How to prepare for...

Performing emergency medicine is a exciting challenge for the whole veterinary team. Increased public demand for state of the art emergency service obligates veterinarians and their staff to provide quality care or make direct referral to an emergency facility. The most important factor that potentially makes a difference between life and death in emergency medicine is time to treatment. Therefore it is necessary that the caregivers are trained to perform diagnostic and therapeutic steps quickly and in a organized fashion.

HOSPITAL READINESS

By pre-assigning roles and practicing responses to various life-threatening situations, valuable time is saved, and patient morbidity is decreased.

Veterinary hospital readiness consists of providing a place for receiving, assessment of and treatment of the emergent patient. The area should have basic equipment and drugs required for resuscitation of the most life-threatening conditions. Hair clippers should be in the ready area for intravenous (IV) catheter placement. IV fluids with attached intravenous administration sets can be hanging ready to use in the receiving area. It is ideal to have supplemental oxygen and suction units as well as small and large ambu bags and oxygen administration sets in near proximity of the resuscitation area.

For those practices that see a large volume of emergencies, setting up a large mobile cart housing the instruments and equipment is of great value.(Table 1) Otherwise, maintaining a tackle box with emergency equipment and drugs can be an inexpensive way to provide emergency care.(Table 2) Having a clipboard with a CPR record and an attached CPR dose schedule facilitates record keeping, billing and drug calculation and administration. Equipment and drugs should be inspected daily as well as after each resuscitation to ensure that it will be ready for the next emergency situation. Marking a check-off list, which itemizes the contents, allows anyone to perform the inspection. The equipment and drugs should be rotated with the hospital supply monthly to avoid waste due to expiration.

These preparatory measures will make any veterinary team ready for most emergency presentations. Additional preparations can be made as incoming calls are taken and information gathered.

Table 1. Emergency Equipment for a Crash Cart

 Endotracheal tubes: #3, 5, 8, 10, 14, with cuff-inflating syringes already attached and stylets in place

 Laryngoscope: large and small blades

 Emergency drugs: epinephrine, lidocaine, atropine, calcium gluconate, insulin, dextrose, sodium bicarbonate, and assorted syringes (1-, 3-, 6-, 12-cc) with needles attached

 Surgical scrub and taping material: for IV catheter placement and surgical procedures

 Drug administration: IV catheters: 14, 16, 18, 20, 24 gauge, intraosseous catheters, polypropylene tubes (for intratracheal administration of drugs)

 Chest aspiration setup: 1.5"-18 and 22 ga. needles, 3-way stop cock, extension set, 60cc syringes; #10 scalpel blade

 Stat database: capillary tubes and clay for PCV/TS, dextrose, BUN and electrolytes

 Minor surgical pack: to include instruments for emergent thoracotomy, tracheostomy, and thoracostomy tube placement

 ECG, Blood pressure with multiple cuff sizes

 Pulse oximetry, End tidal CO2

 Defibrillator:with internal and external paddles

 Suction apparatus: with Yankauer and flexible tips

 Oxygen supply dedicated to area

Table 2. Emergency Equipment for a Tackle Box

 Endotracheal tubes: #3, 5, 8, 10, 14, with cuff-inflating syringes already attached and stylets in place

 Laryngoscope: large and small blades

 Emergency drugs: epinephrine, lidocaine, atropine, and assorted syringes (1-, 3-, 6-, 12-cc) with needles attached

 Surgical scrub and taping material: for IV catheter placement

 Drug administration: IV catheters: 14, 16, 18, 20, 24ga, 3.5 and 8 french polypropylene tubes (for intratracheal administration of drugs)

 Chest aspiration setup: 1.5"-18 and 22ga. needles, 3-way stopcock, extension set, 60cc syringes; #10 scalpel blade

 Stat database: capillary tubes and clay for PCV/TS, dextrose, and BUN

FIRST AID AND TRANSPORT

Owners can provide significant medical assistance at the scene of the injury. The person taking the call must try to determine from the owner what the mentation, breathing pattern and perfusion status of the pet is at the time of the telephone conversation. (possible questions in italic)

The first concern is for the safety of the owner. Instruct the owner to survey the scene and to move to a place of safety.

Is your animal at a safe place?

When moving the animal, try to minimize motion of the head, neck and spine. Using a flat, firm board of wood, cardboard or thick fabric that provides support is a suitable method. Cats can be placed in dark boxes to minimize stress during transport. The owners should place air holes and a hole large enough for observation of the animal.

Is your animal awake or unconscious, does it respond to your commands?

If an animal is unconscious it should be rapidly assessed for breathing and circulation. It might be necessary to interrupt the owner and redirect the conversation to the essentials:

Is your animal breathing, does it have problems with breathing?

Animals suffering respiratory distress should have limited activity during transport, and allowed to maintain a position of comfort. It they are not breathing, mouth-to-nose resuscitation and chest compressions may provide enough respiratory and circulatory support to maintain life during transport. Frequently, this initial breathing action is enough to initiate spontaneous ventilation if there has been a respiratory arrest from a vasovagal reflex.

What is the color of the gums: Is it more red or more white if you compare it with your gum color. Does your animal have external bleeding; is the bleeding pulsating?

If there is a laceration on a distal limb with venous bleeding, elevating the limb above the level of the heart is often enough to stop the bleeding. Active, red, pulsating, arterial bleeding should be controlled by direct digital pressure, and placement of a pressure bandage over the bleeding site.

Does your animal have a limp in an abnormal position without bearing weight on it?

Fractures below the elbow or hock with significant displacement should be supported. The owner can make a support splint from a rolled newspaper or magazine, which is then secured in place by long pieces of fabric or duct tape. Because cats often move aggressively to remove bandages, the cost benefit ratio must be carefully assessed before placing the bandage in each individual cat.

Arrival at the hospital

Once it has been determined that a patient with a potentially life-threatening problem is due to arrive, the treatment staff should be notified verbally.

The nursing staff should have an idea of the usual procedures and equipment required for the critical presenting complaints. The equipment that is usually needed is laid out ahead of time, so that any patient needing life-saving intervention, time is not wasted searching for materials. There should be a list complied by the nurses, under the supervision of the veterinarians, of the equipment, drugs and materials needed, termed "set-ups."

Once the patient arrives at the clinic, the person taking the call will notify the nurse or clinician that a triage (with or without a gurney) is required. A quick statement identifying the presenting complaint and an indication of the urgency (whether stat or not) completes the immediate information.

Triage

Triage is the art of giving priority to patients and their problems upon presentation to the hospital. There are several historical or observed problems that warrant immediate triage to the treatment area, to include: trauma, profuse diarrhea, urethral obstruction, labored breathing, seizures, loss of consciousness, excessive bleeding, history of poisoning, prolapsed organs, potential snake bite, heat prostration, open wounds exposing extensive soft tissue or bone, shock, anemia, burns, dystocia, and expired animals (for the client's benefit)

The Golden Rule of emergency medicine is "treat the most life-threatening problems first." Therefore, the animal's airway, breathing, circulation and mentation must be rapidly assessed. Patients with catastrophic problems (airway obstruction, respiratory failure, and circulatory failure) can die within seconds if left untreated. Severe problems are life-threatening but allow more time for stabilization. The diagnostic, monitoring and therapeutic procedures must be coordinated with a coherent priority approach as the patient moves from the emergency situation, to surgery or diagnostic procedures, and then finally to the critical care area.

The therapeutic life saving steps that discussed below can be easily trained with the staff using cadavers. At the author's hospital, a weekly course in emergency medicine is organized every year including practical sessions for doctors and nurses.

Primary Survey

Airway: The airway is cleared by gently extending the head and neck, pulling the tongue forward, and carefully clearing the mouth of any foreign objects, mucus, blood or vomitus. Tracheal intubation, either orally, or via slash tracheostomy will provide an immediate airway. In situations of airway compromise in a partially conscious animal, mild sedation utilizing diazepam or opioid derivatives may be necessary to facilitate intubation, or a transtracheal oxygen catheter can be placed providing oxygen flow at 0.5ml/kg/min. If a foreign object is unable to be easily removed, a Heimlich-like maneuver can be performed. If intubation is not necessary, 100% oxygen is always supplemented by mask, bag, nasal cannula, or flow-by.

Breathing: Respiratory arrest is not always associated with cardiac arrest. When it is determined that there is no heartbeat, then CPCR measures are instituted. When the heart is beating, the chest is evacuated of air or blood. If fluid or air is suspected, a chest tap should be performed before any radiographs are taken. A negative tap does not necessarily indicate a normal pleural space. If a pneumo- or hemo-thorax is suspected, pleural evacuation with thoracocentesis is performed. In cases of tension pneumothorax, a small incision is made for immediate release of pleural air until a chest tube can be placed and continuous suctioning supplied.

Circulation: Hemorrhage is controlled, and vascular access rapidly obtained. Dose and type of fluid administered, and pharmacological intervention is determined by the level of shock and existing problems present.

Level of Consciousness: If there is a reduced level of consciousness, careful handling of the patient is necessary. Keep the head and neck as level as possible and limit any compression of the neck which may reduce jugular drainage. Avoid placing anything into the nostrils that may stimulate sneezing and an increase in intracranial pressure.

Secondary Survey: History, Physical Exam and Data Base

Following the triage and resuscitation process, more information is obtained from the owner. The presenting complaint and information of when the animal was last normal should have been obtained at the time of triage. Chronology and progression of signs is also important. Organ systems not involved are also reviewed, and background information (including previous medical problems, drug therapies, allergies, vaccination history, and previous transfusions) is obtained. A thorough physical exam involving the entire dog, including rectal and genital exam, and vital signs is required.

On every emergent patient, an initial database consisting of PCV, TS, dextrostick, azostick, sodium, potassium, and urinalysis pre-fluid therapy is necessary for baseline values and early detection of abnormal values. Obtaining lateral and thoracic radiographs in addition to radiographs of injured limbs may detect internal injuries not found on physical exam.