Triage of the emergency patient Flashcards
What are the 4 main components of triage
-Telephone
-Waiting room
-Primary survey with interventions
-Secondary survey with interventions
What are the aims of telephone triage (3 things)
-to determine if patient needs to be seen immediately
-to see what owner can do before arriving
-preparation at hospital (resp emergency, seizing, etc)
What things should you determine over the phone
-type of injury, respiration speed and effort + coughing, MM color, consciousness level/head trauma/seizing, ambulation ability, weakness, any obvious fractures, abdominal distension, intoxication
Which four systems should be assessed during waiting room triage
-Respiratory
-Cardiovascular
-Neurological
-Renal
Should patients be taken back in the order that they arrive
NO! Patients should be sorted and classified in order of disease severity, and a member of the team should quickly assess every patient that arrives for brief history, nature of complaint, and progression
What are some signs of an animal with a respiratory emergency
-Increased heart rate, rhythm, and effort
-Open mouth breathing
-Paradoxical breathing (pleural effusion)
-extended head and neck
-abducted elbows
-flared nostrils
What are some signs of an animal with a respiratory emergency
-Increased heart rate, rhythm, and effort
-Open mouth breathing
-Paradoxical breathing (pleural effusion)
-extended head and neck
-abducted elbows
-flared nostrils
What should you do to assess a patient’s cardiovascular system in the waiting room
-Assess for heart murmur
-Check if heart rate is slow/fast, regular/irregular
-check pulse quality and rate
-check CRT assessment
-check MM color
-Auscultate lungs for pulmonary oedema/dull lung sounds ventrally
What should you look for to assess a patient’s neurological system
-Assess mentation
-assess ability to ambulate
-check if patient is seizuring
- Check for head trauma
-Assess intracranial pressure, decerebrate rigidity, cushings reflex
-hyperexcitability
What should you look for when checking patients renal system
-Is the animal urinating/when did it last urinate
-Assess bladder size and compressibility
-Check is urethra is blocked
-think about AKI if anuric
What is the objective of primary survey
To determine if any life threatening conditions are present and to treat immediately
What should be assessed in the respiratory system during primary survey
-Evaluate if airway is patent
-Check pulse oximetry (60:90 rule), check arterial blood gas
-give pre-oxygen supplementation (20 minutes) if necessary or if hypoxemic
-thoracocentesis
What differential diagnoses should be considered in the cardiovascular system during primary survey
-Congestive heart failure (backward or forward or both)
-Hypotension due to hemorrhage, fluid loss, sepsis
What treatments can you give if you have a cardio issue, and what can you give if you have a vascular issue
Cardio: furosemide, pimobendan, other positive inotropes, antiarrhythmics
Vascular: fluid therapy if hypovolemic shock due to fluid loss/hemorrhage/sepsis
What treatments should you give for seizuring an increased ICP
-Phenobarbital, treat with glucose/dextrose if hypoglycemic, treat with Ca if hypocalcemic
-Mannitol if ICP too high, neeeds to be treated rapidly so brain doesn’t herniate through foramen magnum
What to look for on renal assessment in primary survey
-Urethral obstruction caused by spasm, stricture, stone, neoplasm causing hyperkalemia, metabolic acidosis, post renal AKI, ruptured bladder
-Intrinsic AKI caused by toxin, neoplasia, drugs, hypotension, Lepto, CRGV
-ureteral obstruction
-Check blood gas analysis, serum biochem, ultrasound
When do you do secondary survey
After primary survey and after stabilization of any life threatening pathologies
What do you do on secondary survey
-Get a full detailed history from owner
-do a full thorough physical exam
-asses response to therapy started in primary survey
-perform further diagnostics (lab work, imaging)
What makes up the emergency database
-PCV/TS (always interpreted together)
-Blood glucose
-blood gas to assess pH, electrolytes, and oxygen status
-blood ammonia
-blood smear
-coagulation times
-focused ultrasound (thorax and abdomen)
-blood pressure
-urine SG (prior to IVFT if possible)
What causes a decreased PCV and decreased TS
Hemorrhage/blood loss
What PCV/TS levels would you expect with severe acute hemorrhage
Normal PCV and low TS (due to compensation from splenic contractions)
What causes decreased PCV and normal TS
Hemolysis or bone marrow disease
What is the size of the emergency fluid bolus for hypovolemic shock (ensuring no CHF)
10 ml/kg crystalloid
What treatments options in addition to fluids can you give for hypovolemia
-blood transfusion
-packed red cells
-whole blood transfusion
What are some causes of hypoglycemia
-Iatrogenic (exogenous insulin overdose)
-sepsis
-insulinoma
-hepatic failure
-storage diseases
-hypoadrenocorticism (the great pretender)
-juvenile/toy breed hypoglycemia
How to treat hypoglycemia
-.5g/kg glucose diluted with saline 1:3 and given over 10 minutes
-recheck BG after bolus
-CRI glucose 2.5 or 5% following bolus
-assess BG every 20-30 mins then every 1-2 hours
-ID and treat underlying disease
What are the causes and treatment of hyperglycemia
-Diabetes mellitus, DK, or DKA
-stress hyperglycemia
-toxicity
-seizures
Treatment: treat underlying cause (fluid therapy) plus insulin therapy (for DM/DK/DKA)
What does blood gas analysis check for
-hyponatremia or hypernatremia
-hyperkalemia or hypokalemia
-ionized calcium status
-pH
-oxygenation (if arterial)
-lactate
Treatment for high ammonia (NH3)
-lactulose, antibiotic therapy, IVFT diet, omeprazole if PSS suspected
What to look for on blood smear exam
-RBC, WBC, platelets
-Signs of regenerative vs non-regenerative anemia
-Red cell morphology (spherocytes, schistocytes, Heinz bodies)
-mycoplasma or Babesia
-leukocytes is or leukopenia
-lymphocytosis (should have lymphopenia in sick animal because of stress leukogram
-eosinophilia (additions, allergic disease)
Which coagulation times are prolonged with DIC
Both APTT and OSPT
Which coagulation times are prolonged with rat bait ingestion
OSPT prolonged first because its dependent on factor 7 which has the shortest half life, while APTT works on factors 2, 9, and 10 which have longer half lives
What should you assess on a FAST scan
-assess for pleural effusion (hemorrhage, pyothorax, chylothorax)
-pericardial effusion (+/-tamponade)
-left atrium size
-B lines (wet lungs, hyperechoic lines)
-abdominal effusion (hemorrhage, septic effusion, urine, bile)
How to treat hypotension and hypertension
Hypotension: IVFT, dobutamine, noradrenaline, ID cause and treat
Hypertension: amylodipine, Ace inhibitor, alpha blocker (phenoxybenzamine or prazosin)
