Emergency Board ReviewTriage A- airway (patent, adequate FiO2)- arterial bleeding ( pressure) B- Breathing (characterize pattern)inspiratory, expiratory, paradoxical C- Circulation D- Disability (neurologic, musculoskeletal) E- Evaluate (abdominal, urinary, general)Triage- Secondary Survey A- airway C- Cardiovascular/circulatory R- Respiratory A- Abdomen S- Spine H- Head (eyes, ears, and neck too)Triage- Secondary Survey P- Pelvis (rectal) L- Limbs (including tail) A-Arteries N- Nerves (including cranial nerves, reflexes, pain sensation)Quick Blood Gas- 6 Questions 1. Is the patient hypoxemic? PaO2 2. Is the patient hypo or hyperventilating? PaCO2 3. Is there an acid-base abnormality? 4. What it is the primary abnormality? Metabolic or respiratory 5. Is it simple, simple with compensation or mixed? 6. Why does it exist, how do you fix it?Quick facts for acid base Rules of 4 pH- 7.4 +/- .o4 PaCO2- 40 +/-4 HCO3- 24 +/-2 PaO2- 4-5 x FiO2 You can not compensate to normal pHQuick facts for acid base Most common cause of respiratory alkalosis in emergency is pain or fever induced hyperventilation Most common cause of respiratory acidosis is hypoventilation from anesthetics, upper airway obstruction, severe parenchymal disease, or neurologic diseaseQuick facts for acid base Most common cause of metabolic acidosis in emergency is lactic acidosis (shock), ketosis, other unmeasured anions (ethylene glycol), or hypochloridemia (differentiate with anion gap) Most common cause of metabolic alkalosis is vomitingSmall Animal Toxicology Basic steps Eliminate further absorbtion• Bathe or vacuum• EmesisHydrogen peroxide (3%) 1-2 ml/kgcan repeat once in 10 minDishwashing liquid 1:8 with water and give 10 ml/kg onceSmall Animal Toxicology Eliminate absorbtion - emesisApomorphine (dogs) .03mg/kg IV, .04 mg/kg IM, .08 mg/kg SC, or .3 mg/kg conjunctivalXylazine (cats) .44mg/kg IMSyrup of Ipecac- potential cardiotoxicity, muscle weakness, hemorrhagic diarrheaSmall Animal Toxicology Eliminate absorbtion Gastric lavage- light sedation maybe• 20 ml/kg of tepid water repeated until clear Activated charcoal• 1-4 g/kg with 1g/50 ml water (if not premixed)- not good with heavy metal Cathartic- often with activated charcoalSmall Animal Toxicology Eliminate absorbed toxin Diuresis for some Ion trapping Definitive antidote or competitive inhibitor- depends on toxin Supportive careSmall Animal Toxicology Acetaminophen Clinical signs• Methemoglobinemia- dark blood, dyspnea, facial and front limb swelling (cats typical or dogs with very high dose)• Hepatic necrosis- 24-48 hours later vomiting, abdominal pain, anorexia (cats and dogs)Small Animal Toxicology Acetaminophen Treatment- basic principles plus• N-acetylcysteine IV or PO (140 mg/kg first then 70 mg/kg QID for 6 doses)• Ascorbic acid for methemoglobin• Cimetidine• SupportiveSmall Animal Toxicology Methylxanthines (chocolate, caffeine, theophylline) Clinical signs- vomiting, hyperactivity, restlessness, tachycardia, tachypnea, ataxia, convulsions, cardiac arrhytmia, deathSmall Animal Toxicology Treatment• Arrhythmia- lidocaine (ventricular) or esmolol (SVT)• Tremors/seizures- diazepam, phenobarbital or pentobarbital induction• Renal excretion and can reabsorb in urinary bladderSmall Animal Toxicology Lead Clinical signs• Gi- anorexia, vomiting, pain, diarrhea• Neuro- seizures, hysteria, ataxia, blindness, tremors• Hemolytic anemia (very high nRBCbeyond expected for anemia)Small Animal Toxicology Lead Diagnosis• High nRBC, basophilic stippling with mild anemia and other signs• Radiographs• Blood levels (>0.6ppm) or liver post mortemSmall Animal Toxicology Lead Treatment• Chelation- calcium EDTA, Penicallimine, Succimer• Repeat lead levels after treatment to determine if more is needed• Supportive careSmall Animal Toxicology Cholinesterase inhibitors (organophosphates and carbamates) Clinical signs- depends if muscarinicor nicatinic• Nicotinic- striated muscle stiffness, fasciculation, tremor, weakness, paralysis• Muscarinic- smooth muscle SLUD, bradycardiaSmall Animal Toxicology Ch. Inhibitors Treatment• Atropine (.1-.2 mg/kg, 1/4 IV, ¾ SC) can be repeated, glycopyrrolate not effective b/c does not cross blood brain barrier)• 2-PAM in addition to atropine in organophosphate, may reverse binding to Achesterase• Midazolam and diphenhydramine for nicotinicSmall Animal Toxicology Pyrethrins Clinical signs• Hypersalivation, vomiting, diarrhea, ataxia, hyperexcitability, fasciculation, depression, disorientation, seizures, dyspneaSmall Animal Toxicology Pyrethrin Treatment• Diazepam for seizures• Phenobarbitol for continued seizures• Methacarbamol for muscle tremorsSmall Animal Toxicology Zinc Clinical signs• Depression, vomiting, diarrhea, hemolytic anemia, renal failure Diagnosis• Radiographs, hemolytic anemia• Zinc levls in serum, urine, or tissueSmall Animal Toxicology Treatment Supportive care Remove source Chelation with calcium EDTA or penicallimineSmall Animal Toxicology Ivermectin Clinical signs• Mydriasis, apparent blindness, aggresion, bradycardia, cyanosis, dyspnea, seizures, coma, death Treatment• NO BENZODIAZIPINE• Physostigmine?• SupportiveSmall Animal Toxicology Ethylene glycol Clinical signs• 1st12 hours- vomiting, intoxicated, stuporous, ataxic, comatose, PU/PD• 2nd12-24 hours- may be normal, may have tachycardia, or signs of pulmonary disease• 3rd>24 hours (or 12-24 in cats)- renal failureSmall Animal Toxicology E.G. Diagnosis• Crucial to diagnosis as soon as possible, therapies do not work after 4-6 hours in cat or 8-12 hours in dog• Ethylene glycol test- false positives• Clinical signs plus high osmolar gap or acidosis with high anion gap• Calcium oxalate crystalluria (occ. Early as 3 hours in cat or 6 hours in dog, often later)Small Animal Toxicology E.G. Treatment• Aggressive fluids• Competitive inhibition of alcohol dehydrogenase• Ethanol 7% IV• 4-mehtylpyrazole (better for dogs, high dose in cats early)• Hemo or peritoneal dialysisSmall Animal Toxicology Rodenticide Clinical signs• Generally act via Vitamin K antagonism• Affects factors II, VII, IX, X• Clinical
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