Practical Emergency and Critical Care Veterinary Nursing

Paul Aldridge, Louise O'Dwyer

• Publisher: Wiley-Blackwell
• Year: 2012
• Print ISBN: 9780470656815
• eBook ISBN: 9781118483480
• Edition: 1
• Topic: Medicine
• Subtopic: Veterinary Medicine

Your step-by-step guide to key emergency and critical care procedures and hands-on nursing care. Whether you need to know how to prioritise your response to a patient with multiple injuries, or you need a quick practical guide to fluid therapy, this is the go-to resource.  Colour photographs of real life cases take you through the procedures and after-care, detailing essential skills. This book provides vital information for emergency and critical care situations, whether you're looking for confidence in handling emergency cases in a first-opinion practice, or a relevant, succinct guide for an emergency clinic.  Be inspired to become more confident in your clinical skills and abilities, and learn how to apply your existing skills to an emergency situation.

A companion website provides additional resources useful in the management of emergency and critical patients. Visit the website to find information charts and video clips of procedures.

Written by a veterinary nurse and a veterinary surgeon who work together in the largest UK emergency clinic, this book is a practical, how-to manual with a nursing focus.

Suitable as a complete reference for nurses studying towards qualifications, or as a practical guide for daily use by veterinary nurses working in veterinary emergency and critical care.

1

Triage and Assessment of the Emergency Patient

Introduction

Throughout the management of the emergency patient a successful outcome is more likely to be achieved where prompt, appropriate action is taken as dictated by the clinical findings of observation and examination. Nowhere is this more important than on initial presentation where the patient with a life-threatening condition must be identified and receive immediate attention; this process is triage.

Triage is a system of rapidly evaluating patients and allocating treatment to those patients that are in most urgent need, or in the case of one individual case, allocating treatment to the most serious problem first. To gain this information, a rapid, efficient, clinical examination of the major body systems is carried out: respiratory, cardiovascular and central nervous system (CNS). The initial examination of each body system should concentrate on a small number of clinical signs that provide the most important information.

In human medicine, triage is well established and used in busy accident and emergency departments or at the scene of major incidents. The same principles apply in veterinary medicine, whether in a dedicated emergency out-of-hours practice or when dealing with an urgent case in a first opinion practice.

Telephone Triage

In many cases the initial contact from the owner of the emergency case will be by telephone. The veterinary nurse is often involved in establishing the urgency of the problem, and vitally whether the animal needs to attend the clinic immediately. From conversation with some owners it will become immediately obvious from the clinical signs described that the case is an emergency and should be seen as soon as possible (see Table 1.1). In other cases the nurse will need to try to determine the nature of the problem, and give advice accordingly. It may be necessary to calm the owner to elicit a concise, relevant history, and caution should be used when assessing an owner’s perception of the patient’s problem. If there is any doubt about the need to see an animal, it is safest to advise the owner to attend or for a veterinary surgeon to discuss the case with the owner. It is advisable that all patients with a traumatic injury should attend the clinic immediately.

Table 1.1 Examples of owner-reported clinical signs that warrant immediate attendance at clinic

Respiratory distress Severe coughing Weakness or collapse Neurological abnormalities Ataxia Non-weight-bearing lameness Severe pain

Abdominal distension Persistent vomiting or diarrhoea Inability to urinate Bleeding from body orifices Profuse bleeding from wounds Ingestion of toxins Dystocia

The owner should be questioned as to the signalment of the patient (breed, age, sex and approximate weight) and given clear and concise directions as to where they are to attend (this is especially important where phone lines are diverted out of hours and owners maybe unaware their call has been diverted to another site or clinic) and an estimated time of arrival obtained.

Advice may need to be given on transportation of the animal, especially following trauma. If an animal is unable to walk it may need to be carried; it is preferable for a trauma victim to be carried on a board or something rigid, rather than a blanket (see Figure 1.1). In the case of active bleeding, direct pressure on to a clean cloth is safer than the owner applying a tourniquet. Always warn the owner that the animal may be aggressive due to pain.

Figure 1.1 Transport.

Knowing the nature of the problem, along with the signalment of the animal, allows a great deal of preparation to occur prior to the patient’s arrival (see Figure 1.2); this can save valuable time when initiating stabilisation. For example, equipment for supplementing oxygen or obtaining vascular access can be prepared, or advice can be sought regarding toxic levels, appropriate management and antidotes in cases of intoxication.

Figure 1.2 (a) Preparing for the arrival of a patient. Information gathered during telephone triage allows equipment to be prepared and so save time once the patient has arrived; in this case a dog with a pharyngeal foreign body. (b) Close-up of the trolley in (a). Equipment includes intravenous access, endotracheal tubes, laryngoscope, surgical kit, tracheostomy tubes, etc.

Hospital Triage

On arrival at the clinic the major body systems are assessed during the triage, and a brief ‘capsular’ history obtained from the owner (see Table 1.2). See website documents: Triage assessment sheet.

Table 1.2 Questions asked of owners to obtain a ‘capsular history’

Signalment (age, sex, neutered, breed) Vaccination history

Duration of presenting complaint Current medication

During assessment, any abnormality detected with a major body system is likely to be life-threatening; therefore measures are immediately taken to start stabilising that condition, prior to completing the rest of the examination. The aim is not to reach a definitive diagnosis, but to start treatment of life-threatening conditions. So, for example, if an animal is immediately noted to be in respiratory distress, oxygen is administered before any other part of the examination is carried out.

Patients with certain presentations should be taken to the treatment area immediately, regard­less of major body system findings (see Table 1.3; Figure 1.3).

Table 1.3 Examples of presenting conditions that should be taken immediately to the treatment area on arrival

Seizures Trauma Prolapsed organs Dystocia

Ingestion of toxins Excessive bleeding Open fractures Burns (see Figure 1.3)

Figure 1.3 Severe burns on a puppy, an example of a patient that should be taken directly to the treatment area.

A useful path to follow in the initial assessment of major body systems is ABCD, where:

A: Airway

B: Breathing

C: Circulation

D: Dysfunction of the CNS.

A and B: Respiratory System

Emergencies involving the respiratory system require rapid assessment, cautious restraint and prompt measures to start stabilisation. Assessment of the respiratory system should begin as the patient is approached by observing their posture, respiratory effort and pattern, and whether any airway sounds are clearly audible.

In the normal patient, both cats and dogs have a respiratory rate of approximately 10–20 breaths per minute (bpm), ventilation involves very little chest movement, and the chest wall and abdomen move out and in together. Whilst open mouth breathing and panting in a dog is considered normal, the same in a cat is always considered to indicate respiratory distress and oxygen supplementation is indicated.

The respiratory system of the patient is assessed by observation, auscultation and palpation.

Airway

In a collapsed patient, assess if the airway is patent by listening for breathing, and looking in the mouth for any obstruction (blood, vomit, foreign bodies). Facial injuries or cervical bite wounds can interfere with the airway by disrupting the larynx or trachea.

Breathing

Observation

The patient should be closely observed before moving on to auscul...

Table of contents

• Cover
• Dedication
• Companion website
• Title page
• Copyright page
• Preface
• 1 Triage and Assessment of the Emergency Patient
• 2 Monitoring the Critical Patient
• 3 Vascular Access
• 4 ‘Shock’ and Intravenous Fluid Therapy
• 5 Blood Gas, Acid–Base Analysis and Electrolyte Abnormalities
• 6 Analgesia and Anaesthesia of the Emergency and Critical Patient
• 7 Practical Laboratory Techniques
• 8 Techniques for Oxygen Supplementation
• 9 Nursing the Dyspnoeic Patient
• 10 Nursing the Cardiac Patient
• 11 Nursing the Acute Abdomen Patient
• 12 Nursing Urinary Tract Emergencies
• 13 Nursing the Poisoned Patient
• 14 Nursing the Trauma Patient
• 15 Nursing the Reproductive Patient
• 16 Small Animal Critical Care and Hospitalised Patient Nutrition
• 17 Nursing the Emergency Ophthalmology Patient
• 18 Cardiopulmonary Arrest and Resuscitation
• 19 Nursing Considerations in the Critical Patient
• Index