Final Flashcards
Define category 1 emergency, give examples
Will die without immediate intervention; arrest, distressed or not breathing (open mouth in cats), pale or blue gums, severe arrhythmias, hemorrhage, etc
Define category 2 emergency, give examples
Critical, needs attention within 30 min; pale, severe fever, dystocia, LUT obstruction, severe dehydration
Define category 3 emergency, give examples
Sick, needs attention within hours; minor allergic rxn, laceration, stable fracture, V/D
Define category 4 emergency, give examples
Not true emergency, tx within 24 hours; V/D w/o dehydration, abrasions/cute, broken nail, sneezing/URT, hematuria
Most common cause of bradycardia
AV block
Causes of atrial standstill
hyperK (UO, Addisons), cardiac dz, hypothermia
Most common cause of weak pulses
Hypovolemia
Bounding pulses indicate what
Compensated hypovolemia
MM and CRT in: compensated hypovolemia
Injected,
MM and CRT in: hypoxia
cyanotic
MM and CRT in: anemia (normal or severe)
N: pale, normal CRT; severe: pale, absent
Pale MM with delayed CRT indicates
Decompensated shock (past compensation and progressing)
Most common type of breathing increase
Inspiratory
Localize- inspiratory effort
Upper airway (or abdominal distension, pleural space dz, diaphragmatic hernia)
Localize- expiratory effort
Lower airway (bronchitis, asthma)
PTE, pain and abdominal distension will likely cause what pattern of breathing
non-specific dyspnea
Short and shallow breathing indicates
Parenchymal dz or pleural space dz pr diaphragmatic hernia
Causes of paradoxical breathing
pneumothorax, pleural space dz, diaphragmatic hernia
Respiratory manifestations of parenchymal dz
mixed insp/exp dyspnea, harsh, loud sounds or crackles, short and shallow
Levels of consciousness
Coma- stupor- obtunded- dull- quiet- bright
Respiratory manifestations of pleural space dz or diaphragmatic hernia
inspiratory effort, short/shallow, quiet, +/- paradoxical
Respiratory manifestations of lower airway dz
Expiratory effort, harsh sounds/crackles, wheezing
Respiratory manifestations of upper airway dz
Inspiratory effort, stridor, referred upper airway noise on auscultation
MDB in triage
PCV/TS, glucose (esp neonates), renal, electrolytes (esp K)
Tx ventricular arrhythmias
Lidocaine (1/10th dose in cats)
Tx severe bradycardia
Atropine (fix electrolytes, warm, reverse opioids)
Blood typing- dogs vs cats
Not needed in first time dogs, mandatory in cats
Tx seizures
Diazepam IV or rectally
Tx ICP
Mannitol or hypertonic saline
Why do we monitor
ID problem for early intervention- monitoring always resulting in action
BP =
CO x VR (vascular resistance) (CO= HRxSV)
Limitations to CO
Dog >180- decreased SV maxes out CO
Vascular resistance formula
Inversely proportional to radius of tube to 4th power
What is the hidden killer in ECC, most patients susceptible to?
Thrombosis
Where to monitor for coagulation issues
Gums, pinnae, ventral abdomen
Common electrolyte disturbance in ECC patients
hypoK and hypoCa
Electrolyte imbalance in refeeding syndrome
hypoGly, hypoK, hypoP, hypoMg (all shift intracellularly when food introduced and insulin responds)
Dog and cats max normal HR in hospital
D- 120; C: 220 (should not be lower than 160 (180?)
When should arrhythmias be treated
When CS present or severe tachycardia concurrent
What dz states can cause decreased contracility
Sepsis, SIRS, heart dz
Tx decreased contractility
Positive inotropes- sepsis/SIRS: dobutamine; heart dz: pimobendan/digoxin
What is decreased oxygen tension in the tissues
Hypoxia
Define hypoxemia
Decreased partial pressure of O2 or saturation of O2 in the blood
Hypoxemia, hypoxia: ______ can be present without ____
Hypoxia, hypoxemia
What does using the arterial oxygen content equation demonstrate?
Hgb most important in oxygen delivery to tissues, dissolved O2 only a small percentage of total oxygen (ex- normal PCV 1.5% O2 is dissolved, 15% PCV- ~4% O2 is dissolved, remainder is bound to Hgb)
T/F inflammation indicates infection is present
F
What would indicate that a patient is developing an infection or an infection is overwhelming the patient
Degenerative left shift, more immature WBCs
What structure modulates temperature in the patient, via what signals
Anterior hypothalamus; monoamines and cutaneous deep receptors
Name the mechanisms of gaining heat
Increased production: catecholamines, thyroxine, shivering; decreased loss: vasoconstriction, piloerection, postural change
What causes fever
Stimulation of pyrogens (IL-1), increased hypothalamic set point
Describe starling forces in relation to fluid flux
Fluids net movement is out of the capillaries and picked up by lymphatics to prevent accumulation- when too much leaves the capillaries, causes peripheral/pulmonary edema and third spacing of fluid (pleural effusion, ascites)
How frequently should PCV be checked in patients receiving fluid therapy
daily at a minimum (more frequently if also anemic)
What concentration determines IV volume and why
Na- because water follows sodium- “total body Na determines total body hydration”
What are the proportions of total body water
60% of body weight is water, 40% intercellular, 20% extracellular (5% in vessels, 15% interstitial)
Na/K concentrations in and out of cell
Na high OUT of cell, K high IN cell
RER water calculation
70 x BW^0.75 or [(30 x kg)+70] = mL/kg/day
XS - S- M- L- XL fluid maintenance guidelines
XS (neonate) 80-100, S- 60, M (and cats) 50, L 40, XL 30 mL/kg/day
Dehydration v hypovolemia
D: interstitial and intercellular, progresses slowly, correct slowly, no bolus H: intravascular, rapid loss and rapid correction
Three types of fluid loss
Sensible- U, feces, V, exudative wounds; Insensible- sweat, saliva, panting
Estimate fluid dehydration deficit
kg x %dehy= L
What % dehydrated? mild skin tenting, slightly tacky to normal MM, CRT normal
moderate 5-7%
What % dehydrated? hypovolemia signs, cold extremeties, shock
Critical- 10% or greater
What % dehydrated? prolonged skin tent, dry MM, some tachycardia
Severe 8-10%
How is 5% dehydration assessed
Usually via Hx, no CS present on PE
What two conditions must be considered in correcting fluid losses and how
Heart disease (less need), renal compromise (more need)
Tachycardic, prolonged CRT, hypotensive, hypothermic, cool extremities, weak pulses- Dx, Tx
Hypovolemia- Rapid correction with 10-20mL/kg isotonic bolus, then goal directed therapy
What are the two major determinants of fluid balance
Alb and Na
Tonicity refers to
Effective osmolality of a solution compared to plasma
Why is a weak base sometimes added to crystalloid fluids
Excess Cl in fluids binds to HCl and creates acid, so bicarb added to create appropriate pH
Crystalloid fluids- what compartments, what speed
All compartments at different rates
What makes a fluid balanced, give some examples
If it resembles the proportion of plasma (extracellular fluid); normosolR, plasmalyte 148, LRS
What type of solutions should be avoided in end stage liver disease and why
Lactate buffered solutions because lactate is metabolized in the liver
Name two “unbalanced” fluids
0.9% saline, 5% dextrose in water (D5W)
What happens when water is bolused IV
RBC will swell and lyse due to zero tonicity causing rapid intracellular shift
Name three maintenance fluids
NormosolM, 0.45% saline, plasmalyte 56
When are maintenance fluids used
When patient is euvolemic but not eating/drinking, never as a bolus- rarely used in vet med
What are the characteristics of maintenance fluids
Lower in NaCl (Na 50-70), higher in K (10-20) (because regular losses (from kidney) low in NaCl, higher in K), usually hypotonic
What are the characteristics of replacement fluids
Similar to ECF- so High in NaCl (130-154), lower in K (0-5), tend to be isotonic- these are resuscitation fluids
Describe the movement of replacement fluids
Meant to go to interstitial space
Name three replacement fluids
0.9% saline, NormosolR, plasmalyte A or 148, LRS
What are hypertonic fluids used for (function and indications)
Rapid intravascular volume expansion (hemorrhage), reduction of ICP in head trauma- DO NOT USE FOR RESUSCITATION
Describe the effects of hypertonic fluids
Short acting (15-20min) rapid pull of fluids from interstitial space into intravascular space causing 3-3.5x volume expansion per unit administered
How are hypertonic fluids administered
In short, 5-15 min boluses (may be repeated once) followed by isotonic/maintenance fluids to avoid electrolyte abnormalities and dehydration
Name three hypertonic fluids
3% or 7.5% saline, 20% mannitol
What are the other benefits of hypertonic saline
Decreased cerebral edema, increased cardiac contractility, possible anti-inflammatory effects
What are the disadvantages of hypertonic saline
hypernatremia, rapid admin (>1mL/kg/min) can cause bradycardia, hypotension, bronchoconstriction
Indications for mannitol
Head trauma, acute glaucoma
Mannitol- adv and disadv
Adv: dec cerebral edema and blood viscosity, free radical scavenger; DisAd: can exacerbate edema, hemorrhage (esp in brain)
1 tsp = __mL, 1 c= ____ mL
5, 236
What is the most important part of a fluid plan
Reassessment during treatment
What are colloids
Fluids with large insoluble molecules that wont cross membranes easily and hold water in vascular space for longer than crystalloids
What is the V of D of iso and hypertonic cystalloids
Initally to plasma then rapidly equillibrate (go more to intravasc (20%) and interstitial bc Na pumped out of cell)
What is the V of D of crystalloids
meant to have 100% V of D in intravascular space to maintain volume, but in vivo this is not fully the case
What value of the Starling Equation explains why very hypoproteinemic patients get limn edema but not pulmonary
Reflection coefficient- because this is the degree too which a membrane prevents transfer of colloid molecules-
How can colloid therapy be monitored
COP measured by colloid osmometer, measures the change in pressure; refractometer does not change above 4.5
How well does USG measure colloid administration
USG overestimated compared to urine osmolality with HES after 2-3 hours, usually correlate
What are the most important drugs in a crash cart
Atropine and epinephrine
What does the 10 second CPR assessment check for
Responsiveness, breathing/agonal breaths, pulses/heartsounds
What is the most important part of CPR
Compressions
What is the aim of CPR
Perfuse the brain and heart with oxygenated blood
What is the formula for cerebral perfusion pressure
MAP- ICP
What is the formula for coronary perfusion pressure
Aortic diastolic pressure - right atrial diastolic pressure
CPR breaths rate, depth, pressure
10-12 bpm, enough to make chest wall rise, no more than 20mmHg ((avoid pneumothorax)
Type of CPR- up to 15kg patient
Direct
Direct CPR- describe method, function
compression directly over heart, compression of heart chambers and artificial systole
Type of CPR for large dogs
Thoracic pump mechanism
Thoracic pump CPR- method, function
Compressions at deepest part of chest, complete relaxation between each- increase pressure in chest to force blood away from heart, relaxation allows blood to flow back towards thanks to one way valves
CPR compression rate
>100bpm (100-120, faster not better)
Open chest CPR- method, approach
Technique to maximize flow via direct cardiac massage- cut right side between 5th and 6th rib space
Open chest CPR indications
Pneumothorax, pleural effusion, pericardial effusion, chest trauma, DOA, too large for external
When to stop CPR
return of pulse, spontaneous apex beat, sudden increase in CO2 output
Capnograph- what does 0-5 mean
Initial reading in arrested patient, 0 means ineffective chest compression
Capnograph- what reading indicates ROSC
Return of spontaneous circulation- 50-60, built up is leaving
What two ECG readings are indications for defibrillation
Ventricular fibrillation and pulseless ventricular fibrillation
Pulseless ventricular fibrillation
Ventricular fibrillation
Pulseless electrical activity- can look REGULAR, but has NO pulse!
Asystole
What is the most common EKG rhythm in vet med
Asystole
Which drugs cause constriction and increase arterial pressure
Vasopressors- epinephrine, vasopressin
Epinephrine administration
0.01 mg/kg @ 1mg/mL q 3-5 min during CPR- IV or endotracheally(double dose with saline flush and a large breath)
What can be used as a rescue medication if epinephrine fails during CPR, what other indications does it have
Vasopressin; helpful in severe acidosis or prolonged arrest
What is the effect of atropine, when should it be given
Reduce parasympathetic tone, first choice in bradycardia (and vagally mediated arrest)
Function of anti-arrhythmics besides arrhythmia correction; name two
Improve arterial BP; amiodorone, lidocaine
What contraindications are there for lidocaine
Cats and fibrillation (defibrillate first or it will reduce efficacy)
Amiodorone- indications, cautions
In V-fib after 2 unsuccessful defibrillations, possible anaphylaxis risk
What drug should only be used in severe pre-existing metabolic acidosis and hyperK arrests which arent responding to fluid therapy
Sodium bicarbonate- use with blood gas analysis
When should Calcium gluconate be used
HyperK cause of death or pre-existing hypoCa (like in eclampsia)- CONTRAINDICATED IN ALL OTHERS
What is the reversal for opioids
Naloxone
What is the reversal for benzos
Flumazenil
What is the reversal for alpha2agonists like xylazine and metomidine
atipamezole or yohimbine
What should be tried if defib is not successful
Amiodarone
What is the defib dose
2-4J/kg (4-6 in monophasic); increase by 50% on second try
Describe the flow of defib
shock- 2 min CPR - check ECG- increase dose 50%
What should be used if possible in open chest defib
Saline soaked gauze between heart and paddles
What is a possible effect of excess fluid therapy, explain
Overload goes to RA, increasing coronary pressure and reducing cardiac perfusion
What are some concerns for colloid therapy
Kidney damage and coagulopathy
What is a common post-resuscitation complication and how should it be treated
Myocardial dysfunction- pressors like dopamine or dobutamine (careful in cats); norepi can be added to dopamine
When to stop CPR
Assess q 3-5 min, avg stopping time 15-20 min, max 20-30 without improvement signs
What are the muscles of inspiration
Diaphragm, external intercostals, (in effort: scalene, nasal alae, and sternomastoids)
Muscles of expiration
Normal breathing elasticity of lung and chest wall recoil, but in effort- abdominal wall contraction increases intra-abd pressure to push diaphragm cranially
Define labored breathing
Engaging accessory inspiratory or expiratory muscles
Orthopnea
positional increases in difficulty- elbows abducted, head/neck extended
Ddx upper airway dz
LarPar, tracheal collapse, FB, cat polyps, BOAS
Ddz lower airway dz
asthma, chronic bronchitis, coughing/whezes
Tx for primary cardiac dz of respiratory parenchyma
Furosemide! (congenital, MVD, DCM, HCM, RA enlargement)
Tx non-cardiac respiratory parenchyma dz
Bronchodilators (Hx of V, anesthesia, coughing)
How can cardiac and non-cardiac respiratory parenchymal dz be differentiated
Rads-
Cardiac- LA backpack, PA/V enlargement, lung patterns
What are the three most important things in respiratory distress
Hands off- oxygen- sedate when needed
Indications and Rx for sedated airway exam
Upper airway: stridor, obstruction, BOAS; sedate to effect with propofol (dont knock out), avoid acepromazine and opiates (decrease laryngeal and cough fxn)
Sedated airway exam: what to check
Larynx for arytenoid fxn; tissues surrounding for saccules, elongation; oral masses; inflammation of proximal trachea
Upper airway dz- exam ddx
SCC (cat larynx), LarPar polyneuropathy (L side), lymphoma (looks like edema, not mass)
What Rx can be given to increase breathing and show arytenoid movement
Doxapram
Thoracocentesis- approach
8th or 9th intercostal space, avoid caudal edge of ribs for vessels and nerves; Fluid- bottom third; Air- top third- 16g catheter through nick in skin from scalpel
Can also do over the wire or surgical approach
Nasal oxygen- tube type, drugs needed, approach
Measure from end of nose to medial canthus8-14 Fr, wider tube causes less pressure/irritation; tetracine local drops in nostril; ventromedial approach
Technique: temporary tracheostomy
Inscise skin and SQ longitudinally in the midline (patient must be straight), separate strap muscles, go 2-3 rings below larynx, incise horizontally less than 1/3 circumferance, use stay sutures labeled up and down to open hole later when changing tube
Stages of labor: 1
12-24 h, restlessness, queens dig/bitches quiet, temp drop to 98F
Stages of labor: 2
6-12h, temp normal, see uterine contraction, fetal expulsion
Stages of labor: 3
Immediately after stage 2- placental expulsion
Signs of dystocia
Stage 2 > 12h, Weak contractions for 2-3 h, strong contractions with no expulsion in 1h, >3 hours between deliveries, temp drop and no birth in 24-36h, fetal HR <160
Fetal causes of dystocia (5)
Monster, oversize, singleon, improper presentation, death
Maternal causes of dystocia (5)
Uterine inertia, abdominal hernias, pelvic stenoses, uterine/vaginal trauma, hydrops
Primary uterine intertia
contractions never were going to happen, oxytocin wont help
Secondary uterine intertia
so exhausted uterus gives up
Why does singleton cause dystocia
Not enough to send hormonal signals to start uterine inertia or sustain
Breeds susceptible to fetal oversize and singleton
persian, himalayans, bulldogs
Describe hydrops
Golden retriever with cankles/edematous vulva, excess fluid in amniotic sac occluding CaVC- caudal and ventral edema
Causes of uterine inertia
Hormonal- abnormalities of cascade (est, progest, relax, prolactin, PGs)
Metabolic- hypoGly, hypoCa
Myometrial- single pup, age, overstretch
Anatomic- cervix/vagina/vulva- immaturity, under-dilated, dz, abnormal, etc
Psychologic
Dx dystocia
Fetal HR <160 is best (also PE, rads, U/S, acid/base, etc)
Rx for metabolic uterine inertia
Oxytocin
When can medical tx be used to dystocia
Only when not obstructed, healthy, failure to progress, contractions present, no oversize
First Rx, medical dystocia tx
Calcium- 10% CaGluconate to increase strength of contractions
Secondary Rx for medical dystocia tx
Oxytocin- to increase freq of contractions
Indications for Sx tx of dystocia
obstruction, stressed/dead, oversize, sick mom, failed medical tx
Sx tx of dystocia, Rx used
Balanced electrolytes throughout all, pre-oxygenate ebfore anesthesia, propofol induction, iso maintenance, lidocaine block
Sx approach- C-section
Ventral midline incision, extrude uterus, the three options:
take out, put back in
Take out, OHE
En Bloc- OHE then remove fetus (MUST BE FAST)
Dystocia surgical emergencies
uterine torsion, uterine rupture
Neonate resuscitation
Remove fetal membranes, suction mouth/nose, clamp umb 1/4” from body (suture, betadine, dry), DV with head extended, stimulation of respiration, thermal support with 60% humidity
If none after 35-40 sec, GV26 acupuncture point at nasal filtrum and doxapram sublingual
Indications for maternal Abx after birth
Rupture, torsion, fetal fluid contamination of abdomen
Cause of pregnancy toxemia, CS
Nutritional related ketosis and negative energy balance late in prenancy from lack of carbs; weakness, lethargy, seizures, hyporexia
Dx pregnancy toxemia
ketosis with glucosuria
1-4 weeks after whelping, face rubbing, anorexia, hyperthermia, tremor, seizure
Eclampsia
Dx eclampsia
iCa- <1.4 mmol>L
or
tCa <6.5 dog or <6 cat
Tx eclampsia
CaGluconate IV over 10-15 min,
When does pyometra occur
During diestrus due to high progesterone in middle to older aged
Tx pyometra
Dont let the sun set- IV fluids, OHE, IV Abx
What causes vaginal hyperplasia
Estrogen influence
Tx vaginal hyperplasia
lubricate and protect if no necrosis, wait til follicular phase pases and will resolve; Sx if mucosal damage or too large
Mastitis- causes, dx, tx
e. coli or staph; milk cytology/culture, cidal abx, lance/drain
Causes of testicular abscess
trauma, brucellosis
Paraphimosis
Penis stuck out, not erect
Priapism
Erect penis stuck out
Tx paraphimosis or priapism
sedation/anesthesia, no drugs with peripheral vasodilation, lubrication or hypertonic soak
Top causes of blocked cat
uroliths and FIC (cells/mucus/cystal plugs)
What kills blocked cat
HyperK, hypovolemia, metabolic acidosis
Tx blocked cat- stable
Bolus LRS or 0.9 saline, sedation, catheter
Dx, tx sick blocked cat
K >8, sine wave or absent P wave on ECG; Fluid resuscitation to tx hyperkalemia before unblocking,
Lowering K in blocked cat
Ca gluconate- changes threshold to restore gradient
Insulin/NaBicarb/terbutaline to send K intracellularly
Sedation options for blocked cat (without ET, with ET, sick
without ET- ket, midazolam, buprenorphine
With ET- propofol
Sick: sacro-coccygeal blck or buprenorphine
Unblocking procedure
Open ended tom cat catheter, extrude penis then pull prepuce over catheter to straighten S shape, flush while passing if resistance, gently twist while applying gentle pressure to bladder, empty bladder, replace with red rubber tube, suture to skin
Post-unblock tx
Buprenorphine q6-8, monitor urine output q1-2, copious fluids to deal with possible post-obstructive diuresis- WATCH OUT FOR HYPOKalemia
Causes of post-obstructive diuresis
medullary washout, osmotic diuresis, pressure necrosis, ADH resistance
When is blocked cat surgical
Repeats, stones, cant unblock
Why not PU right away?
