Module 2 - Triage to First Aid of an Emergency Patient - Course Notes.docx

LEARNING OUTCOMES: ================== ### This module will help you to: - Recognise and understand normal and abnormal vital signs - Communicate competently with clients in emergency situations, both over the phone and in person - Prepare your clinic for an emergency - Appropriately...

LEARNING OUTCOMES: ================== ### This module will help you to: - Recognise and understand normal and abnormal vital signs - Communicate competently with clients in emergency situations, both over the phone and in person - Prepare your clinic for an emergency - Appropriately triage patients, using Primary and Secondary Surveys - Understand and perform initial life-saving treatment - Identify some common emergency presentations VITAL SIGNS =========== ### Normal Vital Signs -- -- -- -- -- -- ### General Tips for Performing a Quality TPR - Perform it head to toe! - Or develop your own systematic process so you don\'t forget anything - Palpate the pulse while auscultating the heart - This helps to determine if a pulse deficit is present- pulse deficits will be present with patients who have a significant medical condition causing peripheral perfusion disruption. - Take into account stress, signalment and medical conditions - Perform in a quiet environment where possible - Write down the numbers as you go! - If you are unsure about the results you get then ask someone else to repeat COMMUNICATION with CLIENTS in the EMERGENCY SITUATION ----------------------------------------------------- ### Step 1: Phone Triage #### Effective Telephone Communication #### Establish if the pet has a life-threatening concern #### Gather Information #### Information to obtain: - Presenting concern - Breed, age, sex - How long has this been going on for - is this an acute or chronic problem? Has the animal had this issue before? *(**establish the urgency of the problem**)* #### Specific Questions to Ask! - Is the animal conscious and aware of surroundings? - Any difficulties breathing? - Is the animal in pain/vocalising or distressed? - Are there any wounds or bleeding? - Is there any vomiting or diarrhoea? Straining to urinate? - Is there any abdominal distension, or change in conformation? - Dependent on the issue: gum colour, respiratory effort, demeanour, gait, lethargy and urination status - Access to toxins/medications? - Any other pre-existing diseases/issues? - Is the animal on any medication? - Is the animal up to date with its flea and tick/prophylactic prevention? ##### (This is important in tick prone areas) #### Specific Information to Give - Details of the clinic's location - What to do on arrival - For example, are they to wait in the car and call for assistance or bring the pet straight to the front door? - Is there a specific place for them to park? - Cost of the consultation - Potential wait time ### Phone Advice for Common Emergencies #### Below are some common emergencies and advice to give owners over the phone: - **Patients in respiratory distress** - Minimal handling, restraint (in particular neck leads as this may compromise breathing) and stress is of paramount importance. - Keeping the environment quiet, cool and calm can be helpful, especially being in a moving vehicle is very stressful, especially to a cat, so getting to the clinic quickly and safely is very important. - #### Toxin exposure - ##### A client should never be advised to induce vomiting anywhere other than in the veterinary hospital! - Doing so can lead to further complications such as aspiration pneumonia, respiratory distress or oral trauma. - Unfortunately, pets have access to a wide variety of toxins not only in the home but in the outside environment. - Find out the approximate time that the ingestion or exposure occurred. - This will assist with what is prepared at the clinic, whether induction of emesis or an antidote for example is administered. - Referring to toxicology information on VIN (Veterinary Information Network) or using the Animal Poisons Information Services at the clinic is always advised. - Instructing the owner to bring any product information with them is beneficial to the veterinary team performing treatment. - #### Seizures in animals - Keeping clients calm is essential. - It's important to instruct the owners **not to touch their pet's head or mouth** - this is for their own safety as there is a risk of them getting bitten. - Dimming lights and placing soft bedding around the animal is encouraged to help reduce further injury. - When transporting to the clinic, wrap the pet in a towel/blanket to protect not only the pet but the owner. Ideally, have someone other than the driver caring for the pet. - **T**he advice for animals that have had a seizure will depend on your clinic protocol. - Generally, if an animal has a seizure who has not had seizures before, is not recovering well or at all after one or is having subsequent seizures they should see a veterinarian as soon as possible. - #### Frequent vomiting and diarrhoea - There are a multitude of causes of gastroenteritis and it is always better to advise the client to bring their pet in to be seen by a veterinarian. - This can help avoid severe dehydration and fluid/electrolyte imbalance, especially in young, old or pets with medical issues such as Diabetes or heart disease. - Occasionally a vomit can be a secondary sign of a much more severe disease (e.g., snake bite, pericardial effusion). - #### Ingestion of foreign bodies - Frequently owners call after seeing their pet eat foreign material. - Any strings/wires/fishhooks should not be pulled on or removed by the owner and the animal should be brought to the clinic immediately. - Advice on specific materials should be obtained from a veterinarian. It is always safest for the animal to come to the clinic and be treated. **Do not advise emesis at home.** - #### Trauma (HBC, dog attacks etc) - Attending the clinic should always be advised regardless of the severity, as animals can disguise pain and life-threatening injuries will not always be initially obvious. - If an animal has a penetrating foreign body the client should be advised NOT to remove this, as it can lead to severe bleeding. - Any profuse bleeding should have pressure applied by the owner using a soft absorbent dressing or towel. Soaked dressings should not be removed, additional dressing should be placed on top. - With any fractures the affected limb should be moved as little as possible. A make-shift splint and dressing can be applied by using rolled up soft bandaging. - #### Heat stress - If a patient is suspected of suffering from heat stress, owners should be encouraged to come to the clinic as soon as possible, even if the animal appears fine. - Owners should be advised to commence active cooling prior to transport. - Instructing the owner to apply cool **(NOT COLD!)** water and place wet towels to the groin area can help to slowly reduce the animal's body temperature. ##### NEVER advise covering an animal with a wet blanket, as in some cases this can increase their body temperature. - Air conditioning (where possible) is a must for the transportation of the animal to the clinic. Cooling the feline patient can cause extreme stress which is contraindicated in heat stroke patients. - It is best to advise owners to gently dampen down their cat if possible, however air conditioning and fans may be more suitable in these cases. - #### Cane Toad toxicity patients - If a dog has mouthed a cane toad and is hyper salivating at home but is still alert and walking around the owner should commence wiping the mouth out. - It is really important to discourage the use of a hose to rinse the mouth as many owners will put the hose in the dog's mouth and they are at risk of aspiration. - ALWAYS suggest the owner uses a very wet cloth or face washer to wipe the sticky toxin from the gums. - The face washer can be rinsed regularly under a tap and wiping should occur for at least five minutes. - The patient should then be brought into the clinic to see the vet. - Animals that are more severely affected should be brought into the clinic immediately and the gums can be wiped on the way down if safe to do so without getting bitten. PREPARING for an EMERGENCY ARRIVAL ---------------------------------- +-----------------------------------+-----------------------------------+ | - *Oxygen Supply* | - *Suction and suction tips* | +-----------------------------------+-----------------------------------+ | - *Endotracheal Tubes* | - *Intravenous catheters* | | | | | | | | | | | | - *Accessories* | +-----------------------------------+-----------------------------------+ | - *Cuff inflator and tube ties* | - *Syringes and needles | | | (assorted selection)* | +-----------------------------------+-----------------------------------+ | - *Laryngoscope* | - *Butterfly catheters* | +-----------------------------------+-----------------------------------+ | - *Ambu Bags (selection of | - *Fluid bag (LRS/Hartmann's), | | sizes)* | Administration set already | | | primed* | +-----------------------------------+-----------------------------------+ | - *Anaesthetic masks/nasal | - *Fluid pump* | | lines (selection of sizes)* | | +-----------------------------------+-----------------------------------+ | - *Blood collection equipment | - *Clippers* | | and tubes* | | +-----------------------------------+-----------------------------------+ | - *Surgical scrub and swabs* | - *Multi parameter monitor - | | | including ECG (dots and BP | | | cuffs required)* | +-----------------------------------+-----------------------------------+ | - *Stethoscope and Thermometer* | - *Pen and Paper (or | | | Anaesthetic Chart)* | +-----------------------------------+-----------------------------------+ ### The Ideal 'Ready Area' #### It is important that this area is not used for general examinations, only for emergency patients. CLIENT COMMUNICATION upon ARRIVAL to the CLINIC ----------------------------------------------- #### This relationship is developed by performing the following: - Introduce yourself and your role - Explain what you are doing and why - Be calm! (the higher energy you have the more stressed the client will be) - Use the pet and owners name as often as appropriate - Provide an initial assessment/treatment fee - Explain what the next communication step will be (I.e. the vet will be out in "x" time or once we have done radiographs the vet will have a discussion with you). - Give some time frame to the next step (i.e. there is a big difference between 20 mins and 2 hours) #### Below is a dialogue example: PATIENT TRIAGE ==============  #### Primary Survey #### Airway and Breathing - Signs and Indications +-----------------------------------+-----------------------------------+ | | - Causes noisy breathing; | | | stridor/stertor and | | | inspiratory dyspnoea. | | | | | | - This can be caused by | | | foreign material in the | | | oropharynx, laryngeal | | | collapse (paralysis tick | | | potentially), tracheal | | | collapse or elongated | | | soft palate. | | | | | | - Cyanosis and anxiety are | | | often present with these | | | cases and referred sound can | | | be heard on auscultation of | | | the thorax. | | | | | | - Compromise of the upper | | | airway causes inspiratory | | | stridor, and compromise of | | | the lower airway can cause | | | expiratory stridor. | +-----------------------------------+-----------------------------------+ | | - Have laboured breathing with | | | an expiratory push of the | | | diaphragm, in addition to | | | cyanosis and anxiety. | | | | | | - Auscultation of the thorax | | | reveals high pitched wheezes | | | throughout the lung field. | +-----------------------------------+-----------------------------------+ | | - Have a very short, sharp | | | inspiratory phase, and spend | | | most of the respiration | | | trying to exhale. | | | | | | - This form of breathing is | | | often related to more chronic | | | disease, for example asthma | | | or bronchial disease. | | | | | | - Patients with pleural space | | | disease may also present with | | | shortness of breath and | | | display a more short and | | | shallow breath. | | | | | | - Their chests will have | | | minimal movement due to | | | the pleural space being | | | restricted by air or | | | fluid and may also have | | | an abdominal component | | | when breathing | | | (asynchronous). | | | | | | - Combination of Inspiratory | | | and Expiratory Dyspnoea may | | | have disease at any level of | | | the respiratory tract. | | | | | | - Often these cases may have | | | lung contusions after trauma | | | (HBC, dog attacks etc) or | | | pneumonia (aspiration post | | | drowning incident or | | | paralysis tick etc). | | | | | | - On auscultation crackling | | | sounds can be heard and dull | | | lung sounds. | +-----------------------------------+-----------------------------------+ #### Circulation - Signs and Indications - Mucous membrane colour (MM) - Capillary refill time (CRT) - Heart rate and rhythm - Pulse quality - Rectal temperature (and peripheral temperature) - Mentation/Neurological Status - Blood pressure #### Mucous Membranes (MM) (Colour and CRT) +-----------------+-----------------+-----------------+-----------------+ | | | | | +-----------------+-----------------+-----------------+-----------------+ | | | - Inadequate | - Cats | | | | perfusion | generally | | | | to the | have paler | | | | extremities | pink MM | | | | and is an | when in a | | | | emergency. | normal | | | | | state | | | | - Vasoconstri | | | | | ction | - Cats in the | | | | of the | decompensat | | | | blood | ory | | | | vessels to | level of | | | | compensate | shock can | | | | for low | present | | | | blood | with pale | | | | volume or | to grey | | | | systemic | mucous | | | | shock can | membranes | | | | manifest as | | | | | a slow CRT. | | +-----------------+-----------------+-----------------+-----------------+ | | | | - Which can | | | | | have life | | | | | threatening | | | | | implication | | | | | s | | | | | | | | | | - can be seen | | | | | with cane | | | | | toad | | | | | toxicity, | | | | | and | | | | | anaphylaxis | | | | | and acute | | | | | sepsis | +-----------------+-----------------+-----------------+-----------------+ | | | | - Cats in the | | | | | decompensat | | | | | ory | | | | | level of | | | | | shock can | | | | | present | | | | | with pale | | | | | to grey | | | | | mucous | | | | | membranes | +-----------------+-----------------+-----------------+-----------------+ | | | | | +-----------------+-----------------+-----------------+-----------------+ #### Heart Rate and Rhythm #### Bradycardia #### Tachycardia - Pericardial effusion (fluid in the pericardial space) - When auscultating the thorax there are muffled heart sounds that are difficult to hear. - Certain cardiac arrhythmias (abnormal heart rhythm) such as ventricular and Supraventricular Tachyarrhythmias. #### Pulse Assessment #### If there are any pulse deficits (where there is no corresponding heartbeat) an ECG and Blood Pressure should be performed immediately. +-----------------------+-----------------------+-----------------------+ | | - Caused by low | | | | cardiac output | | | | | | | | - Decompensatory | | | | shock | | +-----------------------+-----------------------+-----------------------+ | | - Increased cardiac | - Often present in | | | output due to | patients with | | | vasodilation | sepsis or | | | | systemic | | | | inflammatory | | | | response (SIRS). | | | | | | | | - Further | | | | circulatory | | | | examination | | | | should always | | | | include arterial | | | | blood pressure | | | | measurement. | | | | | | | | - In some cases, a | | | | blood lactate | | | | reading is | | | | beneficial when | | | | examining a | | | | patient's | | | | circulation and | | | | perfusion. | | | | Anything greater | | | | than 2.5mmol/L | | | | may indicate | | | | reduced | | | | perfusion. | +-----------------------+-----------------------+-----------------------+ #### Temperature #### Neurological Status - Signs and Indications - Alert - Obtunded (mentally dull) - Stuporous (semi-conscious - roused only by painful stimuli) On the primary survey the following should be closely examined: - Pupil size, symmetry and pupillary light reflexes - Presence and direction of any nystagmus - Menace response - Facial symmetry and any head tilt - Posture - gait, ability to walk, weakness - Pain sensation, conscious proprioception and withdrawal reflexes - Anal tone ### Blood Pressure #### Hypotension - Appropriately sized cuff (¾ diameter of the limb) - Place the cuff mid shaft (not on or near a joint) - Ensure the patient is as still as possible #### Common Causes #### +-----------------------------------+-----------------------------------+ | | - Haemorrhage | | | | | | - Fluid deficits | | | | | | - Relative hypovolaemia due to | | | vasodilation | +-----------------------------------+-----------------------------------+ | | - Anaesthetic drug-induced | | | | | | - Severe metabolic or | | | respiratory acidosis | | | | | | - Severe hypoxaemia | | | | | | - Endotoxaemia | | | | | | - Septicaemia | | | | | | - Anaphylactic reactions | +-----------------------------------+-----------------------------------+ | | - Decreased contractility (drug | | | induced, hypoxaemia, | | | acid-base disturbances, | | | electrolyte imbalances, | | | cardiomyopathy) | +-----------------------------------+-----------------------------------+ | | - Bradycardia | | | | | | - Bradyarrhythmias | | | | | | - Atrial fibrillation | | | | | | - Ventricular tachycardia | +-----------------------------------+-----------------------------------+ | | - Mechanical ventilation | | | | | | - GDV | | | | | | - Pericardial effusion | | | | | | - Tumours | +-----------------------------------+-----------------------------------+ | | - Drug induced | | | | | | - Pressure on the eye | | | | | | - Excessive traction of | | | abdominal organs. | +-----------------------------------+-----------------------------------+ ### Urinary System Evaluation ### Secondary Survey UNDERSTAND and PERFORM INITIAL LIFE-SAVING TREATMENT ---------------------------------------------------- ### PROVIDING FIRST AID ### Facilitating first aid: Intravenous Access - Gives us the ability to act very quickly and administer the following. - Fluid therapy - At significant volumes pending the size of the gauge of the catheter. - Always aiming for the largest gauge without doing vessel damage. - Medications - If a post ictal patient suddenly starts seizing again, an IVC can ensure medication can be given immediately. - A respiratory compromised animal can be given sedatives IV to have immediate effect, and even induced into a general anaesthetic for them to be intubated. - Pain relief can be administered for a faster onset of action. #### Order of common veins used: +-----------------------------------+-----------------------------------+ | | - Most used/easily accessed | | | | | | - Typically, long wide vessels | | | that are easily taped in. | | | | | | - Ease of placement with the | | | patient in either sternal or | | | lateral recumbency | +-----------------------------------+-----------------------------------+ | | - Hindlimb placements are great | | | for aggressive patients or | | | those with significant | | | forelimb injuries | | | | | | - Helpful in seizing patients, | | | when forelimb 'paddling' can | | | make cephalic access | | | difficult. | | | | | | - Can be tricky to tape in | +-----------------------------------+-----------------------------------+ | | - Can be useful in larger | | | patients as it is often a | | | nice length with minimal | | | kinking of the extension | | | set/catheter | +-----------------------------------+-----------------------------------+ | | - Great for cats | | | | | | - Can be challenging to tape in | | | (at times is glued in) and is | | | often preference for a | | | temporary catheter while the | | | patient is non ambulatory | +-----------------------------------+-----------------------------------+ | | - Great for neonates or | | | extremely hypovolaemic | | | patients | | | | | | - A temporary jugular catheter | | | can be placed using a | | | peripheral catheter and glued | | | in, while initial fluid | | | therapy is administered and | | | then either a proper central | | | line or a peripheral vessel | | | can be used | +-----------------------------------+-----------------------------------+ ### Emergency Oxygen Therapy -- -- -- -- -- -- -- -- ### Control of External Haemorrhage ### Active Heating/Cooling #### Active Heating - Bair Hugger (hot air) - Heat Mats - Care needs to be taken to ensure that recumbent patients are regularly checked for burns, the patient should not be placed directly onto it, a blanket or towel must be between the mat and the patient. - Warmed IV fluids - Although, it may be debated that this is quite an inefficient way to warm a patient as the fluid rate needs to be quite high for it to not lose heat by the time it gets to the patient. - Blankets - Is best as an additional source, more to reduce further heat loss than increase a patient\'s internal temperature. #### Active Cooling - Water baths (NOT COLD WATER!) - Fan ### Analgesia ### Toxin Decontamination #### Types of Decontamination - Emesis - Oral Lavage - Gastric Lavage - Enema ### Emesis ### Oral Lavage ### Gastric Lavage ### Enema ### Stabilising fractures IDENTIFYING COMMON URGENT EMERGENCIES ===================================== ### Gastric Dilatation and Volvulus GDV #### Common Clinical Signs: - Patient is unsettled - not wanting to lie down or is pacing - Bloated abdomen (Tympanic - when flicked sounds like a watermelon) - Gastric dilatation can be present without volvulus (bloat without the torsion which is still an emergency due to potential to worsen and contribute to perfusion issues) - In some patients, the bloated abdomen is challenging to pick up due to the location of their stomach underneath the ribcage. - Hypersalivation - Unproductive vomiting/retching - Collapse #### Common Primary Survey Findings: - Tachycardia - Dyspnoea - Poor peripheral pulses - Tympanic abdomen - Pale MM with prolonged CRT #### Immediate Steps on Arrival: - Continuous monitoring placed (ECG, BP, SPO~2~) - Assessment by Vet & administration of pain relief - Oxygen therapy - IVC placed - bilateral intravenous access & IV fluid therapy - Blood samples for analysis - Prep for Abdominal radiographs - Prep for Decompression of stomach (Trochars, mixed bore stomach tubes, large catheters vs Surgical Decompression) #### Options for Decompression: - Trocharisation - Placement of typically an 18-20G Catheter into the lateral side of the patient into the stomach (typically the area of most tympany), the stylette is removed and thus the air can be released from the stomach. - This air may refill, but it will give some relief to the patient and reduce perfusion issues even if it is temporary - Stomach Tube - Using a stomach tube to decompress a GDV, will depend on the ability of the clinician to pass a stomach tube, the tube needs to be significantly lubricated and the patient needs to be somewhat sedated/recumbent to allow the passing of the tube. - At times you will need to use a small bore orogastric tube, to be able to pass through the sphincter - Surgical Decompression - Most if not all patients, who have a confirmed GDV, will need surgical decompression and subsequent return of the stomach and other organs to their original position. - Patients with a GD, will rarely require surgical decompression, use of Trocharisation and/or stomach tube will be enough to decompress the stomach. ### Urethral Obstruction #### Common Clinical Signs: - Frequent trips to the litter tray - Straining to urinate (owners may confuse with straining to defaecate) - Inappetence - Blood in urine - Inappropriate urination (i.e. in cupboards etc) - Vocalisation & crying - Prolonged obstruction cases may have altered/dull mentation, lethargy and collapse #### Common Primary Survey Findings: - Painful bladder, firm on palpation - inability to express - Tachycardia - Bradycardia (pending severity of illness - elevation of serum potassium can cause marked cardiac arrhythmia and progressive bradycardia, with potential for cardiac arrest) - Hypothermia #### Immediate Steps on Arrival: - Bladder expression attempt - gentle pressure only to avoid rupture - IVC placement - Pain relief - Blood samples for analysis - Continuous monitoring (cardiac auscultation and ECG monitoring particularly important) - Preparation for urinary catheterisation ### Seizures #### Common Clinical Signs (These will depend on the type of seizures and stage): - Paddling - Altered mentation - Twitching - Urination +/- defaecation - Circling - Jaw chomping #### Common Primary Survey Findings: - Altered mentation - Hypersalivation - Tachycardia - Bounding pulses - Injected MM - Hyperthermia - due to excessive muscle activity & stress - Brachycephalic breeds may exhibit respiratory distress #### Immediate Steps on Arrival: - Quick Assessment - Alert Vet so that anticonvulsants can be dispensed - IVC Placement regardless of stage - This allows anticonvulsant medications to be administered if needed (usually Diazepam) - IV administration if available but also can be admin rectally if unable to get IVC - Provide Oxygen if needed - Active cooling if hyperthermic ### Cane Toad Toxicity #### Common Clinical Signs: - Hypersalivation - Scratching at face/mouth - Foaming from mouth - Seizuring - Collapse #### Common Primary Survey Findings: - Mucous membranes bright red due to irritation from the toad's secretions - Tachycardia - Bounding pulses - Hyperthermia - Altered mentation - Muscle tremors and generalised seizures. - Cardiac Arrhythmia - may see ECG changes #### Immediate Steps on Arrival: - Vet Assessment - IVC placement - Decontamination of mouth - see detox notes above (continue flushing/wiping mouth for up to 10 mins as absorption by the mucous membranes can be prolonged) - Anticonvulsant (usually diazepam) if needed - Constant Monitoring (SPO2, ECG) REFERENCES ========== CASE STUDY SCENARIOS ==================== #### Please complete each scenario for discussion at your Module Tutorial 1. A client calls with a 6-year-old male French Bull dog in respiratory distress. She explains she has recently taken the dog for a long walk and has been concerned about its breathing ever since. #### What would you advise the owner to do? Would you recommend any first aid? 2. A 9-year-old female Doberman arrives at the clinic, the owner reports she has been gagging and trying to vomit for the last two hours. #### What would you identify upon your primary survey? What would be your life saving first aid and why? 3. You have four animals arrive at your clinic: a collapsed, suspected GDV patient, a cat with obstructed urethra, a Pug with a proptosed eye and a Greyhound, which has a deep laceration on a forelimb that is bleeding. #### Explain what triage category you would place them in and why? 4. A client arrives at the clinic with her 4-year-old male neutered DSH cat. She explains that he has been constipated for the last 24 hours, and now seems very quiet and is acting strangely. #### What differentials would you consider with this patient? What triage category would you place it in? 5. A 5-year-old male DSH cat arrives at the hospital. The owner is concerned about her cat's breathing. The cat is an indoor/outdoor patient, and the owner reports he is not up to date on his flea and tick treatment. The patient is usually stressed when handled at his regular vet and is currently open mouth breathing in his carrier.