Emergency Critical Care Flashcards
What does the the RCVS state regarding emergency care practices provide?
- Must take steps to provide 2-4 hour emergency first aid and pain relief
- Practice can provide this
- Can use specific emergency care provider
- Should never be refused to an owner
What can be done once initial first aid treatment has been given?
- Safely examined by RVN or VS
- Ascertain if needing urgent treatment or can wait
What does the Veterinary Surgeons Act 1966 say regarding first aid treatment?
- Anyone can perform animal first aid to save life, prevent suffering or prevent condition deteriorating
- This can be used if VS or RVN not available
- Owners can administer first aid to patients
- This includes CPCR, pressure on haemorrhage, anything preserving life
What are the objectives of first aid?
- Preserve life
- Reduce pain and discomfort
- Prevent further deterioration
Who is best to perform first aid if a VS is unavailable?
- RVN have greater knowledge and skill base
- Have clinical experience with emergencies
What do successful first aid outcomes depend on?
- Early recognition of severity
- Good communication with owner and team
- Implementing correct treatment
- Careful and regular monitoring
Rules for emergency practice
- Remain calm
- Be prepared
- Don’t put self, owner, staff at risk (pain causes aggression)
- Ensure safe environment
- Ensure animal at no further risk
- Assess severity of injury/illness
- Administer appropriate FA
- Contact VS ASAP
What is often the first point of call between owners and the practice in emergency stituations?
- Telephone calls
- Owners often distressed
What needs to be remembered when asking questions on the phone in emergency situations?
- Reassure they are priority and being heard
- Need to see if life threatening
- If so, bring to practice immediately
- Question further once arrived
- Any delay can impact survival
- Be concise and polite
Why is a veterinary call out not appropriate in emergencies?
- No access to equipment needed
- Limited oxygen supply as mobile smaller
What emergencies need to be seen without delay?
- Respiratory distress
- Severe haemorrhage
- Collapse/unconsciousness
- Rapid + progressive abdominal distension
- Inability to urinate
- Sudden onset neuro abnormalities
- Severe vomiting, especially if depressed
- Severe D+, especially if haemorrhagic
- Witnessed ingestion of toxin
- Sudden weakness/inability to stand
- Extreme pain
- Open fractures
- Dystocia
- RTA
- Head injuries
- Prolapsed eyeball
What conditions need seeing quickly but not immediately?
- Mild to moderate V+
- Non-haemorrhagic D+
- Small wounds with minimal blood loss
- Discomfort when passing U+
- Polyuria/polydipsia
- Weight baring lameness
What important information is needed when discussing emergencies with clients?
- Patient and client details
- Characteristics of patient
- Any medication, last dose
- Exact nature of problem
- When started
- Progressively got worse?
- Happened before? Treated?
- Depressed or lethargic?
- Any other symptoms?
What information should be taken at the start of an emergency phone call?
- Client name and number
- In case call cuts off
Rules for emergency telephone conversations
- Introduce self and practice
- Calm, polite, reassuring
- Find problem quickly, is life threatening?
- Directions to practice
- Advise alternative transport
- How to safely transport pet
- Ask ETA
- Get client contact details
- Are they registered?
- If not get history from registered vets
- Estimate cost of consult, especially in OOH
What advice should be given to clients transporting their pets during emergencies?
- Pain can cause aggression
- Client must stay safe
- Cats in carriers
- Dogs in safe area, crate?
What can be used in an RTA for the client to transport their pet?
Parcel shelf
What is important in practice when waiting for an emergency to arrive?
- Communication
- Prepare equipment
- Paperwork, room, equipment, consumables, oxygen, crash box, muzzle, restraint equipment, stretcher, other transport equipment
What is triage?
- Prioritisation of critically ill or injured patients
- Take less than 5 minutes
- Good history taking essential
- Classified into 4 main sections
- Attend to in seconds, attended to within hour, within a few hours, within 24 hours
What emergencies fall into Class 1 triage emergencies, to be attended to in seconds?
- Catastrophic and dying
- Cardiopulmonary arrest
- Respiratory failure
- Unconsciousness
- Severe trauma
- GDV
- Penetrating thoracic wounds
What emergencies fall into Class II triage emergencies, to be attended to within under an hour?
- Shock
- Multiple injuries
- Toxicity
- Penetrating abdominal wounds
- Haemorrhage
- Dystocia
What conditions fall into Class III triage emergencies, to be attended to within a few hours?
- Open fractures
- Blunt injuries without altered mentation or shock
- Profuse D+, not dehydrated
- V+
- Urethral obstruction
What conditions fall into Class IV triage emergencies, to be attended to within 24 hours?
- Lameness
- Anorexia
What is a primary survey in emergencies?
- How likely to go into imminent cardiopulmonary arrest
- A - Airway patency
- B - Breathing
- C - Circulation; HR + pulses
- Only take 30 seconds
- If concerned should start CPCR immediately while a VS is called
- If okay, major body system approach can be considered
What are the 3 major body systems to be assessed during emergencies?
- Cardiovascular
- Respiratory
- Neurological
How should the cardiovascular system be assessed and monitored during emergencies?
- Auscultation of heart; clear/muffled
- HR and PR
- Synchronised HR + PR
- Pulse quality; normal, bounding, weak, thready
- MM colour
- CRT, normal, fast, prolonged
How should the respiratory system be assessed and monitored during emergencies?
AUSCULTATE CHEST
- Clear, crackly, muffled?
- Dorsal or ventral aspect?
- Dorsal = air; pneumothorax
- Ventral = fluid; pleural space disease
- RESPIRATORY EFFORT
- Increased on inspire, expire, both?
- No chest movement but abdominal movement?; indicate tension pnemothorax
- Posture when attempting breath
- Abducted elbows/trying to stand = orthopnoea
- Extension of neck + paradoxical abdominal breathing are signs of resp distress
RESP RATE
MM COLOUR
How should the neurological system be assessed and monitored during emergencies?
GAIT
- Paresis (weakness)
- Plegia (paralysis)
- Quadraplegia (4), paraplegia (2), hemiplegia (one side), hypermetria (exaggerated limb movements)
MENTATION
- Alert
- Obtunded (dull, depressed)
- Stuporous (only roused by pain)
- Coma (unconscious, unrousable)
How frequently should observations for critical patients be recorded?
- Every 5 - 15 minutes
- Trends can be observed
Why is it important to monitor the vital signs of critical patients?
To monitor patients response to treatment
What vital signs should be monitored in critical patients?
- Temperature
- Heart/pulse rate
- Respiration rate
- Lung auscultation
- Mucous membrane colour
- Capillary refill time
What is a pulse deficit?
- No matching pulse to every heartbeat
How can pulse quality be described?
0 - Absent, not palpable
1+ Weak, thready
2+ Normal, strong,
3+ Bounding, full
What is hypokinetic pulse?
- Weak, thready
- Barely palpable
- Easy to obliterate with light pressure
What is a normal pulse?
- Easily palpable
- Normal, strong pulse
- Easily found
- Obliterated by strong pressure
What is a hyperkinetic pulse?
- Bounding, full pulses
- Increased strength
- Difficult to obliterate with fingers
What causes stridor?
- High pitched breathing sound
- Laryngeal paralysis
What causes stertor?
- Snoring sound
- BOAS
What causes a goose honk cough?
- Tracheal collapse
What causes diminished or absent lung sounds?
- Pleural effusion
- Pneumothorax
What causes crackles in the lungs?
- Pulmonary oedema
- Pneumonia
What are the two methods of blood pressure monitoring?
- Direct, invasive, arterial
- Indirect, non-invasive
What is direct blood pressure measurement?
- Place cannula directly into artery
- Often dorsal pedal artery on hind limb
- Used in emergency + referral
- Required 24 hour nursing
- Good for critical patients that may rapidly deteriorate
What cautions should be taken when using direct blood pressure monitoring?
- Clearly label to avoid drug injection
- Care in patients with coagulopathies
How is indirect blood pressure monitored?
- Cuff around distal limb or tail
- Inflated until pulse occluded
- Slowly deflated until pulse returns and pressure read
What devices are used to measure indirect blood pressure?
DOPPLER
- Gives systolic reading
OSCILLOMETRIC
- Systolic, diastolic and mean
What are normal blood pressure readings?
SYSTOLIC
- Above 90mmHg
MEAN
- Above 70mmHg
What size should a blood pressure cuff be?
- Width = 40% of the circumference of the limb
- Incorrect sizes = inaccurate results
- Too small/tight = overestimate BP, gives high reading
- Too large/loose = underestimate BP, gives low reading
Why are times between BP readings important in indirect monitoring?
- Multiple frequent readings can have tourniquet effect
- Can cause ischaemic damage
What percentage of body weight is water?
60 - 70%
What does water contain that is important for normal cell and organ function?
Electrolytes
What are normal water losses from the body?
- Faecal - 10-20ml/kg/24hrs
- Urinary - 20ml/kg/24hrs
- Inevitable losses (Respiratory, cutaneous) - 20ml/kg/24hrs
- Total losses - 50-60ml/kg/24hrs
What are the indications for fluid therapy?
- Correction of dehydration
- Expansion/support of intravascular volume
- Correction of electrolyte disturbances
- Correct history is important to determine appropriate fluid type and volumes for treatment
What history should be taken to determine fluid needs?
- Duration of illness
- V+/D+ frequency
- Water intake
- Food intake
- Blood loss
Which electrolytes are found in the intracellular fluid?
- Potassium
- Magnesium
Which electrolytes are found in the extracellular fluid?
- Sodium
- Chlorine
- Bicarbonate
What are the clinical signs of inadequate fluid balance?
- Urine output < 1ml/kg/hr
- Tacky/dry MMs
- Prolonged CRT
- Skin tenting
- Sunken eyes
- Weak peripheral pulses
- Collapse/shock=severe dehydration and hypovolaemia
- Tachycardia
- Bradycardia (Cats)
What is the normal urine output equation?
1-2ml/kg/hr
How often should patients with low urine output be monitored?
Every 30 minutes
What are the clinical signs of <5% dehydration?
- No detectable clinical signs
- Increased urine concentration
What are the clinical signs of 5-6% dehydration?
- Subtle loss of skin elasticity
- Skin tenting
What are the clinical signs of 6-8% dehydration?
- Marked loss of skin elasticity
- Slightly sunken eyes
- Dry MMs
What are the clinical signs of 10-12% dehydration?
- Tented skin stays in place
- Sunken eyes, protruded 3rd eyelids
- Dry MMs
- Progressive signs of hypovolaemic shock
How is severity of dehydration estimated?
- Percentage of body weight
- Fluctuations in BW are most accurate way of measuring alterations in fluid balance
- Patients should be weighed once a day
- Critical patients should be weighed 2-3 times a day for IVFT plan amendments
What is the calculation for fluid therapy for dehydrated patients?
- % dehydrated x BW kg = ml dehydrated
- This should be added to maintenance fluid amount
What are crystalloid fluids?
- Water based solutions
- Easily leave IV space and enter all body compartments
- Small molecules, electrolytes, other solutes
- Osmotically active, able to cross capillary membrane
What are the 3 different kinds of crystalloid solutions?
ISOTONIC
- Most common
- Osmolarity similar to plasma and ECF
HYPERTONIC
- Osmolarity > plasma
- Pulls water from interstitial and intracellular into IV space
HYPOTONIC
- Osmolarity < plasma
- Fluid moves to interstitial and intracellular spaces
When are hypotonic crystalloids used?
- Primary water loss and dehydration
- No evidence of hypoperfusion
When are hypertonic crystalloids used?
- Small volumes of hypovolaemia
What are colloid fluids?
- Large molecule
- Increase oncotic pressure of plasma
- Holds fluid in IV space and increases IV volume
- Don’t pass into interstitial spaces
- More effective at maintaining IV volume
What are natural colloids?
- Whole blood
- Human albumin
- Plasma
What are synthetic colloids?
- Hydroxyethyl starched and gelatins
- Used to be commonly used
What method is used when creating fluid plans?
The five R’s
What are the five R’s?
RESUSCITATION
- Correcting shock and life threatening deficits
ROUTINE MAINTENANCE
- Provide fluids to support homeostasis
REPLACEMENT
- Replace dehydration deficits
REDISTRIBUTION
- Move fluids + electrolytes between body compartments
REASSESSMENT
- Regular monitoring of IVFT
What are the routes of fluid therapy administration?
- Orally
- Subcutaneously
- Intravenously
- Intraperitoneal
- Rectal
- Intraosseous
What are the most common routes of fluid administration in emergency?
- Intravenous
- Intraosseous
What are central lines?
- Placed directly into jugular vein at entrance to right atrium
- Can be multi-lumen with 2-4 ports
- Allows multiple infusions of fluids and medications at same time
- Allows repeat blood sampling
- Used to monitor central venous blood pressure
What is important to label in central lines?
Label ports to distinguish what each port is used for
What hygiene requirements are needed for central lines?
- Aseptic handling
- Clear adhesive dressing to monitor site without handling
- Dressing only changed when visibly contaminated or signs of phlebitis
What are the types of central lines?
- Over needle catheter; Seldinger
- Through needle; Intracath
- Peel away sheath; type of through needle
What are the signs of overhydration and increased fluid balance?
- Increased urine output
- > 2ml/kg/hr
- Coughing
- Hypertension
- Peripheral oedema
- Clear nasal discharge
- Ascites
What is fresh whole blood?
- Collected directly from donor in closed system with citrate-phosphate-dextrose (CPD)
- Then administered to recipient
- Contains RBCs, functional platelets, coagulation factors and plasma proteins
- For patients with reduced O2 carrying capacity due to haemorrhage or anaemia
- Should be used within 4-6 hours of collection
What is stored whole blood?
- Similar to fresh, stored in refrigerator prior to use
- Platelets lose viability when refrigerated; 50% decrease in 12-18 hours
- Some clotting factors also affected
- Similar use to fresh blood, for patients that don’t need viable platelets
What are packed red blood cells in reference to blood transfusions?
- Produced by centrifuging whole blood
- Used in patients with anaemia
- Used in place of fresh whole blood when donor is unavailable and patient needs immediate RBCs
What is fresh frozen plasma?
- Plasma portion of centrifuged whole blood
- Frozen to -18 in 24 hours
- Contains coagulation factors, albumin and immunoglobulins
- Thawed in warm water bath
- Expires within a year
- Can be labelled as frozen plasma and stored for 4 more years
What is frozen plasma?
- Plasma not frozen within 24 hours
- OR been frozen over a year
- Contains albumin and globulin
- Minimal clotting factors
What is blood typing?
- Checking blood groups in cats and dogs prior to a transfusion
What is important with blood typing cats?
- Must blood type all donors and recipients before transfusion
- Even in emergencies
What is cross-matching blood?
- In vitro mixing donor and recipient components
- Can be blood or plasma
- Looks for potential incompatibilities
- Agglutination or haemolytic reactions
When should cross-matching be performed in dogs?
- Recipient received transfusion more than 4 days prior
- History of transfusion reaction
- Unknown transfusion history
- Recipient has had puppies
When should cross-matching be performed in cats?
- If recipient requires more than one transfusion
- Previously transfused blood can induce antibody production against RBC antigens
What is required for dog blood donors?
- Healthy, fully vaccinated
- Not receiving medication
- Suitable temperament
- > 25kg lean body weight
- 1-8 years old
- Normal PCV; >40%
- Ideally DEA1.1 negative
- Not received blood transfusion
- Not vaccinated in last 14 days
- Not travelled out of UK
- Can be collected every 8 weeks
What is required for cat blood donors?
- Healthy, fully vaccinated
- Not receiving medication
- Suitable temperament
- > 4kg lean bodyweight
- 1-8 years old
- Normal PVC; >35%
- Blood type A, B or AB
- No previous transfusion
- Not travelled out of UK
- FeLV + FIV negative
- Haemotropic mycoplasma negative (PCR test)
- Can donate every 8 weeks
- Only 50-60 ml can be taken
What is DEA1.1 referring to blood typing dogs?
- Dog Erythrocyte Antigen
- 8 dog blood types number 1-8
- DEA1.1 causes most severe transfusion reactions
- Must check donor and recipient blood type
- Or only use DEA1.1 negative donors
How should blood be administered to dogs?
- DEA1.1 -ve should only receive DEA1.1 -ve blood
- DEA1.1 +ve can have +ve or -ve
- Blood giving set has filter to trap small clots
How should blood be administered to cats?
- Type A must only receive type A
- Type B must only receive type B
- Type AB are rarer and don’t possess either antibody
- Should receive type AB but can have type A
- Type B should be used as a last resort
- Plain 150ml collection bag can be used with blood giving set
What is important to check before administering blood?
- Syringe drivers and infusion pumps can destroy some cells
- Visually inspected for clots, discolouration or haemolysis; can indicate bacterial contamination
- Does not need to be warmed unless given to neonates or very small animals
- Warming can cause haemolysis, damage cells and promote microbial growth
- Never warm in microwave
What is an alloantibody?
Antibody against RBC antigen
What is the transfusion rate of blood?
- 2ml blood/kg raises PCV by 1%
- First 15-30 minutes 0.5-1ml/kg/hr while close monitoring
- To notice transfusion reactions promptly
- If tolerated well, can be increased to 5-10ml/kg/hr
- Remaining transfusion delivered within 4 hours to minimise bacterial infection
What parameters must be monitored during blood transfusion?
What do animals presenting with trauma require?
- Rapid, accurate triaging
- Ongoing monitoring
- Prevent complications
- Problems treated
- Patient stabilised
- Ongoing plan made
What constitutes a traumatic emergency?
- Haemorrhage
- Wounds
- Fracture
- Luxation (dislocation)
- Foreign bodies
What is haemorrage?
- Loss of blood from vessels
- Prolonged or acute is severe
- Likely to go into hypovolaemic shock
- Can lead to death
How can haemorrhage be classified?
- By location and type
- External or internal
ARTERIAL - Bright red, spurts
- Immediate action needed to control rapid blood loss
VENOUS and CAPILLARY - Dark red blood
- Oozes from area
What surgical procedures may need to be performed in an emergency?
- Airway surgery
- Thoracotomy
- Laparotomy
- Spinal surgery
- Caesarean section
