MA VetMB MSc CertVA DACVECC DipECVECC FHEA MRCVS
Senior Lecturer in Emergency and Critical Care and Director of the Transfusion Medicine Service, Royal Veterinary College, London, UK
DVM, PhD, Dip ACVIM, Dip ECEIM, Dip ACVECC, FHEA, MRCVS
Senior Lecturer in Equine Medicine, Royal Veterinary College, UK
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All patients presenting as an emergency should receive a triage examination, assessing initially whether they have a functioning airway, are breathing spontaneously and have an effective circulation (heat beat and palpable pulses) i.e. an ABC examination is performed. If any of these components are not present then cardiopulmonary resuscitation is indicated. In most cases, fortunately, this is not the case and so a major body systems examination can then be performed. This involves assessment of the stability of the cardiovascular, respiratory and neurological systems. The aim of this triage assessment is to recognise whether stabilisation is required or if the patient can await a standard consultation when a full history and physical examination is performed.
Assessing the patient’s heart rate, mucous membrane colour, capillary refill time and pulse quality can all be helpful to aid assessment of the cardiovascular system. Dogs with cardiovascular instability will tend to become tachycardic, paler and have bounding pulses which become weaker with progressive shock. It should be noted that cats in shock can become bradycardic rather than tachycardic. Foals often present in the late stages of shock with tachycardia and barely palpable pulses. Cardiovascular instability is most commonly due to hypovolaemia, often caused by gastrointestinal fluid losses or bleeding. In foals, a major cause for cardiovascular instability is septic shock. Patients in hypovolaemic shock require fluid therapy (with a dose of 10-20ml/kg of Hartmann’s (or any isotonic crystalloid fluid) given as a bolus being a good starting point. Once this dose has been administered the patient should be re-assessed to determine the effect of the fluid therapy and to see if further fluid resuscitation is required. While fluid therapy is being administered an underlying cause for the cardiovascular instability should be searched for.
Cardiac failure can also cause tachycardia and poor pulse quality, but these patients will generally also have a murmur, gallop and/or arrhythmia and will generally be in respiratory distress. These patients should be treated with positive inotropes and diuretics.
There are many possible causes of dyspnoea, but administration of oxygen is a universal therapy. Full assessment of the respiratory tract by noting respiratory rate and effort, listening for upper respiratory tract noise and carefully auscultating the thorax will aid in localisation of the cause of any respiratory distress. This will then allow further investigation and therapy to be appropriately tailored to the patient.
A full neurological examination is not required for initial triage assessment of a patient. However, it should be noted whether the patient is painful, mentally appropriate and ambulatory. It is important to perform this brief assessment before any analgesics which could affect mentation are administered such as opioids.
The assessment described here should only take minutes, allowing you to rapidly decide whether emergency therapy is required.