1
Q
What are the 3 aims of first aid ?
A
Preserve life
Prevent suffering
Prevent deterioration of suffering
2
Q
What to consider at all times when dealing with emergency patients ?
A
Safe methods of movement
Safety of self and others
Welfare of animals
ABC
Keep reassessing
3
Q
What is the RVNs role to assess emergency patients ?
A
Remain calm
Be prepared
Don’t put anyone at risk
Remove any further risk from the patient
Assess the severity of the condition and get the vet ASAP
4
Q
A successful emergency outcome is more likely with?
A
Recognition - early assessment of the severity and nature
Communication - between owner/team etc
Implementation - tx performed
Monitoring - careful and continuous monitoring of condition and care amended
5
Q
Modes of casualty assessment
A
Triage - phone call f2f appt
Primary survey - 1st check no more than 30secs-1min
Secondary survey - looking for further injury/disease. A nose to tail assessment.
6
Q
Basic questions to ask an owner?
A
Nature of accident/illness
Severity of accident/illness
When was the onset of symptoms of when did accident happen
Animals details
Any medication/previous condition
Where animal is
Owners details
7
Q
Life threatening emergencies
A
Unconscious
Severe haemorrhage
Pyometra
RTA
C-section
Blocked bladder
GDV
Poison
Prolapsed eye
Severe burns
Resp arrest
Heatstroke
Electrocution
8
Q
Immediate attention
A
Dystocia
Haemorrhage - small cut
Broken bones
HGE
Pancreatitis
Eye wound
Seizure
9
Q
Minor emergencies
A
Lame
Anorexia
Aural haematoma
Cuts
Insect stings
Abscesses
Small superficial burns
10
Q
Triage
A
Rapid assessment of patients (identify most urgent, primary survey)
‘Capsular history’
Rapid but efficient clinical exam of major systems
Focus on clinical signs that give most info - resp, cardiovascular, CNS, urogential
11
Q
Secondary survey
A
Once stabilised conduct a second survey to include:
Airway
CVS
Respiration
Abdomen
Spine
Head
Pelvis
Limbs
Arteries
Nerves
12
Q
Safe methods of movement
A
Approach calmly, slowly and positively.
Restraint and emergency immobilisation to prevent further injury. Muzzle where needed
Transport. Don’t roll, if they can walk let them
Veterinary attendance
13
Q
Define syncope
A
Fainting due to brain anoxia
14
Q
Define collapse
A
Animal remains conscious and responds normally to stimuli but is unable to or unwilling to stand up
15
Q
Define death
A
Absence of all vital functions.
16
Q
Pathophysiology of burns
Cell membrane damage
A
Cell membrane damage caused by oxygen free radicals
Prostaglandin release
Reduces the release of noradrenaline which helps regulate cardiovascular function and muscle tone
17
Q
Pathophysiology of burns
Inflammatory reaction
A
Increased microvascular permeability, vasodilation (caused by histamine release)
Increased osmotic activity
Causes rapid oedema formation
Both continuous loss of fluids
Causing
Increased haematocrit, reduced plasma volume, reduced cardiac output = SHOCK
18
Q
Types of burns
A
Dry burn
Scald
Cold
Electrical
Radiation
Chemical
19
Q
First degree (superficial) burn
A
Affects only the outer layer of skin (epidermis), causes rednesss, pain, dryness and mild swelling but no blisters.
20
Q
Second degree burns
A
Damages outer layer of skin and into the second layer (dermis).
Causes intense pain, redness, swelling, blisters that may oozese and often look moist/wet pink/red.
21
Q
Third degree burns
A
Involves all layers of skin and sometimes fat and muscle tissue.
Skin may appear stiff, black/charred, leathery or grey.
Often needs skin grafts to close the wound.
May not immediately hurt due to destruction of nerve endings
Patient likely to be in shock.
22
Q
What is the mortality rate for burn patients?
A
30% 2nd degree
50% 3rd degree burns are unlikely to recover.
23
Q
Immediate first aid for burns
A
Prevent further burning - remove source if safe to do so
Douse with cold water. 10 mins minimum, 20 mins if chemical burn
Prevent infection, clip area around burn
Cover with sterile non-adherent dressing or cling film
Analgesia, once prescribed by vet
Prevent self trauma
Treatment of shock - IVFT
24
Q
After a house fire a dog is bought to a practice for clinical assessment, what would their symptoms be?
What is the treatment?
A
Dyspnoea
Coughing
MM colour - cherry red, CO2 poisoning
Nasal discharge
Evidence of burns or singed hair
Neurological signs, several days later
Treatment: blood gas analysis, thoracic radiographs, oxygen therapy and supportive care, close observation
25
How can poisons enter the animal ?
Ingested - most common
Inhaled - CO
Absorbed via skin - permethrin
26
What animals are at increased risk of poisoning ?
Young - eat everything
Cats - liver not as good at detox
Animals roaming free - farm animals
27
What information would you ask the client if they called informing their animal had eaten toxic items
What
When
How much
Animals details - age, size, weight
Signs, how the animal is doing
Can they bring a sample/packet
How long getting to practice
28
How would poisoned animals present?
GI signs
Neuro
Bleeding
Unconscious
Death
V/D - profuse salivation - toads
Changes in behaviour, ataxia, seizures, collapse, coma
29
Tests for poisoning
Bloods
Urinalysis (sediment exam)
Clotting profile (rodenticide)
Vomit and faeces kept frozen in case toxicology needed
30
Treatment for poisons
Aim to stabilise the patient ASAP
- identify the poison and amount ingested
- stop further absorption
- treat clinical signs symptomatically
- give antidote or specific tx as prescribed
- prevent further absorption
- emetics. Contraindicated if toxin will cause further damage as vomited, patient is depressed or seizuring, species is unable to vomit (activated charcoal, topical toxins)
31
Define triage
Identifying a minor emergency or severe life-threatening emergency
32
What needs to be prepared for an emergency admission?
Consult room - clear workspace, diagnostic tools
Equipment - emergency box, anaesthetic machine/O2, ETT
Consumables - drugs, IV cathete, IVFT, swabs/dressings
Theatre - damp dust, lighting, heating, sterile instruments, kits, gowns, gloves, anaesthetic equipment
33
What needs to be within a crash box?
Kept in an easy accessible place and easily transportable
Contents: needles, syringes, catheters, swabs, dressings, bandages, aseptic scrub solution, scalpel blades, IV fluids, tape, 3 way tap, stethoscope
Equipment: self inflating resuscitation bag, ET tubes, tracheotomy tubes, scalpel handle, defibrillator
Drugs - adrenaline, atropine, lidocaine, saline
Contents should be checked regularly, rotating stock and replenishing after use.
34
Define opisthotonus
Severe hyper extension and spasticity in which the pets head, neck and spinal column enter into a complete ‘bridging’ or ‘arching’ position.
The abnormal posturing is an extrapyramidal effect and is caused by spasm of the axial muscles along the spinal column
Associated with tetanus and diseases which induce a cerebellar syndrome
35
Breathing and cardiovascular function - nursing care
Postural adaptions - limit resistance to airflow (open mouth breathing, orthopnea, standing/sternal)
O2 therapy
Resp physiotherapy
36
Resting energy requirement (RER) formula
RER kcal/day = 70 x BW(kg) to power of 75 =
Animals between 2-30kg
RER kcal/day = (30 x bw) + 70 =
37
Formula for how many meals a day?
Ml/day = RER / kcal/ml
Ml/meal = ml/day / number of meals
38
What is the difference between enteral and parenteral feeding?
Enteral - by mouth/tube - using gut
Parental - bypassing gut, given IV
39
What is the feeding protocol for enteral feeding tubes?
Day 1 - 1/3 a day, diluted with water
Day 2 - 2/3 a day
Day 3 - full amount
Shouldn’t exceed 10ml/kg per meal
40
Parental nutrition
Nutrients supplied IV bypassing GI tract allowing it to rest, short term measure.
Used for:
- mechanical intestinal obstruction, ileus or hypomobility
- severe diarrhoea or chronic vomiting
- unconscious or severe neurological deficits
- acute pancreatitis or hepatitis
- In conjunction with enteral nutrition when unable to meet calorific requirements.
41
Feeding guidelines for parenteral nutrition
Final osmolarity of 400-500 moms/L
Maximum rate of infusion 30ml per hr
Goal day 1 50% RER, goal day 2 100% RER
Dogs - 15-25% RER as protein calories, remaining calories as 50:50 between lipids and sugars
Cats - 25-35% RER as protein calories, remaining calories as 60% lipid and 40% dextrose.
42
Considerations and complications to parenteral nutrition
Consideration - solutions can be nutritionally incomplete, lack taurine and lesser important nutrients, should be used longer than 10 days, expensive, time and care demanding, patient must be fully hydrated, electrolyte and acid-based balance corrected.
Complications - thrombophlebitis, occlusions, sepsis, hyperglycaemia and azotaemia
43
Central lines
Internal jugular typically right side as its vertical course straight down into the cranial vena cava via the right brachioccephalic vein.
Peripherally inserted central catheters (PICC) can be placed into the medial saphenous vein. It’s usually more comfortable and tolerated better than cats.
44
Common types of central lines
Through the needle
Peel-away sheath technique
Over-the-wire catheters
45
Seldinger technique
(Central lines)
Common technique used with over-the-wire
A needle or introducer catheter is inserted and a wire passed through
The introducer is then removed
A vessel dilator can be advanced over the wire to increase the diameter of the s/c tunnel and venous puncture site before its removed
A catheter is then advanced over the wire
The wire is removed
The catheter is secured by suturing to skin
46
Contraindications for use in central lines
Coagulopathies - immune mediated haemolytic anaemia
Skin site infection
Jugular placement - head/neck trauma, resp distress, laryngeal paralysis, cerebral oedema or cranial disease
Medical condition with increased risk of thrombosis
47
Nursing care for a patient with a central line
Monitor for blockage - regular flushing
Signs of inflammation/infection
Regular dressing changes
Aseptic techniques
Physical exam (inc temp) BID
Blood sampling/culture e.o.d.
48
Basic checks of an inpatient
Rectal temp every 4-12hrs
MM colour, CRT, pulse quality and HR every 4-12 hrs
RR and effort, auscultation of the lungs every 2-12hrs
Note urine output or palpate bladder every 2-6hrs
Note presence or V+ or regurgitation or bowel movements very 4-8hrs
Assess comfort and adequacy of pain control every 2-4hrs
Turn from side to side or stand and walk every 4hrs
Lubricates eyes every 2-4hrs
Offer food and water
Check O2 % every 2-4hrs
Check IVFT rate
Drain checks/dressing changes every 4-8hrs
Evaluate patency of IV catheters every 4-6hrs
PCV, total solids, blood glucose and BUN every 4-24hrs
49
Advanced checks of an inpatient
ECG monitoring - note arrhythmias
Bp monitoring continuous or every 2-12hrs
CVP every 2-6hrs
Pulmonary artery or pulmonary capillary wedge pressure monitoring continuous or every 2hrs
Pulse ox every 2-12hrs
End tidal capnography every 2-12hrs
Arterial blood gas analysis every 2-24hrs
Urine output via closed system every 2-4hrs
Intra-abdominal pressure monitoring every 2-6hrs
Electrolyte measurement every 4-24hrs
Colloid osometry every 4-24hrs
Nebulise and coupage 10-20 mins every 4-6hrs
Check and clean inner cannula of tracheostomy tube every 2-4hrs
Aspirate chest tubes every 2-4hrs, record volumes
Record mechanical ventilator settings, airway pressure and tidal volume every 2 hours
Peritoneal dialysis - infuse dialysate, dwell and drain every 1-2hrs and record volumes and quality of fluid obtained.
50
Diurnal cycle and veterinary impacts
The diurnal cycle refers to the natural 24-hour pattern of biological, physiological, and behavioral processes in animals that are primarily active during daylight and rest at night.
Impact on normal function - hormonal rhythms, metabolism and digestion, body temp, immune response, reproduction.
Hormonal - cortisol peaks just before active period (early morning)
Resp rate - lower at night compared to the day. Aligns with lower heart rates and activity levels.
Blood pressure - Higher in the morning and lower in the evening.
Heart rate - peaks in the evening and is lowest in the early morning. Influences on the autonomic nervous system.
Body temp - core body temp dips to lowest point during deepest phase of sleep and rises upon waking/eating.
51
Invasive vs non-invasive blood pressure measurement:
Invasive - placement of a catheter into a peripheral artery (commonly dorsal metatarsal or femoral). Catheter is connected to a pressure transducer with non compliant tubing filled with heparinised saline to allow continuous monitoring.
Non-invasive - cuff and machine is used, machine should be checked and callibrated twice yearly. Cuff should be 30-40% of the limb circumference and level with the right atrium, patient can be in lateral, sternal or standing. take 3-7 readings but discard first one, less than 20% variability in systolic values should be recorded and averaged.
Allow the patient to familiarise with surroundings and undertake readings in a quiet location.
52
What is electromechanical dissociation ?
AKA pulseless electrical activity ‘PEA’
53
Define depolarisation and repolarisation on an ECG
Depolarisation - Contraction of myocardium
Repolarisation - relaxation of cells after depolarisation
54
Waves on an ECG
P: depolarisation atria
PR interval: beginning of atrial depolarisation into ventricular depolarisation. Interval due to slow conduction through AV node.
QRS: ventricular depolarisation
T: repolarisation of ventricular myocardium
Atrial repolarisation is hidden by QRS complex
55
Describe atrial fibrillation
Signs: rapid ventricular rate (often 200-300 bpm), irregular heartbeat, pulse deficits, loss of atrial contraction and chaotic electrical activity in the atria.
No P waves
Baseline irregular due to many erratic impulses passing through the atrial myocardium.
The ventricular depolarisation rate is also irregular and rapid.
56
Ventricular tachycardia
4 or more consecutive electrical impulses originates from the ventricles of the heart at a rapid rate.
Rhythm is usually regular but can be slightly irregular.
Beats typically exceeding 160-180bpm in dogs and 200-250bpm in cats.
P waves generally absent
T waves large and directed opposite to the main deflection of the QRS complex
Severe dysfunction - results in reduced cardiac output, hypotension and poor tissue perfusion.
57
Premature beats
Early electrical impulses that interrupt the normal sinus rhythm of the heart, originating from the ventricles.
QRS is early and widened
No P wave
T wave inverted or opposite in direction to the QRS
Etiology: ventricular hypertrophy, hypoxaemic states (anaemia, GDV, heart failure), acidosis, drugs (digitalis, barbiturates, antiarrhythmic agents), hypokalaemia.
Consequences: may initiate ventricular tachycardia or fibrillation, cardiac output may fall if sufficient premature beats are present, treatment if signs due to dysrhythmia.
58
Describe mentation terms
Alert - no issues
Obtunded - respond to noise/touch but wont move
Stuporous - respond to noxious stimuli
Coma - unconscious/unresponsive
59
Cranial nerves
An evaluation of the cranial nerves tests mental activity, head posture and coordination and reflexes of the head.
Signs identified during this evaluation indicate an injury or disease of the brain.
Signs of damage to the cerebrum and brain stem can include mental deterioration, constant pacing, seizures, depression or come, or a head turn or circling in one direction.
A head tilt, bobbing, tremors or other unusual head movements may indicate damage to the cerebellum
60
List the 12 cranial nerves
Olfactory (I) - smell
Optic (II) - vision
Oculomotor (III) - eye movement, pupil adjustment
Trochlear (IV) - eye movement (superior oblique muscle)
Trigeminal (V) - facial sensation, chewing
Abducens (VI) - lateral eye movement
Facial (VII) - facial expressions, taste
Vestibulocochlear (VIII) - hearing and balance
Glossopharyngeal -( IX) taste and swallowing
Vagus (X) - parasympathetic control of heart/digestive tract
Accessory (XI) - shoulder and neck movement
Hypoglossal (XII) - tongue movement
61
Quantitive analysis of urine
Regular collection of urine samples over a period of time and generally is used for:
- investigation of renal function
- study of renal diseases
- evaluation of metabolic and/or endocrine abnormalities
- evaluation of nutritional and metabolic requirements
62
What is qualitative analysis (urine)
A small quality of urine will suffice for qualitative urinalysis which includes the measurement of pH, protein, glucose, bilirubin, haemoglobin, ketone, urobilinogen and creatine levels
63
What are peripheral catheters made out of ?
Polypropylene, polyethylene, polyvinylchloride
64
What are through-the-needle catheters made out of?
(Central lines)
Centracath, vygon
65
Sepsis
Body’s immune system goes into overdrive setting off widespread inflammation, swelling and blood clotting.
Significant dec in bld pressure which affects bld supply to vital organs can lead to organ failure and death.
Early signs of- pyrexia, very low temp, tachycardia, tachypnoea, nausea, vomiting, D+, oliguria
More severe sepsis or shock can inc pyometra, pyelonephritis, septic peritonitis.
66
Disseminated intravascular coagulation (DIC)
Blood clots from throughout the body’s small bloods vessels, the clots can reduce or block blood flow through the blood vessels which can damage organs.
The increased clotting uses up platelets and clotting factors in blood, can cause serious bleeding internally and externally.
Can be caused from septic shock, pancreatitis, heat stroke.
Two types acute and chronic
Tx includes treating clotting and bleeding problems and establishing the underlying cause.
67
Hypoproteinaemia
Serious complication of several disease - can have a poor outcome.
Reduction in blood globulins mainly albumin.
If the pressure gradient in blood vessels is less than 15g/dL the fluid leaves the vessel causing interstitial oedema, ascities and or pleural effusions.
Reduced production - liver disease (only albumin), malnourishment/malabsorption.
Increased loss - renal disease (only albumin), GI disease, haemorrhage, critically ill patients (burns, peritoneal/pleural effusions), sepsis.
Clinical signs - depends on underlying disease.
GI - weight loss, V+, D+
Renal - uraemia, nausea, anorexia, dehydration, hypocholesterolaemia
Hepatic - hypoglycaemia, coagulation defects, reduced blood urea nitrogen, low cholesterol, hypoglycaemia, increased bilirubin
Tx - replace loss albumin by using colloids, blood (if anaemia) or plasma (replaces albumin and clotting proteins).
68
What must a blood donor be?
In good health
Free from infectious diseases
Good temperament and comfortable in a vets
Not pregnant
Easy access to jugular vein
Between 1-8 yrs old
Blood types
Regularly screened for diseases, wormed and vaccinated
Not received a bld transfusion in the past
69
Specific dog criteria for bld donation
Min weight 25kg
Min PCV of 40%
Adequate vWF
70
Specific criteria for cat blood donation
Min weight of 4.5kgs
Min PCV of 35%
Ideally indoor - if not FeLV tested before donation
71
Specific criteria for rabbits for blood donation
Min weight of 2.5kgs
Same as a cat
72
Equipment needed for blood donation
Clippers
Local anaesthetic cream
Diluted warm chlorhexidine or equivalent and sterile swabs
Surgical spirit or equivalent
Collection equipment: 450ml single blood collection bag with CPDA-1/CPD
Electronic weigh scales weighing in grams
Metal line clamps (optional)
Line strippers (optional)
Dressing material for a neck bandage
Scissors
Cat specific:
Small animal single bag syringe collection system
250ml or 450ml collection bagor 60ml syringe, 3 way tap, 19G butterfly and donor bag
Sterile 10ml syringe to withdraw anticoagulant
Plastic or guarded haemostat (have protective cover over teeth)
Line strippers and line sealing apparatus
IVFT - 100ml isotonic crystalloid
Sedation drugs, O2, eye lubricant, bp monitor
73
Protocol for blood donation
Assistant to restrain animal
Second assistant to hold and mix blood bag
Person to carry out venepuncture
Donor may be sedated - monitor
Collect all equipmemt needed
Place bag below animal
Asepetically prepare site over jugular
Insert catheter
Ensure blood keeps flowing
Remove needle and hold swab over needle site
Tie collection bag tubing several times
Date and label bag with donors name and exp date
74
Amount that can be taken for blood transfusions
Dog 19ml/kg
Cats & rabbits 11ml/kg
No more than 20% of blood volume should be obtained.
Blood volume
88ml/kg - canine
66ml/kg - cats & rabbits
75
Blood typing - dogs
Depends on the presence of antigens on the surface of the RBC
Dog erythrocyte antigen (DEA) system is the most common way of classifying blood type
Recognised blood types = 1.1, 1.2, 3, 4, 5, 6, 7, 8
Most antigenic DEA is 1.1 so most likely to cause a reaction followed by 1.2 and then 7.
Greyhounds have low levels of these antigens and also high PCV so are good donors
Universal donor - negative for DEA 1, 3, 5 and 7. Positive for DEA 4
DEA 1.1 is most clinical significance
About 30% of dogs are DEA -ve
First transfusion can be un-typed
76
Blood typing - cats
The surface of feline RBCs also contains antigens (A, B, AB)
Typing cats is essential before transfusion.
77
Cross matching - blood transfusion
Testing for existing antibodies against RBC antigens
This is important in cats and animals that have had a previous transfusion
Positive result - cells at or near top of tube - DO NOT transfuse
Negative result - cells at or near the bottom of the tube, unlikely to cause a reaction.
78
Transfusion quantities
Aim of transfusion is to inc recipients PCV to above 20-30%
Vol ml = BW X N X (desired PCV - actual PCV) / PCV of donor
N dogs = 80 (pet blood bank 70)
N cats = 60
79
Administration of blood for transfusions
Blood can be given straight away but if refrigerated it must be warmed to body temp (37 degrees) slowly to prevent clotting
Blood giving set must be used as it has a filter.
Speed must not exceed 2-3mls/kg/hr to prevent transfusion reactions (first 30 mins 0.25-1ml/kg/hr).
Packed RBC may require fluid to increase viscosity.
DON’T use calcium containing fluids (not Hartmans)
80
Things to check before and during blood transfusion (recipient)
Attitude
PCV/total protein
Temp
Pulse rate and quality
RR and character
MM colour and CRT
(Urine colour if available)
Monitor vitals every 15-30 mins during then 1, 12 and 24hrs after transfusion.
Observe for any evidence of reactions
Most likely to occur within the first hour of transfusion (acute or delayed, immunological or non-immunological) acute immunological reactions are the most common
81
Signs of transfusion reactions
Discomfort
Tremors
Crying
Facial oedema
Tachypnoea or dyspnoea
Tachycardia or bradycardia
Vomiting
Increased temperature
Collapse
Haematuria
82
What to do if there is an acute reaction during a blood transfusion ?
Stop transfusion and inform vet
Check animals major body systems
If severe remove Iv catheter used for the transfusion
Check correct transfusion given
83
What influences how we provide oxygen supplementation ?
Patient size
Anatomical conformation of airways
Temperament
Likely duration
Equipment available
Direct from cylinder/piped from O2 source/breathing system from anaesthetic machine
84
What additional considerations are needed for long term oxygen supplementation ?
Long term oxygen therapy needs to be:
- humidified to prevent irritation and drying of the MM (>1hr)
- the oxygen is provided through sterile water
- nasal cavity normally humidifies, so nay source bypassing it
- CO2 accumulation
- hyperthermia (esp brachy breeds)
85
Oxygen tents and oxygen rich environment
Improvised - buster collar & cling film - cheap but rapidly hot and build up of CO2. Well tolerated, initially high flow rates then lower to 1L/min usually 60% O2
Cage - convenient, lightweight, collapsible or permanent
Size limitations, some struggle to rise above O2. hyperthermia a risk
Hard to monitor unless open door but O2 will drop
Some allow up to 90% and animal is left to rest
86
Endotracheal intubation
To maintain patient airway
Cannot raise O2 by non invasive methods
Ventilation necessary
Emergency surgery procedure
100% O2, control of breathing, needs GA, not viable long term
87
Nasal catheter A&D
Convenient and inexpensive with inspired concentrations ranging from 30-60%
Relative contraindications for this procedure include nasal massses, rhinitis and coagulopathy
Silicone or PVC feeding tube, measure nostril to medial canthus of eye and mark. Local nose for 10 mins.
Nose Dorsally, advance into ventral meatus, aiming ventromedially, base of ear on other side, secured, loop around alar cartilage, between eyes
E collar
88
Nasal prongs A&D
Nasal prongs can be used but rely on prongs fitting the patient
Only relevant in non-brachycephalic breeds
Held with tissue glue, tape or skin staples
The FiO2 achieved via nasal prongs is not well established but may be similar to that seen with longer nasal catheters, provided the patient doesn’t dislodge prongs
89
Flow by A&D
Easy method
Modestly enriches the fraction of inspired O2 (FiO2) but potentially only a few points above room air (25%) up to approx 40% if high oxygen flow rates are used (2 to 3 L/min)
Flow by is not usually well tolerated - may contribute to anxiety
Approach is impractical for any protracted period
90
Oxygen masks A&D
Simple but may not be tolerated by anxious patients
FiO@ achieved will vary depending on how tight the mask fits and flow rate administered
Higher oxygen rates (2-5L/min) are recommended to achieve an FiO2 of 35-60%
Rebreathing of carbon dioxide can occur with tight fitting masks, may need to switch masks out.
91
Trans-tracheal catheter A&D
In patients with severe resp distress caused by upper airway obstruction that do not respond to flow-by oxygen administration
It is possible to place a percutaneous catheter into the trachea and administer oxygen into the resp tract at a level below the obstruction.
Useful in dogs over 10kg that have a sufficiently large trachea to allow a catheter to be confidently placed.
92
Tracheostomy equipment
Procedere carried out under GA, as much prep as possible carried out before induction.
Need:
Tracheostomy tube - 60-70% tracheal diameter
Surgical kit
Self-retaining retractors
Monofilament suture material
Tape ties to secure
93
Tracheostomy technique
Place in dorsal recumbency
Ventral midline incision over the trachea from caudal larynx to the 7th tracheal ring
Incise through s/c tissue and bluntly dissect through muscle in midline
Retractors aid exposure to the trachea
Incise circumfernentially between 4-6th rings >40% circumference
Place stay sutures around proximal and distal rings and induce tube
Partially close skin and secure tape around their neck
94
Management of tracheostomy tube
Aim is to maintain patent airway, asepsis and patient comfort
Monitor closely for first 12-24hrs
Suction tube every hour
Humidify air - instil sterile saline no more than hourly
Change tube every 2-6hrs depending on exudate
95
Suction of tracheostomy tube
Signs indication suction necessary - dyspnoea, distress, coughing, harsh sounds from tube, discharge from tube, patient discomfort
Procedure:
Pre-oxygenate, technique must be aseptic, soft, pliable and sterile suction catheter is used, inner cannula if used is removed and cleaned then replaced after suction, catheter is inserted to the carina, suction is applied as the catheter is removed in a circular fashion, skin incisors and around the tube should be cleaned carefully
96
Thoracic drains equipment
Placed to allow the removal of air or effusion from the pleural cavity, re-establish the negative pressure necessary for ventilation.
Equipment: sterile gloves and kit, monofilament suture material, lidocaine, thoracostomy tube, three way tap, syringe for aspiration, dressing materials
97
Thoracic drains protocol
Clip and asepetically prepare skin
Mark the tube from the point of insertion to the 2nd rib
Make a skin incision over the dorsal third of the chest over the 10th intercostal space
Trochar is passed through the incision and s/c cranioventally to the 7th intercostal space
Trochar is moved to the perpendicular chest wall and heel of hand pushes it through the intercostal muscles
Trochar is withdrawn slightly and advanced a further few cms cranioventrally
Drain is advanced from the trochar to the premeasured length
The drain must be clamped before the trochar is fully removed and connected to a bung or a collecting system.
Drain is secured with a Chinese finger trap suture.
98
Management of thoracic drains
Regularly drained with syringe or suction intermittently or connected to continuous suction.
Carefully bandaged and managed, as damage may cause communication to pleural cavity with fatal results
Aseptic management
Antibiotics
Prevent interference from patient protected from contamination
Purse string suture before removal
Monitoring resp distress/draining regularly and appropriately, recording results
Analgesia and contact vet if worried.
99
Pulse Ox
Most common monitor used in veterinary
Non-invasive
Monitors both pulse rate and arterial oxygen saturation
Very sensitive to movement artefacts
Alpha-2 agonist cause peripheral vasoconstriction that can give altered readings
100
Blood gas analysis
Most efficient way to measure resp efficiency is to measure the levels of oxygen and carbon dioxide in the arterial blood.
These measurements can also give valuable information on the status of the patients acid base balance
Arterial blood sample is collected over several resp cycles
101
Resp physiotherapy
Coupage
Percussion of the thorax should be done in a caudo-cranial and dorso-ventral direction and carried out for 5-10 mins 4-5X daily.
Aids loosening and expulsion of secretions so it’s very useful in recumbent patients with pulmonary disease.
Can be used in conjunction with nebulisation to aid removal of bronchial secretions
102
Resp physiotherapy
Postural drainage
Position in which the patient is placed to drain the fluid from the lungs by coupage, depends on location of fluid.
103
Oesophageal foreign body
Signs: salivation, excessive swallowing effort, dysphagia, regurgitation (not vomit), resp distress, inc RR or effort, bradycardia
Diagnosis: endoscopy/radiography
Treatment: correct perfusion deficits before GA, suction?, anticholinergics, gastrotomy feeding tube
104
Gastrointestinal foreign body
Signs; nausea, vomiting, inappetence, abdo pain,
Diagnosis; contrast studies/ultrasound
Treatment; shock - IVFT, peritonitis?, dehiscence of intestinal anastomoses, pre-op low albumin?, enteral feeding
105
Pre-op & Intra-op considerations in resp distress patient
Pre-op = oxygen therapy, maintain patent airway, control body temp
Consider sedation for calming, corticosteroids for swelling. Prepare patient as much as possible before inducing
Intra-op = compromise to the airway, haemorrhage, swelling, GA complications
106
Post-op complications in a resp distress patient
High risk of complications
Analgesia - care not to sedate and depress resp
Oxygen supplementation
Positioning in recovery
Avoid pressure on their neck
Maintenance of tracheostomy tube if present including positioning and bedding/litter
Feeding implications - soft palate resection, may consider bypass initially until swelling subsides, also increased risk of asp pneumonia after tie back
107
Thoracotomy
Why? Lung lobectomy, investigation of pleural effusion or pneumothorax, patent ductus arteriosus ligation, pericardiectomy, other thoracic procedures.
Approaches - lateral or medial. Lateral most common
Prep - prepare as much as possible before inducing, drain chest, keep in sternal as long as possible, place IV catheter, pre-oxygenate
During - close monitoring, maintain ventilation (IPPV), keep drain open until chest is closed.
Post - high risk of hypoxia, analgesia, management of drains, prevent patient interference, position.
108
Laparotomy
Pre-op = body temp, investigations, dehydration status, stabilisation
Intra-op = body temp, minimising contamination, monitor as high risk GA
Post op = monitor, analgesia, antibs?, IVFT, nutritional support, urine output
109
Neurosurgery
Pre-op = neuro exam, care moving patient, elective or emergency? Urinary management
Intra op = close monitoring, analgesia, urinary management, Opioids/NSAIDs
Post op = cage rest/bedding, tempt to eat, catheterise bladder, turning or propped in sternal, physiotherapy
Spinal surgery considerations - avoid pressure on neck, IVFT, ventilation support may be necessary
110
Head trauma
Lateral recumbency and raise head to a max of 30 degrees to dec intracranial pressure (mannitol to help dec this)
Airway management and O2
Close monitoring, full neuro exam inc cranial nerves
Bloods, skull radiographs, bp, CT/MRI
IVFT with caution
Analgesia & treat conditions
Body temp
Bladder size/catheterise
Manage intracranial pressure and avoid procedure that may increase.
Hypertonic saline. Steroids now contraindicated.
111
Caesarean
When? >24hr drop in rectal temp, foetal oversize/small pelvic diameter, after 2 doses of oxytocin and no contractions, bitch/queen distressed
Intra op = slightly tilt dorsally and raised cranially, pre-oxygenate - inc risk of aspiration esp if not fasted. Uterine perfusion depends on blood pressure MAP >80, lavage/suction peritoneal cavity.
Post-op = common D+ due to hormones, peritonitis, antimicrobials, analgesia.
Spaying at same time has greater morbidity but doesn’t affect lactation.
Goal: short GA as poss - prep whilst conscious. Optimal removal within 15-20 mins post induction, adequate analgesia
112
Neonates during caesarean
Incubator - O2 and warmth of 30 degrees for first 24hrs then 26 degrees onwards.
Resuscitation - no flicking downwards- archaic
Umbilical cords - absorbable sutures
113
How many breaths are given in 2 minutes of a CPR cycle?
10 breaths
CCOAS - VN
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