Triage, fluid and oxygen therapy Flashcards
Define triage
CLASSIFICATION OF PATIENTS TO DETERMINE PRIORITY OF NEED
AND THE OPTIMAL ORDER IN WHICH THEY SHOULD BE TREATED
Before arrival, the following information about the patient should be gotten via phone: (7)
Short history
Breed
Sex
Age
Approx. weight
Instructions for a safe arrival
Phone nr
Triage categories
Categories can vary dependent upon literature.
Green = non-emergent
Yellow = urgent but not life-threatening
Orange = very urgent, potentially life-threatening
Red = immediate care needed, life-threatening
Black = dead on arrival
What does primary triage involve broadly?
Airways
Breathing
Circulation
Disability
MBSA =
(5)
MBSA (major body system assessment)
Respiratory system
Cardio-vascular system
Nervous system
Urinary/reproductive system
Other parameters/changes
Describe respiratory system triage
Observation from a distance as well as auscultation of the trachea and lungs in order to detect hypoxemia and
hypoventilation.
Open airways
Stertor (above larynx)
stridor (larynx or below)
Respiratory rate and pattern
+ mucous membranes
Auscultation
Palpation of the thorax
Stertor vs stridor
Stertor (above larynx)
stridor (larynx or below)
parameters for assessment of hypoperfusion: (5)
Colour of mucous membranes
Capillary refill time (CRT)
Pulse-presence/quality
- Femoral pulse
- Dorsal metatarsal pulse
Heart rate
Heart auscultation
Parameters of shock (7)
mm can vary
crt typically prolonged
heart rate elevated
resp. rate elevated
peripheral pulse weak or absent
BP decreased
lactate elevated
Color of mucous membranes.
What do the varying colors indicate?
brown mm = methemoglobinemia
Triage of the nervous system involves? (4)
Assessment of:
Mentality (stupor, coma etc.)
Cranial nerves (anisocoria etc.)
Movement
Pain/deep pain (in paralysis, paresis cases espesh)
stupor vs coma
stupor = unconscious, reactions to external manipulations can be present
coma = unconscious,
no reactions to external manipulations except for potentially some autonomic reflexes
Triage of the Urinary/reproductive system, 4 main issues to check for.
Big painful bladder
Uterine prolapse
Dystocia
Persistent erection/paraphymosis (dogs, chinchillas especially)
hyperthermia vs fever
hyperthermia = elevated temperature due to external factors
fever = under control of the body’s own thermoregulation center
Modified ATT (Animal Trauma ‘Triage) score
The animal trauma triage (ATT) score is a veterinary illness severity score that numerically classifies the degree of trauma in an attempt to quantify mortality risk probability.
Parameters Assessed in mATT:
Perfusion
Cardiovascular
Respiratory
Neurological
Gastrointestinal (GI)/Urogenital
Musculoskeletal
Ranges from 0 (normal) to 18 (severely compromised).
MGCS (Modified Glasgow Coma Scale)
is an adaptation of the human Glasgow Coma Scale, specifically designed for veterinary use to assess the level of consciousness and neurological function in animals.
The MGCS evaluates three main neurological parameters:
Motor Activity
Brainstem Reflexes (Pupillary Light Reflex and Ocular Position)
Level of Consciousness
total score ranges from 3 to 18.
18 indicates a normal neurologic function, while 3 indicates severe brain dysfunction or deep coma.
Primary stabilization includes (4)
IV catheter
O2 therapy
Fluid therapy
Analgesia
Blood sample diagnostics that may be used for triage: (7)
PCV/Total Solids
Glucose
Lactate
Blood gases
UREA
Blood smear
Electrolytes
aFAST/tFAST
abdominal and thoracic focused assessment with sonography for trauma/triage
Describe secondary triage.
After first stabilization, do a secondary examination. Did you miss something? Recheck and cover any unassessed bases.
The goal of secondary triage is to provide a more detailed evaluation of a patient’s condition, prioritize further treatment, and ensure that medical resources are allocated efficiently.
2nd triage gives you further info for communication with owners
Prognosis
Cost Etc…..
Why exactly is oxygen therapy important during primary stabilization?
PROLONGED HYPOXEMIA AND POOR TISSUE OXYGEN DELIVERY MAY RESULT IN
MULTIPLEORGAN FAILURE AND THEREFORE SHOULD BE TREATED IMMEDIATELY.
Oxygen is an IMPORTANT THERAPEUTIC TOOL IN THE MANAGEMENT OF EMERGENCY AND CRITICAL CARE PATIENTS.
Goal of Oxygen therapy. (5)
Its aim is to increase the fraction of inspired oxygen (FiO2).
To improve PaO2(partial pressure of arterial O2).
To improve hemoglobin saturation.
To increase oxygen delivery to tissues.
To avoid hypoxemia, tissue hypoxia and lactic acidosis.
Indications for oxygen therapy. (4)
PaO2 less than 80 mm Hg (Blood gas
analyzer)
Pulse oximetry reading less than 95%
Respiratory distress symptoms
All shock patients
Respiratory distress symptoms
Increased respiratory rate and effort
Extended head and neck posture
Cyanosis(indicates severe hypoxemia)
Flaring of the nares
Open mouth breathing
Changes in respiratory pattern
Abnormal findings in auscultation
Non-invasive and invasive methods of oxygen therapy depends on (5)
Choice depends on FiO2 desired (fraction of inspired O2)
Length of treatment
Equipment available
Type of patient
In most cases FiO2 30-40% provides sufficient oxygenation
What does Long –term O2 therapy require?
requires humidification
Avoids drying of nasal mucosa and degeneration of respiratory epithelium.
Avoids impaired mucociliary clearence
Non-invasive O2 therapy methods:
Flow-by oxygen
Oxygen hose near the mouth or nostrils
Flow rate of 2-3 L /min provides FiO2 of 25%
Well tolerated by most patients especially
cats
Short term administration
Non-invasive methods: Oxygen mask
Can be used in any patient who lying still and/ or tolerates the mask
More suitable in short term oxygen administration
2-6 L/min flow recommended (patient size)
Possible to reach 40-50%FiO2
minimal equipment required
Needs supervision
Non-invasive methods: Oxygen hood or
self-made cage
Easily made in hospital
Leave 2-5 cm from the top open to allow
humidity and CO2 elimination
Not tolerated by all patients
Temperature inside collar area may
increase rapidly
Maintenance flow 2-5L/min
FiO2 obtained is 30-40%
Non-invasive methods: Oxygen cage
Suitable for patients suffering for severe
stress and not tolerating other methods (cats)
FiO2 40-50%
Disadvantages - cost
Hyperthermia can develop easily
Possible lack of patient access
Invasive methods: Nasal prongs
Human nasal prongs can be used
Well tolerated by most dogs
Easily dislodged
Unknown FiO2, Possibly higher than flow by oxygen
Invasive methods: Nasal catheter
If O2 is needed more than 24h
Simple to place and requires minimal
equipment
Catheter should be changed every 24-48h
Flow rates 50-150ml/kg can provide FiO2 30-70%
Higher flow can be irritating and cause
sneezing
Humidification is needed
Invasive methods:
Trans-tracheal oxygen
Cathether is inserted through the cricothyroid ligament or caudal to it (between 3rd-5th ring)
Needs experience
May need sedation
Aseptic technique
O2 flow rates of 50 ml/kg/min
provide FiO2 40-60%
Risks associated with sedation and infection
Lesions or damage of trachea
Invasive methods:
Tracheostomy tube
- Needs experience
- Need sedation
- Aseptic technique
- Risks associated with pneumomediastinum, infection and
dislodging.
If you can’t get a patient’s pulse oximetry reading over ? with non-invasive O2 therapy then consider what?
If you can’t get a patient’s pulse oximetry reading over 95% with non-invasive O2 therapy then consider sedation and intubation.
Describe Oxygen toxicity.
Excessive oxygen can be toxic to pulmonary epithelium.
- Destruction of cells causes inflammatory reaction.
Inflammatory mediators result in increased tissue permeability and due to this: pulmonary edema, atelectasis, fibrosis and pulmonary function disorders, can result.
FiO2 (fraction of inspired oxygen) more than 50% should not be administered for longer than 24-48 h.
Neonates are more sensitive to O2 toxic effects.
Aims of fluid therapy. (4)
MAINTAIN ADEQUATE PERFUSION IN THE BODY
RESTORING FLUID BALANCE/TREATMENT OF DEHYDRATION
RESTORING ELECTROLYTE IMBALANCES
RESTORING NORMAL BLOOD CIRCULATION AND CARDIAC FUNCTION IN SHOCK AND HYPOVOLEMIA
total body water percentage
intracellular fluid percentage
extra cellular fluid percentage
interstitial fluid percentage
plasma percentage of total body water
total body water percentage 60%
intracellular fluid percentage 40% of the above
extra cellular fluid percentage 20%
interstitial fluid percentage 15% of the above
plasma percentage of total body water 5%
Indications for isotonic fluids. (4)
Quick correction of hypovolemia
Treatment of dehydration and
electrolyte imbalances
General anaesthesia
Correcting metabolic acidosis
Dangers of isotonic fluids. (3)
Lung edema: fluid overload (cats, small
dogs), cardiogenic diseases
Dilution of blood in anemia and
thrombocytopenia cases further exacerbating tissue hypoxia
Trauma patient with lung contusion/edema (may worsen it) or brain contusion/edema (may increase intracranial pressue)
Describe hypertonic fluids such as NaCl
5-7,5% solutions
Increases osmotic pressure
Water moves from tissues to blood
stream, causes cellular dehydration so you must administer isotonic fluids concurrently via separate IV.
Quickly increases the volume in the
blood vessels.
Quick way to fix hypovolemia
Used in Head trauma patients to get “water off the brain”. Careful in bleeding patients.
Dog: 4-5ml/kg
Cat: 2-4ml/kg
Time of action 30-60min after IV
administration
Describe Colloids.
Synthetic involve big polysaccharide molecules in isotonic fluid.
The bigger the molecule, the longer it
stays in the blood vessel.
E.g: Dextran-40, Dextran-70, Starch, Hetastarch etc.
Non-synthetic colloid options include:
Natural
Fresh frozen plasma
Human albumin
Indications for colloids
Rapid increase in blood volume needed
Hypovolemia
Hypotension
Hypoproteinemia
Dangers of colloids include: (6)
Kidney Damage
Coagulation Issues
Allergic Reactions
Volume Overload: leading to pulmonary edema or other forms of fluid retention
Electrolyte Imbalance: may lead to hypokalemia or hyperchloremia.
Increased Mortality Risk: In some studies, the use of certain colloids has been associated with an increased risk of mortality.
Describe blood products
Fresh whole blood- 10-20ml/kg
- RBC; WBC; platelets, coagulation factors, plasma protein (albumin)
Packed red blood cells (pRBC)-5-10ml/kg
- Erythrocytes (PCV 70-80%)
Fresh-frozen plasma- 10-20ml/kg (frozen
quite soon after collection)
Frozen plasma-10-30ml/kg (frozen 8h+ after collection)
Indications for transfusion of whole blood versus packed red blood cells?
whole blood - acute hemorrhage, anemias with coagulopathy, hypoalbuminemia or thrombocytopenia
packed red blood cells - anemia without coagulopathy
Indications for transfusion of plasma?
coagulopathy and DIC
Alternative routes for fluid administration (5)
dorsal pedal
intraosseous
jugular/ central venous line
NG or NE tube
subcut
Define dehydration.
Symptoms?
Causes?
loss of fluids into the interstitial space from cells (can involve cellular crenation)
Symptoms: decreased skin turgor, dry mucous membranes, enophthalmos,
weak pulse, hypotension, tachycardia, weakness
Causes: diarrhea, vomiting, kidney dysfunction, use of diuretics, diabetes,
insufficient fluid intake etc.
Define hypovolemia.
Symptoms?
Causes?
Hypovolemia: insufficient amount of blood in blood vessels (intravascular space)
Symptoms: pale mucous membranes, prolonged CRT, weak pulse, tachycardia
(Cats!), weakness, cold extremities
Causes: severe dehydration, blood loss, vasodilatation.
Dehydration versus hypovolemia
Dehydration primarily involves a loss of fluid from the intracellular space and the extracellular space.
Hypovolemia specifically refers to a reduction in the intravascular fluid volume.
Describe the treatment of Hypovolemic shock and Fluid therapy.
Low volume/hypotensive resuscitation uses isotonic crystalloids.
Aiming for a mean blood pressure of 60-90 mmHg
Fluid rate: boluses 15-20ml/kg within 10-15min
Repeated up to 4 times with reassessments in between
If isotonic crystalloids do not work,
Add colloids:
Dogs: 5-10ml/kg
Cats: 1-5ml/kg
Hypertonic fluids: Do not use in hypernatremia and severe dehydration!
Dogs: 4-5ml/kg
Cats: 2-4ml/kg
If blood loss due to active bleeding, try to stim it and Consider blood products.
Fluid therapy and Cardiogenic shock
Stop or decrease diuretics first.
Consider: does the patient even need
fluid therapy. Remember in cardiogenic shock, its not that there isnt enough fluid, its that the heart can pump it properly.
Offer water to drink or in wet food.
If needed: crystalloids
20-35ml/kg/ 24h
Avoid colloids because pulmonary permeability is increased so increased risk for lung edema.
Fluid therapy and Cardiopulmonary arrest
Administration using crystalloids is reasonable when suspected hypovolemia.
Conservative doses: 20ml/kg over 15-
20min
But You won`t save patient with only fluids!
Cardiopulmonary resuscitation and
drugs!
Prognosis is bad anyway so don’t focus on fluids in this situation.
Fluid therapy and head trauma
Head trauma patients Usually present in hypovolemic shock cause these are usually bleeding patients.
Aim of fluid therapy:
Maintain cerebral perfusion
Reduce cerebral ischemia
Reducing and maintaining normal mean
arterial BP
Isotonic fluids: low volume resuscitation
Hypertonic fluids (decrease intracranial pressure)
Dogs: 4-5ml/kg
Cats: 2-4ml/kg
Remains in vasculature for 1h (alternative is Mannitol)
Colloids only if really needed; combination of hypertonic solution and colloid.
Fluid overload is when
A Normovolemic patient is receiving too much fluids.
Increase in body mass >10%
Clinically: edemas and effusions, changes in mental status.
Predisposed patients:
Heart failure
Kidney failure in anuria or oliguria
Hypoalbuminemia
Vasculitis
Fluid leaks out of vessels into tissues resulting in fluid overload in the two prev.
In shock patients:
Decreased renal perfusion due to shock, can cause…?
Kidney contusions can cause…?
Damage to the lower urinary tract can cause…?
pre-renal azotemia
renal azotemia
post-renal azotomia
