The SA Emergency Patient

Question 1

What is triage?

Answer 1

To identify which patients need urgent care, and which problems need to be prioritised.
– over telephone.
– in the clinic.

Question 2

Purpose of telephone triage?

Answer 2

To determine if the patient needs to be seen at the clinic.
Allows provision of first aid advice to the owner.

Question 3

Questions that could be asked on telephone triage.

Answer 3

• Are there any known injuries?
• How is animal breathing? Coughing?
• Level of consciousness?
• Any bleeding and how severe?
• Can the animal walk?
• Are they able to pass urine?
• Vomiting, ineffectual retching, diarrhoea and severity?
• Any obvious distension of the abdomen?
• MM colour (w/ care!)

Question 4

What are the 3 steps to dealing with the emergency patient?

Answer 4

Triage assessment.
Primary survey.
Secondary survey.

Question 5

What is an in-clinic triage assessment?

Answer 5

A major body system assessment generally performed w/ owner.
Abbreviated and shortened exam, focused on organs where abnormalities would be life threatening.

Question 6

1. Why would we move onto primary survey?
2. What is the purpose of the primary survey?

Answer 6

1. If upon triage, patient has life threatening changes, so unstable and at risk of deterioration and potentially death.
2. To expand upon the major body system assessment, the institution of quick monitoring (ECG, pulse oximetry etc.), to identify and treat problems that are immediately life threatening.

Question 7

What is secondary survey?

Answer 7

Full CE, collection of detailed clinical history, monitoring the patient’s response to therapy and creation of a more comprehensive diagnostic and therapeutic plan.

Question 8

What initial decision must be made once in-clinic triage performed?

Answer 8

Does the patient need to be taken straight to the procedures area or can they sit and wait?

Question 9

How long should history taking in a major body system assessment last and what do we want to determine?

Answer 9

<1min.
To determine main complaint and progression of this.

Question 10

Main body systems to assess in a triage assessment.

Answer 10

Cardiovascular.
Respiratory.
Neurological.
(also consider renal system and pain).

Question 11

What would you check to assess the CV system in triage assessment?

Answer 11

• CRT.
• MM colour.
• Peripheral pulses and quality.
• HR.
• Obvious signs of haemorrhage?
• Auscultate chest for any abnormal heart sounds, rhythm, volume.

Question 12

What parameters would we check to assess the respiratory system in triage assessment?

Answer 12

• Respiratory effort and pattern.
• Auscultate the chest for lung sounds.
• RR.
• Percuss the chest.

Question 13

What would we check when assessing the neurological system as part of a major body systems assessment?

Answer 13

• Mentation and responses.
• Pupils for symmetry and pupil light reflex.
• Seizures – most commonly tonic-clonic.
• Signs of raised intracranial pressure.
  – systemic hypertension.
  – bradycardia.
  – deterioration on mental status.
  – dilated and non-responsive pupils.
  – loss of physiological nystagmus.
  – decerebrate posturing.

Question 14

What would we check to assess renal system as part of a major body systems assessment?

Answer 14

Palpation for bladder size, integrity and any pain.
And check ability to urinate.
If cannot feel bladder:
- patient has recently urinated.
- bladder has ruptured.

Question 15

Examples of quick monitoring in primary survey.

Answer 15

• ECG, pulse ox, BP.
• ETCO2 (can place near patient mouth and nose).
• ‘minimum’ or ‘emergency database’ – series of blood tests that will be performed in any emergency patient.
• Point Of Care Ultrasound (POCUS) e.g. to check for free fluid in the abdomen.
• (Blood gas analysis).

Question 16

1. What parameters in the blood do we assess in a. ‘emergency database’?
2. Advantages of running ‘emergency database’.

Answer 16

1. • PCV and TS.
     - Blood Urea Nitrogen (BUN).
     - Lactate.
     - Electrolytes (sodium, chloride and potassium).
     - Blood smear examination.
     - Blood glucose
2. • Quick.
     - Cheap.
     - Little blood required.
     - Aids decision making.

Question 17

Stabilising CV system in primary survey.

Answer 17

• IV access.
• Hypovolaemic shock? > IV fluids indicated.
• Active bleeding? > attempt to stop e.g. pressure bandages.
• Treat hypo/hyperthermia as appropriate.
• Cardiogenic shock?
  – Fluid boluses contra-indicated.
  – Clinically sig. arrhythmia? > anti-arrhythmic agents.
  – Poor systolic function > inotropes.
  – Pericardial effusion? > pericardiocentesis.
  – Presence of hyperkalaemia > bradycardia > correct blood potassium.

Question 18

Stabilising resp. system in primary survey.

Answer 18

• O2.
• minimise stress – may need to postpone IV access, maybe sedate as needed w/ drug w/ minimal CV and resp. effects.
• Body positioning.
• Pleural effusions? > thoracocentesis.
• Drugs
  – Cardiogenic pulmonary oedema? > frusemide.
  – Bronchoconstriction > Terbutaline.

Question 19

Stabilising the neurological system in primary survey.

Answer 19

• Risk of raised IC pressure.
  – > keep head elevated above 15 degrees.
  – > Avoid pressure on jugular veins.
  – > Maintain normal BP, but care with fluids if no evidence of hypovolaemia.
  – > Consider mannitol (as osmotic diuretic).
• Seizures? > anti-epileptic therapy.

Question 20

Stabilising renal system in primary survey.

Answer 20

• UT obstruction? > obtain urine output.
  – > place u cath.
  – > Decompressive cystocentesis.
• In patients in concurrent hypovolaemic shock, you will need to stabilise the CV system first.
  – > Poor perfusion to the kidneys will mean not producing anymore urine anyway.
• Hyperkalaemia > correct blood potassium levels.

Question 21

1. Commonly used analgesics in emergency patients.
2. Commonly contra-indicated analgesics in emergency patients.

Answer 21

1. Methadone and buprenorphine.
2. NSAIDs.