Somebody Call 911: Top 5 Emergencies We See

Megan Brashear, BS, CVT, VTS (ECC)

VCA Northwest Veterinary Specialists Clackamas, Oregon

Emergencies can arrive at any moment, no matter what type of hospital or clinic. Some emergencies can develop in patients who were stable when they were checked in. Emergencies require quick recognition, and timely treatment can prevent a big disaster down the road. Technicians who are critically thinking and are aware of what to watch for are vital to patient comfort and survival. Be ready to receive the most common emergencies in your practice and you can be the one who everyone looks to in an emergency.

Gastrointestinal Emergencies

Gastrointestinal emergencies are the most common reason for veterinary visits outside of preventive care. Dogs and cats are sneaky at eating anything and everything they can get their mouths around. As humans, we often want to love our pets through food. While minor vomiting and/or diarrhea are usually not a major deal, some of our GI distress patients can arrive already in trouble, or quickly get in trouble if they are not assessed and treated quickly.

The cause of shock in small animal patients is the result of a deficit of oxygen supply and oxygen demand. When a lack of oxygen delivery from poor perfusion occurs, cells cannot produce necessary energy. Every cell in the body requires ATP to protect cell wall integrity and perform cellular functions. ATP has a life span of 3 seconds and the body needs oxygen in order to create ATP and keep up with need. In a shock situation, because the body is no longer able to provide normal blood flow to tissues oxygen distribution is interrupted, ATP production decreases, and cells begin to die. Patients experiencing trauma can be in shock from lung injury (not performing gas exchange well enough to provide oxygen to cells), crushing injury (blood vessels are damaged and cannot carry oxygen to tissues), from obstruction (blood cannot flow to cells due to a physical obstruction), or from blood/fluid loss (not enough volume to carry oxygen to tissues). If left untreated, patients in shock can die.

The body has baroreceptors to warn the body of decreased blood flow in an attempt to avoid this cell death. These receptors are located in the aorta and kidneys and in times of hypovolemia (for example) sense when blood flow is low and signal back to the body that blood flow is lacking. The sympathetic nervous system reacts with vasoconstriction, increased cardiac contractility, and tachycardia. These adjustments will increase cardiac output in an attempt to maintain blood flow and oxygen flow as normal. The kidneys, via the renin-angiotensin-aldosterone system will begin to retain sodium and water in order to increase intravascular volume. These compensatory efforts will display as subtle clinical signs in early shock and are often missed by pet owners.

As shock progresses without any intervention, these compensatory mechanisms are soon overwhelmed and can no longer keep up the “business as usual” blood flow. Vasoconstriction begins to preferentially decrease blood flow to major organ systems (beginning with the periphery, then the gastrointestinal tract, progressing to the liver, then kidneys, and eventually brain) in order to maintain as much perfusion as possible to the heart, lungs, and brain. This whole body decompensation exhibits in the clinical signs of shock: pale mucous membranes, poor pulse quality, decreased blood pressure, and depressed mentation. If these signs are ignored and treatment not administered, organ systems will fail due to lack of oxygen and the animal will die.

Animals can be in shock from either a lack of fluid (dehydration) or a lack of perfusion (hypoperfusion) and in some cases, both. Perfusion and hydration is not the same thing, and we are able to measure these in a patient by using different modalities. Perfusion is monitored by measuring mucous membrane color, capillary refill time, pulse quality, and heart rate. Hydration is monitored by measuring skin turgor, the moisture of mucous membranes, and assessing whether the patient’s eyeballs are sunken.

As patients present to the hospital with shock, or as those in the hospital are monitored closely, the technician team must be aware of and look for the clinical signs of shock. As discussed, the body begins with subtle signs of compensation that may go unnoticed like light pink mucous membranes, mild mental depression, tachycardia, and mildly prolonged capillary refill time. In compensatory shock the blood pressure and pulse quality remain normal.

Early decompensated shock sees the patient still trying to keep up with decreased perfusion. This stage mimics the pain response in animals, so pain management is important to not only keep the patient out of pain, but to rule out this stage of shock. Dogs suffering from early decompensated shock will exhibit pale mucous membranes, tachycardia, dull mentation, hypotension, poor pulse quality, and increased capillary refill time. If patients in early decompensated shock are not assessed and treated, they will continue to worsen. In late decompensated shock the body begins to shut down and can no longer keep up with oxygen needs. The heart rate may be decreased, mm color is white or gray, and pulses may be absent. These patients are minimally responsive or obtunded.

Patients that present with these physiologic signs of shock need immediate treatment. Unless the patient has cardiac disease, the mainstay of shock treatment is intravenous fluid therapy. A large bore short length IV catheter will deliver a large amount of fluids quickly, and should be placed in a cephalic or jugular vein. Crystalloid fluids are electrolyte and water replacement and are administered quickly in an attempt to restore circulating volume and therefore oxygen delivery to cells. The “shock dose” of crystalloid fluids is 90ml/kg in a dog, 45 to 60ml/kg in a cat. This large dose is often divided into smaller amounts (20ml/kg for example) and administered as a quick bolus. Once the bolus is complete, the vital signs are once again assessed. The bolus amount is repeated until vital signs begin to improve.

Colloids are fluids comprised of large molecules that will remain in the intravascular space; they may also help to draw fluid into the intravascular space. In many trauma cases colloids (like hetastarch and VetStarch™) can be used in conjunction with crystalloid fluids to improve patient blood pressure and perfusion parameters. Colloids have a dose limit of 20ml/kg/day but small amounts can be given as a bolus during the resuscitation period.Blood products are natural colloids and can be used for volume expansion and to boost oxygen carrying capacity in animals bleeding from trauma.

Hypertonic saline may be administered to facilitate a quick draw of fluids from the extravascular to the intravascular space. Hypertonic saline has a much higher sodium concentration (usually 7% NaCl) as compared to physiologic saline (0.9% NaCl) which draws fluid into the intravascular space in an attempt to equalize the sodium content. Relatively small volumes are needed (5ml/kg) administered over 5-10 minutes. The intravascular volume expanding effects of hypertonic saline last about 30 minutes, but their administration may keep the patient alive long enough to allow a large bolus of crystalloid fluids or other therapies time to work. The fluid shift that occurs with the use of hypertonic saline can help to reduce intracranial pressure in head trauma patients, as well as modulate inflammation. Hypertonic saline should not be used as the sole fluid used for resuscitation as it can cause dramatic changes in the patient’s serum sodium levels.

It is important to note that cats do not respond to shock the same way dogs do. Cats in shock will often vasodilate (not vasoconstrict like dogs), lose body heat, and often experience extreme hypotension. This hypotension is not necessarily from low circulating volume. As cats warm back to a normal temperature their vessels will constrict back to normal size. If large amount of fluids are administered to a severely hypothermic cat the blood pressure may read normal, but as the cat warms vasoconstriction occurs. As their temperature returns to normal the excess fluid from their vascular space can become pulmonary edema. It is important to be judicious with fluid administration on hypothermic cats and focus on warming them as much as providing fluid therapy. While the cat is warming, small (20ml) boluses of crystalloids can be given as they are closely monitored. When their body temperature approaches normal and they are still hypotensive more aggressive IV fluid therapy can begin. Cats can be bradycardic or tachycardic with shock, goals from treatment need to be vital signs approaching normal.

Respiratory Emergencies

Receiving respiratory emergencies takes quick action. These patients need immediate oxygen support in the form of an oxygen cage, flow by, nasal prongs, or an oxygen hood. These patients are fragile and must be handled with care; an important goal during treatment is to minimize stress. Observe the breathing pattern of the animal when they first arrive. Watch their posture and note if they are positioned with elbows abducted and/or their neck stretched out. Watch their thorax and abdomen as they breathe; are the chest and abdominal muscles moving together (outward movement during inhale, inward movement during exhale) or opposite each other? Patients exhibiting paradoxical breathing are at risk for respiratory arrest and should be closely monitored.

Ascultation of the chest is necessary and can assist in localizing the underlying problem causing the distress. Listen for upper airway sounds, absence of lung sounds, harsh lung sounds, crackles, and for cardiac abnormalities like a murmur or arrhythmia. Ascultation can help guide treatment and lead to interventions such as thoracocentesis which can stabilize the patient. Radiographs are helpful in diagnosing respiratory problems but are stressful and can be detrimental to the distressed patient; effort must be made to attempt to stabilize the patient as much as possible prior to radiographs. Ultrasound can also be utilized to identify pericardial effusion, pleural effusion, and penumothroax and can be performed with the patient in sternal recumbency with minimal stress.

Mild sedation can be administered early in the treatment plan for these patients; sedation can help to facilitate procedures and diagnostics and provide mild relaxation while these animals rest in oxygen. For non-traumatic respiratory distress, butorphanol (0.2mg/kg IV or IM) can help with relaxation. Traumatic injuries need pure mu opioid pain management. In patients that are not responding to therapy, those too fractious to allow handling, or those with severe respiratory exhaustion, the best treatment plan may be general anesthesia and intubation. Sedation with an opioid and benzodiazepine may be sufficient but a slow titration of propofol or alfaxalone can also be utilized for induction and intubation. Although anesthesia in a critical respiratory distress patient can be a frightening thought, intubation provides a secure and open airway and allows full control (if necessary) of respiratory rate.

Take diagnostics slowly with these patients. They are easily stressed and small things (like a temperature or blood pressure) can increase their distress. Prioritize treatments, discuss IM vs IV injections of medications, and allow long rest periods between interventions. When restraining for IV catheter placement, blood draws, or injections, allow the patient to remain sternal if possible and be cognizant of their head position. Do not put any unnecessary pressure on their neck or chest during restraint. If the patient allows, continue to provide at least flow by oxygen during treatments.

Many respiratory patients will eventually need radiographs; minimize time and stress by ensuring good diagnostic images. Be sure your positioning is good; watch the rotation on both lateral and VD views. Ensure your cranial landmark is the thoracic inlet and include all of the lung fields. If at all possible take the radiograph on inspiration. The ventral-dorsal view is the most stressful for the patient; rather than wrestle, discuss taking a dorsal-ventral view if possible.

Once a treatment plan is created for any patient needing oxygen support the next step is monitoring. Along with routinely checking all of the animal’s vital signs, their oxygen needs must be assessed regularly. A Sp02 reading is certainly part of that monitoring but it shouldn’t be the only parameter used.

  • Sp02 – results for a patient on supplemental oxygen support should be monitored and improve throughout hospitalization. As the patient improves they should be challenged off of oxygen support for a time and a Sp02 reading taken off oxygen to help wean down to room air. Remember the limitations to Sp02 (ambient light, patient compliance, mucus membrane color)
  • Respiratory rate and effort – frequent (every 2 hours) monitoring of respiratory rate should be performed. It is important to try and observe the animals in secret as values may change in the presence of a technician. Effort should be noted as well.
  • Mucous membrane color should be closely monitored; gray or muddy mucous membrane color can mean the patient’s respiratory status is worsening.
  • Heart rate should be closely monitored. Hypoxia will result in tachycardia; evaluate the patient if sudden tachycardia occurs or if the heart rate increases between treatments.
  • Arterial blood gas –if your hospital has the ability, an arterial blood can be utilized to accurately record respiratory disease progress or decline.

A patient in respiratory distress may spend only hours in your hospital or may spend days in the ICU with mechanical ventilation. The technician role is to quickly recognize respiratory distress, provide oxygen support, and closely monitor patients for changing needs.

Trauma Emergencies

When a patient presents to the hospital with a trauma emergency a technician should perform a triage in the lobby to determine next steps.In many cases of trauma, the patient should be brought to the treatment area for a full assessment and immediate treatment. Begin with the ABCs:

  • AIRWAY – ensure the patient has a patent airway and is moving air. If not, intubation and ventilation is the first step to take.
  • BREATHING - many trauma patients can present to the hospital with some degree of respiratory distress. Provide at least flow-by oxygen to these patients and observe their breathing pattern to help determine the cause of their distress. Trauma, bleeding, and pain can all cause changes in respiratory rate and effort. Listen to sounds the patient makes while breathing; are the sounds on inhalation or exhalation? Listen for lung sounds; are they increased or decreased? Watch the patient breathing; are they using their abdominal muscles? Is the effort increased on inhalation or exhalation? Watch for flail chest and observe for any open wounds which may penetrate the thoracic cavity; if present these must be covered and bandaged as soon as possible.Have the supplies necessary to perform thoracocentesis as needed.
  • CIRCULATION: Trauma patients are often suffering from hypovolemic shock due to hemorrhage. Team members must be comfortable recognizing the signs of shock and familiar with the appropriate treatment and monitoring of these patients. To assess circulation, evaluate femoral pulses, heart rate, mucous membrane color, capillary refill time, and blood pressure.

One the ABCs of the patient is evaluated, it is important to record all vital signs. It may be tempting to skip over this step as the patient may require a multitude of treatments and care, but unless the patient needs immediate CPR, admitting vitals are important to the team’s ability to monitor and track progress. Move systematically through the patient while performing a brief exam, and include the blood pressure in the admitting vitals if at all possible.

When treating a trauma patient you must prioritize their conditions and treat first what will kill them first. While a giant wound may look impressive, dealing with respiratory distress or decompensated shock must take priority. Patients experiencing trauma can be in shock from lung injury (not performing gas exchange well enough to provide oxygen to cells), crushing injury (blood vessels are damaged and cannot carry oxygen to tissues) or from blood/fluid loss (not enough volume to carry oxygen to tissues). If left untreated, patients in shock can quickly die.

When resuscitating a trauma patient, goals are set for the patient’s vital signs and treatment administered until those goals are met. Some patients may be resuscitated until their heart rate and blood pressure are normal or approaching normal. The role of the technician is to closely monitor these patients and recheck all vital signs after each bolus of fluids. This information is relayed to the veterinarian and the next steps ordered. In some patients, particularly those with abdominal bleeding or thoracic trauma, more conservative goals may be set so as not to cause further bleeding and contribute to respiratory distress.