ICU/ER - Respiratory Distress
You have a patient in that presents to you for emergency. You're going to perform your primary survey first and foremost RAPIDLY.
1.) These are the 3 systems you're evaluating when doing this.
2.) This is the reason you're evaluating those 3 systems FIRST in an emergency.
3.) You have a patient that presents to you comatose/non-responsive, this is the FIRST thing you're going to do after you quickly walk back to the E.R. as fast as possible with the patient.
1.) What is: Cardiovascular, Respiratory, Neruologic
2.) What is: These are the main systems that can KILL your patient (quickly), so you want to assess them first.
3.) What is: Intubate immediately!!! (to protect airways from aspiration pneumonia)
1.) Explain the importance/limitation of use cyanosis to determine if a patient is hypoxemic
2.) Assuming a patient has enough RBCs, what amount of deoxygenated hemoglobin in each 100 mL of arterial blood (1 dL) constitutes a patient as cyanotic?
3.) True or False. A dog/cat with anemia (like PCV 10%) almost never becomes cyanotic because there is not enough hemoglobin for 5g of hemoglobin to be deoxygenated in 100 ml of arterial blood.
1.) What is: Cyanosis means a patient is SEVERLY hypoxemic. HOWEVER, if a patient has to have enough RBCs to show the blue color! If a patient is too anemic (so they don't have enough RBCs), then you're not going to see cyanosis (blue color) even though the patient is very much hypoxemic!
2.) What is: 5g
3.) What is: True
1.) Explain the difference between between hypoxia versus hypoxemia
2.) Can a patient be hypoxic but NOT hypoxemic? Explain/give scenario(s) if so.
3.) Can a patient be hypoxemic but NOT hypoxic? Explain/give scenario(s) if so.
1.) What is: Hypoxia = Insufficient oxygen reaching the tissues/cells. Hypoxemia = Insufficient O2 in arterial blood.
2.) What is:
3.) What is:
1.) This diagnostic tool is a graphic representation of the electrical activity of the heart used to diagnose arrhythmias.
2.) On an ECG, the P-wave means this.
3.) On an ECG, the QRS complex means this.
4.) On an ECG, the T-wave means this.
1.) What is: Electrocardiogram (ECG)
2.) What is: Atrial depolarization
3.) What is: Ventricular depolarization
4.) What is: Ventricular repolarization
You have a dog that is having breathing issues. You performed your primary survey (where you evaluated the respiratory system), you sedated the patient with butorphanol since they were in respiratory distress and did not see anything abnormal with their upper airways. You have stabilized the patient, and are still trying to figure out what's going on. While examining/touching the patient, you notice that it's holding its neck stiff and doesn't want you touching its head/neck. Based on what you have read, what could be a possible connection you could make to explain what is going on and why the patient seems to not be able to breathe well and is suffering from the effects of that.
What is: In dogs, cervical nerves (7, 6, and 5) innervate the diaphragm. A dog with a neck injury could have damaged those nerves as well, which is impairing the diaphragm from working properly, which is why you're seeing the breathing issues and associated effects of not being able to breathe properly.
1.) Once your primary survey is complete (where you QUICKLY evaluated the respiratory, cardiovascular, and neurologic system), these are the "Big 4" parameters we always want to evaluate in our E.R. patients.
2.) When thinking about the respiratory system:
- the respiratory center is located in this region of the brain
- these nerves innervate the diaphragm and keep a dog alive!
3.) Match whether an INspiratory issue versus and EXpiratory issue is usually associated with the upper versus lower airways.
1.) What is: Blood Glucose, Total Protein/Packed Cell Volume (TP/PCV), Lactate, and Azo Stick
2.) What is:
- medulla
- C7, C6, and C5 (keep the diaphragm alive in dogs)
3.) What is: Upper airways tend to be involved in INspiratory issues. Lower airways tend to be involved in EXpiratory issues.
1.) A 4 yr M/N DSH cat presents HBC. The cat has very short breaths and cyanosis. Via radiographs, you diagnose pneumothorax. This should be your next move.
2.) This term represents the ability of lungs to exchange O2 for CO2.
3.) This term represents the process of providing oxygen to blood/tissues.
4.) This is goal of evaluating the cardiovascular system (the thing you're trying to identify).
1.) What is: Thoracocentesis (tap the chest!).
2.) What is: Ventilation.
3.) What is: Oxygenation.
4.) What is: The goal is to identify poor perfusion.
1.) List 5 causes of hypoxemia
2.) Give some examples of each cause of hypoxemia
1.) What is: 1 - Low inspired oxygen (FiO2); 2 - Hypoventilation; 3 - V/Q mismatch; 4 - Right to left shunt; 5 - Diffusion impairment.
2.) What is:
1.) This value on the ECG represents the electrical activity/sensitivity of the ECG.
2.) This is the standard sensitivity (amplitude) on an ECG in vet med.
3.) In vet med, this is the typical amount of leads used in an ECG.
4.) In an ECG: Lead __ compares right front to left front. Lead __ compares right front to left rear. Lead __ compares left front to left rear.
1.) What is: Amplitude
2.) What is: 1 cm/mV
3.) What is: 3 leads
4.) What is: 1, 2, 3
1.) A cat was in respiratory respiratory distress, so you gave it butorphanol (opioid sedation). Afterwards, you notice the cat seems obtunded and is not as bright/alert as it was when it first entered the E.R., but you're not sure because you didn't complete your neurologic evaluation before giving the sedation. What went wrong in this scenario, and what do you need to make sure you intentionally do the next time to prevent this confusion/uncertainty from happening again?
1.) What is:
- Wrong: You didn't evaluate neuro BEFORE sedations, so now you're not sure if the neuro signs are from the opioids or from the disease/patient issue.
- Correct: Evaluate the neurologic status of the patient BEFORE giving sedation, so you know whether the change is from the sedation or if it's an actual neuro issue.
1.) This is purpose of the upper airways in breathing, especially during inhalation.
2.) This class of sedatives are cardiovascular-safe, so we tend to use them especially in emergency cases when we don't know what all is going on and need to stabilize the patient.
3.) ___ _____ is impaired/decreased when a patient has:
- pulmonary edema or pulmonary fibrosis because the _____ of the alveolar membrane has increased.
- lung lobectomy or emphysema (damaged alveoli) because the ______ _____ of the alveoli has decreased.
1.) What is: Warm, humidify, and filter inspired air
2.) What is: Opioids!
3.) What is: Gas Exchange, thickness, surface area
The body's circulation is responsible for carrying O2 to the tissues, which is maintained by an appropriate blood ______.
Blood pressure (BP) = ____________ x Systemic Vascular Resistance (SVR).
The SVR is based on the vascular ____.
Cardiac Output (CO) = Heart Rate (HR) x __________.
The SV depends on these 3 things: ______, _______, and __________.
1.) What is: pressure, Cardiac Output (CO), tone, Stroke Volume (SV), Preload, Afterload, Contractility
1.) You should always try to characterize dyspnea (difficulty breathing) as _________ dyspnea or _________ dyspnea.
2.) Noising breathing can be classified as stertor or stridor. ______ = low pitched/snoring. ______ = high pitched. There is usually an issue with the soft palate or nares when we hear ______. There is usually a laryngeal issue if we hear ______.
3.) List 3 classic examples when dyspnea is related to an INspiratory issue in small animals
1.) What is: Inspiratory, Expiratory
2.) What is: Stertor, Stridor, Stertor, Stridor
3.) What is: Laryngeal paralysis, Brachycephalic airway syndrome, Feline URTD (Upper Respiratory Tract Disease)
1.) Your patient is hypokalemic, so you want to administer potassium IV. This is the maximum rate of infusion of potassium that you can give (without causing euthanasia)?
2.) Hypernatremia can be caused by sodium gain or fluid loss. Fluid can be lost via normovolemia or hypovolemia. Normovolemia is the loss of ___ ____. Hypovolemia is the loss of _______ fluid.
1.) What is: 0.5 mEq/kg/hr
2.) What is: pure water, isotonic
A blocked tom presents to you. You expect electrolyte disturbances, such as hyperkalemia, since he is not peeing (and bloodwork confirms this). Next, you give the cat sedation so you can place the urinary catheter so he can pee. A little while later, the cat begins to breath slower and you notice his heart rate is dropping fast. Not long after, he is comatose and you realize the cat has died. What happened? How do you prevent this from happening in the future?
What is: YOU killed the cat by giving sedation while he still had hyperkalemia. When we euthanize, we give sedation + KCl (which is essentially what happened). To prevent this from happening again, you need to lower the potassium levels FIRST before sedating to place the urinary catheter so you don't inadvertently euthanize your patient.
Explain how you would know if your patient is in a state of hypoxemia versus hypoventilation:
1.) Give the meanings of both terms
2.) Outline parameters you could look at and the cut-off values for those parameters
1.) What is:
- Hypoxemia - Insufficient/Low oxygen in ARTERIAL blood (because oxygen is in the arteries!).
- Hypoventilation - build up of CO2 in the blood because we have a reduced ability to exchange O2 for CO2 in the lungs (this happens when you're breathing slower too)
2.) What is:
- Hypoxemia: PaO2 < 80 mmHg (partial pressure of oxygen in the arterial blood from an arterial line) or SpO2 <95% (from pulse oximeter)
- Hypoventilation: PaCO2 > 45 mm hg (from arterial blood gas or venous can be used too); clinically we may see respiratory depression or shallow breaths
1.) True or False. You should avoid sedation or pain medications before assessment of the CNS.
When you use ultrasound in an emergency setting, you are using Point Of Care Ultrasound (POCUS). A component of POCUS includes a FAST scan (aFAST, tFAST) and a VetBLUE scan.
2.) This is what FAST stands for.
3.) These are the 4 sites of an aFAST (of the abdomen) that you would look at on the left and right side of the patient.
4) This is what VetBLUE stands for.
1.) What is: True
2.) What is: Focused Assessment with Sonography for Trauma (FAST)
3.) What is: 1 - Diaphragmatic hepatic. 2 - Splenorenal. 3 - Cystocolic. 4 - Hepatorenal.
4.) What is: Veterinary Bedside Lung Ultrasound Exam
1.) A sedated upper airway/oral exam is most helpful if a patient has an ____ airway issue while chest x-rays are most helpful if a patient has an ____ airway issue.
2.) Dyspnea with an expiratory issue may have an ________ component to breathing, a _______ pattern (chest wall not moving much), and typically has a ____ rate than inspiratory dyspnea.
3.) List 5 classic examples of dyspnea from an expiratory issue.
1.) What is: upper, lower
2.) What is: abdominal, restrictive, faster
3.) What is: 1 - Pulmonary edema; 2 - Pleural effusion; 3 - Pneumothorax; 4 - Aspiration pneumonia; 5 - Feline asthma
1.) A blocked tom cat can have hyperkalemia because...
2.) This is a drug we can give IV to balance hyperkalemia and protect the heart.
3.) Compare/Contrast how hyperkalemia versus hypokalemia affects aldosterone release.
1.) What is: He is not peeing! (K+ gets excreted in the urine with urinating)
2.) What is: Calcium gluconate (10% solution)
3.) What is:
- Hyperkalemia -> Aldosterone release -> K+ gets excreted in the urine in the kidney and in feces in the colon.
- Hypokalemia -> Inhibited aldosterone release -> K+ doesn't get excreted as much so K+ reabsorption occurs in the kidney and less is lost via feces as well.
1.) These factors are impaired by anticoagulant rodenticide toxicity.
2.) With anticoagulant rodenticide toxicity, will you see an increase in PT or PTT first? Why?
3.) This is the first line treatment in general for anticoagulant rodenticide toxicity.
4.) This is a common neurotoxic rodenticide poisoning that we'll see in small animals poisoning cases.
1.) What is: Factors II, VII, IX, X
2.) What is: PT (because factor VII is involved and it has the shortest half-life of 6 hours, so the PT will increase first before)
3.) What is: Vitamin K
4.) What is: Bromethalin
When you're using Pulse Oximetry (SpO2):
1.) This is what you're assessing
2.) This is the difference between oxygenated versus deoxygenated blood and what type of light they absorb best
3.) This is the ideal SpO2 we want in a patient.
4.) This is the cut-off value in SpO2 when we should DO SOMETHING
1.) What is: % of Hemoglobin saturated with oxygen (so Oxygen saturation)
2.) What is: Deoxygenated hemoglobin absorbs more red light. Oxygenated blood absorbs more infrared light.
3.) What is: 100%
4.) What is: < 95% (that's BAD)
1) You're doing a Vet BLUE scan of the _____: You see a gator sign (shadowing from the ___), A lines, and a glide sign (which rules out __________). These all indicate ______ lung. If you were to see B lines, that would indicate ___ lung (meaning there is ____ in the lungs)
2.) If you're concerned about hypovolemia or dehydration in your patient, the first thing to do is ____ therapy.
1.) What is: lungs, ribs, pneumothorax, normal, wet, fluid
2.) What is: fluid
1.) This is the gold standard for assessing oxygenation & ventilation status of our patient
2.) To assess oxygen levels in the blood, this is the type of blood sample you take.
3.) On chest radiographs, the pattern/distribution of increased opacity in the lungs can be helpful to make differential list. A ventral pattern (Right cranial, Left cranial, Right middle) suggests ________ ________. A _________ pattern suggests non-cardiogenic pulmonary edema. A perihilar pattern suggests _________ pulmonary edema. A ______ pattern suggests neoplasia/fungal disease.
1.) What is: Blood Gas Acid Base Analysis
2.) What is: Arterial blood sample only
3.) What is: aspiration pneumonia, caudodorsal, cardiogenic, miliary
1.) In a hypovolemic patient, you should restore the intravascular volume with fluids with an osmolality ______ to the patient's osmolality. Even if the patient needs lower Na+, we'll worry about lowering Na+ later, so just give the osmolality equivalent.
2.) Reason you may see hyperkalemia with metabolic acidosis
3.) Explanation/Reason why it's bad for the brain if you correct severe hypernatremia with low sodium fluids.
1.) What is: similar
2.) What is: With acidosis, H+ will move into cells in exchange for K+, so now there is more K+ outside of the cells, causing hyperkalemia.
3.) What is: High Na+ in the vessels is going to want to pull water from cells. The brain pushes the Na+ into the cells so the brain cells don't lose water. Later, the brain will make its own osmolytes to keep vessels/extracellular space salty in order to balance the the intracellular/extracellular osmolality so that the cells don't lose water and that water will be attracted to the brain in this state of dehydration. Because the brain is so salty (as compensation), if you give low sodium fluids (so hypotonic fluids), then the fluids will rush into the brain and cause cerebral edema, which is not good.
You have a patient present in respiratory distress. The patient is NOT going to have time for you to try to figure out what you should do in order to get them stabilized. Discuss the main things you're going to do/consider with a patient in respiratory distress immediately (this is not an easy question, but it's important for the patient that you don't waste time!).
What is:
1.) Give oxygen - regardless of if you know if it is a true respiratory problem, stress/pain/anxiety related, or a compensatory mechanism for another issue (there are many ways to do this; depends on how serious it is)
2.) Sedation (such as butorphanol): *** Makes sure you evaluate their neurologic system/function BEFORE you give sedation!!!
- to calm a patient in respiratory distress to help them breathe better (it's a terrifying feeling like you can't breathe, so calming the anxiety associated with it can help the patient breathe a bit better and makes them easier to handle so you can do what you need to do to help them)
- especially to be able to evaluate their upper airways (along with performing the rest of your tests/physical exam)
3.) Intubate: If you think their airway is compromised/at-risk (or that it could be), then intubate immediately with an endotracheal tube! (the patient will LOVE you for doing it too; they'll have a wide open airway)