Emergency Stabilization Techniques

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Emergency Stabilization Techniques

• A. Kirsten Lawson, DVM, DACVECC
• Puget Sound Veterinary Referral Center, PLLC
• 27th January 2008

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Hershey

• 2yr MN Labrador
• HBC
• Carried into clinic by owners

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Hershey Primary scan

• Airway clear
• Breathing pant
• MM pale, moist
• CRT 3-4 seconds
• HR 210
• Pulses weak, thready femoral pulse
• Lung fields audible on right, inaudible on left
• Non-ambulatory swollen left thigh with dangling
  lower limb.

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Hershey Primary assessment

• Shock Hypovolemic
• Pain
• Suspect pneumo- or hemothorax on left
• Suspect left femur fracture

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Hershey Initial treatment

• Pain medication
• IV fluids
• Thoracocentesis

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Hershey Pain Control

• OPIODS
• Only realistic option in a trauma case. NSAIDs,
  sedatives, anesthetic agents should not be used
  in an unstable patient.
• Hydromorphone/oxymorphone ideal because they can
  be given IV with minimal risk of anaphylaxis. If
  morphine is given go IM or very slow IV

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Hershey Pain control

• Partial Agonists
• Butorphanol is very effective if given at high
  enough doses (0.4mg/kg), however very short
  acting maybe only 2-4 hours.
• Advantages less likely to induce vomiting, will
  not induce panting (may be ideal if thoracic
  trauma is present)

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Hershey Pain control

• Non-opioids if the animal is frantic and
  sedation is also needed, try diazepam/midazolam.
• NO Acepromazine marked vasodilation,
  contraindicated for an unstable patient.

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Hershey Pain Control

• Roughly 65 pound dog about 30 kgs.
• Concern for thoracic trauma
• Butorphanol
• 12mg IV

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Hershey IV Fluids

• IV catheter LARGE BORE minimum of 18g in this
  dog, short not more than 4 inches (i.e. no
  central lines)
• Balanced electrolyte solution (NormR, Plasmalyte,
  LRS) or normal saline solution (0.9NaCl)

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Hershey IV Fluids

• Shock Dose?
• NO

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Hershey IV Fluids

• Downsides to the shock dose of IVF
• Normo/hypertension can lead to pop the clot
  phenomenon
• Edema can lead to decreased tissue perfusion
• Altered electrolytes especially high chloride
  if using saline
• Possibly hypotension from acetate buffered fluids
  (unlikely)

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Hershey IV Fluids

• End Point Resuscitation
• What end points controversial.
• Blood pressure (or pulse pressure if BP cannot
  be measured
• Normalize Heart rate
• Mm, crt
• Urine output, mentation, oxygen delivery
• 20ml/kg crystalloids 5ml/kg colloids
  (hetastarch or dextran70)
• Repeat to effect

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Hershey IV Fluids

• Hypotensive resuscitation for trauma avoid
  further hemorrhage
• No more than 90mmHg systolic
• Normalize/improve CRT

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Hershey IV Fluids

• 600ml Norm R 150ml Hetastarch IV
• Crt 2 seconds, mm light pink
• HR 150
• BP 84mmHg
• STOP

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Hershey Thoracocentesis

• Should you always tap first or radiographs
  first?
• Depends on degree of cyanosis/dyspnea and
  confidence in diagnosis based off auscultation
  alone.
• Cons to tap without rads not without risk
  could cause lung laceration or laceration of an
  intercostal vessel. Also localize tap based on
  air (tap caudodorsal) vs fluid (tap
  cranioventral).

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Hershey - thoracocentesis

• Pneumothorax more common than hemothorax in
  trauma cases
• Thoracocentesis on left between in dorsal 8th
  intercostal space.
• 700ml of air, few drops of blood, then negative
  pressure

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Hershey Secondary scan

• Mentally alert and responsive
• MM pink, moist, crt 1-2 seconds.
• RR varies from 30 to pant
• BP 94mmHg systolic, palpable distal pulses
• Audible lung sounds throughout both fields
• Non-painful abdominal palpation with no fluid wave

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Hershey Secondary Scan

• Partial thickness abrasions on rear legs and
  caudal ventral abdomen.
• No external bleeding noted.
• Palpable left mid femoral fracture normal
  withdrawl and sensation
• No blood on rectal no overt pelvic instability
• Will stand on three legs with assistance and try
  to walk.

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Hershey - Plan

• Radiographs thorax, abdomen, pelvis, left
  femur. Ideally two views each
• PCV/TP monitor q 6 to 8 hours
• Monitor RR, effort, mm color, CRT recheck
  rads/retap if concern for returning pneumothorax,
  also at risk for developing pulmonary contusions.
• Monitor urine output
• Monitor mentation

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Hershey - Plan

• Continue IVF and monitoring
• Ideally stable x 24 hours prior to surgery for
  femoral fracture
• Hydromorphone, morphine, or MLK cri for pain
  control
• Splint only if spica which may be more
  trouble than its worth if surgery can be done in
  timely manner.

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Ramses

• 6yr MN DSH
• Presenting complaint weak, not eating,
  declining over 2 days.

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Ramses Primary Scan

• Obtunded, laterally recumbent
• Mm pale, tacky, crt 3-4 seconds, oral ulcers
  noted
• Severe bradycardia HR 90bpm, no palpable
  femoral pulses
• Severe hypothermia 87F
• Very large, firm, inexpressible bladder

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Ramses Primary assessment

• Urethral Obstruction
• Bradycardia suspect hyperkalemia
• Obtunded suspect secondary to poor
  perfusion/shock state

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Ramses Initial Treatment

• Treat Hyperkalemia
• Unblock
• IVF
• Pain control
• Active rewarming

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Ramses Active rewarming

• Bair Hugger
• Warm water bottles, warm blankets caution with
  how hot they are and be especially aware in a
  mentally altered patient or physically
  handicapped patient who cannot move away from the
  heat source.
• Warm IVF (1min in microwave /- fluid line warmer)

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Ramses Hyperkalemia Diagnosis

• ECG or lytes?
• ECG bradycardia, loss of P waves, spiked T
  waves and a sinoventricular rhythm

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Ramses - Hyperkalemia

• Options
• Dextrose causes endogenous insulin release that
  drives K intracellularly
• HCO3 causes alkalosis to drive K
  intracellularly (risk hypernatremia, paradoxical
  cerebral acidosis)
• Ca Gluconate protects heart from high K. Give
  slow (over 10-20min) while watching ECG or
  ausculting heart/palpating pulses.

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Ramses - Hyperkalemia

• Given 6mls 25 dextrose IV bolus (dilute 50
  dextrose with sterile water to decrease risk of
  hemolysis)
• Given 6mls CaGluconate over 15 minutes
• ECG went from sinoventricular rhythm to NSR with
  spiked T waves HR increased to 150, palpable
  weak femoral pulses, improved crt.

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Ramses Pain control

• 2mg butorphanol IV
• Obtunded means still responsive to pain!

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Ramses - Unblock

• Unblocked with tomcat catheter switched to soft
  indwelling catheter with closed collection system
  (clamps removed from line)
• No anesthesia needed if needed etomidate
• No ketamine! increases myocardial workload

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Ramses IV Fluids

• Lytes obtained while giving calcium
• Na 128, K 10.3, Cl 97, BG 378
• Ideally balanced electrolyte solution if you
  know your sodium try to match it to minimize
  sodium shifts.
• LRS 120ml bolus (warm) (20ml/kg)

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Ramses Secondary scan

• Improved mentation
• HR 160 with palpable femoral pulses
• Mm pink, crt 2-3 seconds
• Abdominal palpation unremarkable
• Previous rear limb amputation
• Can sit sternal on own and stand with assistance.

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Ramses labs (pre-treatment)

• BUN gt 130
• Crea gt 12.1
• Phos gt 16.1
• tCa 7.1
• PCV/TP 43/7.4

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Ramses secondary assessment

• Severe azotemia hopefully post-renal /-
  pre-renal
• Concern for continued shock state- still weak
  pulses (BP not checked-conserving finances),
  delayed crt and abnormal mentation

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Ramses - IVF

• Has had 1 bolus more fluids?
• Yes and No
• Hypothermic cats often wont come out of shock
  until rewarmed and if given large amounts of
  fluid when hypothermic risk of fluid overload
  once temperature has normalized.
• However needs aggressive rehydration and diuresis
  60ml/hr

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Ramses doing well

• Over next 3 hours
• Became normothermic
• HR remained 160 stronger femoral, distal pulses
• Mentation improved
• Crt normalized, improved color

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Ramses - oops

• Grand Mal Seizure - hypoglycemia
• Why?
• Theory
• Massive endogenous insulin release from dextrose
  bolus
• Changed protocol now put cats on dextrose cri
  for at least 12 hours after dextrose bolus.
• 3ml 25 dextrose bolus and spiked fluids to 2.5
  dextrose

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Ramses - labwork

• At time of seizure
• BG 33
• HCO3 6.6 severe metabolic acidosis
• Na 148
• K 6.1
• iCa wnl at 1.4

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Ramses metabolic acidosis

• Likely due to both uremic acidosis and lactic
  acidosis
• Give Bicarbonate?
• Yes due as appeared volume replete and the
  acidosis was severe
• Another fluid bolus also given when ins and outs
  calculated and marked post-obstructive diuresis
  noted.

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Ramses - Bicarbonate

• HCO3- deficit 0.5xBW(kg)x(10-current HCO3-)
• Give ½ of deficit as NaHCO3 over 3 to 6 hours in
  regular fluids then recheck.

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Ramses - IVF

• Changed IVF to Norm R why?
• Trying to match Na levels some concern about
  abrupt shift due to free water loss with
  post-obstructive diuresis no way to
  prevent/predict check frequently.

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Ramses - Labwork

• Recheck labs in 2.5 hours
• HCO3- 18.7
• Na 153
• K 3.9
• BG 115
• Discontinued NaHCO3, added 20mEq KCl/L

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Ramses 24 hours

• Continued on diuresis, antibiotics, pain
  medication, measuring ins/outs
• Initial urine pH 8.0 fragments crystals
  unidentifiable likely struvite
• Recheck labs
• Normal renal values!
• BG 264
• Discontinued dextrose supplementation, removed
  urinary catheter

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Ramses oops again

• Reblocked
• Needed propofol this time unblocked another
  24 hours on IVF, u. cath
• Straining after u. cath removal but able to
  urinate!
• Home finally!

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Questions?