Emergency care Flashcards
What is triage ?
prioritising
gather data - make decisions
What makes up your primary survey in triage?
-TPMR
-POCUS e.g GFAST ( TFAST,AFAST and VetBLUE )
-BP- how aggressive do fluids need to be
-neuro assessment - quick mentation and eyes
-pain assessment - pain relief ( * be careful of hypovolaemic patient NSAIDS will inhibit prostaglandin )
What makes up your secondary survey ?
-further diagnosis - patient side tests
-focused exam -neuro, opthp, ortho, organ - ultrasound
What makes up tertiary survey ?
-full clinical exam
-full history
-imaging /radiography
-other - bloods - haematology/biochem
Shock
tissue hypoxia
What is hypovolaemic shock ?
loss of intravascular volume causing inadequate perfusion ( less cardiac preload )
What 3 things can cause hypovolaemic shock ?
-trauma - fluid pulled out of blood
-haemorrhage - coagulopathy
-fluid loss - vomiting , diarrhoea , polyuria
Clinical signs seen in hypovolaemic shock .
*all relate to body compensating to try restore bp
-tachycardia
-peripheral vasoconstriction- pale mm , prolonged CRT , poor pulse quality
-low bp
-elevated lactate - not enough oxygenated blood to tissues
-on POCUS - collapse of caudal vena cava , poorly filling heart
How to treat hypovolaemic shock ?
-fluid loss - isotonic fluids ( use bolus fluids need to restore quickly )
-blood/plasma loss - transfusion
Distributive shock
relative hypovolemia due to pathological redistribution of intravascular volume
What causes distributive shock ?
-loss of regulation of vascular tone (primarily inappropriate vasodilation )
-leaky vessels
-septic most common form we’ll see - inflammatory cascade release pro inflammatory cytokines to promote vasodilation and permeability
- can occur due to sepsis , anaphylaxis , neurogenic cause
Clinical signs of distributive shock .
-vasodilation - injected mm, shortened CRT ( pooling of blood in membrane capillaries ) ,bounding pulse ,tachycardia due to hypotension
-permeability - peripheral odema , pulmonary oedema , cavitatory effusion * fluid everywhere
-low BP
-elevated lactate
- on POCUS - collapse caudal vena cava , poor heart filling , septic abdomen ( free fluid ) , fluid , gal bladder halo ( oedema of wall )
What are you feeling when feeling a bounding pulse ?
feeling the difference between systolic and diastolic - feels bigger
How to treat distributive shock ?
-volume support - bolus
-vascular tone support - vasopressor - noradrenaline or dopamine
-permeability support - ( make sure oncotic pressure is adequate ) - check albumin levels -if low plasma transfusion , start feeding
TRUE/FALSE distributive and hypovolaemic shock can both occur at the same time
true
How can tell difference between hypovolaemic and distributive shock ?
give fluid bolus- if not responding assume distributive shock and treat as such
What are 2 other types of shock not including distributive and hypovolaemic ?
cardiogenic
obstructive
Cardiogenic shock
cardiac dysfunction - reduced pumping - poor perfusion - blood isn’t getting out to body - only in very small amount
Causes of cardiogenic shock
-myocardial failure - end stage heart disease
-arrythmias - cardiac disease or secondary of splenic disease , hyperkalaemia
-valvular disease -not common
Clinical signs cardiogenic shock
*to do with poor output and peripheral vasoconstriction
-poor pulse
-pale mm
-prolonged CRT
-reduced temp
-low BP - less than 90 systolic
-elevated lactate
-on POCUS - poorly contracting heart , cardiac disease
-ECG - brady-arrythmia or tachy-arrythmia
How treat cardiogenic shock ?
*depend cause
-hyperkalaemia - glucose, insulin , fluid therapy
-splenic disease - remove spleen
-myocardial failure - use a positive inotrope
Obstructive shock
obstruction of big vessels or heart itself
What does bstructive shock cause?
-less circulation - reduced filling - cardiac tamponade
-increased workload for right ventricle
-impendance - blood flow wrong way e.g due to aortic stenosis ( narrowing )
-reduced pre load - e.g reduced venus return due vena cava compression
Clinical signs obstructive shock
-elevated lactate
-on POCUS
loss of glide sign ( tension pneumothorax ) cardiac tamponade =pericardial effusion, collapse RV and A
pulmonary thromboembolism - pulmonary hypertension and RV enlargement
CVC distention / compression
aortic flow obstruction
neoplasia
How treat cardiac tamponade ?
pericardiocentesis
How treat tension pneumothorax ?
thoracocentesis
How to treat GDV ?
Gastric decompression
What to do if immediate removal of obstruction in obstructive shock isn’t possible ?
supportive care
-pulmonary thromboembolism -platlet inhibitors ,oxygen therapy
-neoplasia - force preload through fluid bolus before surgery
Why is ultrasound good for emergency patients ?
-safe
-minimal restraint
-can be performed in unstable patients
-quick
FAST
Focused assessment using sonography for trauma
T-FAST
thoracic FAST
-pericardial effusion , cardiac chambers and contractility
-5 point scan
A-FAST
abdominal FAST
-free fluid in abdomen - abdominal fluid score
-caudal vena cava and gall bladder
- 4 point scan
VetBLUE
vet beside lung ultrasound exam
Global FAST
VetBLUE + TFAST + AFAST
PLUS
Pleural lung Ultrasound
FLASH
fast localised abdominal sonography of horses
-abdominal and thoracic free fluid and small intestine loops
-7 point scan
TRUE/FALSE critical illness promotes protein catabolism and impairs healing
true
Enteral feeding
using tube to enter GI tract to delivery food
Parenteral feeding
use pharmacologically designed product via IV
Approach to head trauma
-can animal breathe - Bony stuc ( crushed nasal bones) , soft tissue ( oral bleeding aspiration risk m crushed/damaged airway )
-brain - bony struc ( skull ) , soft tissue trauma to brain
other injuries - not emergent - e.g broken jaw , proptosis of eye
What can occur secondary to head trauma )?
-rapid metabolism of energy stores in brain - neuronal damage
-proinflammatory state - neuronal damage
- loss of BBB
How to detect head trauma ?
- mentation - obtunded
- eyes - miosis , PLR , mydriasis ( if bilateral mydriasis /normal size pupil /no PLR - poor prognosis )
-cushings reflex = cerebral response to ischaemia - hypotension , bradycardia ( severe )
-glucose - elevated ( stress response )
How treat head trauma ?
-reduce intracranial pressure - with hypertonic fluids
-normalise perfusion - if hypotension fluid therapy and vasopressor , if hypertension pain relief and anti-hypertensive med *don’t want to use , last point of call
*if CO2 doesn’t fix with bp consider intubating
What are the 2 types of thoracic trauma ?
-blunt trauma -pneumothorax, haemothorax ,chylothorax , diaphragmatic hernia
- penetrating injury
Why is getting IV access in a thoracic trauma case important ?
deteriorate rapidly so need to be able to induce and ventilate
Why is tension pneumothorax life threatening ?
-build up of air in the thoracic cavity obstructs venous return to heart , can’t fill properly
TRUE/FALSE completely draining a haemothorax can make it worse
true - allows them to keep bleeding out , pressure stops bleeding ( try not do anything surgical can heal on own)
Approach to penetrating thoracic injury
- anaesthetise
-close wound
-antibiotics
Approach to traumatic thoracic injury
-drain ( unless haemothorax -can resolve on own ) * if not air drain til ventilation improves
Approach to blunt trauma haemoabdomen ( non-penetrating
-usually nonsurgical - if organ not ruptured
-conservative management - fluid therapy ( help perfusion )
-could do abdominal wrap
-tranexamic acid - helps clots form and stay ( seems quite dangerous , maybe good grey hounds as they bleed )
Approach to penetrating haemoabdomen injury
-usually surgical
-stabalise - fluid therapy , transfusion ( blood products )
-anesthetise ( have lidocaine ready )
-ex lap - look for site of bleed *if can’t be stopped pack and close re-operate 24-48 hours later
Approach to pneumoperitoneum ( blunt or penetrating
-usually surgical
-radiography better than POCUS ( air interferes )
-stabilise - can become septic ( distributive shock )
-antibiotics
-exlap ( free gas usually indicative of GI damage - looking for damaged GI )
Approach to uroabdomen
-usually surgical * not always emergency
-life threatening problem =hyperkalemia -treat with glucose and insulin ( these will drive potassium into cells ) , alkalising fluid therapy
-drain abdomen and lavage
-urinary catheter - drain , can use contrast to look at origin of injury (* if not leaking from bladder can be leaking from ureters )
Why is hyperkalemia life threatening ?
prevents repolarisation - bradycardia – atrial standstill
How to spot spinal trauma
-neurological deficits
- at risk distributive shock - lack response to fluid therapy , need vasopressor therapy
TRUE/FALSE if no lesions on radiography of suspected spinal trauma could have spinal bruising which can resolve with time
true
TRUE/FALSE if pectin in back of eye of birds damaged - will never recover
true
