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FCP > 5. Emergency Critical Care > Flashcards

5. Emergency Critical Care Flashcards

1
Q

What does the word ‘triage’ refer to when talking about a group of animals

A

Process of quickly examining patients who are taken to decide which ones are the most seriously ill and must be treated first

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2
Q

What does the word ‘triage’ refer to when talking about an individual animal

A

Process of examining problems in order to decide which ones are the most serious and must be dealt with first

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3
Q

What is a primary survey when looking at triaging

A

A quick way to find out how to treat any life threatening conditions a casualty may have in order of priority e.g. using DR ABC

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4
Q

What is a secondary survey when looking at triaging

A

A rapid but thorough head-to-toe examination assessment to identify all potentially significant injuries - done after the primary survey

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5
Q

What is the definition of shock

A

Inadequate cellular energy production

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6
Q

What is shock commonly secondary to?

A

poor tissue perfusion

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7
Q

What does shock lead to

A

Leads to critical decrease in oxygen delivery (DO2) compared to oxygen consumption in the tissues (VO2)

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8
Q

Give the 5 main parameters to evaluate for shock

A
  1. mentation
  2. mucous membrane colour
  3. capillary refill time
  4. Cold extremities
  5. pulse evaluation
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9
Q

What does a pale to white colour mucous membrane suggest

A

Depletion of volume or of haemoglobin

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10
Q

What does a red colour mucous membrane suggest

A

Poor perfusion and vasodilation (trapping blood in capillary beds)
Sepsis

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11
Q

What are you actually evaluating when evaluating the pulse for shock

A

Estimate of stroke volume

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12
Q

What does SIRS stand for

A

Systemic Inflammatory Response Syndrome

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13
Q

Name 3 causes of SIRS

A

Burns
Bacterial infections
Neoplasia

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14
Q

What is sepsis

A

SIRS with an infectious agent identified

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15
Q

What is severe sepsis/SIRS associated with

A

Associated with organ dysfunction, hypoperfusion or hypotension

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16
Q

What is refractory (septic) shock/ SIRS shock

A

A subset of severe sepsis/SIRS
Defined as sepsis-induced hypotension despite fluid resuscitation

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17
Q

What is Multiple Organ Dysfunction Syndrome (MODS)

A

Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention
Generally comes just before death

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18
Q

Name the 7 types of shock

A
  1. Hypovolaemic
  2. Cardiogenic
  3. Distributive
  4. Metabolic
  5. Hypoxaemic
  6. Cryptic
  7. Combined
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19
Q

Describe hypovolaemic shock

A

Decreased circulating volume
Fluid loss from intravascular space e.g. trauma or haemorrhage

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20
Q

Describe cardiogenic shock and give examples of situations which can cause it

A

Decreased forward flow from the heart
E.g. congestive heart failure, cardiac dysrhythmias, cardiac temponade, drug overdose

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21
Q

Describe distributive shock and give examples of situations which can cause it

A

Loss of systemic vascular resistance - blood vessels inappropriately vasodilate
E.g. Sepsis, Obstruction, anaphylaxis

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22
Q

Describe metabolic shock and give examples of situations which can cause it

A

Deranged cellular metabolic machinery
E.g. hypoglycaemia, cyanide toxicity, mitochondrial dysfunction, cytopathic hypoxia of sepsis

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23
Q

Describe hypoxaemic shock and give examples of situations which can cause it

A

Deceased oxygen content in arterial blood
E.g. anaemia, severe pulmonary disease, carbon monoxide poisoning, methaemoglobaemia

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24
Q

Describe cryptic shock and give examples of situations which can cause it

A

Normal global circulation but poor microcirculation
E.g. SIRS, Sepsis

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25
Q

Which two types of shock are most commonly found in combined shock

A

Hypovolaemic and distributive

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26
Q

Name 3 mechanisms of shock

A

Loss of intravascular volume
Maldistribution of vascular volume
Failure of the cardiac pump

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27
Q

Describe common clinical presentation of hypovolaemic shock

A

Decreased cardiac output
Vasoconstriction
Increased contractility
Increased HR

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28
Q

What happens to/in the kidney in hypovolaemic shock

A

Decreased renal circulation
Activates RAAS
Na and H2O retention due to increased aldosterone and ADH

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29
Q

What are the initial signs of hypovolaemic shock

A

“Compensated shock”
Mild depression
Tachycardia
Normal to prolonged CRT
Cool extremities
Tachypnoea
Normal BP
Normal pulse quality

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30
Q

What are the signs in ongoing compromise of hypovolaemic shock

A

“Decompensated shock”
Compensatory mechanisms fail
Pale MM (sepsis they are red)
Poor peripheral pulse
Depressed mentation
Fall in blood pressure

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31
Q

What occurs in the hyperdynamic phase of shock

A

Tachycardia
Fever
Bounding peripheral pulses
Hyperaemic mucous membranes

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32
Q

What is the “shock organ” in dogs

A

GI tract

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33
Q

What is the “shock organ” in cats

A

Lungs
rarely see hypodynamic phase

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34
Q

What is the “shock organ” in cows

A

GIT

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35
Q

What is the “shock organ” in horses

A

GI involved but not displayed as obviously

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36
Q

What is hypovolaemia

A

Loss of circulating volume (ECF)
Salt and water loss

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37
Q

What is dehydration

A

Loss of body water
Just water lost, no salts - hypernaetraemic

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38
Q

Over how many hours do you replace deficit for hypovolaemia

A

6-8 hours

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39
Q

Over how many hours do you replace deficit for dehydration

A

12-24 hours

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40
Q

Clinical signs seen with fluid loss of <5%

A

No clinical signs

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41
Q

Clinical signs seen with fluid loss of 5-7%

A

Mild depression
Slightly prolonged CRT
Slightly increased HR
Increased blood lactate
Creatinine concentration concentrated in urine

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42
Q

Clinical signs seen with fluid loss of 10%

A

Depressed
May have cold extremities
Dry mucous membranes with a CRT >3 seconds
Heart rate >50% above the normal reference range
Increased blood lactate concentration
Increased creatinine concentrations
Small volume of very concentrated urine

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43
Q

Clinical signs seen with fluid loss of 12-15%

A

Depressed
Cold extremities
Dry mucous membranes with a CRT >4 seconds
Heart rates >100% above the normal reference range
Increased blood lactate concentrations
Increased creatinine concentrations
Unlikely to produce any urine

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44
Q

How to estimate fluid deficit

A

% fluid deficit x Bodyweight

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45
Q

Give the shock dose fluids for cat/sheep/goat

A

60ml/kg

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46
Q

Give the shock dose fluids for dog/horse/pig

A

90ml/kg

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47
Q

Give ml/kg of fluid challenge for cat or dog

A

Cat - 10ml/kg
Dog - 20ml/kg

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48
Q

Name the 3 board categories of fluids we can give and example of each

A

Hypotonic - 5% dextrose
Isotonic - Hartmann’s
Hypertonic - Hypertonic saline

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49
Q

What 3 situations is Hartmann’s NOT suitable

A

Hypernatraemia
Hyponatraemia
Renal failure

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50
Q

What 2 electrolytes are all fluids low in

A

K+
Mg2+

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51
Q

Give 2 physiological benefits of using hypertonic saline

A

Cause vasodilation
Increased cardiovascular contractility

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52
Q

Name adverse effects of hypertonic saline

A

Hypernatremia
Inappropriate in patients with dehydration
DO NOT use in foals

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53
Q

When do you use enterally given fluids

A

No GI obstructions
Have a fluid deficit less than 5%

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54
Q

Why use fluids per rectum

A

Support until vascular access gained or in animals where vascular access can be a problem
Cheaper

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55
Q

Can the body absorb electrolytes per rectum

A

No

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56
Q

Give 5 indications for use of blood products

A

Severe anaemia
Coagulopathy
Thrombocytopenia (TCP)
Thrombopathia - platelet abnormalities
Hypoproteinaemia

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57
Q

When would you use RBC transfusion

A

Anaemia
Peracute blood loss

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58
Q

Give 3 situations where you would use fresh frozen plasma transfusion

A

Coagulopathies
SIRS and sepsis
Hypoprotanaemia in horses

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59
Q

What is auto transfusion (blood products)

A

Giving the animals blood back to itself from a non contaminated body cavity

60
Q

How many DEAs are there in dogs (blood types)

A

12

61
Q

Which DEA is the universal donor in dogs

A

DEA 1.1 negative

62
Q

What are the blood types in cats

A

A, B or AB (very rare)

63
Q

Should all cats be blood types before transfusion

A

Yes

64
Q

What is a major cross-match when talking about blood

A

Recipients plasma and donor cells

65
Q

What is a minor cross match when talking about blood

A

Donor plasma to recipients cells

66
Q

Give the main signs of adverse reaction to blood products

A

Fever
Vomiting
Haemolysis - Fatal

67
Q

What are the 20 critical parameters of Kirby’s rule of 20

A
  1. fluid balance
  2. oncotic pull
  3. blood glucose
  4. electrolytes and acid-base balance
  5. oxygenation and ventilation
  6. level of consciousness and mentation
  7. hypotension
  8. HR, rhythm and contractility
  9. albumin
  10. coagulation
  11. RBC/Hb concentration
  12. renal function
  13. immune status, antibiotics and WBC count
  14. GI motility and mucosal integrity
  15. Drug doses and metabolism
  16. nutrition
  17. analgesia
  18. nursing care and patient mobilisation
  19. wound care and bandage changes
  20. TLC
68
Q

For Kirby’s rule of 20, describe what you should consider for 1. fluid balance

A

Where is the fluid
Is the patient hypovolaemia
Is the patient dehydrated

69
Q

For Kirby’s rule of 20, describe what you should consider for 2. Oncotic pull

A

Any signs of inability to keep products in the intravascular space
e.g. peripheral oedema, tissue oedema

70
Q

For Kirby’s rule of 20, describe what you should consider for 3. Blood glucose

A

Increased/deceased blood glucose

71
Q

For Kirby’s rule of 20, describe what you should consider for 4. electrolytes and acid-base balance

A

Calcium and magnesium
Sodium
Chloride
Potassium
Acidosis

72
Q

For Kirby’s rule of 20, describe what you should consider for 5. oxygenation and ventilation

A

Arterial blood gasses
If you want to give oxygen supplementation

73
Q

For Kirby’s rule of 20, describe what you should consider for 6. Level of consciousness and mentation

A

Repeated assessments and investigation if any decline

74
Q

For Kirby’s rule of 20, describe what you should consider for 7. Hypotension

A

Mean above 60-65mmHg
Systolic above 90mmHg
If low, fluid challenge
If no response check for ongoing losses

75
Q

For Kirby’s rule of 20, describe what you should consider for 8. HR, rhythm and contractility

A

Check for murmurs, dysrhythmias

76
Q

For Kirby’s rule of 20, describe what you should consider for 9. albumin

A

Should be above 20g/L
Causes - GI or renal loss, liver failure, cytokine suppression of albumin production in SIRS

77
Q

For Kirby’s rule of 20, describe what you should consider for 10. coagulation

A

Small animals - bleeding diseases
Large animal - excessively coagulate

78
Q

For Kirby’s rule of 20, describe what you should consider for 11. RBC/Hb concentration

A

Need enough RBC and Hb to deliver oxygen
Consider blood transfusion
Cross match

79
Q

For Kirby’s rule of 20, describe what you should consider for 12. renal function

A

May have chronic renal failure
Use urinalysis to assess function
Creatinine also useful

80
Q

For Kirby’s rule of 20, describe what you should consider for 13. Immune status, antibiotics and WBC count

A

If immunocompromised, need isolation and barrier nursing
Antibiotics - C&S

81
Q

For Kirby’s rule of 20, describe what you should consider for 14. GI motility and mucosal integrity

A

Critical illness often complicated by gut stasis, ileus and gastric disease
Promote GI motility, use antiemetics
Ideally feed enterally

82
Q

For Kirby’s rule of 20, describe what you should consider for 15. Drug doses and metabolism

A

We don’t know how sick animals handle drugs
Young animals handle drugs different to adults
Consider where the drug is metabolised

83
Q

For Kirby’s rule of 20, describe what you should consider for 16. nutrition

A

Enteral better than parenteral
Needs constantly assessing
Feed small volumes, high calorie

84
Q

For Kirby’s rule of 20, describe what you should consider for 17. analgesia

A

Care with NSAIDS
Consider cardiovascular effects of alpha 2 agonists
Consider sedative effects and respiratory depression of opioids

85
Q

For Kirby’s rule of 20, describe what you should consider for 18. nursing care and patient mobilisation

A

Essential
Check catheter sites often
Ensure human contact
Appropriate temperatures
Get animals outside and moving

86
Q

For Kirby’s rule of 20, describe what you should consider for 19. wound care and bandage changes

A

Frequent checking
Bandage shouldn’t be loose, tight or wet

87
Q

For Kirby’s rule of 20, describe what you should consider for 20. TLC

A

Mental health of the patient
Owner involvement that has a bond
Blankets, favourite toys etc

88
Q

What is the main goal of enteral nutrition

A

Provide adequate caloric and nutrient intake via GIT to prevent adverse consequences of malnutrition

89
Q

What 4 things can protein catabolism have effects on

A

Tissue synthesis - healing
Immunocompetence
Maintenance of GI integrity
Drug metabolism

90
Q

What about nutrition should you consider for a patient with hepatic encephalopathy

A

They are protein intolerant

91
Q

What counts as a “high risk” patient when talking about nutrition

A

A patient which hasn’t consumed RER for 3-5 days

92
Q

What 2 patient factors affect if you feed enterally or parenterally

A

GI function
Ability to protect their airway

93
Q

What 4 non-patient factors affect if you feed enterally or parenterally

A

Cost
Predicted length of hospitalisation
Technical expertise
Level of patient monitoring

94
Q

What is the formula for RER

A

RER = 70 x BW^0.75
Should use lean bodyweight
OR RER = 30 x (BW+70)

95
Q

What 3 conditions require more than their RER

A

Sepsis
Head trauma
Burns

96
Q

How should you approach nutrition in patients with prolonged anorexia or GI compromise

A

start at 30-50% RER and slowly increase

97
Q

When should we use supportive feeding

A

The animal is unable to eat as it normally would or is unable to absorb nutrition from specific sections of its GI tract.

98
Q

What does TPN stand for (nutrition)

A

Total parenteral nutrition

99
Q

What does PPN stand for (nutrition)

A

Partial parenteral nutrition

100
Q

Name the 4 different types of feeding tubes

A

Naso-oesophageal, naso-gastric?
Oesophagostomy
○ Gastrostomy/PEG
Enterostomy

101
Q

What tube should you use for short term feeding

A

Naso-oesophageal/nasogastric

102
Q

What tube should you use for medium term feeding (3-4 weeks)

A

Oesophagostomy

103
Q

What tube should you use for long term feeding (months)

A

Percutaneous endoscopic gastrotomy

104
Q

Common problems with feeding tubes

A

Blockages
Dislodging of the tube, movement
Trauma
Infection
Over-granulation

105
Q

What routes are most common for parenteral nutrition

A

IV or IO

106
Q

What are the typical requirements for parenteral feeding

A

Aseptic vascular access
24 hour nursing care
Glucose monitoring

107
Q

Maximum time frame to use parenteral nutrition

A

1-2 weeks

108
Q

Name the main metabolic complications associated with parenteral feeding

A

Hyperglycaemia
Lipemia
Azotaemia
Hyperammonaemia
Refeeding syndrome

109
Q

How to calculate protein requirement for: dogs and cats

A

Dog: 4-6g/100KCal
Cat: 6g/100KCal

110
Q

Name the 4 micronutrients to consider when feeding

A

Vit B complex
Potassium phosphate
Magnesium sulphate
Zinc

111
Q

What GI changes occur when we withhold food

A

Villi stunting
Decreased absorptive capacity

112
Q

What is transfaunation

A

“poo soup” - give animals own poo to repopulate gut flora

113
Q

What is a traumatic brain injury (TBI)

A

Severe head trauma associated with high mortality

114
Q

What is the primary injury when talking about traumatic brain injury

A

The damage caused by the trauma
Development of haemorrhage and oedema
Little we can do about this

115
Q

What is the secondary injury when talking about traumatic brain injury

A

The progression of the injuries after the initial damage
Pro inflammatory cytokines, ROS and excitatory neurotransmitters

116
Q

What 4 things does the secondary injury lead to in traumatic brain injury

A

Cerebral oedema
Increased intracranial pressure
Compromise to the blood brain barrier
Alterations in cerebrovascular reactivity

117
Q

What is the most common cause of death from traumatic brain injury

A

Increases in intracranial pressure - perfusion decreases

118
Q

How to assess a patient with traumatic brain injury

A

Neurologic assessment
Recognise and treat hyperaemia and hypovolaemia
Modified Glasgow Coma Scale - high the score the better the prognosis

119
Q

What 2 things are involved in the initial extra cranial stabilisation for traumatic brain injury

A

Correction of tissue perfusion deficits
Optimising systemic oxygenation and ventilation

120
Q

What are the 3 goals for intracranial stabilisation for traumatic brain injury

A

Optimising cerebral perfusion
Decreasing intracranial pressure
Minimising increases in cerebral metabolic rate

121
Q

Should you give fluid therapy in cases of traumatic brain injury

A

Yes
Fluid restrictions are contra-indicated

122
Q

What fluid therapy should you use for traumatic brain injury

A

1/4 aliquots of ‘shock’ rates - Hartmanns
7.2% hypertonic saline followed by crystalloids can be a good option - draws fluid from interstitium => decreasing oedema

123
Q

Name the 6 important things to do when treating traumatic brain injury

A
  1. Oxygen supplementation
  2. Carbon dioxide tensions (38-40mmHg aim)
  3. Minimise increases in intracranial pressure
  4. Hyperosmolar therapy
  5. Avoid hyperglycaemia - use insulin if needed
  6. Hypothermia - may reduce secondary brain injury
124
Q

Name 3 positives of induced hypothermia for traumatic brain injury

A

Decreases metabolic demands of the brain => decreased cerebral oedema and intracranial pressure
Reduces release of excitatory neurotransmitters
Reduce 2ndary injury by inhibiting post traumatic inflammatory response

125
Q

Name 4 disadvantages to induced hypothermia for traumatic brain injury

A

Coagulation disorders
Increases susceptibility to infections
Hypotension and bradycardia
Dysrhythmias

126
Q

What drugs are used to treat traumatic brain injury

A

Analgesia
Anti-convulsants
Prophylaxis for seizures
GI protectants

127
Q

What drugs are used to prevent and stop seizures with traumatic brain injury

A

Prevent - phenobarbitone
Stop - diazepam

128
Q

What are the adverse effects of seizure activity on traumatic brain injuries

A

Hyperthermia
Hypoxaemia
Cerebral oedema

129
Q

Give 5 reasons why corticosteroids are contraindicated for use in traumatic brain injury

A

Associate with:
Hyperglycaemia
Immunosupression
Delayed wound healing
Gastric ulceration
Exacerbation of catabolic state

130
Q

What are the GIT risks associated with traumatic brain injury

A

Gastrointestinal bleeding
Enteral feeding intolerance
Delayed gastric emptying

131
Q

Why is there delayed gastric emptying associated with traumatic brain injury

A

Increased intracranial pressure
Cytokine release
Hyperglycaemia
Opioid use

132
Q

What drugs would you use to support GI function and feeding during traumatic brain injury

A

Erythromycin combined with metoclopramide

133
Q

Should you do enteral or parenteral feeding for traumatic brain injury

A

Enteral best as maintains GI integrity
Intragastric enteral feeding
If unconscious, parenteral can be easier

134
Q

What are the 3 sections of the Modified Glasgow Coma Scale

A

Motor activity
Brain stem reflexes
Level of consciousness

135
Q

What are the advantages and disadvantages of using a urinary catheter in traumatic brain injury cases

A

Adv - Reduces urine scalding, can measure urine output and assess success of fluid therapy
Disadvantages - Indwelling catheters can cause UTI

136
Q

Why are CT scans preferred for traumatic brain injury

A

Rapid scan times
Better visualisation of fractures and peracute haemorrhage

137
Q

What can be the complications of traumatic Bain injuries

A

Coagulopathies
Pneumonia
Sepsis
Diabetes insipidus
Seizures

138
Q

What are the patient safety factors to consider when imaging an ECC patient

A

If cardiovascular compromise - don’t position animal on they back
If respiratory compromised - don’t position animal on the side of the good lung
If neurological compromise - don’t let head drop down

139
Q

Positives and negative of CT imaging of the ECC patient

A

+ve - Good for detection of free fluid and gas, good organ detail, quick processing time
-ve - Slow to prep patient, not good availability in vet practices, expensive

140
Q

Positives and negative of MRI scan of the ECC patient

A

+ve - Good for diagnosis of intracranial and spinal lesions, good for equine distal limb
-ve - Poor for speed, utility and availability

141
Q

Positives and negative of radiography of the ECC patient

A

+ve - good for free gas and bones, widly available, cheap
-ve - requires restraint/sedation, limited assessment of organs

142
Q

Positives and negative of ultrasound imaging of the ECC patient

A

+ve - minimal restrain, good for unstable patients, rapid, easy, cheap, good for free fluid, allows for interventions
-ve - can’t assess deep structures, can’t assess airways

143
Q

what are the 4 regions looked at in an A-FAST scan

A

Splenorenal
Hepatorenal
Bladder region
Diaphragmatic hepatic window

144
Q

What is the FLASH equine scan used for

A

FLASH - fast, localised abdominal sonography of horses
Looking for signs of colic in 5 windows

145
Q

What is a T FAST scan

A

Thoracic focused assessment with sonography for trauma (TFAST)
Looking for pneumothorax and other thoracic injuries

FCP (8 decks)

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