U1 O1 Triage & Cardiopulmonary Resuscitation Flashcards
1
Q
What is meant by the term triage?
A
Triage is the process of prioritising sick and injured animals, according to the severity of the illness or injury. Patients are evaluated, problems identified and treatments implemented in order to maximise the number of survivors.
2
Q
How do you triage a patient with multiple injuries?
A
Similarly, if an animal has multiple injuries or problems (e.g. an RTA), treatment is prioritised so that the most serious problem is focused on before the more minor problems.
3
Q
What is the main aim of a telephone triage?
A
The immediate aim of this conversation is to determine whether the pet needs to be evaluated by a vet immediately or whether it can wait until a scheduled appointment. Unfortunately, this is rarely a straightforward decision, since some owners will be overly concerned by minor signs, whilst others will not seek veterinary attention until signs are severe. As such developing a logical approach to the questions, we ask to assess the patient over the phone should focus on major body systems and dysfunction of those initially. We need to try not to be distracted by the owner and their concerns, as often they will focus on what they see, whilst remaining professional and sympathetic to the client’s needs.
4
Q
What type of questioning style should be used on a telephone triage?
A
Consider also how you ask the questions. Closed questioning styles do not elicit much information and are mainly Yes/No answers. Open questioning styles allow the client to be descriptive of their concerns. Both may be used throughout a triage phone call
5
Q
What question should be asked on a telephone triage?
A
-What is the reason for the phone call - why are they concerned about their pet? An open questioning style at this stage may elicit more information than closed questioning.
• When it started and how it has progressed/ has it occurred previously?
• Are there are significant co-morbid conditions?
• Is their pet receiving any medication? What/ how much? When last administered?
• An attempt to assess the animal’s level of consciousness/ whether collapsed
• An attempt to assess the animal’s demeanour/ presence of pain
• An attempt to assess how the animal is breathing
• It might be prudent to see if the owner can assess respiratory rate/ pattern, heart rate (via chest wall) and colour of mucous membranes (IF deemed appropriate to ask: this judgement will have to be made during the telephone call- it is important not to cause the owner further distress nor to waste time on unhelpful patient assessments. This might be more useful in a situation where the owner is reluctant to bring their pet for emergency assessment.)
o ** N.B. Many owners will be reluctant or unable to make a reliable clinical assessment of their pet- asking them to do so could increase their concern and waste time.
• Frequency of vomiting/diarrhoea +/- presence of blood
• Presence/ location/ description of wounds, possible fractures etc.
** N.B. Asking owners to describe the severity of clinical signs and wounds, also requires them to make a clinical assessment. In this situation, it is preferable to ask closed questions which can elicit, definite answers e.g. ‘how many times has he vomited this morning’ is more reliable and less worrying than ‘how severe is the vomiting’?
• Ability to urinate
• Presence/(degree) of abdominal distension
Basic client and pet details should be taken in an emergency e.g. client name, postcode, phone number, pet name, breed, sex, presenting complaint (as above) and further detail can be gained when they attend the clinic/practice.
6
Q
Can treatment advice be given over the phone?
A
Appropriate guidance should be given to the owner to allow them to decide what is in the best interests of their animal (RCVS, 2018: 3.11) - it is, however, important to explain to owners that treatment advice cannot be given over the phone. Equally we can explain the limitations of telephone triage and the inability for a diagnosis of the animal’s condition to be, made without being examined by a veterinary surgeon. Owners should not be advised to give their pet any medication. If the animal is already receiving medication, veterinary guidance should be sought if the owner queries giving an additional dose/or not administering the medication.
In this situation we should be able to advise the client on what we would consider to be a deterioration, whilst reiterating we cannot make a diagnosis over the phone and if there is any doubt whatsoever of the urgency the recommendation is that the pet should be examined.
Concise, clear records of all communication and advice should be kept.
7
Q
What signs of situations would require immediate evaluation by a veterinarian?
A
Animals with any of the following should be immediately evaluated by a veterinary surgeon:
• Collapse especially with loss of consciousness (even if they now appear normal)
• Multiple seizures or other neurological abnormalities
• Breathing difficulties (respiratory distress/ dyspnoea)
• Difficulty or inability to urinate
• Extreme pain or dullness
• Protracted/frequent vomiting or diarrhoea, especially if blood
• Toxin ingestion
• Trauma
• Unusual behaviour
This is not an exhaustive list and there are many other reported findings that may lead to an owner being advised to attend as an emergency. As it is often hard for an owner to gauge, if they report that their pet appears to have an unduly rapid, slow or irregular heart rate or has pale mucous membranes they should be seen. Any significant change in demeanour would also be a reason for the animal to be seen.
8
Q
Should owners be aware of consultation costs? What would happen if they could not afford the consultation fee?
A
If an emergency attendance charge is to be made for seeing an animal out of hours, the owner must be made aware of this during the telephone call; however patient welfare should be our primary concern and first aid and analgesia should be offered as necessary to prevent and alleviate pain and suffering for any animal including wildlife.
9
Q
Who is responsible for transporting animals in an emergency?
A
‘Owners are responsible for transporting their animals to a veterinary practice, including in emergency situations. The RCVS encourages owners to think about how they can do this and make plans before an emergency arises’ (RCVS, 2018).
It is important to be able to give advice to the owners about how best to transport their pet to the practice in an emergency. They should also be given the full name, address and telephone number of the premises they are attending; with details of how to get there. It is essential to take a contact number for the owner, in case of delays etc. As many practices use dedicated out of hours providers it is extremely important to explain clearly to the client which practice to attend and how to access the building e.g. if there is an intercom system.
Whilst it is the owner’s responsibility to transport the animal to the veterinary practice it can be helpful to have a list of pet friendly taxi services to hand should they be needed, as well as discussing other options, such as friends or neighbours. In the emergency situation it is important we are empathetic and as far as possible assist clients with how to get to their pet into the clinic if they do not have transport immediately available.
10
Q
What should advice to a client regarding transporting their pet always be based on?
A
Advice to the client regarding transporting their pet should always be based on preserving life and limiting pain; preventing deterioration of the pet’s condition; health and safety of the client and availability of client resources.
11
Q
Give some different examples of how owners can be advised to safely transport their pet in an emergency situation?
A
Advice to the client regarding transporting their pet should always be based on preserving life and limiting pain; preventing deterioration of the pet’s condition; health and safety of the client and availability of client resources.
Cats, small mammals, birds and exotics should be transported in appropriate cages or baskets; when ambulatory, dogs should be on leads, although small dogs, especially with respiratory distress/dyspnoea may be better in baskets. Cats, small mammals, birds and exotic patients will all benefit from being in a darkened, covered carrier to reduce the stress associated with car journeys. Large breed dogs can be transported on a duvet or blanket, for example, to the car especially if respiratory distress or collapse is a concern. Sympathetic guidance should be given to the client on how best to handle their pet in the specific situation they are dealing with. It is important to explain that scared or painful animals may become aggressive or try to escape. The advice may be as simple as placing a blanket over the feline patient, for example, prior to picking it up and placing in a basket. Although this advice comes easily to us owners often need clear explanations to carry this out, due to being upset and worried. Owners should be advised about careful handling of animals, potentially or actually, contaminated with toxic materials; or specific situations, such as transporting of pets with suspected spinal injuries.
There is much advice that may need to be given over the phone- including first aid that the owner may need to provide before attending or on the way to the surgery e.g. appropriate cooling of a patient who has been burned prior to transport. This must be tempered with the fact that the pet should be seen as soon as possible. As qualified and experienced veterinary nurses we expect that this should be something with which you are already familiar- it is, however, a very important situation that must be dealt with sensitively and appropriately. It is important to keep accurate records of any communication and advice given.
12
Q
How does the triage process work when their are several emergencies all at one time?
A
Triage is the process of sorting out and prioritising which patients require most immediate attention, when there are several patients to be seen; triage is also the process of sorting out and prioritising an individual patient’s problems to see which needs most urgent attention e.g. breathing difficulties, haemorrhage and skin wound.
13
Q
During the triage process what is is helpful for the owner to understand?
A
Communication with the client is important during the triage process. We need to often build a rapport rapidly, whilst ensuring the client understands we are the RVN on duty and are checking for injuries and clinical signs that indicate a threat to life so we can act on those promptly.
14
Q
What should the initial triage focus on?
A
It is vital to follow the same process of triage assessment and not be distracted by injuries that, although will need attention, are not life threatening. Our initial triage focuses on the stability of the major body systems as this is what keeps our patient alive. Clients naturally will be distracted by what they can see e.g. wounds and fractures. However, these will only very rarely threaten the animal’s life.
15
Q
How long should the initial primary survey triage take?
A
The initial primary survey, triage, assessment should take no longer than 60-90 seconds – obtaining a detailed patient history or performing a full physical examination is not required at this stage. This will be done after the initial primary survey assessment.
16
Q
What is signalment and how can it help in a primary survey triage?
A
Signalment (age, breed and sex) can help to provide important clues as to the disease/injury process that is affecting the patient.
17
Q
What does a primary survey involve when triaging an animal?
A
The primary survey involves assessing the three major body systems- whilst at the same time determining the presenting complaint and signalment.
18
Q
What three major body systems need to be assessed in a primary survey?
A
• Respiratory
• Cardiovascular
• Neurological
If there is dysfunction of any of these systems, then immediate veterinary attention is necessary
19
Q
In what situations would you hold off taking a patient’s temperature during a triage?
A
There will be some exceptions to this, and they may include the patient presenting with breathing difficulty, for example, who would deteriorate should a rectal temperature measurement be attempted. It may also not be appropriate in patients with pelvic and hind limb trauma.
20
Q
As well as assessing the 3 major body systems during a triage what else should be obtained?
A
Following assessment of the major body systems, a baseline body temperature should be obtained ideally, as well as a brief general examination of the rest of the patient
21
Q
What factors can affect the accuracy of auricular thermometers?
A
Whilst this is a useful technique and can be utilised to monitor trends in body temperature, the accuracy is questionable and affected by multiple factors including presence of hair in the ear canal, pigmentation and perfusion. Auricular thermometer readings are not interchangeable with rectal temperature readings
22
Q
Aside from the 3 major body systems, what other systems or history would need urgent veterinary attention?
A
Veterinary attention should also be sought, immediately, if other important systems, especially the urinary system, are affected or there is a history of: • Recent toxin ingestion/or topical exposure • Recent seizures • Trauma • Open wounds/excessive bleeding • Snake bite • Burns • Dystocia • Hyperthermia • Difficulty or inability to urinate • Inability to walk • Distended abdomen
23
Q
What should always be considered in a triage (including telephone) with any male cat with vague clinical signs?
A
Cats with urethral obstruction may present with a definite history of dysuria but the presenting signs are often vague; such as hiding, lethargy and inappetence. Straining to urinate may not have been noticed. As such, urethral obstruction is a potential consideration in any male cat with vague clinical signs. Following the primary and secondary survey approach means that life threatening issues are identified rapidly, and a treatment plan can be devised whilst ensuring all of the patient is assessed.
24
Q
What basic patient details should be collected by a receptionist/VS/RVN whilst an animal is being triaged?
A
Basic patient details can be collected by a receptionist (or VS/RVN) whilst the animal is being triaged by a member of the medical team. The patient details should be recorded as shown: • Age • Species • Breed • Sex • Neutering status • Vaccination status • Previous medical/surgical history • Other current medical problems • Current medication • Previous trauma etc. • Any previous blood / plasma transfusion
25
What questions can be asked to an owner to gain a history for a patient that has presented for an emergency?
Questions to ask include:
• What is the major problem?
o Termed presenting complaint
• When was the patient last normal?
o This helps to determine chronicity
• Have signs been getting better, worse or stayed the same?
o Termed progression of illness
o Chronological progression
• Systemic manifestations of disease?
o Are there signs such as vomiting, diarrhoea, PUPD etc., that are not associated with the presenting complaint
• Current and previous medications? What and when was this given/administered?
o Has the owner given the animal any treatment e.g. aspirin, NSAIDs? If so what, how much and when?
o Is the pet on any prescription only medicine? If so, what is it and what is the frequency and dose administered? When was this last administered? Is there any possibility the animal may not have received the medication?
o It is also sensible to ask if the patient is on any additional supplements. Turmeric for example may alter coagulation and be relevant. Cannabis oils compete with the opioid receptors. In this situation, complications could arise if a pure opioid or some other agents are given.
• Are there any other medical problems?
o Identify prior relevant medical history
o Identify co-morbid conditions such as diabetes mellitus or hyperadrenocorticism
• When did the animal last eat and what is the normal diet?
• Has it had this problem previously? If so when?
• Are any other members of the household affected?
• Other questions may be relevant depending on the circumstances e.g. has the patient ever/ recently been in another country?
Some emergency clinics have an admission questionnaire covering these points and others that may be useful if the animal is hospitalised e.g. the type of substrate the animal prefers. Whilst these can be useful it’s important in the emergency to communicate sympathetically and clearly with the client.
26
What does examination of the cardiovascular system enable assessment of?
The cardiovascular system examination enables assessment of the haemodynamic stability of a patient. Blood flow to body tissues (perfusion) is vital to supply enough oxygen for normal cellular activity and therefore patient survival.
27
What is appropriate mentation dependent on?
Appropriate mentation is dependent on a normal blood flow to the brain, as well as normal CNS neuron function.
28
How does cardiovascular compromise alter mentation?
If the blood flow is compromised (e.g. hypovolaemic shock) or the patient is hypoxaemic, there will not be enough oxygen delivered to the brain and mentation will be altered. Understandably, therefore, ensuring there is enough blood and oxygen delivery to the brain is always a priority. Alteration in cerebral blood flow, enough to affect mentation, is an indicator of marked cardiovascular compromise.
29
What type of problems can alter mentation?
Changes in mentation can also be seen in patients with electrolyte and acid-base disturbances, as well as intoxications. Marijuana toxicity, for example, has some specific clinical signs but significant CNS depression is commonly noted. Patients with a low blood glucose on presentation will often be depressed and may even be seizuring.
cardiovascular compromise
Patients with hypoperfusion/shock are likely to be depressed or obtunded.
30
What are the 6 patient consciousness levels?
Patient consciousness levels can be assessed as -
1. Normal – alert and appropriately responsive to stimuli
2. Depressed – alert but not appropriately responsive to stimuli
3. Obtunded – decreased consciousness or appearing unconscious but rousable with non-noxious stimuli
4. Stuporous – unconscious and only rousable with noxious stimuli
5. Comatose – unconscious and not rousable with any stimuli including noxious
6. Hyperexcitable – excessive reaction to stimuli
31
What is delirium? and what condition is it usually seen with?
We may on occasion encounter patients that have periods of delirium. They spend some of the time behaving and responding normally to voice, touch and the environment and then have periods of time where they do not respond or respond inappropriately. This type of alteration to mentation is common in patients with a space occupying lesion, problem within the brain structure or in patients with intermittent increases in intra-cranial pressure.
32
What information does assessment of the mucous membranes give you?
Mucous membrane (MM) colour can be quickly assessed and provides rapid information regarding the cardiovascular system. The colour of the gums is most commonly assessed, but conjunctival membranes can also be evaluated, as can the vulva or penis if the head of the patient is not accessible. Care should be taken to avoid getting bitten when evaluating an animal’s gums. Mucous membranes are sometimes pigmented, so that assessment of colour may be difficult.
33
What is the normal colour of mucous membranes and why are they this colour?
The mucous membranes of most animals are normally pale pink- this colour is due to the presence of red blood cells within the capillary beds of the mucous membranes (peripheral circulation). The colour of mucous membranes may be affected by abnormalities of the cardiovascular system; abnormalities of the respiratory system and other conditions e.g. poisoning/intoxication.
34
What can pale/white mucous membranes indicate?
Indicates absence of red blood cells with the capillary beds
35
What can cause an animal to have pale/white mucous membranes?
Anaemia (insufficient red blood cells in the overall circulation)
Hypoperfusion - various causes but hypovolaemia is the commonest cause. As a result of the compensatory mechanisms stimulated by hypovolaemia, peripheral vasoconstriction will lead to decreased blood supply to the area thus pale mucous membranes
36
What can cause icteric mucous membranes and what is this problem due to?
icteric or jaundiced
▪ Indicates elevated bilirubin in the circulation. This may be due to excessive haemolysis, liver disease or biliary tract disease (pre-hepatic, hepatic or post-hepatic jaundice)
37
What can cause blue/purple mucous membranes?
Blue/purple
o Termed cyanotic
o Secondary to de-oxygenated haemoglobin
o Seen with severe hypoxaemia (N.B. clinically evident cyanosis only occurs at a SPO2 of <85%)
o The absence of cyanosis does not preclude hypoxaemia
38
What can cause red mucous membranes?
o Seen with early sepsis/ SIRS in dogs
o May also be seen in patients that are hyperthermic/ suffering from heat stroke
o Secondary to a ‘hyperdynamic state’ of increased cardiac output and vasodilation
39
What can cause bright red mucous membranes?
Carbon monoxide intoxication
40
What can cause brown mucous membranes?
Methaemoglobinaemia e.g. paracetamol (acetaminophen) intoxication
41
How should you assess the mucous membranes?
it is important to assess the colour of the mucous membranes, the texture and the capillary refill to obtain meaningful information.
42
What does tacky or dry mucous membranes indicate?
Tacky or dry mucous membranes will be present in dehydrated patients. Dry mucous membranes may also be present in animals that are mouth breathing.
43
Are hypovolaemic patients usually dehydrated?
Remember that acutely hypovolaemic patients are rarely dehydrated; and dehydrated patients are not necessarily hypovolaemic. Hypovolemia is defined as a loss of circulating volume which leads to cardiovascular system dysfunction –it must addressed rapidly once identified. Dehydration is a loss of total body water and, on its own, will rarely be immediately life threatening. However, if a patient is both hypovolaemic and dehydrated, the hypovolaemia will need prompt treatment.
44
Why would mucous membranes be excessively moist?
Mucous membranes can be excessively moist in animals that are hypersalivating due to nausea or have recently vomited etc.
45
What is the capillary refill time?
Capillary refill time (CRT) is defined as the amount of time it takes for blood, and therefore colour, to return to the capillary bed after it has been forced out of the capillaries through digital pressure
46
What would be considered a normal and prolonged capillary refill time?
Normal CRT is 1-2 seconds.
| Prolonged CRT > 2 seconds
47
What would be the cause of a prolonged CRT?
o Consistent with hypoperfusion/shock
| o CRT may not be discernible if very prolonged
48
How could the CRT help to differentiate between anaemia and hypoperfusion?
Assessing CRT can help in the differentiation between anaemia and hypoperfusion/ shock as the cause of the pale mucous membranes:
▪ Pale MMs and normal CRT is consistent with anaemia (N.B. If anaemia is significant, however, it may be impossible to evaluate CRT)
▪ Pale MMs and prolonged CRT is consistent with hypoperfusion/ shock
49
What can a rapid CRT be associated with?
Rapid CRT
o Less than 1 second is abnormally fast
o Usually occurs along with the hyperaemic/red mucous membranes and can be associated with sepsis
50
What is hypoperfusion?
Hypoperfusion= decreased blood perfusion of tissues so decreased delivery of oxygen to cells. Hypoperfusion can lead to shock.
51
What is shock?
Shock = this is a life-threatening lack of oxygen delivery to cells/ tissues. Decreased cell oxygenation causes organ dysfunction and cell death.
52
What can happen if shock is left untreated?
If untreated, this will result in multiple organ dysfunction (MOD) and patient death.
53
Describe the progression of shock and compromised perfusion in 6 steps?
reduced perfusion
reduced oxygen delivery to tissues and collection of bi products (carbon dioxide)
reduction in oxidative metabolism and and increase In anaerobic metabolism
impaired cellular function
cell death
organ failure
54
What is a pulse deficit?
The heart rate and the pulse rate should be the same. With some cardiac arrhythmias, there may be fewer pulses palpated than heart beats heard-this is termed a pulse deficit.
55
How do you assess the pulse rate and heart rate?
The pulse rate and heart rate should be assessed by simultaneous cardiac auscultation and pulse palpation. The heart rate and the pulse rate should be the same.
56
What would be considered tachycardic in a dog?
Tachycardia (dogs)
o Generally, heart rates above 140 beats per minute (bpm) would be considered tachycardic (although this depends on the context, age, breed etc.) e.g. for some dogs > 120/ bpm would be abnormal. It is very important to monitor and note alterations in the individual patient’s heart rate- ‘trends’ e.g. a heart rate that is consistently at 140 bpm, may be of less concern than a heart rate that changes from 80 bpm to 130 bpm in a patient with a recent history of trauma.
57
What are the causes of tachycardia in dogs? what would be the most significant?
o The most significant cause of tachycardia is hypoperfusion/shock
o Additional causes include cardiac arrhythmias, congestive heart failure, anaemia, stress, pain, excitement, electrolyte abnormalities and intoxications
58
What is inappropriate bradycardia?
In a dog that has signs of hypovolaemic shock (pale mucous membranes, prolonged CRT, weak pulses), tachycardia would be expected. If it has a normal heart rate in this situation, e.g. 90 bpm, this would be inappropriate bradycardia.
59
What are the possible causes of bradycardia in dogs?
Possible causes of bradycardia (or inappropriate bradycardia) include:
▪ Hyperkalaemia (e.g. typical hypoadrenocorticism or urethral obstruction)
▪ Increased vagal tone
▪ Drugs e.g. lidocaine
▪ Atrioventricular blocks
▪ Sick sinus syndrome
▪ Raised intracranial pressure (Cushing’s reflex)
▪ Hypothermia
60
What are the causes of tachycardia in cats?
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Differentials for tachycardia include
▪ Hyperthyroidism
▪ Congestive cardiac failure
▪ Electrolyte disturbances
▪ Intoxications
▪ Pain/stress
Unlike dogs, cats with shock are not typically tachycardic especially as the shock becomes more advanced
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61
What rate would be considered tachycardia in a cat?
A heart rate above 180bpm. Would be considered tachycardic in a cat It is however important to consider other factors that may cause such as stress, pain anxiety, white coat effect.
62
What can be the causes of bradycardia in cats?
Cats with hypovolaemic shock are often bradycardic, especially in the later stages, when they have decompensated, or if they have septic shock (Pachtinger, 2015).
o Cats with sepsis are often bradycardic (e.g. < 120 bpm) (Pachtinger, 2015).
o Hyperkalaemia (e.g. urethral obstruction/ uroabdomen)
o Atrioventricular block
o Hypothermia
o High vagal tone
63
What pulses should be assessed during the primary survey?
Central e.g. femoral pulses should be assessed bilaterally. This may be challenging in obese patients or those with hind limb trauma. Care should be taken when attempting to palpate femoral pulses in patients that have trauma not to cause further discomfort. Additionally, peripheral dorsal metatarsal or pedal pulses should be palpated in dogs and, attempted in cats- these may be difficult to palpate even in normal cats, however. Regular assessment of central and peripheral pulses should be performed in normal animals as well as sick ones.
64
What does the pulse quality reflect the difference between?
Pulse quality reflects the difference between diastolic and systolic blood pressure-
65
What parameters can pulse quality be affected by?
it can be affected by several parameters including stroke volume, cardiac contractility and vasomotor tone e.g. degree of peripheral vasoconstriction.
66
What is assessed when feeling a pulse quality?
Pulses are assessed for pressure (strength of pulse) and duration.
67
What type of pulse quality would you expect to find in an animal with sepsis and why?
Bounding pulses (strong and longer duration) may be palpated in septic dogs due to the vasodilation that is present in early stages.
68
What type of pulse quality would you expect to find in a hypovolaemic patient? why?
Weak femoral pulses may be palpated in seriously hypovolaemic patients
Peripheral pulses may be hard to detect/absent in hypovolaemic patients due to compensatory mechanisms e.g. vasoconstriction
69
What is the blood pressure likely to be if there are absent peripheral pulses?
They tend to disappear when the mean arterial pressure (MAP) decreases below 60 mmHg
70
What type of pulse quality would you expect with anaemia?
Snappy pulses (strong but short duration) may be present with anaemia.
71
Why is it important to assess pulses bilaterally? especially in cats?
It is important to compare femoral pulses bilaterally, especially in cats at risk of aortic thromboembolism (ATE). Attempts should ideally be made to assess forelimb pulses as ATE may occasionally affect the forelimbs.
72
What should be assessed and noted when listening to an animals heart?
The heart of all animals should be auscultated- noting the rate, rhythm, position and audibility of heart sounds.
73
What might muffled/absent heart sounds be secondary to?
Muffled/absent heart sounds may be secondary to pericardial or pleural space disease e.g. pleural effusion (ventrally) or pneumothorax (dorsally)
74
If the primary survey shows a patient is showing clinical signs suggestive of shock (e.g. hypovolaemic), What initial treatment will be required?
* Provide emergency oxygen by the manner most well-tolerated by the patient
* Intravenous fluids are likely to be indicated- choice, route and rate will be chosen by the veterinary surgeon. (Fluid therapy is discussed further in Unit 1, outcome 2) - an intravenous catheter should be placed (under veterinary direction) It is however essential that the RVN can select an appropriate site of placement for an intra-venous catheter; as well as a suitable type and size of catheter for the patient.
* At the time of placement, blood can be collected for, at least some of, the following emergency tests (it may, however, only be possible and appropriate to get sufficient blood at this stage to put into two capillary tubes) A minimum database can be performed with 0.2ml of blood, so should be achievable from the catheter, thus providing important information rapidly.
75
What would a vets NOW minimum database include?
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A blood test including:
Minimum database (MDB)
▪ Packed Cell volume (PCV)
▪ Total solids (TS)
▪ Blood urea nitrogen (BUN)
▪ Blood glucose
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76
What would a vets NOW extended database include?
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o Minimum database (MDB)
▪ Packed Cell volume (PCV)
▪ Total solids (TS)
▪ Blood urea nitrogen (BUN)
▪ Blood glucose
plus
o Extended database (EDB)
▪ MDB as above
▪ Electrolytes
Blood gases
o Lactate
o Blood smear
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77
After the initial primary survey and blood collection has been performed, what other diagnostic tests will help with the immediate investigation?
Following the primary survey, it might be decided that additional immediate investigation may be needed to give a better assessment of the cardiovascular/ haemodynamic status of the patient
• Electrocardiography (ECG)
• Blood pressure measurement
o Indirect Doppler
o Indirect Oscillometric
o Direct Arterial.
• POCUS (Point of care ultrasound) may also be carried out bedside for the trauma patient or emergency presentation.
78
What are the signs that an animal is in respiratory distress?
The respiratory system should be assessed in ALL patients during triage. Signs of respiratory distress (dyspnoea) can be subtle, especially initially, and include:
• postural changes such as head and neck extension and elbow abduction
• abnormal breathing patterns e.g. rapid/ shallow, irregular, stridor, paradoxical abdominal breathing,
• restlessness
79
Why is stress an important consideration in animals in respiratory distress?
It is important to remember that patients demonstrating these signs are at the limit of their physiologic reserves. It is essential to minimise patient stress to avoid respiratory and/or cardiac arrest. A hands-off approach is essential for any patient in respiratory distress to avoid fatality.
80
What conditions might cause an increase in respiratory effort?
An increase in respiratory effort may be seen with:
o Pleural space disease (e.g. pneumothorax, haemothorax, or diaphragmatic hernia/ rupture)
o Pulmonary parenchymal disease (e.g. pulmonary contusion)
o Upper airway disease / airway obstruction
81
What conditions might cause an increase in respiratory effort?
An increase in respiratory effort may be seen with:
o Pleural space disease (e.g. pneumothorax, haemothorax, or diaphragmatic hernia/ rupture)
o Pulmonary parenchymal disease (e.g. pulmonary contusion)
o Upper airway disease / airway obstruction
82
What is the normal respiratory rate?
The normal resting respiratory rate in is ~ 10 - 30 breaths per minute. Bear in mind, however, that the resting respiratory rate may be increased for various reasons including the stress of visiting the veterinary practice.
83
What respiratory rate would be considered tachypnoeic?
Increased respiratory rate (tachypnoea) in dogs and cats is generally considered to be above 50 breaths per minute.
84
What can be the causes of tachypnoea?
causes of tachypnoea include pain, pyrexia/ fever, hyperthermia, stress/fear, and compensation for metabolic acidosis.
85
What can cause bradypnoea?
Bradypnea is respiratory rate below 10bpm. It can be caused by certain toxins.
86
How would you describe normal respiratory effort?
Normal respiratory effort involves hardly perceivable chest excursions - with a minimal component of abdominal musculature motion.
87
How would you describe an increase in respiratory effort?
Increased respiratory effort (respiratory distress/ dyspnoea) is characterised by increased chest and abdominal muscle movement. It is perceived as laboured breathing or the patient having difficulty in breathing. There is obvious exertion of the thorax +/- the abdominal muscles to assist with moving air.
88
Why is it important to note whether respiratory effort is inspiratory or expiratory?
It is important to note whether there is more inspiratory or expiratory effort- this can aid in the ultimate diagnosis and management e.g. a patient with an upper respiratory tract obstruction will usually present with marked inspiratory effort and paradoxical abdominal movement. Patients with small airway/bronchial disease will often have a marked expiratory, rather than inspiratory effort, because of air entrapment.
89
What are the signs of an increased respiratory effort?
Signs of increased respiratory effort include:
o Extension of the head and neck
o Abduction of the elbows
o Flared nostrils during inspiration (species dependant)
o Open-mouthed breathing may be a sign of severe respiratory distress in cats. Sometimes it can be for other reasons e.g. injury/disease to the nasal passages and sinuses.
90
What disease processes would be associated with a decreased respiratory effort?
Decreased respiratory effort is less commonly seen and is characterised by decreased chest and abdominal muscle movement. Disease processes associated with decreased respiratory effort include head and spinal injury, intoxications (e.g. tetanus)) and end stage respiratory fatigue.
91
What is paradoxical respiratory motion?
Paradoxical respiratory motion may be seen in some animals with breathing difficulties- increased intercostal muscle action, during inspiration, draws the diaphragm cranially and the abdominal muscles appear to be sucked inwards.
This is due to the increased effort involved in attempting to breath, as the thorax expands outwards with inspiration, the abdominal muscles are pulled inward.
92
What can be the causes of paradoxical respiratory motion?
Causes of paradoxical respiration include upper airway obstruction, diaphragmatic injury (rupture or paralysis secondary to the cervical spinal cord or phrenic nerve injury), and a severe decrease in pulmonary compliance.
93
What is a tension pneumothorax?
Patients with a tension pneumothorax deserve special consideration. With this condition, air enters the pleural space, e.g. penetrating wound, but cannot leave - there is no escape “valve” for air in the pleural space. As the condition progresses these patients develop worsening inspiratory respiratory distress, with minimal movement of the thorax.
94
What are the signs of a tension pneumothorax? what emergency procedure needs to be carried out with this condition?
minimal movement of the thorax. They may be gasping, have cyanotic mucous membranes and often present in lateral recumbency. They are the exception to the ‘hands off’ management – they require immediate veterinary attention and emergency thoracocentesis.
95
What area is usually affected with laboured inspiration
Upper airway issue
96
What area is usually affected with laboured expiration?
lower airway issue
97
What does cyanosis indicate?
Blue mucous membranes (cyanosis) are seen with severe hypoxaemia and indicate a profound deficiency in the oxygen saturation of haemoglobin. Significant hypoxaemia must therefore occur before a patient’s mucous membranes are cyanotic- thus, the absence of cyanosis does not rule out significant respiratory compromise and hypoxaemia.
98
What level of partial pressure of oxygen in arterial blood (PaO2) indicates severe hypoxemia? and at what level would you see cyanosis?
A patient with PaO2 < 60 mmHg of oxygen is seriously hypoxaemic but cyanosis may not be apparent until PaO2 has dropped further to 35-40 mmHg.
99
What is PaO2?
partial pressure of oxygen in arterial blood
100
What is stridor?
high pitched sounds of upper airway origin
101
What is stertor?
lower pitched sounds generally of pharyngeal origin)
102
What causes stridor?
Stridor occurs where there is damage or obstruction to the upper airways- it is an abnormally loud sound created as air passes through a narrowed airway during breathing. It may be present during inspiration and expiration. N.B. for some brachycephalic patients, this may be considered to be “normal” by the owner.
103
Why can stridorous sounds be heard in the intrathoracic area? and what can you do to determine where the noise is coming from?
Stridorous sounds are often heard as referred upper airway noise on thoracic auscultation. Caution must therefore be exercised to prevent the noise being inaccurately attributed to intrathoracic pathology. Laryngeal and tracheal auscultation will aid in localisation of the noise.
104
Are stertorous sounds heard inspiratory or expiratory?
Stertor is lower-pitched than stridor (often gasp or snore-like) heard during inspiration
105
When assessing thoracic sounds in a triage, what fields and zones do you divide the thorax in to?
Each hemi-thorax should be divided into dorsal, middle, and ventral lung fields. Depending on the size of the patient, each field should be further split into two to three cranial to caudal zones of auscultation.
106
What lung sounds would you expect to hear with pleural space disease?
A decrease in, or absence of lung sounds (in one or both sides of the thorax) is usually consistent with pleural space disease.
107
What are the different types of pleural space disease?
This may be secondary to air (pneumothorax), fluid (pleural effusion), soft tissue or organ displacement (e.g. diaphragmatic hernia).
108
What signs are usually seen with pleural space disease?
A patient with pleural space disease will often have rapid, shallow breathing pattern as they are unable to expand the lungs properly.
• Depending on the severity of the pleural space disease (e.g. volume effect), the patient may be showing signs of air hunger.
Dull lung sounds heard dorsally on auscultation can be consistent with pneumothorax.
109
What different types of fluid can be seen in a pleural effusion?
Causes of pleural fluid include
o Pure transudate (right sided heart failure)
o Haemorrhage (rodenticide intoxication, neoplasia, trauma)
o Chylothorax
o Pyothorax (pus)
110
What may be detected on clinical examination of a patient with a diaphragmatic hernia in to the pleural space? What diagnostic tests can help to confirm diagnosis?
A patient with a diaphragmatic hernia/ rupture may present with dull lung sounds ventrally and/or dorsally. Auscultation may be normal, depending on the extent of organ herniation into the thorax but it is possible that abnormal sounds e.g. gut sounds (borborygmi) will be heard. Following a more comprehensive secondary survey, it may be considered that imaging techniques such as survey radiography, point of care ultrasound, contrast radiography, computed tomography (CT) or magnetic resonance imaging (MRI) are necessary to confirm the diagnosis. Following patient stabilisation, emergent surgical intervention is indicated for this condition.
111
What ways can oxygen be delivered to a patient?
* using an oxygen tent or incubator for smaller animals
* by holding the supply in front of the nasal cavity for larger animals (flow-by)
* nasal prongs
112
What method of oxygen delivery is the most effective and give the highest consistent fraction of inspired oxygen?
Bilateral Nasal oxygen lines
113
how much inspired oxygen does a nasal catheter provide?
20%
114
How much inpired oxygen does room air provide?
20%
115
How much inspired oxygen does bilateral nasal catheters provide?
60%
20% for each nasal line and 20% for room air
116
Why can you not keep a patient on 100% oxygen for a long period of time?
as there is a risk of oxygen toxicity
117
Why is it important to carry out a painscore before giving analgesia?
Baseline pain scores are important and should be taken prior to analgesia being given. This allows us to fully monitor response to the analgesic given and then re-evaluate. Repeat scores should be carried out once the drug of choice for analgesia has reached peak plasma levels to ensure the patient’s pain is sufficiently controlled.
118
How should a patient be positioned for a thoracocentesis?
Patients should be kept in sternal recumbency during this procedure, if possible, as lying in any other position will impair respiration
119
What are the nursing considerations for a patient having an emergency thoracocentesis? (5)
```
minimal stress and handling
oxygen supplementation
Sternal recumbency
suitable analgesia
IV catheter placement (this should not cause any stress) the VS should do a risk vs benefit assessment
```
120
Why is stress detrimental in hypoxic patient?
Stress leads to increased oxygen demands in a patient that is already hypoxic.
121
What needs to be carried out rapidly in a bracycephalic patient that presents with an upper airway obstruction caused by its anatomy? What can happen if treatment is delayed?
if a patient presents with an upper airway obstruction caused by its anatomy, it may need to anaesthetised and intubated rapidly. If this is delayed, there is a risk of laryngeal oedema, developing leading to swelling and a complete airway obstruction
122
If laryngeal oedema occurs due to the prolonged upper airway obstruction caused by the anatomy in a bracycephalic dog, what procedure will they most likely need?
Once laryngeal oedema and complete airway obstruction has developed, the only option for this patient would be placement of a tracheostomy tube. However, ideally placement of a tracheostomy tube should be carried out in controlled circumstances rather than when the patient goes into cardiopulmonary arrest.
123
What tests can be done to provide more detailed information about the oxygen and carbon dioxide status of a patient?
arterial blood gas analysis (PaO2) and pulse oximetry (SpO2) can be used to provide more detailed information about the oxygen and carbon dioxide status of the patient.
124
What can cause inaccurate pulse oximetry readings?
peripheral vasoconstriction, have dark pigmentation on the ears or lips, or are anaemic then readings may not be accurate.
125
What initial assessment of the neurological system should be carried out in the primary survey of a triage?
Is the patient seizuring?
level of consciousness
The patient’s position should be monitored closely.
If the patient is ambulatory, any gait abnormalities should be assessed e.g. ataxia, knuckling, hypermetria
The initial examination of the head should involve both an initial brief assessment of cranial nerve function (e.g. drooping eyelids, unequal pupil size etc.) and close visual inspection for evidence of head trauma.
Pupil size and symmetry should be assessed. If unequal, direct and consensual light reactivity should be assessed during the secondary survey.
The patient should be observed for other abnormalities e.g. pathologic and physiologic nystagmus, intention tremor and/or a head tilt.
Assess whether it could be a spinal or brain injury
126
What are the deffering levels of consciousness
Levels of consciousness should immediately be assessed
o Over-excited/agitated
o Normal
o Depressed
o Obtunded
o Stupor (unconscious but responds to noxious stimuli)
o Coma (unconscious and does not respond to noxious stimuli)
127
What is stuporous demeanour?
o Stupor (unconscious but responds to noxious stimuli)
128
describe what comotose is?
Coma (unconscious and does not respond to noxious stimuli)
129
On intial presentation what may an altered mentation be secondary to?
On initial presentation, decreased mentation may be secondary to hypoperfusion and hypoxia; or a result of primary neurological disease/injury.
130
What should happen to a patients mentation after receiving intravenous fluids if altered mentation is due to hypoperfusion?
If intravenous fluid therapy (IVFT) is indicated, the patient’s neurologic status should be re-assessed, after volume resuscitation, to determine the extent of signs attributable to hypoperfusion e.g. mentation should improve after IVFT if the signs were due to decreased oxygen delivery to the brain due to blood loss
131
If there are concerns of a brain injury how should the patient be positioned and why? What other things should be avoided?
If there is any concern of traumatic brain injury, great care should be taken in handling the patient. The patient should be positioned such that its head and neck are elevated (using e.g. a flat board) by 15-30º, to decrease intracranial pressure.
132
How should a patient with a possible spinal or neck trauma be positioned and what can be used for transport?
A patient with possible spinal or neck trauma should be secured to a backboard for transport if appropriate. Large rolls of coflex are useful for this- however anything can be used to immobilize the patient.
133
Describe the schiff-sherrington position and what this is secondary to?
Abnormalities of body-position which may be seen in the trauma patient include-
o Schiff-Sherrington – forelimb extensor rigidity and hind-limb flaccidity secondary to a serious spinal cord lesion between T2 and L4.
134
What is decerebrate rigidity?
Decerebrate rigidity – opisthotonus with hyperextension of all four limbs and loss of consciousness.
135
What is decerebellate rigidity?
Decerebellate rigidity - hyperextension of the forelimbs with variable flexion and extension of the hind-limbs and appropriate level of consciousness. The prognosis for decerebellate rigidity is more favourable than that for decerebrate rigidity.
136
Should deep pain be assessed in the primary survey?
During the secondary survey, assessment of spinal reflexes and deep pain might be indicated for patients with limb paralysis. N.B Deep pain assessment should not be performed during a primary survey. It is only indicated in patients with serious spinal cord injury/ disease- for welfare reasons it should only be performed on veterinary direction.
137
How do you check a patient for deep pain?
The withdrawal reflex is checked by pinching the webbing or skin between the toes on the hind leg – the patient should pull its leg away. In many cases the withdrawal reflex will be present even if deep pain is absent. Deep pain is checked by applying forceps to the base/periosteum of P3. If deep pain is present, gradual closing of the forceps will elicit a significant pain response (growl/snarl/snap/cry) from the patient.
138
What was the modified Glasgow coma score developed to help determine?
The Modified Glasgow Coma Score (MGCS) was developed to determine the severity of neurologic injury. Whilst it has its limitations, it is a very useful tool for monitoring progression of the patient with neurological disease.
o It uses a combination of observed neurologic signs to ascertain patient prognosis. Scores for motor function, cranial nerve function, and level of consciousness are added to render the final MGCS.
139
Why is it important that increases in intracranial pressure is avoided in patients with head injuries?
With head injury patients it is important that increases in intra-cranial pressure are avoided, as this will cause decreased cerebral blood flow, which may be rapidly life threatening.
140
What drugs are used to reduce intracranial pressure?
Drugs such as mannitol and hypertonic saline may be administered on veterinary direction if there is raised intra-cranial pressure.
141
What should veterinary staff avoid doing in patients with suspected or intracranial pressure?
Therefore, the following should be avoided:
Applying pressure to the jugular veins. Do not take jugular blood samples where there has been an injury to the head.
Placement of intra-nasal catheters or any irritation of the nose as sneezing increases intracranial pressure.
Inducing the gag reflex or administering drugs that can cause vomiting.
142
How do you calculate the cerebral perfusion pressure?
Cerebral perfusion pressure is a product of intra cranial pressure and mean arterial pressure - CPP = ICP – MAP. It is only possible to measure and influence measure mean arterial pressure. It is essential therefore that a patient is volume resuscitated to a normovolaemic status with fluid therapy under veterinary direction to ensure adequate cerebral perfusion.
143
How can injury of the spinal column occur?
Injury may originate from intervertebral disc disease (most common), fracture/luxation if secondary to trauma, fibrocartilagenous embolism or even neoplasia.
144
What is the aim of therapy when treating a patient with a spinal injury?
prevent further damage to the spine and spinal cord
provide analgesia - make the animal comfortable
ensure the patient can urinate, place urinary catheter if necessary
monitor for any respiratory signs if the injury is high up
Many spinal cases will be recumbent and will require special care – suitable bedding, regular movement to prevent pneumonia, padding of bony prominences to prevent pressure sores, grooming, care of any urinary catheter and mental stimulation should all be part of a nursing plan.
145
What negative effects can occur with repeat bladder expression in a spinal patient?
Repeated bladder expression or intermittent catheterisation can cause problems such as bruising, bladder wall trauma and cystitis; so an assessment should be made on a case by case basis over the best way to manage the patient’s recumbency and bladder.
146
Why is it important that assessment of neural function is carried out daily?
The care required by a spinal case patient will change as the condition alters. Whilst it is hoped that most cases will improve and regain movement, pain sensation and normal urination, it is to be expected that some cases will deteriorate. Therefore, assessment of neural function will take place daily and should be recorded.
147
What is the secondary survey?
After the primary survey has been completed, and the most life-threatening problems addressed, the secondary survey is performed. This includes obtaining a detailed history, performing a complete physical examination and assessment of the response to the initial therapy if provided (e.g. intravenous fluid therapy, oxygen +/- analgesia).
N.B. Placement of IV catheter, rate, route and choice of administration of IV fluids and analgesic should all be determined by a veterinary surgeon and only performed on delegation.
148
What are the 6 H's (conditions) that predispose a patient to cardiopulmonary arrest?
The 6H`s are hypovolaemia, hypoxia, hydrogen ion (acidosis), hypo or hyperkalaemia, hypothermia and hypoglycaemia
149
What are the 5 T's (conditions) that predispose a patient to cardiopulmonary arrest?
The 5T`s are tamponade(cardiac), toxins, trauma, tension pneumothorax and thrombosis.
150
What 5 steps should be taken following cardiopulmonary arrest?
Following recognition of impending or actual cardiac or respiratory arrest:
1. Call for assistance
2. Note time
3. Turn off anaesthetic agent (if relevant)
4. Start immediate CPR
5. Quickly determine the most experienced member of staff present who should take responsibility for decision making and organisation of the rest of the team. This will often be the veterinary surgeon due to the need to prescribe drugs throughout the arrest period. However, a very experienced RVN could lead the arrest team with a veterinary surgeon on hand to prescribe resuscitation drugs.
The leader should identify themselves rapidly and assign roles to the rest of the team. The first of these roles is to start basic life support by beginning chest compressions.
151
In a non intubated animal where there is only 1 person performing CPR how many breaths to chest compressions can be given?
In non-intubated animals or if there is only one person performing CPR, 2 breaths should be delivered per 30 chest compressions.
152
What monitoring equipment should be attached following chest compressions in CPR?
If not already in place, ECG leads should be attached to the patient as soon as possible, following the start of chest compressions and ventilation.
153
How often should the ECG be interpreted during CPR?
The ECG should be interpreted after every 2 minutes of uninterrupted compressions/ventilation – (N.B. the rhythm looks like ventricular fibrillation (VF) during compressions).
154
What are the 3 pain cardiac arrest rhythms?
The three main arrest rhythms are:
1. Asystole
2. Pulseless electrical activity
3. Ventricular fibrillation (VF)
155
If an ECG is showing a sinus rhythm what should be done to determine if the heart is contracting or if it is pulseless electrical activity?
If the ECG is showing a sinus rhythm, then auscultation of the heart and palpation of pulses is necessary to determine if the heart is contracting or if it is pulseless electrical activity.
156
What needs to be present for the return of spontaneous circulation?
Return of spontaneous circulation is present when the electrical and muscular heart activity delivers a perfusing rhythm- this will be before the patient regains consciousness and returns to normal. i.e. the patient may still be unconscious, non-responsive and apnoeic, however they will have a palpable pulse for every heartbeat.
157
What does an ETCO2 of 15 mmHg or above indicate during CPR?
ETCO2 of 15mmHg or above indicates that there is perfusion to the lungs and that compressions are adequate. An ETCO2 of 15 mmHg equates to effective cardiac compressions.
158
If an ETCO2 is below 15 mmHg then what needs to be reviewed?
If the ETCO2 is below 15 mmHg then the BLS technique needs to be reviewed - are compressions at the appropriate rate (100-120bpm) and appropriate depth (30-50% depth of the thorax)? Is there an underlying issue affecting perfusion of the lungs such as pneumothorax, haemothorax, pulmonary parenchymal damage?
159
What different routes can drugs be administered in CPR?
Drugs can be administered via the intravenous, intraosseous and intratracheal routes. Intratracheal delivery is often used in patients with CPR although intravenous/ intraosseous is preferred as it is more effective
160
Why should intracardiac injections be avoided in CPR apart from in open chest CPR?
intracardiac injections should not be performed except during open-chest CPR due to the potential for myocardial damage. Injections into the heart should be into the ventricular chamber, not into the myocardial wall which could result in intractable arrhythmias.
161
What is the technique for administered drugs intratracheal in a CPR?
The intratracheal route provides an easy and rapid delivery of arrest drugs into the lungs that are then absorbed into the circulation. The arrest drugs (including atropine and adrenaline) can be administered via a long catheter (e.g. urinary) advanced to the carina. The dose of drug should be doubled and diluted in 2-5 ml of isotonic saline (depending on the patient size). A large breath should be given after delivery of the drug to ensure good dispersal of the drug within the lung tissue.
162
Where is drug administration preferable in CPR?
Central venous administration of drugs is preferable to peripheral venous in a patient in CPR, although more time, skill and experience may be required to place a central venous catheter.
163
What can be done if there id difficulty placing a central or peripheral catheter?
A surgical cut-down to the central or peripheral vein may be required if there is any difficulty placing a catheter percutaneously.
164
Following drug delivery in CPR what should be done immediately after administration?
Following drug delivery, catheters should be flushed in with 5-20ml of isotonic fluids to ensure the drug reaches the central circulation.
165
What peripheral vein should be avoided to administer drugs in CPR and why?
When considering routes of administration, the saphenous vessel is often cited as being useful; however even if large volumes of flush are administered, it is unlikely medication administered by this route would reach the central circulation where it is needed.
166
What is the choice of arrest drug dependent on?
The choice of arrest drug is dependent on the underlying arrest rhythm/ potential cause of cardiac arrest and is decided by the veterinary surgeon.
167
What drugs may be administered if a dog is in pulseless electrical activity or asystole?
If the dog is in PEA or asystole, low-dose adrenaline/ epinephrine (0.01mg/kg) (or vasopressin) +/- atropine may be administered every 4 minutes. High dose adrenaline/ epinephrine (0.1 mg/kg) may be tried if 3 rounds of the above combination have failed
168
What do vasopressors do?
Vasopressors are medicines that constrict (narrow) blood vessels, increasing blood pressure. They are used in the treatment of extremely low blood pressure, especially in critically ill patients. The major vasopressors include phenylephrine, norepinephrine, epinephrine, adrenaline, dopamine, dobutamine and vasopressin
169
Why are vasopressors useful in CPR?
Even with effective cardiac compressions, only 25–30% of a normal cardiac output is achieved. To ensure adequate, cerebral and coronary perfusion during CPR high peripheral resistance is required – this should result in more of the circulating volume being diverted to the central circulation. Vasopressors are an essential component of ALS drug therapy
170
Why should adrenaline only be administered at a low dose during CPR?
Epinephrine/ adrenaline is a catecholamine which is a nonspecific adrenergic agonist. It has been used as a vasopressor, due to its
α -1 adrenergic effects for many years. Its additional β-1adrenergic activity (positive inotrope and chronotrope) is less important and possibly harmful as it increases myocardial oxygen demands and can exacerbate myocardial ischaemia/ predispose to arrhythmias once ROSC is achieved.
171
How often should a low dose of adrenaline be administered during CPR?
It is recommended that low dose epinephrine (0.01 mg/kg IV) is administered every other cycle of BLS. This normally means that epinephrine will be dosed at 2 minutes then 6 minutes then 10 minutes. Once 10 minutes has elapsed, CPR is considered prolonged.
172
When might you consider using a high dose of adrenaline in CPR?
Once 10 minutes has elapsed, CPR is considered prolonged. Different (higher) doses of epinephrine may now be considered (High Dose Epi). Higher doses (0.1 mg/kg IV) are more likely to be associated with side-effects but might be used after prolonged CPR
173
What is vasopressin? How does it differ to other vasopressors?
It is a type of vasopressor
Vasopressin is antidiuretic hormone – when administered at a higher dose it acts on peripheral V1 receptors present on vascular smooth muscle to cause peripheral vasoconstriction. The mode of action is different to epinephrine/ adrenaline. It is unlikely to worsen myocardial ischaemia because there are no inotropic or chronotropic effects. Vasopressin is still active in an acidic pH. It can be used as an alternative or in conjunction with epinephrine/ adrenaline although there is limited evidence to support this currently
174
When is electrical defibrillation indicated?
Electrical defibrillation is indicated, if available, if there is pulseless ventricular tachycardia (PVT) or ventricular fibrillation (VF) – shockable rhythms. Shockable rhythms occur less frequently in small animal patients than PEA and asystole, although following adrenaline and chest compressions, many dogs do develop VF.
175
What does vagolytic mean?
pertaining to or caused by vagolysis. 2. having an effect like that produced by interruption of impulses transmitted by the vagus nerve; see also parasympatholytic.
176
What does stimulating the vagal nerve do?
WE can stimulate our vagus nerve to send a message to our bodies that it's time to relax and de-stress, which leads to long-term improvements in mood, pain management, wellbeing and resilience
177
What effect on the body does atropine have when you administer it during CPR?
Atropine has parasympatholytic effects and its main use in CPR is for its vagolytic effect. There is not much evidence to support the use of atropine in patients with CPA (Fletcher et al., 2012). It is thought to be most likely to be effective in patients with ventricular asystole or pulseless electrical activity
178
What reversal agents are most commonly used in CPR?
The following reversal agents could be administered, on veterinary direction, if indicated:
• Naloxone for opiates
• Flumazenil for benzodiazepines
• Atipamezole for alpha-2 agonists
179
What reversal agent is used for opioids in CPR?
naloxone
180
What reversal agent is used for benzodiazepines?
Flumazenil
181
What reserved is used for alpha 2 agonists?
Atipamezole
182
What electrolyte treatments may be administered in CPR?
Anti-arrhythmic agents and electrolyte treatments (e.g. calcium/ potassium) may also be required. If CPA has continued without ROSC for greater than 10 minutes, then sodium bicarbonate (9mEq/kg) may be administered. In addition, sodium bicarbonate and calcium gluconate could be administered if the animal is hyperkalaemic.
183
Are intravenous fluids always indicated in CPR?
IV fluids will only be required if the patient hypovolaemic although it can be difficult to determine if a patient is hypovolaemic if it has not been assessed before developing CPA. If the patient is hypovolaemic, isotonic crystalloids may be started, although a more rapid response may be seen with hypertonic saline. If using isotonic crystalloids, a pressure bag or infusion pump can be used to rapidly infuse the fluids in the case of severe hypovolaemia
The dose of fluid administered should be upon based upon on the estimated degree of hypovolaemia.
Fluids should not be administered if the patient is euvolaemic or hypervolaemic as this may reduce myocardial blood flow and cause other complications e.g. pulmonary oedema
184
What should a defibrillator be charged to and who is responsible for defibrillation?
The defibrillator should be charged to 4 J/kg if using a monophasic defibrillator, or 2 J/kg with a biphasic defibrillator. Defibrillation should only be performed by a vet. The vet performing defibrillation must ensure that no personnel are touching the animal or the table by clearly calling out “Clear”, and visually confirming that everybody is clear before discharging the defibrillator. The vet defibrillating is responsible for the safety of his or her team
185
What does the electrical defibrillation do to the heart?
It is important to consider the action of electrical defibrillation is to stop the heart. An electrical current is applied which stops the abnormal activity in the hope that the sino-atrial pacemaker will start up and bring the patient back into a normal rhythm. This is why asystole is not a shockable rhythm- there is no electrical activity at all.
Immediately following the shock, the ECG should be quickly re-evaluated. If the patient remains in ventricular fibrillation, chest compressions should immediately be resumed for 2 minutes, before repeating electrical defibrillation with a higher energy.
A precordial thump may be considered if electrical defibrillation is not available.
186
What are the main features to note when a patient comes in to the practice for first aid treatment and a triage?
The provision of first aid and triage of cases coming into the practice can prove challenging. The main features to note are:
• The condition of the patient and the severity of the condition
• The cardiovascular status
• The presence of any respiratory problems
• The neurological status of the patient
• The clinical history
187
What is the aim of first aid?
The aim of first aid is to preserve life, alleviate pain and minimise and prevent further damage occurring before the veterinary surgeon can carry out a work up and administer treatment to the patient.
188
What should the veterinary nurse be familiar with when receiving an animal for first aid treatment?
The basic principles therefore require:
• A knowledge of possible conditions that may be encountered
• How these conditions could progress
• How to prevent these conditions from progressing
• How a patient should be monitored
• How and when to provide appropriate first aid
• Difference between first aid and treatment
189
Which statement is FALSE?
Select one:
a. A patient with anaemia could have pale mucous membranes
b. A patient with respiratory distress could have blue mucous membranes
c. A patient with carbon dioxide toxicity could have brick red mucous membranes
d. A patient with paracetamol intoxication could have brown mucous membranes
c. A patient with carbon dioxide toxicity could have brick red mucous membranes CorrectNo- a patient with carbon monoxide poisoning is likely to have brick red mucous membranes
190
Which statement follows the RECOVER recommended guidelines for performing IPPV to a patient in cardiopulmonary arrest?
Select one:
a. 30 breaths should be delivered per minute at a tidal volume of 10 ml/kg at a pressure of ~ 30-35 cm H2O
b. 6 breaths should be delivered per minute at a tidal volume of 15 ml/kg at a pressure of ~ 42-45 cm H2O
c. 10 breaths should be delivered per minute with a tidal volume of 10 ml/kg at a pressure of ~ 10-15 cm H2O
d. 12 breaths should be delivered per minute with a tidal volume of 15 ml/kg at a pressure of ~ 22-25 cm H2O
c. 10 breaths should be delivered per minute with a tidal volume of 10 ml/kg at a pressure of ~ 10-15 cm H2O Correct
191
Advanced life support (ALS) for a patient in cardiopulmonary arrest (CPA) could involve administration of low-dose adrenaline/epinephrine.
What is the main action of low-dose adrenaline/epinephrine in this situation?
Select one:
a. It has a thrombolytic effect to prevent disseminated intravascular coagulation (DIC).
b. It decreases the heart rate to minimise central perfusion
c. It acts as a vasopressor to cause peripheral vasoconstriction
d. It increases pulmonary vascular resistance to increase blood flow to the heart
c. It acts as a vasopressor to cause peripheral vasoconstriction Correct
192
When carrying out CPR, how many cardiac compressions should be delivered to a cat in one minute?
Select one:
a. 140-160
b. 60-80
c. 40-60
d. 100-120
d. 100-120 Correct
193
Nalaxone could be administered to reverse the effects of which drug?
Select one:
a. Midazolam
b. Diazepam
c. Dexmedetomidine
d. Morphine
d. Morphine
194
Epinephrine/ adrenaline is described as being a positive inotrope. This means that it .....
Select one:
a. increases the rate of cardiac contractions
b. decreases the force of cardiac contractions
c. increases the force of cardiac contractions
d. decreases the rate of cardiac contractions
c. increases the force of cardiac contractions
195
Which statement is TRUE?
Select one:
a. The capillary refill time provides information about peripheral perfusion
b. The capillary refill time is likely to be > 4 seconds in a patient with sepsis
c. The capillary refill time shows the hydration status of a patient
d. The normal capillary refill time for a dog is 2-3 seconds
The capillary refill time provides information about peripheral perfusion
196
Which statement about a patient with a pleural effusion is FALSE?
Select one:
a. The lung sounds are likely to be muffled dorsally
b. The patient may have cyanotic mucous membranes
c. The heart sounds may be muffled
d. Respiration is likely to be rapid and shallow
a. The lung sounds are likely to be muffled dorsally
197
Which describes the level of patient consciousness, in order, from most to least alert?
Select one:
a. Alert,responds to painful stimuli, responds to visual stimuli, coma
b. Responds to visual stimuli, responds to painful stimuli, alert, coma
c. Coma, responds to painful stimuli, responds to visual stimuli, alert
d. Alert, responds to visual stimuli, responds to painful stimuli, coma
d. Alert, responds to visual stimuli, responds to painful stimuli, coma
198
Which statement regarding first aid of a wound is TRUE?
Select one:
a. A tourniquet should be used where possible to reduce bleeding
b. Direct pressure over a wound is the best method to control venous bleeding
c. A wound should be left open to minimise contamination
d. Arterial bleeding can be stopped with gentle pressure over the wound
b. Direct pressure over a wound is the best method to control venous bleeding
199
Which is NOT an emergency abdominal presentation?
Select one:
a. Gastric torsion
b. Uroperitoneum
c. Intestinal volvulus
d. Chylothorax
d. Chylothorax
200
A cat presents following a road traffic accident (RTA) with a degloving wound of the right hind leg. In the first instance, the wound should be
Select one:
a. left alone until the cat is anaesthetised for lavage and debridement
b. flushed with povidine-iodine and covered with an adherent dressing
c. kept moist with sterile 0.9 % saline and covered with a non-adherent dressing
d. scrubbed with 8% chlorhexidine
c. kept moist with sterile 0.9 % saline and covered with a non-adherent dressing Correct
201
What is the first line approach for a patient presenting in respiratory distress?
Select one:
a. oxygen should be administered prior to handling the animal
b. radiography should be performed immediately
c. an intravenous catheter should be placed immediately
d. thoracocentesis should be performed immediately
a. oxygen should be administered prior to handling the animal Correct
202
Which of the following assessments is of least value when monitoring the progress of a patient with a spinal cord injury?
Select one:
a. Measure urine output
b. Check the panniculus reflex
c. Check anal tone
d. Assess the consensual pupillary light reflex
d. Assess the consensual pupillary light reflex
