Veterinary Emergency Protocols

Course Objectives and Required Reading

• Allowable tasks for credentialed veterinary technicians in emergencies should be known.
• Key to know what questions to ask clients during telephone triage.
• Be able to describe emergency patient classes and prioritize treating a simulated group.
• Equipment used in emergency veterinary hospitals needs to be identified.
• Crash cart contents should be known, and a restocking checklist can be utilized.
• Major drugs in a crash cart must be listed and categorized.
• Proper trauma patient restraint has to be demonstrated.
• Critical thinking and observation skills are required.
• Monitoring critically ill or injured patients needs to be done.
• Receiving emergency patients is required.
• Should be able to communicate with clients in emergencies.

Emergency Situations and Treatments by LVTs

• Under Texas State Law, an LVT in an emergency can issue treatment directions to a non-veterinarian via communication, without violating the Act.
• The veterinarian assumes full responsibility for such treatment.
• Applying a tourniquet or pressure bandage controls hemorrhage.
• Appropriate drugs can be given to prevent or control shock after communicating with a DVM.
• Resuscitative oxygen procedures can be performed.
• Open airways can be established, including intubation, but excluding tracheostomy surgery.
• External cardiac resuscitation can be performed.
• Temporary splints or bandages can be applied to prevent further injury.
• Appropriate wound dressings and cleaning and external treatment can be applied.
• External treatment for heat prostration can be performed.

LVT Emergency Competencies

• An LVT must be a team leader/player, able to take orders quickly and efficiently.
• An LVT must remain calm in stressful situations, seeing through emotion and catecholamine release.
• Must be competent at venipuncture and IV catheter placement, as patients may be in shock with decreased BP/perfusion.
• Must be competent at administering medications IV, SQ, IM, IC, etc.
• An LVT must perform a brief but thorough PE from nose to tail, even if distracted by obvious problems.
• It is key to be able to perform endotracheal intubation even with epiglottis swelling.
• Be able to run stat bloodwork, including PCV, TP, blood gases, clotting times, and electrolytes.
• Must have the ability to perform CPCR.
• Monitor vital signs, recognizing a patient's condition worsening.
• Accurate patient records and controlled substance logs are a must.
• TLC needs to be provided for seriously ill patients.
• LVT's must be understanding and patient with distressed owners and technicians act as a link between DVM and patient.

AVECTT and Triage

• AVECTT-certified technicians have additional training in emergency and critical care.
• AVETT technicians possess the knowledge and experience needed to work in equipped emergency facilities.
• Triage involves sorting patients by condition severity, not order of arrival.
• Know what questions to ask and limit the initial patient survey to 30 seconds.
• Ask about pre-existing conditions, presenting complaint, exposures, and permissions during triage.
• Triage designations include: Green (Urgent), Yellow (Emergent), Red (Life Threatening), and Black (Slight or no injury).

Classes of Emergencies

• Class III emergencies require immediate treatment or result in death within minutes.
• Class III includes respiratory or cardiac arrest, airway obstruction, and severe shock.
• Class II patients are critically ill with adequate respiratory function.
• Class II requires treatment within minutes for burns, wounds, or fractures, and the patient is not in shock.
• Class I patients are less serious but still concerning.
• Class I patients may have a mildly depressed mood, but still requires treatment within 12 hours.
• Class 0 emergencies involve patients that only have a slight or no injury.

Triage Assessments

• Two historical facts to gather in triage are: primary complaint and when the patient was last normal.
• When questioning the client in triage ask: When did the presenting complaint start, if it is acute, acute on chronic, or progressive.
• Four circulatory assessments: Mucus membranes, Capillary Refill Time, Pulse Rate and Pulse Quality.
• Mucus membrane color/texture: tacky, petechiae, injected (brick red), or icteric.
• Tacky membranes are dry or sticky.
• Petechiae are small red or purple spots indicating broken capillaires.
• Injected membranes are brick red and indicate: infection, sepsis, CO2 poising heat stroke, certain medications, or trauma.
• Icteric indicates: jaundice
• Capillary refill is <2 seconds when normal.
• Pulse quality: Bounding, weak, or non-palpable.
• Two respiratory assessments include the rate and effort.
• A mental assessment: Level of Consciousness (Awareness, appropriateness, responsiveness to touch), and must use correct terms such as: Hysterical/dysphoric, Normal, Non responsive, Obtunded, Stupor, or Coma.
• Bonus point: check for Urinary Obstructions: Cats are notorious offenders.

Performing Triage

• Triage is a method of classifying patients by the urgency of emergency care.
• Evaluations should be performed by either a DVM or tech upon arrival.
• Prioritize patients involved in a vehicle accident, and experiencing vomiting/diarrhea, respiratory distress, and URT disease.
• Airway/Breathing: Assess RR/RE, pattern, and sounds.
• Note the presence or absence of bleeding, and posture/mentation.
• Categories of mentation: Conscious, Depressed, Hysterical/dysphoric, Stupor, Obtunded, and Coma.
• Automatic triages: Trauma, Respiratory distress, Seizures/collapse, Non-responsive, "Yowling" cats, Straining in litterbox. Other automatic triages are: Dragging hindlimbs, Bleeding, pain, toxicities, and if in doubt.
• Triage supplies include pens, paper, watch with second hand, stethoscope, thermometer, bandage scissors, hemostats, and a sense of urgency.

Initial Assessment and Key History

• Initial assessments should be short (around 5 minutes) and should be focused on airway, breathing, bleeding, circulation, mentation, consciousness, and a brief PE.
• Physical Exam (PE) should be conducted: From nose to tail.
• History should be obtained on: Signalment, current medications, C/S/V/D status, eating and drinking normally, changes in activity/attitude, other animals, indoor only or fenced yard. Also ask about: Toxins.
• Detailed patient history is as important as taking vitals.
• Owners know their pets best.
• History should be current.
• Use open ended questions such as: What is a normal day like for Fluffy?

Airway and breathing in Emergencies

• Key vital statistics: Temperature, pulse rate, respiration rate, mucus membranes, CRT, blood pressure, responsiveness, and weight.
• Airway patency needs to be unobstructed and clear of foreign material.
• If there are obstructions to airway you should then: Suction, use your fingers, or use gravity to clear airway.
• If animal is not breathing: clear the airway, intubate, and ventilate with 100% oxygen.
• DVM must perform a tracheostomy if you are unable to intubate.
• Lack of cardiac and respiratory function impacts the brain and may show: Irreversible brain damage occurs when respiration has ceased for more than 3 minutes.
• If an animal is breathing effectively: Evaluate RR/RE, provide oxygen, and lung sounds are absent or increased.
• Evaluate for if an animal is either: Labored, cyanotic, or tachypnic.

Emergency Equipment

• Oxygen cages provide oxygen without assisted ventilation and has controlled temperature and humidity.
• Oxygen cages have small holes in the doors for manipulation.
• Can double as ICU cages, but be cautious of the temperature.
• Capnographs measure end-tidal CO2. Normal measure are 35-55mmHG.
• Capnographs are more sensitive indicators of gas exchange than pulse oximetry.
• Minimum baseline for QATS tests include: BG- hypo/hyperglycemia and USG/dipstick-kidney function.
• Lactate testing determines lactic acid levels, elevated with hypoxia or poor perfusion.
• Coagulation testing is performed at >normal times to r/o: toxicities, bleeding disorders, or impending DIC.
• Ethylene glycol, HW, Parvo. and FeLV/FIV can be tested for.
• FeLV: Feline Leukemia Virus (retrovirus), leading cause of death in cats and it attacks the IS. Virus is spread via: saliva, urine, feces and milk.
• It can be transferred from an infected mother to her kitten either before birth or from nursing.
• FIV: Feline Immunodeficiency Virus, weakens the immune system, is difficult to transmit between cats and it can be transferred by: Bite wounds, sex, mother to kitten.
• Azostix are reagent strips that use whole blood to test for BUN.
• PCV/TP helps to to evaluate anemia, polycythemia, and dehydration.
• Blood Gas/Electrolyte Analyzers use venous or arterial blood sample. Arterial blood: process immediately or cork without air and place on ice (no >10 min). It provides rapid assessment of electrolytes, blood gases, acid-base balance, bicarbonate, EtCO2 etc. It also enables Collection at sites such as: dorsal pedal, femoral, sublingual (anesthetized).

Crash Cart Basics and Drugs

• Crash carts contain ECG supplies, chest tap, open chest supplies, syringes/needles and drugs.
• In addition, you should also have Airway and breathing, circulation. And can be organized by: Suction Supplies, breathing AMBU bag and fluids such as: IV access.
• Crash carts are mobile stations containing necessary supplies for treating unstable patients and that contain: quick dosage guides.
• Crash cart vs crash box: so that A fully stocked “crash cart” is not likely to be practical in a small private practice, so a smaller tackle box or equivalent would be sufficient as A “crash box”.
• Some common CPCR Drugs used are: Atropine, Dobutamine, Epinephrine, and Lidocaine. Other useful CPCR drugs include: Magnesium, Sodium bicarbonate, Vasopressin, and Naloxone.
• Routes of drug administration in emergencies include: Jugular, Peripheral (cephalic), IO, IT and IC.
• Must be able to Check drug expiration dates weekly in the crash cart.
• All drug(s) administered MUST be recorded.
• Defibrillators: are used to help fix the rhythm of the heart. Usually are present on top of carts. The CPCR success rate in animals is only 6-9 %. Meaning, Less than 10% of successful CPCR's go home to be functional pets. Statistics are relevant to patients NOT under anesthesia. Animals that experience cardiopulmonary arrest due to anesthesia have a much better survival rate if CPCR is started immediately.
• Fluid pumps: deliver a specified amount of fluids over a specified time
• Syringe pumps are used to: give small amounts of drugs over an extended period of time.

Monitoring: Indirect and Indirect Blood Pressure

• Indirect Blood Pressure Monitoring is done using Oscillometric or Doppler methods.
• Oscillometric: Cuff is placed around a leg or base of tail, the cuff inflates, and the BP is measured with a machine
• Doppler: Sensor placed on palmer or planter surface of shaved paw, ultrasound gel applied, pressure taken manually
• Cuff diameter- approx. 40-50% of the circumference of the limb at the site of placement
• Direct requires an indwelling arterial catheter, Provides more accurate measurement--continuous rather than periodic, is More temperamental
• It measures systolic (contraction) and diastolic (filling/relaxation) and mean arterial pressure (MAP)
• Normal MAP is 60-90mmHg
• Systolic pressure: 100-160mmHg
• Diastolic Pressure: 50-70mmgHg
• In cats and dogs: pulses should be palpable if the MAP is >60mmHg
• Systolic should be: >90mmHg and mean values should be: >60mmHg, in order to maintain adequate perfusion of vital.
• Central Venous Pressure (CVP) is also need to be calculated, where The Amount of pressure in right atrium: roughly equals blood volume in the body, CVP: blood pressure in central veins (thoracic vena cava), and Helps to assess efficacy of fluid therapy. In order to be accurate, Central lines are required and that are:
• Usually and Other placement sites include cephalic, saphenous or metatarsal vein, Normal measures are: 0-10cmH2O/
• Too low=hypovolemia, dehydration, inadequate fluid and a > 10cmH2O indicates: venous congestions, increased Thoracic pressure, or volume overload.

Heat Support, Blood Products and Triage Reminders

• Heat Support is present by using: Circulating warm water, with Heat- ed kennel floors or by Bair huggers
• If a Bair hugger blanket becomes unavailable the unit can still be used to help heat a patient.
• Create a tent with a blanket and place hose beneath it. Do NOT allow air flow to be directly on the patient.
• Some clinics do their own blood banking. Which means the: "Keep a controlled “colony” of dogs and cats Hemo
• Solutions and Powers Pet Emergency and Specialty—local blood banks where you must: Use local animals that have gone through screening and testing for BBP, infectious dz, and parasitic dz.
• There should be, in Dogs >55lbs, Cats >10lbs, good temperament, usually 1-8 years old and their owner's must be compensated.
• There MUST be strict control over and recording of each product utilized, where : Time is of the essence!!! so that's y;
• Some owners have no idea how close their animals are to death and.
• Some owners come in hysterical because their dog has too much hair in it's ears to hear her calling his name...

General Information for the Veterinary Technician

• It’s up to YOU to determine if the emergency is something that needs to be seen quickly or can wait since many of the owners have no idea.
• Priority number 1 must always be the goal to be to stop bleeding and the patient should be brought back immediately away from upset owners.
• If the client provides a wrap, Do NOT remove wraps owner applied even if soaked through, Apply more bandage material, Note where bleeding is coming from before wrapping, Apply direct pressure w/clean cloth or gauze, Allow clot to form, Bind cloth in place using bandage material or tape, and Elevate extremities above heart level.
• Only use: A tourniquet should only be used for a severe, life-threatening hemorrhage in an extremity, is ONLY applied by veterinary staff with. Do not leave in place more than 20 minutes or the limb can be devitalized. Tech tip- Put time on a piece of tape and stick to the forehead.
• You can also evaluate the Cardiovascular/Circulatory signs;
• MMs, Where Pallor can indicate: anemia, shock, pain, hemorrhage, or poor circulation, Cyanotic: poor 02 perfusion or poor oxygenation, "Muddy”/Brown: methemoglobinemia, sepsis, Tylenol or onion toxicity, shock. The presents of, Icteric: (Inc. bilirubin), liver dz, RBC destruction/hemolysis, IMHA, and Brick red that can be caused by: early (hyperdynamic) shock, heatstroke, and sepsis.
• Asses CRT by noting: Provides crude indication of hydration status and peripheral, rapid/increased ( 1 sec): an indication of: early shock, hyperthermia, sepsis OR from Slow/decreased (> 2 sec), that has: dehydration, hypovolemia, hypothermia, pain, shock.
• Determine pulse quality by noting if: Palpable femoral pulse estimates systolic BP of at least 60 in mmHg.
• Is it: Strong, bounding: which is and indication of pain, or is: Weak, thread: which shows: decompensating shock. Assess it for Pulse deficits, where: auscultated heart beat does not match palpated pulses, and if: Absent for: auscultation; If unable to auscult heart beat start CPCR immediately!!!
• Use you assessment to determine if their could be: A Saddle thrombus in cats.
• Abnormal Heart Rates also need to be recognized: (lg-breed dogs), with Tach: > 160 or with, < 60 (sm- breed dogs), with Tach: > 180 or with, < 90. Also use the: (puppy) - Tach: > 200 and, < 90-100 for a cat (cat) - Tach: > 220
• Normal sinus arrhythmia which must include recognition that there are increases to rate on inspiration and, decreases when their its done onexpiration. Which means, its: Normal for dogs or Abnormal with cats,.
• Remember when assessing body temps must be done and with an action taken upon each finding: where If is above:108°F Then do their best as then: Active cooling is essential and, Can result in multiple organ failure and where If above: + 106°F as their: Active cooling will then become essential in the hope to: Prevent brain damage is that point occurs. If the patients below 106.0 degree and that Can result in sudden: cardiac arrest and to prepare for that possibility,

Additional Tips: Toxins, GI, Wounds, & Seizures

• Always determine heat injuries and when, their is a: Heat stroke: their is always a - BUT: CNS signs (Depression and lethargy), if Ataxia and blindnesses are seen and with the + or - seen Neuro signs like seizures, their then best is to: Can lead to death"
• Remember in any case to: Always ask If they're, above all: stable" or with Shock or some kind. Such as to look for; with - Ineffective blood perfusion over tissues. Which can cause, then A lack of oxygen in body and difficulty regarding :mentations, neurological function, or on motor reflexes
• This lack of oxygen Then leads with - Blood to be shifted from the skin, abdomen, and muscles to the heart and is seen as an effort for: maintain life. And that has the possible ability to increase for any Prolonged period, That when, Severe, Damage can Occur and Then affect: " all of these organs and tissues When the 4 Types seen in a: "Hypovolemic shock
• What the, First goal must be for one must get (Urinary Obstructions), at ones such as, Pain meds, Heating and always To minimize their stress and to do our best to:"
• "Always Anticipate and prepare for anesthetizing patient then, " always then do the next process to, Prepare for blood draw ASAP since. The Hematuria can be due for a Bacterial infections,"
• "With All GI Cases, try asking the, "Patient is Vomiting but, at all has: "Assess the level" of "dehydration and if you can, what about getting HX, before placing: "them into a room to see the doctor" Ask about recent; A eating of foreign material", "toys", or such that can include, (blankets", or any signs for it with a possible.

Key Reminders for Technicians

• Know what the severity of wounds are by noting if: Always seen ( over the phone""," all be Always do your best to check on: All can always look what, Was the "Electro", Cution to their; Owner and in each test of which will result for better: " You the test before " Always do your best, such as with a:
• All information from the presentation and the audio are completely to all the credits and legal actions of the one who produced this all. Always be safe."