Midterm Flashcards
Define CPR
Emergence procedure performed in order to manually maintain perfusion until spontaneous circulation can be restored
Define CPA (cardiopulmonary arrest)
Cessation of normal circulation due to failure of the heart to contract effectively
What is the biggest influence on whether CPR will work or not
If CPA does not have a reversible cause, CPR is unlikely to be successful - example, if it is due to anesthesia it is likely reversible, if it is due to a terminal disease, it probably is not
What is the success rate of CRR
5%
What are 3 key features in recognizing CPR
Loss of consciousness, loss of normal spontaneous breathing, loss of palpable pulses
What are common preceding events to CPR
Bradycardia, worsening mentation, sudden increase in vagal tone (vomiting, straining to defecate), sudden change in breathing pattern
Which pose are you going to feel if concerned about CPA
Femoral pulses
What are common diseases that predispose to CPA, warranting intense monitoring and aggressive therapy
Sepsis, sirs , heart failure , pulmonary disease, trauma, neoplasia, general anesthesia
What are the 6 roles of a CPR crash team
Leader, ventilator, compressor, time keeper, recorder, drug administrator
When performing CPR, do you follow the ABC rule (airway, breathing , circulation)
No - start compressions immediately before securing airway (because it takes too long together supplies ) - it is circulation , airway and breathing
How many breaths per minute do you give when patient is intubated and you are giving manual breaths
8-12 breaths/minute
What amount of oxygen do you use when giving manual breaths
100% oxygen
What is our ultimate goal in CPR
Get the heart beating again _ we con manually give breaths for while but without circulation it doesn’t matter
When do you use the thoracic pump theory in CPR
Over 15 kg dog, wide chest
When do you use the cardiac pump theory
Less than 15 kg
How many compressions per minute do you do with CPR
100 compressions per minute
How do you give chest compressions
Depress the chest by one third then allow complete chest recoil to allow venous blood return to heart
When is open chest CPR indicated
Large dogs with thoracic trauma, pleural or pericardial disease, intra operative arrest, ineffective chest compressions
If you are successful with open chest CPR I what do you need to be prepared for
Thoracotomy - cut into the there to reach lungs or other organs
What are examples of pleural or pericardial disease that would indicate open chest CPR
Pneumothorax, pleural or pericardial effusion, diaphragmatic hernia
What are the 4 recognized arrest rhythms
Ventricular tachycardia, ventricular fibrillation, systole, pulseless electrical activity
What are the two shockable rhythms
Ventricular fibrillation and pulse less ventricular tachycardia
Is the goal of defibrillation to start the heart again
No - goal is to shut down the electrical activity to let the heart and sinus node do its thing
What is the shock dose for external defibrillation
2-10 joules/ kg
What position is the dog in when you do defibrillation
Dorsal
How long after defibrillation do you recheck the rhythm
2 minutes
What is the most common CPR drug used and how is it given
Epinephrine - give IV at 1 ml/10 kg every 4 minutes
When would no use atropine in a CPA
Before arrest for bradycardia - give 1ml/10kg IV
What 2 things do you monitor with CPA
ECG and end tidal co2
What does end tital co2 tell you during CPA
Confirms ET tube placement and identifies ROSC (return to spontaneous circulation) I also assesses quality of CPR compressions
When do you give fluids during a CPA
Only if the patient was hypovolemic prior to arrest - otherwise can reduce coronary perfusion
Do yo use antiarrhytmic agents like lidocaine in CPA
no - can decrease success of defibrillation and suppress ventricular activity
How do you assess brain function during triage
Mention - due, stuporous , comatose, death. And if patient is seizing
What is the difference between dull and stuporous and comatose
Dull - responds to all stimuli with less Vigor,
Stuporous - only responds to noxious stimuli
Comatose - no response to noxious stimuli
How do you check lung function with triage
Breathing rate and effort , abdominal effort on expiration , neck extension, stressed look
Do we care about crackles or where’s on triage exam
No
What is the only cause for panting in dog
Thermoregulation - trying to cool off
What do you check on triage to assess perfusion
Heart rate , mm, CRT, mention, temperature, pulse quality, thermometer!
On cardiovascular triage, we are looking for - in dogs and - in cats
Tachycardia in dogs (60 - 120 bpm), bradycardia in-cats (180 - 240 bom)
When do cats usually become bradycardic
When in shock and decompensating
When there is low perfusion ( in dogs especially) , what is the first thing the body does
Heart rate increases
Where does gum color come from
Hemoglobin
What do mm colors indicate - pink, red, brown, blue yellow, white
Pink - enough hemoglobin
Red -oxyhemoglobin
Brown - toxins leading to methemoglobin
Blue - deoxhemoslobin (no oxygen bonding to hemoglobin)
Yellow - bilirubin which is a by product of hemoglobin break down
While - decreased hemoglobin (anemia or vasoconstriction)
What is CRT look like with vasoconstriction? Vasodilation?
Over 2 seconds with vasoconstriction
Les than one second with vasodilation
How can mentation indicate perfusion
Brain reeds ouch and sugar to work (gets these by blood fow) - correct perfusion then reassess the mention
Poor mention in the absence of other neuro signs indicates
Poor perfusion
How can temperature indicate perfusion
Hypothermia concerning - when cold you vasoconstrictor and when u vasoconstriction you get cold (shunt blood away from periphery to maintain blood now to the core organs)
A low body temp and cold toes can indicate
Perfusion problems
Describe weak pulse
Distance between systole and diastole is shortened - less volume per bolus
Define shock
Severe imbalance between oxygen supply and demand, leading to inadequate cellar energy production significant decrease in oxygen supply to tissues or an overconsumption of oxygen
Shock is a balance between
Oxygen deliver and oxygen consumption
Oxygen delivery = - x -
Cardiac output times arterial content of exigen
What does art trial content of oxygen mean
How much oxygen is in the bloodstream
What are the 3 types of shock
Circulatory, hypoxic, metabolic
What are the types of circulatory shock
Hypovolemic, distributive, obstructive, cardigenic
The majority of shocks are - and due to
Most are circulatory and due to decreased oxygen delivery
What’s the most common type of circulatory shock? Describe it
Hypovolemic - decreased intravascular volume, decreased preload, decreased cardiac output
What are causes of hypovolemic shock
Hemorrhage, severe dehydration (GI or renal losses), third space fluid loss, severe burns (loss of proteins and electrolytes)
Describe distributive shock
Mal distribution of fluid from changes in vascular tone and increased vascular permeability (there is enough volume but it is not getting to the tissues , decreased systemic vascular resistance (deficits in preload or contractiling)
What are causes of distributive shocks
Anaphylactic Shock ( histamine induced vasodilation) , septic shock (endothelial dysfunction) , neurogenic shock, extreme fear
Describe obstructive shock
Compression of heart or great vessel that interferes with venous return, decreased diastolic filling and preload, decreased cardiac output
What are causes of obstructive shock
GDV ,obstruction of vena cava ,tension pneumothorax, cardiac tamponade from periodical effusion, positive pressure ventilation
When there is pericardial effusion and increased pressure over the heart - which part of the heart collapses first
The right atrium (least pressure)
Describe cardiogenic shock
Decrease in forward flow from heart due to pump failure - primer decrease in cardiac output due to an issue with the heart and tie pump failure
What are causes of cardiogenic shock
Systolic failure (dcm), diastolic failure (hcm), atrioventricular valve degeneration, Brady or tachy arrhythmias
Describe hypoxia shock - what are causes
Decreased arterial oxygen content and decreased oxygen deliver to tissues - caused by severe pulmonary disease, anemia, dyshemoglobinemias
Describe metabolic shock and its causes
Deranged cellular metabolism leading to inappropriate oxygen tissue use due to severe hypoglycemia and mitochondrial dysfunction
What do catecholimines cause
Increased heart rate, contractility and peripheral vasoconstriction
What are 4 compensatory mechanisms of shock
Barocreceptor reflex, chemoreceptors I RAA S activation, antdiruetic hormone
- Is often considered hallmark for decompensatory shock
Hypotension - map determines peripheral perfusion
What ave 2 types of distributive shock? Describe them
Anaphylactic and septic - initial vasodilation then vasoconstriction
What are clinical signs of anaphylactic or septic shock
Tachycardia, CRT less than 1second (because of the vasodilation), red to injected mucus membranes , elevated temp, bounding pulses
, Bradycardia in cats is - until proven other wise
Shock
What is the shock organ for dogs? For cats?
Dogs - git
Cats - lung
Hypothermia in dogs indicates what type of shock
Crudiogenic - in cats it can indicate any type of shock
What is the goal of shock treatment
Restore oxygen delivery to tissues as soon as possible - flow by oxygen, obtain IV access, IV find bolus UNLESS in cordiogenic shock
What are indications for peripheral venous catheters
Emergency like CPA, fluid admin, sedation , euthanasia
When do you often place auricular catheters
Mostly GDVs
What type of catheter is best for fluid administratrion and blood products especially in shock patients
Large bore, short catheters
What is the purpose of venous cut down for peripheral venous catheters
Temporary utilization to provide fluid resuscitation until routine peripheral venous catheter can be more readily replaced - emergency situations to provide stability with fluids or blood products
What should you do after rending venous cut down catheters
Contaminated nature of catheter placement means you need to lavage and close aseptically
Where is venous cut down done in dog? Cat?
Lateral saphenous dog, medial saphenous cat
Define phlebitis
Inflammation of a vein near the surface of the skin
If you have a dog with a fever and a catheter who is otherwise doing well, what should you do
Change the catheter in case of phlebitis
When do you place intraosseous catheters and where
Small or neonatal patients, exotics, failure for peripheral venous catheter - placed in femoral or humeral or tibia
Describe the efficacy of intraosseous catheters
Slower onset of drug admin, is for fluid resuscitation until venous peripheral access can be had, quicker time to place a venous cut down , blood samples less accurate because it is from bone marrow
What is the Max time an intraosseuos catheter should be placed
24 hard max
When are intermittent uincy catheters best
For contrast procedures or to relieve an obstruction
When should you prescribe antibiotics in emergency
Know bacterial infection that has positive culture or suspected bacterial infection (due to signs like a fever, information)
Does fever mean infection
No - fever means inflammation (not all inflammation is caused by an infection)
Should you give antibiotics for upper respiratory tract infections
No-usually is due to a virus with secondary bacterial infection
Should you give febrile patients antibiotics
Sometime but usually it is due to viral infections
What are the 5 classes of analgesics used in the Er
Opioids, NSAIDs, alpha 2 agonists, NMDA receptor antagonists, local anesthetics
What are pros of opioids
Excellent analgesia , minimal cardiovascular effects, reversible, sedation
How do you reverse opioids
Naloxone
Opioids in an Er setting are good for dogs with - and -
Safe for shock dogs and congestive heart failure due to the minimal cardiovascular effects
What are the cons of opioids in Er patients
Possible respirators depression, parental primary (oral bioavailability low), sedation, abuse, GI upset and illus
Summarize the use of opioids in Er and the time limit
Good analgesic for acute, severe pain , safe and effective but is not good for chronic use (max 24-48 hour use)
Stop opioids at 48 hours max due to
Adverse GI effects
What are the pros of NSAIDs
Excellent analgesia , .oral and parental, inexpensive
What are the cons of NSAIDs
Possible GI ulceration, no use in dehydrated or hypovolemic patients due to decreased renal blue flow and not reversible
What is the reversal for NSAIDs
No reversal
If an animal is on NSAIDs and they stop eating , what should you do
Stop the NSAIDs became if they aren’t eating , they aren’t drinking so it is not safe
Immediately after trauma, would you start a dog on NSAIDs
No - you reed to make sure renal perfusion is good first
How do NSAIDs affect the kidneys
Renal autoregulation is mediated by prostaglandins and NSAIDs block prostaglandin production so during a trauma the kidneys are not able to adjust in the face of hypotension (leaves the kidneys unprotected)
How do NSAIDs affect git and stomach
They block prostaglandins that lead the gut to be more susceptible to ulcer formation (prostagladino importat to make mucus buffers and secrete more bicarb)
Summarize NSAIDs
Excellent analgesia for severe, chronic and orthopedic pain contraindicated in dehydration and hypovolemia (big risk of renal damage ) I risk of GI upset and ulcers
When do you use NSAIDs generally? Can you give them on an empty
If patient is well hydrated and perfusing well for both qs
What are pros of alpha 2 agonists
Effective analgesia, powerful sedation, cheap, reversible
What are the cons of alpha 2 agonists
Significant decrease in cardiac output so limit use to very stable patients, profund sedation , respiratory depression, parental only
What can be the risk with the profound sedation seen by alpha 2 agonists
Decreases ability to detect pain in Er patients
Is dexmedetonidine a good option for patients with decreased cardiovascular status
No - significant decrease in cardiac output
Does a lower dose of dexmedetomidine (an alpha 2 agonist) men it is safer for heart patients
No - no matter the dose there is always a 60-70% drop in cardiac output; it is a yes or no drug -i either the patient is stable enough or not
What is an example of NMDA receptor agonist
Ketamine
When are NMDA receptor antagonists best
Most effective if given before the painful stimulus (like if you give before surgery)
What are the beeline of NMDA receptor antagonists
Reduces amount of opioids needed for analgesia, prevent windup can increase in pain intensity caused by the same stimulus over time
What is a pro of NMDA receptor antagonists
Minimal to no GI effects so good for severe pain and GI signs
What is the main stay therapy for shock patients
Fluid resuscitation with isotonic crystolloids like LRS IV over 10-20 minutes, then immediate reassessment after bonus , whole blood if bleeding or blood loss
What are treatments for obstructive shock patients (a subcategory of distributive shock)
Gashed trocharization, thoracocentesis , pericordiocentesis (relieve pressure causing the obstruction)
What ave quick treatments for patients in septic shock
Vasopressors like norepinephrine, broad spectrum antibiotics, fluids
How do you treat anaphylactic shock
Vasopressers like epinephrine, antihistamines, fluids
What would you not use to treat cardiogenic shock? What do youdo?
No IV fluids! Correct underlying disease, oxygen therapy, minimize stress
How do you treat chf leading to cardiogenic shock
Diuretics like furosemide , oxygen therapy
How do you treat life threatening arrhythmias leading to cardiogenic shock
Lidocaine or atropine
What are your resuscitation endpoints for shock therapy
Clinical reassessment every 5 to 10 minutes or after every therapy used during stabilization - can desolate after normal perfusion parameters are reached
What is the most sensitive indicator of Shock
Heart rate
When triaging, what is usually the easiest pulses to feel
Femoral pulses
What is the most common shock in poly trauma patients
Hemorrhagic shock - tissue hypopefusion due to decreased cardiac output and decreased mean arterial pressure
What do you look for first in poly trauma patients
Check lactate, tissue perfusion, signs of hemorrhagic shock (heart rate, mm, etc)
What is the goal of IV fluid resuscitation
Restore tissue perfusion and oxygen delivery
Crystalloids are a-
Balanced electrolyte solution
A benefit of colloids is that they stay
In the intravascuor space longer
What is point of care ultrasonography
Abdominal fast scans Or thoracic fast scans
What are benefit of pocus
Portable and we don’t need a radiologist to interpret, fast, can be done while other tests are being done
What is the ultimate goat of fast scans
To see if there is free fluid in the thorax or abdomen and tren use as a guide for procedures like thoracocentesis, pericordiocentesis, etc
Why is performing A fast in right lateral best
Decreased risk of hitting the spleen if aspirating - dorsal recumbency bad for patients with respiratory distress
What is important to check for on an afast especially after trauma
Check to make sure the bladder is intact
What are the 4 views to check on an afast
Diaphragmatic hepatic, spleen renal, cysto colic, hepatorenal
How do you use abdominal fluid scores
Purpose is to gauge severity of abdominal effusions - a score of I men’s file seen in to 4 sites and so on (this score should correlate with CBC, PCI, etc)
How often should you repeat afast scans and scores
Every 4 hours (even hour if patient is shock)
Lung rockets on tfasf scans indicate what
Lung contusions, wet lung, some sort of interstitial disease
Bar code signs on M mode on TFast could indicate
Pneumothorax
Rain sign on m mode for tfast could indicate what
Wet lung or interstitial disease
What is the benefit of a mushroom view on tfast
To see heart function and contractility
What size should the left atrium be compared to the aorta on tfast
Left atrium should be 1- 1.5 times the size of the aorta (if bigger left atrial enlargement)
Define orthopnea
Positional increases in difficulty breathing - head and reck extended, elbows abducted (basically trying to extend path of breathing)
Define dyspnea
Sensation of breathless
Issues breathing on inspiration localize the problem to where
Upper respiratory
Issues on expiratory breathing indicates a problem where
Lower airway like bronchial disease
Where is the problem localized to with increased effort during all breathing phases
Parenchymal
Short shallow breathing localizes the problem to where
Pleural space
What are 3 things to do over a patient is in respiratory distress
Minimize stress , oxygen supplementation, provide sedation (butorphanol usually) - it patient is really bad I con heavily sedate and intubate to reduce stress and the work of breathing
It is better to - a living patient in respiratory distress than to
Better to intimate a living patient than a head patient who just went into respiratory arrest
What ave possible upper airway diseases that can cause issues on inspiration
Laryngeal paralysis , tracheal collapse, foreign bodies, polyps, brachycephalic airway syndrome
What can help you differentiate between cardiac and non cardiac caused
Temperature - if congestive heart failure, they should be hypothermic
What are the 3 fluid compartments in the body
Intracellular fluid, extracellular (interstial and intravascular)
What is the total body water
65% (multiply body weight by 0.65 )
Describe the relationship between sodium and potassium intracellularly and extracellularly
Inside the cell, there is low sodium and high potassium, outside the cell there is high sodium and low potassium
What determines intravascular concentration
Sodium because water follows sodium
Total body sodium determines
Hydration
Serum sodium concentration reflects - not-
Reflects total body water not total body sodium because water is freely permeable across cell membranes and sodium is not
High sodium on bloodwork lovely means -
Low water and vice versa
Huponatrenia indicates a-
Water excess -losing both water and electrolytes like sodium
What does the sodium in a dehydrated animal usually look like
Normal or high sodium - depends on if losing water in excess or Normal amount
Hypernatronic indicates a
Water deficit - severely dehydrated
Hypotonic loss means
More water is lost than solute loss - usually with a polyuric patient, can lead to a huperatrenia
A hypertonic loss means what
More solute is lost than water, could lead to a hyponatremia
Fluid loss is most often
Isotonic and the sodium remains unchanged - isotonic to extracellular fluid
Differentiate between dehydration and hypovolemia
Dehydration - loss of fluid from the interstitial space, happens slow and replaced slow
Hypovolenia - loss of fluid from the intravascular space happens rapidly
Where do the losses occur with dehydration and hypovolemia
Extracellular comportment - interstitial (dehydration) and intravascular (hypovolemia)
Which type of fluid loss requires rapid restoration and why
Hypovolemia fluid loss from the intravascular space - because the body can’t quickly replace the fluid
A gradual fluid loss or lack of replacement indicates
Dehydration and lack of interstitial water
What general type of replacement said do you need for dehydration and hypovolemia and why
High sodium because these are both extracelluar fluid losses so losing high sodium and low potassium
What are 6 reasons to give fluids
Dehydration, hypovolemia, anorexia over 24 hours, severe losses, general anesthesia , as a vehicle to get other stuff in the patient
What are the main 2 reasons to give finds
Dehydration and hypovolemia
If an animal has diarrhea and they are eating/ drinking , will they need fluids
No -if eating will be drinking
What are crystalloids
Salt water - moves freely within extracellular space and redistributes rapidly into interstium
What are colloids
Contains molecules that don’t readily leave the intravascular space so should stay in the intravascular space, (more than salt in the water)
All fluids will redistribute in the first - but - distributes faster
All fluid will redistribute in the first few hourrs - crystalloids redistribute faster
The greatest absolute increase in blood volume is seen with - while the greatest increase in blood volume per volume delivered is seen with -
Crystalloids lead to greatest absolute volume increase, hypertonic saline leads to greatest increase in blood volume per volume
The most sustained increase in blood volume is seen with
Colloids - because colloids stay in the intravascular space longer
What are risks of colloids
Potential interstitial leak leading to edema , changes incoagulation, kidney injury, more expensive than crystalloids
What are risks of crystalloids
Large volume, transient effect, potentates edema
Give examples of isotonic fluid
LRS , normal saline, normosol R, plasma lyte A
Describe isotonic fluids
Same amount salt as extracellular fluid
Describe hypotonic fluids - what is important to note about them
Less salt than Extracellular fluid - can never bolus hypotonic finds became too much water can cause cells to explode
Describe hyper tonic saline
Plus free water fromn interstitial and intracellaar spaces to increase the intravascular volume - excess salt compared to fluid
When should you avoid using hypertonic fluids
Hypernatremic or dehydrated patients - because it could make the hypernatremia worse
What are benefits of hypertonic fluids
Increased tissue oxygen delivery, sustain heart rate and cardiac output, decreased cellular edema
You should have lower - man - in extracellular fluid
Lower chloride than sodium in Extracellular fluid
Describe replacement fluid and give examples
Mimics extracellar fluid, high in sodium - lactated ringers, normal saline , normosol r, plasmalyte
Describe maintenance fluids and give examples
Mimics daily electrolyte requirements , low in sodium and chloride higher in potassium - half strength saline , normosol m
When are sub Q fluids appropriate
Only in stable patients
How does the baroreceptors reflex compensate for shock
Changes in pressure lead to increased heart rate and contraction, and peripheral vasoconstriction
How do chemoreceptors compensate for shock
Chases in things like pH or po2 need to increased respiratory rate and tidal volume - the bigger breaths to increase oxygen delivery to tissues
How does RAAS activation compensate for shock
Increases angiotensin 2 (a potent vasoconstricter) to increase peripheral vasoconstriction and increase real sodium absorption (because water follows sodium)
How does antidiuretic hormone compensate or shock
Increases renal water absorption
Describe decompensatory shock
Decreased blood pressure and decreased heart rate
Describe compensatory shock
Increased heart rate and normal blood pressure
