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3. Cat & Dog > ECC Triage > Flashcards

ECC Triage Flashcards

1
Q

what is the 5 point triage system with wait time limits?

A

0 mins - immediate
10 mins - very urgent
60 mins - urgent
120 mins - standard
240 mins - non-urgent

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2
Q

what is the Acute Patient Physiological Laboratory Evaluation (APPLE)? what variations exist?

A
  • 10-point system (APPLEfull) vs. 5-point system (APPLEfast)
  • Assess severity of diseases presenting to ICU
  • Requires blood results
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3
Q

Triage Team consists of

A

Client - Receptionist - Veterinary Technician - Veterinarian

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4
Q

compenents / stages of triage

A
  • telephone triage
  • waiting room triage
  • primary survey
  • secondary survey
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5
Q

main components of telephone triage

A
  1. extract information
    Signalment
    1° complaint
    Duration / time of event
    Breathing status
    Gum color
    Mentation
    Ambulatory status
  2. Determine urgency
    Immediate consultation
    Consultation (1-2 hours)
    Later appointment
  3. First aid & transport
    Bandage, cooling, immobilize, etc.
    Referral: emergency
    Initial stabilization
    Sedation & analgesia
    Medical records
    ETA
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6
Q

conditions requiring immediate consultation

A
  • Respiratory distress
  • Choking, gagging, coughing
  • Cyanosis, white MM
  • Collapse, loss of consciousness
  • Status epilepticus
  • Heat stress / heatstroke
  • Distended abdomen, unproductive retching
  • Massive bleeding
  • Inability to urinate / no urine production
  • Acute poisoning (antifreeze, xylitol, rodenticide, chocolate, etc.)
  • Electric shock, burns
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7
Q

conditions requiring Consultation ASAP (1-2 hours)

A
  • Cluster seizures
  • Paresis / paraplegia
  • Esophageal / linear foreign body
  • Trauma, bite wounds, fractures
  • Stranguria
  • Severe vomiting / diarrhea
  • Hematemesis, hematochezia
  • Ophthalmological abnormalities
  • Acute deterioration
  • Lethargy, recumbency
  • Pain
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8
Q

Waiting Room Triage
- what do we immediately examine upon arrival?
- what happens if we find life-threatening abnormalities?

A

ØImmediately examined upon arrival:
- Level of consciousness
- Respiratory pattern, rate, effort, noise
- HR, MM, CRT, pulse quality
- Temperature

ØLife-threatening abnormalities:
- Straight to triage / ER area
- Medical urgency, not “first come, first served” - How long animals can safely wait?

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9
Q

examples of life-threatening abnormalities

A
  • White, cyanotic, grey muddy, severely hyperemic MM
  • Bradycardia: cat <120 bpm, dog < 40-60bpm
  • Tachycardia: cat >240 bpm, dog >180 bpm
  • Irregular heart rhythm
  • Perforated or open body cavities
  • Distended abdomen
  • Hyperthermia >41°C, heatstroke
  • Hypothermia <36.7°C
  • Stanguria with firm bladder
  • Dystocia
  • Acute poisoning
  • Burns, chemical injury
    ** If ever in doubt… **
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10
Q

Waiting Room Triage
- things we need verbal consent for

A
  • IV access
  • Initial diagnostics & stabilization
  • Emergency procedures
  • Resuscitation status
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11
Q

Triage Area should have:

A
  • Oxygen supply
  • Vascular access supplies
  • IV fluids
  • ECG monitor
  • NIBP monitor (oscillometric, Doppler)
  • Stocked crash cart
  • In-house laboratory equipment
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12
Q

basic emergency drugs should be on hand to treat what conditions

A

hyperkalemia

hypoglycemia

hypocalcemia

seizures

cardiopulmonary resuscitation

malignant ventricular arrhythmias

anaphylaxis

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13
Q

Primary Survey - what does it assess? when should we start CPR?

A

ØRoutine approach to emergency patient:
- Airway
- Breathing
- Circulation
- Disabilities
> unresponsive, apneic patient > start CPR

ØMajor body systems: respiratory, cardiovascular, central nervous

ØBrief pertinent history (presenting complaint):
- signalment, 1° problem, onset & progression, treatment, preexisting disorders - medications, dose, timing

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14
Q

Respiratory System Evaluation
- what do we do / look for in our visual exam?

A

Ø Hands-off visual examination:
- Orthopnea, nostrils flare, cheek puffing, skin sucking
- ↑ insp. effort: upper airway obstruction
- ↑ exp. effort: intrathoracic lower airway obstruction
- Rapid shallow breathing: pleural space disease, ↓ lung compliance
- Paradoxical breathing
- Cyanosis (SpO2 < 75%, PaO2 40-50 mmHg)
- Brown MM: methemoglobinemia (e.g. acetaminophen toxicity)

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15
Q

Respiratory System Evaluation
- what do we look for with our thoracic auscultation?

A
  • Stertor (snore) vs. stridor (high-pitched noise): upper airway issues
  • Wheezes (whistling): small airway inflammatory disease
  • Crackles: pulmonary edema, pneumonia, contusions
  • Dull / quiet: pleural space disease, lung consolidation
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16
Q

Respiratory System Evaluation
- what do we look for with pulse oximetry? what is normal vs abnormal?

A
  • 100% hyperoxemia (PaO2 >110 mmHg)
  • > 95% normal (PaO2 80-110 mmHg)
  • <90% severe hypoxemia (PaO2 <60 mmHg)
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17
Q

basic components of respiratory system evaluation

A

Ø Hands-off visual examination
Ø Thoracic auscultation
Ø Pulse oximetry

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18
Q

first part of emergency stabilization
- what should we do?
- what do we do to stabilize respiratory system?

A

Ø Minimize stress + handling
Ø Sedation, sedation, sedation
- Butorphanol 0.2-0.4mg/kgIV,IM
- Acepromazine 0.01-0.05mg/kgIV

ØOxygen supplementation
- Flow by, mask
- Hood, cage
- Nasal prongs, intranasal cannula (unilateral, bilateral)
- High flow nasal cannula
Ø Endotracheal intubation + positive pressure ventilation
Ø Emergency tracheostomy
Ø Thoracocentesis

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19
Q

Cardiovascular System Evaluation
- main things we look at

A

Ø Perfusion parameters
Ø Heart auscultation + pulse assessment
Ø Shock index (HR ÷ systolic BP) >1.0
Ø ECG rhythm
Ø Non-invasive blood pressures

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20
Q

Cardiovascular System Evaluation
- what perfusion parameters do we look at?

A
  • Pale / white / grey muddy vs. injected MM
  • Prolonged vs. rapid CRT
  • Cool extremities / hypothermia vs. pyrexia
21
Q

Cardiovascular System Evaluation
- what heart auscultation and pulse assessment parameters do we look at?

A
  • Tachycardia, bradycardia
  • Muffled heart sound, high-grade heart murmurs
  • Arrythmia, pulse deficits
  • Weak, thready vs. bounding pulses
22
Q

what is the shock sequence of events?

A
  • poor tissue perfusion
    > decreased tissue DO2
    > critical tissue hypoxia
    > multiorgan dysfunction
    > death
23
Q

Cardiovascular System Evaluation
- what should we assess about ECG rhythm?

A
  • Ventricular tachycardia
  • Supraventricular tachycardia
  • Atrial fibrillation
  • 1-3° AV blocks
  • Torsade de pointes
  • Ventricular fibrillation
24
Q

Cardiovascular System Evaluation
- what systolic and mean blood pressures are problematic?

A
  • Systolic <90 mmHg, >200 mmHg
  • Mean <60 mmHg
25
Q

Emergency Stabilization for cardiovascular sysytem
- what do we need? what if there is V-tach?

A

Ø Vascular access
- Short, large IV catheter
- IO catheter
- Cut down approach

Ø Intravenous fluid resuscitation
- Pressure infusion bag vs. fluid pump

Ø Vasopressors, antiarrhythmics, pericardiocentesis

ØFour (4) criteria to treat V-Tach:
i. symptomatic
ii. >160-180 bpm
iii. polymorphic / multiform ventricular premature complexes (VPCs)
iv. R-on-T phenomenon

Ø Lidocaine bolus: 2 mg/kg IV, can be repeated - toxic dose 🐕: 10 mg/kg
- toxic dose 🐈: 5 mg/kg - avoid

Ø Followed by lidocaine CRI: 25-80 ug/kg/min

26
Q

Four (4) criteria to treat V-Tach:

A

i. symptomatic
ii. >160-180 bpm
iii. polymorphic / multiform ventricular premature complexes (VPCs)
iv. R-on-T phenomenon

27
Q

Central Nervous System Evaluation
- what should we assess?

A

Ø Mentation / level of consciousness
Ø Pupils
Ø Cushing’s reflex
Ø Posture
Ø Gait (ambulatory) vs. spinal integrity (non-ambulatory)

28
Q

Central Nervous System Evaluation
- what do we assess about level of consciousness?

A
  • Obtunded&raquo_space; stuporous (painful stimuli)&raquo_space;> comatose
  • Tremor vs. seizures
29
Q

Central Nervous System Evaluation
- what do we assess about pupils?

A
  • Anisocoria, pinpoint vs. fixed & dilated, -ve PLR: midbrain (CN III nucleus)
  • Strabismus (CN III, IV, VI)
  • -ve physiologic nystagmus: brainstem pathway (CN VIII, MLF, III, IV, VI)
30
Q

Central Nervous System Evaluation
- what is cushing’s reflex?

A

CPP = ↑↑ MAP - ↑ ICP
- Hypertension, reflex bradycardia

31
Q

Central Nervous System Evaluation
- what do we assess about posture?

A
  • Decerebrate (severe midbrain-pons) vs. decerebellate (cerebellum) rigidity
  • Schiff-Scherrington (T3-L3)
  • Cervical ventroflexion: severe hypokalemia
32
Q

Central Nervous System Evaluation
- what do we assess about Gait (ambulatory) vs. spinal integrity (non-ambulatory)?

A
  • Motor activity: paresis vs. paralysis
  • Spinal reflexes
  • Deep pain
33
Q

Emergency Stabilization for seizures?

A

(rule out hypoglycemia, hypocalcemia)
- Benzodiazepines IV, PR, IN, CRI
> Diazepam 0.5 mg/kg
> Midazolam 0.3 mg/kg
- Phenobarbital, levetiracetam
- GA: propofol, isoflurane

34
Q

Emergency Stabilization for increased ICP?

A
  • Hypertonic saline 3-5 mL/kg IV
  • Mannitol 0.5 g/kg over 20 mins IV
35
Q

Emergency Stabilization if you suspect spinal instablity?

A
  • Immobilization
36
Q

Emergency Stabilization for hypoglycemia

A
  • 50% dextrose bolus: 0.5-1.0 mL/kg IV (at least 1:1 or 1:4 dilution)
  • recheck (30 mins) ± repeat bolus
  • consider 2.5% or 5% dextrose CRI
  • no vascular access: corn syrup PO
37
Q

Emergency Stabilization for hypocalcemia

A
  • 10% calcium gluconate: 0.5 mL/kg slow IV
  • with ECG monitoring
38
Q

how do we assess urogenital system and abdomen for triage

A

ØShort abdominal palpation
- Large, firm bladder: urethral obstruction

ØReproductive emergency
- Dystocia
- Priapism
- Paraphimosis

ØExternal injuries
- Active hemorrhage, open wounds
- Prolapsed organ
- Fractures

Ø Intoxication

ØSignificant pain

POCUS

39
Q

Preliminary Diagnostics for emergency care

A

ØMinimum emergency database
- PCV, TS
- Blood glucose
- Electrolytes (Na+, K+, Cl-, iCa2+)
- Blood gas (pH, PCO2, HCO3-, ABE)
- Lactate
- BUN
- Activated clotting time (~aPTT)

ØSave extra blood: EDTA + serum / heparin&raquo_space;> citrate

40
Q

Emergency Stabilization for hyperkalemia

A
  • 10% calcium gluconate 0.5-1 mL/kg IV over 2-5 mins with ECG monitoring
  • regular insulin 0.25-0.5 U/kg IV + 50% dextrose 2-4 mL/U insulin (diluted 1:1)
  • 50% dextrose: 1-2 mL/kg IV bolus (diluted 1:1)
  • Transient: address underlying cause!
41
Q

Triage Diagnostics - what do we examine?

A

Ø Pleural / abdominal effusion
Ø Urine

Septic process
Uroabdomen
Bile peritonitis
Blood smear
Fluid cytology

42
Q

Triage Diagnostics
- what do we do to examine pleural / abdominal effusion?

A
  • PCV, TS: recent hemorrhage
  • TS, cytology: transudate vs. modified transudate vs. exudate
  • In-house fluid analysis: septic, uroabdomen
  • In-house fluid cytology: septic, neoplasia
  • Extra: fluid cytology, bacterial culture & antimicrobial susceptibility testing
43
Q

Triage Diagnostics
- what do we do to examine urine?

A
  • USG
  • Urine dipstick: ketonuria, glucosuria, proteinuria, heme
  • Extra: UA, bacterial culture & antimicrobial susceptibility testing
44
Q

Triage Diagnostics
- how do we assess a septic process?

A

Blood - effusion glucose = >1.1 mmol/L Effusion - blood lactate = >2.0 mmol/L

45
Q

Triage Diagnostics
- how do we assess a uroabdomen?

A

Effusion: serum K+ (dog) = >1.4:1
Effusion: serum K+ (cat) = >1.9:1

46
Q

Triage Diagnostics
- how do we assess a bile peritonitis?

A

Effusion: serum bilirubin = >2:1

47
Q

Triage Diagnostics
- how do we assess a blood smear?

A

Platelet clumps
Normal platelets: 8-15 plt/hpf
Spontaneous bleeding: <2 plt/hpf

48
Q

Triage Diagnostics
- how do we assess fluid cytology?

A

Cellularity: cell population
Neutrophils: degenerated
Intracellular bacteria: rod, cocci, etc.

49
Q

what is included in the secondary survery?

A

ØFull PE
ØThorough history
ØProblem lists
ØDiagnostic plans
ØFull discussion
- Significant findings
- Prognosis
- Financial implications
- Informed, written consent

3. Cat & Dog (33 decks)

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