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Triage is the art of assigning priority to emergency patients and their problems based on rapid assessment of historical and physical parameters (see Evaluation and Initial Treatment of the Emergency Patient: Parameters to Evaluate During Triage ). Several historical or observed problems warrant transfer of the animal to the treatment area regardless of physical findings. These problems include known or suspected trauma, poisonings, profuse vomiting or diarrhea, urethral obstruction, labored breathing, cardiopulmonary arrest, seizures, loss of consciousness, severe alterations in mental state, acute inability to walk, excessive bleeding, prolapsed organs, potential snake bite, heat prostration, open wounds exposing extensive soft tissue or bone, anemia, burns, dystocia, shock, and disease that may rapidly decompensate such as gastric dilatation and volvulus.
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Table 1
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Parameters to Evaluate During Triage |
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Parameter
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Evaluation
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Significance
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Mucous membrane color
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Pink
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Normal PCV and adequate perfusion
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Pale or white
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Anemia or shock
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Cyanotic
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Severe hypoxemia
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Yellow
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Increased serum bilirubin due to hepatic disease or hemolysis
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Capillary refill time
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1–2 sec
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Normal perfusion and rapidity with which capillaries refill with blood
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>2 sec
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Poor perfusion or peripheral vasoconstriction
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<1 sec
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Hyperdynamic states; could be associated with fever, heat stroke, distributive shock, or early compensatory stage of hypovolemic shock
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Heart rate
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70–120 bpm (small dogs)
60–120 bpm (large dogs)
120–200 bpm (cats)
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Normal heart rates; indicate that at least one component of cardiac output is normal
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Bradycardia
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Decreased cardiac output and subsequent poor perfusion; cats in particular will develop bradycardia (<120 bpm) in shock; an irregular, slow heart beat can be associated with imminent cardiac arrest or conditions such as sick sinus syndrome, severe hyperkalemia
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Tachycardia (dogs >180 bpm, cats >220 bpm)
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Compromised diastolic filling; sinus tachycardia often results from hypovolemic shock or pain; tachycardia that is irregular or associated with pulse deficits usually indicates an arrhythmia, and an ECG is indicated
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Pulse rate and quality
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Strong and synchronous with each heart beat
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Normal; both femoral and digital pulses should be palpated
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Irregular
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Usually indicative of a cardiac arrhythmia
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Bounding
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Hyperdynamic state of shock
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Weak or absent
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Decreased cardiac output, peripheral vasoconstriction, or decreased pulse pressure
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Level of consciousness
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Alert and responsive to surroundings
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Normal overall neurologic and metabolic state
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Depressed (less responsive to visual and tactile stimuli, sleepy appearance but still arousable)
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Can be caused by any illness
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Stupor (arousable only with painful stimuli)
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Severe neurologic or metabolic derangements
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Comatose (unarousable with any stimuli) or seizures (usually associated with whole body convulsions, salivation, facial tremors, possibly involuntary urination and defecation)
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Abnormal cerebral electrical activity from primary neurologic disease or secondary to metabolic derangements seen in diseases such as diabetes, hepatic encephalopathy, hypoglycemia, or toxin exposure; accurate history or prior health problems, current medications, and possible toxin exposure important
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Airway, breathing, and circulation are evaluated sequentially, followed by examination for sources of hemorrhage, and determination of the level of consciousness and level of pain. The most common reasons for an animal in catastrophic distress include: 1) airway—airway obstruction or disruption; 2) breathing—cyanosis from tension pneumothorax, alveolar flooding (edema fluid or blood), severe bronchoconstriction with air trapping or brain-stem pathology affecting ventilation; and 3) circulation—cardiopulmonary arrest, extreme brady-arrhythmias or tachyarrhythmias, cardiac tamponade, and acute intravascular volume loss usually due to internal or external hemorrhage.
Airway
Life-threatening airway pathology (catastrophic or severe) includes complete large airway obstruction and partial obstruction of the large and small airways.
Diagnosis
Animals with complete large airway obstruction are unconscious and apneic. Partial large airway obstruction causes noisy breathing (stridor or stertor), heard without the aid of a stethoscope. Cyanosis and anxiety are often present with loud referred airway sounds heard throughout the thorax on auscultation. Compromise of the extrathoracic airway (nasal passages, pharynx, larynx, or cervical trachea) causes inspiratory stridor; compromise of the intrathoracic trachea or bronchi causes expiratory stridor. Possible causes of large airway pathology include foreign bodies, edema, laryngeal paralysis or paresis, tracheal collapse, elongated soft palate, aspiration of stomach contents, neoplasia, and pharyngeal hematomas. Animals with severe small airway obstruction have labored breathing with an expiratory push of the diaphragm, cyanosis, and anxiety. Auscultation reveals high-pitched wheezes throughout the lung field. In severe life-threatening situations, the animal is cyanotic, open-mouth breathing, collapsed, and asphyxiating. Common etiologies include anaphylactic reactions; asthma (cats); and bronchial obstruction from edema, mucus, exudates, or foreign material.
Treatment
Unconscious, apneic animals require immediate tracheal intubation. If the upper airway is obstructed, oxygen can be supplemented by a transtracheal catheter inserted below the obstruction until a tracheotomy is quickly performed. Once an airway is established and secured, ventilation is initiated with 100% oxygen via an ambu bag. Should auscultation during ventilation detect absent or muffled lung sounds indicative of pleural fluid or air, immediate thoracocentesis is warranted. Heart sounds and pulses are checked and when absent, cardiopulmonary-cerebral resuscitation (see Specific Diagnostics and Therapy: Cardiopulmonary-Cerebral Resuscitation) is initiated.
With partial large airway obstruction, flow-by oxygen is delivered through oxygen tubing at a high flow rate aimed at the open, panting mouth until an airway is secured. Heavy sedation using a narcotic/tranquilizer combination may be used to relieve anxiety and struggling, to allow a cursory examination of the pharynx and larynx, and to remove pharyngeal foreign bodies. When tracheal intubation is necessary, general anesthesia (eg, etomidate, ketamine/diazepam, propofol) should be induced rapidly. The ability of the laryngeal cartilages to abduct during inspiration should be assessed during intubation. A tracheotomy is necessary when pharyngeal, laryngeal, or tracheal pathology prevents orotracheal intubation or when prolonged intubation is anticipated. A transtracheal catheter can be used to provide oxygen support during stabilization. When the airway pathology lies within the thoracic cavity, airway patency must be established down to the bifurcation of the trachea.
Cyanosis from small airway obstructive disease is treated by providing oxygen by flow-by, hood, or nasal cannula and sedation with a narcotic/tranquilizer combination. Epinephrine is given for its bronchodilatory effects both in anaphylaxis (0.01–0.02 mg/kg, IV) and in life-threatening asthma (0.02 mg/kg, IM). Corticosteroids (prednisone sodium succinate, 15 mg/kg, IV, or dexamethasone, 2–4 mg/kg, IM or IV) are given for allergic bronchitis or asthma. Other bronchodilators, such as aminophylline or terbutaline, are given IM, or albuterol can be given by nebulization in the case of an animal in crisis.
Breathing
Diagnosis
Compromised breathing in both dogs and cats manifests with an increased respiratory rate and effort, immediately followed by a change in the respiratory pattern. Postural changes (orthopnea) follow; dogs stand with the elbows abducted and the back arched or high on the rear haunches with the head and neck extended, while cats may sit crouched on all 4 limbs with the sternum slightly elevated. Obvious labored, open-mouth breathing and cyanosis develop last and indicate significant loss of pulmonary function and impending pulmonary arrest.
The location of the pathology—pleural space or parenchymal disease—can be determined at presentation by careful observation of the breathing pattern and auscultation of the thorax. This will direct resuscitative efforts. Taking radiographs or performing stressful diagnostic procedures before the animal has been stabilized can lead to rapid decompensation.
Pleural space disease causes dysynchronous breathing. The chest expands on inspiration as the abdomen is pulled inward, then the chest moves inward on expiration as the abdomen expands. In cats, breathing is slower and more deliberate than in dogs. The respiratory pattern is the same whether air, fluid, or abdominal contents are in the pleural space. Thoracic auscultation reveals muffled lung sounds over the affected regions.
Lung parenchymal disease causes quiet, smooth breathing, with the chest and abdominal wall moving in the same direction. Inspiration and expiration are equally labored unless concurrent small airway edema or constriction adds an expiratory push. Cats demonstrate rapid, shallow synchronous breathing with active movement of the cupula. Thoracic auscultation reveals louder than normal lung sounds in early phases. As disease progresses, harsh lung sounds with moist crackles and rales are heard over the affected lungs. The most common cause of lung parenchymal disease is pulmonary edema. Other abnormalities to exclude include CNS disease, pneumonia, aspiration, pulmonary contusions, or hemoglobin abnormalities. Rapid evaluation of the heart for a murmur, gallop, or arrhythmia aids in identifying cardiogenic versus noncardiogenic causes of the parenchymal pathology. Noncardiogenic causes of pulmonary edema include seizures, post-choking, near-drowning, electrocution, acute lung injury, or respiratory distress syndrome.
Treatment
Oxygen is administered immediately via flow-by, mask, hood, or plastic bag techniques. Sedation with a narcotic/tranquilizer combination can relieve struggling and anxiety. Longterm continuous supplemental oxygen is best provided by a nasal oxygen catheter. The intranasal oxygen catheter is placed after topical anesthetic has been instilled into the nostril where the tube is to be inserted. Nasal oxygen flow rates of 50–100 mL/kg/min deliver 40–60% inspired oxygen while allowing the animal to be examined and treated. Nasopharyngeal or nasotracheal catheters or bilateral nasal cannulas may provide higher percentages of inspired oxygen. If cyanosis and decompensation persist or work of breathing is profound, intubation and positive-pressure ventilation with 100% oxygen is necessary.
Catastrophic pleural space disease with rapid cardiovascular decompensation, absent lung sounds throughout the thorax, and a barrel-shaped chest suggests tension pneumothorax. Lidocaine is injected for local anesthesia, and a small skin incision is made between ribs (at the seventh to eighth intercostal space). Hemostats are used to enter the pleural space, relieving the tension within the thorax. This allows cardiovascular filling and lung re-expansion. The open pneumothorax is then managed by placing a chest tube and surgically closing the intercostal incision.
When breathing is severely compromised by pleural air or fluid without tension pneumothorax, the pleural space should be drained by thoracocentesis. The intended site is clipped and aseptically prepared (when time permits). If fluid is expected, the needle is inserted ventrally between the sternum and the costochondral junction. When air is to be recovered, the needle is inserted into the dorsal half of the thorax, above the costochondral junction. A local anesthetic is placed into the skin, subcutaneous tissue, and intercostal muscle at the site to be tapped. After the needle is inserted just through the skin, a drop of saline is placed in the hub of the needle. The needle is then gradually inserted straight into the thorax (with the needle perpendicular to the chest wall) until the saline in the needle hub moves. The movement of the saline in the hub indicates that the pleural space has been entered. The needle is immediately directed so that it lies against the parietal pleura. This prevents laceration of the lung by the needle as the lung re-expands. As soon as the pleural space is entered, the evacuation apparatus (usually an IV extension set, 3-way stopcock, and syringe) is attached and aspiration begins. In animals in which the pleural space cannot be emptied (eg, tension pneumothorax, ongoing hemorrhage) or when repeated chest taps are required within minutes to hours, an indwelling chest tube should be placed for continuous closed suction.
Lung parenchymal disease is primarily treated using oxygen supplementation, diuretics (furosemide, 1–4 mg/kg, IV), and sedation to relieve anxiety. Cardiogenic edema is usually associated with a gallop, murmur, or arrhythmia (determined by auscultation) and can benefit from venodilation from nitroglycerin ointment (¼ in. for cats and ½ in. for larger dogs) applied topically to a shaved area of the abdomen, inguinal region, or directly to a mucous membrane. After initial stabilization, further diagnostic procedures (eg, thoracic radiography and echocardiography) aid in determining the cause and specific therapy.
If respiratory failure is imminent with pulmonary fluid visible in mouth or nares, intubation, airway suctioning, and manual ambu bag ventilation with 100% oxygen are required. Elevated or postural pulmonary parenchymal evacuation (EPPE) can be performed with ≥2 people elevating the pet vertically, head down, while guarding the endotracheal tube. The thoracic cavity is manually compressed to assist airway and lung fluid drainage. Manual ventilation with 100% oxygen should be performed between EPPE efforts.
Circulation
Diagnosis
Animals with circulatory compromise have alterations in their physical perfusion parameters (ie, heart rate, mucous membrane color, capillary refill time [CRT], rectal temperature, and pulse quality). Careful auscultation of the heart for a murmur, gallop, arrhythmia, or muffled heart sounds and of the lungs for evidence of fluid is important to help identify heart failure as a cause of poor perfusion. Measurement of arterial blood pressure and central venous pressure provide objective data for reaching resuscitation endpoints and monitoring trends of change after resuscitation.
In the early compensatory stages of hypovolemic shock in dogs, there is a rapid heart rate, pink to red mucous membranes, rapid CRT, and bounding pulses. This stage is rarely seen in cats unless there is significant pain. As the pathology progresses, dogs begin to have pale mucous membranes, prolonged CRT, weak pulses, and tachycardia—the classic signs of the middle or early decompensatory stage of shock. Cats have gray mucous membranes, slow CRT, weak or absent pulses, hypothermia, and a normal or low heart rate. As shock approaches the terminal stages, the heart rate slows in both dogs and cats, and animals begin to lose consciousness. Clinical signs in this terminal stage include heart failure, pulmonary edema, severe hypotension, oliguria, and abnormal respiratory patterns. Cardiopulmonary arrest is a common sequela.
Treatment
The therapeutic goal is to deliver oxygen and substrate to the tissues. This requires a heart that effectively pumps blood and adequate hemoglobin, intravascular volume, vascular tone and patency, as well as sufficient oxygen and substrate. General guidelines for treatment of hypovolemic and distributive shock are described below, but modifications may be needed for specific animals or disease processes.
Oxygen Supplementation
Oxygen (at least 40–60% inspired concentration) should be administered by flow-by technique, mask, hood, nasal cannula, endotracheal tube, or transtracheal catheter.
Hemostasis
Control of ongoing hemorrhage is essential for stabilization and often required before restoration of circulation. The animal must be carefully examined on both sides for any evidence of external hemorrhage. Direct pressure should be immediately placed over the bleeding skin site, and bleeding arteries clamped. When blood slowly oozes from a skin wound, a compression bandage should be placed. If more aggressive hemostasis is required, a pneumatic cuff or tourniquet can be temporarily placed above the bleeding site until hemorrhage stops.
Intrathoracic or abdominal hemorrhage may not become evident until blood pressure and circulation are restored. The focused abdominal sonography for trauma (FAST) technique is recommended to rapidly identify free abdominal fluid, focusing the probe on the ventral midline caudal to the xiphoid, over the urinary bladder, and on the right and left dependent flank regions.
Ongoing abdominal hemorrhage is initially managed by small volume fluid resuscitation to low normal endpoints and abdominal counterpressure (see below). Ongoing intrathoracic hemorrhage should be managed with a chest tube to evacuate the blood and to allow measurement of the volume lost. Exploration of these body cavities is often required for assessment and definitive hemostasis.
Intravascular Volume Replacement
Intravenous or intraosseous catheters are used, with multiple catheters placed for rapid, large volume infusion in dogs >30 kg body wt. Isotonic crystalloids can be administered by repeated low volume boluses (10–15 mL/kg) until desired endpoints of resuscitation are reached (eg, low normal cardiovascular parameters). However, the interstitium is at risk of fluid overload with crystalloids alone. The concurrent use of colloids and crystalloids can reduce the amount of crystalloid required, rapidly expand the intravascular space with a smaller volume of fluid infused, and reduce the amount of fluid extravasating into the interstitial spaces of vital organs (eg, lung, brain). Isotonic crystalloids are given with hetastarch or stroma-free hemoglobin. Whole blood, stroma-free hemoglobin, or packed red cells are necessary during initial volume resuscitation when hemorrhage has been significant.
Small volume resuscitation to low normal endpoints (measured perfusion parameters) is used to avoid volume overload or hypertension and is ideal for animals with head injury, pulmonary edema or contusions, abdominal or intrathoracic hemorrhage, heart disease, and all cats in hypovolemic shock. Isotonic crystalloids are given (10–15 mL/kg, IV), followed by hetastarch or stroma-free hemoglobin (dogs 5 mL/kg, IV; cats 1–5 mL/kg, IV, slowly), repeating the colloid infusion, to effect. The least amount of crystalloids and colloids possible are used to obtain and maintain a systolic blood pressure of 90 mm Hg, lower heart rate, and improve CRT and pulses. For an in-depth explanation, see Fluid Therapy.
Pain Control
Analgesia is provided during initial fluid resuscitation for optimal cardiovascular response and relief of anxiety. Narcotics are administered systemically, and local anesthetics can be infiltrated into the affected area. (Also see Pain Assessment and Management.)
Warming
Animals in shock should be warmed during fluid resuscitation until rectal temperatures are >98°F. This is best accomplished by increasing the environmental temperature using warm air blowers or hot water bottles with blankets and warm water blankets. Gastric, peritoneal, or urinary lavage may be needed for severe hypothermia. Surface warming is instituted only after initial volume resuscitation has provided enough intravascular volume to offset the peripheral vasodilation.
Corticosteroids
Corticosteroids are administered when a deficiency is suspected (ie, Addisonian crisis, relative adrenal insufficiency). High-dose steroid administration has not been proved to improve mortality in hypovolemic, septic, or cardiogenic shock and has been associated with increased morbidity, so it is not recommended.
Cardiovascular Support
Pharmacologic agents (positive inotropes, systemic vasodilators, and vasopressors) can be used when fluid infusion has adequately replaced intravascular volume (ie, central venous pressure >5–8 cm H2O) but fails to restore blood pressure and perfusion, or when poor cardiac contractility is thought to contribute to hypotension. A positive inotropic agent can be administered (eg, dobutamine, initially at 2–5 μg/kg/min, and the dosage titrated for optimal cardiac output). Stroma-free hemoglobin (dogs 5 mL/kg; cats 1–3 mL per cat, slowly) can be administered, and repeated as indicated, for its colloid effect as well as its mild pressor effect. The initial resuscitation doses may be followed by a slow constant rate of infusion (dogs 10–15 mL/kg/day; cats 1–3 mL/hr up to 5 mL/kg/day) to maintain perfusion if the initial dose was successful and further support is anticipated. Dopamine (5–20 mg/kg/min, IV, constant rate infusion) is another option that can be infused for vasopressor effects and delivered in the smallest dosage needed to maintain arterial systolic pressure >90 mm Hg. The blood flow to the kidneys and GI tract, as well as other organs, may have been significantly impaired during shock. Urine output, heart rate, blood pressure, ECG, pulse intensity, and mucous membrane color should be closely monitored because further vasoconstriction can worsen function. If organ function declines or if arrhythmias become a problem, the IV drip should be stopped; the effects of dopamine should reverse within 5–10 min.
Hind Limb and Abdominal Binding
When ongoing abdominal hemorrhage is suspected from trauma, hind limb and abdominal counterpressure can improve perfusion. This procedure compresses the arteries and arterioles within the bound regions, increasing regional vascular resistance, and produces abdominal tamponade, thereby effectively slowing or arresting hemorrhage and redirecting blood flow from the periphery to the more central (core) circulation. Hind limb and abdominal counterpressure can be performed by first placing a rolled towel or rolled cotton between the legs and along the ventral midline of the abdomen. This prevents the wrap from impairing ventilation or fracturing the spleen or liver. If time permits, a urinary catheter is placed. The hind limbs and abdomen are then firmly wrapped with padded bandage material or towels, beginning at the toes of the hind limb and moving cranially toward the xiphoid. The bandage should be secured with tape or stretch bandage material wrapped in a spiral pattern starting caudally and moving cranially. Abdominal binding should be avoided in cases of intrathoracic or intracranial hemorrhage. Once perfusion has stabilized, the wrap is removed slowly by sections (releasing one section every 15 min) from the abdomen, moving caudally. Any signs of decompensation warrant rapid rebinding of the region last unwrapped.
Last full review/revision March 2012 by Rebecca Kirby, DVM, DACVIM, DACVECC; Andrew Linklater, DVM, DACVECC
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