Veterinary emergency interventions: Ready to step in?
Mindy Valcarcel is the Medicine Channel Director for dvm360.com, Vetted and dvm360 magazine.
Who knows what's ahead of you when a veterinary emergency is waiting for you? Dr. Garret Pachtinger is on call with tips to have in your back pocket and help you save the day.
(Shutterstock.com)The scary door-the stuff of nightmares for pet owners and veterinarians alike. When an emergency arises, clients rush their pets to your veterinary clinic, passing over your threshold in the hopes that you can save their beloved pet. And veterinarians can't be sure what exactly they're going to face as they pass through the exam room door where a pet in the midst of a life-threatening situation waits for intervention.
At a recent Fetch dvm360 conference, VETgirl co-founder Garret Pachtinger, VMD, DACVECC, delivered critical tips on emergency care to a packed audience in what he admits is his favorite session. Here are a few highlights.
Should CPR protocol mirror that for humans?
A Fetch attendee pointed out that in CPR in people there is a new emphasis on hands-only CPR, skipping the respiration. But Dr. Pachtinger says that in human patients, the most common reason for cardiac arrest is an arrhythmia called ventricular fibrillation, when rapid, erratic electrical impulses cause your ventricles to quiver uselessly instead of pumping blood. Not so in most veterinary patients where we see a variety of causes for cardiac arrest including anesthetic issues, airway obstruction, systemic organ failure or disease and asystole. But he does say there is a movement toward performing chest compressions first in veterinary patients. “We should not delay chest compressions for any reason.”
Go with “Stayin' Alive,” not “I Will Survive.” Did the Bee Gees know their song would become the go-to reference for the right tempo at which to perform chest compressions in CPR? Gee, who knows? But if you mentally summon this '70s classic and perform chest compressions to the beat, it's about 100 to 120 beats/min, which is what to aim for to give patients a helping hand toward stayin' alive, stayin' alive, says Dr. Pachtinger.
Don't lean in. Dr. Pachtinger says that for chest compressions to work, the chest must recoil after compression. “You need negative pressure to pull the blood back into the chest cavity,” he says. So don't lean on the patient, and he says that you should compress about one-third of the chest width.
Delineate a line of succession. Dr. Pachtinger says that studies have shown that the longer you do chest compressions, the more ineffective they become. He recommends that you switch out who is doing the compressions at least every two minutes.
Watch the capnograph. A Fetch attendee asked when you know it's OK to stop performing CPR. Dr. Pachtinger says that, ideally, you'll have an end-tidal carbon dioxide reading. “It's one of the first ways you'll know they're coming back to life,” he says.
If you refer after that life-saving moment: Papers before patients, people
If a patient's transferred or referred to or from the ER/specialty hospital, it's imperative that all the appropriate documentation (lab results, discharge details and diagnosis paperwork) arrives before the patient. Nothing's more frustrating to the clinician (or client) when they show up and the appropriate paperwork hasn't been sent. A patient arrives for “recheck evaluation and bloodwork,” and without the appropriate documentation, the clinician may find it difficult to appropriately evaluate and care for that patient. This can delay treatment and lead to a frustrating interaction.
Also, emails, text messages and videos can help clients better understand their plan of care at both hospitals, and communication between hospitals improves.
-Garret Pachtinger, VMD, DACVECC
You've got a neonate that's hypovolemic, hypothermic and hypotensive. Think you're going to be able to get an intravenous catheter in there? Instead, turn to an intraosseous (IO) one, says Dr. Pachtinger. Most drugs that can be given intravenously can be given intraosseously. A little uncertain with the thought of this procedure? You're not alone. Several vets in the audience expressed discomfort. But it's a life-saver! Here are Dr. Pachtinger's tips:
• Get a 22-ga, 1-in needle and aim for the femur-“the little divot between those trochanter ridges,” he says. Use a twisting motion, and it should slip right in.
• Flush in sterile saline solution with a 1-ml syringe.
• At this point, one of three things will happen:
Voilà! It's in. Ready for dosing.
As you start flushing, the leg swells. Dr. Pachtinger says the femur in neonates is cartilaginous-not fully calcified, which is why you are able to easily place the IO catheter in (as compared to an adult patient). You probably went in one cortice and out the other. Take it out and try again,” he says. “No big deal-it happens.”
You try to flush but get resistance. “The core of the bone is probably sitting in your needle,” says Dr. Pachtinger. Take it out and try again.
• Dr. Pachtinger says he likes to replace the IO catheter within two hours since it's not comfortable for the patient and by then the patient should be normothermic, normotensive and normoglycemic.
Dr. Pachtinger gets on a soapbox for this one: “If you feel like there's pleural space disease-whether you're talking about something like a pneumothorax or pleural effusion-you should diagnose that with thoracocentesis, not radiographs.” And the likelihood of doing damage is very small. Hear all about it in this audio clip in which he starts with one of his favorite quotes from the book “The House of God” by Samuel Shem, MD, a novelized account of a group of medical interns:
No need for fancy tools here, says Dr. Pachtinger-just a 22-ga needle attached to a 3-ml syringe. “I will try to remove air or fluid if there, for treatment and diagnosis-maybe with sedation,” says Dr. Pachtinger. “I like butorphanol with diazepam.”
When does Dr. Pachtinger most commonly opt for this life-saving measure? Food bloat? Nope. It's poisoning! Not in all cases, of course. He says if there is a good antidote, like vitamin K for anticoagulant rodenticide exposure, go for the antidote. But for cases in which emesis is not effective enough and life-threatening illness is right around the corner (e.g. pets that get into lots of bromethaline, cholecalciforol, lilies, baclofen) try gastric lavage.
“I do strongly recommend that if you're going to orogastrically intubate, that the patient is intubated for two reasons,” Dr. Pachtinger says. “One is if you've intubated them, there's only one other hole for the tube to go down. You can't accidentally go down to the lungs.” The second reason-you protect the airway.
Why not gastric lavage for food bloat? You end up hydrating food sitting in the stomach, creating “big, fluffy kibble that doesn't want to come down the tube,” says Dr. Pachtinger. “You aspirate and all the food is still left in the stomach.” Better bets for food bloat-fluids, metoclopramide, buprenorphine and regular walks, he says.
These are but a few of the pointers passed on to the Fetch audience, but we hope they make you feel a bit more equipped to face the scary door of ER care.
You. Can. Do. This!
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