ECP 1 Flashcards
What are 4 ways to make a diagnosis and the best way
- Pattern recognition - I know what that is and what causes it
- Hypothetic-deductive reasoning - problems most likely due to x, I’ll examine and test to verify
- Problem-oriented approach - identify all problems, all differentials for every problem
- Key abnormality method - identify main problem - identify body system associated with signs, id lesions and causative agent
What are the 3 main steps in the HEAPC process and briefly describe
1. History and Examination - identify abnormalities ○ Subjective, objective, diagnostic 2. Assessment - Problem ○ Pathophysiology (general) ○ Differential diagnoses 3. Plan ○ Diagnostic ○ Therapeutic ○ Monitoring ○ Communication
What does the H in HEAPC stand for - 8 steps
- Signalment
- Chief complaint - symptom, clinical finding
- Last normal
- Progression of the current problems
- Systems - vomiting, diarrhoea, coughing, regurgitation, sneezing, polyuria, polydipsia, AAA (attitude, appetite, activity)
- Previous pertinent history - medication or surgical
- Medications
- Environmental history
What does the E,A,P,C stand for in the HEAPC
E
1. Physical examination
2. Other diagnostic techniques
A
1. Problem list and differentials for each problem
P
1. Plan -> Diagnostic, therapeutic, monitoring, communication
C
1. Communication -> referring vets and owner
what problem would you group the following as:
- lethargy, anorexia, painful abdomen, caudal organomegaly, vomiting
Acute abdomen with vomiting
when have hyperthermia what are the 3 things you consider
1) infectious
2) inflammatory
3) neoplasia
what are some things that are possibly life-threatening
- Collapse/loss of consciousness
- Seizures
- Bleeding
- Large or penetrating wounds
- Choking or difficulty breathing
- Protracted or severe vomiting or diarrhoea
- Difficulty urinating
- Toxin ingestion
- Previous life-threatening problems
What do you consider when you first get a emergency patient
ABCs Airways - Is there a patent airway? Breathing - Is the animal making useful breathing efforts Circulation - Is there a heartbeat with pulses
Cardiovascular assessment what are the 5 main assessments and brief
1) Pulses - femoral and metatarsal
2) mucous membranes
3) capillary refill time - gum above canine
4) heart rate
Dogs 80-120 bpm
Cats 160 - 220 bpm
5) cardiac auscultation
Mucous membrane colour in dog what does cyanosis, icterus, brown and cherry red suggest
§ Cyanosis -> hypoxaemia, polycythaemia, paracetamol/acetaminophen
§ Icterus -> sclera best for mild icterus, rarely blue to green eyes in cats
§ Brown -> paracetamol
§ Cherry red -> carbon monoxide poisoning
Respiratory assessment what are the 4 main assessments in brief
1) rate -> RR: 15-25bpm
2) effort -> mild, moderate or severe dyspnoea
3) pattern
4) auscultation and lung sounds = cranioventral louder than dorsocaudal left and right the same
What is the normal inspiration pattern
On inspiration both the chest and abdomen both move out together
□ Chest expansion and diaphragmatic contraction (70-80%)
□ Fall in intrapleural pressure
□ Lung expansion
□ Dilation of intrathoracic trachea
□ Collapse of extrathoracic airways
What are 3 main signs of abnormal inspiration and 4 reasons for this
□ Increased appropriate abdominal movement
□ Abdominal effort
□ Paradoxical abdominal movement -> inspiration abdomen moves inwards
1. Upper airway obstruction 2. Diaphragm dysfunction
3. Stiff lungs
4. Rarely: severe, chronic, pleural effusion
What clinical signs suggest mild dyspnoea
□ Tachypnoea □ No or minimally increased effort □ +/- mild patient distress □ +/- anxious facial expression □ Usually increased, appropriate abdominal movement □ NOT PANTING
what clinical signs suggest “Moderate” Dyspnoea
□ Mild/moderate increased effort □ Extended neck, (abducted elbows) □ Moderate patient distress □ +/- open mouth breathing □ +/- paradoxical abdominal movement □ Glazed-eyed stare □ Often severe paradoxical abdominal movement
what clinical signs suggest severe to critical dyspnoea and what is cyanosis
□ Severely increased effort
Open mouth breathing
Cyanosis -> life-threatening hypoxaemia - ABSOULTE, at this point animal will die if don’t do anything
Neurological assessment what are the 2 main things looking for
1) Gait § Recumbency § Single or multiple limb lameness § Ataxia § Paresis or paralysis 2) Mentation § Depressed, stuporous, comatose § Hyperexcitable, dysphoric, hysterical
What are the 5 main assessments want to do in critical situation and what first
1) cardiovascular
2) respiratory
3) neurological
MOST IMPORTANT
4) abdominal palpation
5) body temperature
What are the 6 things in the structure of the consultation model
1) Preparing for the consultation
2) Initiating the consultation
3) Gathering information
4) Physical exam
5) Explanation and planning
6) Closing the consultation
When preparing for the consult what is the main goal and how to achieve this
GOAL - good first impression
- Familiarise (name, sex, signalment, problem)
- Anticipate potential conflicts or difficulties
- Create a safe and professional environment
Initiating the consultation what are the 2 main goals and briefly how to achieve
1) establish rapport - greet, introduce, demonstrate interest/concern, attend to needs of client/animal
2) identify reason for consult - open-ended question, negotiates agenda
Gathering information what are the 2 main goals and how to achieve
1) explore problems
- Encourage client to tell the story, Open and closed questions, Listen attentively, don’t interrupt, Facilitate
2) understand the client’s perspective - client ideas, beliefs, expectations
What is important to ask in a production system consultation
- ‘Signalment’ of the mob and of the farm
- Chief complaint
- Last normal
○ Has farmer observed the problem, how many affected, other mobs affected - Environment
○ Pattern, treatment, response, protective husbandry - Contacts w other animals on and off farm
Physical examination what is the goal and 3 steps
Goal: a safe and compassionate interaction
- Announce
- Ask about temperament
- Explain
Explanation and planning what are the 4 goals and how to achieve
1) correct amount and type of info
- Assess client’s starting point, “Chunks and checks”
2) aid in recall and understanding
-Organise explanation
○ Signposting ○ Repetition and summarizing ○ Concise, no jargon ○ Use visuals
3) Check for understanding
achieve shared understanding; incorporate client’s perspective
- Explanations that relate to the client’s concerns
4) client understands and is a part of process; increase commitment to the plan
- Share own thoughts, Offer choices, Encourage client to contribute, Negotiate, Check with client
Closing the consultation main goal and how to achieve
Goal: summarize and forward planning
- Recap - Safety net - Check for agreement - Say goodbye!
What are advantages and disadvantages of inhalant anaesthetics
Advantages of Inhalants
- Allow/promote use of supplemental oxygen for patient
- Easy and rapid control of patient depth
- Fairly cost effective
Disadvantages of Inhalants
- Require specialized machine to deliver
○ Initial cost $$$$
○ Can deliver via injection of liquid into system (difficult)
- Risks/hazards of exposure
○ Mutagenic/teratogenic effects in mice
○ Potential for abortions in OR personnel
what is saturated vapor pressure and what leads to it
- Molecules move and collide with each other and walls of container, these allow molecules to escape liquid surface and enter vapor phase, occurs until number of molecules in each phase are in equilibrium. This movement creates pressure leads to SVP
- SVP = measure of liquids ability to evaporate
What does knowing saturated vapor pressure get us and give example with isoflurane and sevoflurane
Knowing the SVP of an anaesthetic allows us to predict the maximum percentage of that anaesthetic that can be achieved
Sevoflurane lower saturated pressure than isoflurane
Maximum percentage is lower than isoflurane
What controlled how much inhalant given to patient and what are the 3 important partial pressures into lungs
- Modern vaporizers deliver a precision controlled concentration of inhalant anaesthetic to the patient
- Vaporizers operate in concentrations (%)
1. Concentration leaving vaporizer = 3% - Partial Pressure (PD) = 760 mmHg x 0.03 = 22.8 mmHg
2. Gas from vaporizer mixes with other gases in rebreathing system. - Concentration & PP ↓
- PI = PP that patient is inhaling
3. Gas reaching alveoli mixes with gas left in alveoli and other gases in airways. - Concentration & PP ↓
- PA = Alveolar PP
What are the 2 things that affect the amount of anesthetic reaching alveoli (at equilibrium reflects the brain)
1) inspired concetration of anaestehtic (vaporiser setting)
2) alveolar ventilation
what do time constants allow us to estimate and how does it rise
- Allows us to estimate how long it will take for the animals tissue concentration to be equal to the concentration in the system
- Concentration in the system rises by first order kinetics
What are the 3 things that increase inspired concentration and how do they work
1) increase vaporiser setting -> set higher initially to reach desired concentration faster
2) increase fresh gas flow -.> increase value on bottom of time constant -> decrease time constant
3) decrease volume of breathing circuit -> decrease number on top of time constant to decrease time constant
Alveolar ventilation what does it affect and how to increase
affects the amount of anesthetic reaching alveoli
- increases ventilation (breath deeper and more often) decreases time constant bringing more gas/inhalant into the body
What are the 3 things that affect anaesthtic uptake into the blood and what does it do to anaesthetic induction
Anything that pulls more anaesthetic from the alveoli will slow anaesthetic induction (alveolar won’t be able to fill up and build concentration gradient)
1) Solubility - MORE soluble taken up from alveoli faster therefore SLOWER induction
2) Cardiac output (CO) - INCREASED more anaesthetic picked up therefore SLOWER indution
3) Alveolar-venosus pressure gradient - INCREASED more movement SLOWER induction
How is solubility measured for inhalant anaesthetics and which is higher sevoflurane or isoflurane
Blood: Gas Partition Coefficient:
- Compares the # of anaesthetic molecules present in each “phase” after equilibration!
- Partial pressure is equal, NOT # of molecules!
Sevoflurane -> lower - LESS SOLUBLE -> faster induction
- Ratios approach 1 faster, steeper curve, equilibrium faster
Isoflurane -> higher - MORE SOLUBLE -> slower induction
- Ratios approach 1 slower, less steep, equilibrium
Distribution of inhalant anaesthetic into the tissues what are the 3 things its dictated by and what causes faster
1) % CO to tissues - INCREASED - faster
2) Volume of tissues - LOWER body weight - faster
3) solubility in tissues - INCREASED - faster
What are the 4 body compartments for inhalant anaesthetics and how long does it take for equilibrium to occur
- The VRG (vessel rich group - brain, major organs) is equilibrated in ~5-20 mins
- The MG (muscle group) is equilibrated in ~2-4 hrs
- The FG (fat group) takes many hours to days to equilibrate
- Vessel poor group (VPG) - igaments ->
You have intubated a dog and placed it on 100% oxygen with the isoflurane vaporizer set at 2%. After 5 minutes you notice that the dog’s HR, RR, and BP all start to rise. You believe the dog is becoming light. What would you do next?
Increase the vaporizer to 2.5% and provide intermittent positive pressure ventilation (squeezing the bag)
MAC what is it, what is it a measure of and the relationship, where measured how differs
The percentage of inhalant in the alveoli that will prevent movement in response to supramaximal noxious sitimulus in 50% of the population (equivalent to ED50)
- MAC is a measure of anaesthetic potency (how much concentration needed to accomplish what is needed)
- Higher MAC LESS POTENT -> higher concertation to accomplish anaesthesia
- Measured at equilibrium between alveoli and brain
- AKA - the ED50
- Differs slightly between species
