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ER Procedures #2
Cardiac & Respiratory
| Question | Answer |
|---|---|
| What does A CRASH PLAN stand for? | Airway, Cardiovascular, Respiratory, Abdomen, Spine, Head, Pelvis, Limbs, Arteries/Veins, Nerves |
| What is "A CRASH PLAN" used for | It's a mnemonic used to remember the steps to further evaluate the patient once it is stabilized. It comes after the "ABC"s of Triage, but both begin with airway. |
| What is the first question you should ask yourself about "Airway?" | If the animal is breathing, is it effective? |
| While completing the PE what should you as a matter of course? | Administer supplemental oxygen by mask, O2 cage, etc |
| How do you classify a breathing pattern? | Is the breathing noisy (snoring or squeaking); is there abdominal effort to inspiration, expiration, or both; Upon auscultation do you hear crackles or wheezes; and are the respirations just fast but lungs are clear (pain, anxiety, trauma, fever, etc) |
| What is the normal range for the respiration rate? | 8-30 rpm |
| If respirations are labored, lung sounds are absent or increased, or animal is cyanotic or tachypneic then this is considered what? | A respiratory emergency |
| If the animal is attempting to breath and unable what should be the first three attempted steps? | Make sure the airway is clear, intubate, and bag with 100% oxygen |
| If the animal is not breathing and you are unable to intubate because you can’t pass the ET tube due to some form of obstruction, what will need to happen? | The vet must perform an emergency tracheostomy |
| What is the first thing you do in the "Cardiovascular" step? | Evaluate Mucus Membranes and Assess CRT |
| Pale mucus membranes indicate what? | anemia, shock, pain, or poor circulation |
| Blue mucus membranes indicate what? | cyanosis which can occur with impaired respiration & Tylenol toxicity |
| Brown or "muddy" mucus membranes indicate what? | sepsis or Tylenol toxicity in cats |
| Yellow mucus membranes indicate what? | icterus |
| Brick red mucus membranes indicate what? | shock (at the beginning), heatstroke, and some toxins |
| What does CRT tell us? | Provides a crude indication of hydration status and peripheral perfusion (circulation) |
| Capillary refill times that are rapid < 1 sec (almost immediately refill) indicate what? | Early shock, hyperthermia, sepsis. You need to get ready to deal with them going into shock. |
| Capillary refill times that are slow > 2 sec (Really anything more than a second) indicate what? | dehydration, hypovolemia (low blood volume), hypothermia, pain, shock |
| How do you determine pulse quality? | Palpate the femoral pulse and metatarsal pulse, this will tell you roughly how well the animal is perfusing |
| A strong, bounding pulse indicates what? | early shock, pain |
| What is something important that you should always check with pulses? | Synchronization of the pulses |
| A weak, thready pulse indicates what? | decompensating shock, pneumothorax |
| What is a pulse deficit? | Ausculted heart beat does not match palpated pulses |
| What should you do if the pulse is absent and there is no auscultable heart beat? | CPR |
| If the heart beat is present, but there is no pulse what can it indicate? | A thromboembolic disease (blood clot- saddle thrombus in cats; they’re usually really painful/stressed and the pulse-less leg is cold) |
| Common causes of tachycardia include what? | hypovolemia, pain, hypoxemia, hyperthermia, sepsis, anemia, stress |
| When checking the heart rate what is an unexpected finding in a stressed emergency patient. | Bradycardia |
| A bradycardia in a stressed emergency patient can be seen in what conditions? | It can be seen in serious conditions like head trauma, Addison’s crisis, etc. |
| What are the three things you should check in "A CRASH PLAN" in regards to the "Cardiovascular/Circulatory" aspect or "C"? | Pulse Quality, Heart Rate, and Temperature |
| Active cooling needs to be done to bring down temps if they are above what? | Greater than 106 (>106) |
| Temps > 108 can result in what? | Multi-organ failure |
| Active re-warming is required when temp less than what? | Less than 94 (<94) |
| Temps < 82 can result in what? | arrhythmias and coagulopathies |
| Low or elevated body temperature can affect what? | blood pressure and perfusion |
| When should IV catheters will be placed, blood drawn, fluids (colloids vs. crystalloids) started, and pain medications and other drugs specific to the animal’s condition are given | After you have assessed the "A" and "C" of "A CRASH PLAN". |
| Is it ok to draw blood and place an IVC before any sort of estimate has been presented to the owner? | Technically it depends on the clinic, but it's a couple bucks so better to get it in and blood drawn and be out a couple bucks than to wait. |
| The R is Respiratory so if we've already checked Airway what do we need to do? | Auscultate patients now that they're calmer, recheck and keep checking respiratory distress patients - monitor rate and effort |
| When evaluating the "effort" with airway what are some things you should be looking at/for? | Panting, short shallow, sniffing, is there an abdominal component to the breathing? Are the chest and abdomen synchronized when breathing or asynchronize? |
| What is the normal inspiration:expiration ratio? | 1:2, meaning a patient exhales for twice as long as it inhales when breathing normally |
| When checking the "Abdomen" A what should you look for? | Is it distended or discolored? |
| What is the first step of S in "A CRASH PLAN"? | PALPATE. Palpate the spinal vertebra checking for pain or misalignment |
| How do you palpate the spine? | You press your thumb along the vertebrae looking for abnormalities. |
| What is the second step of S in "A CRASH PLAN"? | REFLEXES. Check spinal reflexes, pupillary and palpebral response, voluntary motor movement, and pain perception in all 4 limbs; use a percussion hammer |
| What is the third step of S in "A CRASH PLAN"? | RECTAL. Perform a rectal exam checking for pelvic fractures, anal tone, and tail tone; usually we take the tem and the DVM does the rectal exam |
| What is the fourth step of S in "A CRASH PLAN"? | TOES. Evaluate toe-pinch for animal’s recognition of deep pain sensation and assess for crossed-extensor reflexes; use a hemostat |
| This is characterized by extensor rigidity in the front limbs and flaccid paralysis of the hind limbs. It denotes a severe SC lesion between T2-L4 | Schiff-Sherrington syndrome |
| Lack of deep pain sensation and crossed-extensor reflexes are seen with what? | severe SC damage |
| Loss of anal or bladder tone can indicate what? | severing of nerves and will result in euthanasia, as these animals have a grave prognosis and cannot usually be repaired surgically or even with time |
| What is included in the H of "A CRASH PLAN"? | The head includes evaluation of eyes, ears, nose, mouth, and face |
| When evaluating the eyes it's important to note Anisocoria (uneven pupil size), pupillary light reflexes; depressed or absent menace, palpebral, corneal, or nasal reflexes as these can indicate what? | They can indicate brain trauma. |
| Why is it important to check the sclera of trauma patients? | Scleral vessels may be ruptured from head trauma, choking, or extreme stress |
| Why is it important to check the ears of trauma patients? | Blood in the ears, ruptured eardrums, or CSF in the ears indicates head trauma |
| What should you check with the nose of a trauma patient? | Check for bleeding or any deviation |
| What should you check with the mouth of a trauma patient? | Check the jaw for any deviation or inability to close it which would indicate fracture. Check the teeth (teeth are often lost in dog fights and HBC’s), tongue, and pharynx for normal swallowing/gag reflex (only in a patient that will not bite you!) |
| What should you check with the face of a trauma patient? | Check for any drooping of the facial muscles; palpate the skull for pain and possible fractures (gently- the brain’s under there!) |
| What should you do to assess the pelvis? | Gently palpate all areas of the pelvis for pain and swelling |
| Bruising is usually present in the inguinal and caudal abdominal regions when what is true? | The pelvis is fractured |
| In a HBC or dog fight victim, even if trauma didn’t occur in that exact location why can pain still be present? | From the muscle trauma sustained when the dog/cat was thrown/shaken by the other dog or car- over manipulation of the pelvis and limbs may cause pain in general |
| Why should you always check the toenails and footpads closely? | The toenails get ripped-off during an HBC and the footpads can be severely abraded. |
| How should you treat injured foot pads and toenails? | Stop any bleeding, clean-up abraded footpads, and sometimes a nice padded bandage will make the patient feel better; some patients will be hesitant to walk on exposed toenail pulp and will require padding until the toenails re-grow. |
| What is the most important fact about the A & N step of "A CRASH PLAN"? | Most of it has been checked already, BUT the patient's status is always changing and should be reassessed at various points |
| It is normal for animals to have a slight jugular pulse when laying how? | Laterally |
| Animals should not have a jugular pulse when laying how? | Sternally |
| A jugular pulse when laying sternal can indicate what? | This could indicate right-sided heart failure, etc |
| If the patient is stable a central line or jugular catheter can be place to measure what? | Central Veinous Pressure |
| When assessing the patient for serious neurological abnormalities of the brain what do we check? | Head tilt, nystagmus, strabismus, unresponsive pupils, and LOC |
| When assessing level of consciousness (LOC) | A: Alert V: responds to voice or visual stimuli P: responds to painful stimuli only U: coma, unresponsive |
| Once the animal has been brought to your hospital what do you need to determine? | Where the animal and the owner are going to go. This is based off your hospital protocol and may include separating them and taking the patient to the treatment area or both to the exam room. |
| The animal is stable, now what? | Continue to monitor the animal while paperwork, payment, etc is getting taken care of |
| What does it mean when an animal is "In patient"? | Animals that are admitted to the hospital for observation, IVF, pain management, oxygen support, etc |
| What does it mean when an animal is "Out patient"? | Animals that present with a cause and treated then sent home; acute gastritis, minor lacerations, torn toe nails, non-anaphylactic bee stings, vaccine reaction, limping, etc. |
| What happens when a cat get shocky? | Vasodilation, so warm them up before administering fluids |
| What happens when dogs get shocky? | Vasoconstriction |
| What does Manitol do? | It reduces swelling in the brain, it can also decrease swelling in the vertebra |
| What does Manitol do in the vial? and what should you do in response? | It forms crystals so put it in warm water to break them up. |
| Pulled tail in cats can cause what and why? | Defecation issues because of damage to the nerves too high up. |
| In cats, when a heartbeat is present, what is a pulse deficit or lack of a pulse an indicator of? | A saddle thrombus |
| True or False You can have a high HR and a low BP | True, if blood pressure drops your heart may speed up to compensate and keep the tissues perfused. |
| CVP stands for what? | Central Venous Pressure |
| What are the 4 steps to a successful Triage? | Know your normals, Communicate with Owners, ABCs, and A CRASH PLAN |
| What are the normals you need to know from most to least critical? | Respiratory, Cardiovascular, Neurological, Urogenital, Abdominal, Muscoskeletal |
| What is shock defined as? | When cellular energy production has fallen to a critically low level and organ function is compromised "systemic hypoprofusion" |
| What does shock mean? | we are not getting enough blood to the tissues therefore not getting enough O2 to the tissues for the cells to function |
| How does shock work? | In the early stages the body is able to compensate with things such as vasoconstriction and the HR going up to increase tissue perfusion |
| The early stages of shock is known as what? | hyperdynamic phase |
| Regardless of what the cause is of shock what happens? | cellular damage and death of cells, at first the body compensates but if we don't intervene the body will get to an irreversible state of shock. It produces insufficient circulation and reduced blood flow through microcirculation |
| What are the different classifications of shock? | Hypervolemic, Obstructive, Distributive, Cardiogenic, and Septic Shock |
| Do the different classifications of shock overlap? | YES |
| What is Hypervolemic Shock? | Lack of tissue perfusion due to blood volume loss |
| When we have problems with hypervolemic shock what happens with the heart? | Blood pressure drops because there isn't enough blood so HR increases to compensate |
| Dog seems fine, but you know trauma has happened, what should you do? | Treat for shock because shock (like winter) is coming |
| What is obstructive shock? | There is a physical block in the circulatory system; heartworms, pericardial effusion & gastric torsion |
| Why do you get hypoperfussion with obstructive shock? | Because something is obstructing and keeping the tissues from getting properly perfused. |
| What is Distributive Shock? | It is a subcategory where ther is relative or functional hypovolemia due to something like vasodilation (blood is still there, but the vessels are all dilated and BP falls suddenly) |
| What is Cardiogenic shock? | Shock resulting in cardiac failure; the heart is unable to pump blood |
| What is the cause of cardiogenic shock? | Hemorrhagic shock occurs post trauma - severe lacerations (artery severed), ruptured organs or from severe blood loss in surgery. Can include fluid losses from severe vomiting/diarrhea, plasma losses from severe burns or other protein losing processes. |
| What causes metabolic shock? | low oxygen in the blood from hempglobin carrying problems, hypoglycemia, anemia, sepsis, heat stroke, cyanide poisoning |
| What is the primary method of treating shock? | Fluid therapy |
| What is HGE? | Hemorrhagic gastroenteritis |
| Why do we gie supportive fluids with surgery? | 1. we are anesthetizing them and those agents cause BP to drop and 2. Possible blood loss |
| When particles inside a membrane are equal to the particles outside the membrane what is this called? | Isotonic |
| When there are more particles inside the membrane as opposed to outside the membrane what is this called? | hypertonic |
| When more particles are outside a membrane than inside this is called what? | hypotonic |
| If a cell is hypertonic what will happen to the water in/outside the cell? | It will move into the membrane as it moves towards an isotonic state |
| If a cell is hypotonic what will happen to the water in/outside the cell? | It will move out of the membrane as it moves towards an isotonic state |
| Breath: Ketoacidic | smells sweet |
| Breath: Uremic Ulcer | smells like amonia |
| Breath: Renal or Kidney disease | smells like petroleum or markers |
| What is the LVT's most important jobs in a trauma situation? | To monitor without monitors and to administer TLC that the doctor doesn't have time for |
| Inability to visualize the bladder post trauma can indicate what and how to do we test for it? | Rupture of the bladder, specific gravity |
| When dehydrated, what do an animal's MM feel like? | Dry and tachy |
| Dehydration: Clinical signs not detectable | <5% dehydration |
| Dehydration: Slight increase in skin turgor, MM tacky | 5-6% dehydration |
| Dehydration: Slow return of skin back to normal, MM dry; CRT may be increased | 6-8% dehydration |
| Dehydration: Skin remains tented; increased CRT; sunken eyes; tachycardia, weak pulses | 10-12% dehydration |
| Dehydration: rominent signs of shock and or death | 12-15% dehydration |
| Central lines are usually placed when? | When the patient is stable |
| When determining a baseline, what tests should be done? | PCV, TP, Urinalysis, chemistries and electrolytes |
| What are some diagnostic indicators of dehydration? | Increased PCV, Total Protein, and Urine Specific Gravity |
| When do we administer IV fluids? | With high water loss (5-8% dehydration) or severe disorders |
| How should catheters be prepared? | Flushed with heparin |
| How often should catheters be replaced? | Every 3 to 7 days, while checking for infection daily |
| When do we administer SQ fluids? | When the animals water loss is minimal 2 to 3% dehydration |
| What type of fluid would you never give SQ? | Hypertonic solutions and those containing 5% or more dextrose |
| When does giving oral fluids not work? | Vomiting or having other GI problems |
| What type of fluid administration rarely has an effect on hydration in a emergency situation? | Oral, the body doesn't have time to distribute the fluids |
| What are the 2 types of catheters used in veterinary medicine? | Over the needle and through the needle |
| When are over the needle catheters used? | Are the most commonly found in practice and are only good for the short term use. Typical days of use is 3-7 days with proper care. |
| When are through the needle catheters used? | Are used when fluid therapy and serial blood draws are needed for the long term care of the patient. Typical days of use is up to 14 days |
| What is the ultimate goal of treating any type of shock? | To maximize the delivery of oxygen to all tissues through different modalities of treatment |
| What are the potential risks associated with catheters? | Introduction of air, broken catheter tip, burring the catheter, accidental fluid overload |
| What is the most common type of shock seen? | Hypovolemic Shock |
| What causes hypovolemic shock? | loss of blood or fluids, V/D, hemorrhage, or severe dehydration |
| What is sepsis? | State of circulatory collapse that occurs secondary to inflammatory disease over the whole body |
| What are the early signs of Sepsis in dogs? | Brick red mm, bounding pulses, quick CRT, tachypnea |
| What are the early signs of sepsis in cats? | They typically hide their symptoms until it is too late |
| What are the later signs of sepsis in dogs | Poor pulse quality, prolonged CRT, cyanotic or gray mm, dehydrated and dull mentation |
| What is the one shock that is considered it's "own shock?" | septic shock |
| What is an advantage of giving fluids IO? | Good route for small puppies and kittens and others where you cannot access a vein |
| What is an advantage to giving fluids IP? | You can give large volumes |
| Where is an IO catheter usually placed? | Too femur right below knee and must be placed aseptically |
| What are the potential risks associated with catheters? | Introduction of air, broken catheter tip, burring the catheter, accidental fluid overload |
| How long can a silicone IVC stay in? | 7 days |
| How long can a Teflon IVC stay in? | 3 days |
| What are central line catheters used for? | Serial blood draws, CVP, or parental nutrition |
| How long can a central line (peel away and jugular catheter )stay in? | 14 days |
| How do you measure the central line catheter for proper length? | Mandible to manubrium, and midline to midline |
| How would you control pain for a central line placement? | Administer a small amount of lidocaine under the skin at placement site, sometimes general anesthesia, give pain medication IM or IV |
| How should you prepare for a central line placement? | Put on sterile gloves and drape area, 11 blade make a small incision into SQ portion of skin, have restrainer hold off target vein |
| 1st step of central line placement | Remove stylet from catheter and place J guide wire thru the catheter, then remove the catheter through the guide wire |
| 2nd step of central line placement | Once you have the guide wire inserted about 1/2 of its length into the vein, you will then take the vein dilator and place it over the guide wire, thru the skin |
| 3rd step of central line placement | With a gentle twisting motion, place the dilator into the vein. Leave it there for a few seconds, pull the vein dilator out (at this point it will bleed profusely) |
| 4th step in central line placement | Take off the cap on the shortest port, (this is the longest lumen that opens at the distal tip of the catheter) and thread the catheter over the wire to place it in the vein |
| What should you never do with a guide wire? | Let go of it |
| What are some reasons for placing a multi lumen catheter? | Multiple blood draws, TPN nutritional supplements, CVPs, insulin CRI |
| When should you avoid placing a jugular catheter? | Suspected coagulopathies, complete all lab testing prior to placement |
| Why would we take a radiograph after central line placement? | To ensure the catheter tip is in the cranial aspect of the heart |
| For initial stabilization of a patient in shock what needs to be done as quick as possible? | IVC placement, preliminary lab tests, fluid therapy, oxygen delivery, invasive or non-invasive, sedation, pain management, ventilation |
| What is the Hyperdynamic Phase? | Early stages of shock, vasoconstriction and increase heart rate to try and maintain blood pressure and increase cardiac output; leads to hypovolemic shock |
| How does shock start? | Progressive at first, body will compensate. BUT if not instituted quickly the body will decompensated and it will become irreversible |
| What is cardiac output? | It produces the Heart rate and stroke volume CO=HR x SV |
| What is stroke volume? | Volume of blood ejected by the ventricles with each heartbeat and has 3 determinants |
| What are the three determinants of Stroke volume? | Preload, Afterload, and contractility |
| What is Preload? | Force stretching the ventricles and filling just before contraction (blood volume) |
| What is Afterload? | Resistance at the vasculature that the heart must overcome for blood to leave the heart. |
| What is Contractility? | Strength for the heart to contract |
| What is happening during Obstructive shock? | Decreased cardiac preload returning to the heart. Ventricle fibers unable to stretch , decreased systemic delivery of oxygen to the tissues |
| What causes distributive shock? | Sepsis, Anaphylaxis, and neurogenic disease |
| What is sepsis? | State of circulatory collapse that occurs secondary to inflammatory disease over the whole body |
| What is Cardiac Tamponade? | A build up of blood or pericardial fluid in the pericardial sac putting pressure on the heart |
| What is the systemic inflammatory response? | The local inflammatory response gets out of hand and affects tissues in other parts of the body |
| What happens with septic shock in relation to free radicals? | The inflammatory cascades all start feeding back on each other and cause more inflammation , causing system wide effects; happens with chemotherapy, febrile, or an abscess gone untreated |
| What are free radicals? | Free elements floating around and binding to other compunds |
| What is the cause of Septic shock? | Sepsis, heat stroke, severe pancreatitis, disseminated cancer, autoimmune disease, |
| Patents with septic shock usually have a history of what? | Known infection, event cause infection (IVC), a disorder to predispose (DM, Renal Failure), Predispose cause of drug therapy(steroids and immunosuppressants |
| What does MODS Stand for? | Multiple Organ Dysfunction Syndrome |
| What happens with MODS? | The systemic response becomes severe and tissue injury causes multiple organ malfunction including endotoxemia |
| What is endotoxemia? | A toxin found inside the bacterial cell and is released when the cell diminishes |
| What does SIRS stand for? | Systemic Inflammatory responce syndrome |
| What are some indications of SIRS? | Temp> 103.5, HR>160 for dogs, >260 for cats, and WBC >12000 or a left shift |
| What are the stages of shock? | Compensatory, early decompensatory, late decompensatory |
| What are the signs of compensatory stage of shock? | Starts once the animal has suffered the initial injury; can include slight increase in RR, red or pale mm, tachycardia, bounding pulse |
| What are the signs of Early Decompensatory? | Pale mm w/ prolonged CRT, cool skin, hypothermia, weak pulses, tachycardia, decreased urine output, hyper excitability, hemorrhage may be active or slow bleed |
| What is the Late Decompensatory phase? | The terminal stage of all forms of shock, due to severe tissue hypoxia; |
| What are the signs of Late Decompensatory phase? | Pale to cyanotic mm w/ undetectable, severe hypotension, hypothermia, absent or weak pulse, bradycardia |
| When do we use oxygen therapy? | If there is any question that the patient has low oxygen saturation. Flow by should be provided until SP02 or arterial blood gas panel can confirm |
| What are some other things you can be doing to treat shock? | A peripheral catheter should be place |
| Why would you give fluids? | Shock, blood loss, dehydration, systemic disease, supportive treatment, diuresis |
| What are Crystalloids? | contain sodium as their osmotic active particle +/- other electrolytes |
| What are some examples of Crystalloid fluids? | LRS, Normosol R, Plasmalyte, NACL 0.9%, 2.5% Dextrose and 0.45& saline |
| What are Colloids? | High molecular weight substances that do not easily cross capillary membranes |
| True or False Crystalloids and Colloids are never given together? | False; usually together |
| What are some examples of Colloids? | Hetastarch, Pentastarch, Dextrans |
| What is the half life concentration of Pentastarch? | 2.5 hours |
| What is the half life concentration of Hetastarch? | 25.5 hours |
| True or False Dextrose containing solutions metabolize slowly into carbon dioxide and water | False they do so rapidly |
| What are the pros of dextrose containing solutions? | Used to provide free water to replace insensible losses and can provide intercellular carbs in septic patient |
| What are the cons of dextrose containing solutions? | Redistribute rabidly; caution when mixing; breeding ground for bacteria |
| What are isotonic crystalloids? | Distribute evenly in the extracellular space when given IV, but only 25% of the volume will remain in the vascular space after 1 hour |
| Examples of Isotonic crystalloids? | Normosol R, 0.9% sodium chloride, LRS Plasmalyte |
| What are the pros of Isotonic Crystalloids? | Inexpensive and readily available, great for replacement fluid loss and resuscitative fluids for small animals |
| What are the cons of Isotonic Solutions? | Rapid redistribution not good for maintenance because of high sodium and chloride content, osmolality and inadequate potassium |
| What are Hypotonic Crystalloids? | Start out as prepared isotonic solutions but contain dextrose ; when metabolized in the body can become hypotonic |
| Examples of Hypotonic Crystalloids? | 0.45% NACL with 2.5% Dextrose |
| What are the pros of Hypotonic Crystalloids? | Excellent maintenance fluids when KCL is added, fluid of choice with Sodium retention patients (heart disease) |
| What are the cons of Hypotonic Crystalloids? | Not to use with shock resuscitation as the water will rabidly redistribute out of the vascular space |
| What are Hypertonic solutions? | Highly osmolar and are meant for rabid resuscitation Not often used in vet med |
| What is an example of Hypertonic Crystalloids? | 0.7% NACL |
| What are the pros of Hypertonic Crstalloids? | Used for rabid volume expansion, small volumes can increase intravascular space in large dogs |
| What are the cons of Hypertonic Crystalloids? | Effect is transient, often combined with colloids, expensive |
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Adeprey4311
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