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Emergency medicine & critical care > Triage, fluid and oxygen therapy > Flashcards

Triage, fluid and oxygen therapy Flashcards

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1
Q

Define triage

A

CLASSIFICATION OF PATIENTS TO DETERMINE PRIORITY OF NEED
AND THE OPTIMAL ORDER IN WHICH THEY SHOULD BE TREATED

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2
Q

Before arrival, the following information about the patient should be gotten via phone: (7)

A

Short history
Breed
Sex
Age
Approx. weight
Instructions for a safe arrival
Phone nr

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3
Q

Triage categories

A

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

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4
Q

What does primary triage involve broadly?

A

Airways
Breathing
Circulation
Disability

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5
Q

MBSA =
(5)

A

MBSA (major body system assessment)

 Respiratory system
 Cardio-vascular system
 Nervous system
 Urinary/reproductive system
 Other parameters/changes

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6
Q

Describe respiratory system triage

A

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

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7
Q

Stertor vs stridor

A

Stertor (above larynx)
stridor (larynx or below)

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8
Q

parameters for assessment of hypoperfusion: (5)

A

 Colour of mucous membranes
 Capillary refill time (CRT)

 Pulse-presence/quality
- Femoral pulse
- Dorsal metatarsal pulse

 Heart rate
 Heart auscultation

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9
Q

Parameters of shock (7)

A

mm can vary
crt typically prolonged
heart rate elevated
resp. rate elevated
peripheral pulse weak or absent
BP decreased
lactate elevated

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10
Q

Color of mucous membranes.
What do the varying colors indicate?

A

brown mm = methemoglobinemia

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11
Q

Triage of the nervous system involves? (4)

A

Assessment of:
 Mentality (stupor, coma etc.)
 Cranial nerves (anisocoria etc.)
 Movement
 Pain/deep pain (in paralysis, paresis cases espesh)

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12
Q

stupor vs coma

A

stupor = unconscious, reactions to external manipulations can be present

coma = unconscious,
no reactions to external manipulations except for potentially some autonomic reflexes

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13
Q

Triage of the Urinary/reproductive system, 4 main issues to check for.

A

Big painful bladder

Uterine prolapse
Dystocia

Persistent erection/paraphymosis (dogs, chinchillas especially)

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14
Q

hyperthermia vs fever

A

hyperthermia = elevated temperature due to external factors

fever = under control of the body’s own thermoregulation center

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15
Q

Modified ATT (Animal Trauma ‘Triage) score

A

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).

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16
Q

MGCS (Modified Glasgow Coma Scale)

A

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.

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17
Q

Primary stabilization includes (4)

A

IV catheter
O2 therapy
Fluid therapy
Analgesia

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18
Q

Blood sample diagnostics that may be used for triage: (7)

A

 PCV/Total Solids
 Glucose
 Lactate
 Blood gases
 UREA
 Blood smear
 Electrolytes

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19
Q

aFAST/tFAST

A

abdominal and thoracic focused assessment with sonography for trauma/triage

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20
Q

Describe secondary triage.

A

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…..

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21
Q

Why exactly is oxygen therapy important during primary stabilization?

A

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.

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22
Q

Goal of Oxygen therapy. (5)

A

 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.

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23
Q

Indications for oxygen therapy. (4)

A

 PaO2 less than 80 mm Hg (Blood gas
analyzer)

 Pulse oximetry reading less than 95%

 Respiratory distress symptoms

 All shock patients

24
Q

Respiratory distress symptoms

A

 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

25
Q

Non-invasive and invasive methods of oxygen therapy depends on (5)

A

 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

26
Q

What does Long –term O2 therapy require?

A

requires humidification

 Avoids drying of nasal mucosa and degeneration of respiratory epithelium.

 Avoids impaired mucociliary clearence

27
Q

Non-invasive O2 therapy methods:
Flow-by oxygen

A

 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

28
Q

Non-invasive methods: Oxygen mask

A

 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

29
Q

Non-invasive methods: Oxygen hood or
self-made cage

A

 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%

30
Q

Non-invasive methods: Oxygen cage

A

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

31
Q

Invasive methods: Nasal prongs

A

 Human nasal prongs can be used

 Well tolerated by most dogs

 Easily dislodged

 Unknown FiO2, Possibly higher than flow by oxygen

32
Q

Invasive methods: Nasal catheter

A

 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

33
Q

Invasive methods:
Trans-tracheal oxygen

A

 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

34
Q

Invasive methods:
Tracheostomy tube

A
  • Needs experience
  • Need sedation
  • Aseptic technique
  • Risks associated with pneumomediastinum, infection and
    dislodging.
35
Q

If you can’t get a patient’s pulse oximetry reading over ? with non-invasive O2 therapy then consider what?

A

If you can’t get a patient’s pulse oximetry reading over 95% with non-invasive O2 therapy then consider sedation and intubation.

36
Q

Describe Oxygen toxicity.

A

 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.

37
Q

Aims of fluid therapy. (4)

A

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

38
Q

total body water percentage
intracellular fluid percentage
extra cellular fluid percentage
interstitial fluid percentage
plasma percentage of total body water

A

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%

39
Q

Indications for isotonic fluids. (4)

A

 Quick correction of hypovolemia

 Treatment of dehydration and
electrolyte imbalances

 General anaesthesia

 Correcting metabolic acidosis

40
Q

Dangers of isotonic fluids. (3)

A

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)

41
Q

Describe hypertonic fluids such as NaCl

A

 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

42
Q

Describe Colloids.

A

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

43
Q

Indications for colloids

A

 Rapid increase in blood volume needed
 Hypovolemia
 Hypotension
 Hypoproteinemia

44
Q

Dangers of colloids include: (6)

A

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.

45
Q

Describe blood products

A

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)

46
Q

Indications for transfusion of whole blood versus packed red blood cells?

A

whole blood - acute hemorrhage, anemias with coagulopathy, hypoalbuminemia or thrombocytopenia

packed red blood cells - anemia without coagulopathy

47
Q

Indications for transfusion of plasma?

A

coagulopathy and DIC

48
Q

Alternative routes for fluid administration (5)

A

dorsal pedal
intraosseous
jugular/ central venous line
NG or NE tube
subcut

49
Q

Define dehydration.
Symptoms?
Causes?

A

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.

50
Q

Define hypovolemia.
Symptoms?
Causes?

A

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.

51
Q

Dehydration versus hypovolemia

A

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.

52
Q

Describe the treatment of Hypovolemic shock and Fluid therapy.

A

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.

53
Q

Fluid therapy and Cardiogenic shock

A

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.

54
Q

Fluid therapy and Cardiopulmonary arrest

A

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.

55
Q

Fluid therapy and head trauma

A

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.

56
Q

Fluid overload is when

A

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.

57
Q

In shock patients:
Decreased renal perfusion due to shock, can cause…?
Kidney contusions can cause…?
Damage to the lower urinary tract can cause…?

A

pre-renal azotemia

renal azotemia

post-renal azotomia

Emergency medicine & critical care (7 decks)

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