Critical Care Flashcards
Estimation of crystalloid and hypertonic saline for burn patients based in TBSA. Discuss benefits and monitoring
“The amount of isotonic fluid required during the first 24 hours may be estimated using the formula 3 to 4 mL/kg per percentage TBSA burned. Hypertonic saline solutions are beneficial in reducing total fluid requirements, limiting edema, and increasing cardiac output. Hypertonic saline (4 mL/kg bolus) plus lactated Ringer’s solution (1 mL/kg per percentage TBSA burned) may be administered. When giving hypertonic saline, the serum sodium concentration should not exceed 160 mEq/L. ”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Discuss the role and proper timing of protein and non-protein colloids in burn patients
“Nonprotein colloid solutions (i.e., dextran 70, hetastarch) given in the early postburn period (16–24 hours after injury) may improve survival and reduce edema formation (see p. 33). Administration of protein colloids (i.e., fresh-frozen plasma or albumin) to hypoproteinemic patients should be delayed for 8 to 12 hours to allow the stabilization of membrane permeability and increased lymph return that reduces protein loss. Protein colloids given within the first 8 to 12 hours are lost into the burn wound and worsen edema formation. Dogs with partial-thickness burns involving 20% TBSA may lose 28% of their plasma volume during the first 6 hours.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Describe the typical presentation for a patient with electrical injury cause by electrical cord
“Animals are often found collapsed in a tonic state with an electrical cord in the mouth. The body stiffens from contraction of striated muscles while receiving the electric current. Generalized tonoclonic activity with vomiting and defecation can also occur. If the animal survives, the tonic state resolves when the cord is removed from the mouth, although the animal may be weak and ataxic for a short period. Burns primarily occur on the lips, gums, palate, or tongue. These areas initially may appear charred, pale gray, or tan. Edema develops after 1 to 2 days. The extent of injury may not be apparent for 2 to 3 weeks. Pulmonary edema frequently occurs shortly after electrocution, causing dyspnea and moist rales.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Describe the basic therapy of pulmonary edema caused by electrical injury. What drugs are usually utilized and what precautions must be taken.
“Pulmonary edema may be treated with oxygen therapy, diuretics (i.e., furosemide, 2.5–5 mg/kg IV or IM every 1–4 hours as needed, or as a constant-rate infusion [CRI] at 0.66–1 mg/kg per hour), terbutaline, vasodilators (e.g., nitroprusside or nitroglycerine: these are potentially dangerous drugs; the reader is referred to a medical text for more information in using them), and aminophylline (5–10 mg/kg given intramuscularly or intravenously three times a day: IV administration should involve diluted drug given over 30 minutes). Terbutaline is generally preferred over aminophylline because the latter may cause vomiting, diarrhea, anxiety, or nervousness. IV administration in particular can cause tachycardia, arrhythmias, and central nervous system excitement and/or seizures. Caution should be used when giving aminophylline to dogs with seizure disorders because antiseizure medications (see Chapter 39) can lessen its effectiveness. It should be used cautiously in animals with hypothyroidism, liver or kidney disease, or congestive heart failure. Ventilatory support is needed if there is no response to medication.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Describe the general guidelines for the care of frostbite
“The affected body parts should be rapidly rewarmed in warm water (39°C–42°C [102°F–107.6°F]) for approximately 20 minutes to improve circulation. Affected areas become erythematous and edematous, form large vesicles, and are often painful, necessitating analgesics (see Chapter 13). Topical aloe vera or silver sulfadiazine should be applied to the affected areas. Bandages are used to prevent self-trauma. Conservative therapy should be continued until viable tissue can be distinguished from nonviable tissue (i.e., 3–6 weeks). Necrotic tissue should then be debrided and the area reconstructed if necessary. Healing may be complete beneath the mummified tissue.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Describe the effects and acute care of alkali contact burns
“Lye (sodium hydroxide), cement (calcium, sodium, and potassium hydroxide), and many detergents produce saponification of fat and liquefaction necrosis of tissues, leaving them with a soapy feel. Irrigation should continue until the soapy texture is gone. Some alkalis (e.g., the common fertilizer anhydrous ammonia) penetrate the skin quickly and may require extensive irrigation for many hours.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
What are the 4 degrees of radiation injury
“There are four degrees of radiation injury: (1) cutaneous erythema, (2) superficial epidermal (dry) desquamation, (3) moist desquamation from loss of basal layers of epidermis, and (4) necrosis with dermal destruction and irreversible ulceration.”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
Seizures are the most common complication observed after the ligation of congenital PSS, particularly in cats. What can be done to decrease this problem and how are these patients treated if seizures develop?
“Seizures (typically cluster seizures) may occur after ligation of congenital PSS. These seizures are generally first noted 2 to 3 days after shunt ligation; their origin is unknown. This complication seems more common in cats, so much so that some recommend routine pretreatment of cats undergoing surgery for congenital PSS with phenobarbital (not potassium bromide, which can cause respiratory problems in cats). Diazepam is not recommended for these patients; constant-rate infusion propofol plus IV fluid support seems to be the most effective therapy. The patient is anesthetized for 24 hours and is then awakened. If seizures recur, then the patient is reanesthetized and awakened in another 24 hours. This cycle is repeated until control is achieved. Long-term anticonvulsant therapy may be required. Owners should be counseled that permanent neurologic abnormalities, such as blindness, may occur (especially in cats).”
Excerpt From
Small Animal Surgery E-Book
Theresa Welch Fossum DVM, MS, PhD, Dipl ACVS
https://books.apple.com/us/book/small-animal-surgery-e-book/id1367916984
This material may be protected by copyright.
List 5 of the 20 factors of the “Rule of 20” for monitoring of patients with SIRS
- Fluid balance
- Blood pressure and perfusion
- Cardiac function
- Albumin
- Oncotic pull
- Oxygenation and ventilation
- Glucose
- Electrolyte and acid-base balance
- Mentation
- Coagulation
- Packed cell volume
- Renal function and urine output
- WBC count and antibiotic therapy if indicated
- GI motility and integrity
- Drug metabolism and doses
- Nutrition
- Pain control
- Mobility and catheter care
- Bandage and wound care
- Tender loving careGI, Gastrointestinal; WBC, white blood cell.”
Excerpt From
Veterinary Surgery: Small Animal Expert Consult
Spencer A. Johnston VMD, DACVS & Karen M. Tobias DVM, MS, DACVS
https://books.apple.com/us/book/veterinary-surgery-small-animal-expert-consult/id1250368401
This material may be protected by copyright.
Differences in survival rate between open and closed peritoneal drainage techniques
“Survival rates for treatment of peritonitis with these techniques are similar, with 71% survival with open peritoneal drainage and 70% with closed suction drainage.274,349”
Excerpt From
Veterinary Surgery: Small Animal Expert Consult
Spencer A. Johnston VMD, DACVS & Karen M. Tobias DVM, MS, DACVS
https://books.apple.com/us/book/veterinary-surgery-small-animal-expert-consult/id1250368401
This material may be protected by copyright.
Describe the pathophysiology of heat stroke. Include MODS & SIRS
Heat stroke begins with the failure of heat loss mechanisms, leading to generalized peripheral vasodilation, hypotension and distributive shock. This impairs perfusion of various organs, leading to multi organ dysfunction syndrome (MODS). The gastrointestinal tract is among the most severely affected systems, rapidly developing mucosal hypoperfusion, necrosis and breakdown of the because of barrier, leading to bacterial translocation into the bloodstream. Bacteremia quickly evolves into sepsis, leading to systemic inflammatory response syndrome (SIRS). Thermal injury to hepatocytes can affect hepatic function, leading to hypoproteinemia, hypoglycemia and coagulopathy.  Thermal injury to endothelial cells leads to disseminated intravascular coagulation with massive thrombosis, further compromising organ perfusion. Neuronal damage leads to edema and cell death, leading to altered states of consciousness, seizures and coma.
What laboratory tests would you request and what abnormalities would you expect to observe in a patient presented for severe hyperthermia?
All patients with hyperthermia should have serial complete blood counts, biochemical analyses, coagulation profiles, arterial blood gases, venous lactates, and urinalyses performed. In many cases, prerenal and renal azotemia is present, with elevated BUN and creatinine concentration secondary to renal tubular necrosis. Alterations and elevations in hepatocellular enzyme function secondary to hepatocellular thermal injury or hepatic thrombosis are also demonstrated with elevated ALT, AST, and total bilirubin. Elevations in creatine kinase (CK) and AST are secondary to rhabdomyolysis. Blood glucose may be decreased, but this finding is inconsistent. Packed cell volume and total solids may be increased secondary to hypovolemia and dehydration, with subsequent hemoconcentration. Thrombocytopenia, prolonged PT and APTT, and elevated FDPs may be observed if DIC is present. In some cases, thrombocytopenia may not become apparent for several days after the initial insult. Arterial blood gas analyses can be variable, with a mixed respiratory alkalosis and metabolic acidosis secondary to increased lactate. Urinalysis may reveal the presence of renal tubular casts or glucosuria, both indicators of renal tubular epithelial damage.
What is the most immediate therapeutic goal when presented with a hyperthermic patient?
It is fundamental to reduce body temperature below 103°F within the first 30 to 60 minutes of presentation. This should be done with the use of cool wetting of the hair coat (Not cold!), Cool packs under the axilla‘s and groin as well as the use of a fan if available.
Do use of cold baths is CONTRAINDICATED as it promotes peripheral vasa construction which raises core temperature. Methods such as cold IV fluids, cold enemas and cold peritoneal lavage have been tried and proven ineffective.
How should IV fluids be provided to the patient presented for hyperthermia?
Intravenous fluids should be administered judiciously during the early stages of hyperthermia and heat-induced illness, as early in the course of disease, fluid loss is not great, and oversupplementation of crystalloids can worsen cerebral edema and cause pulmonary fluid overload. A balanced electrolyte fluid, such as Normosol-R, Plasma-Lyte M, or lactated Ringer’s solution, can be administered, tailoring each patient’s individual fluid needs based on central venous pressure, acid-base and electrolyte status, blood pressure, thoracic auscultation, and colloid oncotic pressure. If a free water deficit is present, as evidenced by hypernatremia, the clinician should calculate the free water deficit and replace it slowly over a period of 24 hours, to prevent further cerebral edema.
List in bullet point the most important therapeutic steps to be taken in a patient presented for hyperthermia
- Cooling below 103°F within 30 to 60 minutes
- Oxygen therapy
- Low volume therapy to maintain normovolemia (Fluid losses initially low, risk of cerebral/pulmonary edema)
- broad-spectrum antibiotics to prevent/control bacteremia (sultamicillin (Unasyn), cefoxitin, ampicillin with enrofloxacin, and sometimes metronidazole)
- possibly plasma transfusions and heparin in case of DIC
What are the three most important questions to be answered immediately upon arrival at the hospital, immediately prior to or concurrently with the primary survey?
Signalment
Chief complaint
Medical history (concomitant diseases)
What are the 4 systems which must be immediately evaluated as part of the primary survey?
Respiratory
Cardiovascular
Neurologic
Urogenital
List 7 tests typically performed as part of the initial assessment of most critical patients
PCV/TS
Venous Blood Gasses
Lactate
SpO2
NIBP
ECG
AFAST/TFAST
