Important factors to consider in the emergency and critical care patient Flashcards
(26 cards)
What are important factors to consider for gold standard management of an emergency and critical care patient?
- A trained team/at least a few people who know what they are doing
- Protocols for some things
- Confidence in what you are doing
- Being able to do a physical examination
- Having equipment and drugs on hand/accessible
Reasons for increased blood glucose?
- Stress (esp cats and camelids)
- Underlying disease (DM)
Why is increased blood glucose problematic in in fluid therapy?
- Problematic as leads to osmotic diuresis
- If you have BG above the renal threshold you are going to struggle to sort out fluid loss due to osmotic diuresis
Reasons for decreased blood glucose?
- Hypotensive SIRS and sepsis patients
- The disease process and inflammation is metabolically active and leads to overuse of BG
- Significant energy imbalance
- Endocrine disease – primary or secondary to underlying disease
What should albumin levels be ideally in the sick patient?
- Should be above 20g/L in the acutely ill animal
- Oncotic pull
- If you don’t have enough protein in the body to heal, you will not heal
Main causes of albumin losses?
GI or renal loss, liver failure (liver not producing enough), cytokine suppression of albumin production in SIRS
How do coagulopathy/bleeding disorders generally differ between small and large animals?
Small animals usually see bleeding diseases whereas large animals inappropriately excessively coagulate
Which species should be cross-matched before a blood transfusion?
- Cats – need to cross-match
- Dogs and horses – often can get away without cross-match with first transfusion
- Can probably do multiple transfusions within the first 5 days within cross matching
Lifespan of transfused blood cells in dogs and cats compared to horses?
Lifespan of transfused cells relatively long in dogs and cats; often last <5-7 days in horses
Signs that an animal Is not coping with its anaemia?
- Tachycardia
- Tachpnoea
Which is the preferred route of nutrition in a critical patient?
- Enteral better than parenteral
- But parenterally if you cannot do so
What sort of food should be given to critical patients generally?
- Small volume, high calorie and appropriate but on increased side of protein (except in liver failure!)
- AD works really well in small animals (tasty so encourages them to eat)
- Do not feed GI diets which are not tasty if you are trying to tempt them to eat
If you have a patient with poor perfusion due to hypotension, that is not responding to fluid challenge, what should you look for?
- Check for ongoing fluid loss
- E.g. diarrhoea or vomiting
- Cardiac disease or dysrhythmias
- Low temp
- Will become inappropriately vasodilated if hypothermic
- Low glucose
- High glucose
- Low oxygen
- Electrolyte derangements
- Brain stem pathology
- That is not responding to cardiac baroreceptors
- Poor analgesia
Level of consciousness and mentation needs REPEATED assessment and immediate investigation if declines. If it does decline is it due to what?
- Hypotension
- Hypoglycaemia
- Hyperammonaemia
- If none of the above can think about hypoxia, hypovolaemia, sepsis etc. (Oxygenation; Electrolytes; Fever; Hypovolaemia, Sepsis; Cardiac dysrhythmias)
Roughly what blood pressure do you need to have enough forward flow to perfuse organs?
Mean above 60-65mmHg and systolic above 90mmHg
Signs of coagulopathies in small animals?
- 1) Decreased ATIII (antithrombin III)
- 2) Decreased platelet count
- 3) Shortened PT, PTT, ACT
- 4) Decreased fibrinogen
- 5) Increased FDP’s
What is the most sensitive test of renal function in an emergency patient?
Urinalysis
- Glycosuria in absence of hyperglycaemia
- Casts
- Infection in compromised animal
What should be considered with immunocompromised emergency patients?
Need isolation and barrier nursing – FOR THEIR PROTECTION and care with invasive techniques
E.g. passing of urinary catheters etc.
What type of antibiotic should be considered in most very sick critical patients (where necessary)?
- Bactericidal (low/no functioning neutrophils likely)
- Ideally C and S (but tend to have to wait 3 days)
What are the GI risks in a critical patient?
- Critical illness often complicated by gastric stasis, ileus and gastric disease
- Don’t forget gut sounds in small animals – check whether present
- Bacterial translocation from compromised gut a massive concern…but also remember gastric acid there for a reason
- When you get ileus it increases change of bacterial translocation
- Gastric acid suppressants in sick animals may not be ideal as a result
How can you minimise risks to the GI tract in critical patients?
- Stop animals being SICK and promote GI motility
- Get them to eat
- May involve the use of pharmacological agents
- Ideally avoid acid suppressants if you can (to avoid higher risk of bacterial translocation from the gut)
- Ideally feed enterally
What should you consider when considering pharmacological agents in critical patients?
Where they are metabolised - liver, kidneys etc. - will influence your choice of drug in individual cases
Clinical signs of pain?
Depression, restlessness, irritable, anorexia, tachycardia (not cats)
What factors should you consider when choosing analgesia for critical patients?
- Care with NSAIDS in small animals (esp if renal compromise); not a concern in large animals (except neonates) – hardier kidneys
- Consider cardiovascular effects – alpha-2’s
- Consider sedative effects and respiratory depression (SA only) – Opioids
- Tend to only see respiratory depression if large doses of opioids
- Don’t under-estimate the use of low-dose ketamine and intravenous lidocaine
