5. Emergency Critical Care Flashcards
(145 cards)
1
Q
What does the word ‘triage’ refer to when talking about a group of animals
A
Process of quickly examining patients who are taken to decide which ones are the most seriously ill and must be treated first
2
Q
What does the word ‘triage’ refer to when talking about an individual animal
A
Process of examining problems in order to decide which ones are the most serious and must be dealt with first
3
Q
What is a primary survey when looking at triaging
A
A quick way to find out how to treat any life threatening conditions a casualty may have in order of priority e.g. using DR ABC
4
Q
What is a secondary survey when looking at triaging
A
A rapid but thorough head-to-toe examination assessment to identify all potentially significant injuries - done after the primary survey
5
Q
What is the definition of shock
A
Inadequate cellular energy production
6
Q
What is shock commonly secondary to?
A
poor tissue perfusion
7
Q
What does shock lead to
A
Leads to critical decrease in oxygen delivery (DO2) compared to oxygen consumption in the tissues (VO2)
8
Q
Give the 5 main parameters to evaluate for shock
A
- mentation
- mucous membrane colour
- capillary refill time
- Cold extremities
- pulse evaluation
9
Q
What does a pale to white colour mucous membrane suggest
A
Depletion of volume or of haemoglobin
10
Q
What does a red colour mucous membrane suggest
A
Poor perfusion and vasodilation (trapping blood in capillary beds)
Sepsis
11
Q
What are you actually evaluating when evaluating the pulse for shock
A
Estimate of stroke volume
12
Q
What does SIRS stand for
A
Systemic Inflammatory Response Syndrome
13
Q
Name 3 causes of SIRS
A
Burns
Bacterial infections
Neoplasia
14
Q
What is sepsis
A
SIRS with an infectious agent identified
15
Q
What is severe sepsis/SIRS associated with
A
Associated with organ dysfunction, hypoperfusion or hypotension
16
Q
What is refractory (septic) shock/ SIRS shock
A
A subset of severe sepsis/SIRS
Defined as sepsis-induced hypotension despite fluid resuscitation
17
Q
What is Multiple Organ Dysfunction Syndrome (MODS)
A
Presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention
Generally comes just before death
18
Q
Name the 7 types of shock
A
- Hypovolaemic
- Cardiogenic
- Distributive
- Metabolic
- Hypoxaemic
- Cryptic
- Combined
19
Q
Describe hypovolaemic shock
A
Decreased circulating volume
Fluid loss from intravascular space e.g. trauma or haemorrhage
20
Q
Describe cardiogenic shock and give examples of situations which can cause it
A
Decreased forward flow from the heart
E.g. congestive heart failure, cardiac dysrhythmias, cardiac temponade, drug overdose
21
Q
Describe distributive shock and give examples of situations which can cause it
A
Loss of systemic vascular resistance - blood vessels inappropriately vasodilate
E.g. Sepsis, Obstruction, anaphylaxis
22
Q
Describe metabolic shock and give examples of situations which can cause it
A
Deranged cellular metabolic machinery
E.g. hypoglycaemia, cyanide toxicity, mitochondrial dysfunction, cytopathic hypoxia of sepsis
23
Q
Describe hypoxaemic shock and give examples of situations which can cause it
A
Deceased oxygen content in arterial blood
E.g. anaemia, severe pulmonary disease, carbon monoxide poisoning, methaemoglobaemia
24
Q
Describe cryptic shock and give examples of situations which can cause it
A
Normal global circulation but poor microcirculation
E.g. SIRS, Sepsis
25
Which two types of shock are most commonly found in combined shock
Hypovolaemic and distributive
26
Name 3 mechanisms of shock
Loss of intravascular volume
Maldistribution of vascular volume
Failure of the cardiac pump
27
Describe common clinical presentation of hypovolaemic shock
Decreased cardiac output
Vasoconstriction
Increased contractility
Increased HR
28
What happens to/in the kidney in hypovolaemic shock
Decreased renal circulation
Activates RAAS
Na and H2O retention due to increased aldosterone and ADH
29
What are the initial signs of hypovolaemic shock
"Compensated shock"
Mild depression
Tachycardia
Normal to prolonged CRT
Cool extremities
Tachypnoea
Normal BP
Normal pulse quality
30
What are the signs in ongoing compromise of hypovolaemic shock
"Decompensated shock"
Compensatory mechanisms fail
Pale MM (sepsis they are red)
Poor peripheral pulse
Depressed mentation
Fall in blood pressure
31
What occurs in the hyperdynamic phase of shock
Tachycardia
Fever
Bounding peripheral pulses
Hyperaemic mucous membranes
32
What is the "shock organ" in dogs
GI tract
33
What is the "shock organ" in cats
Lungs
rarely see hypodynamic phase
34
What is the "shock organ" in cows
GIT
35
What is the "shock organ" in horses
GI involved but not displayed as obviously
36
What is hypovolaemia
Loss of circulating volume (ECF)
Salt and water loss
37
What is dehydration
Loss of body water
Just water lost, no salts - hypernaetraemic
38
Over how many hours do you replace deficit for hypovolaemia
6-8 hours
39
Over how many hours do you replace deficit for dehydration
12-24 hours
40
Clinical signs seen with fluid loss of <5%
No clinical signs
41
Clinical signs seen with fluid loss of 5-7%
Mild depression
Slightly prolonged CRT
Slightly increased HR
Increased blood lactate
Creatinine concentration concentrated in urine
42
Clinical signs seen with fluid loss of 10%
Depressed
May have cold extremities
Dry mucous membranes with a CRT >3 seconds
Heart rate >50% above the normal reference range
Increased blood lactate concentration
Increased creatinine concentrations
Small volume of very concentrated urine
43
Clinical signs seen with fluid loss of 12-15%
Depressed
Cold extremities
Dry mucous membranes with a CRT >4 seconds
Heart rates >100% above the normal reference range
Increased blood lactate concentrations
Increased creatinine concentrations
Unlikely to produce any urine
44
How to estimate fluid deficit
% fluid deficit x Bodyweight
45
Give the shock dose fluids for cat/sheep/goat
60ml/kg
46
Give the shock dose fluids for dog/horse/pig
90ml/kg
47
Give ml/kg of fluid challenge for cat or dog
Cat - 10ml/kg
Dog - 20ml/kg
48
Name the 3 board categories of fluids we can give and example of each
Hypotonic - 5% dextrose
Isotonic - Hartmann's
Hypertonic - Hypertonic saline
49
What 3 situations is Hartmann's NOT suitable
Hypernatraemia
Hyponatraemia
Renal failure
50
What 2 electrolytes are all fluids low in
K+
Mg2+
51
Give 2 physiological benefits of using hypertonic saline
Cause vasodilation
Increased cardiovascular contractility
52
Name adverse effects of hypertonic saline
Hypernatremia
Inappropriate in patients with dehydration
DO NOT use in foals
53
When do you use enterally given fluids
No GI obstructions
Have a fluid deficit less than 5%
54
Why use fluids per rectum
Support until vascular access gained or in animals where vascular access can be a problem
Cheaper
55
Can the body absorb electrolytes per rectum
No
56
Give 5 indications for use of blood products
Severe anaemia
Coagulopathy
Thrombocytopenia (TCP)
Thrombopathia - platelet abnormalities
Hypoproteinaemia
57
When would you use RBC transfusion
Anaemia
Peracute blood loss
58
Give 3 situations where you would use fresh frozen plasma transfusion
Coagulopathies
SIRS and sepsis
Hypoprotanaemia in horses
59
What is auto transfusion (blood products)
Giving the animals blood back to itself from a non contaminated body cavity
60
How many DEAs are there in dogs (blood types)
12
61
Which DEA is the universal donor in dogs
DEA 1.1 negative
62
What are the blood types in cats
A, B or AB (very rare)
63
Should all cats be blood types before transfusion
Yes
64
What is a major cross-match when talking about blood
Recipients plasma and donor cells
65
What is a minor cross match when talking about blood
Donor plasma to recipients cells
66
Give the main signs of adverse reaction to blood products
Fever
Vomiting
Haemolysis - Fatal
67
What are the 20 critical parameters of Kirby's rule of 20
1. fluid balance
2. oncotic pull
3. blood glucose
4. electrolytes and acid-base balance
5. oxygenation and ventilation
6. level of consciousness and mentation
7. hypotension
8. HR, rhythm and contractility
9. albumin
10. coagulation
11. RBC/Hb concentration
12. renal function
13. immune status, antibiotics and WBC count
14. GI motility and mucosal integrity
15. Drug doses and metabolism
16. nutrition
17. analgesia
18. nursing care and patient mobilisation
19. wound care and bandage changes
20. TLC
68
For Kirby's rule of 20, describe what you should consider for 1. fluid balance
Where is the fluid
Is the patient hypovolaemia
Is the patient dehydrated
69
For Kirby's rule of 20, describe what you should consider for 2. Oncotic pull
Any signs of inability to keep products in the intravascular space
e.g. peripheral oedema, tissue oedema
70
For Kirby's rule of 20, describe what you should consider for 3. Blood glucose
Increased/deceased blood glucose
71
For Kirby's rule of 20, describe what you should consider for 4. electrolytes and acid-base balance
Calcium and magnesium
Sodium
Chloride
Potassium
Acidosis
72
For Kirby's rule of 20, describe what you should consider for 5. oxygenation and ventilation
Arterial blood gasses
If you want to give oxygen supplementation
73
For Kirby's rule of 20, describe what you should consider for 6. Level of consciousness and mentation
Repeated assessments and investigation if any decline
74
For Kirby's rule of 20, describe what you should consider for 7. Hypotension
Mean above 60-65mmHg
Systolic above 90mmHg
If low, fluid challenge
If no response check for ongoing losses
75
For Kirby's rule of 20, describe what you should consider for 8. HR, rhythm and contractility
Check for murmurs, dysrhythmias
76
For Kirby's rule of 20, describe what you should consider for 9. albumin
Should be above 20g/L
Causes - GI or renal loss, liver failure, cytokine suppression of albumin production in SIRS
77
For Kirby's rule of 20, describe what you should consider for 10. coagulation
Small animals - bleeding diseases
Large animal - excessively coagulate
78
For Kirby's rule of 20, describe what you should consider for 11. RBC/Hb concentration
Need enough RBC and Hb to deliver oxygen
Consider blood transfusion
Cross match
79
For Kirby's rule of 20, describe what you should consider for 12. renal function
May have chronic renal failure
Use urinalysis to assess function
Creatinine also useful
80
For Kirby's rule of 20, describe what you should consider for 13. Immune status, antibiotics and WBC count
If immunocompromised, need isolation and barrier nursing
Antibiotics - C&S
81
For Kirby's rule of 20, describe what you should consider for 14. GI motility and mucosal integrity
Critical illness often complicated by gut stasis, ileus and gastric disease
Promote GI motility, use antiemetics
Ideally feed enterally
82
For Kirby's rule of 20, describe what you should consider for 15. Drug doses and metabolism
We don't know how sick animals handle drugs
Young animals handle drugs different to adults
Consider where the drug is metabolised
83
For Kirby's rule of 20, describe what you should consider for 16. nutrition
Enteral better than parenteral
Needs constantly assessing
Feed small volumes, high calorie
84
For Kirby's rule of 20, describe what you should consider for 17. analgesia
Care with NSAIDS
Consider cardiovascular effects of alpha 2 agonists
Consider sedative effects and respiratory depression of opioids
85
For Kirby's rule of 20, describe what you should consider for 18. nursing care and patient mobilisation
Essential
Check catheter sites often
Ensure human contact
Appropriate temperatures
Get animals outside and moving
86
For Kirby's rule of 20, describe what you should consider for 19. wound care and bandage changes
Frequent checking
Bandage shouldn't be loose, tight or wet
87
For Kirby's rule of 20, describe what you should consider for 20. TLC
Mental health of the patient
Owner involvement that has a bond
Blankets, favourite toys etc
88
What is the main goal of enteral nutrition
Provide adequate caloric and nutrient intake via GIT to prevent adverse consequences of malnutrition
89
What 4 things can protein catabolism have effects on
Tissue synthesis - healing
Immunocompetence
Maintenance of GI integrity
Drug metabolism
90
What about nutrition should you consider for a patient with hepatic encephalopathy
They are protein intolerant
91
What counts as a "high risk" patient when talking about nutrition
A patient which hasn't consumed RER for 3-5 days
92
What 2 patient factors affect if you feed enterally or parenterally
GI function
Ability to protect their airway
93
What 4 non-patient factors affect if you feed enterally or parenterally
Cost
Predicted length of hospitalisation
Technical expertise
Level of patient monitoring
94
What is the formula for RER
RER = 70 x BW^0.75
Should use lean bodyweight
OR RER = 30 x (BW+70)
95
What 3 conditions require more than their RER
Sepsis
Head trauma
Burns
96
How should you approach nutrition in patients with prolonged anorexia or GI compromise
start at 30-50% RER and slowly increase
97
When should we use supportive feeding
The animal is unable to eat as it normally would or is unable to absorb nutrition from specific sections of its GI tract.
98
What does TPN stand for (nutrition)
Total parenteral nutrition
99
What does PPN stand for (nutrition)
Partial parenteral nutrition
100
Name the 4 different types of feeding tubes
Naso-oesophageal, naso-gastric?
Oesophagostomy
○ Gastrostomy/PEG
Enterostomy
101
What tube should you use for short term feeding
Naso-oesophageal/nasogastric
102
What tube should you use for medium term feeding (3-4 weeks)
Oesophagostomy
103
What tube should you use for long term feeding (months)
Percutaneous endoscopic gastrotomy
104
Common problems with feeding tubes
Blockages
Dislodging of the tube, movement
Trauma
Infection
Over-granulation
105
What routes are most common for parenteral nutrition
IV or IO
106
What are the typical requirements for parenteral feeding
Aseptic vascular access
24 hour nursing care
Glucose monitoring
107
Maximum time frame to use parenteral nutrition
1-2 weeks
108
Name the main metabolic complications associated with parenteral feeding
Hyperglycaemia
Lipemia
Azotaemia
Hyperammonaemia
Refeeding syndrome
109
How to calculate protein requirement for: dogs and cats
Dog: 4-6g/100KCal
Cat: 6g/100KCal
110
Name the 4 micronutrients to consider when feeding
Vit B complex
Potassium phosphate
Magnesium sulphate
Zinc
111
What GI changes occur when we withhold food
Villi stunting
Decreased absorptive capacity
112
What is transfaunation
"poo soup" - give animals own poo to repopulate gut flora
113
What is a traumatic brain injury (TBI)
Severe head trauma associated with high mortality
114
What is the primary injury when talking about traumatic brain injury
The damage caused by the trauma
Development of haemorrhage and oedema
Little we can do about this
115
What is the secondary injury when talking about traumatic brain injury
The progression of the injuries after the initial damage
Pro inflammatory cytokines, ROS and excitatory neurotransmitters
116
What 4 things does the secondary injury lead to in traumatic brain injury
Cerebral oedema
Increased intracranial pressure
Compromise to the blood brain barrier
Alterations in cerebrovascular reactivity
117
What is the most common cause of death from traumatic brain injury
Increases in intracranial pressure - perfusion decreases
118
How to assess a patient with traumatic brain injury
Neurologic assessment
Recognise and treat hyperaemia and hypovolaemia
Modified Glasgow Coma Scale - high the score the better the prognosis
119
What 2 things are involved in the initial extra cranial stabilisation for traumatic brain injury
Correction of tissue perfusion deficits
Optimising systemic oxygenation and ventilation
120
What are the 3 goals for intracranial stabilisation for traumatic brain injury
Optimising cerebral perfusion
Decreasing intracranial pressure
Minimising increases in cerebral metabolic rate
121
Should you give fluid therapy in cases of traumatic brain injury
Yes
Fluid restrictions are contra-indicated
122
What fluid therapy should you use for traumatic brain injury
1/4 aliquots of 'shock' rates - Hartmanns
7.2% hypertonic saline followed by crystalloids can be a good option - draws fluid from interstitium => decreasing oedema
123
Name the 6 important things to do when treating traumatic brain injury
1. Oxygen supplementation
2. Carbon dioxide tensions (38-40mmHg aim)
3. Minimise increases in intracranial pressure
4. Hyperosmolar therapy
5. Avoid hyperglycaemia - use insulin if needed
6. Hypothermia - may reduce secondary brain injury
124
Name 3 positives of induced hypothermia for traumatic brain injury
Decreases metabolic demands of the brain => decreased cerebral oedema and intracranial pressure
Reduces release of excitatory neurotransmitters
Reduce 2ndary injury by inhibiting post traumatic inflammatory response
125
Name 4 disadvantages to induced hypothermia for traumatic brain injury
Coagulation disorders
Increases susceptibility to infections
Hypotension and bradycardia
Dysrhythmias
126
What drugs are used to treat traumatic brain injury
Analgesia
Anti-convulsants
Prophylaxis for seizures
GI protectants
127
What drugs are used to prevent and stop seizures with traumatic brain injury
Prevent - phenobarbitone
Stop - diazepam
128
What are the adverse effects of seizure activity on traumatic brain injuries
Hyperthermia
Hypoxaemia
Cerebral oedema
129
Give 5 reasons why corticosteroids are contraindicated for use in traumatic brain injury
Associate with:
Hyperglycaemia
Immunosupression
Delayed wound healing
Gastric ulceration
Exacerbation of catabolic state
130
What are the GIT risks associated with traumatic brain injury
Gastrointestinal bleeding
Enteral feeding intolerance
Delayed gastric emptying
131
Why is there delayed gastric emptying associated with traumatic brain injury
Increased intracranial pressure
Cytokine release
Hyperglycaemia
Opioid use
132
What drugs would you use to support GI function and feeding during traumatic brain injury
Erythromycin combined with metoclopramide
133
Should you do enteral or parenteral feeding for traumatic brain injury
Enteral best as maintains GI integrity
Intragastric enteral feeding
If unconscious, parenteral can be easier
134
What are the 3 sections of the Modified Glasgow Coma Scale
Motor activity
Brain stem reflexes
Level of consciousness
135
What are the advantages and disadvantages of using a urinary catheter in traumatic brain injury cases
Adv - Reduces urine scalding, can measure urine output and assess success of fluid therapy
Disadvantages - Indwelling catheters can cause UTI
136
Why are CT scans preferred for traumatic brain injury
Rapid scan times
Better visualisation of fractures and peracute haemorrhage
137
What can be the complications of traumatic Bain injuries
Coagulopathies
Pneumonia
Sepsis
Diabetes insipidus
Seizures
138
What are the patient safety factors to consider when imaging an ECC patient
If cardiovascular compromise - don't position animal on they back
If respiratory compromised - don't position animal on the side of the good lung
If neurological compromise - don't let head drop down
139
Positives and negative of CT imaging of the ECC patient
+ve - Good for detection of free fluid and gas, good organ detail, quick processing time
-ve - Slow to prep patient, not good availability in vet practices, expensive
140
Positives and negative of MRI scan of the ECC patient
+ve - Good for diagnosis of intracranial and spinal lesions, good for equine distal limb
-ve - Poor for speed, utility and availability
141
Positives and negative of radiography of the ECC patient
+ve - good for free gas and bones, widly available, cheap
-ve - requires restraint/sedation, limited assessment of organs
142
Positives and negative of ultrasound imaging of the ECC patient
+ve - minimal restrain, good for unstable patients, rapid, easy, cheap, good for free fluid, allows for interventions
-ve - can't assess deep structures, can't assess airways
143
what are the 4 regions looked at in an A-FAST scan
Splenorenal
Hepatorenal
Bladder region
Diaphragmatic hepatic window
144
What is the FLASH equine scan used for
FLASH - fast, localised abdominal sonography of horses
Looking for signs of colic in 5 windows
145
What is a T FAST scan
Thoracic focused assessment with sonography for trauma (TFAST)
Looking for pneumothorax and other thoracic injuries
