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ER Procedures #2

Cardiac & Respiratory

QuestionAnswer
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
Created by: Adeprey4311