Emergency Critical Care Flashcards
first step in an emergency
triage exam- ABC
A-Assess airways
B-Breathing?, Circulation
if no issues with htese check also DE
D- disability: seizure? ambulatory? demenour
E- skin bone or musce damaged??? evalutate uriary system. palpate bladder in every cat
Paradoxical breathing
when the chest expands during inhalation and the abdomen is drawn inwards and then during exhalation the abdomen is pushed outwards. as opo
Stertor
‘Stertor’ is noisy breathing which occurs above the larynx.
more like a snore
wetter sound
Stridor
noisy breathing that occurs at the level of the larynx or below.
an abnormal, high-pitched respiratory sound produced by irregular airflow in a narrowed airway
dryer sound
honking cough
issue in the trachea
wheezes auscultated in stethoscope
expiritory issue
crackles auscultated in stethoscope
lung parenchima issue
emergency treatment for respiritory distress
- Oxygenate-
□ Oxygen tent- allows control of FiO2, control of temp, control of humidity, co2 removal
□ Mask/ flow by- can be given while doing procedure, needs to be close to patient to be effective, Small increase of Fio2
□ Intubation- can achieve Fi02 100%, protection of airways, invasive- Localized in lower airway?- bronchodilator, contraindicated in pneumonia - Sedation - Gain IV access
sedation for respiritory distress
butorphanol- mu antagonist, kappa agonist. good sedation, little to no analgesia. good choice for everything EXCEPT anything needing analgesia. has antitussive properties. blocks the opertunity to give other opiods- 4 hours
alpha 2s cause peripheral constriction and then reflexive vasodilation and bradychardia. reverasble and short acting. much better pain managment but not benign on cardiovascular system. do not give to decrease heartrate
benzodiazapines- good fir unknown cardiovascular status, short acting and benign on those systems. can cause exitability
ACP- good sedative, no analgesia, NOT benign on cardiovascular system- vasodilation and not reveribe, takes longer to act. prolonged sedation- 4-6-8 hours. good for a prolonged recovery- heat stroke, BOAS, larygngeal paralysis ect
alfaxan and propofol usually interchangable however for longer term use alfaxan safer for cats (heinz body anemia)- alfaxan can be given IM
emergency diagnostics for respiritory distress
T-POCUS
NT-proBNP
C-POCUS
chest x rays should be done later when the appropriate tim ecan be taken
t- pocus
normal- should see rib, rib shadow, pleural line, subcutanious muc=scle and fat
a- lines: horizontal lines caused by reverberation from the air in the plural line- you cannot see the lung on ultrasound but you can only see a-lines with healthy lung
abnormal-
B lines- vertical lines caused by fluid accumulation in interstissial space- blood, oedema, inflamation (cannot tell what the fluid is but put it into context of case- RTA= BLOOD ECT)
When seen cranioventrally- Aspiration
when seen- perihelially (base of heart)- cardiogenic pulmonary oedema
hypoechoic line- fluid- can see conotour of lung. beam has not encountered air
NT- proBNP
a hormone released when their is atrial streach- the atrium is streached
if abnomal problem could be cardiact however can be abnomal in absense of heart disease
more diagnostic when it is normal as it its ore sensitive than specific
thoracosentesis
first step to treating pulmonary oedema caused by heart failure
interconstal space 7- position needle ventral and crainially
go on cranial aspect of rib to avoid vesels
use three way tap- needle in front, syringe and back, siscade line
butterfly needle
if blood is drained run pcv solid- pcv is low in effusion, so you know you are in pleural space and not vessel or heart. blood not from pleural space will clot and so needle should be retracted
once much of the fluid is drained the lung may brush up against the needle, o needle can be directed downwards to collect fluid
transudate
fluids that pass through a membrane or squeeze through tissue or into the EXTRACELLULAR SPACE of TISSUES. Transudates are thin and watery and contain few cells or PROTEINS.
indicated issue with hydrostatc or oncocotic pressue
congestive heart failure= high hydrostatic pressure
liver falure= low osmitoc pressure = transudate or modified transudate
<2.5 total protien (modified transudate >2.5 but less than 5 nucleated cells)
<1.5 nucleated cella
macrophages, neutorphils , lymphocytes and mesothelial cells present
exudate
s fluid that leaks out of blood vessels into nearby tissues. The fluid is made of cells, proteins, and solid materials. Exudate may ooze from cuts or from areas of infection or inflammation.
infection or inflamation causes vesseles to become “ leakier”- resulting in exudate
> 2.5 protien, often >4
greater than 5 nucleated cells
predominantly neutrophils on cytology
chylous effusion
looks like strawberry milkshake
fluid analysis
the presence of chyle in the pleural space and usually result from disruption or obstruction of the thoracic duct.
can do biochem on fluids
can look at glucose (low glucose in infection as it is being consumed)
high lactare indicates infection
pottaium and creataine ratio- compare with blood. higher in effusion can indicate uero abdomen
billirubin can indicate peritonitis
furosomide
Furosemide is a loop diuretic medication used to treat edema due to heart failure, liver scarring, or kidney disease.
second stage of treatment for cardiac disease
can be given im if iv acess cannot be established
pimobendan
a heart medication used to treat dogs with congestive heart failure (CHF), usually caused by either dilated cardiomyopathy or valvular insufficiency. Its use in cats to treat heart failure is ‘off label’ or ‘extra label’
increases contactility- positive ionotrope
makes heart work smarter not harder
better in dogs in dilated carsiomyopathy but in cats not as effective at the ventrical is already woring and the problem is diastolic- the blood cannot travel properly due to the shape of the heart
clopidorel
an antiplatelet medicine. It prevents platelets (a type of blood cell) from sticking together and forming a dangerous blood clot.
helps prevetn clots due to the turbulent flow of blood in cat heart falure- hypertorphic cardiomyopathy
monitoring in cardiac cases
createnine and electroliytess- 24-48 hours- how are the kidneys doing on diaretics, will increase pre-renally but still good to monitor for AKI
monitor sodium and chlorisde, check if pottasium needs suplimented
hypradion status- q12hrs
reaspiritory rate and effort-q1-2hr
diagnostics for a blocked cat
Minimum database- check for high K, urea, createnine
latate- marker of perfusion but also up with stress
ECG- looking for absent p waves and HIgh T (greater than 1/3 of QRS indicating atrial standtill- this is a consiqiuense of high potassium
contrast study
urinalysis
managment for a hypercalemic blocked cat
resolve primary problem- when safe- cystocentesis, sacrococcygeal block, catheter
ivft- encorages excretion to excrete clcium
10% calcium gluconate
- allows action potentail to be reastablished and puts threshold higher so protects the heart form unwanted depolarisation
insulin and dextrose- drives pottasium into cells but mantains blood sugar- dextrose alone can also spike insulin which can be helpfull but giving insulin is quicker. with insulin dextrose must be given as CRI
sodium bicarbonate- rarley used. promotes metabolic alkalosis rebalences acid base levels to bring pottasium inside cells
terbutaline- bronchodilator, rarely used. beta 2 agonist. promotes potaissium shift inside cell
urinalysis can indicate need for antibiotics- ISCAID study guidence
cystocentesis
can be performed consous
aseptic prep
lateral reumbancy or standing
use ultrasound guidence
place needle at the level of pelvic brim and advance caudally
use right side fo abdomen if standing
post managment for blocked cat
fluid balance?- post obstructive diurisis requires constant assesment- fluids until cat can compensate, withdraw treatment when able
electrolyte monitoring
pain managment
catheter managment
when to discharge
medication
shock
you do not have enough blood circulating around your body.
a lack of xygen delivery or uptake from cells
systemic vascular resistance
cardica output- preload, after load, contractility, rate
arterial xygen content
factors determining oxygen delivery-
how fast/ how much blood is there
how fast can it get there?
obstructive shock
hypovolemic shock
cardiogenic shock
distributive shock (septic)
managment of hypovolemic shock
oxygen
fluid therapy
warm slowly
tanexamic acid- a medication used to treat or prevent excessive blood loss- 15mg/kg iv. bolus doese every 6 hrs
maropitant- 1mg/kg iv
co-amoxiclav 20mg/kg
pain relief can be considered once stable
ascular volume status
assesed by perfusion parameters
hyovolemia
euvloeamia
hypervolemia
hydration status
= intersitial tissue assesment
dehydrated
overhydrated
fluid therapy hypertonic saline
hyper tonic saline draws fluids into the iv and so rehydrated quicker but nees to be imediatly with hartmans to replace the fluid from the interstitial space
best method to achive adiquate circulating volume quickly as ess fluids are needed
good for situations where the dog may be activly bleeding as less fluids meen less disruption and less dilution of nay clots forming
not 100% neccesary but usefull to know if available
3-5mls over 10 mins- not faster as salt will irritate the heart
fluid therapy- crystaliods for hypovolemic shock
lactated ringers (hearman)best and commonly avilable
0.9% NaCl too much pottassium
plasmalyte not commonly availale but good if magenesium needed
isotonic- roughly the same composition as plasma
10-20ml/kg in boluses over 10-15 mins- consider patient size
fluid pumps cant go faster than a liter per hr- two pumps? pressure infuser? manual pressure?
reasees perfusion perameters between and stop boluses once fine
total shock doses (maximum to give)-
dogs- 80-90/kg per kg
cats- 40-60ml/ kg
then go to hight rate (10ml/kg for an hour
then go at maintinance
coloids
fluids with salts and large molecules
mostly albumin
provided oncotic pressure
used when theres poor oncotic pressure- liver disease ect
natural-
whole blood
fresh frozen plasma
frozen plasma
albumin solution
synthetic- often not used due to aki risk (in long term use in humans)
tetrastarch
pentastarch
hetastarch gelatins
blood products for hypovolemic shock
whole blood
placked rbc
frozen/fresh plaams
platlets
whole blood best but not readily avialable or easy to store
can replace clotting factors with plasma but frozen plasma doesnt have 3,5 and 8
fresh frozen plasma does
frozen plasma has albumin and is a good option- use water bath to defrost
supports vascular lining
provides clotting factord
shock dose (in bolus)- 5-10ml per kg
dogs- blood type if 2nd transfusionm
cats- ALWAYS BLOOD TYPE
autotransfusion??-
will start to dilute
missing platlets
risk of sepsis
drawn out of body cavity with three way tap
diagnostics for hypovolemic shock
ecg- ventricular premature complexes triggered by low output and oxygen
blood pressure- high? due to trying to maintain pressure= compensated shock
ususlly hypotensive in distributive shock
point of care ultrasound- locate and chack for fluid
pcv- low- normal 40, tp= 50-60
pcv and tp
normal 40 and 50-60
both increased= dehydration
decreased and increased Polycythemia vera
breed variation
normal and increased hyper globulinemia, artifactual
normal and decreased- liver not making enough, loosing protien. early bleed
decreased and normal- IMHA ect
decreased and decreased- blood loss
anemia + hypoprotinemia
lactate in hypovolemic shock
marker of shoc and perfusion
product of anabolic respiration
can be a prognostic indicator
how to monitor improvment in hypovolemic shock
monitor vitals
monitor perfusion
monitor mentation
repeat POCUS
repeat bloods- be aware giving colloids can reduce calcium in bloods due to the anti coagulants
repeat pcv and tp- ongoing bleeding ?
do clotting factor testing
