Critical Care Flashcards
What percent will a dog or cat recover when they go into cardiopulmonary arrest
<10% but since RECOVER it has increased
Higher ROSC rates are seen in
1) patients with witnessed CPA
2) IVC in place at time of arrest
3) Palpable pulses were generated during CPR
Patients had higher odds of survival to hospital discharge if **
Peri-anesthetic arrest
Were cats or dogs more likely to survive to hopsital discharge after cardiopulmonary resuscitation
cats, same with those of lower body weight
CPA during _____ time was associated with worse patient outcomes
night
Were more or less people associated with decreased offs of ROSC
more people
What two devices do we hook up to for a cardiopulmonary arresting patient
1) End-tidal CO2 (18+ mmHg)
2) ECG
We do not administer high volumes of IVF for cardiopulmonary arrest except for __________ *
when they are hypovolemic (e.g bled out)
when doing CPR, we dont want too much fluid sitting in the venous side
No fluids during CPR unless
hypovolemic (e.g bled out)
What are the non-shockable rhythms
Asystole
PEA
What can you do for neuroprotection after cardiac arrest
Hypothermia if comatose
Mannitol /HTS if neuro signs
Seizure prophylaxis
What are physical signs of shock
1) Abnormal mucous membrane color
2) Tachycardia (cats = bradycardina <120bpm)
3) Cool distal extremities
4) Abnormal pulse quality
5) Abnormal Capillary refill (CRT)
6) Decreased level of consciousness
What are the types of shock
1) Hypovolemic (blood volume)
2) Distributive (blood vessels)
3) Obstructive (vessel occlusion)
4) Cardiogenic (heart/pump)
5) Metabolic
6) Hypoxemic
What are causes of hypovolemic shock
Acute blood loss
-Trauma
-Coagulopathies
-Surgery
-GI bleeding
-Neoplasia/necrosis
Profound dehydration
-Gastroenteritis
-Heat stroke
-Renal disease
-Diabetes
What are compensatory factors for loss of vascular volume
Once the stretch on the baroreceptors occurs
1) Release of catecholamines, Aldosterone, Cortisol, ADH, activation of renin-angiotensin
2) Increased systemic vascular resistance, heart rate, contractility, splenic contraction, renal water retention
3) Increased venous return cardiac function
What are causes of distributive shock
1) Bacterial (pneumonia, perforated intestines, wounds, GI translocation)
2) Trauma
3) Burns
4) Pancreatitis
5) Anaphylaxis
What are causes of cardiogenic shock
Dogs:
-Valvular disease
-DCM
-Pericardial effusion “obstructive”
-Atrial fibrillation
Cats:
-HCM and FUCM
-Restrictive cardiomyopathy
-DCM
What is the pathophysiology of cardiogenic shick
-Myocardial failure (failure as a pump)
-Cardiac tamponade (inadequate ventricular filling)
-Arrhythmias (ineffective contraction or inadequate filling)
How often should you run PCV/TP for shock patients
prior to fluids and every 30-60 minutes until stable
What are the steps of the primary survey
1) Exsanguination (frank, red bleeding, or distended brusined abdomen)
2) Airway (Upper airway sounds, or visual sweep)
3) Breathing (Increased respiratort effort, bronchovesicular sounds, or absent)
4) Circulation (Shock, mucous membranes, pulse quality)
5) Disability: Level of consciousness, brainstem reflexes, motor activity
6) Exposure/Enviroment: cover open wounds and minimize heat loss
What signs might show that a patient has exsanguination
1) frank, red, pulsatile bleeding
-is there blood present on a hand sweep
2) Distended, bruised abdomen
if evaluation of exsanguination reveals no life-threatening abnormalities, what are the adjunct tools that are not indicated until after the primary survey is completed
POCUS
Blood pressure
PCV/TP
Lactate
What immediate actions can you do for exsanguination
Compression
Packing
Application of a hemostatic clamp
Why should you not immediately reach for POCUS to evaluate for internal bleeding
It can be evaluated further during the circulation step of the primary survey and/or during the secondary survey based on the patient status
What is a common pitfall when assessing for exsanguination
Being distracted by minor bleeding
Unless the loss is pulsatile or patient at risk for imminent death, do not pause during primary survey to address it
Which of the following is used in the exsanguination step in the primary survey of an injured patient?
Blood sweep
Pulse oximeter
Laryngoscope
Electrocardiogram
Blood sweep
What is MIST
M- mechanism: description of mechanism of injury (ie HBC, attack, gunshot, etc.)
I- Injury: ex- nonambulatory, evidence of wound to head and neck, etc
S- Signs and Symptoms
T: Treatment- What was done to fix the issue
What question do you ask yourself when evaluating the airway
IS there any adequate path for air to get to the alveoli
partial or ocmplete upper airway injury or obstruction which may interfere with oxygen delivery to alveoli anf removal of carbon dioxide
How do you evaluate the airway in your primary survey
1) Look- quality of breathing, positioning
2) Listen to sounds, stertor or stridor, is there audible evidence of air moving
3) Feel- laryngeal or cervical regional areas
noising breathing that occurs above the larynx at the level of the pharynx and nasopharynx
Stertor
noisy breathing that occurs at the level of the larynx or trachea
Stridor
What are adjunct tools to assess airway after primary survey
Pulse oximetry
Laryngoscope
What are immediate actions for the airway you can do
Oxygen supplementation
Advanced (tracheostomy or other temporary airway)
How does head/facial trauma impact obligate nasal breathers
they may have significant nasal injury requiring basic airway interventions
What might tell you a patient has a compromised airway
Stertor or Stridor
Extended heack and neck/ tripod stance
Cyanotic mucous membranes
Is a complete oral exam indicated during primary survey
No- not uinless the patient is at risk of imminent death due to airway injury or obstruction
Why is it important to check the airway in the primary survey of an injured patient
To ensure oxygen is able to reach the alveoli
How do you evaluate a patient’s breathing in the primary survey
Look- evidence of breathing, rate, symmetric expansion
Listen- Do you hear breath sounds on both sides of the chest
What critical findings of breathing primary survey require immediate attention
1) Extended head and neck/tripod stance
2) Abnormal rate/character/effort
3) Abnormal lung sounds
What adjunct tools are important after your breathing primary survey
Pulse oximetry
Capnography
Thoracic point of care ultrasound
Arterial blood gas
What interventions might you do after your breathing survey
CPR- if not breathing
Thoracocentesis +/- chest tube
Sedation
Intubate and ventilate
When doing breathing primary survey you should always listen to both sides of a laterally recumbent patient
True
T/F: tachypnea reflects a respiratory problem
False- it may be due to shock, pain, or stress
How can you assess the circulatory system
1) Look- mentation, mucous membranes, CRT, nailbed color
2) Listen- heartbeat, rate, irregular?
3) Feel - pulse quality of central and peripheral pulses (femoral, metatarsal), feel temperatures of the extremities
What are adjunct tools to assess the circulatory system of a patient
POCUS
ECG
Lactate
Blood gas
Blood pressure
What immediate actions can you do for patients with circulatory system compromise
Vascular access
Intravascular fluid infusion
During primary survey, should you get definitive heart/pulse rate
NO- the goal is to have qualitative assessment of the rate in order to determine interventions, not determine the definitive rate
When do you do complete cardiac ausculatation and assessment
Secondary survey
When shouild you measure blood pressure
rarely indicated during primary survey
may be initiated during the secondary survey if indicated
What is the primary goal of assessing circulation in the primary survey of an injured patient?
To identify signs of hypovolemic shock
What does the disability step of the primary survey address
Is there evidence of traumatic brain injury (TBI) or spinal injury
How do you assess a patient’s neuro system in the primary survey
Look- mentation, Reflexes (PLR, oculocephalic), breathing pattern
Feel- toe pinch, motor, deviations in spinal column from base of skull to the sacrum
What are adjunct tools necessary to perform the disability step in the primary survey
Blood pressure
Capnogrpahy
Blood glucose
MGCS score
What are immediate actions to take when assessing the disability of a patient
1) Oxygen
2) Fluid selection
3) Head elevation
4) Temporary spinal stabilization (backboard)
5) Analgesia after documentation of neuro status
In primary survey, should you perform a full neuro exam
No- it is prudent to ensure the spinal column is cleared prior to manipulating the patient for a thorough neuro exam
When should you avoid evaluating the oculocephalic reflex
in a patient with suspected neck injury
Your should determine the neurologic status prior to
pain medication
do the MGCS
Should you assume TBI with decreased level of consciousness
No- decreased level of consciousness may also be an indicator of circulatory shock
What are findings that might indicate risk for environment/exposure
Open wounds
Sources of heat loss
Recent risk for hyperthermia (heatstroke)
What immediate actions can you do for exposure/environment
-Sterile gauze and bandage material to cover open wounds. Attenuation of bleeding and minization of further contamination
-Bedding/passive warmth to prevent hypothermia
-Cooling (heat stroke)
-Minimize patient distress. Consider pain and patient positioning
What should be the initial priorit in assessing any injured patient
Checking for pulsatile hemorrhage
The trauma bay should be equipped with which of the following tools for assessing the exposure (environment) portion of the primary survey evaluation of a trauma patient?
thermometer
When can pain meds be administered
1) After MGCS score
2) At admission for patient and/or team safety
3) Prior to secondary survey
What intervention is crucial in the primary survey of a trauma patient with evidence of spinal injury
Using a backboard to temporarily stabilize the patient
What is a common pitfall in the primary survey of trauma patients during the airway step
Not applying basic interventions such as oxygen early enough
The secondary survey does not begin until
the primary survey (XABCDE) is completed, resuscitative efforts are underway, and improvement of the patient’s vital parameters has been demonstrated
Once vital signs arei mproved and primary and secondary surveys are complete. What is a good abbreviated history you should get
AMPLE
-Allergies
-Meds (current)
-Past illnesses
-Last in/outs (urine/stool/meal/water)
-Events of injury (mechanism, description)
What should you do to ensure better visualization and identification of all injuries
fur should be clipped
What tools can you do to assess the head
larngoscope
otoscope
ophthalmoscope
radiographs/CT
Pupil abnormalities (anisocoria, miosis, mydriasis, abnormal PLR) might occur due to
primary ocular injury or central neurologic injury
Why do you need to perform an aural examination
Examine ear canal for hemorrhage, spinal fluid, anatomic displacement
If you are suspicious of spinal injury you should do what
obtain additional imaging to make sure the cervical spine is okay before cervical spine manipulation
If a pneumothorax is suspected based on respiratory pattern the
a thoracocentesis should be performed and has low risk to patient
can confirm with thoracic POCUS
a change in breathing may indicate
need to return to primary survey
need to reassess if changes and provide immediate intervention (thoracocentesis, intubation,etc)
Removal of impaled objects should only be performed
during surgical exploration in order to ensure good visualization
blind removal may cause catastrophic hemorrhage and pneumothorax which can destabilize the patient
What tools can you do to evaluate the abdomen
POCUS
Abdominocentesis
Radiographs/CT
What are the steps of the secondary survey
Head
Neck/Cervical
Thorax
Abdomen
Pelvis + Perineum
Neurologic
Limbs/Tails
Why shouldnt you assume peritoneal effusion is hemorrhage
it can be uroabdomen and perforation of GI tract (causing peritoneal effusion)
do diagnostic abdominocentesis
T/F: you should perform a single abdominal POCUS with intraabdominal injury
False - serial imaging is very important
What should you do for the neurologic system in your secondary survey
Updated MGCS score
Complete neurologic exam
Do not overmanipulate animals with
1) Fractures
2) Soft tissue injury
3) Spinal cord injury
What should you do in addition to your pelvic/perineal/ rectal exam?
assess the patient’s anal sphincter tone and sensation
What parameters are often measured during the secondary survey
1) Initial vitals: temp, HR, pulse strength, resp rate, mucous membrane color, CRT
2) Diagnostic tests: PCV/TS, blood gas, lactate, blood type
Avoid NSAIDS in
cardiovascularly unstable patients due to renal and GI impacts
What does the tertiary survey involve
therapeutic and diagnostic tests and additional interventions like wound repair
How can the mechanism of injury help identify potential injuries
suggests the type and force of trauma
Who typically oversses the assessment and management of injuries during the initial assessment
Team leader
What information is really important to get on the pre-arrival phone call with the owner
the mechanism of injury
Reassessment is key and the frequency of the rechecks should be
based on re-examination findings
