Assessment and basic care of emergency patients (Proceedings)
When a patient first arrives we have all been taught the ABCs of emergency care. We know that the assurance of a clear airway is paramount and the first thing we should all do, and then we move one to B and assure breathing is adequate. Then we move on to C (for cardiovascular) and assess and ensure the heart is pumping and pumping adequately... This process is termed vertical resuscitation and is a "step by step" process that is completed in a "priority of need" sequence. There is absolutely nothing wrong with this approach and is still the gold standard in the "on-arrival resuscitation" of the critical patient. However, I would like to introduce to you a process called "horizontal resuscitation" for the "on arrival immediate care of the critical patient. This method approaches ALL the "ABCs of the critical patient at the same time or nearly at the same time. This, of course, requires a team of at least 2-3 so that simultaneous assessments and treatments of the various areas can occur. Simultaneous assessments and treatments of the ABCDE areas of emergency concerns are then accomplished with the protocol below (Table 1)
Table 1. Horizontal resuscitation of the critical patient on arrival
A. Open the airwayExtending the head and neck if needed, providing a tracheotomy or cricothyroidotomy if needed AS JET – BLOW-BY OXYGEN IS DIRECTED TO THE PATIANT'S NOSE OR MOUTH; intubating using succinylcholine HCl (0.1 mg/kg IV, IM if can't get an IV established with mini-cutdown or rapid IO needle placement...begin bag-valve mask ventilation as the tracheotomy or cricothyroidotomy and ET tube is being placed or as the succinylcholine istaking effect. Immediately follow with acepromazine 0.01 mg/kg, butorphenol 0.1 mg/kg, and ketamine 1 mg/kg as a mixture with all three in the same syringe, given IM, IV, IO.
Do whatever it takes to get the airway clear so breaths can be given...
Example: Boston Terrier with torn trachea example as described above = cardiac arrest in radiology brought to anesthesia –prep room, BVM w/ 100% O2,. No pulse, Chest Compressions initially then intubated, checked for bilateral lung sounds = none = but O2 going in easily.....severe tracheal tear supposed = cervical approach found trachea OK, parasternotomy found trachea pulled apart cranial to heart = elevated distal end of trachea and intubated, direct cardiac massage.. heart responded began beating slowly = gave atropine and 0.01 ml/kg epinephrine and responded very well. patient began waking up (good sign. Started isoflurane and gave oxymorphone 0.03 ml/kg and ace to color(.1 mg) and continued PPV and observation , ECG, Doppler flow and BP with chest covered while went to discuss case w/owner...... The owner was told of the crisis that occurred and approved the next step (see D)
B. Ensure adequate ventilation
(providing Bag Valve Mask Ventilation [Galls 1-800-854-2706] and use of a PEEP valve if needed (pulmonary pathology believed present) Ambu. Attach to oxygen source at 5, 10,15 L/min for infant, pediatric adult resuscitator bags. Alternative = Anesthetic machine BUT you have to play with pop-off valve and this distracts you; A suggestion = use the machine as oxygen source by inserting a Y connector in the line going to the circuit, clamping off the section then going to the circuit then
C. Control hemorrhage with immobilization
(forced; taped to board with towels and duct tape) with the board made of plastic, cardboard, wood and applying pressure (direct) and using pressure points (brachial, femoral, other) and applying a counterpressure dressing , torso wrap, and
C2. Control pain and hypertension with medication
(ketamine 1-2 mg/kg, butorphenol 0.1-.2 mg/kg, acepromazine 0.01-02 mg/kg all in same syringe giving IV or deep IM in epaxial muscle. IF NOT DONE ALREADY. ¼- ½ mcg/kg metomidine can also be used very effectively. Do not give any NSAIDs at this juncture as they help induce renal compromize and failure