“I’ve Fallen and [email protected] I Can’t Get Up” Assessing Acute Collapse For Presentation PowerPoint and Handouts: http://wendyblount.com Wendy Blount, DVM Kinds of Shock [email protected] Anaphylactic Shock •Obstructed airway •Acute allergic reaction •Lung Disease •Mast Cell Tumor Degranulation •Pleural air or effusion Cardiovascular Shock Neurogenic shock •Arrhythmia •Forebrain and brainstem - For Presentation PowerPoint •Left Heart Failure decreased consciousness •Right Heart Failure •Spinal cord – flaccid paralysis and Handouts: •Pericardial Disease Septic Shock http://wendyblount.com Hypovolemic Shock •Overwhelming infection •Dehydration Traumatic Shock •Hemorrhage •Due to pain •Hypoproteinemia Toxic Shock Hypoxic Shock •Due to inflammatory mediators, •Anemia endogenous and exogenous •Hemoglobin Pathology toxins Collapse Other Than Shock Assessment of Inability or Unwillingness to get up Collapse Profound Weakness Ataxia – lack of coordination •Metabolic weakness •Vestibular ataxia Quick Assessment •Hypercalcemia •Cerebellar ataxia Life Saving Treatment •Hypokalemia •Sensory ataxia •Hypoglycemia Paresis - loss of voluntary Physical Exam •Neurotoxins motor Emergency Diagnostics •Polyneuropathy •Lower Motor Neuron •Junctionopathy •CNS Lesion at level of History •Myopathy paresis Pain •Flaccid paresis In House Diagnostics •Spinal Cord/Nerve Pain •Upper Motor Neuron •Orthopedic Pain •CNS Lesion above paresis •Muscular Pain •Spastic paresis 1 Assessment of Assessment of Collapse Collapse Quick Assessment Life Saving Treatment Airway Oxygen Breathing IV fluids and colloids Circulation Therapeutic centesis Vital Signs – TPR & BP Thorax, abdomen, pericardium Diagnostic Centesis Normalize temperature thorax, abdomen Emergency Surgery Assessment of Assessment of Collapse Collapse Physical Exam Emergency Diagnostics General Exam PCV, TP, glucose, BUN creat Cardiovascular Exam Blood gases/lytes Neurologic Exam ECG Radiographs Lateral thorax Lateral abdomen Assessment of Assessment of Collapse Collapse Quick Assessment In House Diagnostics Life Saving Treatment CBC, profile, UA - Get urine prior to fluid therapy Physical Exam Heartworm test in dogs Emergency Diagnostics FeLV/FIV in cats History Coags - PT, PTT/ACT, In House Diagnostics BMBT If all else fails, US abdomen 2 Quick Assessment Quick Assessment Check Airway and Breathing If dyspnea and muffled heart/lung sounds, •Clear airway perform diagnostic/therapeutic chest tap •Intubate and begin IPPV if not breathing •If in sternal Check Pulses, Heart Sounds and Pulse deficits •Hook up ECG if pulse deficits or auscultable arrhythmia recumbency, tap •Begin CPR if no pulses or heartbeats right & left •Plan for chest x-rays if abnormal heart/lung sounds or pleural caudodorsal rubs lung fields Place IV catheter Supplement oxygen by mask, nasal or flow-by Quick Assessment Quick Assessment If dyspnea and muffled heart/lung sounds, If abdominal fluid wave, do a diagnostic perform diagnostic/therapeutic chest tap abdominal tap – 4 quadrants •If in lateral recumbency, tap the highest point on •R cranial, L cranial, R caudal, L caudal each side •Syringe and 18-20g needle are fine •Butterfly catheter with 6-12 cc syringe first •Put fluid in EDTA and red top tubes for analysis •Attach larger syringe & 3-way stopcock if •Spin down for cytology evacuation is needed •Save red top tube for culture if needed •Save fluid for analysis and possibly culture •Run EDTA through CBC machine for cell counts •EDTA tube for fluid analysis •Red top tube for culture Fluid Analysis Handout DDx By Fluid Analysis DDx By Fluid Analysis Pure Transudate •Coagulopathy •Hypoalbuminemia (<1.5 g/dl) •Vasculitis Septic Exudate Bilious Effusion •Rupture of a cyst – Hepatobiliary. •Idiopathic pericardial effusion •GI perforation •Ruptured gall bladder Pancreatic, perirenal, prostatic •Trauma •Neoplasia •Ruptured biliary vessel Non-Septic Exudate •Thrombosis Uroabdomen Modified Transudate •Volvulus •Ruptured urinary bladder •Early hepatic cirrhosis •Neutrophilic •Intussusception •Caval occlusion, HW Disease •Pancreatitis, steatitis •Penetrating Wound Chylous Effusion •Right CHF •Tissue necrosis •Surgical Dehiscense •Heartworm disease •Neoplasia •Idiopathic pericardial effusion •Ruptured abscess •RHF •uroabdomen, bile peritonitis •Pulmonary hypertension •FIP •Septicemia •Idiopathic •lymphangitis •Eosinophilic •Bile peritonitis •Trauma •Neoplastic effusion •Heartworm disease FIP •Lymphangitis •Eosinophilic effusions •Systemic mastocytosis •Lymphoma •Rarely FIP •Hypereosinophilic syndrome Hemorrhage •Eosinophilic lung disease •Bleeding neoplasia •neoplasia Interpret dysplastic epithelial/mesothelial cells with care Culture exudative, bilious and hemorrhagic effusions 3 Fluid Therapy Fluid Therapy “Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •NO shock fluids if there is anuria or CHF (Angel) •YES if evidence of dehydration, anaphylaxis, hemorrhage, •Anuria - you can probably get way with one shock dose if or sepsis the dog hasn’t had prior fluid therapy •Anaphylaxis •MONITOR URINE OUTPUT AFTER THE SHOCK •pale mucous membranes and weakness despite no DOSE dehydration, no CHF and no apparent external/internal fluid •YES shock fluids if there is evidence of hypovolemia loss •Pale mucous membranes, slow CRT •Cats often have pulmonary edema (tachypnea/dyspnea) •Dogs often have abdominal pain •Weak peripheral pulses Fluid Therapy Fluid Therapy “Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •YES if confirmed pericardial effusion (PE) without CHF •YES if confirmed pericardial effusion (PE) without CHF •Muffled heart and lung sounds, dyspnea •If modified transudate, RHF is possible •Negative diagnostic thoracocentesis •Signs of RHF on exam – •Lateral chest x-ray raises suspicion of PE •peripheral edema •Huge heart (DDx cardiomegaly, Pericardial Dz) •Diarrhea •Quick ultrasound of the heart confirms PE or PPDH •distended jugular veins or abnormal jugular pulses •If hemorrhagic PE (PCV PE = PCV blood), then bolus •positive hepatojugular reflux fluids Fluid Therapy Fluid Therapy “Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •YES if confirmed pericardial effusion (PE) without CHF •CAREFUL if hypoalbuminemia •If modified transudate, RHF is possible •If TP low, get albumin ASAP •RHF can be a cause of or a result of pericardial effusion Aggressive fluid therapy + hypoalbuminemia = •Tricuspid murmur (right apex) suggests primary pulmonary edema RHF •Re-listen AFTER pericardial tap •Replace colloids first – hetastarch •Resolution of RHF after pericardial tap suggests no •shock fluids may not be necessary, and could even primary RHF (by the next day) lead to volume overload 4 Fluid Therapy Pneumothorax Maintenance Fluids •1-2 ml/lb/hr – fine tune later 1. Use butterfly catheter and 3-way stop cock to •To keep the IV line open while the patient is assessed evacuate the air from the left and right sides •Most patients fall under this category • Continue until you get negative pressure • Take chest x-rays to confirm lungs expanded No Fluids – if CHF is possible • Some cases of spontaneous pneumothorax will resolve with •Heart murmur this treatment •Auscultable arrhythmia or pulse deficits • If the patient is getting worse, or you can not get negative pressure after several minutes, continue to step 2 •Undiagnosed thoracic effusion or ascites – modified transudate •Dyspneic animal who has not had chest x-rays yet •Be especially careful with cats •Fluids, corticosteroids or x-rays can KILL a cat in CHF Pneumothorax Pneumothorax 3. Keep pneumothorax evacuated. 2. Place chest tube and evacuate air. • Evacuate hourly at first, then less often as needed to get • You may need to place a chest tube on each side negative pleural pressure. • If air constantly re-enters the chest, place continuous • Apply continuous negative pressure if necessary. suction on the chest tubes. • Offer referral to a 24-hour ICU if your clinic does not offer 24- • Slow leaks will sometimes eventually seal without surgery hour care • Take chest x-rays to confirm tubes placed well and lungs • An uncapped chest tube can cause death by expanded pneumothorax within minutes. • If the patient is getting worse, and you can not get negative • Remove chest tube when no air is aspirated for 24 hours, pressure, you must induce anesthesia and open the chest to and chest x-rays confirm resolution of pneumothorax. get immediate control of lung expansion, and find and • It is normal for a chest tube to produce a small amount of correct the source of the leak. serosanguinous pleural fluid as long is it is present. article Pleural Effusion Pleural Effusion 1. Use butterfly catheter and 3-way stop cock to 2. Indications for a chest tube. • Pyothorax evacuate the fluid from the left and right sides • Managed by treating with antibiotics, and lavaging the • Continue until you get negative pressure chest with small amounts of sterile isotonic fluid • Take chest x-rays to confirm lungs expanded • 5-10 ml/lb, sit for 5 minutes, drain • Some scalloping of the lungs may remain if effusion is • Lavage BID chronic • Chest tube can be removed when: • Perform fluid analysis to characterize the fluid, then the • bacteria are no longer present in the retrieved