Small Animal Critical Care Medicine

Deborah Silverstein, Kate Hopper

• Editorial: Saunders
• Año: 2014
• ISBN:
  9780323243520
• Edición: 2
• Categoría: Médecine
• Categoría: Médecine vétérinaire

Emphasizing evidence-based therapy for critically ill or injured dogs and cats, Small Animal Critical Care Medicine, 2nd Edition puts diagnostic and management strategies for common disorders at your fingertips. It covers critical care medical therapy, monitoring, and prognosis — from triage and stabilization through the entire course of acute medical crisis and intensive care treatment. To make therapeutic decisions easier, clear guidelines address underlying clinical findings, pathophysiology, outpatient follow-up, and long-term care. From lead editors Deborah Silverstein and Kate Hopper, along with a Who's Who of experts from the veterinary emergency and critical care world, this comprehensive reference helps you provide the highest standard of care for ICU patients.

• Over 200 concise chapters are thoroughly updated to cover all of the clinical areas needed for evaluating, diagnosing, managing, and monitoring a critical veterinary patient.
• More than 150 recognized experts offer in-depth, authoritative guidance on emergency and critical care clinical situations from a variety of perspectives.
• A problem-based approach focuses on clinically relevant details.
• Practical, user-friendly format makes reference quick and easy with summary tables, boxes highlighting key points, illustrations, and algorithmic approaches to diagnosis and management.
• Hundreds of full-color illustrations depict various emergency procedures such as chest tube placement.
• Appendices offer quick access to the most often needed calculations, conversion tables, continuous rate infusion determinations, reference ranges, and more.

• All-NEW chapters include Minimally Invasive Diagnostics and Therapy, T-FAST and A-FAST, Systemic Inflammatory Response Syndrome (SIRS), Multiple Organ Dysfunction Syndrome (MODS), Sepsis, Physical Therapy Techniques, ICU Design and Management, and Communication Skills and Grief Counseling.
• NEW! Coverage of basic and advanced mechanical ventilation helps you in deliver high-quality care to patients with respiratory failure.
• NEW! Coverage of increasingly prevalent problems seen in the Intensive Care Unit includes multidrug-resistant bacterial infections and coagulation disorders.
• NEW chapters on fluid therapy and transfusion therapy provide information on how to prevent complications and maximize resources.
• UPDATED coagulation section includes chapters on hypercoagulability, platelet function and testing, anticoagulant therapy, and hemostatic drugs.

Part I

Key Critical Care Concepts

Outline

Chapter 1 Evaluation and Triage of the Critically Ill Patient

Chapter 2 Physical Examination and Daily Assessment of the Critically Ill Patient

Chapter 3 Cardiopulmonary Resuscitation

Chapter 4 Post–Cardiac Arrest Care

Chapter 5 Shock

Chapter 6 Systemic Inflammatory Response Syndrome

Chapter 7 Multiple Organ Dysfunction Syndrome

Chapter 8 Hypotension

Chapter 9 Hypertensive Crisis

Chapter 10 Hyperthermia and Fever

Chapter 11 Interstitial Edema

Chapter 12 Patient Suffering in the Intensive Care Unit

Chapter 13 Illness Severity Scores in Veterinary Medicine

Chapter 1

Evaluation and Triage of the Critically Ill Patient

Erica L. Reineke VMD, DACVECC

Key Points

• Triage refers to the sorting of ill animals for treatment based on priority when resources are insufficient for all to be treated immediately.

• The use of triage lists may help to categorize patients based on treatment priority along with targeted waiting times.

• The triage examination consists of a primary survey, in which the cardiovascular, respiratory, neurologic, and urinary systems are evaluated to identify life-threatening abnormalities. It includes both subjective and objective assessments.

• Intravenous catheterization, emergency blood testing, and a FAST ultrasound evaluation can offer additional information to guide patient stabilization procedures.

• The secondary survey, or a more thorough physical examination, should be performed once the animal is stabilized.

Introduction

Triage, derived from the French word trier, refers to the sorting of patients for treatment priority when resources are insufficient for all to be treated immediately in an emergency setting. The roots of triage can be traced to the battlefields in the mid-1800s where the medical needs of military casualties were prioritized. Military triage was refined during subsequent wars and demonstrated that early triage assessment and prompt resuscitation significantly reduced mortality rates.¹ The utility of military triage captured the attention of hospital providers, and during the late 1970s emergency departments began to develop their own triage systems.²

In veterinary medicine the term triage is also used to describe the sorting of animals in an emergency department based on medical priority: the sickest are treated first. Rapid and accurate triage of the animal is also essential for a successful veterinary emergency department. An initial, brief assessment of the animal (described later) is performed by a trained veterinary technician and a veterinarian to identify those animals needing immediate, lifesaving interventions. If multiple emergent animals are presented at the same time, the veterinary medical team must determine how long the animals can safely wait.³ Less urgent cases are typically treated on a “first come, first served” basis.

Triage Systems

Triage systems have been developed for use in people to improve the acuity of triage because of the overcrowding of human emergency departments and prolonged waiting times.³ These systems provide clear guidelines on how to assess the patient's clinical needs and priority for care. Many different triage systems, such as the Emergency Severity Index, Australasian Triage Scale, Canadian Triage & Acuity Scale, and Manchester Triage System, have been developed and validated for use in human emergency departments. These triage systems typically use a 5-level system to categorize patients (e.g., 1, resuscitation [red]; 2, emergent [orange]; 3, urgent [yellow]; 4, less urgent [blue]; 5, nonurgent [green]). Each level has an associated time required for physician assessment; all level 1 patients must be treated immediately.^4,5 The triage systems are generally based on vital signs (e.g., heart rate, respiratory rate) and, in some systems, on a presenting complaint algorithm.⁶ In these systems, triage is generally performed by an emergency department nurse. However, in some recent studies, physician triage has been implemented in which a designated physician is used to intervene early in a patient's emergency department course to guide triage or accelerate the initial evaluation and treatment of patients. These studies have found that time to initial physician evaluation, length of stay, and number of patients leaving without being seen were reduced.^7-9

The first veterinary triage scoring system was developed at the University of Pennsylvania for animals presented for treatment after acute trauma.¹⁰ The Animal Trauma Triage (ATT) scoring system was devised to provide stratification of veterinary trauma patients. Although primarily developed for clinical research and outcome prediction, this scoring system may also be useful in identifying trauma patients requiring immediate medical or surgical intervention. In this system, physical examination findings in six categories (perfusion, cardiac, respiratory, eye/muscle/integument, skeletal, and neurologic) are scored on a 0 to 3 scale in which 0 indicates slight or no injury and 3 indicates severe injury. In this system, animals with higher ATT scores would receive treatment priority compared with animals with lower ATT scores. In several studies the ATT score has been shown to predict survival; animals with higher ATT scores are less likely to survive compared with animals with lower scores.^11-14

More recently a veterinary triage list (VTL) based on a human 5-point scoring system was developed and evaluated for use in categorizing all emergency patients. In this triage system, animals are categorized into color-coded triage categories along with target waiting times: red, immediate; orange, 15 minutes; yellow, 30 to 60 minutes; green, 120 minutes. The VTL described in this study was developed by modifying the Manchester triage scale with common clinical conditions seen in veterinary medicine. For example, animals with severe decompensatory shock, exsanguinating hemorrhage, severe respiratory distress, or seizures would be triaged as red and require immediate treatment, whereas animals with mild respiratory distress, uncontrollable minor hemorrhage, and history of unconsciousness would be triaged to a yellow category. In this study, intuitive triage performed by trained veterinary technicians based on the medical history and a visual examination of the animal was compared with a retrospective evaluation of the VTL applied by a veterinary review team. The results of this study suggested that the use of the VTL was more effective at categorizing emergency patients with target waiting times as compared with intuitive triage performed by the veterinary technicians.¹⁵ Although future prospective studies are needed to validate this veterinary triage list, this study raises awareness of the importance of triage and appropriate target waiting times in veterinary medicine, especially in a busy emergency service where resources may be limited.

Initial Patient Triage

On arrival to the emergency service, an initial brief triage assessment of the animal should be performed. At the author's institution, experienced veterinary technicians who exclusively work in the emergency service and have specific training in veterinary triage typically perform this first assessment. The technician first obtains a brief medical history from the owner, including patient signalment, the reason for seeking medical care, and concurrent medical conditions. A brief visual inspection of the animal and a focused physical examination may be performed in the triage area. The brief focused physical examination includes an evaluation of the respiratory, cardiovascular, neurologic, and urinary systems.¹⁶ Abnormalities in other organ systems, such as the gastrointestinal tract, may not be immediately life threatening but could result in significant intravascular fluid losses and hypotension, which are apparent during the cardiovascular evaluation. Patients with an abnormality in any of these four systems are brought quickly to the treatment area for a doctor assessment. Other conditions that warrant immediate evaluation by a veterinarian include severe pain, recent ingestion of a toxin or signs of intoxication, recent seizures, trauma, active bleeding, prolapsed organs, recent snake bites, hyperthermia or hypothermia, open wounds, fractures, burns, dystocia, and death.¹⁷

If ...