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ADVERSITY

ADVERSITY. “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon. Emergency Procedures. Normal PE. Use belts and your hands. ABCD. A = Establish airway B = Breathe for animal

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ADVERSITY

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  1. ADVERSITY “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon

  2. Emergency Procedures

  3. Normal PE

  4. Use belts and your hands

  5. ABCD • A = Establish airway • B = Breathefor animal • C = Maintain circulation with thoracic compressions and IV fluids • D = Disability

  6. Triage of Emergency Patients • Initial exam (by RVT) • Wear gloves • Animal muzzled (use discretion) • Minimize movement of patient • Initial Assessment (30-60 sec; from rostral direction) • Mentation (level of consciousness) • A Alert • V Verbally responsive • P responsive to painful stimuli • U Unresponsive • Extend head/neck to provide clear airway; check for patency • Breathing/respiratory pattern (shallow, labored, rapid, obstructed) • Abnormal body/limb posture (fracture, paralysis) • Presence of blood or other material around patient

  7. Mucous membrane

  8. Triage of Emergency Patients • Initial Assessment (continued) • Breathing/respiratory pattern • Total/Partial blockage of airways (Requires immediate Rx) • Exaggerated inspirations • Nasal flare, open mouth, extended head/neck • Cyanosis • Breathing assessment • Watch chest wall movement • Auscult lungs bilaterally to r/o hemo- or pneumothorax

  9. Breathing – Airway patent • NO • Clear airway: use suction • Intubate • Ventilate (don’t over ventilate drive CO2 down) • 10/12/min • < 20 cm H2O • YES • Provide flow-by air

  10. Triage of Emergency Patients • Vital signs (taken after initial assessment) • HR, pulse rate (same as HR?), strength • RR • mm color, CRT • Temp • BP • High HR, high BP→ pain • High HR, low BP → hypovolemic shock • Baseline data • ECG • Chem panel, CBC

  11. Triage of Emergency Patients • History (mnemonic) • A Allergies • M Medications • P Past History • L Lasts (meals, defecation, urination, medication) • E Events (What is the problem now?)

  12. Triage of Emergency Patients • Events • How long since injury • Cause of injury (HBC, dog fight, gunshot) • Evidence of loss of consciousness • Blood loss? • Deterioration/improvement since accident (good indicator of Prognosis) • Any other underlying medical conditions/medications

  13. Triage of Emergency Patients Treatment to restore life/health • Analgesics for pain • Once airway patency and heart beat are established (these are critical for life) • Control hemorrhage • Pressure bandages (sterile gauze, laparotomy pads, towels) • If bleed thru, do not remove initial bandage, apply another on top • On distal extremity, BP cuff can be placed proximal to wound (avoid tourniquet if possible)

  14. Triage of Emergency Patients • Control hemorrhage • External counterpressure using body wrap of pelvic limbs, pelvis, and abdomen • Insert urinary catheter to monitor urine output • Use towels, cotton rolls, duct tape, etc • Monitor respirations (diaphragm/abdominal breathing compromised) • Leave on until hemodynamically stable (6-24 h) • Monitor BP during removal • If BP drops >5 mm Hg, stop removal; infuse more fluids • If BP continues to drop, reapply wrap

  15. Triage of Emergency Patients

  16. SHOCK: RECOGNITION AND TREATMENT • SHOCK is inadequate tissue perfusion resulting in poor oxygen delivery • Cardiogenic • Distributive • Obstructive • Hypovolemic

  17. Shock • Types of Shock: • Cardiogenic—results from heart failure • ↓ blood pumped by heart • HCM, DCM, valvular insufficiency/stenosis • Distributive—blood flow maldistribution (Vasodilation) • Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from vessels to interstitial spaces →↓BP→ ↓ blood return to heart • Obstructive—physical obstruction in circ system • HW disease → heart pumping against the adult worm blockage • Gastric torsion →↓blood return to heart • Hypovolemic—decreased intravascular volume • Most common in small animals • Blood loss, dehydration from excessive vomiting/diarrhea, effusion of fluid into 3rd spaces

  18. Hypovolemic Shock • Pathophysiology of hypovolemic shock ↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP • Stage I: Compensation • Baroreceptors detect hypotension (↓BP) • Sympathetic reflex—(Epi, Norepi, cortisol released from adrenals) • ↑ HR, contractility • Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart • Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex • ↑ Na+ and water retention → ↑ intravascular vol (↑BP) • PE findings • Tachycardia • Prolonged cap refill time • Pale mm

  19. Hypovolemic Shock • Pathophysiology of hypovolemic shock • Stage II: Decompensation • Tachycardia • Delayed cap refill time • Muddy mm (loss of pink color, more brown than pink) • BP is dropping • Altered mental state • Stage III: Irreversible shock • PE findings worsen • cannot revive • death will occur

  20. Shock • Treatment: the goal of therapy is to improve O2 delivery • O2 supplementation (If pulse ox < = 93%) • Face mask • O2 cage/hoods • Transtracheal/nasal insufflation • Venous access • Cephalic • Saphenous • Jugular • Intraosseous

  21. Oxygen supplementation NASAL CANNULA FACE MASK OXYGEN HOOD

  22. Fluid Administration

  23. Shock • Treatment • Fluid resuscitation (O2 delivery is improved by ↑CO) 1. Crystalloids • Isotonic solutions (electrolytes: Na+, Cl-, K+, bicarbonate) • Examples (body fluid=280-300 mOsm/L) • Lactated Ringer’s (273 mOsm/L) • Normal saline (0.9%) (308 mOsm/L) • Dose: Dog 80-90 ml/kg/hr Cat 50-55 ml/kg/hr • Hypertonic solutions—when lgvol of fluid cannot be administered rapidly enough • Examples—7.5% saline • Causes fluid shift from intracellular space→ intravascular space →↑vascular vol →↑venous return → ↑CO • Also causes vasodilation → ↑ tissue perfusion • Dose: 4-6 ml/kg over 5 min • Hypotonic solutions should never be used for hypovolemic shock • Examples—5% Dex in water (252 mOsm/L)

  24. Shock • Treatment • Fluid resuscitation (O2 delivery is improved by ↑CO) 2. Colloids— • Large molecular wt solutions that do not leave vascular system • Better blood volume expanders than crystalloids • 50-80% of infused volume stays in blood vessels • Examples • Whole blood • Plasma • Dextran 70

  25. Shock • Rx (continued) • Sympathomimetics Use only after adequate fluid administration if BP and tissue perfusion have not returned to normal • Dopamine (Inotropin®) • 0.5-3.0 μg/kg/min • Dilation of renal, mesenteric, coronary vessels • 3.0-7.5 μg/kg/min • ↑ contractility of heart • ↑ HR • >7.5μg/kg/min • Vasoconstriction • Dobutamine (Dobutrex®) • 5-15 μg/kg/min • ↑ contractility of heart (min effect on HR)

  26. Shock • Monitoring Hemodynamic/metabolic sequelae of shock are continually changing • Physical Parameters • Respiratory • Color of mm • RR • Breathing efforts smooth? • Breathing pattern regular? • Auscultation normal? • Cardiovascular • HR normal? • ECG normal? • Color of mm • Cap refill time (1-2 sec) • Urine production? (1-2 ml/kg/hr) • Weak pulse? → ↓stroke volume

  27. Shock Monitoring Physiologic Monitoring Parameters O2 Saturation Pulse oximetry—noninvasive Normal: Hb saturations (SpO2)>95% SpO2<90%--serious hypoxemia Arterial BP—a product of CO, vascular capacity, blood volume If one is subnormal, the other 2 try to compensate to maintain BP

  28. Shock • Monitoring • Laboratory Parameters • Hematocrit (PCV) • Increase →dehydration • Decrease →blood loss • Electrolytes (what is that?) • Proper balance needed for proper cell function • Fluid therapy may alter the balance; supplement fluid as needed • Arterial pH and blood gases • PaCO2 tells how well patient is ventilating • PaCO2 <35 mm Hg → hyperventilation • PaCO2 >45 mm Hg → hypoventilation • PaO2 Tells how well patient is being oxygenated • PaO2 <90 mm Hg → hypoxemia • pH tells acid/base status of patient • <7.35 → acidosis • >7.45 → alkalosis

  29. VISION “It is a terrible thing to see and have no vision.” -Helen Keller

  30. CPCR CARDIOPULMONARY CEREBROVASCULAR RESUSCITATION

  31. Cardiopulmonary Arrest and Resuscitation (CPR) Cardiopulmonary Arrest (CPA)— sudden cessation of effective ventilation and circulation. • Causes • Anesthesia • Trauma: head trauma • Infections (e.g. pneumonia) • Heart disease: arrhythmia • Autoimmune disease • Malignancy Hypoxemia, shock, anemia

  32. Cardiopulmonary Resuscitation • Resuscitation Team Members • Should be 3-5 members • Team leader—Veterinarian or RVT with most experience • All members have several responsibilities • Provide ventilation • Chest compression • Establish IV line • Administer drugs • Attach monitoring equipment • Record resuscitation efforts • Monitor team’s effectiveness • Teams should practice on a regular basis to stay sharp

  33. Cardiopulmonary Resuscitation • Facilities • Adequate room for entire team and equipment • O2 source • Good lighting • Crash cart with all needed Rx (should be checked at beginning of each shift) • Defibrillators • Electrocardiogram • Suction • Table to perform chest compression • Grated surgery prep table not solid enough for chest compression • Use board underneath patient • Recognition • RVT should ID patients at risk and observe any deterioration • Preventing an arrest is easier than treating one Agonal breaths, apnea, collapse, fixed gaze, no palpable pulase

  34. Cardiopulmonary Resuscitation • Standard Emergency Supplies (on crash cart) • Pharmaceuticals --Venous access supplies • Atropine ● Butterfly cath • Epinephrine ● IV caths • Vasopressin ● IV drip sets • 2% lidocaine (w/o epi) ● Bone marrow needles • Na+bicarb● Syringes • Ca++ chloride or gluconate● Hypodermic needles (var sizes) • Lactated Ringer’s, hypertonic saline, ● Adhesive tape dextran 70, hetastarch● Tourniquet • Airway access supplies --Miscellaneous supplies • Laryngoscope ● Gauze pads (3 x 3) • Endotracheal tubes (variety of sizes) ● Stethoscope • Lubricating jelly ● Minor surgery pack • Roll gauze ● Suture material ● Scalpel blades ● Surgeon’s gloves

  35. Emergency Drugs in Dogs

  36. Emergency Drugs in Cats

  37. CPR • Basic Life Support: • A -- Establishment of an Airway. • B-- Breathing support. • C -- Circulation support. • Advanced Life Support: • D -- Diagnosis and Drugs. • E -- Electrocardiography. • F -- Fibrillation control. • Prolonged Life Support: • G -- Gauging a patient's response. • H -- Hopeful measures for the brain • I -- Intensive care.

  38. Cardiopulmonary Resuscitation • Basic Life Support (Phase I) • Remember the priorities (ABC; Airway, Breathing, Circulation) • Establish patent Airway • Endotracheal tube • Tracheostomy tube for upper airway obstruction • Suction to remove blood, mucus, pulmonary edema fluid, vomit • Artificial ventilation (Breathing) • Ambu-Bag • Anesthetic machine • Ventilate once every 3-5 sec (6-10 breaths/ min) • Chest compressions in between breaths if working alone • 1 to 2 times per second (80 times per minute for a large dog and 120 times for a small dog or cat) • 10 compression for every 2 breaths (or 5:1)

  39. CPR http://www.youtube.com/watch?v=VJGlsYHI9cU

  40. Cardiopulmonary Resuscitation Intubation

  41. Basic Life Support (Phase I) Circulation External cardiac compression Lateral recumbency—one/both hands on thorax over heart (4th-5th intercostal space) In larger patients, arms extended, elbows locked In small patients, thumb and first 2 fingers to compress chest Rate of compression: 80-120/min Cardiopulmonary Resuscitation

  42. Cardiopulmonary Resuscitation • Basic Life Support (Phase I) • Circulation • Internal cardiac compression • More effective than external compression • ↑CO, ↑BP, higher survival rate • Indications • Rib fractures • Pleural effusion • Pneumothorax • If not responsive after 5 min of external cardiac compression • Preparation • Clip hair ASAP, no surgical scrub • Incision at 7th and 8thintercostal space • With a gloved hand, compress heart between fingers and palm (Do not puncture heart with finger tips or twist heart) • After spontaneous beating returns, flush chest cavity with saline, perform sterile scrub of skin and close

  43. Cardiopulmonary Resuscitation • Basic Life Support (Phase I) • Assessing effectiveness (must be done frequently) • Improved color of mm • Palpable pulse during cardiopulmonary resuscitation (difficult) • If efforts are not effective, do something differently • Use different hand • Change person performing compression • Ventilate with every 2nd or 3rd chest compression • Compress chest where it is widest in lg breed dogs • Apply counter-pressure to abdomen (hand, sandbag) • Prevents posterior displacement of diaphragm and increases intrathoracic pressure

  44. Cardiopulmonary Resuscitation • Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) • Drugs • Fluids • Lactated Ringer’s is standard (do not use Dextrose) • Initial dose: Dogs—40 ml/kg (rapidly IV) Cats—20 ml/kg • Atropine—parasympatholytic effects (blocks parasympathetic effects) • 0.02-0.04 mg/kg • ↑HR • ↓secretions • Epinephrine—adrenergic effects • 0.02-0.2 mg/kg • Arterial and venous vasoconstriction→ ↑BP

  45. Common arrhythmias: electrical mechanical dissociation, (no pulse), asystole (flatline), ventricular tachcardia, bradycardia

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