Triage and Stabilization of Small Animal Emergencies

What are the 5 different stages of an emergency evaluation?

1) Telephone triage

2) Waiting room triage

3) Primary survey

4) Secondary survey

5) Emergency plan

What is the telephone triage stage important for?

Gathering initial information to form an action plan

• Establishing the current concern

• Advice on first aid and transport

• Directions to the clinic

• Pet and owner details

• Payment policy

REMEMBER: better to fully assess the patient in the clinic, rather than diagnosing over the phone

What are some questions you could ask over the phone to establish the main complaint?

• Level of consciousness?

• Difficulty breathing?

• Gum color?

• Current/history of seizures?

• Active bleeding or obvious fracture?

• Toxin ingestion?

• Can the animal walk?

• Is there abdominal distension?

• Can they pass urine?

What are some first aid preparations you can advise a client to do before they bring a patient in?  What about for significant bleeding, topical toxins, or heatstroke?

If they experienced trauma and are hurt → muzzle

If bleeding significantly → temporary pressure bandage

If exposed to topical toxins → wash off

If potential heat stroke → soak in cold water

What are 5 items of basic emergency preparation you will always want to have out?

1) Oxygen provision / ET tube

2) IV catheter setup

3) Basic monitoring tools

4) CPR equipment

5) Potentially US

What is the next stage in emergency evaluation once a patient gets to the clinic? Why is it important?

Triage in the waiting room

• Important for immediately identifying any life threatening abnormalities

  • Based on vital signs (airway, breathing, circulation)

• Includes a BRIEF history and CPR code status, and a brief physical exam

What are the first things you should examine when initially presented with an emergency case? State them in order…

1) Respiratory compromise

2) Circulatory compromise

3) Neurologic compromise

After the initial triage exam, you can then move on to your primary survey… what does this include? What is the goal?

This is a more detailed evaluation of the same physical parameters as the triage exam… SHOULD STILL BE QUICK, < 2 minutes

A → Airway

B → Breathing

C → Circulation

D → Demeanor

E → Entire body

Goal is to identify and stabilize life-threatening problems

When investigating the airway, what do you need to determine first?

Is there a patent airway?

Is the patient breathing? 

Is there stridor or stertor?

Are there signs of obstruction?

Say you have a patent airway… now you need to investigate their breathing. What are 5 things you need to determine in terms of their breathing/O2 levels?

1) Respiratory rate and effort

2) Auscultation (louder / quieter / abnormal sounds)

3) Mucous membrane color

4) Pulse ox levels

5) Potential T-POCUS (thoracic point-of-care ultrasound)

When should you consider a patient to be hypoxemic?

When their SpO2 → < 95%!!!!

• To correct, either flow-by (2-3L/min) or face mask (2-5L/min)

You may need to consider sedation when treating a dyspneic patient… what are 3 drugs you could use, and what are their doses?

Butorphanol → 0.1-0.3mg/kg IM or IV

• IS an opioid (not good for resp rate), but this one in particular has more of a sedative effect when given in small doses

Acepromazine → 0.005-0.02mg/kg IM or IV

Methadone → 0.1-0.3mg/kg IM or IV

• Used more for analgesic effects, less so sedation

What is one diagnostic tool you should consider doing while assessing an animals airway / breathing? What could it help determine?

POCUS - could help us see:

• Pleural effusion

• Pneumothorax

• B lines from pulmonary edema

• Consolidation

What is the next step of your primary survey after investigating the airway and the patient’s breathing? What do you need to investigate / what measurements should you take?

Circulation - need to investigate:

• Tissue perfusion (your perfusion parameters)

  • MM

  • CRT

  • Auscultation of heart

  • Pulse palpation

  • Core body temp

• BP

• ECG

• Blood lactate (for shock: normal is <2.5mmol/L)

When a patient is going into shock, what should be your first step?

ESTABLISH VENOUS ACCESS; may need to be delayed for dyspneic animals until their O2 is better

• Continue with fluid resuscitation

• Blood transfusions may be needed

What are the 2 main fluid types, and which one is usually used during fluid therapy for a patient in shock?

Crystalloid and colloid…

Isotonic crystalloid is usually used when giving “goal directed therapy”

• Dogs – 10-20ml/kg intravenous bolus 

• Cats – 5-10ml/kg intravenous bolus - more conservative, prone to fluid overload

• Reassess perfusion parameters

** Boluses can be repeated up to 3 times before needing to find an alternative method

When assessing a patient’s demeanor, what is the first thing you need to investigate?

Mentation - can present as:

• BAR, QAR (normal)

• Obtunded (decreased response to environmental stimuli)

• Stuporous (unresponsive, only responds to pain)

• Comatose (Unconscious)

What is one big thing you also look for when assessing a patient’s demeanor?

SIGNS OF RAISED INTRACRANIAL PRESSURE

• Determined via neurological exam

• If you see the signs, DO NOT GIVE PATIENT OPIOIDS

  • Can make bradycardia and hypertension worse

What are the late signs of increased intracranial pressure?

Cushing’s Reflex

• Bradycardia + hypertension

How it works:

• High Pressure: Swelling, a blood clot (hematoma), or bleeding raises intracranial pressure (ICP)—pressure inside the skull.

• Brain Ischemia: Pressure exceeds blood pressure, starving the brainstem of oxygen.

• Compensatory Push: The brain triggers a massive sympathetic surge to force blood past the blockage.

Cushing's Triad (The Classic Signs)

1. Widened pulse pressure: High systolic blood pressure with a dropping diastolic pressure.

2. Bradycardia: Slow heart rate caused by baroreceptors reacting to the high blood pressure.

3. Irregular respirations: Erratic breathing or Cheyne-Stokes patterns from brainstem compression.

How would you treat increased intracranial pressure?

Mannitol

• 0.5-1g/kg IV over 15-20 minutes

Hypertonic saline (7.2%)

• 2-4ml/kg IV over 10-15 minutes

What medications are the first line of treatment for a seizure? What are their doses?

Diazepam

• 0.5mg/kg IV

• 1mg/kg rectal

Midazolam

• 0.2-0.4mg/kg IV

When assessing mentation, what are 3 possible causes for them to be less than bright and alert? (If the issue doesn’t stem from respiration, circulation, or neurological causes)?

Hypoglycemia

• Treated via 0.5-1mL glucose 50% IV; dilute in saline

Depleted electrolytes

• Na+ → neurological signs

• K+ → arrhythmia and weakness

• Ca2+ → Weakness, tremors

Temperature

• Heat stroke

• Hypothermia

Say everything is stable with a patient’s respiration, circulation, and mentation… What do you examine next?  What are you looking for in this next step?

Entire Body examination. Includes:

• Basic abdominal palpation

  • Blocked bladder

  • Severe pain

  • Fluid thrill

• Identification of any life-threatening injuries such as spinal fractures, arterial bleeding or open body cavities.

• Abdominal POCUS

If a patient comes in with a penetrating object, what should you NOT do first?

Should NOT be removed until conditions are controlled

What is the point of using a POCUS?

• Determination on whether or not there is free fluid within a cavity in a trauma patient 

• Should do one FOLLOWING fluid resuscitation; more fluid in circulation  = more obvious internal bleeding 

What are the 5 different options of vascular access one has for a critical patient?

• Peripheral venous catheter – cephalic/saphenous

• Central venous catheter

• (PICC) → peripherally inserted central catheters

  • Inserted peripherally, threaded through to the caudal vena cava

  • More for hospitalized patients rather than emergency arrivals

• Intraosseous catheter – EZ-IO gun or spinal needle

• Venous cutdown

  • Dissecting skin away from the vein to visualize it; done in cases where blood volume is extremely low