Transcript adversity - Dr. Roberta Dev Anand

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