) or intratracheal (IT). Common sites for IO catheterisation include the femoral head or humerol head. Anything that can be given IV can be given IO at the same dosage. The protocol for IT administra- tion involves placing a red rubber catheter down the ET tube, administering the drug (doses usually at 2.5–10 times the IV dose), then flushing the red rubber catheter with 5–10 ml sterile saline to ensure the drug reaches the pulmonary tissues and does not remain within the ET tube. The drugs that are safe to give via the IT route are noradrenaline, atropine, vasopressin, lidocaine and adrenaline. The primary drug therapies used in CPR a Figure 3. The author demonstrating cardiac pump theory chest compressions on a feline include vasopressors, parasympatholytics CPR mannequin. and anti-arrythmics. Additional drug therapies include reversal agents, alkalin- of 100–120 compressions/minute (cpm). lateral recumbency so chest compressions ising therapy and IV fluids. Compression depth should be delivered by aren’t interrupted. Using a laryngoscope compressing one-third to one-half of the ensures endotracheal versus oesophageal Vasopressors are powerful drugs that increase width of the patient’s chest. When com- intubation. Once intubated, inflate the cuff peripheral vascular resistance (cause vaso- pressing, the rescuer needs to allow for and securely tie the endotracheal tube to constriction), which redirects blood flow full chest wall recoil between compression prevent dislodgement. The breath delivery from peripheral circulation to central circula- depths in order to optimise cardiac output. rate in dogs and cats should be 10 breaths tion. Use of vasopressors are essential as they Rescuers should perform compressions by per minute (bpm). Manual ventilation can improve cerebral and coronary perfusion. standing behind the patient and should be be provided with either an AMBU bag con- Adrenaline is a catecholamine that improves above the level of the patient, which means nected to an oxygen source or a rebreath- arterial blood flow, cardiac contractility and it’s sometimes necessary to use a step stool. ing bag connected to an anaesthetic circuit. heart rate by alpha and beta adrenergic activ- The rescuer should place one hand over the ity. Vasopressin improves myocardial and other, with the heel of their hand over the The practice of performing compressions cerebral oxygenation and maintains effective- appropriate compression point (directly at 100–120 cpm and delivering breaths at ness despite hypoxemia and acidotic states. over the heart or over the widest part of the 10 bpm should be done in uninterrupted chest). They should also have their elbows 2-minute BLS cycles. It is known that it Parasympatholytics reduce the activity locked and bend at the waist in order to draw takes approximately 60 seconds of con- of the parasympathetic nervous system. compression power and force from their core tinuous chest compressions to build up Atropine decreases vagal tone by increasing rather than their arms (Figure 5). Following cerebral perfusion pressure (CPP). There sinoatrial automaticity and atrioventric- this chest compression technique is essen- are human studies that have shown an ular conduction and can also prevent an tial, as even high-quality compressions only increased survival when doing uninter- unstable bradycardia from progressing to produce approximately 25–30% of normal rupted chest compressions compared to asystole. Anti-arrythmics are used to treat cardiac output. It’s strongly stressed that any more frequent pauses in CPR. Human abnormal heart rhythms resulting from delay of initiation or prolonged pauses of studies have also shown rescuer fatigue irregular electrical activity of the heart. chest compressions reduces the likelihood of when doing compressions for 1–3 min- ROSC. utes, which results in poorer quality. Anti-arrhythmic agents such as lidocaine At the end of each 2-minute BLS cycle, and amiodarone should be used to treat Intubation should occur as soon as pos- rescuers should rotate out to prevent ventricular fibrillation or pulseless ven- sible once chest compressions start, with fatigue and the patient should be rapidly tricular tachycardia in the event defibrilla- ventilation being delivered simultaneously. assessed for ROSC before starting the next tion is not available or in if the arrhythmia Ideally, intubation should be done in 2-minute cycle. is refractory to defibrillation. © 2019 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal VOL 34 August 2019 Page 209 Clinical Asystole indicates complete suffer from the post-cardiac arrest (PCA) cessation of electrical and mechan- syndrome, which involves multi-organ ical heart activity (Figure 6). PEA failure, cardiogenic shock, hypoxic/anoxic indicates cessation of mechanical brain injury, and whatever pre-existing heart activity (lack of pulses) but condition(s) contributed to the inciting CPA continuation of electrical heart event. PCA care requires dedicated one-on- activity (Figure 7). During PEA, one nursing to minimise the likelihood of the electrical activity in the heart is CPA reoccurring and to maximise the sufficient to generate electrical likelihood of the patient recovering and potentials that can be picked up by going home. PCA care focuses on cardiovas- ECG. However, there’s absent or cular, respiratory and neurological support. very weak mechanical activity, Cardiovascular support includes haemody- meaning the heart fails to generate namic support with IV fluids, vasopressor sufficient blood flow to produce agents and positive inotrope agents. It also palpable pulses. V-fib indicates includes continued ECG monitoring and the uncoordinated mechanical heart initiation of blood pressure monitoring. activity (Figure 8). During V-fib, Respiratory support includes oxygen the muscle cells in the ventricles support, evaluation of pulse oximetry, have a “quivering” mechanical continued ETCO2 (if still intubated), and activity, resulting in ineffective evaluation of blood gases. Neurologic contractions and insufficient support includes oxygen support, neuropro- cardiac output. If uncorrected, tection using osmotic agents (i.e. mannitol, V-fib can progress to pulseless hypertonic saline), 30–45 degree elevation, ventricular tachycardia (PVT), and permissive hypothermia (allows a lower which occurs when the quivering than normal temperature in order to a Figure 4. The author demonstrating thoracic pump mechanical activity of the ventri- decrease the metabolic demands of the theory chest compressions on a large breed canine cles becomes very rapid (HR > brain). CPR mannequin. 200bpm) and complexes repeat. When V-fib progresses to PVT, Unfortunately, many animals still perish Reversal agents (naloxone, flumazenil, there’s insufficient ventricular despite CPR efforts. Statistics range from atipamezole) should be administered if filling and therefore no cardiac output. 35% to 44% of ROSC with only 6% sur- there has been recent administration of a Capnography is the best indicator of chest vival to discharge. reversible drug. compression efficacy and earliest indicator of ROSC. Effective chest compressions Sodium bicarbonate should only be result in increased pulmonary blood flow, considered after CPR efforts have lasted which in turn improves alveolar gas greater than 10 minutes, or in severe cases exchange. ETCO2 values greater than of metabolic acidosis (pH < 7.2), as there 15 mmHg have been associated with an are conflicting studies on whether there is increased rate of ROSC. improved or detrimental outcomes with the Due to the lack of a pulse and adequate use of alkalinising therapy. pulse quality during CPA, monitoring tools such as pulse oximetry and indirect The use of IV fluids was also investigated blood pressure devices are ineffective and it was found that routine use of fluids in until ROSC has been achieved. euvolemic patients is not recommended; it has been associated with decreased coronary Electrical defibrillation is the process in perfusion from increased central venous which the entire heart is depolarised and pressure, which causes opposing blood flow “reset”. Defibrillation is warranted if V-fib to heart and brain circulation. Conversely, or PVT is noted on ECG. The dosing in hypovolemic patients, use of IV fluids depends on the type of defibrillator; may be beneficial in increasing circulating monophasic dosing is 4–6 J/kg, biphasic volume during CPR. dosing is 2–4 J/kg. Chest compressions should continue up until and immediately following defibrillation. After defibrilla- Monitoring tion, the 2-minute BLS cycle restarts and The mainstay of monitoring equipment ECG should not be evaluated until the during CPR is electrocardiogram (ECG) end of the cycle. and capnography (ETCO2). Having an ECG is essential to evaluating the heart rhythm a Figure 5. The author demonstrating correct and should be quickly interpreted between chest compression technique on a large each 2-minute cycle of BLS so as not to Post-cardiopulmonary arrest breed canine CPR mannequin. This includes interrupt chest compressions. The three care standing behind the patient, bending at the most common arrest rhythms in dogs and ROSC is the resumption of a heartbeat, waist, keeping elbows locked, having hand- cats are asystole, pulseless electrical activity palpable pulse, or spontaneous breathing. over-hand, and using the correct compression (PEA) and ventricular fibrillation (V-fib). Following CPR efforts and ROSC, patients point. Page 210 VOL 34 August 2019 Veterinary Nursing Journal © 2019 British Veterinary Nursing Association (BVNA)  Clinical a Figure 6. An ECG tracing showing the common arrest rhythm asystole. a Figure 7. An ECG tracing showing the common arrest rhythm pulseless electrical activity (PEA). a Figure 8. An ECG tracing showing the common arrest rhythm ventricular fibrillation (V-fib). CPR positions and the During a CPR event, using closed-loop done well?”, “what can be improved upon?” communication is preferred. This consists of and “how does everyone feel?” allow for nurse’s role the leader giving a clear, directed order to a an open discussion in a safe environment The positions nurses take part in during team member by name and then that order that can be used as a therapeutic learning CPR are BLS rescuers (1 – chest compres- is repeated back to the leader to verify it was experience. sor, 2 – airway manager/breather), ALS heard correctly. Closed-loop communica- rescuer, and team leader. tion reduces the chance of medical errors from misunderstanding verbal orders. RECOVER certification The team leader is responsible for As the veterinary field advances, so do delegating tasks to each member of the All aspects of CPR need to be documented expectations pet owners place on veteri- rescue team. The leader organises CPR as part of the medical record. Using a nary professionals. Similar to our human efforts, assigns team positions, ensures standard CPR flowsheet serves as a check- counterparts, RECOVER has established proper technique of each rescuer, facil- list of tasks and ensures the details of CPR certifications for veterinary CPR, which itates communication, and directs the are recorded. RECOVER subcommittees include becoming certified as a RECOVER flow of the team. It’s important to note developed a standard CPR reporting form BLS Rescuer, RECOVER ALS Rescuer, or that the team leader doesn’t need to be a that is available at www.recoverinitiative. both. veterinarian; there have been studies in org/cpr-guidelines/current-recover-guide- the human field showing there was no line. The person responsible for recording Certification is a two-part process that difference in CPR outcome whether the the CPR rescue attempt is delegated by the involves both an online didactic course team leader was a clinician or nurse. The team leader, and is often either the team and an in-person hands-on course. BLS rescuers are primarily responsible leader themselves, the ALS rescuer, or an There is also an option of certifying as for providing compressions and deliv- additional staff member if available. a RECOVER BLS and ALS Instructor ering breaths, and they usually rotate once you’ve completed the rescuer amongst themselves after each 2-minute Following any CPR event, it’s recommended certifications. Detailed information cycle. The ALS rescuer is responsible for for the rescue team to have a debriefing about the certification process can be obtaining venous access, delivering drugs session. Debriefing allows the team to talk found at www.recoverinitiative.org/ and connecting the ECG and ETCO2 and review their performance and team veterinary-professionals/how-certifi- monitoring equipment. dynamics. Questions such as “what was cation-works-2. As RECOVER is the © 2019 British Veterinary Nursing Association (BVNA) Veterinary Nursing Journal VOL 34 August 2019 Page 211 Clinical internationally recognised authority for guidelines ensures we are providing the CPR. Part 7: Clinical guidelines. Journal of Veterinary Emergency and Critical Care, 22(S1), S102–S131. veterinary CPR, certification is available best CPR to have the best possible patient doi:10.1111/j.1476-4432.2012.00757.x to all practising veterinarians and veter- outcomes. Hopper, K., Epstein, S. E., Fletcher, D. J., & Boller, M. (2012). inary technicians/nurses who complete RECOVER evidence and knowledge gap analysis on the online course and hands-on train- ing. The hands-on training is currently Disclosure statement veterinary CPR. Part 3: Basic life support. Journal of Veterinary Emergency and Critical Care, 22(S1), S26–S43. being offered at conferences such as No potential conflict of interest was reported doi:10.1111/j.1476-4431.2012.00753.x International Veterinary Emergency by the author(s). Mcmichael, M., Herring, J., Fletcher, D. J., & Boller, M. (2012). RECOVER evidence and knowledge gap analysis on and Critical Society (IVECCS) and veterinary CPR. Part 2: Preparedness and prevention. Journal European Veterinary Emergency and References of Veterinary Emergency and Critical Care, 22(S1), S13–S25. Battaglia, A. M., Steele, A. M., & Battaglia, A. M. (2016). Small Critical Care Society (EVECCS). Detailed animal emergency and critical care for veterinary technicians. doi:10.1111/j.1476-4431.2012.00752.x information about hands-on BLS and St. Louis, MO: Elsevier. Norkus, C. L. (2018). Veterinary technicians manual for small ALS Rescuer Certification courses can Boller, M., & Fletcher, D. J. (2012). RECOVER evidence animal emergency and critical care. Hoboken, NJ: Wiley. be found at https://recoverinitiative.org/ and knowledge gap analysis on veterinary CPR. Part 1: Rozanski, E. A., Rush, J. E., Buckley, G. J., Fletcher, D. J., & Boller, recover-rescuer-certification-courses-2/. Evidence analysis and consensus process: Collaborative M. (2012). RECOVER evidence and knowledge gap analysis path toward small animal CPR guidelines. Journal of on veterinary CPR. Part 4: Advanced life support. Journal Veterinary Emergency and Critical Care, 22(S1), S4–S12. of Veterinary Emergency and Critical Care, 22(S1), S44–S64. Conclusion doi:10.1111/j.1476-4431.2012.00758.x doi:10.1111/j.1476-4431.2012.00755.x The RECOVER initiative was founded to Brainard, B. M., Boller, M., & Fletcher, D. J. (2012). Silverstein, D. C. (2015). Small animal critical care medicine. St. RECOVER evidence and knowledge gap analy- Louis, MO: Elsevier, Saunders. provide a standard set of guidelines for sis on veterinary CPR. Part 5: Monitoring. Journal of veterinary CPR. Veterinary nurses play a Veterinary Emergency and Critical Care, 22(S1), S65–S84. Smarick, S. D., Haskins, S. C., Boller, M., & Fletcher, D. J. (2012). RECOVER evidence and knowledge gap analysis critical role in the recognition, initiation, doi:10.1111/j.1476-4431.2012.00751.x on veterinary CPR. Part 6: Post-cardiac arrest care. Journal monitoring and care of patients who Fletcher, D. J., Boller, M., et al. (2012). RECOVER evi- of Veterinary Emergency and Critical Care, 22(S1), S85–S101. experience CPA. Following these dence and knowledge gap analysis on veterinary doi:10.1111/j.1476-4431.2012.00754.x Multiple Choice Questions 1. How often should a crash cart be 5. What is the RECOVER- 9. Which of the following is not a audited? recommended breath rate for dogs common arrest rhythm? (a) Bi-weekly and after every code and cats? (a) Ventricular tachycardia (b) Weekly and after every code (a) 40 (b) Ventricular fibrillation (c) Daily and after every code (b) 30 (c) Asystole (d) Every other day and after every code (c) 20 (d) Pulseless electrical activity (d) 10 2. When assessing the unresponsive 10. An ETCO2 reading of greater than patient to determine if they are in 6. Basic life support should be _____ is associated with ROSC cardiopulmonary arrest, how long performed in _____ minute cycles should your assessment be? (a) 5 mmHg (a) 1 (b) 10 mmHg (a) 10–15 seconds (b) 2 (c) 15 mmHg (b) 15–20 seconds (c) 3 (d) 20 mmHg (c) 20–30 seconds (d) 4 (d) 30–45 seconds 11. Based on current evidence-based 7. What class of drug is adrenaline? medicine, what is the likelihood 3. What is the new algorithm for (a) Anticholinergic for ROSC? providing basic life support? (b) Anti-arrhythmic (a) 45–50%% (a) ABC (c) Catecholamine (b) 35–45% (b) CAB (d) Vagolytic (c) 25–30% (c) BCA (d) 15–20% (d) CCB 8. What two pieces of monitoring 4. What is the RECOVER- equipment are the MOST 12. Based on current evidence-based recommended compression rate for ­important during CPR? medicine, what is the survival to dogs and cats? (a) ECG and stethoscope discharge? (a) 120–140 (b) ECG and Doppler (a) 6% (b) 100–120 (c) ECG and pulse oximeter (b) 10% (c) 80–100 (d) ECG and capnography (c) 12% (d) 60–80 (d) 15% For the answers to the MCQs, please go to: http://www.bvna.org.uk/publications/veterinary-nursing-journal Page 212 VOL 34 August 2019 Veterinary Nursing Journal © 2019 British Veterinary Nursing Association (BVNA)