Emergency and Critical Care Nursing: Small animal Flashcards
Triage
A triage is when patients are quickly sorted into groups based on a quick assessment of illness or injury severity.
Telephone Triage
The veterinary technician must ask specific and essential questions rapidly to distinguish between an actual life threatening emergency or a situation that can wait.
In-Hospital triage is broken into what 3 groups?
- those needing immediate care or stabilization
- those needing to be taken to tx for other reason (bleeding, vomiting, diarrhea, contagious ect.)
- those that can wait with O until staff available
How long is the initial triage exam?
1-2 minute systematic evaluation of essential organ systems (resp, cardiac, neurological exams).
Define Tachypnea
Increased respiratory rate
Define Hypoxemia
Decreased oxygen in the blood
What medical issues can cause tachypnea?
Hypoxemia, thoracic trauma, shock
Non respiratory sources: pain, stress, increased temp, traumatic brain injury or metabolic acidosis
Define Bradypnea
Decreased respiratory rate
What is bradypnea commonly associated with?
Toxin exposure or elevated intracranial pressure
Inspiratory dyspnea- results in slow, long inspirations with short exhalations. What can this indicate?
Extra-thoracic airway obstruction (laryngeal paralysis) or swelling associated with an acute hypersensitivity reaction
Expiratory dyspnea- increased abdominal effort on expiration. Usual causes:
Often develops if an intrathoracic airway obstruction (ex. mass) compressing the airway or an inhaled foreign body is present
How is labored breathing described?
Breathing that is prolonged and deep
What would indicate restrictive breathing?
Fast, short, and shallow breaths (reflect impaired ability to expand the lungs).
What are some causes of restrictive breathing?
Rib fractures, pleural space disease )pleural effusion, pneumothorax, tumors), late diseases of lung tissue
Define Orthopnea
Term used to describe the condition of maintaining a specific posture to ease breathing. (p can become very stressed when placed in a different position)
Describe apneustic breathing pattern
Deep inhalation with an abnormally long pause before exhalation (typically indicates brain injury)
Define Cheyne-Stokes breathing
Refers to a pattern of alternating tachypnea and bradypnea (occurs when CO2 regulation of respiration is interrupted)
What does it indicate if a P has Cheyne-Stokes breathing pattern?
Severely increased intracranial pressure
After initial triage exam checking respiratory, circulatory, and neurological systems the abdomen should be palpated. The abdomen is palpated for what?
- pain- could indicated need for sx
- tympany- possible gas-filled GI structure
- fluid wave- could indicate hemorrhage, fluid buildup from inflammation or heart failure
Define Kussmaul breathing
Slow, deep, regular respiratory pattern ( indicating respiratory compensation for a metabolic acidosis such as DKA)
Describe flail chest (paradoxical chest excursion)
When segment of thoracic wall moves opposite to breathing (chest wall moving in on expiration and chest wall going out on inspiration)
Describe paradoxical abdominal breathing
When the abdomen moves inward during inspiration instead of outward(indicates diaphragm likely paralyzed and p may need immediate assistance to stabilize breathing)
If lung sounds decreased dorsally think..
Pneumothorax
If lung sounds decreased ventrally think..
Pleural effusion
Borborygmi in the thorax may indicate
Diaphragmatic hernia, but can also be referred from abdomen
What does the initial cardiovascular triage exam assess?
Mentation, HR and rhythm, pulse quality, CRT, extremity temp, and MM color
Name one difference between cats and dogs presenting with shock
Cats typically present bradycardic wild dogs typically present tachycardic
Tachycardia in a p can indicate what in an emergency situation?
Compensation for a shock state, pain, anemia, anxiety, or a combination of these
Bradycardia in a p can indicate what in an emergency situation?
Life -threatening arrhythmia or in animals with urethra obstruction it can indicate extremely elevated potassium level
What is the difference between pulse quality and pulse pressure?
Pulse pressure is the diff between systolic and diastolic pressures, pulse quality is how quickly the pulse pressure changes and how long each pulse lasts
A weak and thready pulse typically occurs in conjunction with tachycardia. What can this indicate?
Hypotension, hypovolemia, decompensated shock
A snappy pulse has very large pulse pressure and an extremely rapid rise and fall. When does this commonly occur?
Anemia, patent ductus arteriosus, or severe aortic regurgitation
What does the Neuro exam during initial emergency triage try to determine?
Whether or not there is a TBI (traumatic brain injury) or not
What are findings supportive of TBI
Abrupt changes in mentation, changes in pupil (size, symmetry, responsiveness), altered gait or posture, altered proprioception and evidence of trauma to the head
How does a stuporous animal react to environment or stimuli?
P is completely disconnected from environment and reacts only to noxious (painful or prolonged) stimuli
How does a stuporous animal react to environment or stimuli?
P is completely disconnected from environment and reacts only to noxious (painful or prolonged) stimuli
Define mydriatic pupils.
Fixed and dilated
What does unresponsive mydriatic pupils indicate?
Can indicate irreversible midbrain lesion
What do unresponsive midrange pupils suggest?
Lesion in the medulla and supportive of brain injury
Define anisocoria
Asymmetry in pupil size.
What can anisocoria indicate?
Acute cerebral injury (blood clot, hemorrhage, TBI) or Horner syndrome
Define Horner syndrome
Nerves controlling the pupil are affected but brain is not injured
Describe decerebrate posture
Extreme rigidity of all four limbs. May involve opisthotonus (arching of neck and back)
What does decerebrate posture indicate?
Complete disconnect between the forebrain and the brainstem. Often p is stuporous to comatose and carries a grave prognosis
Describe decerebellate posture
Rigid forelimbs and flexed hindlimbs- rigidity may be noted in all four limbs
What is the main difference between decerebrate posture and decerebellate posture?
P with decerebellate posture present with normal mentation
What does decerebellate posture indicate?
Severe injury to the cerebellum
Describe Schiff-Sherrington posture
Can mimic decerebrate or decerebellate posture. Typically forelimbs are rigid and hindlimbs are flaccid. However, p has normal mentation and can often ambulate when placed on its feet
What is Schiff-Sherrington posture assoc. with?
T3-L3 spinal cord lesion
What are some common labwork abnormalities assoc. with dehydrated p’s?
Hemoconcentration, azotemia, hypernatremia, and elevated albumin
Define hemoconcentration
A decrease in plasma volume, which causes a simultaneous increase in the concentration of red blood cells and other commonly tested constituents of the blood
Define azotemia
Elevated levels of urea and other nitrogen compounds in the blood
Define hypernatremia
A high concentration of sodium in the blood
If azotemia noted, USG should be checked. What USG value indicates prerenal (resulting from decreased renal blood flow) azotemia?
USG greater than 1.050- usually secondary to dehydration
What is the typical USG in the case of isosthenuria?
1.012-1.018 (dogs) and 1.012-1.022 (cats)
Isosthenuria in combination with dehydration and azotemia suggests what?
Renal disease is present
What is the normal blood pH for veterinary p?
7.4pH
What can cause a high pH?
Severe vomiting
What are the normal blood pressure ranges for cats and dogs?
Systolic- 100-140
Diastolic- 60-80
Mean- 70-100
What signs of hypovolemia may be noted?
Tachycardia, prolonged CRT, weak pulse, hypotension
Initial diagnostics in an emergency should include what?
PVC, TP, BG, BP, blood gas analysis, pulse ox, ECG, FAST scan
Low PCV may be from what?
RBC loss or RBC destruction (immune mediated)
PaO2 = what?
partial pressure of oxygen in arterial blood- can be used to assess pulmonary function
What is a normal PaO2 value?
80-100 mmHG
What is a concerning PaO2 value?
less than 60 mmHG- if p can’t maintain above 60 w/O2 supplementation mechanical ventilation is warranted
What 4 abdominal sites are checked with the FAST scan?
subxiphoid area, each kidney, and bladder
What type of shock is seen most often in cats and dogs?
Hypovolemic shock-result of decreased circulating blood volume
Why does distributive shock occur?
Maldistribution of blood flow, from inappropriate vasodilation leading to pooling of blood in the capillaries
When is distributive shock typically seen?
In cases of anaphylaxis, sepsis, heat stroke, and envenomation- usually weak or bounding pulses and pink mm are noted
When does obstructive shock occur?
When venous return to the heart is impaired
When is obstructive shock seen?
Commonly with GDV, pericardial tamponade
Describe pericardial tamponade
When increase intrapericardial pressure causes the collapse of the right atrium
When does cardiogenic shock occur?
Secondary to problems in the heart itself, P will have weak pulses, hypotension, and pale MM, cold extremities, pulmonary edema, ascites
When does septic shock occur?
After a severe infectious insult-pneumonia, GI perforation, infected bite wounds. TX with fluids, broad-spectrum antibiotics
How do septic animals often present?
Bright red mucous membranes, bounding pulses, often with fever and sometimes generalized erythema
Describe systemic inflammatory response syndrome(SIRS).
During shock, an inflammatory response develops (normally with infection it’s localized). Shock results in widespread tissue hypoxia and damage and inflammation can progress from local to systemic response.
SIRS results in widespread vasodilation leading to what?
Hypotension, tachycardia, tachypnea, fever and often marked increases or decreased in WBC count
What does DIC stand for?
Disseminated intravascular coagulation- results from SIRS- widespread inflammation causes activation of WBC , causing additional damages to tissues endothelial lining of blood vessels and organs, causing PLT to activate and the clots occlude capillaries (causing more impairment to blood flow) and spontaneous bleeding can occur while concurrent clotting is happening =(DIC)
What does MODS stand for?
Multiple organ dysfunction syndrome- results from SIRS-as SIRS progresses to microvascular clotting it can lead to organ failure
TX for DIC
IV fluids, vasopressors, antibiotics, blood transfusion, mechanical ventilation
When are vasopressors used?
Vasopressors are medicines that constrict (narrow) blood vessels, increasing blood pressure. They are used in the treatment of extremely low blood pressure, especially in critically ill patients.
Describe reperfusion injury
During shock or CPA, cells become starved for O2 and use anaerobic respiration- resulting in elevated levels of lactate and cellular byproducts, which promote tissue damage. As blood flow and O2 delivery to tissues restored the lactate and free radical molecules are released into systemic circulation, WBC drawn to damaged tissue where they activate and release additional inflammatory mediators, contributing to free radical production
If pneumothorax suspected where should the needle be places for thoracocentesis?
Insert needle or IV cath should be placed in dorsal 1/3 of thorax
If pleural effusion suspected where should the needed be placed for thoracocentesis?
Insert needle or IV cath in ventral 1/3 of thorax
During thoracentesis where should the needle or catheter be placed?
At the 7th-9th intercostal spaces- needle or catheter should always be advanced off the cranial aspect of the rib
Describe dyspnea
Respiratory difficulty or distress
Why might you choose to do thoracentesis in a dyspneic p before radiographs performed?
Helpful as it allows expansion of lungs, making rad identification of tumors and lesions much easier
What does pulse ox measure
Percent of hemoglobin molecules that are saturated with O2- DOES NOT reflect oxygen content of blood or PaO2- as long as pulmonary function is normal, even animals with severe anemia can have normal pulse ox
What is a common complication of mechanical ventilation?
Pneumonia- can lead to sepsis and organ failure-usually p requiring mechanical ventilation have a very guarded prognosis
In terms of CPR- what is the difference between basic life support and advanced life support?
Basic- chest compressions and ventilation
Advanced- medications, defibrillation, open-chest procedures
During CPR- how many chest compressions should cats and small dogs under 15lbs get? “Cardiac Pump Method”
P should get 120-130 compressions per minute
During CPR- How many chest compressions should a large dog get?
P should get 100 compressions per minute
During CPR- what are some ways to monitor the effectiveness of chest compressions?
Place lubricated doppler probe on cornea (provides auditory feedback as eyes and brain are perfused)
Monitor ETCO2- values between 10-15mm Hg indicate compressions adequate- however, survival is most likely when ETCO2 values above 20 mm Hg
Describe the cardiac pump method
P is in lateral recumbency, rescuer’s hand encircles the ventral chest, compression applied directly over the heart using the entire hand
During CPR- How many breaths should a p get per minute? It is the same for p regardless of size.
8-12 respirations per minute
How long is 1 cycle of CPR?
2 minutes
Describe asystole
Flatline- complete cessation of all mechanical and electrical activity in the heart
What are common treatments of asystole?
Epinephrine, vasopressin, or atropine
Describe PEA (pulseless electrical activity)
Occurs when the electrical system of the heart is functioning (evidenced by complexes on ECG) but no mechanical heartbeat occurs in response to electrical stimulation
If PEA occuring what does it look like on ECG?
can be diverse, but it often mimics ventricular arrhythmia, with wide bizarre QRS complexes occuring at a slow rate
What are common TX of PEA?
Epinephrine, vasopressin, naloxone in certain cases
Describe ventricular fibrillation
Highly disorganized contractile activity of the heart- often preceded by rapid ventricular tachycardia
What is the TX of choice for ventricular fibrillation?
Defibrillation- use after 1st cycle of CPR
What is the acronym NAVEL for?
Drugs that can be given safely through ET tube
Naloxone, Atropine, Vasopressin, Epinephrine, Lidocaine
Define Atelectasis
Complete or partial collapse of a lung or a section (lobe) of a lung.
Why might dopamine be given post CPA/ successful CPR?
It improves blood pressure by causing peripheral vasoconstriction-must monitor ECG and PB as it can cause tachycardia and arrhythmias
Why might dobutamine be given post CPA/ successful CPR?
It increases cardiac output by increasing cardiac contractility- must monitor ECG and PB as it can cause tachycardia and arrhythmias
What is CVP and what is the typical pressure of the cranial vena cava?
Central venous pressure- refers to blood pressure in central veins. Monitoring CVP can reflect the efficacy of fluid therapy- norm pressure for cranial vena cava is 0-5 cm H2O
What are the most common sites to monitor arterial blood pressure?
Dorsal metatarsal artery and femoral arteries
How often should arterial catheters be flushed?
Q 2 hrs
What is the cardiac conduction system composed of?
The sinoatrial node, atrioventricular node, bundle of His, left and right bundle branches, and purkinje fibers
Atrial depolarization corresponds to what wave on an ECG?
P wave
Conduction through the AV node corresponds to which interval on the ECG?
P-R interval
Nearly simultaneous left and right ventricular depolarization corresponds to which complex on an ECG?
QRS complex
Ventricular repolarization corresponds to which wave on an ECG?
T wave
How should the electrocardiogram be evaluated? Analyze four basic features
Heart rate, rhythm, measurement of waveforms and intervals, and the mean electrical axis (MEA)
What is a tall P wave (P-pulmonary) consistent with?
Right atrial enlargement
What is a wide P wave (P-mitrale) suggestive of?
Left atrial enlargement
Prolongation of PR interval can occur why?
Increased vagal tone, or structural AV nodal disease
Prolongation of the PR interval is known as what?
First-degree AV block
How is the PR interval measured?
From the beginning of the P wave to the beginning of the QRS complex or the R wave if no Q present
What does the QRS complex indicate?
Ventricular depolarization
A tall R wave in lead II suggests what?
Left ventricular enlargement
A deep S wave suggests what?
Right ventricular enlargement
What might a wide QRS complex indicate?
Ventricular enlargement, bundle branch block, or ventricular ectopic beat
Elevation or depression of ST may be caused by what?
Regional myocardial ischemia
Tall tented T waves are a hallmark finding of what?
Hyperkalemia
Arrhythmias originating above the AV node are classified as what?
Supraventricular arrhythmias
Arrhythmias originating from bellow the AV node are classified as what?
Ventricular arrhythmias
What might a sinus arrhythmia indicate in a cat?
Excessive vagal tone caused by underlying central nervous system, respiratory, or G.I. disease
Differentiate between APC vs. VPC
APC have normal lay shaped QRS and associated with a P wave
VPC have abnormal, wide and bizarre QRS complex and are not associated with a P wave
Define atrial tachycardia
4 Or more APC’s is in succession and often has a sudden onset and termination
What are some causes of APC’s?
Commonly associated with atrial enlargement secondary to structural cardiac disease. Other causes include atrial Neoplasia,hyperthyroidism, and hypoxia
Define atrial flutter
Rapid rhythm with supraventricular QRS complexes and sawtooth flutter waves instead of P waves
When does atrial flutter often occur?
Secondary to severe left atrial enlargement and commonly degenerates into atrial fibrillation
Describe atrial fibrillation
Rapid, irregularly irregular Rhythm with supraventricular QRS complexes, no identifiable P waves, and the presence of fibrillatory waves (F waves)
Define ventricular tachycardia
A run of four or more VPCs in succession at a rapid rate greater than 180 bpm
Define accelerated idioventricular rhythm (AIVR)
A ventricular rhythm with a relatively normal rate ( 60-160 BPM) that competes with the normal sinus rhythm
What is AIVR often caused by?
Extracardiac disease- ex. vehicular trauma, splenic mass, GDV- affects the heart through perfusion deficits or depressant factors
Define ventricular fibrillation
Life -threatening rhythm characterized by chaotic, irregular waves resulting from lack of organized ventricular activity
What does ventricular fibrillation look like on ECG?
No P-QRS-T complexes, only irregular oscillations of varying size are noted- electrical defibrillation should be performed immediately
Describe atrial standstill
A rhythm in which atrial depolarization does not occur- characterized by the lack of P waves- bradycardia
What is the most common cause of atrial standstill?
Hyperkalemia
What would indicate a first degree AV block on ECG?
Prolonged PR interval
What would indicate a second degree AV block on ECG?
P waves followed with QRS complex and some P waves with no QRS complex
What are the two types of second degree AV blocks?
Mobitz type I and Mobitz type II
What would indicate a third degree AV (complete heart block) block on an ECG?
Multiple P waves with no association to QRS complexes- No consistency in PR intervals
