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An Urban Experience
Triage is the art of giving priority to patients and their problems upon presentation to the hospital. The primary complaint and the time of onset are obtained, and the animal is quickly examined for abnormalities associated with the respiratorym=, circulatory and central nervous systems. Significant changes require that the patient be taken directly to the treatment area. There are several historical or observed problems that warrant immediate triage to the treatment area, to include:
trauma, profuse diarrhea, urethral obstruction,
labored breathing, altered mentation, seizures, loss of consciousness, excessive bleeding, history of poisoning, prolapsed organs, potential snake bite, heat prostration, open wounds exposing extensive soft tissue or bone, signs of shock, anemia, burns, dystocia, and expired animals (for the client's benefit)
The emergent patient presents a special challenge because the underlying problem may not be evident
for 24-48 hours’ post-presentation. The problems can arise from an acute illness, from a chronic illness that has decompensated, or from an unexpected complication of another illness. All post-operative patients are considered critical care patients until life-threatening anesthetic or surgical complications are ruled out.
The GOLDEN RULE of emergency medicine is "treat the most life-threatening problems first". The airway, breathing, circulation and level of consciousness must be rapidly assessed. Patients with catastrophic problems (airway obstruction, respiratory failure, circulatory failure, head injury) can die within seconds if left untreated. Severe problems are life-threatening but allow more time for stabilization.
Variables that contribute to the overall success of patient resuscitation include the severity of the primary illness or injury, the amount of fluid or blood lost, previous health problems, the number and extent of associated medical conditions, time delay in instituting therapy, the volume and rate of fluid administration, and the choice of fluids
- crystalloid, blood components, synthetic colloids. Therapy must be done at the right time, in the right amount and in the right order. Therapeutic failures are generally not from ignorance but rather from failure to act promptly at a crucial moment.
Primary Survey
Airway: Loud breathing, heard without a stethoscope
is the hallmark of an airway obstruction. The breathing rate is typically slow, unless the patient has hyperthermia. The airway is cleared and the head and neck gently extended, pulling the tongue forward, and carefully clearing the mouth of any foreign objects, mucus,
blood or vomitus. Tracheal intubation, either orally, or
via tracheostomy will provide an immediate airway. In situations of airway compromise in a partially conscious animal, mild sedation utilizing benzodiazepine or opioid derivatives may be necessary to facilitate intubation, or
a transtracheal oxygen catheter can be placed providing oxygen flow at 0.5ml/kg/min. If a foreign object is unable to be easily removed, a Heimlich-like maneuver can be performed. Oxygen is always supplemented by mask, bag, nasal cannula, or flow-by.
Breathing: Positive pressure ventilation by hand to an inspiratory pressure of 15-20 cmH2O for the dog and 10-15 cmH2O for the cat is required. Fluid in the airways will increase pressure requirements, and suctioning should be performed. Respiratory arrest is not always associated with cardiac arrest. When it is determined that there is no heartbeat, then CPR measures are instituted. When the heart is beating, the chest is evacuated of air or blood. A synchronous, labored and/or rapid breathing pattern is typical for pulmonary interstitial disease. Asynchronous breathing pattern is typically seen with pleural space disease. If fluid or air is suspected, thoracentesis or
chest tube placement is performed should be performed before any radiographs are taken. In cases of tension pneumothorax, a small incision is made for immediate release of pleural air until a chest tube can be placed and continuous suctioning supplied. Mechanical ventilation will insure adequate tidal volume in this case.
Circulation: Hemorrhage is controlled, and vascular access rapidly obtained. Dose and type of fluid administered, and pharmacological intervention is determined by the level of shock and existing problems present.
Level of Consciousness: If there is a reduced level
of consciousness, careful handling of the patient is necessary. Keep the head and neck as level as possible and limit any compression of the neck which may reduce jugular drainage. Avoid placing anything into the nostrils which may stimulate sneezing and an increase in intracranial pressure. Transport the patient on a flat surface between areas of the hospital.

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