Important factors to consider in the emergency and critical care patient

Question 1

What do you think are important factors to consider for gold standard management of an emergency and critical care patient?

Answer 1

• Trained team
• Some protocols
• Confidence in what you are doing
• Being able to do a physical exam
• Knowing when to do stuff!

Question 2

What is Kirby’s rule of 20?

Answer 2

The Rule of 20 is a check-off list of 20 critical parameters to evaluate at least daily in the critically ill animal. This check-off list is pasted into the patient record with the daily SOAP to prompt the clinician to assess and intervene as required. Comments are written regarding the status and therapeutic strategy for each. The following is a brief synopsis of these 20 parameters. The order of priority will differ depending upon the clinical situation.

Question 3

When considering the emergency and critical care patient, what should consider and think about with regard to fluid balance?

Answer 3

•Where is the fluid?

–SIRS

•Is patient vasodilated?

–Third space

• In chest or abdomen?
• Is the patient hypovolaemic? How will we make sure we know this?

–MBSA

•Physical exam parameters

–Lactate

–Urine output

•Is the patient dehydrated?

–Weight loss

•Only if weighed regularly! Might not just be fluid, might be good intake but can help!

–Skin tent

–Tacky MM

Question 4

How can we assess is a patient is hypovolaemic?

Answer 4

MBSA

Lactate

Urine output

Question 5

How can we assess if a patient is dehydrated?

Answer 5

Weight loss

Skin tent

Tacky MM

Question 6

When considering the emergency and critical care patient, what should consider and think about with regard to oncotic pull?

Answer 6

• Is there enough protein to keep fluid in intravascular space – if you haven’t, might do more harm than good!
• Any signs of inability to keep products in the intravascular space?

–Peripheral oedema

–(Tissue oedema)

–TP <40g/L and/or albumin < 20g/l; some effects seen before this if sudden fall in protein whereas many can cope with lower than this if fall has been more gradual

•If you use crystalloids, will make tissues blobby – peripheral oedema but will end up with tissue oedema which will reduce organ function

–Blood, plasma, (artificial colloids??)

•Would the patient benefit from this? Stopping protein losing process is important in this role

Question 7

When considering the emergency and critical care patient, what could cause an increased blood glucose?

Answer 7

–Stress (esp. cats and camelids)

–Underlying disease (DM)

–Problematic as leads to osmotic diuresis

Question 8

When considering the emergency and critical care patient, what could cause a decreased blood glucose?

Answer 8

–Esp prob in hypotensive SIRS and sepsis patients

–Significant energy imbalance

–Endocrine disease – primary or secondary to underlying disease

–Likely to have significant energy imbalance, esp if in adult animals

Question 9

When considering the emergency and critical care patient, what should consider and think about with regard to electrolyte and acid-base balance?

What is significant with regards to sadoium, chloride, potassium?

Answer 9

• Calcium and magnesium (ideally ionised)
• Sodium

–Doesn’t need to be too high or too low. Change slowly so don’t damage brain

•Chloride

–Don’t care too much! Often sorts itself out when other things do

•Potassium

–Needs to be basically within a normal reference range

•Acid-base derangements

–Often metabolic and complex

–Usually acidosis, but not always

–Blood gas analysis – doesn’t require too much to work out

–Often complicated

Question 10

What are some things that can cause mild metabolic alkalosis?

Answer 10

• Gastric fluid loss
• Diuretics
• Hyperaldosteronism
• Hyperadrenocorticism

Question 11

What are some things that can cause respiratory acidosis?

Answer 11

• ? Is it just because its compensatory, trying to sort out alkalosis by breathing less?
• Central resp depression – secondary to intracranial dx
• Extracranial disease – uraemic encephalopathy
• Muscle weakness – chronic dx/ cachexia/ low K+ can contribute

Question 12

When considering the emergency and critical care patient, what should consider and think about with regard to oxygenation and ventilation?

Answer 12

•ABP (arterial blood gases)

–Hypoxaemia, hypercarbia or hyperventilation

–Needed to detect pulmonary oedema and ARDS early

•Oxygen supplementation

–Perfusion

–Breathing abnormalities

–AS STRESS FREE AS POSSIBLE

• Cages, prongs, nasal tubes
• May need mild and careful sedation
• Don’t put them in a cage that’s too small as could increase CO2 in this cage and don’t want them to rebreathe this in

Question 13

When considering the emergency and critical care patient, what should consider and think about with regard to level of consciousness and mentation?

Answer 13

•Needs REPEATED assessment and immediate investigation if declines

–Hypotension

–Hypoglycaemia

–Hyperammonaemia

–(Oxygenation; Electrolytes; Fever; Hypovolaemia, Sepsis; Cardiac dysrhythmias)

Question 14

If poor perfusion that does not respond to fluid challenges, you then need to look for other reasons

Name some

Answer 14

–Check for ongoing fluid loss

–Cardiac disease or dysrhythmias

–Low temp

•Going to be inappropriately vasodilated

–Low glucose

•High glucose is also important

–Low oxygen

–Electrolyte derangements

–Brain stem pathology that’s not responded to cardiac barorecptors

–Poor analgesia

Question 15

When considering the emergency and critical care patient, what should consider and think about with regard to heart rate. rhythm and contractility?

Answer 15

• Check for murmurs and dysrhythmias
• Primary cardiac disease or secondary to SIRS or sepsis…..or both
• If you have weird HR, consider doing an ECG to look for dysrhythmias

Question 16

When considering the emergency and critical care patient, what should consider and think about with regards to albumin?

What if its low?

Answer 16

• Should be above 20g/L in the acutely ill animal
• Many causes – GI or renal loss, liver failure, cytokine suppression of albumin production in SIRS
• Associated with increased mortality in sick people
• If not enough protein in body – wont heal!
• In critically ill people, more likely to die if you have a low albumin. Can fix GI disease so less loss, but sometimes liver doesn’t produce enough

Question 17

When considering the emergency and critical care patient, what should consider and think about with regards to coagulation?

Answer 17

• Monitor sick animals for coagulation problems e.g. petechiation, bleeding at Venopuncture sites etc. in large animals, more likely to throw clots in an inappropriate manner
• Small animals usually see bleeding diseases whereas large animals inappropriately excessively coagulate
• DIC – usually seen in sick animals
• 1) Decreased ATIII
• 2) Decreased platelet count
• 3) Shortened PT, PTT, ACT
• 4) Decreased fibrinogen
• 5) Increased FDP’s

Question 18

When considering the emergency and critical care patient, what should consider and think about with regards to RBC/Hb concentration?

Answer 18

• Need to have enough to deliver oxygen and transport around the body. If not enough oxygen, can hyper oxygenate animals so oxygen is distributed in plasma but not efficient way
• Tolerance varies on rate of RBC loss or reduced production
• <20% acutely and <15% chronically rules of thumb

–If you have physical exam findings that suggest the animal is not coping with anaemia, think about transfusion. E.g. tachycardia, tachypnoea – need to differentiate from hypovolaemia

•Transfusions are not innocuous however so should be used prudently

–Cats – NEED TO cross-match

–Dogs and horses – often can get away without cross-match with first transfusion and probably for the 1st transfusion over 5 days, can probably od multiple within 3-5 day period if you need to

–Lifespan of transfused cells relatively long in dogs and cats; often last <5-7 days in horses

•If they don’t have a reaction – the cells will live a reasonable length of time

Question 19

How can intrinsic renal function be compromised?

Answer 19

•May have CRF or may be secondary to shock, hypovolaemia, hypoxia, nephrotoxic drugs

–Secondary factors called acute kidney injury

•Urinalysis MOST sensitive

–Glycosuria in absence of hyperglycaemia

–Casts

–Infection in compromised animal

• Urine output – can be a challenge to measure, especially if animals incontinent
• Creatinine (Urea in small animals, but not large animals)

–Remember for this to significantly increase need to have lost 2/3 or ¾ of renal function

Question 20

When considering the emergency and critical care patient, what should consider and think about with regards to immune status, antibiotic dosage and selection and WBC count?

Answer 20

• WBCC and neuts and lymphs, globulin concentration, pyrexia
• If immunocompromised need isolation and barrier nursing – FOR THEIR PROTECTION and care with invasive techniques
• Consider metaphylaxis for seriously sick animals that may not be due to sepsis – e.g. RTA
• Antibiotics – ideally C and S; if sick, bacteriocidal

–Wouldn’t need to be critically important antibiotic, but might think if you have pyrexia and low cell count – might consider.

–Culture and sensitivity – can take 3 days

Question 21

When considering the emergency and critical care patient, what should consider and think about with regards to GI motility and mucosal integrity?

Answer 21

• Critical illness often complicated by gastric stasis, ileus and gastric disease
• Don’t forget gut sounds in small animals – check whether present
• Bacterial translocation from compromised gut a massive concern…but also remember gastric acid there for a reason
• Stop animals being SICK and promote GI motility

–Might involve use of pharmacological agents

• Ideally avoid acid suppressants if you can
• Ideally feed enterally

Question 22

When considering the emergency and critical care patient, what should consider and think about with regards to drug dosages and metabolism?

Answer 22

• We know that all drugs are tested in healthy animals but with ECC patients, they are sick
• Be aware that we don’t know how sick animals handle drugs…..studies done in healthy animals
• Young animals do not handle drugs the same as adults
• Lots of extrapolations of dosages from other species that may be wrong! Probably od this more in horses than in dogs
• Use of antimicrobial dosages set 50 years ago that may be inappropriate/ineffective – probably not right now! Bacteria have had 50 years to involve and likely to need higher MICs than when these drugs were tested
• Consider where metabolised as may influence choices

–Liver, kidneys

Question 23

When considering the emergency and critical care patient, what should consider and think about with regards to nutrition?

Answer 23

• ABSOLUTELY ESSENTIAL AND OFTEN FORGOTTEN!
• Enteral better than parenteral
• Feeding better than via tube

–Physiological and might need to facilitate with drugs, dealing with emesis and nausea

•Needs implementing immediately and constantly assessing

–No-one gets better if their tissues are catabolising

•Feed appropriate foods – small volume, high calorie and appropriate but on increased side of protein (except in liver failure!)

–AD works well for small animals and is tasty so they will eat it. Don’t try GI diets if they wont eat as isn’t very nice!

•Work out how much you need to feed and might need to reassess it!

Question 24

When considering the emergency and critical care patient, what should consider and think about with regards to analgesia?

Answer 24

• Depression, restlessness, irritable, anorexia, tachycardia (not cats)
• Should be aiming for multi-modal
• Care with NSAIDS in small animals; not a concern in large animals (except neonates) – hardier kidneys
• Consider cardiovascular effects – alpha-2’s
• Consider sedative effects and respiratory depression (SA only) – Opioids
• Don’t under-estimate the use of low-dose ketamine and intravenous lidocaine

Question 25

When considering the emergency and critical care patient, what should consider and think about with regards to nursing care and patient mobilisation?

Answer 25

• ABSOLUTELY ESSENTIAL!
• Check catheter sites often – any concerns, remove, culture and replace
• Ensure kind management and human contact….incl hand feeding
• Ensure appropriate temperature
• Try and get outdoors doing some normal functions as soon as possible
• Be ready for animals to seizure or for intubation if a risk
• Human contact, out of kennel, give them reassurance etc.

Question 26

When considering the emergency and critical care patient, what should consider and think about with regards to wound care and bandage changes?

Answer 26

• Frequent examination of the wound
• Check bandage not too loose or tight and not wet – change if latter
• Optimal wound management should be to keep them moist but not macerated
• Compression bandages used with care and good supervision
• Make sure bandages appropriate and not wet

Question 27

When considering the emergency and critical care patient, what should consider and think about with regards to tender loving care?

Answer 27

• Mental health of the patient as important as physical health
• Owner involvement in animals that have a bond (probably not horses!)

–Dogs and cats

• Blankets, bedding, space, favourite toys or food/treats
• Ensure can either see or not see other animals

–Cats – NO

–Horses and goats….if you can

–Dogs