SAM Exam 4 - EEC

Triage Categories

• Category 1: Emergency: needs to be seen NOW

  • toxins, GDV, male cat no peeing, trauma, resp issues, diabetes, heart disease, 2+ seizures in 24hrs, paralysis, anaphylaxis, heat stroke

• Catagory 2: ASAP: needs to be seen today

  • toxins, pain, anorexia >24hrs, rapid decline, lethargy, bldy diharreah, swollen eyes

• Catagory 3: Routine: should be seen in 24-48h

  • chronic lameness, allergy’s, infections, non bleeding wounds, GIT upset

Fundamental history questions to ask the owner

• Topics: SAMPLE

  • Signs, Allergies, Medications, Past history, Last knowns, Events

• Phone: breathing? Conscious? Bleeding? Mobile? Open wounds/fractures? When did it happen? How far away? Do you know where clinic is? Transport? Explain triage process and emerg fee.

• Arrival: Contact? Pet info? Records? Authorization? What happened? When did it happen? Progression? Any care given prior? STAT consent? Last meal/BM?

Crash cart

• Contents:

  • Drugs: CPR medications and dosing charts

  • Airway: ET tubes, laryngoscope, ties, Ambu bag, stylets

  • IV supplies: syringes, needles, large flushes, clippers

  • Packs: thoracocentesis, pericardiocentesis, urinary catheter kits, laceration repair, tracheostomy

• Audit:

  • Restock every shift and check for functionality

  • Label and keep organized

CPR guidelines

• Training: CPR drills every 6 month, recover training

• CPR Stats: <6% of dogs and <20% of cat survive 

  • Timing is critical: 0.5 minutes = ROSC vs 1 minute

  • Catheter: improves ROSC 

• Recognize: absence of breathing, agonal breaths, no pulse

• Personnel: switch q2min to avoid fatigue 

  • 1: lead

  • 2: airway/breathing, intubate 

  • 3: compressions (30 bpm)

  • 4. Vascular access

  • 5. Drugs

  • 6. Monitor, pulses/rhythm checks

Primary and secondary survey and Minimum emergency database

• Primary Survey: ASAP

  • Airway: Patency?

  • Breathing: RR/effort, localize obstruction

  • Circulation: MM color, CRT, pulse, HR

  • Disability (brief neuro exam) & pain

• Secondary Survey: once stable

  • Minimum database: PCV/TS, Bld Glucose, Lactate, Acid base, Bld gas, Electrolytes, iCa

    • From catheter hub blood

  • Full PE, Neuro exam, BP, SPO₂, temp

SIRS criteria

• Use: triage alert system evaluating vitals

  • Limitations: Non-specific

• Criteria:

  • Dogs: ≥2 abnormal vitals

  • Cats: ≥3 abnormal vitals

    

Scoring systems in veterinary medicine

• Modified Glasgow Coma Scale (MGCS): Neurological scoring

• Animal Trauma Triage (ATT):

  • 6 categories (perfusion, cardiac, respiratory, neuro, skeletal, integument)

  • Higher score = worse prognosis

• SOFA: systemic organ failure assessment

Localization of respiratory

• Upper airway obstruction

  • Inspiratory dyspnea

  • Externally audible noise: stertor/stridor

• Lower airway obstruction

  • Expiratory dyspnea

  • Audible wheeze on auscultation not externally audible

• Pulmonary parenchymal disease

  • Inspiratory and expiratory efforts may both be increased

  • Increased or wet lung sounds, crackles, harsh lung sounds

• Pleural space disease

  • Paradoxical chest wall movement

  • +/- Fast and shallow breathing

  • Quiet or decreased lung sounds

Shock

• MOA: inadequate cellular energy production

• Hypovolemic: Loss of volume circulating

  • CS: tachycardia (not cats), pale, CRT >2, poor pulse, MAP <60mmHg(severe)- unable to palpate pulse

  • Hypothermic: <98F, Hyperthermic: >102.5 F

  • TX: Buffered isotonic fluids

• Cardiogenic: decreased forward flow from the heart 

• Distributive: decrease in or increase in SVR or maldistribution of blood

• Metabolic: deranged cellular metabolism

• Hypoxemic: decreased 0² content

• Septic: subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality

Blood pressure

• Doppler

  • Gives only systolic pressure

• Oscillometric

  • Gives systolic, diastolic and mean pressure

• Invasive

  • Catheterization of dorsal pedal or femoral artery

• Normal:

  • Systolic: > 90-140 mmHg

  • Diastolic: 50-80 mmHg

  • Mean: 70-100 mmHg

Vascular access options

• Peripheral IV

• Jugular IV

• Intraosseous (IO)

Minimum database

• PCV/TS – must interpret PCV with TS!

  • both decreased: hemorrhage

  • Decreased PCV w/ normal TS: RBC issue

• Blood glucose

• Lactate

• Blood gas/acid-base

• Electrolytes

• iCa

  ALL this can be obtained from Catheter hub!

Fluid resuscitation

• Isotonic crystalloids for resuscitation

• Avoid colloids and hypotonic fluids in early phase

• Fluids: Buffered isotonic IV fluid bolus

  • 5–10 mL/kg (cats), 15–20 mL/kg (dogs) over 15-30 mins

  • Colloids and hypotonic fluids contraindicated

• Monitor fluid responsiveness

Lactate/lactate clearance

• by-product of anaerobic glycolysis

• Normal: < 2.5 mmol/L

• High: inadequate perfusion (Type A) or cellular metabolism dysfunction (Type B)

  • Persistent elevation = worse prognosis

• Use: Serial measurements can guide fluid therapy

Blood glucose

• Hypoglycemia:

  • MOA: Collapsed/mentally altered patients, Neonates, Diabetics

  • TX: 2.5% Dextrose bolus

    • Easy to test and fix!

SPO2

• Cyanosis late indicator for hypoxemia

  • SPO2 < 95 % = PaO2 < 80 mmHg

  • SpO2 90% = PaO2 60 mm Hg

Point of care ultrasound

• Done Before x-rays

• Done in lateral or standing

• Use: Detect fluid, pneumothorax, effusion before rads

  • Not for resp distress patients

  • Take DV views not VD

    • NOT in a patient in respiratory distress

• AFAST: 4 quadrants (liver, bladder, spleen, kidneys)

  • REPEAT once fluid resuscitated

• TFAST: Pericardial, pleural, diaphragmatic views

The role of low stress and fear free handling in the ECC patient

• Reduces worsening of respiratory distress and shock

  • Oxygen in carrier

  • Gentle restraint

  • Sedation if needed

Pain relief

• Give 1st!!

• Key part of stabilization

• Opiates are first line

  • no NSAIDS

• Lidocaine: good for motility, adjunctive analgesia, VPCs

• Ketamine: good for wind up and visceral pain relief 

  • pancreatitis

Kirbys rule of 20

• Critical parameters that should be evaluated at least daily in all critically ill animals

  1. Fluid Balance, Electrolytes

  2. Oncotic Pull/Albumin

  3. Glucose

  4. Acid-Base Balance

  5. Oxygenation and Ventilation

  6. Neurologic Status, Renal Function, immune status 

  7. Blood Pressure, Heart Rate, Rhythm, and Contractility

  8. Temperature

  9. Coagulation, RBC/Hemoglobin Concentration|

  10. GI Motility, Mucosal Integrity, Nutrition

  11. Drug Dosages and Metabolism

  12. Pain Control

  13. Wound Care and Bandages

  14. Loving Care

Timing for emergency surgery

• When: stabilized for 24–48h first

  • Exceptions: Hemorrhage, GDV, septic peritonitis, perforation

• Client Comm: Discuss timing with owners in context of stability and urgency

Body water distribution

• 60% of BW is water

• ICF: 40% BW, 2/3 TBW

• ECF: 20% BW, 1/3 TBW

• Electroneutrality: ∑ cations = ∑ anions

  • Na⁺ + K⁺ + UC = Cl^- + HCO₃^- + UA

  • UA – UC = Anion Gap

Regulators of water balance

• Kidneys: Na and volume

• Volume Receptors: Cardiopulmonary circulation, carotid sinus, aortic arch, kidneys

• Effectors of Circulating Volume: sympathetic nervous system, renin/angiotensin, renal Na excretion

Body’s response to Blood Loss

• Phase I: within 1 hr of hemorrhage, movement of fluid from interstitium into intravascular space

• Phase II: Activation of R-A-A-S system: Na retention

• Phase III: Bone marrow begins to increase production of RBC’s

  • occurs within a few hours of blood loss, takes 7 days

2024 AAHA Fluid therapy guidelines

• Takaways: Compartmentalize your thinking, one fluid rate does not fit all, don’t overload

• Actions: Don’t set it and leave it, choose a fluid administration route 

• Remember: Fluids are drugs

Individualized and goal directed fluid therapy

• 1 Recognize which fluid compartment deficit(s) exists

  • Intravascular, intracellular, interstitial

• 2 Understand which fluid type and administration route will best replace each deficit 

  • Kidney issues, toxins

  • IV, SC, IP, IO Enteral

• 3 Calculate the fluid dose and administration rate

  • Resuscitation, Rehydration, Maintenance

• 4 Monitor patients for response to therapy and signs of complication

  • BW, Temp, PR, MM, CRT, RR, Skin turgor, Auscultation, Mental status, Urine output, PCV/TS, Serum lactate, USG, BUN, Cr, BP, Bld gas, O²

Assessment of interstitial space

• MOA: assessed as dehydration

  • excessive panting, vomiting, diarrhea, diabetes

• CS: skin tent, MM, retracted globes, dull corneas

Physical findings in dehydration

• <5%: none

• 5-6%: decreased skin turgor 

• 6-8%: decreased skin turgor, dry MM

• 9-10%: decreased skin turgor, dry MM, retracted globes

• 10-12%: persistent skin tent, dry MM, retracted globes, dull corneas

• >12%: death, shock

Assessment of intravascular space

• History

  • Hypovolemia: excessive bleeding, severe burns, severe diarrhea or vomiting, kidney disease, or inadequate fluid intake

  • Hypervolemia: fluid overload, PD, salt intoxication, osmotic agent admin 

• Cardiovascular: HR, CRT, pulse quality, BP, ECG

  • Hypovolemia: MAP: >80 = mild, >60 moderate, <60 severe; arrhythmias 

  • Hypervolemia: hemodilution, arrhythmias

• Imaging: POCUS

  • Hypovolemia: Collapsibility index >27%, microcardia, small vasculature

• Hypervolemia: ascites, effusion, Collapsibility index <27%

Addressing hypotension

Situational fluid therapy

• Resuscitation

  • Rx: Buffered isotonic IV fluid bolus

  • Dose: 5–10 mL/kg (cats) or 15–20 mL/kg (dogs) over 15–30 min

• Replacement

  • Dose: L = BW (kg) x %D

    • 12–24 hr SQ

• Maintenance

  • Dose: 30 x BW (kg) + 70 = mL/kg/day

Crystalloids

• Isotonic: hypovolemia, anaphylaxis, dehydration, always good 1st step

  • 0.9% NaCl: No added K, Mg, Ca, dextrose, buffers

  • Plasma-lyte: added K, Mg, acetate, gluconate 

    • No added Ca, dextrose

  • Normosol R:  added K, Mg, acetate, gluconate 

    • No added Ca, dextrose

• Hypertonic:

  • 5.0, 7.5, 23.4% NaCl: No added K, Mg, Ca, dextrose, buffers

• Hypotonic: 

  • Plasmalyte 56% w/ dextrose: added K, Mg, acetate, dextrose

    • No added Ca

  • 0.45% NaCl: No added K, Mg, Ca, dextrose, buffers

  • 0.45% NaCl w/ dextrose: added dextrose

    • No added K, Mg, Ca, buffers

  • Dextrose in water: added dextrose

    • No added Na, Cl, K, Mg, Ca, buffers

  • Normosol M w/ dextrose: added K, Mg, acetate, dextrose

    • No added Ca, buffers

Colloids

• Natural: blood, albumin, fresh frozen plasma

• Artificial: hetastarch, vetstarch, dextrans

  • Risks: AKI, coagulopathy, delayed platelet closure time in dogs. 

    • Banned by FDA in people

• Contradictions: bleeding, inflammatory states, anaphylaxis

Replacing interstitial and intravascular volume

• Hypovolemia: 5-10mL/kg (cats) or 12-20mL/kg (dogs) over 30 min of buffered isotonic fluid IV

  • IV moves from vascular to interstitial 

• Dehydration: buffered isotonic fluid over 24hrs IV, oral, SQ

  • IV moves from vascular to interstitial to intracellular

• Determines patient “fluid responsiveness”

  • Infusion of a rapid bolus of small volume

  • 10 – 20 ml/kg

Anesthesia fluid guidelines

• Indications: renal disease, recovery optimization in heathy patients

• IVFT rates = 5ml/kg/hr (dogs) or 3ml/kg/hr (cats)

Recognize signs of fluid overload

• MOA: Aggressive fluid therapy

• CS: hypervolemia, edema, cavitary effusions, BW increase >10%, discharge, murmurs, distention, low SPO2, loss of serosal detail, enlarged veins/arteries, decreased collapsibility index

Appropriate management of an IV catheter

• Use: Lg bore and short cannula

• Steps: aseptically prep, secure

• Maintenance: check 2x per day, clean when disconnecting

Acid/base Definitions

• Acid: molecule that donates a H+

• Base: molecule that accepts a H+

• Buffer: weak acid/base that protects against pH changes

  • EC: bicarbonate

  • IC: PO4, proteins, hemoglobin

Blood gas analysis

• Respiratory 

  • Arterial blood gas: O2(paO2)

  • Venous blood gas: CO2

• Metabolic: HCO3

Anion Gap

• Increase in serum lactate, ketoacids, uremia

  • Alkalemia

• (Na⁺ + K⁺ + UC) - (Cl^- + HCO3^- + UA) = 10-20AG

• High: low UC, high UA

• Low: high UC, low UA

  • Acidosis

Metabolic acid/base disturbances

• Acidosis: Low pH, Low HCO³

  • Myocardial contractility decreases if pH < 7.2

  • Venous vasoconstriction, Arterial vasodilation

  • ↑ AG: EG toxicity, Salicylate toxicity, DKA, Uremia, Lactic acidosis

  • Normal AG: Diarrhea, Carbonic anhydrase inhibitors, Dilutional acidosis, Addison’s, Posthypocapnic metabolic acidosis

    • Hyperchloremic

  • Compensation: hyperventilation, ↓ PCO²

• Alkalosis: High pH, High HCO³

  • Arteriolar vasoconstriction, Decreases stroke volume, less oxygen delivery to the tissues

  • MOA: Vomiting, diretics, heart failure, renal dx, crons dx, Alkali administration, cushings

    • Cl resistant: addisons, cushings

  • Compensation: low RR to increase CO^2, urine is alkaline

Respiratory acid/base disturbances

• Acidosis: Low pH, High PCO²

  • MOA: asthma, COPD, opiates, heat stroke, high ICP, MG, paralysis

  • Compensation: renal retention for ↑ of HCO₃

• Alkalosis: High pH, Low PCO²

  • MOA: hypoxia, fever, anxiety, Pulmonary dx, anemia, pain

  • Compensation: renal excretion for ↓ of HCO₃

Simple vs. mixed acid/base disturbances

• Simple: There is a primary disorder and there is an adequate compensatory response

  • Lungs: Excretion of CO2

    • Rapid compensation

  • Kidney: Reclaim filtered bicarb, excrete acid

    • Slow compensation

• Mixed: Two separate primary disorders are occurring and compensation is inadequate or there is “overcompensation”

Osmoles

• Ineffective: does not generate osmotic pressure or an influx/efflux of water

• Effective: does exert osmotic pressure

  • does not freely cross membranes

  • Effective ECF osmolality (mOsm/kg) = 2 x Na⁺ + [glucose]/18 + [BUN]/2.8

Hyponatremia

• Dog: <140, Cat: <147

• Hypervolemic: increase in TBW, CHF, liver dx, nephrotic syndrome, renal failure

• Normovolemic: PD, myxedema coma, hypotonic fluids, SIADH

• Hypovolemic: addisons, GI loss, third-spacing effusion, renal dz

• CS: Abnormal mentation, ataxia, seizures, CNS deficits, edema

• TX: 1mmol per hour

  • ≤10 mmol/L over 24 hours

    • Watch for Osmotic demyelination with chronic (>48hr) correction: CS takes days to occur

Hypernatremia

• Dog: >155, Cat: >162

• Hypervolemic: prolonged replacement fluids, salt toxicity 4g/kg. 

  • CS: Tachycardia, weak pulse, prolonged CRT, anorexia, Lethargy, Vomiting/diarrhea, Behavior change, Ataxia, Seizures , Coma, renal

• Normovolemic: hypodipsia, diabetes insipidus

  • CS: PU/PD, norexia, Lethargy, Vomiting, Behavior change, Ataxia, Seizures , Coma

• Hypovolemic: Vomiting, diarrhea, third spacing, burns, CKD, post obstructive diuresis, excessive water loss

  • CS: Tachypnea, respiratory distress, pulmonary edema, norexia, Lethargy, Vomiting, Behavior change, Ataxia, Seizures , Coma

• Pheudo: hyperglycemia 

• TX:  Up to 1 mmol/L/hr if acute (<24hrs), <12 mEq/L per day if chronic (>24hrs), LR, plasmalyte A, Normosol R, 0.9% NaCl

  • No 0.45% NaCl

  • Shock: Expected change in [Na] with 1 liter of fluids = (Fluid [Na + K] – Patient [Na])/(TBW + 1)

    • TBW = BW× 0.6

  • Stable:

    • FWD (in liters) = {(Patient [Na] – Target [Na])/Target [Na]} × TBW

      • Target [Na] = Midrange of the reference interval

    • FWD acute = Patient [Na] – Target [Na] 

    • FWD chronic = 2(Patient [Na] – Target [Na] )

Potassium

Normal: 3.5-5.5 mEq/L

Hypokalemia

• MOA: diet, NaCL/D5W fluid therapy, AlkalemiaInsulin, insulin/glucose, hypothermia, albuterol toxicity, Hypokalemic myopathy of Burmese kittens, vomiting, diarrhea, CKD, Post-obstructive diuresis, Hyperadrenocorticism, Hyperaldosteronism, diuretics, penicillin, rattlesnake antivenom 

• CS: Ventral neck flexion, arrhythmias, PU/PD, poor urine concentration

• TX: <0.5 mEq/kg/hr K MAX !! & label IV bags

Hyperkalemia

• MOA: CKD, urinary obstruction, addisons, puedo from translocation, whipworms  

• CS: slow HR, prolonged QRS, atrial stand still, high T aves, short Q-T interval

  • Do not rely on ECG or bradycardia to tx, not reliable

• TX: LRS, Normosol R, insulin @ 0.25-0.5 u/kg, Calcium gluconate 10% @ 0.5-1 ml/kg if bradycardic, albuterol 

Chloride

• Most abundant anion in ECF, produced in GIT, reabsorbed in the renal tubules

• Normal Dog: 110, Cat: 120

Hypochloremia

• MOA: pseudo w/ lipemic samples, diuretics, vomiting, GI dx, thiazine/diuretic therapy, chronic resp acidosis, hyperadrenocorticism 

• TX: 0.9 % NaCl + buffered isotonic crystalloid

Hypercholermia 

• MOA: KBr, diarrhea, diet, salt poisoning, renal failure, diabetes mellitus, chronic resp alkalosis, hypoadrenocorticism, fluid therapy 

• TX: avoid NaCl, oral bicarb, discontinue iatrogenic fluids

  • HCO₃⁻ deficit = Weight (kg) × {Desired [HCO₃] – Patient [HCO₃]} × 0.3

Phosphate

• Most important intracellular anion

  • maintaining calcium balance

Hypophosphatemia

• MOA: DKA tx, insulin, resp alkalosis, TPN, PPN, refeeding, hyperparathyroid, rena; tubu;ar dysfunction. Eclampsia, vomiting, malabsorption 

• CS: erythrocytes fragility, hemolysis, poor WBC function, muscle weakness, poor platelet aggregation, pain due to rhabdomyolysis, seizures, coma, vomiting, ileus, diarrhea

• TX: 0.01-0.06 mmol/kg/hr for 12hrs perenteral, prevention is best!

Hyperphosphatemia 

• MOA: tumor cell lysis, tissue trauma, rhabdomyolysis, hemolysis, metabolic acidosis, PO4 enemas, Vit D toxicity, Kphos administration, renal failure, hypoparathyroidism, hyperthyroidism

• CS: Tremors, hyperthermia, seizures, tetany

• TX: Balanced isotonic IVFT, dietary restriction, phosphate binders

Calcium

• 99% of Ca stored in bone

  • Regulation via kidneys and GIT

  • Regulates: Parathyroid gland, Kidney, thyroid C cells

Hypocalcemia

• MOA: CKD, pancreatitis, ↓ albumin, hypoparathyroid, ethylene glycol toxicity, artifact, eclampsia

• CS: anorexia, facial rubbing, growling, nervousness, twitching, stiff gait, tetany, seizures

• TX: 10% calcium gluconate @1–1.5 mL/kg over 10/30min slowly, monitor on ECG 

Hypercalcemia

• MOA: malignancy, idiopathic, hyperparathyroid, kidney dx, addisons, granulomatous inflam, toxins 

• CS: PU/PD, uroliths, incontinence, prerenal azotemia, dehydration, anorexia, vomiting dihharea, depression, weakness, twitching, muscle wasting, bradycardia, arrhythmias 

• TX: 0.9% saline, LR, Plasmalyte, normosol R, furosemide, calcitonin, dex, pred, bisphosphonates

Hypomagnesemia

• Kidneys control and regulate Mg balance

  • Majority of absorption is in the loop of Henle

  • maintaining resting cell membrane potential

• MOA: ↓ protein, ↓ intake, ↓ absorption, colitis, short bowel, diuretics, aminoglycosides, kidney dx, insulin, hypoparathyroid, refeeding syndrome 

• CS: ventricular arrythmias, ↓BP, neuronal excitability, can see refractory ↓ Ca and K

• ECC TX: 0.15-0.3mEq/kg for 1 hr

Important electrolytes

• Magnesium

  • ID: ICF cation

  • Role: enzymatic rxn, muscle contractions, PTH production

  • Physio: kidneys reg, ileum absorbs  

• Potassium

  • ID: ICF cation

  • Role: maintaining resting cell membrane potential

    • Low increases potential (more -/polarized) and vise versa

• Sodium

  • ID: ECF cation

  • Role: determines ECF volume

  • Physio: glomeruli filtered, absorbed in tubules  

• Chloride

  • ID: ECF anion 

  • Physio: produced in gastric acid, absorbed in intestines, filtered by kidneys 

  • Role: determines metabolic acidosis

    • hyperchloremic = normal AG

    • Normochloremic = high AG

• Phosphate

  • ID: ICF anion 

  • Role: cell structure/function, O2 delivery, ATP, cAMP

  • Physio: GIT absorbs, kidney regulates, opp relationship w/ Ca

    • high Ca = low Phos

• Calcium

  • Role: Enzymatic rxn, transport, stability, Coagulation, Neuro, Vascular tone, Muscle contraction, Bone formation, metabolism

  • Total Ca: 9-11.5mg/dl (dogs) or 8-10.5 mg/dl (cats)

  • Ionized Ca: 56% of plasma, bio active

Blood pressure Monitoring

Direct: Gold standard

• Indications: hypovolemic/septic shock, CHF, vasopressors, mechanical ventilation, severe hypertension, high anesthetic risk

  • NOT indicated in healthy, ambulatory patients 

• BP = (HR x SV) x SVR

• MAP = (SBP-DBP)/3+DBP

• Indirect: 

  • Doppler: Systolic BP

  • Oscillometric: Use: Systolic, Diastolic, Mean BP

  • Cuff: 40% of the limb circumference

    • Too sm elevates, too Lg decreases

Pulse oximetry

• MOA: Non-invasive measuring the oxygen saturation of Hb in arterial blood

• Normal: SPO2 98-100%,

  • >95% = <80 mmHg moderate hypoxemia

  • 90% = 60 mmHg severe hypoxemia

    • Cyanosis late indicator for hypoxemia

• Limits: pigmented MM, stress, movement, poor perfusion, thin tissue, anemia, lighting

• Benefits of pre-oxygenation

• Causes of hypoxemia

• Oxygen toxicity

• Cuve

Capnography

• Tells us: ventilation & cardiac output

• MOA: Continuous, noninvasive assessment of partial pressure of arterial CO2

• USE: ET tube placement, ventilation assessment, dead space estimate, CPR

  • For CPR: ETCO₂  >  10 to 15 mm Hg = ROSC

    • <10mmHg = poor outcom

• TYPES: 

  • Diverting (side-stream): from breathing system and measures CO2 in main unit 

  • Non-diverting (mainstream): directly in breathing system 

• Troubleshooting:

  • Cuff leak: narrow plateaus

  • Cardiac Oscillation: movement w/ HR seen in phase IV, no significance 

  • Zero: cardiac arrest, disconnection, obstruction, apnea test in brain death dead patient

CO2 dysregulation

Hypercapnia

• MOA: hypoventilation, fever, shivering, malignant hyperthermia, seizures

  • pCO2 > 50 mmHg = respiratory acidosis = cerebral vasodilation

• ID: capnography 

• TX: Increase RR , Increase Tidal Volume

Hypocapnia

• MOA: hyperventilation, hypothermia

• ID: capnography 

• TX: analgesia, deepen anastesia plane

  • Rule out cardiovascular/pulmonary cause FIRST

ECG

• How: flat clips and pads

• Reading: heart beat

  • P: atrial contraction (depolarization)

    • Tall P wave: RAE

    • Wide P wave: LAE

  • QRS: ventricular contraction (depolarization)

    • Tall R wave: LVE

    • Deep S wave: RVE 

  • T: ventricular repolarization

  • P-R interval: delay in AV node

Arrhythmias

• MOA: Abnormal impulse generation or propagation of sinus, atrial, or ventricular orgin

• ID: ECG + BP!!(#1) 

• CS: Syncope, weakness, decompensation of CHF, poor BF

• TX: 

  • Class I: Sodium channel blockers

    • A: quinidine, procainamide

    • B: lidocaine, mexilitine

    • C: flecanide

  • Class II: Beta blockers

    • propranolol, esmolol, atenolol

  • Class III: Potassium channel blockers

    •  sotolol, amiodarone

  • Class IV: Calcium channel blockers

    • diltiazem, verapamil

Sinus rhythms

• Tachycardia: pain, fear, stress

• Bradycardia

• Respiratory: HR low normal w/ irregular rhythm, high vagal tone, wandering pacemaker 

• Pause/arrest: fail to depolarize, cardiac dx, irregular rhythm, not a P for every QRS

  • TX: atropine, pacemaker

• Sick sinus syndrome: tachy/brady periods, cardiac dx

  • TX:Tachycardia w/ beta blockers, Bradycardia w/ pacemaker

Atrial rhythms

• Premature complex: normal QRS, abnormal P wave, no TX

• Tachycardia: Run of APC’s, atrial enlargement, disease, self limiting

  • TX: short acting beta blockers (esmolol)

• Flutter: fast HR, irregular, sawtooth p waves

  • TX: slow HR if increased

• Fibrillation: fast HR, no p waves, heart dx, DCM

  • TX: Ca channel blockers, beta blockers, digoxin

• Standstill: slow  HR, no p waves, hyperkalemia

  • TX: atropine, glycopyrolate, pacemaker

• Systole: no conductivity, cardiac arrest, flat line

  • TX: CPR

Ventricular rhythms

• Premature complex: abnormal QRS, no TX

• Tachycardia: high HR, irregular, no P for every QRS

  • TX: Lidocaine (AVOID WITH CATS)

  • Most concerning

• Fibrillation: no PQRS, Non-perfusing rhythm

  • TX: defilation

Rhythms involving the AV node/junctional arrhythmia

• Supraventricular Tachycardia: normal QRS, p wave present, fast HR

• AV block: bradycardia

  • 1d: Prolonged PR interval > 0.2 sec, all P waves get through

• CS: asymptomatic, no TX

• 2d: some p waves get through

  • Mobitz type I: Increasing prolongation of PR interval

  • Mobitz type II: PR interval consistent

• 3s: No P waves, complete dissociation, symptomatic

  • TX: pacemaker

Basic Life Support

• Ventilation 

  • Rate: 1 breath per 6sec

    • Single rescuer: 30 bpm/2 breaths

  • Tidal volume: 10ml/kg

• Chest compressions

  • Hand placement

    • Round chest: Lateral recumbency, thorax pump

      • widest pt of chest

    • Keel chest: lateral recumbency, cardiac pump

      • between rib space 3-5

    • Small animal: cardiac pump

    • Wide chest: dorsal recumbency

  • Depth: 1/3-1/2 in lateral and ¼ in dorsal 

    • Switch out every 2 minutes to avoid rescuer fatigue

  • Rate: 100-120bpm

• Monitor: Use of ETCO2 as an early indicator of ROSC

  • >12mmHg= ETT is properly positioned

  • 18 mmHg: compression target

Advanced life support drugs

• Vasopressin/Epinephrine: standard low dose,

  • Epi: can repeat Cycle q 3-5 minutes(0.01 mg/kg)

• Atropine: give early, dont repeat, non shockable rhythms

  • Only give ONCE

• Lidocaine: ventricular antiarrhythmics, NOT cats

• Amiodarone: arrhythmias in cats/dogs

• Method: IV preferred 

• Reverse other drugs: naloxone (opitates), flymazel (benzo), Atipamazole (dex)

• Fluids: isotonic crystalloids in hypovolemic NOT euvolemic

Advanced life support tasks

• Defibulation

  • Biphasic NOT monophasic

  • Start @ 2J/kg then double if no rxn 

  • Before drugs if shockable rhythm 

  • Resume compressions 

• Open chest CPR: Lg round chest dogs, pleural dx, pericardial dx, unsuccessful CPR, sx patients

  • Contradicted in sm pets

• Monitor: Use of ETCO2 as an early indicator of ROSC

  • >12mmHg= ETT is properly positioned

  • 18 mmHg: compression target

Post cardiac arrest care

• Post cardiac arrest syndrome: anoxic brain, cardiac dysfunction, ischemia, reperfusion injury

• Hemodynamic optimization:

  • Therapeutic hypothermia

  • Titrate O2 to achive normal SPO2 

  • Manage seizures

  • Maintain normal glucose, CO2, lactate

Pericardial effusion

• Causes: neoplasia (#1), idiopathic (goldens), bleeding disorders, CHF (cats), rupture

• CS: diarrhea, weakness, episodic collapse, staring 

• ID: US heart (TFAST/POCUS)

• TX: if tamponade, pericardiocentesis immediately, limit stress, NO restraint

  • Do not Xray until AFTER pericardiocentesis

  • Right lateral w/ 6G 2’-4G 5’ needle into thorax

  • Apply suction and bld should come back

  • Monitor + recheck >6hrs, rescan w/ US

Acute abdomen

• CS: vomiting, regurgitation, doharrhea 

• CBC: stress leukogram

• BioChem: 

  • Hypoalbuminemia, hypocholesterolemia, ionized hypocalcemia

  • AKI: high BUN/Crea

  • Sepsis, Addisons: Hypoglycemia

• Rads: VD orthogonal views 

  • GVD, FB, pneumoperitoneum, pneumonia, megaesophagus 

• US: POCUS before rads of diaphragmatic hepatic, splenorenal, cystocolic, pleno-umbilical, hepatorenal views

  • Peritoneal effusion, FB, Pancreatitis, Pyometra, Masses

Abdominocentesis

• How: US guided or 4quad method

  • Cytology: Degenerate neutrophils, neoplastic cells, intracellular bacteria

  • TP: Transudate, modified transudate, or exudate

    • Refractometer

• Results:

  • Transudate: TP<2.5, NCC <100

    • Hypoproteinemia, low COP, high hydrostatic pressure

  • Modified: 2.5-5TP, NCC 500-10,000

    • Increased vascular permeability

  • Exudate: >3TP, >5000

    • Sterile vs non-sterile, FIP, chyle, neoplasia, pancreatitis

Drugs for GIT disorders

• Antiemetics/Gastroprotectants: Maropitant (#1), H2 blockers (famotidine, pepsid), PPI (omeprazol), carafate (req ulcers to work)

• Prokinetics: movement, Metoclopromide, Cisapride, Ranitidine, Erythromycin, Lidocaine

  • For ileus, not for obstruction

Surgical GI conditions

• GDV

• Small intestinal FB

• Intussusception

• Septic peritonitis

• Hemoabdomen

• Mesenteric torsion

• Pyometra

• Dystocia (medical and surgical treatment)

• Esophageal FB

Medical (non surgical) GI conditions

• Hypoadrenocorticism

• Pancreatitis

• Diabetic ketoacidosis

• Hemorrhagic gastroenteritis

Gastric dilation and volvulus (GDV)

• MOA: Lg, deep chested dogs 

• CS: Unproductive retching/gagging, shock, dehydrated, distended, tympanic abdomen, abdominal pain 

• ID: double bubble’ pylorus on rads, hypovolemia, high lactate 

• TX: SX to flip stomach(gastropexy), gas decompression, antibiotics, aggressive fluid resuscitation

Small intestinal FB

• MOA: younger, perforated or obstructive mass

• CS: Vomiting, possible lack of bowel movement, dehydrated, hypovolemic, abd pain, may palpate the FB

• ID: abdominal rads/US (bowel dilation x2 portions)

• TX: SX to remove, antibiotics, GI meds, fluids

Intussusception

• MOA: parasites, viral, bacti, FB, prior sx w/ addhesions

• CS: vomiting, diarrhea, abdominal mass, dehydrated, hypovolemic, abd pain, GI parasites known, mass palpable

• ID: SNAP for parvo, rads, abdominal US (double wall telescoping intestine), low albumin 

• TX: SX repositioning, antibiotics,  anthelmintics, GI drugs, fluids

Pyometra

• MOA: female intact dogs w/ prior heat > 6 months ago or unknown

• CS: Dehydrated, hypovolemic, discharge, sepsis, abd pain, febrile 

• ID: rads/US caudal abdomen mass cranial to bladder, PROFOUND leucocytosis

• TX: antibiotics, spay

Septic peritonitis

• MOA: Perforated foreign body, ruptured mass, ruptured gastric ulcer

• CS: Dehydrated, hypovolemic, abd pain, mentally altered 

• ID: loss of serosal detail w/ rads, abdominal US, Hypotensive, Hypoglycemic, Hypoalbuminemic, high BUN/Crea

• TX: SX to reduce, fluids, GI drugs, antibiotics

Hemoabdomen

• MOA: traumatic, neoplasia, Rodenticide, anaphylaxis

• CS: Pale mm, anemic pulses, hypovolemic, distended abdomen, labored breathing, may palpate mass

• ID: mass effect + loss of serosal detail on rads, abdominal US, Low TS, PT/PTT is prolonged 

• TX: Sx remove spleen, fluids, GI drugs, blood

Mesenteric torsion

• MOA: GSD, Lg dogs 

• CS: Vomiting, lg volumes bloody stool, severe shock, severe pain 

• ID: gas dilation on rads and abdominal US

• TX: Aggressive supportive care + surgery, fluids, analgesia, GI drugs, antibiotics, Ischemia/reperfusion

Dystocia

• MOA: Difficult birth, common in toy breeds, bulldogs, mastiffs, etc.  

  • Maternal: Anatomic abnormalities

  • Fetal: fetal oversize, fetal malposition, fetal death

• CS: no birth 36hrs of temp drop, >30min intervals w/ myometrial contractions or >2hrs w/o, labour lasting >24hrs, active labor >4hrs no fetus produces, contractions >60min w/ no fetus produced 

• TX: oxytocin, Ca gluconate, Dextrose, manual manipulation, C-section if ill or not progressing

Esophageal FB

• CS: Pain with a change in posture or head carriage, drooling, regurgitation, excessive swallowing, anorexia, aspiration pneumonia 

• Chest x-rays

• TX: blind removal, endoscope, surgery, thoracotomy is indicated if perforation occurs.

Hypoadrenocorticism / Addisons

• MOA: poodles

• CS: Dehydrated, hypovolemic, abd pain, mentally altered 

• ID: High k, Low Na, Low Glucose, high Ca, lack of stress leukogram, Baseline cortisol, ACTH stim

• TX: fluid, steroids ASAP (pull bld and give), Mineralcorticoids

Pancreatitis

• MOA: high fat food

• CS: Vomiting, diarrhea, decreased appetite, Dehydrated, hypovolemic, abd pain

• ID: abdominal US w/ sterile exudate, TFAST w/  pleural effusion, Hyper or hypoglycemic, Hypoalbuminemic, high BUN/Crea, may have DM

• TX: fluids, analgesia, GI meds, Prokinetics Corticosteroids, NE tube, bland diet

  • Avoid NSAIDs because of high risk for AKI !!

Diabetic ketoacidosis

• CS: Vomiting, decreased appetite, diarrhea, dehydrated, hypovolemic, can be mentally altered, kussmal breathing

• ID: Hyperglycemia (point of care), ketones, UA, UCS, AUS and CXR

• TX: Fluids, insulin, electrolyte support, GI meds, Antibiotics NE tube

Hemorrhagic gastroenteritis HGE

• MOA: sm dogs

• CS: dietary indiscretion, vomiting, hemorrhagic diarrhea, dehydrated, hypovolemic, abd pain, mentally altered

• ID: abdominal US, Hypotensive, Hypoalbuminemic, high BUN/Crea, Hemoconcentration w/ low TS(PCV >55), Parvo snap

• TX: fluids, analgesia, NG tube, GI meds, antibiotics, anthelmintics

Heat Related Illness

• Presentation: Hypovolemic, distributive shock

• Heat exhaustion: Dizziness, headache, nausea, weakness, unsteady gait, muscle cramps fatigue

• Heat stroke: Change in mental status, loss of consciousness, and a core body temp >104 F

  • Multiple organ failure occurs 107°-109°F

• ID: Shock, high PCV, high PLT,  increased LES, AKI, electrolyte derangements, hypoglycemia, Rhabdomyolysis, DIC

  • owners may have cooled, temp may not reflect

• TX: cold water immersion, evaporative cooling, crystalloids fluids, O2 for all dogs, FF plasma if coagulation issues, fans, ice packs

  • Dogs: crystalloid boluses of 10–20 ml/kg

  • Cats: crystalloid boluses of 5–10 ml/kg

    • Cool first transport second

    • Goal = 103F, stop cooling down

    • Avoid ice water: causes vasoconstriction

    • Add antibiotics if hypoglycemic, GI distress, sepsis, low WBC, aspirated pneumonia

• Time-dependent: 10-20 days, 2 months for complete

  acclimatization

• Effects: CNS, Renal, GIT, Cardio, Respiratory

Anaphylaxis

• Path: 

  • IgE (type 1): no initial rxn, immediate rxn w/ repeat exposure

  • IgG (type II-IV): no prior exposure needed for rxn

  • Mediated: mast cells/basophils w/ histamine, Liver/GIT in dogs, resp in cats

• CS: acute low BP, resp distress, multi system involvement

  • Cutaneous only is NOT anaphylaxis

    • Crazy high ALT

• TX: Fluids, Epi, O2 in cats, antihistamine, Glucocorticoids(dex), bronchodilators 

  • Epi: Vasoconstriction, bronchodilation, increase cardiac output, do not give subQ

  • H1+2: (1) diphenhydramine, chlorpheniramine, cyproheptadine,(2) famotidine, ranitidine, and cimetidine

  • Bronchodilators: albuterol, Aminophylline

Burns

• Superficial Burns (1d): epidermis

• Partial-thickness Burns (2d): Epidermis + dermis

  • CS: blisters, drainage, scaring 

• Full-thickness Burns (3d): epidermis + dermis + SQ

  • 4d: muscle/tendon involvement 

  • CS: charred, lacks sensation, less painful, scaring, shock, systemic dx

• Rule of 9 BSA eval: head+neck (9%), front leg (9%), chest (9%) abdomen (9%), ½ back (9%), ½ back leg (9%)

• TX: dressings, pain relief, fluids, oncotic support, nutrition

Sepsis

• Path: organ dysfunction from dysregulated host response to infection 

  • Vaso disregulation -> inflam imbalance -> microcercuation dysfunction -> coagulation dx -> immune downreg -> MODS

• MOA: bacti, viral, fungi, bugs, GI perforation (dogs) 

• CS: MM, CRT, HR/RR/temp changes, altered mentation, low BP, hypovolemic/vasodilatory shock, hypoglycemia, peritonitis

• ID: Leucocytosis, leukopenia, low PLT, anemia (cats), high bilirubin/BUN/Crea, Low albumin/Ca, 

  • SIRS (TPR), SOFA, qSOFA, BP, MDB: Lactate, PCV/TP, BG

• TX: crystalloid fluids, antibiotics (<1h), vasopressors (, norepi <6h), hydrocortisone, gastroprotectants, nutrition, physio, SX (<12h)

Acute kidney injury

• Pre-renal: reduced BF, >1.030

  • hypotension, shock

• Intrinsic Renal: kidney injury, 1.005-1.030

  • Lepto, ethalyne glycol, grapes, lilies, NSAIDs, antibiotics, lyme

• Post-renal: increased kidney pressure <1.030

  • urinary tract obstruction

• CS: PU/PD, lethargy, hyporexia, anorexia, vomiting, stranguria, bradycardia, neuro signs 

• ID: Differentiated with USG, Oliguria < 0.5ml/kg/day

• TX: fluids, diretics’, antibiotics

Urethral obstructions

• MOA: water intake, stress, diet, infection

• CS: Pollakiuria, Dysuria, Stranguria, Hematuria, Pigmenturia, Vomiting, Lethargy, Abnormal posture, Vocalization

• ID: palpate (do not try and express), POCUS for rupture, rads for cystoliths, hyperkalemia 

• TX: buprenorphine (pain), Gaba (stress), fluids, unblock, Ca gluconate/insulin/dextrose/Terbutaline (hyperkalemia)

  • Unblocking: Male Cats: emergency

    • Cats: Catheters w/ rads after, freeze red rubber, decompressive cystocentesisclip lg, sterile prep, pull urethra to straighten, lube, flush

    • Dogs: catheters, Pulling the legs back or forward away, flush vestibule 

      • UTI risk dogs>cats

Ureteral obstruction

• CS: Abdominal pain, hydronephrosis, AKI, azotemia, hyperkalemia, metabolic acidosis

• ID:US, rads

• TX: suburethral bypass device (SUB) placement

Uroabdomen

• MOA: Secondary to severe UO or trauma

• ID: FF present, azotemia, hyperkalemia, contrast radiographs

  • Potassium fluid to blood ratio of >1.4:1

  • Creatinine fluid to blood ratio of >2:1

• TX: IVFT, Ca gluconate/insulin/dextrose/Terbutaline (manage hyperkalemia), Urinary divergence

Seizure Definitions

• Status epilepticus:  seizure > 3-5 minutes

• Cluster seizures: > 1-2 within 24 hours

Differential diagnosis for seizures

• Degenerative

  • Intracranial: storage diseases, several months old

• Anomalous: Young dogs more likely have infectious diseases, congenital malformations or toxins

  • Extracranial: insulin overdose, hunting dog exertional hypoglycemia 

  • Intracranial: hydrocephalus (chihuahua) 

• Metabolic

  • Extracranial: hypoglycemia, addisons, hypocalcemia, sepsis, hepatic encephalopathy/liver failure, erythrocytosis, severe anemia

• Nutritional, neoplastic: Old dog likely have neoplasia, Brachycephalic have gliomas, Dolichocephalics have meningiomas

  • Extracranial: paraneoplastic

  • Intracranial: primary neoplasia, secondary neoplasia

• Idiopathic (6m-6y), infectious, inflammatory: Toy/small dogs MUE common

  • Extracranial: sepsis

  • Intracranial: epilepsy, MUE,  Distemper, neospora, Toxo, FIP, rabies, FIV/FeLV, fungal, protozoal

  • Idiopathic head tremor/bob: English and French Bulldogs as well as Boxers is NOT a seizure

• Trauma, toxin: young dogs

  • Extracranial: Lead, Ethylene glycol, Organophosphates, /Carbamates, Pyrethroids, bromethalin, chocolate, illicit drugs, strychnine, metaldehyde, mycotoxins

  • Intracranial: penetrating wounds

• Vascular: Old dogs

  • Extracranial: systemic hypertension

  • Intracranial: systemic hypertension

Treatment recommendations for seizures

1. Midazolam

   • 5-10min

2. Levectram, Phenobarb

   • 10-30min

3. Ketamine, Dex, Phenobarb, Inhalant 

   • 30min

4. Third line: everything and the kitchen sink

When to consider MRIs in seizure cases

• Wait: 1st time in dog 1-5y w/ normal neuro exam 

• Go: 

  • 1st time in dog < 1 or > 6 years

  • Multi seizures over time

  • Lateralizing neuro deficits 

  • Cats: they are WEIRD 

    • aggression, dilated pupils, hypersalivation, vocalization

Monroe Kellie doctrine

• volume of brain parenchyma, blood, and cerebrospinal fluid is constant due to closed calvarium

  • High ICP squishes brain

Cerebral perfusion pressure equation

• CPP = Mean arterial pressure (MAP) – ICP

Cushing reflex

• MOA: head injury/bleeding, space occupying lesions 

• Physio: Increased ICP, high BP, Low HR, Dysregulated RR

• CS: Fatal, precedes brain herniation