Triage, fluid and oxygen therapy

Question 1

Define triage

Answer 1

CLASSIFICATION OF PATIENTS TO DETERMINE PRIORITY OF NEED
AND THE OPTIMAL ORDER IN WHICH THEY SHOULD BE TREATED

Question 2

Before arrival, the following information about the patient should be gotten via phone: (7)

Answer 2

Short history
Breed
Sex
Age
Approx. weight
Instructions for a safe arrival
Phone nr

Question 3

Triage categories

Answer 3

Categories can vary dependent upon literature.

Green = non-emergent
Yellow = urgent but not life-threatening
Orange = very urgent, potentially life-threatening
Red = immediate care needed, life-threatening
Black = dead on arrival

Question 4

What does primary triage involve broadly?

Answer 4

Airways
Breathing
Circulation
Disability

Question 5

MBSA =
(5)

Answer 5

MBSA (major body system assessment)

 Respiratory system
 Cardio-vascular system
 Nervous system
 Urinary/reproductive system
 Other parameters/changes

Question 6

Describe respiratory system triage

Answer 6

Observation from a distance as well as auscultation of the trachea and lungs in order to detect hypoxemia and
hypoventilation.

 Open airways
 Stertor (above larynx)
stridor (larynx or below)
 Respiratory rate and pattern
 + mucous membranes
 Auscultation
 Palpation of the thorax

Question 7

Stertor vs stridor

Answer 7

Stertor (above larynx)
stridor (larynx or below)

Question 8

parameters for assessment of hypoperfusion: (5)

Answer 8

 Colour of mucous membranes
 Capillary refill time (CRT)

 Pulse-presence/quality
- Femoral pulse
- Dorsal metatarsal pulse

 Heart rate
 Heart auscultation

Question 9

Parameters of shock (7)

Answer 9

mm can vary
crt typically prolonged
heart rate elevated
resp. rate elevated
peripheral pulse weak or absent
BP decreased
lactate elevated

Question 10

Color of mucous membranes.
What do the varying colors indicate?

Answer 10

brown mm = methemoglobinemia

Question 11

Triage of the nervous system involves? (4)

Answer 11

Assessment of:
 Mentality (stupor, coma etc.)
 Cranial nerves (anisocoria etc.)
 Movement
 Pain/deep pain (in paralysis, paresis cases espesh)

Question 12

stupor vs coma

Answer 12

stupor = unconscious, reactions to external manipulations can be present

coma = unconscious,
no reactions to external manipulations except for potentially some autonomic reflexes

Question 13

Triage of the Urinary/reproductive system, 4 main issues to check for.

Answer 13

Big painful bladder

Uterine prolapse
Dystocia

Persistent erection/paraphymosis (dogs, chinchillas especially)

Question 14

hyperthermia vs fever

Answer 14

hyperthermia = elevated temperature due to external factors

fever = under control of the body’s own thermoregulation center

Question 15

Modified ATT (Animal Trauma ‘Triage) score

Answer 15

The animal trauma triage (ATT) score is a veterinary illness severity score that numerically classifies the degree of trauma in an attempt to quantify mortality risk probability.

Parameters Assessed in mATT:
Perfusion
Cardiovascular
Respiratory
Neurological
Gastrointestinal (GI)/Urogenital
Musculoskeletal

Ranges from 0 (normal) to 18 (severely compromised).

Question 16

MGCS (Modified Glasgow Coma Scale)

Answer 16

is an adaptation of the human Glasgow Coma Scale, specifically designed for veterinary use to assess the level of consciousness and neurological function in animals.

The MGCS evaluates three main neurological parameters:

Motor Activity
Brainstem Reflexes (Pupillary Light Reflex and Ocular Position)
Level of Consciousness

total score ranges from 3 to 18.
18 indicates a normal neurologic function, while 3 indicates severe brain dysfunction or deep coma.

Question 17

Primary stabilization includes (4)

Answer 17

IV catheter
O2 therapy
Fluid therapy
Analgesia

Question 18

Blood sample diagnostics that may be used for triage: (7)

Answer 18

 PCV/Total Solids
 Glucose
 Lactate
 Blood gases
 UREA
 Blood smear
 Electrolytes

Question 19

aFAST/tFAST

Answer 19

abdominal and thoracic focused assessment with sonography for trauma/triage

Question 20

Describe secondary triage.

Answer 20

After first stabilization, do a secondary examination. Did you miss something? Recheck and cover any unassessed bases.

The goal of secondary triage is to provide a more detailed evaluation of a patient’s condition, prioritize further treatment, and ensure that medical resources are allocated efficiently.

2nd triage gives you further info for communication with owners
 Prognosis
 Cost Etc…..

Question 21

Why exactly is oxygen therapy important during primary stabilization?

Answer 21

PROLONGED HYPOXEMIA AND POOR TISSUE OXYGEN DELIVERY MAY RESULT IN
MULTIPLEORGAN FAILURE AND THEREFORE SHOULD BE TREATED IMMEDIATELY.

Oxygen is an IMPORTANT THERAPEUTIC TOOL IN THE MANAGEMENT OF EMERGENCY AND CRITICAL CARE PATIENTS.

Question 22

Goal of Oxygen therapy. (5)

Answer 22

 Its aim is to increase the fraction of inspired oxygen (FiO2).

 To improve PaO2(partial pressure of arterial O2).

 To improve hemoglobin saturation.

 To increase oxygen delivery to tissues.

 To avoid hypoxemia, tissue hypoxia and lactic acidosis.

Question 23

Indications for oxygen therapy. (4)

Answer 23

 PaO2 less than 80 mm Hg (Blood gas
analyzer)

 Pulse oximetry reading less than 95%

 Respiratory distress symptoms

 All shock patients

Question 24

Respiratory distress symptoms

Answer 24

 Increased respiratory rate and effort
 Extended head and neck posture

 Cyanosis(indicates severe hypoxemia)
 Flaring of the nares
 Open mouth breathing

 Changes in respiratory pattern
 Abnormal findings in auscultation

Question 25

Non-invasive and invasive methods of oxygen therapy depends on (5)

Answer 25

 Choice depends on FiO2 desired (fraction of inspired O2)  Length of treatment  Equipment available  Type of patient  In most cases FiO2 30-40% provides sufficient oxygenation

Question 26

What does Long –term O2 therapy require?

Answer 26

requires humidification  Avoids drying of nasal mucosa and degeneration of respiratory epithelium.  Avoids impaired mucociliary clearence

Question 27

Non-invasive O2 therapy methods: Flow-by oxygen

Answer 27

 Oxygen hose near the mouth or nostrils  Flow rate of 2-3 L /min provides FiO2 of 25%  Well tolerated by most patients especially cats  Short term administration

Question 28

Non-invasive methods: Oxygen mask

Answer 28

 Can be used in any patient who lying still and/ or tolerates the mask  More suitable in short term oxygen administration  2-6 L/min flow recommended (patient size)  Possible to reach 40-50%FiO2  minimal equipment required  Needs supervision

Question 29

Non-invasive methods: Oxygen hood or self-made cage

Answer 29

 Easily made in hospital  Leave 2-5 cm from the top open to allow humidity and CO2 elimination  Not tolerated by all patients  Temperature inside collar area may increase rapidly  Maintenance flow 2-5L/min  FiO2 obtained is 30-40%

Question 30

Non-invasive methods: Oxygen cage

Answer 30

Suitable for patients suffering for severe stress and not tolerating other methods (cats)  FiO2 40-50%  Disadvantages - cost  Hyperthermia can develop easily  Possible lack of patient access

Question 31

Invasive methods: Nasal prongs

Answer 31

 Human nasal prongs can be used  Well tolerated by most dogs  Easily dislodged  Unknown FiO2, Possibly higher than flow by oxygen

Question 32

Invasive methods: Nasal catheter

Answer 32

 If O2 is needed more than 24h  Simple to place and requires minimal equipment  Catheter should be changed every 24-48h  Flow rates 50-150ml/kg can provide FiO2 30-70%  Higher flow can be irritating and cause sneezing  Humidification is needed

Question 33

Invasive methods: Trans-tracheal oxygen

Answer 33

 Cathether is inserted through the cricothyroid ligament or caudal to it (between 3rd-5th ring)  Needs experience  May need sedation  Aseptic technique  O2 flow rates of 50 ml/kg/min provide FiO2 40-60%  Risks associated with sedation and infection  Lesions or damage of trachea

Question 34

Invasive methods: Tracheostomy tube

Answer 34

* Needs experience * Need sedation * Aseptic technique * Risks associated with pneumomediastinum, infection and dislodging.

Question 35

If you can't get a patient's pulse oximetry reading over ? with non-invasive O2 therapy then consider what?

Answer 35

If you can't get a patient's pulse oximetry reading over 95% with non-invasive O2 therapy then consider sedation and intubation.

Question 36

Describe Oxygen toxicity.

Answer 36

 Excessive oxygen can be toxic to pulmonary epithelium. - Destruction of cells causes inflammatory reaction.  Inflammatory mediators result in increased tissue permeability and due to this: pulmonary edema, atelectasis, fibrosis and pulmonary function disorders, can result.  FiO2 (fraction of inspired oxygen) more than 50% should not be administered for longer than 24-48 h.  Neonates are more sensitive to O2 toxic effects.

Question 37

Aims of fluid therapy. (4)

Answer 37

MAINTAIN ADEQUATE PERFUSION IN THE BODY RESTORING FLUID BALANCE/TREATMENT OF DEHYDRATION RESTORING ELECTROLYTE IMBALANCES RESTORING NORMAL BLOOD CIRCULATION AND CARDIAC FUNCTION IN SHOCK AND HYPOVOLEMIA

Question 38

total body water percentage intracellular fluid percentage extra cellular fluid percentage interstitial fluid percentage plasma percentage of total body water

Answer 38

total body water percentage 60% intracellular fluid percentage 40% of the above extra cellular fluid percentage 20% interstitial fluid percentage 15% of the above plasma percentage of total body water 5%

Question 39

Indications for isotonic fluids. (4)

Answer 39

 Quick correction of hypovolemia  Treatment of dehydration and electrolyte imbalances  General anaesthesia  Correcting metabolic acidosis

Question 40

Dangers of isotonic fluids. (3)

Answer 40

Lung edema: fluid overload (cats, small dogs), cardiogenic diseases Dilution of blood in anemia and thrombocytopenia cases further exacerbating tissue hypoxia Trauma patient with lung contusion/edema (may worsen it) or brain contusion/edema (may increase intracranial pressue)

Question 41

Describe hypertonic fluids such as NaCl

Answer 41

 5-7,5% solutions  Increases osmotic pressure  Water moves from tissues to blood stream, causes cellular dehydration so you must administer isotonic fluids concurrently via separate IV.  Quickly increases the volume in the blood vessels.  Quick way to fix hypovolemia Used in Head trauma patients to get "water off the brain". Careful in bleeding patients.  Dog: 4-5ml/kg  Cat: 2-4ml/kg  Time of action 30-60min after IV administration

Question 42

Describe Colloids.

Answer 42

Synthetic involve big polysaccharide molecules in isotonic fluid. The bigger the molecule, the longer it stays in the blood vessel. E.g: Dextran-40, Dextran-70, Starch, Hetastarch etc. Non-synthetic colloid options include:  Natural  Fresh frozen plasma  Human albumin

Question 43

Indications for colloids

Answer 43

 Rapid increase in blood volume needed  Hypovolemia  Hypotension  Hypoproteinemia

Question 44

Dangers of colloids include: (6)

Answer 44

Kidney Damage Coagulation Issues Allergic Reactions Volume Overload: leading to pulmonary edema or other forms of fluid retention Electrolyte Imbalance: may lead to hypokalemia or hyperchloremia. Increased Mortality Risk: In some studies, the use of certain colloids has been associated with an increased risk of mortality.

Question 45

Describe blood products

Answer 45

Fresh whole blood- 10-20ml/kg - RBC; WBC; platelets, coagulation factors, plasma protein (albumin) Packed red blood cells (pRBC)-5-10ml/kg - Erythrocytes (PCV 70-80%) Fresh-frozen plasma- 10-20ml/kg (frozen quite soon after collection) Frozen plasma-10-30ml/kg (frozen 8h+ after collection)

Question 46

Indications for transfusion of whole blood versus packed red blood cells?

Answer 46

whole blood - acute hemorrhage, anemias with coagulopathy, hypoalbuminemia or thrombocytopenia packed red blood cells - anemia without coagulopathy

Question 47

Indications for transfusion of plasma?

Answer 47

coagulopathy and DIC

Question 48

Alternative routes for fluid administration (5)

Answer 48

dorsal pedal intraosseous jugular/ central venous line NG or NE tube subcut

Question 49

Define dehydration. Symptoms? Causes?

Answer 49

loss of fluids into the interstitial space from cells (can involve cellular crenation) Symptoms: decreased skin turgor, dry mucous membranes, enophthalmos, weak pulse, hypotension, tachycardia, weakness Causes: diarrhea, vomiting, kidney dysfunction, use of diuretics, diabetes, insufficient fluid intake etc.

Question 50

Define hypovolemia. Symptoms? Causes?

Answer 50

Hypovolemia: insufficient amount of blood in blood vessels (intravascular space) Symptoms: pale mucous membranes, prolonged CRT, weak pulse, tachycardia (Cats!), weakness, cold extremities Causes: severe dehydration, blood loss, vasodilatation.

Question 51

Dehydration versus hypovolemia

Answer 51

Dehydration primarily involves a loss of fluid from the intracellular space and the extracellular space. Hypovolemia specifically refers to a reduction in the intravascular fluid volume.

Question 52

Describe the treatment of Hypovolemic shock and Fluid therapy.

Answer 52

Low volume/hypotensive resuscitation uses isotonic crystalloids.  Aiming for a mean blood pressure of 60-90 mmHg  Fluid rate: boluses 15-20ml/kg within 10-15min  Repeated up to 4 times with reassessments in between If isotonic crystalloids do not work, Add colloids:  Dogs: 5-10ml/kg  Cats: 1-5ml/kg Hypertonic fluids: Do not use in hypernatremia and severe dehydration!  Dogs: 4-5ml/kg  Cats: 2-4ml/kg If blood loss due to active bleeding, try to stim it and Consider blood products.

Question 53

Fluid therapy and Cardiogenic shock

Answer 53

Stop or decrease diuretics first. Consider: does the patient even need fluid therapy. Remember in cardiogenic shock, its not that there isnt enough fluid, its that the heart can pump it properly. Offer water to drink or in wet food. If needed: crystalloids  20-35ml/kg/ 24h Avoid colloids because pulmonary permeability is increased so increased risk for lung edema.

Question 54

Fluid therapy and Cardiopulmonary arrest

Answer 54

Administration using crystalloids is reasonable when suspected hypovolemia.  Conservative doses: 20ml/kg over 15- 20min But You won`t save patient with only fluids!  Cardiopulmonary resuscitation and drugs!  Prognosis is bad anyway so don't focus on fluids in this situation.

Question 55

Fluid therapy and head trauma

Answer 55

Head trauma patients Usually present in hypovolemic shock cause these are usually bleeding patients. Aim of fluid therapy:  Maintain cerebral perfusion  Reduce cerebral ischemia  Reducing and maintaining normal mean arterial BP Isotonic fluids: low volume resuscitation Hypertonic fluids (decrease intracranial pressure)  Dogs: 4-5ml/kg  Cats: 2-4ml/kg  Remains in vasculature for 1h (alternative is Mannitol) Colloids only if really needed; combination of hypertonic solution and colloid.

Question 56

Fluid overload is when

Answer 56

A Normovolemic patient is receiving too much fluids.  Increase in body mass >10% Clinically: edemas and effusions, changes in mental status. Predisposed patients:  Heart failure  Kidney failure in anuria or oliguria  Hypoalbuminemia  Vasculitis Fluid leaks out of vessels into tissues resulting in fluid overload in the two prev.

Question 57

In shock patients: Decreased renal perfusion due to shock, can cause...? Kidney contusions can cause...? Damage to the lower urinary tract can cause...?

Answer 57

pre-renal azotemia renal azotemia post-renal azotomia