Triage & Shock in Veterinary Emergency Care (PDF)

Emergency & Critical care nursing Triage & Shock  Emergency & Critical Care (ECC) Nursing  Emergency and Critical Care Nursing  Chapter 25  McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses, 10th ed  2...

Emergency & Critical care nursing Triage & Shock  Emergency & Critical Care (ECC) Nursing  Emergency and Critical Care Nursing  Chapter 25  McCurnin’s Clinical Textbook for Veterinary Technicians and Nurses, 10th ed  2.Emergency Receiving  Chapter 13  Small Animal Emergency and Critical Care for Veterinary Technicians, 4th Edition Initial Triage and Resuscitation of Small Animal Emergency Patients - Emergency Medicine and Critic al Care - Merck Veterinary Manual (merckvetmanual.com) What do you need to know? Patient Assessment: 1. Triage 2. Primary Survey 3. Secondary Survey Be prepared, be calm, be Triage French: Trier = To sort World War 1 – battlefield strategy  Funnel resources (bandages, time, expertise etc)  Reduces time & resources spent on patients that would otherwise survive without treatment OR on patients that were going to die regardless of intervention Triage in Veterinary Medicine Purposes of triage: 1) Rapid assessment of patients in need of immediate care (closest to death goes first) 2) Prioritization of care for incoming patients *this is the same process for why humans wait for 8 hours at the hospital with a 2 week-old cough  Telephone Triage  #1 ANSWER THE PHONE  You never know what is on the other end  If you don’t answer & triage, people will just show up  may be real emergency, or may just be an emergency to client – ear infection, vaccines for boarding the next day etc)  “Failure to plan on your part does not constitute an emergency on my part” unless it is of course  #2 Obtain Client Name and Phone Number  In case phone call disconnected  Must be a number patient can be reached at  Happens often – dying cell phone, owner panics...Telephone #3 Determine How urgent?  Done by collecting a basic history  What? When (did it happen?), Duration (how long has this been going on)? Current status? Where are they located & ETA or direct else where? Other immediate concerns or related illnesses?  Bleeding & close by – come right over  Owner found tick – book appointment for later in day (owner will be distressed and want to be seen immediately)  Severe distress and not close by – go to nearest facility or Emerg/referral centre  *DO what is best for the patient*  *manage client expectations*  if closing in 1 hour and emergency will need to refer for overnight care if serious, offer these options  does clinic carry the equipment to manage the emergency?...Telephone #4 Give advice  Ideally where to go for professional care  Sometimes appropriate first aid:  Apply pressure to site of bleeding  How to transport patient  Be careful around patient (can bite if in pain, unpredictable due to seizing etc..)  Ingestation? – refer them to call poison control and start a case - to vomit or NOT to vomit  Hydrogen peroxide (causes gastric ulceration – avoid if possible, aspiration?)  Some substances are traumatic or caustic and vomiting should not be induced (should have poison handbook close by)...Telephone #5 Do not waste time  A true emergency – life and death can differ by a matter of minutes (hemorrhaging patient, bloat)  If you are not sure get another RVT or DVM immediately to talk to person to help  Do not worry about non pertinent information (vaccine status, deworming etc… that can be done later, and consider once patient assessed) Patient Arrival & Assessment Notice (called before hand and told to come in) OR Walk in’s As soon as client walks into waiting room, RVT determines patient “acuity” level  Ask what happened, observe & greet  Determine: Ok to wait or not?  If not, move to treatment area  Life threatening problems dealt with first  Cardiovascular, respiratory, neurologic  Evaluation/resuscitation begin immediately Assessing Patient in Triage  Multitask  Obtain brief history, visual & physical exams completed within 1-2 minutes  Goal is sorting  1. Need immediate care/stabilization  2. Those that need to go to treatment area for other reasons (vomiting, diarrhea, contagious, injury – broken or bleeding)  3. Those that can wait with owner until appointment time (ear infection, tick, broken nail that is not bleeding) Primary Survey  Rapid evaluation for critical problems (1-2 min)  Take a brief Hx from owner (pertinent info)  Assess: “ABC”s  Airway  Bleeding/Trauma  Consciousness  variations in “ABC”s (alertness, breathing, cardiovascular) Be prepared: stethoscope, watch/clock, pen light/otoscope, thermometer, muzzle, towel, gloves, stocked supplies  Primary Survey: Airway LOOK at breathing & any signs of respiratory distress:  Increased effort Look  Stance, posture Listen  Abdominal wall movement Feel  Nasal flare, open mouth etc  Hand in front of nostrils – air flow  laboured/tachypnea/orthopnea  fast/shallow/abdominal effort *look in mouth* Primary survey: Airway LISTEN  BOTH lungs (before heart)  Cranial caudal ventral dorsal  Don’t forget trachea! Abnormal sounds:  Loud snoring  Roaring  Wheezing  Decreased/absent sounds Primary survey: Airway FEEL  Palpate trachea  Palpate chest wall for fractures, wounds, subcutaneous emphysema  Multitask: do this while auscultating! Primary survey: BLEEDING Active bleeding (especially arterial):  Direct pressure  +/- fast bandage – gauze, vet wrap  Tourniquet (rubber, rope, shirt/fabric)  Consult DVM  Can only be applied for 20 minutes  For extended amount of time only if amputation option  Only around legs/tail etc.. (not head, body) +/- hemostat clamp bleeding vessel Primary survey: Bleeding  MM colour & CRT  Auscultate heart  Estimate HR (Tachy, Brady, normal)  Assess rhythm, any obvious arrhythmia  Palpate pulse (femoral – quality is it weak, strong, bounding, thready)  Rectal (axillary) temp  Feel paws/extremities for warmth  Hydration (skin tent, mm)  Rapid palpation of abdomen (fluid wave, tense/painful, wound, distention)  Rapid palpation musculoskeletal (wound/fracture)  *if bloat suspected, can auscultate and “ping” for tympany over abdomen (stomach) Primary Survey: Consciousness  Mentation  Neurological concerns/signs?  May suggest cerebral injuries, toxin, spinal cord, pathogen, fever….  Normal (alert and interactive) Terms  Dull/depressed (interactive but not bright or eager)  Obtunded (reacts to stimuli but very slowly or at a lower level)  Stuporous (disconnected from environment, only reacts to noxious stimuli like a loud noise or pain)  Comatose (disconnected from environment, does not react to stimuli) Levels of consciousness - simplified Alert Verbally responsive Responsive to pain Unresponsi ve Primary survey: Consciousness  Pain Perception  Skin pinches  Toe pinches  Pupils  Mydriatic pupils (big) – fixed and dilated, bad if not responsive otherwise  *if responsive* cat – sympathetic response – stress/fear  Compare both sizes, same or different?  Horner’s Syndrome = anisocoria, raised 3rd eyelids)  PLR time Primary survey: Gait/Posture  Guarded (painful)  Laterally recumbent  Limping/non weight bearing  Sawhorse stance  Rigid (fore limbs vs hind limbs)  Help localize injuries (TBI, Spinal, fracture/trauma etc..)  Note: Nonambulatory trauma patients should be treated as spinal trauma until confirmed otherwise PRIMARY SURVEY COMPLETED IN 1-2 min! Recall:  Multitask  LOOK, LISTEN & FEEL at the same time  Triage  Catastrophic abnormalities dealt with NOW  ABCs: Airway, Bleeding/Trauma, Consciousness Primary survey completed - ended week 9 here, will continue in week 10 Review – Primary Triage Assessment Steps in the primary survey A Airway B Bleeding/Trauma C Consciousness Secondary survey  After Immediate problems addressed (pressure bandages, catheter/IV etc…)  Complete history taken  Full PE completed  Diagnostics, plans Vital signs At this point, measure & record:  HR & heart auscultation  Pulse rate & quality  CRT & mm colour & moisture  RR & auscultation  Blood pressure  Body Temp & How extremities feel..Vital & Other considerations  ECG  QATS or QUATS – quick assessment test (made of 4 essential values)  PCV, TP, BUN, BG  Baseline blood work  CBC, chemistry/electrolytes, blood gases Always Be Prepared The “Team”: Who? Equipment & The “Area”: Crash Cart: Where? What? Always Be Prepared Crash Cart  Supplies needed for “unstable” patient  Supplies are usually arranged according to “task”  airway supplies, resuscitation supplies, emergency drugs etc GCVH Crash Cart GCVH Crash cart Gcvh Crash cart Crash cart 2nd crash cart – smaller & more portable *lives in dental  Pathophysiolog y Shocking & Facts Treatment of Shock Definition of Shock Shock (AKA Circulatory shock) medical emergency in which the organs & tissues with inadequate blood flow (poor perfusion). This deprives the organs and tissues of oxygen, & allows the buildup of waste products. Shock can result in serious cell/tissue/organ damage or death.  It is a condition (not a disease)  In short: inadequate perfusion of tissues & hypoxia/hypoxemia  Decreased O2 delivery leads to: Lack of energy production (ATP) within the cell” shock: (cellular respiration) = results in cell death  & leads what is to organ dysfunction & failure it? Goal of Treatment:  Restore tissue perfusion and O2 delivery to NORMAL  Get them out of shock & prevent DEATH  Think of it this way Circulatory system has 3 components:  Pump = heart  Pipes = blood vessels  Fluid = blood/plasma/serum  Shock can occur with failure of any component  Pump failure, pipe failure, or loss of blood volume  Shock can be categorized based on which component failed  Types of Heart = Cardiogenic Shock shock  Cardiac diseases like hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), microvascular dysplasia, arrythmias Based on which etc. component has failed Blood = Hypovolemic Shock  causes of decreased intravascular volume Vessels = Distributive (decreased vessel tone)  sepsis, anaphylaxis, neurogenic states Vessels = Obstructive (obstructive to blood flow)  heartworm disease, clot, bloat or gastric dilation volvulus Pathophysiology 3 steps in the process *using cardiogenic shock as example 1. An event that leads to decreased cardiac output & hypotension eg. Big dog attacks a little dog (BDLD) = multiple bite wounds over the thorax & abdomen resulting in punctured lung, pericardial effusion, diffuse bruising & severe pain 2. Body tries to compensate (cope & improve) for incident via natural natural compensation mechanisms: Sympathetic nervous system (SNS) (fight/flight/freeze) kicks in & adrenals “get to work” & secrete: Epinephrine Norepinephrine Cortisol 3. Response to Hormones Epinephrine and norepinephrine cause: Heart contracts stronger and faster Arteriolar constriction shunts blood away from: Skin, Muscle Kidneys, GI So then where is blood flow redirected to???? - The heart & * brain! Activation of renin-angiotensin system also occurs (in the kidneys) which results in attempts to regulate blood pressure by conserving sodium & H2O to increase IV volume! So, what does this accomplish? Blood flow At the redirected to expense of heart and brain other organs (VITAL all the & tissues (Not vital in the time!) moment) Stages of shock Stage One = Compensated Stage Two = Decompensated Stage Three = Irreversible Stage 1: Compensated Signs: Activation of SNS  Increased Heart Rate  Peripheral  Tachycardia (not Vasoconstriction cats)? & tachypnea  Prognosis likely  Decreased pulse fair to guarded quality  Prolonged CRT  Pale mm  Cool extremities Cats: another special challenge Cats do not always display the classic signs of shock like dogs do Shocky cats often present with  Bradycardia  Hypothermia  Hypotension Even in EARLY stages of shock Cause for this is unknown Then what happens If treatment OR the body’s effort at compensation are not sufficient, the patient progresses to …decompensation  Stage 2: Decompensated Arterioles are starting to become “exhausted”  Tachycardia (cats?)  Prognosis  Weak(er) pulse guarded to poor  MM colour: muddy/gray/cyanoti c  Variable CRT  Hypothermia  Weakness, decreased LOC Stage 3: Irreversible shock  Patient is unconscious or unresponsive  Prolonged hypoxemia results in systemic vasodilation, BP plummets & CV collapse occurs  MM colour: muddy  Cold extremities, & hypothermia common  Therapy is not effective, rapid decline  Prognosis – fatal (rainbow bridge)   Once shock has been treated and steps taken to improve blood flow, treatment shifts to minimize the effects of Reperfusio shock on the body  Lack of oxygen during shock forces cells n Injury to use anaerobic respiration resulting in increased levels of lactate and other byproducts that damage tissues & homeostatsis  So, when blood flow is restored during tx of shock, lactate and free radicals are released into circulation  WBCs are drawn to damaged tissue where they are activated and release additional inflammatory mediators  Risk for SIRS always follows in patients who have been in shock BOTTOM LINE – even if you “bring them back” from the initial shock, they are still at risk of decompensating (“crashing”), monitor closely Shock Treatment! How to nurse the ‘shocky’ patient. Summary  Venous access  Aggressive fluid therapy  Oxygen supplementation  Drugs  Tx underlying disease  GOALS: Restore O2 delivery (adequate tissue perfusion) and circulation saving lives one pet at a time – all in a day’s work for an RVT