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197 Cards in this Set
- Front
- Back
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What does POVMR stand for?
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Problem Oriented Veterinary Medical Record (POVMR)
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What are the components of Problem Oriented Veterinary Medical Records?
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(1) data base- minimum
(2) problem list (3) plan: DX and RX (4) progress notes |
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What is the information in the minimum data base of a POVMR?
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(1) general --> signalment, HX, PE
(2) problem specific (3) system (4) degree of evaluation and treatment |
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What is the definition of a problem when dealing with a POVMR?
How is a problem defined? |
anything that might interfere with the animal's well being and might require further evaluation and treatment
-defined at the highest level of refinement, but not overstated Example: (1) clinical signs: PU/PD (2) Laboratory data: azotemia (3) Pathophysiology: renal failure (4) Final Diagnosis: chronic interstitial nephritis |
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How is information listed on a Master Problem List?
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-transcribed from a temporary problem list within 24 hours and listed in order of clinical importance
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How is a daily plan determined when treating an animal?
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-daily plan is based on DX and RX progress
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What is the first page in the medical records?
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-table of contents --> the Master Problem List
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When are problems dated from on medical records (on the MPL)?
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from their origin - numerical order from their origin
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What are the five things that can happen to a problem on a master problem list?
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(1) Refined with accumulation of facts
(2) combined with another (3) Temporarily inactivated (4) resolved (5) removed - problem in error and was never a problem |
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What is a SOAP and what do the letters in it stand for?
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SOAP=progress notes (each problem should be SOAPed seperately)
S=subjective O=objective A=assessment P=Plan (DX, RX, Client Education) |
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What type of comments would be placed in the S of a SOAP?
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-historical
-overall assessment: (Bright and Alert) -Observations that are not quantitated: (stronger, better appetite, more playful) |
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What type of comments would be placed in the O of a SOAP?
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-daily PE findings
-quantitative data: lab data, radiographic findings, ECG, neuro exam, body temp |
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What type of comments would be placed in the A of a SOAP?
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-interpretation and explanation of problem at this time period
-current differential diagnosis -evaluation of RX -how this case differs from typical cases -shows students understanding of case |
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What type of comments would be placed in the P of a SOAP?
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DX: what tests will be performed in the next 24 hours: include a BOX for initials and time checkoffs
RX: list therapeutic objectives and goals; what treatments will be administered in the next 24 hours (include dose, frequency, route of administration); include a box for initials and time checkoffs CE: list time of communication; list person talked with; summarize conversation (update condition, discuss new dx tests or treatments, risks of any procedures, update bill) |
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What is the definition of shock?
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-inadequate systemic oxygen and nutrient delivery
-impaired utilization of oxygen -poor tissue perfusion (constriction, decreased CO, and vasodilation ) |
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What are the four classifications of shock?
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(1) hypovolemia --> inadequate circulating blood volume
(2) relative hypovolemia (distributive) --> vasodilation and increased pooling of blood in veins is effectively removing blood from circulation (3) cardiogenic --> decreases CO (4) septic shock --> a combination of all three above |
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What is the result of blood volume loss in hypovolemia?
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inadequate circulating blood volume and hypotension due to (hemorrhage, loss to body cavity, GI losses)
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What is the body's response to hypovolemia?
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(1) sympathetic activation (RAAS, ADH, ACTH); causing vasoconstriction, increased contractility, fluid retention
(2) distribution of blood flow towards the heart, brain, lungs and away from splanchnic, skin circulation |
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What are many of the clinical signs of shock due to?
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-the compensatory mechanisms trying to prevent shock (vasoconstrictions may impair blood flow to some organs)
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When does shock occur?
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-when compensation is inadequate or it is so excessive that it results in impaired tissue perfusion
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What are some clinical signs of shock and what do they primarily result from?
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-These signs are the body's attempt to maintain blood pressure and increase CO (come at the expense of tissue perfusion)
-pale mucous membranes -slow cap refill time -weak pulse -cold extremities tachycardia -depression -oliguria -Primary disease - the cause of the shock |
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What are some consequences of shock?
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(1) vasoconstriction (arterioles, venules, spleen and decreased blood flow to viscera and extremities)
(2) decreased myocardial contractility (3) increased vascular permeability (4) cell death due to inadequate oxygen (5) vasodilation occurs with advanced shock and distributive shock (sepsis) |
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What is systemic inflammatory response syndrome?
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-generalized, excessive inflammatory response to various stimuli
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What are risk factors for sepsis?
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(1) localized infection
(2) immunosuppression (3) invasive devices (4) surgery |
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What are clinical signs of early sepsis?
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-depression
-fever -tachycardia -red mucus memranes -rapid CRT -leukocytosis/thrombocytopenia, -hyperglycemia |
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What is the difference between sepsis and bacteremia?
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sepsis is a systemic inflammatory response to infection
bacteremia is a presence of bacteria in the blood |
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What are signs of chronic bacteremia?
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-often mild clinical signs
-fever (intermittent) -lameness (polyarthritis) -vomiting -depression |
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What would a complete blood count look like with sepsis?
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-hemoconcentration
-hemolysis -leukocytosis -leukopenia -left shift -monocytosis (may be only abnormality with chronic bacteremia) -thrombocytopenia |
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What would you do if you suspect sepsis?
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-culture urine because clinical signs of an UTI may not be present
-bacteriuria can occur in sepsis |
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What can cause septic shock?
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-bacteremia and endotoxemia
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What kinds of things would you see in the blood chemistries with sepsis?
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-hypoglycemia - can be LIFE threatening in severe sepsis
-hyperbilirubinemia -elevated liver enzymes -hypoalbuminemia - liver involvement |
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Where would you look for infection in the case of sepsis?
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(1) urinary tract
(2) GI tract (3) respiratory tract (4) abdomen (5) repro tract (6) cardiac valves (7) gingiva |
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What are some origins of sepsis?
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-IV catheter
-peritonitis, transmural migration across GI, immunosuppression (drugs or diseases such as FIV, FELV), pneumonia, discosponsylitis, endocarditis |
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How do you diagnose sepsis?
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(1) Clinical findings
(2) Confirming infection Culture - primary site, urine, catheter tip, -blood culture is done if endocarditis, discospondyltis or no site of infection can be identified in patient with signs of sepsis |
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What are general guidelines to treating sepsis?
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-be aggressive
-treat early -treat primary disease -prevent septic shock -antibiotics |
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How do you treat sepsis with antibiotics?
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-find likey organisms at location of primary infection and gram stain of cytology
-IV administration of drugs -high dose -use broad spectrum antibiotic initially |
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What are signs of septic shock?
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-peripheral vasodilation predominates in early stage (skin, GI tract; brick red mucous membranes, strong pulses)
-vasoconstriction to kidney, heart -increases heart rate, contractility -later stages identical signs to other forms of shock |
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What are clinical signs of septic shock?
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-fever or hypthermia
-tachycardia -tachypnea -depression -weak pulses -slow CRT, pale mm -leukopenia or leukocytosis -hypoglycemia -organ failure |
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What is the treatment for sepsis?
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-IV fluids
-treat for shock if present - vasodilation predominates -treat complications (DIC, organ failure, hypoglycemia) -nutritional support |
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What are the goals for treating shock?
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-Primary goal is to restore adequate oxygen delivery and nutrients to tissues
-restore blood volume (resuscitation) - IV fluids are important in all cases of non-cardiogenic shock |
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When treating for shock, how do you restore blood volume?
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-increase preload, CO, tissue perfusion
- use IV fluids (crystalloids) - treat with a shock dose and assess response every few minutes -animal should respond in one hour |
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What is the shock dose of fluids and what type of fluids do you use?
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-90 ml/kg/ hr for one hour
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What is a typical response to IV fluids when treating for shock?
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-decrease heart rate
- improved pulse character -improved mucus membrane color and CRT -watch for overyhydration |
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What does hypertonic saline (7% NaCl) do for the patient when treating for shock?
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-results in rapid movement of interstitial and intercellular fluid into intravascular space
-it takes a maximum effect in 5-10 minutes and is short-lived |
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What stays in blood longer - colloids or crystalloids?
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colloids stay in vascular space longer thus can be given at a lower dose
-when combined with a crystalloid, will allow smaller volume resuscitation |
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When would you use a colloid when treating for shock?
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-when hypoproteinemic
-lack of response to initial crystalloid administration |
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When would you use a vasopressor or positive inotrope to treat for shock?
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-last resort --> reserved for animals that do not respond to volume replacement or when severe hypotension is present
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What type of drugs would cause increased contractility therefore increased CO when treating for shock?
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-dobutamine (beta-1 agonist)
-beta agonist effects of NE, E, dopamine |
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What types of drugs would cause vasocontriction (alpha-adrenergic) effects when treating for shock thereby increasing effective circulating volume?
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NE, high dose of dopamine
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How is dopamine used when treating shock - good and bad?
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*low doses - dopaminergic receptors (preferential vasodilation of renal, coronary, and splanchnic arterioles at low dose
*moderate dose - beta-adrenergic (increases cardiac output, stroke volume, heart rate) -high dose - alpha adrenergic receptors (undesirable) |
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For what types of shock is oxygen recommended?
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all types of shock
-improves tissue axygenation (increases perfusion and blood oxygen content) -hypoxia is harmful to tissue |
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Why is it good to keep your patient warm when treating for shock and how?
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-hypothermia impairs vascular response to fluids
-use passive warming -warm IV fluids |
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Why is a blood transfusion done when treating for shock and how is it done?
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-done because it ensures oxygen delivery
-transfuse animals with PCV < 20-25% when in shock (maintain 25%) -consider hemoglobin-based oxygen carriers (Oxyglobin) |
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What does sodium bicarb do when treating for shock?
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-treats acidosis if present
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What do GI protectants do when treating for shock?
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-treat/prevent GI ulceration
-H2 blockes (cimetidine, ranitidine, famotidine) |
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What do antibiotics do when treating for shock?
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-used in treatment of septic shock or those with GI hemorrhage
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What does pentoxifyline do when treating for shock?
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-increases RBC membrane flexibility
-increases RBC delivery to peripheral tissues -suppresses pro-inflammatory cytokines |
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What should be monitored in a shock patient?
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-temp, pulse, respiration
-BW (watch fluid overload) -MM color, CRT -urine output -lung sounds -electrolytes, PCV, total protein -pulse oximetry -blood gas -BP -blood glucose |
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Why should a pulse oximeter be monitored during treatment for shock?
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-avoid hypoxemia
-allows continuous monitoring -does not reflect tissue oxygen content |
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What should the BP be kept above in a patient with shock?
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systolic BP> 90mmHg
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What is the normal urine output when monitoring a shock patient?
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1-2 ml/kg/hr
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What is the difference in definitions of hyperthermia and fever?
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hyperthermia - any elevation in body temperature above normal range
fever - elevation in body temperature that occurs due to a changed thermoregulatory set point in the hypothalamus |
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what is the definition of heat stroke?
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-form of nonpyrogenic hyperthermia that occurs when heat dissapating mechanisms of the body cannot accommodate excessive heat
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What is malignant hyperthermia?
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uncommon familial nonpyrogenic hyperthermia that occurs secondary to some anesthetic agents (halothane) and muscle relaxants
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What is thermal homeostais?
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balance between heat load and heat-dissapating mechanisms
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Give examples of heat load and head dissipation.
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heat load: environemental heat, heat generated by metabolism and exercise
heat dissipation: radiation, convection, conduction, evaporation |
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What controls temperature regulation in your body?
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anterior hypothalamus
-peripheral and central thermoreceptors sense body temperature changes and stimulate the AH to cause the body to increase heat production and reduce heat loss or dissipate heat |
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What are mechanisms for heat gain?
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-increased production=catecholamins, thyroxine, shivering
-decreased heat loss=vasoconstriction, piloerection, postural changes, seeking warm environments |
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What are mechanisms for heat loss?
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-panting
-vasodilation -postural change -seek cold environment -perspiration -grooming (cat) |
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Explain the pathophysiology of a fever.
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exogenous/endogenous pyogens cause the release of endogenous substances that reset the hypothalamic thermoregulatory center to a higher temperature, activating appropriate physiologic responses to raise body temperature to this new set point
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Give examples of exogenous pyogens.
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-infectious agents
-Ag-Ab complexes -drugs -tissue inflammation -necrosis |
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Give examples of endogenous pyogens.
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-cytokines releases from leukocytes (IL-1, IL-6, TNF alpha)
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How are fevers protective to a body?
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-directly inhibit viral replication and kill microorganisms
-indirectly increase host immune response - increase susceptibility of granulocyte lysosome breakage thereby increasing microbial death in phagocytes |
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In a fever, IL-1, IL-6, and TNF alpha act on the brain to do what?
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-raise body temperature (by generating heat - muscle contraction and shivering)
-conserving heat (constriction) -induce sleep -suppress appetite -enhance protein catabolism and mob. AA -IL-1 acts on BM to stimulate release of neutrophils |
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What are the consequences of a fever?
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-increases metabolic demands, muscle catabolism, suppressed erythropoesis, increased fluid and caloric needs, possibly DIC and shock
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What are the five major causes of fever?
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-infectious
-inflammatory -immune mediated -neoplastic -drugs/toxin |
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What is a fever of unknown origin in vet med?
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-fever of sufficient duration to rule out common, simple, or self-limiting causes
-initial tests don't reveal cause -failure to respond to short course of antibiotics |
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What is the diagnostic approach for FUO?
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-warn client - can take time, may need diagnostic tests (and repeat), can become expensive
-history -PE -Lab tests -imaging -treatment |
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When looking at temperature in a physical exam, what temperature is considered hyperthermia and not a true fever?
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above 106 degrees
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What may a temperature up to 103 degrees F mean?
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stress/concurrent illness
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When dealing with a FUO, what might you tailor your diagnostics around?
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if a higher yield problem identified in history or physical exam, tailor diagnostics around this
-if not, stage diagnositics starting with safe, non-invasive, and easy to interpret tests |
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What type of laboratory testing might you consider when dealing with a FUO?
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-CBC and blood smear
-chemistry -UA and culture -prostatic wash/ejaculate evaluation -FeLV/FIV test -Occult heartworm test -fecal -lymph node aspirates |
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If there is a mild to moderate fever (less than 106) what is the progrnosis and treatment?
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-usually not life threatening and may have beneficial effects
-antipyretics generally not indicated provide adequate fluid therapy and nutritional support |
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How do you treat a fever above 106?
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-if fluid therapy is insufficient to decreases fever, consider antipyretics
-DO NOT cool patient with fans or cool-water baths - NOT appropriate and will just make patient uncomfortable |
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What can a temperature greater than 106 lead to?
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-organ damage, electrolyte and acid-base disturbances and DIC
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When would you use a glucocorticoid to treat fever?
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-only if infection is ruled out
-may mask clinical signs and immunosuppression |
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What type of NSAIDs would you use to treat a fever?
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-salicylates (asprin) --> acts centrally on the hypothalamus and inhibits prostaglandin production; causes peripheral vasodilation
-NOT for cats -can also use carprofen |
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When does heat stroke occur and what exactly happens?
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-exposure to extreme environmental temperature resulting in elevated body temperature and direct thermal injury to cells
-set point does not change and the normal mechanisms of compensation are overwhelmed |
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When the body temperature is above 106 and there are no signs of inflammation, what is this called?
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heat stroke
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What are predisposing factors to increased heat production?
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-exercises
-fever -seizures |
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What type of CNS effects does heat stroke have on the body?
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-neuronal injury and cell death
-cerebral edema -cerebellar dysfunction -damage to thermoregulatory center - predisposition to subsequent hyperthermic episodes |
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What type of GI/Hepatic effects does heat stroke have on the body?
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-ischemia and ulceration --> bacterial translocation, endotoxemia, sepsis
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What type of renal effects does heat stroke have on the body?
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-acute renal failure from tubular necrosis
-direct thermal injury, hypoxia b/c of hypovolemia, microthrombi due to DIC, myoglobin from rhabdomyolsis |
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What type of hematologic effects does heat stroke have on the body?
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-dehydration and hemoconcentration
-anemia -DIC -thrombocytopenia |
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What do the mucus membranes look like in an animal with heat stroke?
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tacky with prolonged CRT
-animal is panting |
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What is the CBC on a patient with heat stoke?
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-hemoconcentration
-anemia -leukocytosis/leukopenia -thrombocytopenia -increased nRBCs -schistocytes |
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What is the chemisty on a patient with heat stoke?
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-hyppoglycemia
-azotemia -elevated liver enzymes -hyperbilirubinemia -high CK -hyernatremia |
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How do you treat hyperthermia?
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-clip hair coat
-spray with water - coll with fan -cool water lavage or enemas -stope when temperature is 103 to avoid hypotehrmia -NOT cold or ice |
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Why would you not want to use ice or cold water to treat hyperthermia?
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causes vasoconstriction and inhibits cooling
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When treating with oxygen in treating hyperthermic patients, what do you want to avoid?
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-oxygen cages - they contribute to overheating
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What type of fluid thereapy would you use to treat a hyperthermic patient?
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-crytalloids to rehydrate the interstitium (may need shock doses initially)
-hypoalbunemic patients or those with decreased COP may require colloids |
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How do you treat DIC?
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-agressively with plasma transfusions - consider heparinization
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Why would you use a broad-spectrum antibiotic to treat hyperthermia?
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- for bacterial translocation, sepsis
- also treat with a GI protectant - H2 blockers of sucralfate |
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Are NSAIDS indicated in treating hyperthermia?
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NO - set point is not altered
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After rehydrating a patient with hyperthermia, they are not putting out 1-2 ml/kg/hr of urine. What do you do?
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-treat for oliguric renal failure - furosemide, mannitol, dopamine
-For low blood pressure, considere dopamine or dobutamine if hypotensive after volume resuscitation |
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What would you use to treat for seizures in a hyperthermic patient?
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diazepam
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What is the prognosis for a hyperthermic patient?
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-guarded
-most dogs that will die will do so in the first 24 hours -dogs hospitalized for more than 72 hours or whose temp quickly normalized often recover |
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What is anaphylaxis?
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a severe local or systemic Type I hyersensitivity reaction; immediate- IgE mediated
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What are the following:
-type II -type III -type IV hypersensitivity reactions |
II- cytotoxix (IgG and IgM mediated)
III - immune-complex deposition IV - delayed (T-cell dependent) |
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What are the steps to anaphylaxis?
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-1st exposure to antigen leads to production of IgE
-IgE binds mast cells -2nd exposure --> cross-linking of IgE-Ag - mast cell activation and degranulation --> release of inflammatory mediators -anaphylactic reaction |
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What are the effects of histamine?
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-smooth muscle contraction=bronchi and small intestine (pulmonary vasoconstriction)
-stimulate exocrine secretions=bronchial mucus, lacrimation, rhinorrhea, salivation, gastric acid -increases vascular permeability - wheal formation, edema in face and paws -pruritis -stimulates NO in endothelial cells (a vasodilator causing decreased peripheral resistance and BP drops - hypotensive) -enhanced leukocyte chemotaxis -further mast cell degranulation |
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What are local reactions/clinical signs of anaphylaxis?
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-usually limited to one organ system, local to site of Ag, but can progress
-cutaneuous - itchy, wheels, facial swelling -GI - vimit/diarhhea -airway |
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What are the shock organs of ruminants?
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-respiratory shock - show signs of cough, dyspneal, collapse, pulmonary edema, emphysema
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What are the shock organs of equine?
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-respiratory and intestine (cough, dyspnea, diarrhea, collapse, pulmonary edema, emphysema, GI hemorrhage
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What are the shock organs of ruminants?
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-respiratory tract and intestine (cyanosis, pruritus, hypotension)
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What are the shock organs of canines?
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-LIVER and GI
(hepatic congestion and portal hypertension; vomit, diarrhea, visceral bleeding) |
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What are the shock organs of cats?
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-LUNG and respiratory
(laryngeal/pharyngeal edema, bronchoconstriction, excessive mucus |
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What are causes of anaphylaxis?
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Foreign materials:
-vaccines, blood products, venom, drugs -usually follows previous exposure, not always |
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What are the ABCs to emergency life suppoert when treating anaphylaxis?
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A=airway - patent, if not intubate
B=breathing C=cardiovascular support - IV to replace volume deficits * eliminate the inciting antigen |
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What type of IV fluids would you give to treat for systemic anaphylaxis?
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-crystalloids - shock dose to effect (start at 1/4 shock dose) - maintain systolic BP above 90
-colloids - indicated if crystalloids not effective in maintaining pressures -5 ml/kg bolus can repeat |
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What does Epinephrine do for anaphyslaxis patients?
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alpha and beta adrenic agonit
-reduced further degranulation -promotes vasoconstriction - gets BP up -promotes bronchodilation - helpful for patients that are bronchoconstrictive -give IV, intratracheal or IM in less severe cases |
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What can IV doseing of antihistamines do?
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cause hypotension
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What do antihistamines do for a patient in anaphylaxis?
Give an example of one and its dose. |
-inhibit binding of histamine at the receptor sites
-diphenhydramine - 1-2 mg/kg/hr |
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What other drugs (other than epinephrine and antihistamines) could you give to treat analphylasis?
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(1) fast-acting corticosteroids - reduce DELAYED signs of anaphylaxis (no effect for 4-8 hours)
-inhibit histamine synthesis and stabilize vascular membranes -block the AA cascade (2) atropine - if still bradycardic or hypotension (3) vasopressors - dopamine CRI (4) bronchodilators - albuterole inhaled and aminophyline |
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What type of dose would you use when treating with corticosteroids for anaphylaxis?
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anti-inflammatory doses
-dexamethasone SP: 0.1-0.2 mg/kg IV |
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What is the general treatment protocol for treating localized anaphylaxis?
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-antihistamines - diphenhydramine
-corticosteroids -monitor for progression to systemic anaphylaxis |
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How do you avoid future episodes of anaphylaxis?
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-record event so it is easy to see
-avoid future exposures -pretreat with corticosteroids -vaccine reactions - seperate timing of vaccine - don't give all at once -only mandatory vaccinations -consider titers |
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What is the emergency treatment protocol for anaphylaxis?
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-ABCs
-shock dose of fluids IV -oxygen -corticosteroids -maybe epinephrine maybe aminophyline IV or another bronchodilator -monitor in hospital overnight |
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What percent of body is water?
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60% body weight
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Where is fluids loss occuring?
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-PU/PD
-vomiting/diarrhea -hemorrhage -fluid sequestration -lack of intake |
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What are methods to assess hydration status?
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skin turgor
mucous membranes pulse rate and character capillary refill time body weight |
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What are the clinical signs of dehyration?
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-<5% = undetectable
-5-6% = subtle loss of skin elasticity -6-8% = delayed skin tent, dry mm -10-12% = long skin tent, dry mm, slow CRT, sunken eyes, tachycardia, weak pulses -12-15%=hypovolemic shock |
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What are route of fluid administration?
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-oral
-SQ -IP -IV IO |
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What are some advantages and disadvantages to using oral fluid therapy?
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Advantage: most physiologic route, no risk of overhydration, reduce electrolyte loss in diarrhea, inexpensive
Disadvantage: not for vomit, GI obstruction, NPO, slow |
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What is a major disadvantage to SQ fluids?
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-can't correct moderate-severe dehydration
-vasoconstriction impairs absorption -cellulitis is possible |
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What are oral fluids made of?
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electrolytes with glucose for co-transport and water follows
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What are SQ fluids made of?
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-isotonic fluids
-K+ content up to 35 mEq/L no glucose (don't use) |
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What are the disadvantages to IV fluids?
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-IV catheter
-monitoring -overhydration -expense |
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How often do you change an IV catheter?
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72 hours
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What is the proper placement of IV catheter when giving isotonic solutions vs. hypertonic solutions?
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Isotonic--> peripheral vein such as cephalic, saphenous
Hypertonic --> central (jugular) |
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When would you use IO fluids and what are disadvantages?
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-use when other routes are inaccessible
-rapid placement with rapid fluids absorb -disadvantages are that there can be growth plate damage, overhydration and may require a pump |
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What is the definition of a crystalloid solution?
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-contain electrolyte and nonelectrolyte solutes that enter all body fluid compartments ( water with Na, K or glucose)
-can be isotonic, hypertonic, and hypotonic |
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What are replacement fluids?
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contain electrolytes in concentrations similar to plasma (300) - balanced electrolyte solution (LRS, NOrmosol-R)
-can be given rapidly without bad effects |
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What are replacement fluids used for?
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-correct fluid deficits
-shock therapy -alkalizing fluids - bicarb precursors (lactate and acetate) -acidifying fluids - chloride (.9% NaCl) |
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Is LRS alkalizing or acidifying?
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alkalizing
-uses lactate Normosol uses acetate |
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How much Na is normally in a replacement solution?
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130-140 mEq/L
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What does the use of replacement fluids for maintenance often end in?
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hypernatremia
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What are maintenance solutions made of?
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-contain electrolyte concentrations similar to those lost in normal animal - urine GI secretions
-less Na than replacement (40mEq/L) -more K than replacement solutions -given with dextrose (5% dextrose) |
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What is hypertonic saline used for (5 or 7% NaCL Saline)?
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rapid increase in intravascular volume
-treatment of shock -moves fluid from interstitial and intracellular space into vascular space -short-lived effect -increases preload, positive inotrope, and vasodilation --> increases CO |
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Would you use hypertonic saline on a dehydrated patient?
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NO
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What are colloids?
give examples |
large mollecules that stay in vascular space
-osmotically active -dextrans -hetastarch pentastarch albumin plasma |
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What are the indications for using colloids?
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-hypovolemia combined with: hypoalbuminemia, fluid accumulations (ascites, pleural effusion, edema), increased capillary permeability
-inadequate response to crystalloids -shock -hypotension during anesthesis |
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What types of fluids fall under the category of crystalloids?
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-replacement, maintenance, hypertonic saline
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What are the three main components to developing a fluid therapy plan?
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(1) fluid volume
(2) rate of administration (3) type of fluids |
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What are the three components to determining how much fluid to give?
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(1) fluid deficit - dehydration
(2) maintenance requirements - insensible losses, sensible losses, (3) ongoing losses |
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How do you estimate deficit volume for a dehydrated patient in order to calculate the fluids they need?
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-fluid deficit (L)=% dehydration x body weight (kg)
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What is the average amount of insensible losses?
Give an example of insensible losses? |
20ml/kg/day
-fecal, respiratory, cutaneous |
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What are the total maintenance requirements in a dog/cat? Do small and young animals have a higher fluid requirement per Kg?
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40-60ml/kg/hou
-yes |
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What is considered an ongoing loss?
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diarrhea
vomiting polyuria 3rd space loss bleeding easily underestimated |
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What three questions should you ask when determining the rate of fluid administration?
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(1) What was the rate of loss
(2) What was the magnitude of loss (3) What is the current circulatory status |
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How should chronic fluid loss be replaced?
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-correct over 24-48 hours
-replace 50% deficit over 6-12 hours, completing over next 12-24 hours |
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How should acute fluid loss be replaced?
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replace deficit over 2-6 hours or faster
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What will happen if too much fluid is given to patients with chronic loss?
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excessive diuresis - pee it out
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What is the shock dose for dogs and cats?
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dog - 90ml/kg/hour for 15-60 min
cat - 60ml/kg/hr for 15-60 min a colloid should be considered if adequate response is not noted in one hour |
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How do you calculate the IV drip rate?
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drops/min=rate (ml/hour) divided by (60 x # drops/ml of set )
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What type of fluid would you use on a cat that is vomiting, diarrhea, ect?
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standard replacement electrolyte solution - similar composition to plasma in most cases
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What type of fluid would you use on a cat that is vomiting gastric contents only (ie - metabolic alkalosis with hyponatremia, hypochloremia?
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normal saline - an acidifier
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What type of fluid would you use on a dog that has fluid retention issues - heart failure, hepatic failure, hypoalbuminemia, effusion, edema, ascites?
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use low sodium fluid such as a maintenance fluid or a colloid
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What are you doing when you are monitoring fluid therapy?
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complete physical exam 2x per day
-look for overhydration --> serous nasal discharge, chemosis, cough, dyspnea, crakels, edema, ascited, shivering, restless, diarrhea, vomiting |
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What are causes of overhydration?
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-excessive fluid administration
-oliguria -hypoproteinemia -impaired CO |
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What could be some causes of inadequate hydration?
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-calcualtion error
-underestimation of fluid deficit -ongoing losses -rate of infustion too high --> diuresis rather than rehydration -catheter |
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What are the rules of thumb for K supplementation in fluid therapy?
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-first ensure adequate urine output
-don't administer with dehydration -not used in acute renal failure, hyperkalemia -never exceed 0.5 mEq/kg/hr -Do not add K to fluids given at shock rate |
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What are clinical signs of hypkalemia?
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-weakness
-cervical ventroflexion -decreases renal concentrating ability -renal failure |
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Why would you never exceed a K infusion of 0.5 mEq/kg/hr?
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could stop the heart
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What are signs of hyperkalemia?
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-weakness, restless, stuppor
-bradycardia -ECG changes: tall, peaked T waves, wide QRS, prolonged P-R, decreases P, sinoventricular rhythm |
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What are keys to preparation for treatment of CPA?
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-crash area with essential supplies
-trained personnel -specific orders from owner |
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What kind of supplies are kept in the crash area?
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-intubation equipment
-oxygen, monitors, defibrillator, suction -IV catheters, drugs (E, atropine, vasopresin) |
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What are the specific orders from owner that are marked on the form?
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-do not attempt reanimation - 0
-closed chest reanimation only -1 -open chest reanimation if appropriate - 2 |
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How do you recognize a CPA patient that is non-anesthetized?
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-gasping followed by apnea
-absence of peripheral pulse -no audible heart sounds -centralized and dilated pupils -absence of palpebral or corneal reflexes -patient is irresponsive pale/cyanotic/greyish mucous membranes |
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How do you recognize a CPA patient that is anesthetized?
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-agonal breathing or apnea
-absence of peripheral pulses -no audible heart sounds -no doppler sound -flat arterial line -asystole, ventricular firbrillation, pulseless electrical activity, pulseless ventricular tachycardia -no eye reflexes -fixed and dilated pupils -sudden drop on CO2 -surgery - blood gets dark and bleeding stops |
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What are the steps to take when a patient goes into CPA?
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(1) immediately start chest compressions and stop anesthetic
(2) establish a patent airway (3) connect to oxygen (4) give E or atropine - IT, IV, IO (5) establish venous access (6) connect monitors (7) reassess the patient (8) defibrillation if appropriate |
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What is the ideal rate of chest compressions for a SA and LA?
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80-100 - SA
60 - LA -with a 1:1 compression/relaxation |
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Where are compressions performed on large dogs?
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highest point on the chest in R recumbency and compressor behind the patient (spine facing them)
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How do you perform chest compression on round chested dogs?
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dorsal recumbency, compress sternum
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How do you perform chest compressions on small dogs and cats? - less than 10 kg
|
over the area of the heart (4-6th IC space at CC junction)
-use 1 hand: thumb on one side and fingers on other ide |
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What size dogs are open chest compressions effective on?
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large - greater than 20kg
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What are the indications for open chest compressions?
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-penetrating chest wounds
-thoracic trauma -pleural effusion/pneumothorax/pericardial effusion -failure to achieve ROSC within 5 minutes |
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Why do you intubate right away when an animal goes into CPA?
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-provides a patent airway for ventilation
-protect the airway from fluids or debris -provide a route for drug administration |
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What should the respiratory rate be in an animal with CPA?
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-respiratory rate should be 8-12 bpm, limit to 15-20cmH2
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What drugs might you give to an animal with CPA and why?
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-epinephrine (vasoconstrictor, positive inotrope and chronotrope, bronchodilator)
-atropine - positive chronotrope (increase HR) -vasopressin (ADH) - vasoconstrictor, improves coronary perfusion and cerebral perfusion |
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What is defibrillation indicated for?
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ventricular fibrillation or pulseless ventricular tachycardia (2-5 joules/kg)
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What would you use if the upper airway is obstructed?
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-tracheostomy
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What would you use with a pneumothorax?
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thoracocentesis
-persistenet - thoracostomy tube |
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True or false - you would use warming blankets on a dog?
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no- might burn it
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What are good opiods to use in an emergency?
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-oxymorphone
-reversible |
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What type of blood work is good to run in an emergency situation?
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PCV, TP, Azostyk
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What might be reasons for insufficient respiration?
|
-pulmonary contusion
-pneumothrox -upper airway obstruction -diaphragmatic hernia |
