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GENERAL APPROACH TO THE EMERGENCY PATIENT

GENERAL APPROACH TO THE EMERGENCY PATIENT

Doesn’t matter whether you work in small private practice or large referral clinic, you probably can’t totally escape providing emergency veterinary care, which requires knowledge of all areas of medicine, fast thinking and immediate action. Emergencies happen all the time as complications during anaesthesia or even after routine procedures (as vaccinations) or when acutely injured or ill patient is presented to the clinic.

Triage is the procedure that enables differentiation between stable and critically ill patients and helps prioritize the cases. It can occur already on the phone with the owner or/and at the clinic in the waiting room and finally during emergency examination.

 

Telephone triage

Telephone triage is very important to determine the nature and urgency of the problem. Based on history and clinical signs, we must decide if the patient needs to be seen immediately or can wait until later appointment. It is essential to keep in mind, that many clients can’t accurately describe pet’s condition, some clinical signs require immediate action to maintain life and some situations are not immediately life-threatening but may become so. Any pet with traumatic injuries, seizures, difficult breathing or inability to stand up (collapse), must be seen by a veterinarian immediately.

Information obtained during telephone triage can help us prepare for the arrival of the patient. Knowing for example approximate weight, enables us to preselect sizes for vascular catheters, endotracheal tubes and fluids.

Useful questions, that should be posed in telephone triage:

  • Animal’s signalment (breed, age, sex, weight)?
  • What is the main complaint? When did the signs begin and are they getting more severe?
  • What is mucous membrane colour? Are there signs of bleeding?
  • How is the animal breathing? Is it cyanotic, coughing?
  • Is the animal standing, moving, responding, is it conscious?
  • Is the animal receiving any therapy? Was the dosage appropriate?
  • How is general condition of the animal? Vomiting, diarrhoea, urination, pain …? Possible obvious fractures, wounds?

 

Waiting room triage

Waiting room triage is common in human medicine and several triage systems have been developed in order to provide consistency in triage decisions. Those systems are not fully implemented in veterinary medicine yet. A short assessing of breathing, perfusion parameters, consciousness and identifying life-threatening injuries should be done for recognition of emergency patients within seconds of arrival. For patients that are recognized as unstable, care should be taken immediately, and the stable ones can wait to be treated, if necessary.

 

Primary survey

During in-hospital triage we finally assess the patient’s condition and need for immediate care. The initial evaluation should cover three major body systems: respiratory, cardiovascular and neurological. Patients with severe abnormalities in these three systems require rapid medical attention, while conditions that affect other body systems are generally not life-threatening by themselves (but can affect the three major systems!). We should begin by observing breathing effort and pattern, patient’s posture and level of consciousness and looking for presence of blood on patient. At the examination, appropriate precautions should be taken, regarding patient’s temperament. One should bear in mind, that extreme caution is necessary with physical restraint and muzzling patients with respiratory distress!

Systematic approach to examining emergency patient is highly recommended, as it allows rapid identification and stabilization of the problem. During emergency examination we also decide, which of the problems is the most threatening and should be addressed first. The abnormal parameters should be listed and addressed according to priority.

A reasonable approach to triage is the use of the ABCDEs: Airway, Breathing, Circulation, Dysfunction or disability and Examination.

  • First, we assess patency of airway and breathing Concerning signs include breathing with extended head and neck and abducted elbows, exaggerated effort, open mouth, flaring of the nares, absent chest wall motion, paradoxical breathing and cyanosis.
  • In assessing circulation, we focus on six perfusion parameters, which can help us detect decreased cardiac output: heart rate, mucous membrane colour, CRT, pulse quality, temperature of the extremities and mentation.
  • Dysfunction or disability refers to the neurological status of the patient. We should evaluate animal’s mentation and ability to move. Fast neurological exam is performed, focusing on patient’s level of consciousness, pupillary light reflex, posture and response to pain.
  • At the end, a rapid whole-body examination is performed, to address possible additional problems (wounds, fractures, distended abdomen, signs of other disease).

Primary goals of emergency treatment are circulatory stabilization, haemorrhage and seizure control, which are quickly followed by optimizing oxygenation, electrolyte and acid-base balance and pain management. After emergent stabilization, a complete physical exam is performed in order to set the definitive diagnosis and create further treatment plan.

 

LITERATURE:

1.) Drobatz K. J. et al.: Textbook of Small Animal Emergency Medicine. Wiley, 2019

2.) Creedon J. M. B., Davis H.: Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care. Wiley, 2012