Key Elements in Emergency and Critical Care Situations

In triage

Patients are sorted into groups based on a quick assessment of illness or injury severity

Would should you collect first on the phone during an emergency situation?

Their name and phone number in the event the call is lost and the person must be called back

During hospital triage

degrees of urgency are assigned to illnesses or wounds to determine the order of treatment in a group of patients

Sorting occurs into what 3 groups

• needing immediate care or stabilization

• needing passage to the treatment area (bleeding, vomiting, or contagious animals)

• those that can wait until their appointment

Components of an initial triage

• brief history

• rapid physical exam:1 minute to 2 minute evaluation of organ systems

• specific discussion regarding the status and planned initial treatment

Respiratory system exam

Its rate, effort, and pattern should be observed and then the hands-on exam; color of mucous membranes is checked, etc.. The final component is thoracic auscultation.

Tachypnea

An increased respiratory rate that may reflect decreased oxygen in blood (hypoxemia), thoracic trauma, or shock or may be related to a nonrespiratory source, such as pain, stress, increased body temp., traumatic brain injury, or metabolic acidosis

Bradypnea

A decreased respiratory rate is commonly associated with exposure or elevated intracranial pressure

Inspiratory dyspnea

Results in long, slow inspirations with short exhalations and can indicated an extrathoracic airway obstruction, such as layngeal paralysis, or swelling associated with an acute hypersensitivity readction

Expiratory dyspnea

With increased abdominal effort on expiration often develops if an intrathoracic airway obstruction, such as a mass compressing the airway or an inhaled foreign body, is present

Labored breathing

Breathing that is prolonged and deep

Orthopnea

Term used to describe the condition of maintaining a specific posture to ease breathing

Why does orthopnea occur?

When dyspnea is so severe that the patient is “air hungry” and does everything it can to keep the airway open

Patients whose mucous membranes are blue, purple, or dusky

They need supplemental oxygen immediately

Patients whose mucous membranes are brick red, brown, or injected (mottled pink, purple, or red)

These colors could indicated dangerous conditions, as carbon monoxide poisoning, heat stroke, or sepsis, which require immediate intervention

Icteric (yellow) mucous membranes

Indicate high levels of bilirubin

Thee initial triage examination of the cardiovascular system involves

assessment of mentation, HR and rhythm, pulse quality, capillary refill time (CRT), extremity temperature, and mucous membrane color

Tachycardia

An abnormally fast HR, it can indicate compensation for a shock state, pain, anemia, anxiety, or combination thereof

Brachycardia

An inappropriately slow HR, it can indicate life-threatening arrhythmia or, in animals with urethral obstruction, an extremely elevated potassium level

Pulse pressure

Is the difference between systolic and diastolic pressures

Pulse quality

Is a description of how quickly pulse pressure changes and how long each pulse lasts

In a weak or thready pulse

Pulse pressure is lower than normal and typically occurs in conjunction with tachycardia, it can indicate hypotension, hypovolemia, or decompensated shock

A pulse that’s “snappy”

It has a very large pulse pressure with an extremely rapid rise and fall, this often occurs with anemia, patent ductus arteriosus, or severe aortic regurgitation

The focus of the initial triage neurologic exam

is to determine whether evidence of traumatic brain injury (TBI) is present

After assessing respiratory, cardiovascular, and neurologic systems, abdominal palpation is appropriate to check for:

pain that may indicate the need for surgery, tympany, and fluid wave

Tympany

is the possibility of a gas-filled GI structure

Fluid wave

palpate to detect ascites, which could indicate hemorrhage, fluid buildup from inflammation, or heart failure

Dehydration and hypovolemia

conditions characterized by inadequate fluid volume in the body, can have serious implications for a patients health

Common laboratory findings in dehydration

• hemoconcentration

• hypernatremia

• azotemia

• elevated albumin

Hypovolemia

is a loss of blood volume usually occurring due to shock, trauma, hemorrhage, profusely vomiting, or diarrhea

Signs of hypovolemia

• tachycardia

• prolonged CRT

• weak pulse

• hypotension

A crash cart

Is an easily accessible location for emergency drugs and equipment

Emergency crash cart items

must be checked routinely for valid dates and proper function

Ambu

Artificial manual breathing unit bag

Shock

is a complex syndrome resulting in altered blood flow or impaired oxygen delivery to tissues

The different categories of shock

• hypovolemic

• distributive

• obstructive

• cardiogenic

• septic

Hypovolemic shock

is most common type seen in dogs and cats

Hypovolemic shock results from

Decreased blood volume and is usually caused by trauma, hemorrhage, severe vomiting, or diarrhea

Signs of Hypovolemic shock

prolonged CRT, weak pulses, pale mucous membranes, and altered mentation

Hypovolemic shock treatment

restoring intravascular volume through IV fluid or blood transfusion

Distributive shock

is misdistribution of blood flow and pooling of blood in the capillaries

Distributive shock treatment

fluid therapy and vasopressors

Obstructive shock

is impaired venous return to the heart

Obstructive shock can be seen in

Cases of gastric dilation- volvulus or pericardial tamponade

Obstructive shock treatment

By detecting and treating the underlying cause

Cardiogenic shock

considered to be secondary to heart conditions

Cardiogenic shock signs

• weak pulses

• hypotension

• pale mucous membranes

• sold extremities

• pulmonary edema

• ascites

Septic shock

this occurs after a severe infection or tissue damage

Septic shock signs

• bright red mucous membranes due to inflammatory vasodilation

• bounding pulses

Septic shock treatment

treating the infection, providing fluid therapy, and giving broad-spectrum antibiotics

Systemic inflammatory response syndrome (SIRS)

consists of widespread tissue damage, hypoxia, and inflammation that can accompany shock

Some causes of SIRS

• trauma

• surgery

• shock

• Heat shock

• Pancreatis

Disseminated intravascular coagulation (DIC)

simultaneous clotting (thrombosis) and bleeding, is often fatal

Permanent organ failure can occur with

multiple organ dysfunction syndrome (MODS), another complication of shock

Chest tube placement (tube thoracostomy)

is indicated for pneumothorax and pyothorax

Tracheostomy tube

these are placed when there’s a life threatening upper airway obstruction

Temporary tracheostomy tubes

these allow the patient to breathe without being intubated which requires the patients to be sedated enough to maintain the airway

Animals with severe dyspnea

They should be handled with care to avoid stress, which can worsen their condition

Pulse oximetry

Measure hemoglobin saturation with oxygen

Capnography

measures carbon dioxide

Basic life support measures include

performing chest compressions in 2 minute cycles

Small dog and cats compressions

They’re applied directly over the heart using the entire hand

Large animal compressions

They’re provided to the the largest part of the chest

The recommended rate of compressions for small dogs and cats

100 to 120 per minute

The recommended rate of compressions for large dogs

100 per minute

Best resource to monitor CPR effectiveness

End-tidal carbon dioxide (ETCO2)

End-tidal carbon dioxide (ETCO2)

This value will rise if the chest compression are effectively moving the blood and perfusing the tissue

Open-chest compressions

This often for giant dogs that suffered trauma, animals with anesthetic arrest, or other cases where closed-chest CPR isn’t enough to induce blood flow

Respiratory support in the case of respiratory arrest

This can be assisted by placing an endotracheal tube and using an ambu bag

Asystole

pulseless electrical activity or “flatline”

Vascular volume restoration is also performed if

The cardiopulmonary arrest is due to hypovolemic or hemorrhagic shock

Frequent neurologic and organ function assessments are crucial for

patients that have been resuscitated via CPR

Indirect or noninvasive blood pressure monitoring

Is used most often in vet practices with a Doppler or oscillometric device

Direct or invasive blood pressure monitoring

This is the gold standard for this kind

Most common sites for arterial catheter placement

The dorsal metatarsal and femoral arteries, although the tail artery can also be used

Atrial premature complexes can be distinguished from ventricular premature complexes based on

QRS shape (normal for APCs, abnormal for VPCs) and the presence or absence of a Pwave (absent for VPCs)

An ECG

A recording of the summation of electrical potential vectors from the cardia conduction system and multiple fibers of the myocardium

White electrode

It’s placed on the right forlimb

Black electrode

It’s placed on the left forelimb

Red electrode

It’s placed on the left hindlimb

Green electrode

It’s placed on the right hindlimb

P wave

atrial depolarizartion

PR interval

conduction across the atrioventricular node

QRS complex

indicates ventricular depolarization

T wave

repolarization of the ventricles

QT interval

Represents the summation of ventricular depolarization and repolarization and varies inversely with HR

The electrocardiogram should be evaluated in a systematic manner, analyzing four basic features:

HR, rhythm, measurement of waveforms and intervals, and the mean electrical axis (MEA)

A tall P wave (P-pulmonale)

is consistent with right atrial enlargement

A wide P wave (P-mitrale)

suggests left atrial enlargement

Prolongation of the PR interval

Can occur as a result of increased vagal tone or structural AV nodal disease and is called first-degree AV block

A tall R wave in lead II

Suggests left ventricular enlargement

A deep S wave

Suggests right ventricular enlargment

A wide QRS complex

May indicate ventricular enlargement, bundle block, or a ventricular ectopic beat

Arrhythmias that originate above the AV node

Supraventricular arrhythmias

Arrhythmias that originate below the AV node

Ventricular arrhythmias

Sinus rhythm

Refers to normal rhythm in dogs and cats, in which each beat is initiated by SA nodal discharge

Sinus arrhythmia

Is a normal rhythm dogs and typically is associated with high vagal tone and/or breathing

Sinus bradycardia

Refers to regular rhythm that originates from the SA node and is slower than normal

Sinus tachycardia

Refers to regular rhythm that originates from the SA node and is faster than normal

Atrial premature complexes (APCs)

Are abnormal impulses originating from the atrial myocardium instead of the SA node