AUTHOR: Dr Estee Van Zyl, veterinary internal medicine specialist and the head of the Internal Medicine Department at the Fourways Vet Hospital

For many veterinarians, cardiopulmonary resuscitation (CPR) is still performed as it was taught many years ago. In many veterinary practices, the laryngoscope is grabbed before beginning chest compressions, compressions are paused to place an intravenous catheter or endotracheal tube, and everyone assumes the veterinarian should lead the resuscitation effort. If this sounds familiar, then it’s time to rethink the way your team approaches CPR.

The Reassessment Campaign on Veterinary Resuscitation (RECOVER) guidelines challenged many of these long-held habits. Published in 2012 and updated recently, they remain the only comprehensive, evidence-based veterinary CPR guidelines and have fundamentally changed how cardiac arrest should be managed.

The message is simple: Survival is determined far more by how well we perform the basics than by how quickly we perform advanced interventions. This shift in thinking has fundamentally changed the way veterinary CPR should be performed.

Successful resuscitation is no longer viewed as a series of individual procedures. Instead, it is a carefully choreographed sequence of events in which every team member has a defined role, every interruption is purposeful, and every action is designed to protect uninterrupted chest compressions.

Preparedness starts before the patient arrests

One of the greatest determinants of CPR success occurs before a patient ever arrests. Every practice should have a well-stocked crash cart, clearly displayed emergency drug dose charts, readily available airway equipment and clearly defined team roles. Ideally, staff should rehearse these roles regularly through simulation training. The mobile RECOVER app acts as an excellent resource for drug dosage charts, CPR algorithms and practical guidance during a real- life or simulation event.

Basic life support is the priority

Perhaps the most important message from RECOVER is that basic life support (BLS) takes priority above all else.  The goal of successful CPR is not simply to restart the heart. Successful CPR is defined as a patient that survives to hospital discharge, with a good neurological outcome. The only way to achieve this is to maintain adequate coronary and cerebral perfusion throughout resuscitation. And the only way to generate this perfusion is through high- quality, uninterrupted chest compressions.

Every interruption in a two-minute chest compression cycle causes coronary and cerebral perfusion pressures to fall immediately. Once compressions resume, several additional compressions are required before these pressures are restored. In other words, any slight pause in this cycle, comes at a huge cost to the patient’s outcome.

This principle should change the way we approach every cardiac arrest. No intervention is more important than continuing this two-minute cycle of chest compressions. Veterinary staff should now learn to intubate patients in lateral recumbency whilst continuing compressions, and in no scenario should chest compressions be interrupted to prioritise placement of an intravenous catheter. Advanced life support (ALS) should always work around BLS — not the other way around.

CAB Replaces ABC

Most veterinarians were trained to follow the ABC approach to CPR where we begin resuscitation by prioritising Airways and Breathing, before Circulation. The RECOVER guidelines have fundamentally changed this sequence.

We now know that establishing effective circulation as early as possible is one of the strongest determinants of successful resuscitation. Therefore, RECOVER recommends that we should follow a ‘CAB’ approach in a multi- rescuer setting.

This means that rescuer 1 should immediately start an uninterrupted two-minute chest compression cycle, whilst rescuer 2 intubates the patient in lateral recumbency and initiates ventilation. Learning to intubate efficiently whilst compressions continue allows airway management to occur without compromising perfusion. Lateral endotracheal tube placement does involve a mild learning curve, making it an excellent example of why CPR should be practised before the emergency occurs.

Every arrest needs a team leader

Studies have shown that the presence of a clearly designated team leader improves CPR performance, regardless of whether that individual is a veterinarian or an experienced veterinary nurse. The team leader should not become involved in resuscitation but stand back from the patient and direct the resuscitation effort. By overseeing the team rather than becoming involved in individual tasks, the team leader improves coordination and ensures that every team member is focused on their assigned role.

Key responsibilities for the team leader include timing of the two-minute cycle, monitoring the rate and quality of chest compressions and ventilation, coordinating rhythm analysis, directing drug administration, and ensuring compressors are changed at the appropriate intervals.

Team cohesion is further improved through closed loop communication, where any instruction given by the team leader is acknowledged and verbally repeated back by the team member performing the task. This simple communication strategy reduces errors, prevents duplicated or missed interventions, and promotes a calm, coordinated resuscitation effort. Ultimately, the role of the team leader is to transform a potentially chaotic emergency into a coordinated, disciplined response — moving the team from chaos to cohesion.

Advanced life support supports basic life support

The most important principle to remember during CPR is that ALS should never compromise BLS. Once high-quality BLS has been established, other team members can begin implementing ALS while uninterrupted chest compressions continue.

Once high-quality BLS has been established, rescuer 3 can apply monitoring equipment, including an electrocardiogram (ECG) and end-tidal carbon dioxide monitor, while rescuer 4 attempts to obtain intravenous (IV) access. However, attempts to place an IV catheter should never interrupt a two-minute chest compression cycle.

If IV access cannot be established after the initial CPR cycle, intraosseous access should be considered the next route of choice. Intratracheal drug administration via the endotracheal tube remains a last-resort option when neither intravenous nor intraosseous access can be obtained.

The same principle applies to every advanced intervention: If it interrupts high-quality chest compressions, it should wait.

Notably, intracardiac adrenaline administration is no longer recommended. Besides interrupting CPR, it carries significant risks without evidence that it improves patient outcomes. The era of ‘stabbing the heart with adrenaline’ should remain firmly in the past.

The pause-and-check period: Keep it short

At the end of a two- minute cycle, the pause and check period is provided to swop compressors and to decide on next steps. All team members evaluate the ECG rhythms whilst a single team member palpates for the presence of a pulse. If there is no palpable pulse, chest compressions restart regardless of the ECG rhythm, whilst ALS interventions are prepared and implemented.

Importantly, there is no place for a stethoscope as auscultation results in delays, and delays result in poorer outcome. The pause-and-check period is not a time to perform multiple procedures—it is a brief, disciplined assessment before immediately returning to the intervention that matters most: High-quality chest compressions.

Drug therapy: Less is more

The RECOVER guidelines have also changed the way we use resuscitation drugs. While studies have shown that high-dose adrenaline may improve the short-term return of spontaneous circulation, it has also been associated with reduced survival to hospital discharge and poorer neurological outcomes.

For this reason, high-dose adrenaline is no longer recommended. Instead, low-dose adrenaline (0.01mg/kg IV) should be administered every second CPR cycle (about every three- to five- minutes).

The recommendations for atropine have also changed. Repeated administration has not been shown to improve outcomes and may increase myocardial oxygen demand and the risk of adverse cardiac effects. RECOVER therefore recommends administering a single dose of atropine (0.04mg/kg IV) during CPR for patients with non-shockable rhythms, rather than repeated doses throughout the resuscitation.

Ultimately, these changes reinforce one central message: Drugs are an adjunct to CPR, not the treatment itself. High-quality BLS remains the intervention most likely to influence patient survival.

Conclusion

The RECOVER guidelines have fundamentally changed the way veterinary teams should approach CPR. Their message is clear: Prepare before the arrest, prioritise uninterrupted high-quality BLS, and ensure every advanced intervention supports—not interrupts — effective chest compressions. By embracing this philosophy, we can give our patients the greatest possible chance of surviving cardiac arrest with a meaningful neurological recovery.

For a deeper look at veterinary CPR, including the latest RECOVER recommendations, team roles and practical approaches to resuscitation, read our article RECOVER first aid guidelines: Acting fast when every second counts.