Initial survey Flashcards
Define triage
Triage is the process of “sorting out” patients on initial present to the emergency centre. Triage requires a focused on assessment of the “major body systems” to determine the urgency of the situation. All patients presenting for emergency treatment should be triaged immediately with the aim of identifying those requiring immediate emergency treatment and those who are stable and can wait for veterinary attention.
Examples of patients that should be triaged as urgent (6)
Examples of patients that should be triaged as urgent include those with: • Major trauma • Head trauma • Haemorrhage • Altered mentation • Cluster seizures or status epilepticus • Inability to walk or stand • Snake bite Any patient assessed as unstable, should be immediately brought to the treatment room for rapid assessment by a veterinarian.
Define and describe primary survey
This first evaluation is sometimes termed the ‘primary assessment’ or ‘major body system assessment’. The aim of the primary assessment is to evaluate “what will kill the patient first” in order to initiate life-saving treatment as soon as possible. Major body system assessment includes evaluation of cardiovascular, respiratory and neurological stability in addition to abdominal palpation (+/- AFAST* examination)
and rectal temperature. Once a primary assessment has been performed and any life threatening issues addressed, then a secondary (more thorough) assessment can take place.
What is MBSA
Rapid assessment of CVS, RESP, NEURO, ABDO palp, RECTAL TEMP
Describe MBSA - CVS
Cardiovascular system evaluation: Heart rate and rhythm, mucous membrane colour, CRT and pulse quality including synchronicity with HR should all be assessed. Any haematological or cardiovascular condition that leads to reduced DO2 warrants immediate treatment.
Assessing pulses
Pulse pressure is the difference between systolic and diastolic pressure. Poor pulse quality is reduced or loss of palpable pulse pressure.
Pulses may be described in reference to their height (tall or short) and in reference to their width (wide or narrow). Various other terms have been used to describe pulse quality, e.g., bounding, thready or weak. The term ’weak’ typically refers to short, narrow pulses. The term ‘bounding’ generally refers to tall, narrow pulses. Pulse pressure varies with stroke volume and compliance of the artery. Dogs and cats have little variation
in compliance therefore changes in pulse pressure are likely to reflect stroke volume. A tall wide pulse reflects an increased stroke volume such as occurs in a tachycardic euvolaemic animal. A tall narrow pulse occurs with rapid ejection of a reduced stroke volume such as occurs in early hypovolaemia. A short narrow pulse reflects a greatly reduced stroke volume such as occurs with advanced hypovolaemia or cardiac failure.
Equation for MAP?
Mean arterial pressure (MAP) = [1/3(SAP – DAP)] + DAP
where SAP = systolic arterial pressure and DAP is diastolic arterial pressure. Therefore, MAP is approximately 1/3 of the pulse pressure.
Describe MBSA - resp
Respiratory system evaluation: Respiratory rate, breathing effort and pattern should be assessed; any abnormal noises such as stertor or stridor should also be noted. Respiratory instability again warrants immediate treatment. Instability includes rapid respiratory rate, laboured or shallow breathing, open mouth breathing, orthopnoea and any other abnormal patterns such as paradoxical movement of the abdomen.
Desc MBSA - Neuro
Neurological system evaluation: Level of mentation or consciousness and ability to stand or ambulate should be assessed. Instability includes any alterations of mentation or consciousness, acute limb paresis or paralysis, current seizures or recent seizure activity.
Desc MBSA - abdominal assessment
Abdominal assessment: The patient’s abdomen should be palpated for pain; excessive pressure; typany; masses; a fluid wave. An AFAST exam will rapidly rule in or out abdominal effusion.
Desc MBSA - rectal temp
Rectal temperature is an important part of the primary assessment of a patient. Hyperthermic patients may present with obstructive breathing or heat stroke, while a low rectal temperature may be indicative of shock.
What is FAST exam?
FAST examination is becoming increasingly used as part of the primary assessment of emergency patients (both with and without trauma). Thoracic FAST (TFAST) exams allow recognition of pericardial effusion and tamponade, pleural effusions, pneumothorax, increased left atrial to aortic ratio and subjective evaluation of cardiac contractility. Abdominal FAST (AFAST) exams can identify peritoneal or retroperitoneal effusions, allowing rapid detection of abnormalities that may be key to diagnosis of the underlying disorder. E.g. haemorrhagic effusions would identify haemorrhage as the cause of hypovolaemic shock, modified transudates indicate third spacing of fluid which can cause hypovolaemic and possibly distributive shock if volumes are high, and identifying septic effusions would indicate sepsis as the cause of shock.
Why is rapid assessment of shock important?
Patients in shock are unstable patients and warrant immediate attention. Early recognition of shock allows for timely intervention and an increased chance of halting progression into potentially irreversible shock. Shock can ultimately result in cell death and, left unchecked, can cause organ failure and patient death. However, re-perfusion and renewed delivery of oxygen to the cell can also cause cell death due to the formation of reactive oxygen species (ROS). It is therefore clear that prompt and effective treatment of shock is vital for patient wellbeing.
Clinical parameters in the assessment of shock?
Patients in shock will generally present with some or all of the following, depending on the degree of cardiovascular instability or cause of shock: • Increased or decreased heart rate • Pale or injected mucous membranes • Inappropriately fast (< 1 sec) or slow (> 2 sec) CRT • Poor pulse quality • Tachycardia • Tachypnoea • Dull mentation • Cool extremities and/or hypothermia
What is the shock index?
Shock Index = heart rate/systolic blood pressure
The shock index is a measure that designed act as a tool for triage and assessment of the severity of shock. Unfortunately, indirect blood pressure measurement is not reliable in hypotensive veterinary patients and heart rate can vary widely. There is no clear advantage to using a shock index over traditional clinical parameters for triage or assessment of shock.
Which type of shock is important to differentiate and why? What are some PE indicators of this type of shock?
Initially, it is most important to differentiate cardiogenic shock from other forms of shock, as the mainstay of treatment for most forms of shock is aggressive fluid therapy, which would be fatal to a patient suffering cardiogenic shock. Pneumothorax is another exception to the fluid rule, where correction of shock requires removal of the air that is compressing venous return and causing distributive shock.
Patients presenting in cardiogenic shock will have specific indicators of cardiac dysfunction. Auscultation of a cardiac murmur or gallop, palpation of pulse deficits, presence of arrhythmias on ECG, documentation of a pericardial effusion or increased left atrial to aortic ratio on ultrasound exam are indicative of underlying cardiac disease. Patients with congestive heart failure may present with dyspnoea, tachypnoea, cyanosis, pulmonary crackles or pleural effusion.
What is an emergency database?
The emergency database is an integral part of assessing the emergency patient. Ideally, blood for an emergency database is collected and analysed during the primary assessment. It is useful to draw the required blood sample from an intravenous catheter. The emergency database can aid in the recognition of shock and help diagnosis of the underlying cause. Commonly run tests are PCV/TS (packed cell volume and total solids), electrolytes, glucose, lactate and venous blood gases. This allows for immediate recognition of hypo and
hyper glycaemia, anaemia, haemoconcentration, acute haemorrhage, hyperlactataemia, hypoventilation, alterations in pH, and electrolyte derangements.
How can you detect acute haemorrhage?
Detecting acute haemorrhage can be tricky. Total solids will always decrease before the PCV as splenic contraction elevates the PCV in the initial stages of haemorrhage. If TS is less than ≤ 50 g/L then this raises the suspicion of acute haemorrhage.
Why is assessment of glucose important as part of our initial database?
Detecting acute haemorrhage can be tricky. Total solids will always decrease before the PCV as splenic contraction elevates the PCV in the initial stages of haemorrhage. If TS is less than ≤ 50 g/L then this raises the suspicion of acute haemorrhage.
