Silverstein Text (3rd ed) Flashcards
What is the primary survey?
A rapid assessment of an animal’s respiratory, cardiovascular and neurologic system
In the primary survey, what is the main focus of evaluating the respiratory system?
Determining the presence or absence of hypoxemia or hypoventilation
What can tachypnea indicate?
Presence of hypoxemia; hypovolemia, metabolic acidosis, pain, abdominal distension, etc.
In what circumstances is an upper airway obstruction more likely to occur?
Brachycephalic breeds, history of coughing/diagnosed or suspected tracheal or mainstem bronchial collapse, underlying laryngeal dysfunction, traumatic injury to neck/skull, secondary to orofacial surgery (secondary to bleeding/swelling)
Name 3 stabilization efforts in the event of an upper airway obstruction
- Sedatives
- Cooling if hyperthermic
- Antiinflammatory meds
BONUS: intubation or tracheostomy
What are dull lung sounds associated with?
Pleural space disease or severe consolidation of lung parenchyma
What are increased lung sounds/crackles/wheezes associated with?
Development of pulmonary parenchymal disease (ie. aspiration pneumonia)
Why does pleural effusion develop?
Secondary to SIRS and endothelial damage resulting in fluid leakage, severe hypoalbuminemia, massive pulmonary thromboembolism, right sided heart failure, fluid overload in cats, blunt/penetrating thoracic trauma, post thoracic/diaphragm surgery, barotrauma from anesthesia/mechanical ventilation
What are some causes of pulmonary parenchymal disease?
Aspiration pneumonia, ALI, ARDS, fluid overload and CHF, pulmonary thromboembolism
What are the risk factors for developing ALI/ARDS?
SIRS, sepsis, infection, smoke inhalation, near drowning, severe trauma
What does a SpO2 <95% correlate to
PaO2 of <80 mmHg, hypoxemia
What is the difference between hypoxemia and hypoventilation?
Hypoxemia = SpO2 <95/PaO2 <80 mmHg while hypoventilation is PaCO2 >50 mmHg
What does a PaO2/FiO2 ratio indicate?
If <300 it is ALI, if <200 it is ARDS
Why does hypoventilation occur?
Post operatively, patients treated with opioids/benzos/other resp depressing meds, cervical myelopathy, tgoracic trauma or pain, secondary to intoxications, neuromuscular disease, CNS pathology
What can you do when hypoxemia is confirmed?
Provide supplemental O2 (even if SpO2 is >95% but RR/RE increased), administration of a diuretic or bronchodilator, antibiotics case by case
What can you do when hypoventilation is confirmed?
Underlying cause must be addressed (i.e. reverse medications, give pain medications)
What is the purpose of evaluating the cardiovascular system on primary survey?
To identify poor tissue perfusion resulting in decreased tissue oxygen delivery
What critical conditions may develop that result in poor tissue perfusion?
Hypovolemia secondary to GI dysfunction with fluid and electrolyte losses from V+/D+/R+, third space losses of fluid in systemic endothelial damage and vascular leak, massive urinary losses of fluid (post obstructive diuresis), hemorrhage, severe hypoalbuminemia, cardiac disease and ventricular dysfunction, cardiac arrhythmias, cardiac tamponade, vasodilatory states like sepsis/SIRS
What are the physical exam findings consistent with poor tissue perfusion?
Pale mucous membranes, prolonged CRT, tachycardia (bradycardia in cats), tall and narrow pulse profile, poor/absent peripheral pulses, hypothermia, cold extremities, dull mentation, quiet heart sounds
What are some indicates of a vasodilatory state?
Red mucous membranes (dogs) with shortened CRT, peripheral pulses widened due to lower diastolic pressure
What does an absence of peripheral pulses indicate?
Hypotension (SBP <90 mmHg)
What is a rectal interdigital temperature gradient and what does it indicate?
Rectal temperature is taken and compared to the temperature taken between the 3rd and 4th digit on a pelvic limb. If the gradient is -11.6 F, it is suggestive of shock in dogs
Why might cardiac arrhythmias develop?
Secondary to hyperkalemia, cardiac ischemia, intraabdominal disease, underlying cardiac disease, CNS disease
How is a shock index calculated?
Doppler BP/Heart rate
What does a shock index tell us?
> 1.0 in dogs and >1.6 in cats indicates possible presence of shock
When might a shock index be useful?
In patients with early compensatory shock where vital signs and systemic perfusion are not significantly abnormal
What is blood lactate?
A byproduct of anaerobic metabolism that occurs under conditions of hypoxia
What does blood lactate indicate?
> 2.5 mmol/L can indicate systemic hypo-perfusion, but conditions such as sepsis may lead to elevated lactate as well
What should the primary neurologic survey include?
Evaluation of mentation, brainstem reflexes (pupil size, PLR, nystagmus), motor ability, MGCS in critically ill patients with neuro disease allows for comparison over time
Why may seizures develop in patients with known/suspected intracranial disease?
Traumatic brain injury, meningoencephlitis, neoplasia
In critically ill patients without primary intracranial disease, why might seizures develop?
Rapid decreases in BG which causes cerebral edema (diabetic patients),rapid decreases in sodium concentration causing cerebral edema, brain hemorrhage or thrombosis, secondary to hepatic encephalopathy, following congenital portosystemic shunt ligation, secondary to med administration (enrofloxacin or dobutamine)
What are some intracranial and extracranial causes for increased intracranial pressure
Intracranial: TBI, neoplasia, inflammatory brain diseases
Extracranial: hepatic encephalopathy
Both should be considered in cases of severely altered mental state
Where has dysequilibrium syndrome been noted?
In animals following hemodialysis or relief of urinary tract obstruction due to rapid changes in plasma osmolality that result in cerebral edema and elevations in ICP
What is a cardiovascular sign of increased ICP?
Cushings reflex (bradycardia and hypertension)
What can prolonged increased ICP lead to?
Ischemia of the brain and herniation through the foramen magnum
What immediate interventions can be taken in animals with an altered mental state?
Administration of hyperosmotic agents (hyper NaCl or mannitol), placement on a slant board (head higher, 15-30 degrees) to decrease cerebral blood volume through increased venous drainage. Since seizures could be imminent, POC blood work/BG/electrolyres/ammonia. BP measurement as both hypo/hypertension can alter mental state
Why can hypotension lead to an altered mental state?
Severe hypotension = impending cardiac arrest due to cerebral hypoxia
Why can hypertension lead to an altered mental state?
Changes to mental state can occur secondary to cerebral hemorrhage, infarction, or edema
What are some signs of acute brain hemorrhage?
Decerebrate rigidity (stupor/coma with extended front and pelvic limbs)
What should be done (in addition to the usual interventions) to aid an animal with suspected brain hemorrhage?
Tracheal intubation and mechanical ventilation to temporarily lower arterial blood CO2 levels which will result in cerebral vasoconstriction leading to lower ICP (short term management of marked elevations in ICP)
What does the secondary survey consist of?
A more thorough assessment of patient history including past medical problems and chart review including medications, more formal physical exam of all body systems (i.e. abdominal palpation for acute abdominal pain, investigation or urine output to assess for oligoanuria or anuria)
How is metabolic acidosis defined?
pH <7.34, base deficit <-4 mmol/L in dogs or < -5 mmol/L in cats
What is metabolic acidosis often associated with?
Hyperlactatemia due to altered perfusion, DKA, renal failure, renal tubular acidosis, loss of bicarbonate from the GI tract (D+)
What may severe metabolic acidosis (pH <7.2) lead to?
Myocardial dysfunction, vasodilation, hypotension, decreased responsiveness to catecholamines
What is metabolic alkalosis?
pH >7.45
When do we see metabolic alkalosis?
Following furosemide therapy, animals with GI tract obstruction, gastric stasis, regurgitation, secondary to NGT suctioning (loss of chloride)
How cna you correct metabolic alkalosis?
Administration of 0.9% NaCl, correction of underlying hypokalemia, administration of prokinetics like metoclopramide
What is the safest rate to decrease blood sodium levels?
0.5-1 mEq/hr in animal with chronic hypernatremia
What ECG changes might be seen with hyperkalemia?
Tented T waves, bradycardia, widened QRS, atrial stand still
What conditions may cause hypokalemia?
DKA, administration of potassium deficient IVF, renal failure, albuterol toxicity, hyperalodsteronism
What indicates a pneumothorax on TFAST?
Lack of a glide sign in combination with reduced lung sounds
What indicates interstitial alveolar disease on TFAST?
Greater than 3 B- lines in more than one lung field
What indicates CHF or fluid overload on TFAST?
Left atrial enlargement with left atrial to aortic diameter of at least 1.5 to 1
What do pale/white mucous membranes suggest?
Anemia or a vasoconstrictive response to shock
What do red mucous membranes suggest?
Vasodilation, systemic inflammatory states, hyperthermia
What do cyanotic mucous membranes suggest?
Severe hypoxemia with normal PCV, cyanosis cannot be clinically evident without adequate hemoglobin levels
What do icteric mucous membranes suggest?
increased serum bilirubin levels resulting from hepatic disease, post hepatic disease, or hemolysis
What do brown mucous membranes suggest?
Methemoglobinemia
What do cherry red mucous membranes suggest?
Carbon monoxide poisoning
What is a normal CRT?
1 to 2 seconds
What does a CRT >2 sec mean?
poor perfusion due to vasoconstriction
What does a CRT <1 sec mean?
Hyperdynamic state (systemic inflammation, distributive shock, distributive shock) and vasodilation
How is venous distention visualized?
Patient is placed in lateral, lateral saphenous is visualized, if it seems distended the limb is raised higher than the level of the heart. If it remains distended, could indicate increased central venous pressure
What are some potential causes of increased central venous pressure?
Volume overload, pericardial effusions, right sided congestive heart failure
What can venous distention be a sign of?
Volume overload, right sided CHF, increased right sided filling pressure
What is pulse pressure?
The difference between the systolic and diastolic arterial pressures
What can stertor, wheezes and quiet crackles indicate?
fluid overload
When can inspiratory stridor be heard?
Laryngeal paralysis
When can expiratory wheezes be heard?
Small airway collapse and bronchitis
When can crackles be heard in the lungs?
Pneumonia, pulmonary edema, pulmonary hemorrhage and small airway disease
What lung fields does aspiration pneumonia normally affect?
Cranioventral lung fields
In what lung fields does pulmonary edema begin with?
Perihilar lung fields
When might you hear decreased lung sounds?
Pulmonary consolidation, pneumothorax, pleural effusion
Define stupor
A mentation level where a patient can be aroused only with painful stimuli
What is stupor a sign of?
Severe neurologic or metabolic derangements
What do coma and seizures indicate?
Abnormal cerebral electrical activity from either primary neurologic disease or severe metabolic derangements (hepatic encephalopathy)