Hospital Readiness

Along with the first responders, the veterinary team plays an integral role in initial evaluation and stabilization of the emergent and critical patient. Increased public demand for state-of-the-art emergency care obligates the veterinary team to provide quality care or make a direct referral to an emergency facility. By practicing organized team work and hospital readiness, the veterinary team can provide successful resuscitation and stabilization of the emergent patient.

By pre-assigning roles and practicing responses to various life-threatening situations, valuable time is saved, and patient morbidity is decreased. In-hospital training and practice sessions with animal models help the team respond as an effective unit. Online training in BLS, certified by the American College of Veterinary Emergency and Critical Care and based on the findings of RECOVER, is available online (www.ecornell.com/certificates/veterinary-medicine/). CPR drug dosing charts, as well as CPR updates can be obtained through continuing education courses sponsored by the Veterinary Emergency and Critical Care Society (www.veccs.org).

Veterinary hospital readiness consists of providing a place for receiving, assessment of and treatment of the emergent patient. The area should be free of obstacles, and transport of the animal to the area should be uncomplicated. 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. Isotonic crystalloid fluids with attached intravenous administration sets can be hanging ready to use in the receiving area. Synthetic colloid fluids should be kept nearby. Supplemental oxygen and suction units as well as small and large Ambu bags and oxygen administration sets are 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. Otherwise, maintaining a tackle box with emergency equipment and drugs can be an inexpensive way to provide emergency care. Having a clipboard with a CPR record and an attached CPR dose schedule. Equipment and drugs should be inspected daily, and following resuscitation, to ensure that the ready area is set up for the next emergency. 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.

Additional preparations can be made as incoming calls are taken and information gathered. 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. A dry erase board can be placed in the general treatment area and all animals listed that are due to arrive, with their estimated time of arrival and presenting complaint noted. This allows the treatment staff to plan their time and procedures efficiently.

Common complaints that indicate life-threatening problems, and motivate the team to be as ready as possible ahead of time include hit by car, dog fight, falling from height, gunshot, stabbing, potential toxicity, inability to urinate, abdominal distension, labored breathing, seizures, collapse, altered consciousness, profuse bleeding, dystocia, snake bite, prolapsed organs, heat stroke, severe cold exposure, electrocution, and burns.

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 for any patient needing life-saving intervention, time is not wasted searching for materials. There should be a list compiled by the nurses, under the supervision of the veterinarians, of the equipment, drugs and materials needed, termed "set­-ups." There will be different set-ups for different problems.

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. The primary complaint and the time of onset are obtained, and the animal is quickly examined for abnormalities associated with the respiratory, circulatory and central nervous systems. Significant changes require that the patient be taken directly to the treatment area. There are several historical or observed problems that warrant immediate triage to the treatment area, to include trauma, profuse diarrhea, urethral obstruction, labored breathing, altered mentation, seizures, loss of consciousness, excessive bleeding, history of poisoning, prolapsed organs, potential snake bite, heat prostration, open wounds exposing extensive soft tissue or bone, signs of shock, anemia, bums, dystocia, and expired animals (for the client's benefit).

The emergent patient presents a special challenge because the underlying problem may not be evident for 24–48 hours’ post-presentation. The problems can arise from an acute illness, from a chronic illness that has decompensated, or from an unexpected complication of another illness. All post-operative patients are considered critical care patients until life-threatening anesthetic or surgical complications are ruled out.

The GOLDEN RULE of emergency medicine is "treat the most life-threatening problems first." The airway, breathing, circulation and level of consciousness must be rapidly assessed. Patients with catastrophic problems (airway obst ruction, respiratory failure, circulatory failure, head injury) can die within seconds if left untreated. Severe problems are life-threatening but allow more time for stabilization.

Variables that contribute to the overall success of patient resuscitation include the severity of the primary illness or injury, the amount of fluid or blood lost, previous health problems, the number and extent of associated medical conditions, time delay in instituting therapy, the volume and rate of fluid administration, and the choice of fluids - crystalloid, blood components, synthetic colloids. Therapy must be done at the right time, in the right amount and in the right order. Therapeutic failures are generally not from ignorance but rather from failure to act promptly at a crucial moment.

Primary Survey

Airway: Loud breathing, heard without a stethoscope is the hallmark of an airway obstruction. The breathing rate is typically slow, unless the patient has hyperthermia. The airway is cleared and the head and neck gently extended, pulling the tongue forward, and carefully clearing the mouth of any foreign objects, mucus, blood or vomitus. Tracheal intubation, either orally, or via tracheostomy will provide an immediate airway. In situations of airway compromise in a partially conscious animal, mild sedation utilizing benzodiazepine or opioid derivatives may be necessary to facilitate intubation, or a transtracheal oxygen catheter can be placed providing oxygen flow at 0.5 ml/kg/min. If a foreign object is unable to be easily removed, a Heimlich-like maneuver can be performed. Oxygen is always supplemented by mask, bag, nasal cannula, or flow-by.

Breathing: Positive pressure ventilation by hand to an inspiratory pressure of 15–20 cm H₂O for the dog and 10–15 cm H₂O for the cat is required. Fluid in the airways will increase pressure requirements, and suctioning should be performed. Respiratory arrest is not always associated with cardiac arrest. When it is determined that there is no heartbeat, then CPR measures are instituted. When the heart is beating, the chest is evacuated of air or blood. A synchronous, labored and/or rapid breathing pattern is typical for pulmonary interstitial disease. Asynchronous breathing pattern is typically seen with pleural space disease. If fluid or air is suspected, thoracentesis or chest tube placement should be performed before any radiographs are taken. 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. Mechanical ventilation will ensure adequate tidal volume in this case.

Circulation: Hemorrhage is controlled, and vascular access rapidly obtained. Dose and type of fluid administered, and pharmacological intervention are 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 which may stimulate sneezing and an increase in intracranial pressure. Transport the patient on a flat surface between areas of the hospital.

Level of pain: Pain elicits the same responses as circulatory shock. Treatment using intravenous agonist opioids can provide immediate relief. Adding benzodiazepines can reduce the overall need for opioids. Both are titratable and reversible (naloxone for opioids and flumazenil for benzodiazepines).

Following the triage and resuscitation process, more information is obtained from the owner. A thorough physical exam involving the entire dog, including rectal and genital exam, and vital signs is required. An initial database consisting of packed cell volume (PCV), total solids (TS), dextrostick, lactate, electrolytes and venous blood gas panel is performed. Blood samples are collected for pretreatment complete blood count and serum biochemical analysis when time permits.

References

1.  Mathews KA. Veterinary Emergency and Critical Care Manual. Ontario:Lifelearn;2006.

2.  Crowe OT. A general approach to emergency patients. Veterinary Medicine. 2003;98:777–786.

3.  Emergency Medicine. Vet Clin North Am Small Anim Pract. 2005.

4.  RECOVER Campaign http://onlinelibrary.wiley.com/doi/10.1111/vec.2012.22.issue-s1/issuetoc