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.

 A = Establish airway, address arterial bleeding  B = Breathe for animal  C = Maintain circulation with thoracic compressions and IV fluids  D = Drugs ABCD

Normal PE AreaOrgans Cranial ventral abdomenLiver, stomach, pancreas Cranial dorsal abdomenKidneys, stomach, pancreas Mid-ventral abdomenSpleen, small bowel Mid-dorsal abdomenKidneys, ureters, retroperitoneal space Caudal ventral abdomenBladder, uterus Caudal dorsal abdomenColon, sub-lumbar lymph nodes, prostate, uterus

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 Alert – V Verbally responsive – P responsive to painful stimuli – U 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

NO – Clear airway: use suction – Intubate – Ventilate (don’t over ventilate - will drive CO2 down) 10-12/min < 20 cm H2O YES – Provide flow-by oxygen Breathing – Airway patent

– Vital signs (taken after initial assessment) Vital signs 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 Triage of Emergency Patients

Mucous membrane ColorInterpretationCauses PINKAdequate circulation and perfusion Normal circulatory system WHITE OR PALE PINKAnemia, decreased peripheral perfusion, vasoconstriction Anemia ( blood loss, inc. destruction, dec. production) shock BLUE OR GREYHypoxemia, anemiaRespiratory embarrassment, blood loss DARK RED, BRICK REDIncreased peripheral perfusion: cyanide toxicity Fever, sepsis, systemic inflammatory response, smoke inhalation/ cyanide toxicity BROWNMethemoglobenemiaAcetaminophen, ibuprofen YELLOW (ICTERIC)HyperbilirubinemiaHemolysis, hepatic/ biliary disease PETECHIACoagulation disorderThrombocytopenia, decreased platelet function

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 is inadequate tissue perfusion resulting in poor oxygen delivery – Cardiogenic – Distributive – Obstructive – Hypovolemic SHOCK: RECOGNITION AND TREATMENT

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 3 rd spaces 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) -↑ HR, contractility -Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart b.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 Hypovolemic Shock

Treatment: the goal of therapy is to improve O 2 delivery – O 2 supplementation Face mask O 2 cage/hoods Transtracheal/nasal insufflation – Venous access Cephalic Saphenous Jugular Intraosseous Shock

Oxygen supplementation

Fluid Administration

CONTRAINDICATED IN PATIENTS WITH SEPSIS,FRACTURES, OR INFECTED BONES

Treatment – Fluid resuscitation (O 2 delivery is improved by ↑CO) 1. Crystalloids Isotonic solutions (electrolytes: Na +, Cl -, K +, bicarbonate) – Examples (body fluid= mOsm/L) » Lactated Ringer’s (273 mOsm/L) » Normal saline (0.9%) (308 mOsm/L) – Dose: Dog ml/kg/hr Cat 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 (O 2 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®) – μg/kg/min » Dilation of renal, mesenteric, coronary vessels – 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 O 2 Saturation – Pulse oximetry—noninvasive – Normal: Hb saturations (SpO 2 )>95% » SpO 2 <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

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 needed Arterial pH and blood gases – Pa CO2 tells how well patient is ventilating » Pa CO2 <35 mm Hg → hyperventilation » Pa CO2 >45 mm Hg → hypoventilation – Pa O2 Tells how well patient is being oxygenated » Pa O2 <90 mm Hg → hypoxemia – pH tells acid/base status of patient – <7.35 → acidosis – >7.45 → alkalosis Shock