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Emergency Animal Medicine: The Rest of the Story

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karina benish

on 14 February 2013

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Transcript of Emergency Animal Medicine: The Rest of the Story

CRYSTALOIDS colloids 0 + - = 9 8 7 1 2 3 4 5 6 c TEMPERATURE SHOCK Emergency Animal Medicine: Everything Else in Detail Monitoring oxygenation and respiratory pattern,
especially after trauma or septic shock;
Acute Respiratory Distress Syndrome can occur where the alveoli just start collapsing resulting in hypoxemia.
Sometimes a ventilator is the only way to bring them out of this Most animals are going to require close monitoring once the shock has been stabilized. The patient is in ICU or laying in the middle of the treatment floor

The underlying disease needs to be addressed and treated Monitoring Other drugs, depending on the situation
Morphine: used in cardiogenic shock for vasodilation


Diuretics- furosemide, mannitol: used to correct decreased urine output


GI tract protectants- sucralfate, antacids: GI ulcers and sloughing of the mucosa are common after septic shock (bloody vomit or diarrhea) Glucose
May be added to the fluid therapy if the blood level is below 80 mg/dL

Bicarbonate
Added to the fluids if the metabolic acidosis is severe
It must be administered slowly over 20 minutes
Can induce metabolic alkalosis and several other problems if given too fast so great care must be taken to actually know the base deficit (how acidotic is the animal- no guessing) and give it slowly Antibiotics
given in a known or suspected infection.
Some think antibiotics are warranted in any case of severe shock as the body is in a severely compromised condition

A combination of broad-spectrum antibiotics is given unless the specific pathogen is known. -- a penicillin (for gram positive bacteria) and --an aminoglycoside (gentamicin) or --fluoroquinolone (Baytril) are given together. Most animals are hypothermic-
warm IV fluids should be used as well as other warming techniques previously described.

An indwelling urinary catheter should be placed to monitor urine output All animals will require oxygen supplementation either via mask, cage, or modified E-collar

High levels of oxygen should not be administered for longer than 12-24 hrs as oxygen toxicity may occur If a vein cannot be accessed, fluids can be given IO (intraosseously) in the humerus, femur, or tibia but this also requires an aseptically placed

in small pups/kittens, a large gauge IV catheter works in a pinch An IV catheter must be placed to start the fluid therapy

Depending on the severity of the problem, a jugular catheter may be necessary for rapid infusion of life-saving fluids

A peripheral catheter (cephalic) should also be placed for giving drugs, etc. Colloid fluid therapy may be indicated if the blood volume or total protein in the animal is suspected or known to be very low.

Colloids include Hetastarch and plasma

Whole blood transfusions may be necessary if massive blood loss
It may be the only means of correcting the volume deficit quickly Crystalloid replacement solutions are used for acute intravascular volume expansion- LRS, Normosol-R, etc.

The shock rate of fluid therapy is 90 ml/kg/hr in dogs and 45 ml/kg/hr in cats The first priority in treatment of hypovolemic/traumatic and septic shock is to restore the blood volume circulating to the organs;

This is achieved with aggressive fluid therapy using crystalloids and/or colloids

However, aggressive fluid therapy is contraindicated in cardiogenic shock!! Treatment of Shock Mild Stage of Shock
Pale MM’s with prolonged CRT
Cool skin
Hypothermia
Weak femoral pulses
Tachycardia
Decreased urine output (kidneys are starting to fail)
Altered mental status- depression to uncontrolled hyperexcitability
Hemorrhage may be active or a slow bleed Compensatory Stage of Shock
Slight increase in RR
Red or pale MM’s
Normal skin and rectal temperature
Normal or bounding pulses
Tachycardia
Normal urinary output
Rapid CRT (< 1 sec) or may be normal
Animal is mentally alert and conscious or it may be mildly depressed (quiet)
If present, hemorrhage may be slight Stages of Shock Patient’s with septic shock usually have a history of:
A known infection
An event that could cause infection (indwelling catheter or tube)
A disorder that can predispose to infection (DM, renal failure)
Drug therapy that can predispose to infection (steroids, immunosuppressants) Causes include:
Sepsis (bacterial, viral, etc)
Heat stroke
Severe Pancreatitis
Disseminated cancer
Autoimmune diseases
Hypovolemic shock Then MODS sets in (multiple organ dysfunction syndrome):
this happens when the systemic response becomes severe
tissue injury causes multiple organ malfunction- renal failure, heart failure, GI bleeding from endotoxemia, etc. Other organs/tissues become affected when things like free radicals and cytokines start circulating in the blood;
Inflammatory cascades all start feeding back on each other and cause more inflammation,
Perpetuates the problem and causing system wide effects The signs of septicemia are due to the systemic inflammatory response

- the local inflammatory response gets out of hand and affects tissues in other parts of the body The body is in shock due to:
Low oxygen in the blood from hemoglobin carrying problems like methemoglobinemia in Tylenol cats
Hypoglycemia- the brain has no energy for metabolism
Anemia
Sepsis (see septic shock)
Heat stroke
Cyanide poisoning Metabolic Shock Inability of the heart to pump blood resulting in decreased cardiac output

Patients usually have a history of heart disease, trauma, heartworm disease, or other obstruction of the circulation (GDV, pneumothorax)

Cardiogenic shock can also occur due to the heart depressant effects of general anesthesia and the heart damaging effects of some chemotherapeutic drugs like Adriamycin Cardiogenic Shock Distributive shock is a subcategory;

a relative or functional hypovolemia due to something like vasodilation

(the blood’s still there but the vessels are all dilated and the bloodpressure falls suddenly) Hemorrhagic shock occurs post-trauma- severe lacerations (artery severed), ruptured organs or from severe blood loss in surgery

Other causes of hypovolemic shock include fluid losses from severe vomiting/diarrhea (parvo gone untreated for days); plasma losses caused by severe burns The most common type of shock seen in small animal practice

Due to low effective circulating volume of blood and poor venous return caused by loss of blood, plasma, or fluids

These animals will have a history of trauma, blood or fluid loss Hypovolemic Shock Regardless of the type and cause of shock:

--it produces insufficient circulation that reduces blood flow through the microcirculation (capillaries) Shock is a progressive process

1. at first, the body will compensate but

2. if appropriate intervention is not instituted quickly....

3. the body will decompensate and an irreversible stage of shock will ensue Shock is defined as:
ineffective blood circulation and the failure to provide oxygen to organs which require it to make energy for themselves The Pathophysiology of Shock Blood: serial monitoring of PCV, TP, enzymes, urine sp. gravity.

Monitoring for DIC
(disseminated intravascular colagulopathy) is essential as it often occurs after shock
(clotting factors and bleeding) Glucocorticoids
The use of steroids is controversial as they help in the short-term but have no bearing on the ultimate survival of the patient

They are anti-inflammatory; they stabilize membranes; they improve the microcirculation and improve cardiac output; they improve metabolism by increasing O2 uptake so lactic acid levels fall

they may increase mortality in cases of
overwhelming infection

Steroids used include Dexamethasone & Prednisolone Sodium Succinate (Solu-Delta-Cortef) Sympathomimetics
Used in some cases of cardiogenic shock and septic shock, not usually in hypovolemic shock

These drugs help support heart function and increase oxygen delivery and tissue perfusion

Dopamine is used for supporting blood pressure and for enhancing kidney blood flow

Dobutamine is used to promote forward flow of blood; preferred drug in cardiogenic shock Drugs for Shock Decompensatory Stage of Shock
Pale to cyanotic MM’s with a prolonged CRT (> 2sec)
Cold skin
Moderate hypothermia
Absent or weak femoral pulses
Oliguria (decreased urine production)
Mental state is severely depressed- unconscious, stupor, or semicomatose (oxygen to brain too low + the glucose supply to the brain has probably run out)
Most likely substantial hemorrhage
May have seizures due to low blood pressure Continued monitoring of the heart via EKG and blood pressure is usually needed

Monitoring urine output is essential to detect renal dysfunction Septic shock is usually discussed separately and some references consider it its own type of shock.

Septic shock is common, challenging, and encompasses aspects of all the other types of shock Septic Shock The third function to be lost is superficial or skin pain

Pinching the skin of the toe should result in a withdrawal of the foot away from the pain or at least some vocalization Evaluating the neurological patient is based on assessment of 4 spinal functions

Decreased conscious proprioception (CP) and ataxia are the first deficits to develop

Conscious proprioception is the ability of the animal to realize the position of its foot
CP’s are said to be present, slow, or absent Assessing the Neuro Patient The animal’s mentation is the best indicator of the severity of the problem. Brain Trauma Neurological Emergencies A rising temp after bringing it down to normal can indicate possible:
infection,
inflammation, or an
inability on the animal’s part to dissipate heat (such as an upper airway obstruction)
should be investigated Cooling cannot be done too rapidly as hypothermia may result

Most effective and easily controlled method of cooling is wetting the animal and cooling it with a fan Treating Hyperthermia Hyperthermia is, theoretically, any body temperature above normal

Fever is a hyperthermic state; however, temperatures up to ~104 could be an appropriate response to infection Hyperthermia Hyperthermia Active internal or core rewarming: used in patients
with temperatures < 86 degrees,

that have arrested

that didn’t respond to the other methods

This involves peritoneal dialysis Passive external rewarming:

Cover the animals in blankets to prevent further heat loss and allow its own body to generate heat.

OK for mild hypothermia cases. An ECG should be obtained to check for heart activity.

“You’re not dead until you’re warm and dead.”

Warm IV fluids are usually started Treating Hypothermia Mild hypothermia: 90-99.5 degrees F

Moderate hypothermia: 82-90 degrees F

Severe hypothermia: <82 degrees F Hetastarch
Most commonly used type
Relatively expensive
Usually administered in a 2:1 ratio with crystalloids Dextran 70
The least expensive colloid

A mixture of polysaccharides in saline The colloids are indicated when the patient’s TP is < 3.5-4.5 g/dL

Also if hemodilution (with crystaloids) would take it below this level

Colloids cost more than crystalloids fluids of choice in hypovolemic or septic shock. Normosol-R

Another balanced electrolyte solution

It contains acetate and gluconate as buffers LRS (Lactated Ringer’s Solution)
a balanced electrolyte solution 0.9% NaCl
Used in shock to increase plasma volume

Also used for hyponatremia or hypochloremia

Can be used prior to blood transfusions Isotonic Solutions Considered replacement fluids

Can be given rapidly to treat shock or dehydration

Large volumes need to be given in order to achieve near blood volume restoration Isotonic Solutions Fluids containing electrolytes and glucose that are capable of entering all body fluid compartments Crystalloids

Colloids Types of Fluids Animals in shock require rapid fluid rates

dogs - 40 ml/lb/hr

Cats - 20-30 ml/lb/hr Rates of Administration IO (intraosseous):
Good route for small puppies and kittens and exotics if you cannot access a vein

Allows rapid delivery of fluids Oral:
Not a satisfactory way to correct dehydration

IP (intraperitoneal):
Can administer large volumes but absorption is slow SQ:
Useful with ~ 2-3% dehydration (minor)

Never give hypertonic solutions or 5% or more of dextrose SQ IV:
preferred method with high water losses (at least 5-8% dehydrated) or severe disorders Routes of Administration blood tests
increased PCV, TP, and urine sp. gravity History
Signs of illness
Vomiting
Diarrhea
Anorexia Determining hydration status Feline Thromboembolism 3 kinds
dilated
hypertrophic
restrictive

Most cats have marked respiratory distress, muffled heart/lung sounds, rapid, shallow respirations

Feline heart disease can often lead to feline thromboembolism Feline Cardiomyopathy On PE,
weak pulses +/- pulse deficits
soft mitral or tricuspid murmurs muffled heart and lung sounds
or inspiratory crackles Primarily in Dobies, “giant” breeds, and other large dogs

Signs, especially the weight loss, can be dramatic and sudden, occurring over 2-4 weeks Canine Dilated Cardiomyopathy Specific Cardiac Emergencies Echocardiography- Ultrasound of the heart
useful for identifying masses, evaluating valves, and assessing wall thickness & motion as well as chamber size. ECG-
animal should be in right lateral recumbency if possible
If the animal is dyspnic, a standing ECG strip can be obtained Auscultation- listen for murmurs, gallop rhythm, or arrhythmias

Murmurs in cats are best heard low along the sternum Diagnostic Procedures Cardiac emergencies will have concurrent respiratory problems
Pulmonary crackles and wheezes are heard with pulmonary edema
Breathing is often labored and the rate is increased
MM’s may be injected, pale, or cyanotic
Cats with congestive heart failure are often hypothermic with a slow heart rate (100-120) with weak pulses Most animals have weak pulses
Absent pulses and posterior paralysis
cats with cardiomyopathy and saddle thrombus
Pulse deficits
Jugular vein pulses and ascites Dog cardiac signs:
coughing (moist, nocturnal),
exercise intolerance,
labored breathing,
cachexia,
and sometimes syncope

Cats rarely have a history of coughing with cardiac disease; coughing cats usually have asthma or other pulmonary diseases Cardiac Emergencies Treatment includes oxygen supplementation +/- CPR should full arrest occur

Treat the underlying cause Cyanosis Pneumonia (tons of causes)
Noncardiogenic pulmonary edema- due to seizures, electrocution, head trauma, and upper airway obstruction
Cardiogenic pulmonary edema
Parasitic lung diseases- Capillaria, Aelurostrongylus to name a couple
Pulmonary thromboembolism- cardiac disease, Cushing’s, pancreatitis, etc
Pulmonary contusions- HBC or other blunt trauma; lesions worsen over the first 24-36 hours Clinical Signs
Mild tachypnea to severe distress

Soft, moist cough when present

Labored breathing with crackles and wheezes Parenchymal Disease
disease of the lung tissue itself Feline Asthma Clinical signs
Similar to other respiratory diseases
Usually includes coughing
Usually have expiratory dyspnea

Diagnosis/Procedures
Thoracic radiographs
Transtracheal wash
Bronchoalveolar lavage (BAL)- requires the bronchoscope
Nebulization- aids is airway hydration Lower Airway Diseases Specific conditions include:
Pneumothorax- tension pneumo is the most life-threatening and results in progressive signs of shock: tachycardia, weak pulses, pale MM’s- as tissue perfusion worsens and resp distress becomes more pronounced
Hemothorax- coagulopathy, trauma, neoplasia
Chylothorax- cardiomyopathy, neoplasia, idiopathic (most common)
Hydrothorax- heart failure, hypoproteinemia
FIP- Feline Infectious Peritonitis
Pyothorax- many patients are severely dehydrated & septic, too
Diaphragmatic hernia
Flail chest- results from fractures of 2 or more consecutive ribs in 2 places: paradoxical movement of the chest wall
Penetrating chest wound Chest Tubes
placed when there is ongoing requirement for aspiration of fluid, air, or both from the pleural space Pneumothorax Diagnosis
Thoracic radiography

Thoracocentesis- is both diagnostic and therapeutic

Pleuroperitoneogram- injecting contrast into the abdomen; presence of a hernia will have contrast in the chest on radiograph Clinical signs:
Short, shallow breaths with intermittent attempts at deeper breaths

Decreased or absent airway sounds on auscultation
Fluid: decreased ventrally
Air (pneumothorax): decreased dorsally
Severe conditions of either can result in no sounds anywhere Pleural Space Disease Specific conditions include
Elongated soft palate (brachycephalic breeds)
Laryngeal paralysis- congenital in Siberian Huskies, English Bulldogs, and Bull Terriers.
May also occur with myesthenia gravis, hypothyroidism, or idiopathic in Labs, Goldens, Irish Setters, and St. Bernards
Nasopharyngeal polyp- common in kittens or young cats
Foreign body- needles, fish hooks, foxtails, sticks
Neoplasia
Tracheal laceration- neck bite wounds, traumatic intubation
Tracheal collapse- middle aged to aged toy and small breed dogs Diagnosis
Laryngoscopic exam
Radiography
Bronchoscopy
Flouroscopy
These examinations require heavy sedation or light anesthesia to perform Types of Respiratory Emergencies Emergency Procedure
Tracheostomy-
performed under mild tranquilization/sedation and a local block.

Requires continual monitoring of the patient.
Mucoid secretions are stimulated by the tubes presence -can obstruct the tube.
Cleanings done at least 2-4 times/day.

The animal may need humidification to keep secretions moist.
Suctioning can be performed- can lead to arrest or severe hypoxemia. Mechanical Ventilation
Often requires general anesthesia or sedation, constant nursing care, and is invasive

Can be performed with an ambu bag or with a ventilator on the anesthesia machine E-Collar w/ saran (plastic) wrap

an opening is left at the top to allow heated gases and CO2 to escape.

Some animals do not tolerate. Oxygen Cage

The animal must be able to breathe on its own

Cages are expensive & use a lot of oxygen

Cages need to be flushed/filled w/ O2 every time they’re opened Providing Supplemental Oxygen Step 1:
Supplemental oxygen should be given to any animal with signs of respiratory distress. When in doubt, supplement! Clinical signs of respiratory distress
Tachypnea
Open-mouthed breathing
Cyanotic MM’s
Loud breathing
Restlessness, anxiety
Glazed look
Extended head and neck Respiratory Emergencies The fourth function to be lost is the ability to feel deep pain

Testing deep pain involves clamping a hemostat to a toe The second function to be affected is voluntary movement of the legs
Signs are paresis to full paralysis Assessing the Neuro Patient (cont) Assessment of animals with suspected brain trauma includes:
checking the cranial nerves
checking the pupils & PLR’s
palpating the skull for fractures (gently!)
checking the ears for blood or CSF in the ear canals When the rectal temperature is
103-104 degrees F, active cooling is discontinued to avoid rebound hypothermia Any temperature above 106 degrees F needs active cooling to bring the temperature down


Temperatures above 108 degrees will result in multiple organ failure Patients should receive a narcotic for pain once the temp has reached 98 degrees F Peritoneal Dialysis Catheter Active external rewarming: necessary when temp < 94 degrees.
Warm water bottles or bags, warm blankets, or incubators.

Used for moderately to severely hypothermic animals Hypothermia is a body temperature below normal

In dogs, any temperature below 99.5 degrees F is hypothermic

In cats, any temperature below 100
degrees F is hypothermic Hypothermia Plasma

Contains albumin, clotting factors, etc
Comes fresh or frozen: thaw in cold water! PE: skin turgor is increased in dehydration; MM are tacky to dry

< 5% dehydrated
5-6%
6-8%
10-12%
12-15% Sinus tachycardia- due to underlying condition
Atrial tachycardia, atrial flutter- severe underlying structural heart disease
Atrial fibrillation- a sign of serious heart disease and conversion to normal sinus rhythm is not likely
VPC’s, (Ventricular Premature Contrations)- sign of underlying condition
Ventricular tachycardia- may occur 12-48 hrs after shock, trauma, or GDV Life Threatening Arrhythmias
Boxer cardiomyopathy is characterized by severe ventricular arrhythmias and sudden death.


If arrhythmias can be controlled they live 1-3 years before heart failure takes them Present with
tachypnea
harsh lung sounds
inspiratory crackles that progress to crackles/wheezes throughout respiration
a distinguishable heart murmur
These animals need O2, IV catheter, blood pressure monitoring, and life saving drugs! CHF Allergic bronchitis/feline bronchial asthma syndrome- cat can show tachypnea to severe respiratory distress. Oxygen and steroids help
Compression of the mainstem bronchus- from severe left atrial enlargement
Smoke inhalation- can smell the smoke, see singed hair, etc
COPD- chronic obstructive pulmonary disease; results from chronic bronchitis from environmental pollutants like smoke, toxic fumes, paint, dust, or allergens Continuous suction drainage

This is an example of a disposable thoracic pump and collection bottle.
It has an electric motor & vacuum regulator. Thoracocentesis
for air or fluid

Complications are rare when done properly but include lung trauma and laceration of the intercostal vessels Procedures for Pleural Space Diseases Abdominal palpation may indicate fewer organs than normal suggesting a diaphragmatic hernia

SQ emphysema, fractured ribs, tachypnea, weak pulses in a trauma patient should make one think of pneumothorax Clinical signs:

Loud breath sounds heard w/o a stethoscope

Upper airway foreign bodies, inflammation, or infection can often cause coughing, retching, or hypersalivation Upper Airway Obstruction Tracheostomy Step 2:
Place an IV catheter

Allows easy administration of emergency drugs to these critically ill patients Respiratory Emergencies (cont) Nasal O2 Insufflation
nasal catheters can be stressful

allows procedures to be performed without interrupting the flow of oxygen Oxygen by mask

Oxygen flow rate is 100-200 ml/kg/min. Good for providing O2 during the initial evaluation period saddle thrombus
posterior paresis
weak or absent pulses in the rear limbs;
foot pads are pale
gastrocnemius and tibial muscles are rock hard by 10-12 hrs post-clot Cardiology Respiratory Neurological DEHYDRATION Fluids This dog has two primary rhythm abnormalities? What are they?

Atrial fibrillation and ventricular fibrillation
Atrial fibrillation and cardiac arrest
Idioventricular rhythm and ventricular fibrillation
Nodal rhythm and asystole

2. What is the only effective means of treating the rhythm in the last half of the traces?
Defibrillation
Lidocaine
Diltiazem
Amiodarone Type of exposure (skin, eyes, ingestion)
Exposure time (minutes or hours)
Name of toxic/poisonous substance
(have owner bring in labels, bottle, box etc)
Make sure the number to poison control is posted!! Information you need to know
Step 1: assess and stabilize any life-threatening problems

Step 2: elimination of further toxin absorption

Step 3: elimination of absorbed toxin

Animals who have ingested corrosives like alkalis and acids should never be induced to vomit; activated charcoal & gastric lavage are ineffective. Treatment of the poisoned patient Eliminating further toxin absorption
(step 2) Bathe in mild dish detergent (Dawn)

Only bathe if the animal is stable

Wear gloves Skin Exposure Rinse the eye or eyes
water or saline for 20-30 minutes

The corneas will require assessment Ocular Exposure Induction of emesis:
if ingestion occurred within the last 3 hours

NO NO NO NO: dyspneic, seizuring, or comatose

3% H2O2 at 1-2 ml/kg PO in dogs or cats
Apomorphine (dogs only)

Xylazine in cats Ingestion Gastric lavage (pumping the stomach)
when emesis is contraindicated
when induction of emesis failed

Requires light anesthesia so animal can be intubated Activated charcoal
absorbs a chemical or toxicant and facilitates its excretion via the feces

Can be given PO (MESSY, MESSY)
via the stomach tube after gastric lavage Cathartics (causes bowel evacuation)
Enhance elimination of activated charcoal

Not used if diarrhea or dehydrated


Examples include sorbitol, sodium or magnesium sulfate, psyllium Ibuprofen
Chocolate
Ant /roach baits-
Rodenticides – contain anticoagulants or cholecalciferol
Acetaminophen
Pseudoephedrine
Thyroid hormones
Bleach
Fertilizer
Hydrocarbons The 10 most common toxicoses in dogs
as reported in Veterinary Medicine March 2006 Overdose causes:
GI effects- vomiting, diarrhea, abdominal pain, ulceration
Renal effects- acute renal failure (diuresis is critical)
CNS effects- depression, seizures, coma Ibuprofen Contains theobromine & caffeine
Toxicity depends on:
Type of chocolate- baker’s >> dark chocolate >> milk chocolate
The size of the animal
vomiting, diarrhea
tachycardia, arrhythmias, bp problems
CNS effects: hyperactivity & agitation to tremors & seizures 3 types:
Anticoagulant containing
Contain bromethalin
Contain cholecalciferol (vit. D)
Blocks Vitamin K- dependent clotting factors so the animal can bleed out
Requires monitoring of the clotting profiles
Vitamin K1 is given SQ (not IM) and PO for 14-30 days Rodenticides Dog signs:
Acute liver failure- anorexia, vomiting, painful abdomen
Cat signs:
May develop signs at 40 mg/kg or less
Methemoglobinemia- “muddy” brown MM or cyanotic, dyspnea
Facial/ front paw swelling
Specific antidote: N- acetylcysteinea Acetaminophen Signs include:
Increased RR, HR, & temp
Ataxia
Nystagmus
Convulsions
Stiff legs/gait
Stupor/coma
Most predominant sign is muscle tremors Metaldehyde Poisoning Culprit is a flea control product for dogs being used on cats; or, a cat comes into close contact with a recently treated dog Permethrin (Pyrethrin) Toxicity Signs include:
Hypersalivation
Muscle tremors
Hyperexcitability or depression
Ataxia
Seizures

Treatment consists of controlling the muscle tremors (methocarbamol) or seizures (phenobarbital) and lots of baths with Dawn anti-freeze
Rapidly absorbed from the GI tract and reaches peak concentrations in the blood within 1-3 hours
PU/PD are the first signs, often missed by the owner
Then the animal looks intoxicated- ataxic gait to comatose Ethylene Glycol Toxicity Final stage is acute renal failure from calcium oxalate crystals- happens in cats within 12-24 hrs.
Aggressive fluid therapy and giving a 7% ethanol solution IV (80 proof Vodka works well)
specific antidote called Antizol- Vet (4- methylpyrazole)

The sooner this is recognized and treated, the better the prognosis Toxic Plants Easter Lily- GI upset &
renal failure Oleander- bad for the GI tract & heart: DEADLY to horses... 3 leaves will KILL a 1000 lb horse! Pretty but deadly Foxglove- (digitalis)
bad for the heart, too Dieffenbachia or dumb cane plant-
very irritating to the oral cavity Rhododendron (and azaleas)- only takes
a small amount to make the heart very
unhappy Lily of the Valley- GI upset &
renal failure Case Studies “Sippsey” 2 yr old FS mixed breed
Hx: lethargic, anorexic for a few days & now having trouble breathing. Rat poison was put out 1 week ago & now the box is missing
PE:
HR= 170/min RR= 90/min
Very depressed
Mild respiratory distress w/ decreased lung sounds ventrally Case #10 Warfarin Toxicity LAB: PCV= 24 WBC= 25,300 reticulocytes= 162,680/uL

What emergency treatments should be started for “Sippsey?”

What should be done for the dyspnea & decreased lung sounds? Warfarin Toxicity (cont) “Thompson” 5 month old CM Labrador
Hx: owner came home to find the dog vomiting. He’d eaten a bottle of ibuprofen. The owner is not sure how many pills were in the bottle but all are gone now. The owner also found the dog shaking & drooling with droopy eyes and ataxia Case # 13 Ibuprofen Toxicity PE:
HR= 88 RR= 80
Depressed, ataxic
Abdomen and chest are WNL
CRT/hydration are WNL

What emergency treatments would you institute?

What GI problems do you expect in this case & how might the doctor treat them?

What other body system should be watched closely for problems & how might the doctor treat them? “Kato” 1 ½ yr old intact male Husky

Hx: the dog lives primarily in the garage and backyard with another dog. The owner left at 9 AM and thought the dog was sleeping in the garage. She returned at 3 PM and found the dog in the same position. She tried to rouse the dog but he appeared drunk and could not stand. The owner noticed an empty jug of windshield wiper fluid. The other dog is normal

PE:
HR= 180 RR= 40
Semi-comatose
Some cranial nerve deficits including no menace response
CRT, hydration, thorax, and abdomen all WNL Case # 18 Methanol Toxicity What initial emergency treatments would you institute for “Kato?”

What parameters do you need to monitor closely for the next few days to make sure treatment is going well? Other Respiratory

Gastrointestinal System

Eyes/Ears

Urinary System

Reproductive System

Metabolic/Infectious Disorders Other Systemic Emergencies Occurs in brachycephalic breeds (smashed face, no nose) like the English Bulldog, Pug, etc
Respiratory distress can happen at any time but these animals are more prone to problems in the heat
2 main components of the syndrome are:
Stenotic nares
Elongated soft palate
Radiographs and a laryngeal examination under anesthesia are done to confirm the diagnosis
Requires surgical correction Brachycephalic Syndrome If “Brutus” were in severe respiratory distress, what emergency treatments would you institute?

Since surgery usually results in a large amount of swelling, what procedure might your vet do to insure a patent (open) airway? And what drug might be used to decrease edema? Case #11 GI Tract Emergencies Risk factors include a large/giant breed dog +/- a deep narrow chested conformation
Common breeds include German Shepherds, Great Danes, St. Bernards, Rottweilers, Labradors, Malamutes, Dobies, and Irish Setters
Classic symptom: vomiting or retching without results
Other signs include acute abdominal pain and hypersalivation
Shock is common and occurs rapidly
Requires surgical correction to resolve the twist & gastropexy to prevent further episodes Gastric Dilitation-Volvulus (GDV) “Duke” 8 yr old CM Doberman Pinscher

Hx: dog normal at feeding time. The owner heard the dog moaning on the back porch & found him recumbent, retching, & unable to vomit. The belly appeared distended & he was having difficulty breathing. Case #5 GDV PE:
HR= 120/min RR= 77/min
Respiratory distress
Enlarged cranial abdomen w/ moderate sensitivity to palpation
Percussion of the abdomen yielded a resonating sound (ping)
MM slightly pale
Weak pulses

Describe your emergency priorities for “Duke.”

What are potential post-op complications with GDV? Obstruction can be from foreign body, intussusception, and tumor

Symptoms of complete obstruction include vomiting, mild to moderate abdominal discomfort, +/- diarrhea

Partial obstructions can present with chronic, intermittent vomiting and weight
loss; usually progress to complete obstruction if not properly diagnosed GI Obstruction The level of dehydration depends on how long the animal has gone without treatment

Shock is possible and results from days without food/water +/- perforation of intestine

Requires supportive care, NPO, radiographs +/- barium study, and surgical intervention “Honey” 5 yr old FS Chow Chow

Hx: "Honey" presented to the emergency service and she was weak and depressed.  She had been vomiting for 2 months.  For the past month, the vomit has had a coffee ground appearance.  She has become anorexic and has lost a lot of weight. Case #16 Pyloric Obstruction PE:
HR= 148/min RR= 20/min
~ 10% dehydrated
MM’s pale & dry
Very painful to cranial abdominal palpation & melena was observed on her hind-end
Lungs/ heart WNL

What initial medical treatments must be started?

When should she go to surgery? Eye/Ear Emergencies The eyeball is outside the patient’s head
Usually due to trauma (HBC, dog fight)
The longer the eye is out of the head, the worse the prognosis for replacement and preservation of eyesight
The eye must be kept moist with sterile saline until replacement is attempted
E-collar to prevent self-trauma Eye Proptosis Corneal lesions range from:
abrasions (scratch)
ulcers (crater)
desmetoceole (bubble on the cornea)- the last layer of the cornea is the only thing keeping eyeball intact and the aqueous humor may begin to leak at any time! Major ocular emergency


Causes include foreign bodies (grass awn, etc), trauma (HBC- airbag, dog fight), & ocular disease (KCS, glaucoma) Corneal Ulceration Signs include blepharospasm (squinting from pain), photophobia, redness, clear to mucopurulent discharge

Diagnosis: flourescein stain uptake by the lesion. However, a desmetoceole itself does not take up stain but you see a ring of stain around the bubble An ear hematoma is a build-up of blood in between the cartilages of the ear flap

Blood vessels rupture from chronic head shaking and scratching at the ear

Is a secondary problem to the primary issue: otitis externa is the most common cause in dogs; ear mite infection in cats; atopy (allergies) also common Ear Hematoma Hematomas are painful
Most require surgical drainage and suturing to keep the cartilage flat; surgery is also painful. Stents/ sutures should remain in place for 3 weeks
Treat the ear infection appropriately
E-collar Aural Hematoma (cont) Urinary Tract Emergencies The inability of the animal to urinate

Causes include:
Urolithiasis (stones), crystalluria (crystals)- struvite, oxalate, urate (Dalmations)
FLUTD (feline lower urinary tract disorder)
Severe inflammation secondary to severe cystitis
Tumor

Very common in castrated male cats Urethral Obstruction Obstruction must be cleared under anesthesia,
A urethral catheter is left in place,
The patient is hospitalized for several days while monitoring urine output

Stones require surgical removal- cystotomy

If an obstruction cannot be removed,
a PU surgery can be performed (perineal urethrostomy)

Patients require fluids (especially if in acute renal failure), antibiotics, E-collar Bladder Stones Reproductive System Inability to retract the penis into the prepuce

Causes swelling of the exposed penis and can result in urethral obstruction and necrosis of the penis Paramphimosis Penis must be kept moist Anesthetic required.
Penis is cleaned, using hyperosmolar solutions.
Sometimes relaxation is enough to replace the penis in the prepuce.
Other times it requires incising the prepuce, replacing the penis, and then suturing the defect.
Castration should be done as long as the animal is stable.
Post-op, prevent further erections w/ tranquilizers if necessary. E-collar to prevent self-trauma. Monitor for recurrence. A life- threatening infection of the uterus
2 types:
Open- cervix is open and allowing drainage
Closed- cervix is closed and no drainage- bad
In dogs, it usually occurs within 60 days of having been in heat Pyometra PU/PD is the most common first clinical sign! This progresses to illness and debilitation as the infection worsens. Some animals will present laterally recumbent and in shock from endotoxemia and sepsis.
Diagnosis includes x-rays, bloodwork, maybe ultrasound
Surgery and OVH is the only way to correct pyometra. Lower doses of anesthesia will work on these dogs as they are already debilitated. Close monitoring intra-op and post-op must be performed. Many animals arrest after surgery. “Maggie” 7 yr old intact female Golden Retriever

Hx: "Maggie" was lethargic and anorexic for a few days.   However, the owner complained that she was drinking and urinating a lot.   "Maggie" had also been "in heat" last month.

PE:
HR= 160/min RR= 24/min
CRT > 2 sec; MM’s tacky
Mucopurulent vulvar discharge Case #6 Pyometra (Pyometritis) Describe what emergency treatments you would institute for “Maggie.”

The owner doesn’t understand the need for surgery. How would you convince him?

When should surgery be performed? Pyometra (cont) Crying or biting at the vulva
No sign of labor 24-36 hours after the dog’s temperature drops below 100 degrees F (provided their taking the temperature)
Abnormal vaginal discharge: foul odor, profuse hemorrhage, green discharge without production of offspring
More than 1 week overdue
No fetus produced 4 hours after the onset of labor
Strong contractions (actual abdominal pushing) for more than 50-60 minutes without birth
Fetal membranes in vulva longer than 15 minutes
More than 3 hours between births; failure to deliver all offspring within 18-24 hours Dystocia/ C-Section Canine C-section C-section (cont) Metabolic/ Infectious Emergencies Undiagnosed or uncontrolled diabetic animal in a life-threatening crisis

Signs include:
PU/PD
Vomiting/ diarrhea
Weight loss
Severe dehydration with shock Diabetic Ketoacidosis (DKA) In-house tests will give you a diagnosis:
Blood sugar is very high (> 400)
Glucose is present in the urine
Ketones are present in the urine

Treatment includes Regular insulin w/ serial blood glucose monitoring & aggressive fluid therapy w/ saline & potassium Untreated/ undiagnosed Hypoadrenocorticism

Dogs will usually have a history of vomiting, diarrhea, anorexia, weight loss, lethargy, & periodic weakness

They may also have a history of a “stressful” event- vaccinations, surgery/anesthesia, grooming, etc- from which they never seemed to fully recover Addisonian Crisis (true emergency!) Profound bradycardia, dehydration, and hypovolemic shock

Blood: hyperkalemia, hyponatremia, hypochloremia

Crisis Treatment:
aggressive fluid therapy with 0.9% NaCl fluids
Steroids- dexamethasone
Mineralocorticoids- DOCP injection

Diagnosis is via specific blood test- ACTH stimulation test Highly contagious viral infection of dogs
Mainly seen in young, inadequately vaccinated puppies but older, immunocompromised animals may also be affected
Signs include:
Anorexia
Vomiting
Diarrhea
Severely affected animals may present with septic shock and be severely dehydrated
Aggressive fluid therapy, antibiotics, anti-emetics, etc are necessary for saving these puppies Parvoviral Enteritis “Stinky” 3 month old female Labrador

Hx: She has been vomiting and had bloody diarrhea for a few days now.  Her owner says 2 other puppies in this litter are also sick.  They have all been vaccinated once. Case # 14 Canine Parvovirus PE:
HR= 190/min RR= 50/min
~10% dehydrated
Depressed
CRT > 2 sec
Intestines feel fluid-filled

Laboratory:
Neutrophils= 100/uL
Lymphocytes= 800/ uL Parvo (cont) How is parvo spread?

What treatments would you start for “Stinky?”

What parameters should be monitored for the next few days?

What should you tell the owner about cleaning her house? Chocolate Just remember, the critically ill patient will not require as much inhalant anesthesia as the normal, healthy patient

Sometimes 1% isoflurane or 2-3% sevoflurane, or less is enough to maintain a surgical plane of anesthesia

Monitor- monitor- monitor!!! Inhalants Do not use in patients who are prone to hypotension during induction
Potent respiratory depressant which can be more pronounced in a critically ill patient-
be prepared to ventilate
Good for head trauma/ cerebral edema and seizures
Does not cross the placenta so may be used in emergency C-sections Propofol Not good for those who may become hypotensive during induction- only give “to effect”
Do not use in patients experiencing arrhythmias
Can be used in patients with increased intracranial pressure or cerebral edema Barbiturates Has minimal cardiopulmonary effects
May cause pain in peripheral veins so must be given in a central vein or along with fluids in a peripheral vein
Drug of choice in patients who may become hypotensive during induction
Recommended in patients with head trauma Etomidate May cause apnea- be prepared to intubate immediately and bag or ventilate should full respiratory arrest occur
Diazepam is always used with ketamine for the muscle relaxation effects
Usually increases cardiac output & BP
Is a rapid inducer
Not used in head trauma, history of seizures, or hyperthyroidism Ketamine Considered the agents of choice for induction of critically ill dogs
They are potent respiratory depressants so patients should be oxygenated before and after induction
Diazepam commonly used with it
Not recommended in patients with upper airway obstruction, pulmonary disease, or a full stomach
Drugs include oxymorphone & fentanyl Opioids Some general thoughts on Anesthetic Drugs in the critically ill patient Severely ill animals will not require the entire calculated dose of the induction agent
Administer the induction agent “to effect”- meaning, the animal can be easily intubated but is not necessarily completely anesthetized

Monitor- monitor- monitor!!! Premedication may or may not be helpful or needed
Most animals are already depressed from the disease/emergency
If the patient is awake and alert, a sedative should be administered
Opioids are commonly used
Alpha-2 Agonists & phenothiazines should be avoided (hypotension and arrhythmic effects)
Anticholinergics (atropine) should be given if using an opioid or if patient is bradycardic If possible, stabilize the underlying condition as much as possible in the time prior to induction
Pre-oxygenate animals with respiratory problems
Transfuse severely anemic patients
Aggressive fluid therapy for hypovolemic animals General Guidelines for Anesthesia Class V
Extreme risk, moribund
Surgery is being performed in desperation on an animal with a life-threatening problem/disease
Patients with advanced organ disease, profound shock, major trauma, etc. Class IV
High risk, significantly compromised by disease
Severe dehydration, shock, toxemia, high fever, pulmonary disease, etc Class III
Moderate risk, obvious disease
These animals may be anemic, febrile, moderately dehydrated, or have low-grade heart disease Patient’s age
Physical Status
Temperament
Species
Surgical procedure & duration
Inpatient or outpatient
Experience with the drugs Considerations for selecting an anesthetic protocol Critical Patients & Anesthesia Doxapram (Dopram)
Used to stimulate respiration
Actual effectiveness of this drug is debated
1-5 mg/kg IV

dosages are FYI only Atropine
Asystole dosages are FYI only
0.025 mg/kg IV


Lidocaine
used to treat ventricular arrhythmias, principally ventricular tachycardia & ventricular premature contractions (better have it ready to use during and after the GDV surgery!)
2 mg/kg IV Epinephrine
No heartbeat (asystole- flat line- on the EKG)
0.1 mg/kg IV of 1:1000 epinephrine which correlates to 0.5 ml for cats,
1 ml for small dogs,
2 ml for medium dogs, dosages are FYI only
3 ml for large dogs
(double the dose if giving intratracheally) Cardiac Arrest - D Success rate for resuscitation of large dogs is much greater if internal cardiac massage is performed (requires thoracotomy)

Whether external or internal compressions are performed, if spontaneous beating of the heart does not resume within 15 minutes of CPR, more compressions are probably not going to re-start the heart. Circulation

chest compressions must be started

The rate of compressions should be 1-2x per second for ~ 80 bpm for a large dog and 120 bpm for a small dog or cat Cardiac Arrest - C Breathing

bag at a rate of 1 breath every 3-5 seconds.
When bagging the animal make sure the pressure gauge on the anesthetic machine does not exceed 15-20 cm H2O
Remember to turn-off the vaporizer Cardiac Arrest - B Airway

make sure the ET- tube is patent; replace if necessary Cardiac Arrest - A Treatment includes:
Lighten the anesthetic plane, if possible
Administer atropine
Keep the patient warm
Support ventilation

Monitor closely- full cardiac arrest is likely if this is not handled immediately Defined as a HR < 60 bpm in dogs and < 100 bpm in cats

Causes include:
Induction agents
Depth of anesthesia- too deep
Hypothermia
Late stages of hypoxia Bradycardia Causes include:
Anesthetic plane- too light
Hypotension
Hypovolemia
Shock
Drug induced- atropine, ketamine
Hypoxia
Treatment includes increasing the anesthetic plane or treating for shock and hypotension (fluids, oxygen, etc) Defined as:
> 120 bpm in large dogs

> 140 bpm in medium dogs

> 150 bpm in small dogs

> 200 bpm in cats Tachycardia If O2 is not available:
then an Ambu bag
mouth-to-tracheal tube must be instituted.

Ambu bags use room air ( 21% oxygen)

Mouth-to-tracheal tube (~ 14% oxygen) Should arrest occur prior to intubation, the patient must be intubated immediately and placed on oxygen

If the ET tube cannot be passed or the patient is continuing to decompensate, a tracheostomy must be performed Inform your doctor!

Turn off the vaporizer or discontinue all injectable meds/anesthetics

Bag the patient once every 5 seconds, making sure the chest is moving when the animal is bagged. Bag until the vital signs improve

The heart must be monitored and checked frequently for cardiac arrest

Give IV fluids at the shock rate. Having IV access also allows easy administration of drugs You will see:
Hypoventilation/dyspnea/cyanosis are precursors to full arrest
Pulse ox values quickly fall
Tachycardia; bradycardia may be seen if the patient is too deep under anesthesia and all systems have been depressed
CRT > 2 seconds
Pupil dilation; hypothermia May be seen with:
Anesthetic “overdose”: it’s all relative; what might be safe for a healthy animal may not be safe for a sick/debilitated animal.
Cessation of O2 flow
Pop off valve closed, too much pressure
Pre-existing respiratory disease
Just because: some animals arrest due to “allergic” reactions to the induction agents or anesthetic gas A potentially fatal condition, it is complete cessation of respiration by the patient

Often leads to cardiac arrest Respiratory Arrest If the animal is progressing to severe hypoxia despite your best efforts:
Turn-off the vaporizer
Check your oxygen source- is it still flowing?
Check your ET-tube- occluded, out of the trachea? Tracheostomy must be performed if a true airway obstruction exists.
Increase the IV fluid rate; give Doxapram if indicated by the vet
CLOSELY monitor this patient for full respiratory arrest and cardiac arrest Dyspnea, or difficulty breathing, will also result in hypoxia

If severe hypoxia sets in, you will see cardiac arrhythmias, bradycardia, cyanosis, labored or rapid breathing, hypotension, and pulse ox readings < 85% (animal is dying)

In the early stages, increasing the O2, decreasing the anesthetic depth, and bagging the animal is usually sufficient You will see:
The rebreathing bag is barely moving
Pale to cyanotic MM
The animal appears deeper than expected by the vaporizer setting
Pulse oximeter reading < 95%
A capnograph will give a better & sooner indication of hypoventilation than a pulse ox Remember, pre-meds and anesthetics will induce some level of respiratory depression. As long as everything else is good
(MM color, heart rate, pulses)
it’s ok to give the animal a minute or so to trigger the breathing response on its own

True hypoventilation is seen with pulmonary disease, obesity, head down positions, abdominal distention, & airway obstruction Hypoventilation/Dyspnea If an IV catheter is already in place, turn-up the fluid rate

Turn the vaporizer down or off to decrease depth of anesthesia. O2 therapy will help the patient.

Apply heat- warm towels, circulating water bed, hot water bottles, etc.

Dr will order drugs to give if continuing to deteriorate: This animal is in shock

IV catheter NOW!! Rapid fluid therapy is indicated to help reverse the shock.

Max fluid rate for dogs is 90 ml/kg & 65 ml/kg for cats in the first hour.

If really bad, animal may need colloid (plasma, hetastarch) or blood transfusion If the animal is not already on a heat source, give it one. IV fluids will help with the hypotension

If the animal is too deep on injectable anesthetics, intubate and supply O2 and give the reversal agent (if possible) Turn the vaporizer way down or off, especially if the patient’s condition is deteriorating rapidly

Squeeze the bag to get excess anesthesia out and then fill it with pure O2

Bag the patient every 5 seconds until it shows signs of recovery (increased HR, stronger pulses, better MM color and CRT) Steps for correcting the too deep patient Check the vaporizer setting

Know your patient!! Geriatric and severely debilitated animals can overdose on an inhalant anesthetic at a lower vaporizer setting than a young, healthy animal

Correct hypothermia You will see:
A centrally located eye with a dilated pupil
Bradycardia: < 60-70 in dogs; < 100 in cats
Hypotension: systolic bp < 80 mmHg
Pale MM; CRT > 2 sec
Hypoventilation: < 8 breaths/minute
Hypothermia: ears and extremities are cold
No reflexes: namely the corneal or palpebral
Cardiac arrhythmias if animal is connected to an EKG
No muscle tone The animal that gets too deep The patient moves in response to surgical stimulation
“Light” animal usually due to equipment problems
Check the vaporizer: setting, connection; out of anesthesia
Check the O2: is the flowmeter set too low; is the O2 run out, or not turned on.
Check the ET-tube: verify it’s still in the trachea by watching the bag move when the animal breathes; verify cuff inflation; verify it’s still attached to the machine; check to see if it could be in a bronchus (too long for size of animal) The animal that is too light Animals too light/ too deep

Hypoventilation/ dyspnea

Hypotension

Hypothermia/ hyperthermia

Bradycardia/ tachycardia

Respiratory and/or cardiac arrest Anesthetic Issues Include: Stage IV (medullary paralysis)
paralysis of vital centers in medulla
death from resp failure & CV collapse if resuscitation is not immediately performed Stage III (surgical anesthesia)
consciousness, pain sensation & many neuromuscular reflexes abolished
4 Planes
1 & 2 - light anesthesia
3 & 4 - deep or surgical anesthesia (plane 4, toxic)
loss of reflexes (palpebral, pedal, corneal) used to determine stage
muscle tone inhibited
respiratory, cardiovascular, thermoregulatory functions are depressed, used to determine toxicity Pertinent Stages of Anesthesia Good anesthetic monitoring is essential during all procedures, even “routine” ones

All the machines in the world do not replace your eyes, ears & touch!


Do NOT rely on your monitors to keep you informed about the animal’s condition Anesthetic Monitoring Human vs. Equipment Failure (cont) Human failures which lead to anesthetic emergencies are usually due to simple inattention to detail

For example, the animal was induced at a 5% vaporizer setting, intubated, and then you forgot to change the vaporizer setting down to 2%

Another example would be the animal’s body temperature is falling and you find you didn’t turn on the circulating water bed Human vs. Equipment Failure DRAWN BY ARTIST WITH NO ARMS.
PENCIL HELD IN MOUTH!

Think about this when you think you have life struggles! THE END Class I
Minimal risk
Normal, healthy animal
“routine” procedures like OVH, castration, etc

Class II
Slight risk, minor disease is present
These are neonates, geriatric animals, obese, etc. Classifying the Patient’s Physical Status Time to start CPCR >> remember the ABC’s Cardiac Arrest Hypotension can be drug induced; due to blood loss during surgery- hypovolemia; hypoxemia (lack of oxygen)
You will see:
CRT > 2 sec
Pale MM
Weak to absent peripheral pulses
Systolic bp < 80 mmHg or a mean arterial pressure < 60 mmHg
Hypothermia
Tachycardia (maybe not if they’re too deep) Hypotension Check the animal’s breathing: animals after ketamine and propofol inductions hold their breath; small, shallow breaths do not allow sufficient anesthesia to get into the patient; may require bagging

Check the machine: are there any leaks?

It also helps if patient is correctly pre-medicated with analgesics, opioids, etc. (doctor error) Anesthetic Emergencies Equipment failures can be avoided by checking all equipment prior to their use.
Make sure the oxygen tanks are full
Make sure the vaporizer is full
Check the anesthesia machine for leaks
Make sure all tubes & hoses are properly connected
Make sure the CO2 absorbent (Baralyme) is not old and purple
Check that all ET-tubes have cuffs which stay inflated
Maintain properly scheduled maintenance on vaporizers
Make sure pop-off is working and open In addition to monitors,
technicians should be manually monitoring heart rate and character by auscultation;
feeling the animal for hypothermia (the extremities get cold first); and checking MM color and CRT
Watching the respiratory effort

Should a monitor indicate a problem, always double check yourself, especially before giving drugs. Machines can and will fail!! McCurnin Breaths 10-24/minute: old recommendation Intraabdominal compressions In larger patients: Chest compressions are not adequate CPCR Chest compressions
< 15lb = 120/min
> 15lb = 80-100/min 2 full breaths lasting
2 full seconds to start
10-20mm Hg each breath Hyperventilation bad for brain: now recommend 8-10/min Rate: 70-90/min alternating with Chest compressions for patients >40lb or in all patients if CPCR lasts >10 min or trauma/hemorrhage.
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