Emergency clinical examination

Abstract

PHOTO 1: In an emergency clinical examination the first priority is to focus on the efficacy of oxygen delivery and assess the respiratory and cardiac systems. The airway must be cleared of any obstructions and artificial respiration applied if necessary. The respiratory and cardiovascular systems are examined by auscultation of the heart and lungs, palpation of venous distension and arterial pulse and evaluation of mucous membrane colour and capillary refill time. The heart rate and the strength of the pulse are important to take into account. The patient’s level of consciousness should be frequently assessed as a sign of neurologic and metabolic status. Temperature and hydration status should also be assessed. PHOTO 2: When several patients are presented simultaneously after being poisoned, the clinician needs to prioritize patient care. The process of sorting or prioritizing patient care when there are multiple patients requiring care is called triage. When a group of patients require emergency care, those that are not ambulatory are given the highest priority, with those that can walk by themselves but have breathing or circulatory problems receiving the second highest priority. Patients requiring triage include those arriving in emergency situations, patients being transferred to ICU and current ICU patients that deteriorate suddenly. Rapid assessment and triage should be completed as soon as possible after arrival of critically ill or injured animals. A quick assessment of history should be done. The ABCD approach is used in the primary survey of critical patients : airway, breathing, circulation and disability. A secondary survey is done once emergency therapy has been started. This includes a full physical examination and measurement of arterial blood pressure. PHOTO 3: Gastric lavage is the use of an orogastric tube for the administration or removal of small volumes of liquid and to remove toxic substances from the stomach. It is done when emesis has failed or is contraindicated or in cases where charcoal must be administered immediately. Gastric lavage is contraindicated when hydrocarbons or corrosive substances have been ingested. Gastric lavage is most effective within one to two hours after ingestion of the toxic substance. If the animal is conscious, gastric lavage is done under general anaesthesia and the patient is intubated to prevent aspiration. The patient is positioned in lateral recumbency with the thorax higher than the head. The right length of tube is measured from the tip of the nose to the last rib. The tube is gently placed down the oesophagus and correct placement is confirmed. Warm water or saline is infused into the tube to moderately extend the stomach and the fluid is then allowed to drain from the tube via gravity flow until clear fluid is returned. Activated charcoal may then be administered through the tube. PHOTO 4: Endotracheal intubation is the process of inserting a tube into the trachea. If the patient lacks adequate gag reflex due to neurologic disease, sedative administration or cardiopulmonary arrest, it requires immediate intubation to protect the airway. Endotracheal intubation provides a patent airway in patients with upper airway obstructions, protects against aspiration in patients without normal airway protection mechanisms and allows for the administration of oxygen, gaseous anaesthetics or positive pressure ventilation. Intubation is done by laryngeal visualization and inserting a cuffed endotracheal tube of the right size. Intubation is usually performed in a dog in sternal recumbency. Intubation may be difficult in dogs with upper airway obstruction or trauma. Preoxygenation is recommended before intubation of critical patients.

REFERENCE: PHOTOS 1-5: Silverstein, DC & Hopper, K (eds) 2009, ‘Small animal critical care medicine’, Saunders Elsevier, St. Louis, pp. 2-9, 72-73, 327-328.