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542 (emerg class) > Triage & Shock > Flashcards

Triage & Shock Flashcards

1
Q

What broad aspects of the complete physical exam is included in a triage exam?

A

Cardiovas, resp, neuro

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2
Q

When you’re doing your ABC assessment on a pt, if you answer no to any question, what should you do?

A

CPR

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3
Q

What is the acronym for the full triage assessment and what does it stand for?

A

ABCNE

airway, breathing, circulation, neurological, external

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4
Q

How do you answer the question “is my patient dying/dead?” and what is your solution if the answer is yes?

A

You assess ABC
you start resuscitation (CPR)

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5
Q

1st step in triage exam: ____.
What questions are you trying to answer at this stage?

A

A: airway

Is there an airway obstruction?
Sterdor/stridor?
Cyanosis?
Presence of a foreign body?

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6
Q

When you are assessing airway in a triage exam, what are the signs of an abnormal airway?

A

cyanosis, increased resp sounds and efforts, obvious airway obstruction

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7
Q

2nd step in triage exam: ____.
What questions are you trying to answer at this stage?

A

B: breathing

Is the patient breathing?
Effort?
Rate?
Chest wall movement or excursions?
Trauma?

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8
Q

When should you auscultate the lungs during a triage exam?

A

At the same time you listen to the heart

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9
Q

When you are assessing breathing during a triage exam, what are indications of abnormal breathing?

A

Increased resp rate, increase resp effort, abnormal lung sounds

**for increased resp effort, be specific as to when? inspiratory? expiratory? short and shallow?

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10
Q

3rd step in triage exam: ____.
What questions are you trying to answer at this stage?

A

C: circulation

Auscultation
Can I hear a heart?
Heart rate?
Heart murmur?

Touch-observation
Can I feel a pulse?
Pulse quality? (peripheral, proximal)
Mucous membranes?
CRT?
Cool extremities?

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11
Q

Metatarsal pulses are lost when systolic BP is ___ (greater, less, equal) _____ mmHg. How does this differ with femoral pulses?

A

less than or equal to
75 mmHg

Femoral pulses are not lost unless severe hypotension

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12
Q

What is the basic way to tell if a patient is stable/unstable?

A

If CV, resp, or neuro ability is compromised, then unstable

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13
Q

What is shock?

A

clinical expression of decreased cellular O2 utilization

essentially, what happens to the body when it can’t use enough O2

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14
Q

Shock is akin to what kind of instability?

A

Cardiovascular unstable

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15
Q

Shock can result from what 2 things?

A

decrease in O2 delivery

Decrease in cellular O2 consumption = mitochondrial dz

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16
Q

O2 delivery = ____ + _____

A

Cardiac output (CO)
Carrying capacity of O2 (CaO2)

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17
Q

Cardiac output = _____ + ______

A

Stroke vol
Heart Rate

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18
Q

Carrying capacity of O2 (CaO2) = _____ + _____

A

O2 Hb (how much O2 Hb can carry)
H2 dissolved (how much O2 in blood when saturated)

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19
Q

Stroke volume is affected by what 3 things? include definitions

A

preload: amount of blood coming through heart
afterload: resistance heart must overcome for blood to leave heart
contractility: force heart muscle is contracting

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20
Q

How do you calculate O2 Hb?

A

1.34 x Hb x SaO2

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21
Q

How do you calculate O2 dissolved?

A

0.003 x PaO2

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22
Q

Dog has hypovolemic shock. Tell me what happens physiologically?

A
  1. Decrease in CO
  2. Baroreceptors lack of stretch
  3. inhibition of parasympathetic centre –> vasoconstriction of vv & aa –> increase venous return & after load
  4. release of epinephrine –> vasoconstriction unneeded blood supply areas, increase HR, increase contractility = increase CO
  5. Activation of RAAS (due to lack of blood) –> increase Ang 2 = H2O & Na reabsorb –> increase preload & vasoconstriction
  6. ADH release –> increase preload
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23
Q

Animal is in compensated shock. What are the clinical signs?

A

sympathetic release +++
tachycardia (dogs) / bradycardia (cats)
bounding pulses
pale mm
CRT > 2sec

Decreased O2 delivery to brain = decrease mental status

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24
Q

What is the difference between dogs and cats when they are in compensated shock?

A

Dogs display tachycardia
Cats display bradycardia

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25
Q

Animal is in worsening compensated shock. What are the clinical signs?

A

Altered mental status
hypothermia
cold distal extremeties

Cats: HR < 140 bpm (severe bradycardia)

vol loss increases

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26
Q

Animal is in decompensated shock. What are the clinical signs?

A

decrease in BP

hypotension MAP <70 mmHg

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27
Q

Animal is in refractory shock. What are the clinical signs?

A

Absent BP
Stuporous to comatose
Bradycardia (both cats and dogs)

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28
Q

What does refractory shock mean?

A

failure of organ vitals
shock no longer reversible
imminent death

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29
Q

What are the stages of shock?

A
  1. compensated shock
  2. worsening compensated shock
  3. decompensated shock
  4. refractory shock
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30
Q

What is hypovolemic shock?

A

decreased blood vol
not enough blood to bring O2 to tissues

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31
Q

What is distributive shock?

A

bad distribution of blood to tissues bc of inappropriate vasodilation

vessels don’t constrict despite catecholamines and Ang 2 = too much vasodilation

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32
Q

What are the two types of distributive/vasodilatory shock?

A

Septic shock
Anaphylactic shock

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33
Q

Vasodilation causes ——?

A

decrease in tissue perfusion
decrease in venous return
decrease in preload
decrease in CO

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34
Q

What are the specific clinical signs associated with vasodilatory shock?

A

hyperaemic mm
fast CRT
abnormal pulse quality

everything else is the same as hypovolemic shock

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35
Q

What is obstructive shock?

A

physical obstruction of heart/major vessels = inability for blood to return to or be pumped from heart = O2 not able to get to tissues

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36
Q

What common emergency cases cause obstructive shock?

A

Pericardial effusion
GDV
thromboembolism (rare in cats)

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37
Q

obstructive shock causes —-?

A

decrease in preload
decrease in CO

38
Q

How does a GDV cause obstructive shock?

A

stomach compresses caudal vena cava

39
Q

How does pericardial effusion cause obstructive shock?

A

right auricle compressed by pericardial sac being full of fluid

40
Q

How does a pulmonary thromboembolism (PTE) cause obstructive shock?

A

obstruction of pulmonary artery, blood can’t go to L side of heart

41
Q

clinical signs associated with obstructive shock are _____ to the disease process

A

specific

42
Q

what are the clinical signs associated with obstructive shock with pericardial effusion?

A

muffled heart sounds
pulsus paradoxus = BP decreases with inhalation
distended jugs with jug pulse

43
Q

what are the clinical signs associated with obstructive shock with GDV?

A

non-productive retching
large tympanic stomach
painful abdomen

44
Q

what are the clinical signs associated with obstructive shock with thromboembolism?

A

resp distress
collapse

45
Q

What are the 5 types of shock?
I think supposed to be 4 but there are 5 in this lecture

A

Hypovolemic
Distributive
Obstructive
Cardiogenic
Hypoxic

46
Q

What is cardiogenic shock?

A

Myocardium itself isn’t able to pump

47
Q

What causes cardiogenic shock?

A

DCM, HCM, arrhythmias (ARVC = arrhythmogenic ventricular cardiomyopathy), myocardial depression associated with sepsis, myocarditis, ischemic injury

48
Q

Cardiogenic shock leads to —-?

A

decrease in stoke vol
decrease in CO

49
Q

How does DCM cause cardiogenic shock?

A

decrease contractility of heart

50
Q

how does HCM cause cardiogenic shock?

A

decreased ventricular filling

51
Q

how does ARVC cause cardiogenic shock?

A

not enough time to fill ventricle + decrease contractility

52
Q

What are the clinical signs associated with cardiogenic shock?

A

heart murmur
arrhythmia
collapsing episodes (not enough blood to brain)
poor pulse quality
peripheral edema
ascites/jug distension (if R side heart impaired)

53
Q

True or false: cardiogenic shock is the same as congestive heart failure

A

FALSE! IT IS DIFFERENT!

Cardiogenic shock: pump activity not allowing enough O2 to brain and tissues

CHF: there is congestion (regurg blood flow) in heart

54
Q

CHF can lead to ____ shock.

A

hypoxic

55
Q

What is hypoxic shock?

A

carrying capacity of O2 is decreased so O2 delivery to tissues is impaired

56
Q

What causes hypoxic shock?

A

decrease in CaO2, which is caused by:
1. decrease in hemoglobin/RBC –> anemia
2. decrease in SaO2 –> hypoxemia (lung dz)

57
Q

What are the physiologic consequences of hypoxic shock?

A

anemia/low PaO2 –> tissue hypoxia
increase in CO, increase preload
decrease blood viscosity
arterial vasodilation, ROS vasodilation, flow mediated vasodilation

58
Q

What are the clinical signs of hypoxic shock?

A

C/S are specific to the underlying disease
- resp distress
- pale mm

59
Q

True or false: More than 1 type of shock can be present at the same time

A

TRUE!!!

60
Q

Shocky cats will have a _____ HR, >/</= _____ bpm.

A

slowwwwwww
< 160 bpm

the slower the HR, the closer to death is the cat!!!

61
Q

The indicators of shock = _____ _____

A

abnormal perfusion

62
Q

What are the broad indicators of shock/abnormal perfusion? like where should you be looking in the patient?

A
  • mentation
  • abnormal HR
  • abnormal mm
  • CRT
  • pulse quality
  • extremity temp
63
Q

what are the shocky abnormal HRs for dogs and cats?

A

Dogs: 80-140 bpm
Cats: 160-220 bpm
???

64
Q

in shocky patients, what can their mm look like?

A

pale or bright red (depending on type of shock)

65
Q

CRT in a shocky pt looks like:

A

<1 sec > 2 sec
???

66
Q

Which types of shock is it ok to give a fluid bolus for?

A

hypovolemia
distributive
obstructive

67
Q

what is the point of giving a fluid bolus to a patient in shock?

A

to restore intravascular volume = circulating vol

68
Q

How do you give a fluid bolus to a shocky dog? like tell me timing, dosage, what type of fluid

A

small aliquots (portions) of isotonic crystalloids over 25-30 mins
10-30mL/kg

69
Q

How do you give a fluid bolus to a shocky cat? like tell me timing, dosage, what type of fluid

A

small aliquots (portions) of isotonic crystalloids over 25-30 mins
5-20 mL/kg

70
Q

You give a shocky patient a fluid bolus and are looking for improvement. what are you looking for?

A
  • improved mentation
  • normalization of HR
  • improvement of mm color (pink)
  • normalization of CRT (< 2 sec)
  • normal pulse quality
  • extremities no longer feel as cold
71
Q

How should you treat hypoxemic shock?

A

provide RBCs and improve CaO2, if anemia

supplement O2, if severe hypoxemia

72
Q

How should you treat cardiogenic shock?

A

improve contractility if that’s the issue (DCM)

slow HR if that’s the issue (arrhythmia & HCM)

73
Q

4th step in triage exam: ____.
What questions are you trying to answer at this stage?

A

Neurological

What does mentation looks like?
seizure present? history of seizure?
ambulation?

74
Q

What is the range of mentation, from normal to the worst?

A

Normal
Lethargic
Obtunded, auditory stimuli
Stuporous, noxious stimuli
Comatose, non responsive

75
Q

How do you assess brainstem reflexes?

A

PLR and physiologic nystagmus
looking at rigidity

76
Q

What is decerebrate rigidity?
what is the prognosis?

A

opisthotonus with extension of front and rear limbs, severely affected mentation & are stuporous to comatose

grave prognosis

77
Q

What is opisthotonus?

A

extension of head and neck

78
Q

What is decerebellate rigidity? What is the prognosis? What is this a sign of?

A

opisthotonus with extension of front limbs. hind limbs often flexed, but can be extended (may be intermittent)

better prognosis than decerebrate rigidity

sign of progressive brain injury

79
Q

5th step in triage exam: ____.
What questions are you trying to answer at this stage?

A

External assessment - reserved for trauma patients

bleeding?
lacerations?
punctures?
abrasions?
contusions?
instability?

80
Q

____ bleeding is life threatening. Others need to be covered and addressed later.

A

arterial

81
Q

Mentation can be abnormal due to ____ or ______.

A
  1. primary neuro dz
  2. shock and decreased O2 delivery to the brain
82
Q

What are the steps of a triage exam? like broad categories, not talking about organ systems that we’re looking at

A

initial triage
primary survey
secondary survey

83
Q

What are you doing during your initial triage?

A

30 sec-1min

animal has arrested: inform O, ask for CPR status, transport to ICU for resuscitation

Animal has not arrested: do primary survey

84
Q

What are you doing during your primary survey?

A

ABC, auscultation, neuro status (CNs, basic spinal reflexes), external wounds (cover if possible), abdominal palp, rectal temp, POCUS

85
Q

When should you start stabilizing the patient? how do you do this?

A

during your initial assessment
place IV catheter, obtain emergency blood samples, supplement O2, connect ECG, measure BP, obtain pulse ox, record values on medical file
PERFORM LIFE SAVING MEASURES! (ex. thoracocentesis, back board, etc)

86
Q

true or false: our primary survey is a complete PE.

A

FALSE!

87
Q

What is your secondary survey? what is your goal with this?

A

a complete PE (including fundic and rectal exams)

goal is to ID all injuries relative to the trauma

88
Q

During your secondary survey, should you take your time and be thorough, or be as fast as possible?

A

take your time and be thorough - you might only have this 1 time to do a complete PE

89
Q

True or False: you should do rads on triage

A

false!

90
Q

What should you do after completing your secondary survey?

A

get the big picture

list problems (from hx, primary and secondary surveys, POCUS, min emergency database, dx tests) from most to least life threatening

for each major problem: ddx, dx plan, therapeutic plan

overall estimate and prognosis

91
Q

Tell me the difference between emergency and urgent situations. give me 2 examples of each.

A

Emergency: needs immediate to quick w/I 10 mins dr assistance

urgent: should be assessed by dr w/i 30-60 mins after arrival

E: cardio/resp arrest, trauma (HBC, GSW, stepped on, high rise injury, bite), seizures/abnormal mentation, abnormal vital signs, resp distress, unstable GDV, blocked cat, unstable vomiting pt, most toxins

U: IVDD, stable non-ambulatory, minor lac, stable pt w/ fx

542 (emerg class) (1 decks)

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