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ADVERSITY “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon Emergency Procedures TRIAGE is the process of determining the priority of need and the proper order of treament when evaluating a clinical situation. ABCD A = Establish airway, address arterial bleeding B = Breathe for animal C = Maintain circulation with thoracic compressions and IV fluids D = Drugs Normal PE Area Organs Cranial ventral abdomen Liver, stomach, pancreas Cranial dorsal abdomen Kidneys, stomach, pancreas Mid-ventral abdomen Spleen, small bowel Mid-dorsal abdomen Kidneys, ureters, retroperitoneal space Caudal ventral abdomen Bladder, uterus Caudal dorsal abdomen Colon, sub-lumbar lymph nodes, prostate, uterus Triage of Emergency Patients • Initial exam (by RVT) – – – – Wear gloves Animal muzzled (use discretion) Minimize movement of patient Initial Assessment (30-60 sec; from rostral direction) • Mentation (level of consciousness) – – – – A V P U Alert Verbally responsive responsive to painful stimuli Unresponsive » Extend head/neck to provide clear airway; check for patency • Breathing/respiratory pattern (shallow, labored, rapid, obstructed) • Abnormal body/limb posture (fracture, paralysis) • Presence of blood or other material around patient Triage of Emergency Patients – Initial Assessment (continued) • Breathing/respiratory pattern – Total/Partial blockage of airways (Requires immediate Rx) » Exaggerated inspirations » Nasal flare, open mouth, extended head/neck » Cyanosis – Breathing assessment » Watch chest wall movement » Auscult lungs bilaterally to r/o hemo- or pneumothorax Triage of Emergency Patients • Respiratory Distress – Dogs: extend neck and open mouth – Cats: tuck 4 legs in, arch back and elevate sternum Breathing – Airway patent • NO • YES – Clear airway: use suction – Intubate – Ventilate (don’t over ventilate - will drive CO2 down) • 10-12/min • < 20 cm H2O – Provide flow-by oxygen Triage of Emergency Patients – Vital signs (taken after initial assessment) • HR, pulse rate (same as HR?), strength • RR • mm color, CRT • Temp • BP – High HR, high BP→ pain – High HR, low BP → hypovolemic shock – Baseline data • ECG • Chem panel, CBC Mucous membrane Color Interpretation Causes PINK Adequate circulation and perfusion Normal circulatory system WHITE OR PALE PINK Anemia, decreased peripheral perfusion, vasoconstriction Anemia ( blood loss, inc. destruction, dec. production) shock BLUE OR GREY Hypoxemia, anemia Respiratory embarrassment, blood loss DARK RED, BRICK RED Increased peripheral perfusion: cyanide toxicity Fever, sepsis, systemic inflammatory response, smoke inhalation/ cyanide toxicity BROWN Methemoglobenemia Acetaminophen, ibuprofen YELLOW (ICTERIC) Hyperbilirubinemia Hemolysis, hepatic/ biliary disease PETECHIA Coagulation disorder Thrombocytopenia, decreased platelet function Triage of Emergency Patients • History (mnemonic) – A Allergies – M Medications – P Past History of illness/injury – L Lasts (meals, defecation, urination, medication) – E Events (What is the problem now?) Triage of Emergency Patients – Events • How long since injury • Cause of injury (HBC, dog fight, gunshot) • Evidence of loss of consciousness • Blood loss? • Deterioration/improvement since accident (good indicator of Prognosis) • Any other underlying medical conditions/medications Triage of Emergency Patients Treatment to restore life/health – Analgesics for pain • Once airway patency and heart beat are established (these are critical for life) – Control hemorrhage • Pressure bandages (sterile gauze, laparotomy pads, towels) –If bleed thru, do not remove initial bandage, apply another on top –On distal extremity, BP cuff can be placed proximal to wound (avoid tourniquet if possible) Triage of Emergency Patients Control hemorrhage • External counter pressure using body wrap of pelvic limbs, pelvis, and abdomen – Insert urinary catheter to monitor urine output – Use towels, cotton rolls, duct tape, etc – Monitor respirations (diaphragm/abdominal breathing compromised) – Leave on until hemodynamically stable (6-24 h) – Monitor BP during removal If BP drops >5 mm Hg, stop removal; infuse more fluids If BP continues to drop, reapply wrap Triage of Emergency Patients SHOCK: RECOGNITION AND TREATMENT • SHOCK is inadequate tissue perfusion resulting in poor oxygen delivery – Cardiogenic – Distributive – Obstructive – Hypovolemic Shock • Types of Shock: – Cardiogenic—results from heart failure • ↓ blood pumped by heart • HCM, DCM, valvular insufficiency/stenosis – Distributive—blood flow maldistribution (Vasodilation) • Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from vessels to interstitial spaces →↓BP→ ↓ blood return to heart – Obstructive—physical obstruction in circ system • HW disease → heart pumping against the adult worm blockage • Gastric torsion →↓blood return to heart – Hypovolemic—decreased intravascular volume • Most common in small animals • Blood loss, dehydration from excessive vomiting/diarrhea, effusion of fluid into 3rd spaces Hypovolemic Shock Pathophysiology of hypovolemic shock ↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP ◦ Stage I: Compensation Baroreceptors detect hypotension (↓BP) a. Sympathetic reflex—(Epi, Norepi, cortisol released from adrenals) - b. ◦ ↑ HR, contractility Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex - ↑ Na+ and water retention → ↑ intravascular vol (↑BP) PE findings Tachycardia Prolonged cap refill time Pale mm Hypovolemic Shock • Pathophysiology of hypovolemic shock • Stage II: Decompensation – Tachycardia – Delayed cap refill time – Muddy mm (loss of pink color, more brown than pink) – BP is dropping – Altered mental state • Stage III: Irreversible shock – PE findings worsen – cannot revive – death will occur Shock • Treatment: the goal of therapy is to improve O2 delivery – O2 supplementation • Face mask • O2 cage/hoods • Transtracheal/nasal insufflation – Venous access • • • • Cephalic Saphenous Jugular Intraosseous Oxygen supplementation Fluid Administration CONTRAINDICATED IN PATIENTS WITH SEPSIS,FRACTURES, OR INFECTED BONES Shock • Treatment – Fluid resuscitation (O2 delivery is improved by ↑CO) 1. Crystalloids • Isotonic solutions (electrolytes: Na+, Cl-, K+, bicarbonate) – Examples (body fluid=280-300 mOsm/L) » Lactated Ringer’s (273 mOsm/L) » Normal saline (0.9%) (308 mOsm/L) – Dose: Dog 50-90 ml/kg/hr Cat 40-60 ml/kg/hr • Hypertonic solutions—when lg vol of fluid cannot be administered rapidly enough – Examples—7.5% saline – Causes fluid shift from intercellular space→ intravascular space →↑vascular vol →↑venous return → ↑CO – Also causes vasodilation → ↑ tissue perfusion – Dose: 4-6 ml/kg over 5 min • Hypotonic solutions should never be used for hypovolemic shock – Examples—5% Dex in water (252 mOsm/L) Shock • Treatment – Fluid resuscitation (O2 delivery is improved by ↑CO) 2. Colloids— • Large molecular wt solutions that do not leave vascular system • Better blood volume expanders than crystalloids • 50-80% of infused volume stays in blood vessels • Examples – Whole blood – Plasma – Dextran 70, Hetastarch, Vetstarch Shock • Rx (continued) – Sympathomimetics Use only after adequate fluid administration if BP and tissue perfusion have not returned to normal • Dopamine (Inotropin®) – 0.5-3.0 μg/kg/min » Dilation of renal, mesenteric, coronary vessels – 3.0-7.5 μg/kg/min » ↑ contractility of heart » ↑ HR – >7.5μg/kg/min » Vasoconstriction • Dobutamine (Dobutrex®) – 5-15 μg/kg/min – ↑ contractility of heart (min effect on HR) Shock • Monitoring Hemodynamic/metabolic sequelae of shock are continually changing – Physical Parameters • Respiratory – – – – – Color of mm RR Breathing efforts smooth? Breathing pattern regular? Auscultation normal? • Cardiovascular – – – – – – HR normal? ECG normal? Color of mm Cap refill time (1-2 sec) Urine production? (1-2 ml/kg/hr) Weak pulse? → ↓stroke volume Shock • Monitoring – Physiologic Monitoring Parameters • O2 Saturation – Pulse oximetry—noninvasive – Normal: Hb saturations (SpO2)>95% » SpO2<90%--serious hypoxemia • Arterial BP—a product of CO, vascular capacity, blood volume – If one is subnormal, the other 2 try to compensate to maintain BP Shock • Monitoring – Laboratory Parameters • Hematocrit (PCV) – Increase →dehydration – Decrease →blood loss • Electrolytes – Proper balance needed for proper cell function – Fluid therapy may alter the balance; supplement fluid as neede • Arterial pH and blood gases – PaCO2 tells how well patient is ventilating » PaCO2 <35 mm Hg → hyperventilation » PaCO2 >45 mm Hg → hypoventilation – PaO2 Tells how well patient is being oxygenated » PaO2 <90 mm Hg → hypoxemia – pH tells acid/base status of patient – <7.35 → acidosis – >7.45 → alkalosis