ICU/ER - Respiratory Distress, Blood Pressure
- Extra thoracic obstructions: laryngeal tumors, _______ paralysis, nasal or nasopharyngeal obstruction - increase in _________ effort/noise
- Intrathoracic obstructions (small airway disease or intrathoracic tracheal collapse): increase in _______ effort/noise
What is: laryngeal, inspiratory, expiratory
1.) According to the Trauma Lecture, even though situations involving the airways kill more quickly, epidemiologically, hemorrhage is what kills the most in trauma. Thus the primary survey to evaluate the respiratory system is known as (x)ABC. What does "(x)ABC" mean?
2.) This is what tFAST stands for
3.) List the 3 sites to look at on a tFAST when a patient presents for trauma
1.) What is: X = exsanguinating hemorrhage; A = Airway; B = Breathing; C = Circulation.
2.) What is: thoracic Focused Assessment with Sonography for Trauma (tFAST)
3.) What is: 1 - Diaphragmatic hepatic site; 2 - Chest tube site; 3 - Pericardial site.
1.) These are the 4 main steps involved in managing patients presenting for intoxication/poisoning.
2.) Contraindications for inducing emesis.
3.) You're administering activated charcoal to a patient you believe ingested a toxin. This is the reason it is important to place the patient on fluids while administering activated charcoal (especially in conjunction with cathartics like sorbitol).
1.) What is: 1 - Decontamination; 2 - Reduce absorption; 3 - Reversals; 4 - Fluids.
2.) What is: Sharp, corrosive materials. Depressed mentation or airway impairment (unable to protect airways).
3.) What is: Activated charcoal can make the patient dehydrated (and so can the cathartics especially!) and cause electrolyte disturbances. Thus you should put the patient on fluids to mitigate these effects of reducing toxin absorption.
An owner with asthma brings her dog to you because she found her inhaler with bite marks all over it, and there was very little medication left in it for her to use it for herself. Thus, she's concerned the dog ingested or inhaled her asthma medication. This is the toxicity you're most concerned about; and this is why you're concerned about it being a problem. There are also 3 general things you should also consider in terms of treatment/management.
What is:
- Albuterol toxicity
- Albuterol-induced hypokalemia: β-adrenergic receptor stimulation of membrane bound Na-K-ATPase in erythrocytes, liver, and muscle cells -> Intracellular influx of circulating potassium: Hypokalemia, Arrhythmias, lethargy.
- Decontamination if possible, beta blockers (propranolol/atenolol) to counter the arrhythmia effects, potassium supplementation to counter the hypokalemia
1.) This term means a severe imbalance between oxygen supply and demand, leading to inadequate cellular energy production, cellular death, and multiorgan failure.
2.) Poor tissue perfusion can come from ___ blood flow or unevenly ______ blood flow. Poor perfusion is going to lead to a build up of lactic acid, which if not treated can result in MODS and death.
3.) List clinical signs of shock
1.) What is: Shock
2.) What is: low, distributed
3.) What is: Tachycardia (dogs)/Bradycardia (cats), Prolonged CRT (> 2 sec)/CRT < 1 sec, Pale/muddy/cyanotic/injected mucous membranes, Weak/bounding/thready,/asynchronous pulse, ↓ Bowel sounds, ↓Urine output, Cold extremities, Altered mentation (dull), high lactate
With lower airway disease, animals with bronchopneumonia (coarse crackles), pulmonary fibrosis, pulmonary edema (fine crackles), or pleural space disease (short breath) increase their respiratory rate and thus respiratory work of breathing. If prolonged, it will lead to respiratory muscle _____. _______ muscles will then get recruited, causing outward movement of the abdominal wall during expiration. These chest and abdominal wall movements are the opposite of those seen normally: paradoxical movements. The presence of this clinical sign can help to prompt the implementation of appropriate emergency diagnostic and therapeutic procedures.
What is: fatigue, Abdominal
1.) When evaluating the respiratory system via (x)ABC in response to trauma, this is what we're looking for/assessing/doing when we're doing the "A".
2.) When evaluating the respiratory system via (x)ABC in response to trauma, this is what we're looking for/assessing/doing when we're doing the "B".
3.) When evaluating the respiratory system via (x)ABC in response to trauma, this is what we're looking for/assessing/doing when we're doing the "C".
1.) What is: Airway: Does the patient have an open/unobstructed airway? -> Endotracheal intubation (or V-Gel Supraglottic Airway Device which goes in the esophagus or emergency tracheostomy in the unusual cases when intubation is unsuccessful)
2.) What is: Breathing: Is this patient breathing normally or are they in respiratory distress? (increased respiratory rate/effort, cyanosis, pale mucous membranes) -> Give supplemental oxygen (many ways to do this), obtain SpO2 or PaO2, and perform a tFAST
3) What is: Circulation: Is the blood circulation system adequate to provide adequate tissue perfusion? (Tachycardia, poor/bounding pulse, prolonged CRT, pale/muddy mucous membranes) -> IV catheter to get minimum database and start fluids; check blood pressure; look for hemorrhage. If hypotensive/hypovolemia/poor perfusion (indicated by high lactate), then administer a fluid bolus. Perform an aFAST.
1.) 2 main types of rodenticides involved in rodenticide poisoning in small animals.
2.) Even small doses of xylitol in dogs induce an exaggerated ____ release that is 3-7 times than that caused by dextrose
3.) These are the 3 stages of ethylene glycol toxicosis.
1.) What is: Anticoagulant, Neurotoxic.
2.) What is: insulin
3.) What is: 1 - CNS depression; "drunk"; ataxia. 2 - Metabolic acidosis. 3 - Oliguric renal failure
Owner is worried about her cat who seems 'off'. She noticed the cat chewing on some of her house plants, but didn't think anything of it until the cat started making multiple, frequent trips to the litter box and even peeing a little bit outside of the litter box, which is abnormal for the cat. The cat appears depressed upon presentation and does not feel well. You're concerned about potential toxicity especially after bloodwork reveals elevated kidney values and the owner shows you a picture of the her flowering plants that the cat was chewing on. So, you promptly decontaminate the GI tract and provide supportive therapy, such as fluids, for renal failure. This is the most likely toxicity and what is happening in the kidney to have such clinical signs.
What is: Lilly toxicity! Toxic tubular necrosis.
1.) Dehydration, Vomiting/Diarrhea (parvo, FB), Polyuria (DM, Hyperadrenocorticism/Cushing's Disease, AKI), and Third spacing (pancreatitis, peritonitis) can lead to ___ loss, leading to Non-hemorrhagic _______ Shock.
2.) Trauma, Hemoabdomen (splenic mass, trauma), GI bleeding, and Post-operative hemorrhage can lead to ____ loss, leading to ________ Hypovolemic Shock.
3.) In general, this is the first line treatment for hypovolemic shock as we're trying to stop the losses.
1.) What is: fluid, Hypovolemic
2.) What is: blood, Hemorrhagic
3.) What is: IV fluid bolus with isotonic crystalloid fluids
1.) List 3 ways to measure blood pressure in our veterinary patients
2.) 2 general ways to increase blood pressure; and which why should you always try FIRST
3.) 4 vasoactive catecholamines that can be used to increase blood pressure (though not all are really used in vet med)
1.) What is: 1 - Arterial line (gold standard but usually not at ER admission); 2 - Doppler; 3 - Oscilometric.
2.) What is: Fluids, Blood products OR Fluids + Vasopressor. NEVER give meds to increase BP BEFORE fluids!!! Increase the volume first!
3.) What is: Dopamine, Dobutamine, Norepinephrine, Vasopressin
1.) If a patient has pneumonia, pulmonary contusion, or pulmonary edema, then you would likely see this on POCUS that would indicate that.
2.) You identify pleural effusion (or pericardial effusion) on POCUS. This should be your very next step.
3.) This is the purpose of performing an aFAST.
3.) You identify free fluid in the abdomen. It is mostly likely due _______ in a patient with a history/presenting for trauma. Your very next move should be __________.
1.) What is: B lines (which means wet lung)
2.) What is: Thoracocentesis
3.) What is: Check for free fluid in the abdomen.
4.) What is: Hemorrhage, abdominocentesis
1.) True or False. We typically consider 3 stages to ethylene glycol toxicity in our veterinary species; however, death can occur at ANY stage.
2.) Reason why decontamination (vomiting/charcoal) is not usually helpful with ethylene glycol toxicity.
3.) This is the treatment of choice in dogs with ethylene glycol toxicity, which prevents the metabolism of the ethylene glycol
1.) What is: True!
2.) What is: Rapidly absorbed (so already absorbed by the time you try to get it out of the GI tract)
3.) What is: Fomepizole
A 2 yr F/S Labrador retriever presents to you for seizure, which started acutely earlier in the day. Over the phone, while the owner is on the way, she mentions the dogs seems lethargy, weak, and has tried to throw up a couple of times. While you're approaching the owner/dog since they just arrived, the dog has a seizure on you. With permission, you quickly rush back with the dog to administer benzodiazepines, such as diazepam, to stop the acute onset of seizure. While performing your primary survey (Resp., CV, Neuro), you notice a lime green sticky substance in multiple places of the dog's mouth. Bloodwork reveals severe hypoglycemia. The owner admits she recently bought chewing gum (in the same lime green color). This is the most likely toxin; and this is your first step in treatment. This is the most likely reason for the acute seizure history.
What is: Xylitol toxicity; IV dextrose fluids (to correct the glucose!). Hypoglycemia -> Acute onset of seizures!
1.) This is the common recommended shock dose to administer in an IV bolus to small animals
2.) This is one of the most important things to do when a patient is in a state of hypovolemic or hemorrhagic shock (aside from administering fluids to replace volume in the intravascular space)
1.) What is: 10 - 20 ml/kg over 10 to 30 minutes
2.) What is: Stop the losses/bleeding! (you can't feel a leaking bucket!)
1.) (*Super Important!) These are the main locations you should automatically name for the following adrenergic receptors, respectively: alpha-1, beta-1, and beta-2.
2.) This is drug acts on all alpha-1, beta-1, and beta-2 adrenergic receptors to induce vasodilation, which is why it is the drug of choice for anaphylaxis.
1._ What is: Vessels (alpha-1), Heart (beta-1), and Lungs (beta-2)
2.) What is: Epinephrine
1.) Trauma can result in immediate death. Vital ____ are usually involved (like brain, spinal cord, heart) Prevention is key! To treat, the patient will likely need to go to a specialty facility that has all the crazy expensive life-saving gadgets and gizmos.
2.) Trauma can result in ___ death. To save the patient, we're going to perform a primary survey ((x)ABC) which is likely going to be followed up by surgery and emergency procedures. Hemorrhage can be involved to that we need to stop ASAP.
3.) Trauma can result in late death. This is going to be from underlying complications resulting in ____, septic shock, or multiple organ dysfunction syndrome.
1.) What is: organs
2.) What is: early
3.) What is: sepsis
1.) Albuterol is a _____-adrenergic receptor agonist that acts via cAMP resulting in relaxation of _____ muscle. It is commonly used as a _________ in human and veterinary patients.
2.) Reason decontamination may not be possible for a patient that ingests or inhales albuterol.
3.) 2 main toxic components of chocolate to dogs
1.) What is: Beta-2, smooth, Bronchodilator
2.) What is: Albuterol is rapidly absorbed!
3.) What is: Theobromine and Caffeine
You have a cat that presents to you very sick. You ultrasound the kidneys and see: Increased renal cortical and medullary echogenicity, with lower echo intensity at corticomedullary junction (i.e. “halo” sign). Bloodwork indicates: metabolic acidosis, azotemia, hyperphosphatemia, hypocalcemia (and some other things). Urinalysis shows: Calcium oxalate crystalluria, Isothenuria, acidic urine (and some other things). This is the most likely toxicity.
What is: Ethylene glycol toxicity!
Important Key Concepts about Hypovolemic Shock:
Shock = inadequate tissue perfusion (↓DO₂;↑VO₂).
- ________ shock = loss of intravascular volume
- ________ shock = hypovolemic + loss of oxygen-carrying capacity
Compensatory mechanisms happen _____ BP drops. ____ recognition saves lives! Perfusion parameters will be abnormal BEFORE low BP/high lactate
- Treat the cause (“You can’t fill a leaking bucket”) + restore volume + preserve _____ delivery
What is: Hypovolemic, Hemorrhagic, before, Early, oxygen
1.) Oxygen delivery to tissues is based on these 2 main factors (*Hint: There was a flow chart connecting all the things that impact oxygen delivery)
2.) The arterial oxygen content is reduced in hemorrhagic shock because of _______ loss and thus less oxygen-carrying capacity.
3.) This is how many oxygen molecules hemoglobin can carry
1.) What is: Cardiac Output (CO), Arterial Oxygen Content (CaO2)
2.) What is: Hemoglobin
3. What is: 4