heart and perfusion

breathing

neuro status

abdomen (esp male cats)

bleeding

• Category 1: will die quickly without immediate intervention
• Category 2: needs urgent attention within 30 min
• Category 3: sick, needs attention within hours 
• Category 4: not truly an emergency, treat within 24 hours

category 2

category 3

category 1

category 4

decompensated hypovolemia

anemia

what do white mm with absent CRT suggest?

what about cyanotic mm with variable CRT?

severe anemia or cardiac collapse

hypoxia

expiratory dyspnea, loud/harsh lung sounds, crackles, wheezing

lidocaine 2mg/kg IV

0.2mg/kg in cats

PCV/TS

glucose

renal values

electrolytes (K)

PRBCs, whole blood

blood typing mandatory in cats, not for first time in dogs

• diazepam 0.5mg/kg IV or rectally

opioids

hydromorphone

morphine (risk of vomiting)

fentanyl

buprenorphine (not reversible)

• head
• depressed skull fractures, ocular trauma
• thorax 
• penetrating, flail chest, lung lobe contusions, lacerations, pneumothorax, hemothorax
• abdomen
• penetrating wounds, organ laceration
• orthopedic
• open fractures
• integument
• body wall hernias, heavily contaminated lacerations, severe tissue injury

• head
• raised ICP, jaw fractures, skull fractures, ocular injury
• thorax
• pneumothorax, pulmonary contusions, rib fractures
• abdomen
• hemoabdomen
• orthopedic
• long bone, pelvic, spinal fractures
• integument
• shearing injuries, skin lacerations

• thoracic
• diaphragmatic hernia, pulmonary contusions
• abdomen
• urinary bladder rupture, hemoabdomen
• orthopedic
• severe, comminuted pelvic fractures
• integument
• skin lacerations, degloving wounds, body wall hernias, burn injuries (from exhaust)

• head
• trauma, mandibular and hard palate fractures, ocular injuries
• thorax
• pneumothorax, pulmonary contusions
• orthopedic
• spinal fractures

tachycardia (cats can be bradycardic)

weak pulses

pale mm

cool extremities

• PCV: can be variable due to splenic contraction
• PCV normal to high in very acute hemorrhage
• TS: low due to loss of plasma protein
• lactate: elevated due to poor perfusion and reduced O2 delivery

• consumptive (massive blood loss)
• dilutional (fluid resuscitation)
• intrinsic (sepsis-like syndrome, mechanism poorly understood

1. conventional
2. low volume
3. hemostatic
4. delayed (permissive hypotension)

• 20-30ml/kg/5-15min isotonic crystalloids bolus, repeated until resolution of clinical signs or shock dose reached. 
• 90ml/kg (dog), 60ml/kg (cat)
• benefits: cheap and widely available
• drawbacks: dilutional coagulopathy and no O2 carrying capacity

• delay all fluid resuscitation until leak stopped
• benefits: increased survival but only in people with penetrating thoracic trauma, no dilutional coagulopathy
• drawbacks: requires injury to OR time <15 mins as prolonged hypotension fatal
• not practical for veterinarians, unless intraoperative

• colloids (to prolong plasma expansion of) and hypertonic crystalloids
• 2-5ml/kg/5min crystalloid with 3-5ml/kg colloids. 2-3 times to effect. 
• must be slow to avoid hypernatremia
• must follow up with isotonic crystalloids to prevent dehydration
• benefits: significant ongoing bleeding cases, head injury, rapid even with limited venous access, readily available fluids
• drawbacks: artificial colloids cause coagulopathy, no O2 carrying capacity

• 500-1000ml balanced electrolyte solution bolus
• 8-10ml/kg PRBC's
• 1unit fresh frozen plasma with first two units of PRBC's
• after two units, infuse FFP and PRBC's at 1:1
• benefits: replaces what is lost, especially with fresh whole blood, O2 carrying capacity replaced
• drawbacks: no platelets in PRBC's, does not address thrombocytopenia, items not widely available

15-20ml/kg crystalloid bolus

if no CV improvement, 8-10ml/kg PRBCs

1FFP:2 PRBCs

1FFP:1PRBCs

1. pneumothorax
2. pulmonary contusions
3. pleural effusion (hemorrhage)
4. diaphragmatic hernia
5. rib fractures

cidal

time dependent

mainly gram +, but some -.active

against most anaerobes except bacteroides

little activity against pseudomonas

no.

gram positives more 1st generation, gram negatives more 3rd generation

clindamycin

protein synthesis binding 50S ribosome

bacteriostatic, time dependent

gram +

effective against MRSA

potentiated penicillins

inhibit cell wall synthesis

bactericidal

time dependent

gram +, and improved - spectrum

bind to DNA gyrase and topisomerase IV, prevent gene transcription

bactericidal

conc dependent

gram - 

hi doses against pseudomonas

toxic to cats at hi doses and juvenile chondrogenesis

• nephrotoxic if dosed more times a day
• bactericidal 
• conc dependent
• bind to 30S ribosome, prevent protein synthesis
• gram -, including resistant E. coli
• synergistic with penicillins in treating gram + and MRSA
• careful with dehydrated animals
• amikacin, gentamycin

• ICP: mannitol 0.5-1g/kg IV, hypertonic saline 2-4ml/kg IV
• hypercapnia: ventilation of PaCO2>40mmHg, but avoid hypocapnia
• venous drainage: elevate head without occluding jugular, avoid jugular sticks

doxy, tetra, oxytetracycline

bind to 30S ribosome to inhibit protein synthesis

good penetration in lungs

gram +, lepto, mycoplasma

• imipenem, meropenem
• inhibit cell wall synthesis
• bactericidal
• time dependent
• excellent broad spectrum
• no activity against MRSA, limited against MDR enterococcus
• expensive, last resort

causes DNA strand breaks

time dependent

excellent activity against anerobes and protozoa (GI)

at high doses, associated with vestibular signs

• binds to 50S ribosome inhibit protein synthesis
• gram + and -
• good for MDR Enterococcus and E. coli
• risk of bone marrow suppression and anemia, so wear gloves, don't split tablets
• oral form is cheap, good for shelter situations

prior antibiotic use within last 90 days

hospital acquired infection

long standing infection

surgical implants

• healthy
• doxycycline as sole agent, broaden spectrum if no improvement
• sick, outpatient
• likely mixed infection, potentiated penicillin (consider what is easy for the owners) (clavamox)
• sick inpatient
• potentiated penicillins or penicillins (gram+), combined with fluroquinolones (careful of cartilage) or chloramphenicol (gram-)
• sick inpatient, previous treatment with Abx
• potentiated penicillins or penicillins (gram+), combined with aminoglycosides (gram -)

• likely due to aspiration
• mixed population including anaerobes
• otherwise healthy, community acquired
• potentiated penicillins
• penicillins with fluroquinolones
• sick, community acquired
• penicillin with fluroquinolones
• hospital acquired or history of recent Abx use
• hi risk of resistance
• penicillins plus aminoglycoside
• carbapenems as sole agent 

• mixed bacteria including anaerobes, E. coli
• often very sick patients, so treat all with broad spectrum antimicrobials pending culture results
• community acquired
• still some risk of MDR E. coli
• penicillin and fluroquinolone or 3rd gen cephalosporin such as cefotaxime and metronidazole
• hospital acquired
• MDR E. coli, pseudomonas, enterococcus
• do NOT use fluroquinolones if previously treated
• penicillin and aminoglycoside and metronidazole
• potentiated penicillin and aminoglycoside
• imipenem 

often mixed populations, skin contaminants, anaerobes (cats)

mild-penicillins (amoxicillin)

moderate to severe- potentiated penicillins

skin contaminants likely

1st generation cephalosporin 

(cefazolin/cephalexin)

• usually hospital acquired with past Abx use
• implants increase risk of biofilm or MDR bacteria (MRSA)
• potentiated penicillin or clindamycin + aminoglycoside
• clindamycin or potentiated penicillin +chloramphenicol
• TMS if MRSA suspected/cultured

nonazotemic, otherwise healthy, no prior Abx

1st gen cephalosporin or penicillin

• mild: Abx rarely needed
• moderate GE: metronidazole for clostridia
• severe (marked compromise, very sick): potentiated penicillin or penicillin with fluroquinolone. bacterial translocation and secondary sepsis real threat
• severe GE: broad for bacterial translocation: potentiated penicillin or penicillin and fluroquinolone

• evidence of free gas
• intra-abdominal structures hard to assess for trauma, but look for bladder and detail
• body wall hernias

• use a radiolucent backboard for stable transport
• start with laterals, but take orthogonals if safe

1. diaphragmatic hepatic
2. cysto-colic
3. spleno-renal
4. hepatorenal

• Right lateral

§  Much harder to master

§  False negatives and positives

§  Look for fluid

• thoracocentesis
• thoracostomy tube

clip and clean

insert needle/butterfly catheter in 7-9th ICS on cranial edge of the rib

aspirate until you get air

connect extension set and 3 way tap

aspirate until end point reached

• obtundation, stupor, coma
• opisthothonus (full body extension)
• cranial nerve deficits and brainstem signs
• palpable skull fractures
• clear external trauma

slow breathing

cheyne-stokes respiration (cyclic including apnea)

anisocoria

miosis

fixed mydriasis (uh oh.)

• brainstem hypoxia causes catecholamine release causing vasoconstriction and massive increase in blood pressure
• increase in blood pressure sensed by baroreceptors which act to slow the heart
• leads to hypertension with bradycardia

which of the following require surgery rapidly following CV stabilization?

• wounds penetrating body cavity
• reconstructive procedures
• ongoing hemorrhage
• open fractures
• diaphragmatic hernia
• urinary tract rupture
• spinal fracture/lesions with loss of deep pain
• body wall hernia with GI/bladder entrapment
• GI tract damage

• wounds penetrating body cavity
• ongoing hemorrhage
• diaphragmatic hernia
• spinal fracture/lesions with loss of deep pain
• body wall hernia with GI/bladder entrapment
• GI tract damage

DO NOT CLOSE. unless you can have a chest tube in, you will likely cause a pneumothorax

need to intubate and ventilate patient. 

eventually, with management, you can close these wounds, but not if they are severe.

tibia/fibula

radius/ulna

wet to dry

old injuries, bite wounds, shearing/degloving, severe road rash

urinary catheter

temporary abdominal drain or abdominocentesis

on the side of the flail

reduces aberrant movement of flail segment

upright

allows organs to fall through hernia into abdomen

• moderate neutropenia: broad spectrum including anaerobes (potentiated penicillins)
• severe neutropenia: if renal values ok-->AG

• inhibit cell wall synthesis
• bactericidal
• time dependent
• 1st gen: gram + (cefazolin, cephalexin)
• 2nd gen: (cefoxitin, cefuroxamine)
• 3rd gen: gram - (ceftiofur, cefpodoxime, etc)
• not interchangeable

sick, renal disease, urolithiasis

broader spectrum: potentiated penicillin or penicillin with fluroquinolone. AG can be used, but NOT concurrent with kidney disease

• AVOID AMINOGLYCOSIDES
• if Lepto area, penicillin or doxycycline
• if no hx of Abx use, potentiated penicillin or penicillin with fluroquinolone
• if hx of Abx use, MDR likely, potentiated penicillin plus chloramphenicol or carbapenem

o   No chest movements, or air movements

o   No heartbeat or severe bradycardia

o   Unconscious

o   Do NOT rely on pulse

• leader
• recorder
• compressor
• breathing
• catheter placement/monitor
• fetcher

6-10 breaths/min, inspiratory time 1sec

100-120 compressions/min, 30-50% compression of chest wall, 1:1 compression:recoil

by yourself: 30 compressions to 2 breaths

• cardiac pump in smaller patients (direct compression and increased CO)
• thoracic pump in larger animals (indirect increase in CO due to increase in intrathoracic pressure)

• unwitnessed event
• pleural/cardiac related disease
• trauma to chest wall/penetrating wounds
• large breed dogs
• abdominal surgery
• failure of ROSC in closed CPR
• abdominal hemorrhage

• clip, enter with sharp mayos at left 6th ICS
• via diaphragm
• avoid phrenic and vagus
• aortic cross clamping or compression--> diverts to brain
• direct cardiac compressions-2 hands
• apex--> base

• Naloxone, (opioid antagonist)
• Atropine,
• Vasopressin,
• Lidocaine,
• Epinephrine

double doses

up to 10x dose epinephrine

dilute with sterile water of 0.9%saline

catheter down trach tube

follow with PPV (positive pressure) breaths

• turn off anesthetics
• reverse any drugs you can

• Alpha and Beta effects
• High dose (0.1 mg/kg)
• Associated with increased ROSC
•  Not associated with increased survival
• Increased myocardial oxygen consumption
•  Arrhythmogenic
• Consider after prolonged CPR
• Low dose (0.01 mg/kg)
• Repeat doses every other 2 minute compression cycle

•  V1 mediated vasoconstriction
•  Receptors are active in acidosis
•  No inotropic or chronotropic effects
•  May use instead of or in addition to epinephrine

• Parasympatholytic
• No longer recommended routinely in people
• No evidence of positive or negative effect
• Our patients are different
• High number of vagal arrests
• Still give 0.04mg/kg every 3-5 min

hypocalcemia

hyperkalemia

hypermagnesemia

CaChannel Blocker toxicity (e.g. diltiazem)

possible digoxin toxicity 

• prolonged CPR (>10-15 min) to combat acidosis
• 1mEq/kg

for Vtach or Vfib

Lidocaine may make defibrillation more difficult

Amiodarone may cause hypotension, hepatotoxic

defibrillation is the only therapy

• depolarizes
• refractory
• 2 min

• monophasic-shock delivered from one vector. no ability to adjust for patient's impedence.
• 4-6J/kg
• biphasic-shock delivered from two vectors. lower current, sweeping in both directions get cells that are further away from electrodes
• 2-4J/kg

PEA (most common)

asystole

ventricular fibrillation

pulseless ventricular tachycardia

• ETCO2
• cats: 20mmHg
• dogs: 15mmHg
• new compressor, change position of hands, rate, depth
• BP 
• only if arterial line already in
• 30mmHg

•  Shown to increase venous return up to 25%
•  Abdomen/thoracic compression opposed
• Can cause trauma

• During decompression intrathoracic pressure decreases and air moves in
• Air being drawn into the lungs partially impairs venous return
• Device prevents air movement into the lungs during the decompression
• Intrathoracic pressure remains more negative
• Improves venous return, SV, CO and oxygen delivery
• Drawback: Movement of fluids into pulmonary interstitium and alveoli

• Base Excess
• Lactate
• ScvO2
• Venous sample better than arterial

return of spontaneous circulation

increased ETCO2

perfusing heart rhythm

increased respiratory effort

o   Watch electrolytes

§  hyperK, hypoCa

o   oxygen- not benign!

o   Ventilator support as needed

o   Pressor support

o   Inotropic support (dobutamine)

o   +/-cerebral edema therapy

§  Hypertonic saline vs mannitol

o   Mild hypothermia

o   Natural –warm slowly

increase current by 50%, but know that increases risk of myocardial ischemia

if not effective, try amiodarone

Poiseuille's law:

Q = πPr⁴

      8ηl

what does each variable mean? and overall?

Q-flow

P-pressure

r- radius

n-viscosity

l-tube length

flow is proportional to the radius of the catheter (tube)^4 and inversely proportional to the viscosity of the fluid and the length of the catheter

which will cause the greatest decrease in flow through a catheter?

a. doubling the diameter of the catheter

b. halving the diameter of the catheter

c. doubling the length of the catheter

d. halving the length of the catheter

• anything above 5% dextrose needs a central line
• hypertonic saline is the only exception

o   Cephalic

o   Lateral and medial saphenous (also central)

o   Jugular (also central)

o   Auricular (dog)

•Jugular vein

•Medial and lateral saphenous veins

1. phlebitis
2. thrombosis
3. catheter embolism
4. SC fluid infiltration into tissue surrounding vein
5. infection 
6. hemorrhage

o   Phlebitis is inflammation of the vessel wall by endothelial lining damage

§  Swelling, tenderness, erythema over vessel and may be caused by following:

·         Mechanical damage

·         Admin of hyperosmotic fluids

·         Infection

o   Small incision or hole made through skin with a number 11 scalpel blade or the cutting edge of a 20 gauge needle. Helps to prevent flaring of catheter tip and is especially useful in animals with tough skin. 

o   After aseptic prep, local anesthetic administered and taking care NOT to administer a local anesthetic intravenously.

o   1-2 cm skin incision is made parallel to vein taking care not to lacerate vein

o   Vein is dissected out from SC tissue and isolated using hemostats or suture

o   Catheter is placed directly through superficial vessel wall

1. Hemodynamic monitoring such as central venous pressure
2. Admin of meds and fluids (including those >600mOsm)
3. Serial blood sampling
4. Allow venous access for longer periods than peripheral catheters (>72 hours)

aseptic technique when connecting/disconnecting

never leave ports open. risk air embolus

• Seldinger technique
• Use of a smaller introducing catheter or trochar and guidewire to gain access to vessels or hollow organs. Used to replace existing catheter in same location.
• Total aseptic technique (caution with guidewire)
• Catheterize using short catheter, insert guidewire, J-tip at insertion end to help prevent inadvertent puncture of vessel wall. ALWAYS keep hold of the guidewire at ALL TIMES

fractured bones 

pneumatic bones in birds

1. flat medial surface of proximal tibia
2. tibial tuberosity
3. trochanteric fossa

also: wing of ileum, ischium, greater tubercle of humerus

o   Vascularly collapsed (neonates)

o   Access all capillaries in bone marrow

• Pretty painful
•  Administering large amounts of fluid is very uncomfortable.
• Mean intraosseous flow rate of crystalloid solutions under 300mmHg are limited to approx. 29mL/min in puppies
• fluid can back into SC space if not a clean stick

§  Fat embolism

§  Infection

§  Extravasation of fluids

§  Compartment syndrome

§  Bone fracture

• 60%
• intracellular: 40%
• extracellular: 20%
• intravascular: 5%
• interstitial: 15%

o   Hi Na in extracellular 

o   Hi K, Mg, P intracellular

o   Sodium conc determines IV volume

o   Total body sodium determines hydration

o   70 x BW^0.75

o   Or (30x BW) +70 for animals 3-25kg

o   Estimates

• 30mL/kg/day for giant breed
• 50mL/kg/day for medium dogs and cats
• 80-100mL/kg/day for neonates

·         Dehydration-interstitial/intracellular fluid loss

o   Can be replaced slowly

·         Hypovolemia- intravascular fluid loss

o   Can happen quickly and needs quick correction

o   Tachycardia

o   Prolonged CRT

o   Hypotension

o   Hypothermia, cool extremities

o   Weak pulses

o   Weakness, lethargy

20-30mL/kg/day

sweat, saliva, excessive panting

BW (kg) x % dehydration = volume of fluid deficit in L

heart and renal disease

·         270-350 mOsm/kg 

• 5-7% mod- mildly prolonged skin tent, mm may be slightly tacky
• 8-10% severe-prolonged skin tent, dry mm, eyes sunken, tachycardia and poor pulse quality, urine prod decreased
• >10% critical-shock, cool extremities,  hypothermia, CRT prolonged

acid-excess chloride

base-acetate, gluconate, lactate anions-metabolism of these lead to bicarb production

in cats, what hi volume, hi pressure bolus is discouraged?

Use of what solutions are discouraged in patients with end stage liver disease?

• Acetate containing fluids such as Normosol-R
• lactate buffered solutions

what are the isotonic balanced fluids (3)?

what are the unbalanced isotonic fluids (2)?

• Isotonic balanced
• Lactated Ringer's
• Normosol R
• Plasmalyte 148
• Isotonic unbalanced
• normal saline
• 5% dextrose

• lower in Na and Cl
• higher in K
• tend to be hypotonic, but some have dextrose added
• rarely used in veterinary medicine
• NEVER should be bolused!!!
• half-strength saline, Normosol M, Plasmalyte 56, homemade concoctions

• hi in Na, Cl
• lo in K
• tend to be isotonic
• may be bolused or administered at hi flow rates
• often used as maintenance fluid as kidneys will excrete the extra sodium. 
• 0.9% NaCl, LRS, Normosol-R, Plasma-Lyte A or 148

• rapid volume expansion (pull fluid from interstitial space, short-lived <20min, follow by isotonic or maintenance fluids)
• reduction of intracranial pressure
• mannitol for glaucoma 
• administered as IV bolus over 5-15 min
• e.g. big dogs in shock (GDV), HBC, head trauma

• severe dehydration
• hypernatremia

3-3.5 times blood volume expansion

7.2-7.5% for shock and head trauma

• benefits
• rapid IV volume expansion
• dec cerebral edema
• inc cardiac contractility
• immunomodulatory effects
• improved microcirculatory perfusion due to arteriolar vasodilation
• proposed adverse effects
• hypernatremia
• bradycardia, hypotension, bronchoconstriction with rapid admin

• benefits
• decrease cerebral edema
• decreases blood viscosity
• free radical scavenger
• proposed adverse effects
• exacerbate edema or hemorrhage
• dehydration

Theoretically, ____% of saline infused stays in the vascular space, while ___% of colloid stays in the vascular space

·         Theoretically, 20% of saline infused stays in thevascular space vs 100% of colloid

Jv = K [(Pc – Pi) – σ(πc – πi)]

Starling equation. what do the variables mean?

Jv - transcapillary fluid flux

K - filtration coefficient

σ - reflection coefficient (relative permeability)

Pc - capillary hydrostatic pressure

Pi - interstitial hydrostatic pressure

πc – capillary oncotic pressure

πi - interstitial oncotic pressure

• colloid osmotic pressure 
• pressure exerted by large molecules
• osmometer

dogs: 15.3-26.3mmHg

cats: 17.6-33.1mmHg

albumin generates 80% of COP normally

• longer intravascular effects
• smaller volume requirements for intravascular expansion
• less dilutional coagulopathies
• decreased tissue edema formation

False. The size of the particle is unimportant so that a single ion (e.g. sodium) contributes as much to the serum osmolality as a single large protein molecule

However, large molecules persist in the circulation longer

•    Electroneutrality must be maintained on either side of membrane
• E.g. large proteins (albumin) are neg charged, non-diffusable. Draw positive ions (Na) across membrane, pulling water with it. 
•  Increases COP by 7-8mmHg

• natural
• albumin (human, lyophilized canine)
• blood products (FFP, whole blood)
• synthetic colloids
• hydroxyethyl starch
• gelatin
• dextran

• not for healthy patients (critically ill only)
• not for patients who have received human albumin prior
• both run risk fo anaphylaxis, delayed hypersensitivity reactions

how do you calculate albumin deficit in a 20 kg dog with albumin of 1.5g/dL and a desired increase of 1g/dL?

what if average albumin conc in FFP is 3.0g/dL? 

Alb def (g)=10x [Albdesired-Albpateint] xBWx0.3 

10 x [2.5g/dL-1.5g/dL] x 20kg x 0.3

=60g albumin deficit. 

3.0g/dL x 10dL/L = 30 grams in 1 L FFP

need 2 liters FFP. 

• acute renal failure
• anaphylaxis
• volume overload
• coagulopathy
• immunosuppression

hydroxyethyl starch

described by molecular weight and degree of substitution

• proportion of glucose moieties that have been substituted with hydroxyethyl groups
• from 0 to 1
• higher DS correlates to greater negative effect on coagulation.
• interferes with Factor VIII and vWF leading to platelet dysfunction
• may also be incorporated into fibrin clot, weakening clot overall

• 6% Hetastarch in 0.9% saline
• DS = 0.75
• 10% Pentastarch
• DS = 0.5
• 6% Tetrastarch (Voluven)
• DS = 0.4

same as colloids:

• acute renal failure
• anaphylaxis
• immunosuppression
• volume overload
• coagulopathy

20mL/kg/day (commonly divided and done CRI), or administered 2-5mL/kg IV bolus

larger molecules stay in vasculature longer, but there are fewer of them = minimal effect

higher DS =greater adverse effect on coagulation

40mL/kg/day

tetrastarch

shorter half-life than hetastarch bc of smaller MW

what is the COP of:

• hetastarch 6%
• voluven
• human albumin 5%/25%
• canine FFP

• hetastarch 6%                              32.7
• voluven                                       37.1
• human albumin 5%/25%                23.2    
• canine FFP                                   17.1

what degree of dehydration do the following suggest?

• weak pulse
• dry mm
• collapse
• skin tent
• increased HR

• weak pulse:            10-12%
• dry mm:                 5%
• collapse:                >12%
• skin tent:               6-8%
• increased HR:         8-10%

60ml/kg for dogs

40ml/kg for cats

heart rate

urine output

respiratory rate

mm color

systolic BP

lactate

CRT

(CVP, MAP, HCT, ScvO2)

1. standard/hemostatic
2. hypertonic
3. permissive hypotensive
4. supra-physiologic
5. early goal-directed

• blood products
• SEVERE hemorrhage cases
• replace what is lost
• avoids coagulopathy with large volume crystalloid
• expensive

• uses traditional endpoints to maintain tissue perfusion and O2 delivery
• crystalloids, colloids, blood products, vasopressors/ionotropes
• most commonly practiced method regardless of etiology
• lacks standard algorithm 

• crystalloids-shock dose as fast as possible
• colloids-increment 5ml/kg doses as fast as possible
• hypertonic saline 3-4ml/kg over 3-5 min
• oxyglobin, blood, albumin? 1:1 PRBC:FFP

• traditional endpoints
• hypertonic agents used
• lower volumes required for volume expansion
• reduce endothelial and tissue edema
• improve microcirculation
• immunomodulatory effects
• head trauma
• MAP 65-70mmHg

• small volume resuscitation
• admin lower than standard shock dose
• head injury
• pulmonary contusions
• noncardiogenic pulmonary 
• hypertonic saline, hetastarch
• hypotensive resuscitation
• small volume for lower than normal endpoints
• uncontrolled closed body hemorrhage
• attempt to minimize further bleeding due to fluid admin in prepping for surgery
• hetastarch, isotonic crystalloids, hypertonic saline, blood products

• CO is the endpoint
• septic shock
• maximize oxygen delivery to tissues
• avoid hypoxic related organ injury
• also, SAP 100mmHg, MAP 80mmHg, normal lactate

state in which delivery of O₂ to tissues (DO₂) does not meet oxygen requirement (VO₂)

inadequate cellular energy

leads to decreased perfusion

1. measure serum lactate
2. obtain blood cultures prior to antibiotic administration
3. administer broad spectrum antibiotic within 1 hour
4. if hypotension/lactate >4mmol/L: 
1. deliver initial minimum of 20ml/kg of crystalloid or an equivalent
2. apply vasopressors for hypotension not responding to fluid resuscitation to MAP>65mmHg
5. if persistent hypotension/lactate >4mmol/L:
1. achieve CVP >8mmHg
2. achieve central venous O2 saturation (ScvO2) >70% or mixed venous oxygen saturation (SvO2) >65%

• rehydrate 2-3 hours
• push MAP to <70mmHg, wait for urine
• if no urine, try diuretics
• if no urine, go back to insensible losses 15-20ml/kg/day
• monitor Na and K

o   Murmur

§  Mitral valve disease without a history of congestive heart failure will usually tolerate fluids well, especially if they are dehydrated.

§  Monitor resp rate and effort closely.  

o   DCM

§  Generally not tolerant to fluids, but also intolerant of hypovolemia

§  Start at lower rates, monitor closely

§  If v/d, could be digoxin toxicity

§  Replacement fluids at first, but change to maintenance fluids!

§  Consider using inotropic agent to help CO (pimo, dobutamine)

o   Cats

§  Tend to tolerate fluids fine as long as they do not have a history of CHF

§  Not quite so tolerant as dogs with MVD

§  Overshoot

·         Stop diuretic if CHF has resolved, encourage drinking water/pass NG tube to give water

·         Severely azotemic: Isotonic crystalloids or maintenance fluid are ideal

·         Monitor breathing closely

§  If develops V/D (digoxin toxicity?)

·         Stop diuretic, if dehydration is mild and signs resolve quickly, this may be only intervention needed

·         If fluid therapy needed, start slow and titrate to the needs of the patient

·         Remember that dogs with mitral valve disease will tolerate fluids better than patients with DCM

• if fluids needed, start low (insensible loss rate)
• if on digoxin and having azotemia/GI signs-STOP!
• consider inotropic agents to improve CO to help CHF and hypotension (Pimobendan or Dobutamine)

1.      CV (ecg, arterial blood pressure, HR)

2.      Pulmonary (ventilation, oxygenation)

3.      Fluid, electrolytes

4.      Nutritional status (may not want to eat)

5.      Asepsis status

6.      Weight

7.      Other organ systems (GI, hematology, biochem)

8.      Central nervous system (mentation, behavior)

9.      Pain, comfort

10.  Trends or obvious changes

• pneumonia is usually CHF in cats
• any history of CHF 
• rarely needed for feline asthma
• pulmonary infiltrates-MUST rule out CHF
• exception: pyothorax-hi fluid requirement.

• CV support in sepsis
• correction of dehydration
• loosening/moistening of bronchial secretions
• support of concurrent diseases
• hypovolemic shock: crystalloid 20-30ml/kg bolus, correct dehydration over 24 hours
• mildly dehydrated/stable: isotonic crystalloids 60-90ml/kg/day 
• maintenance requirement higher in puppies 75-90ml/kg/day
• prone ot extravasation, don't over-hydrate

1. head trauma
2. choking
3. seizure
4. airway obstruction
5. chewing electrical cord

• very severe respiratory disress
• can require mechanical ventilation
• fluids can worsen 
• tend not to respond to diuretics 
• avoid fluids if at all possible
• dextrose supplementation may be required in puppies
• avoid diuretics unless patient has received lots of fluids

leaky capillaries-->extravasation

may improve with singe dose of furosemide (2mg/kg)

avoid fluids unless really needed, and stay conservative

1. conventional with isotonic crystalloids 20ml/kg and frequent reassessment, then switch to maintenance once stabilized. can worsen bleeding into lungs
2. low volume (hypertonic saline 2-4ml/kg 5-10 min, then crystalloid maintenance plan)(avoids dilution effect)
3. hemostatic (crystalloids 20ml/kg and fresh whole blood, PRBC, FFP)

CO=

oxygen transport=

oxygen content=

BP=

CO=SVx HR

oxygen transport=oxygen content x CO

oxygen content=([Hb x 1.34] x % saturation

saturation= 0.0031x PaO2 

BP=CO x SVR

cardiac US-end-diastolic diameter of ventricles

radiographs-postcava size

CVP

[image]

§  A wave

·         PR interval

·         Right atrial contraction

§  C wave

·         Tricuspid valve closing

§  V wave

·         TP interval

·         Right atrium during ventricular contraction

• vasodilated
• hypothermia
• didn’t give enough

MAP=?

o   MAP=DP +1/3(SP-DP)

[image]

arterial waveform

1. peak systolic pressure
2. diastolic pressure
3. dicrotic notch

(not pictured: anacrotic notch between 2 and 1)

for use in systemic arterial pressure:

·         Underdamping will result in excessive resonance in system and overestimates systolic pressure and underestimates diastolic pressure

·         Overdamping: line to long, air bubble, clot in line, kinked, etc. 

1. doppler
2. oscillometric

doesn't work well in small cats and dogs

poor correlation in hypotension

• low venous return
• hypovolemia
• pre-existing dehydration
• blood loss, plasma exudation
• positive pressure ventilation
• gastric distention
• iatrogenic inflow occlusion
• poor diastolic function
• HCM
• pericardial tamonade
• tachycardia
• fibrosis
• poor contractility/systolic function
• DCM
• negative inotropes
• ventricular arrhythmias
• AV valve insufficiency
• outflow tract obstruction

• HR and pulse quality
• mm color and CRT
• resp rate and effort
• mentation
• BP
• CVP
• lactate

byproduct of glycolysis from pyruvate

skeletal muscle, brain, RBC, renal medulla 

§  Type A

·         Decreased oxygen delivery or increased oxygen demand

§  Type B

·         Inadequate oxygen utilization

• decreased O2 delivery
• volume depletion
• fluid loss
• cardiogenic shock
• severe anemia
• severe hypoxemia
• carbon monoxide poisoning
• increased oxygen demand
• exercise
• seizures
• shivering

• inadequate oxygen utilization
• SIRS
• sepsis
• renal failure
• DM
• neoplasia
• total parenteral nutrition
• thiamine deficiency
• congenital errors of metabolism
• drugs/toxins
• D-lactic acidosis

1. inability to oxygenate blood
2. inability to eliminate CO₂

• respiratory rate and trends
• respiratory rhythms
• breathing effort
• mm
• auscultation
• radiographs
• blood gas

1. Bicarbonate ion-60% to 70%

2. Bound to proteins-20% to 30%

3. Dissolved in plasma-5% to 10%

capnography (measurement and waveform)

capnometry (ETCO₂ only)

• mainstream
• adapter
• no gas removed
• adds bulk
• electronics vulnerable to mechanical damage
• sidestream
• aspirate gas and transport to remote analyzer
• ability to analyze multiple gases
• potential for leak, disconnect

(A-B) exhalation of anatomic deadspace

(B-C) is present as sharp upstroke

(C-D) exhalation of alveolar gas

(D-E) beginning of inspiration

1. trach tube in esophagus
2. increase in inspired CO₂ (rise in baseline)-rebreathing, absorbent exhausted, faulty machinery
3. decreasing ETCO₂
1. gradual-hyperventilation, decrease in metabolic rate, decrease in body temp 
2. rapid-embolism, sudden hypotension, circulatory arrest
4. inadequate seal
5. loss of plateau-obstruction (asthma, COPD, bronchospasm), kinked tube
6. normal
7. curare cleft- inspiring during exhalation phase of mechanical ventilation, muscle relaxant levels subsitding, increasing pain
8. increasing ETCO₂-hypoventilation, increase metabolic rate, increase body temp, release of tourniquet, absorption of CO₂ from peritoneal insufflation, sudden increase in blood pressure

increase in pH

decrease in DPG

decrease in temperature

•    Methemoglobin met Hb
• Carboxyhemoglobin COHb
• severe vasodilation
• dyes
• icterus
• peripheral vasoconstriction
• low pulse pressure
• anemia
• motion
• external light sources

XII. 

problem for old cascade model because it is sequential

scoring system (≥5=DIC) based on: 

• low platelet count
• strong increase in fibrin degradation product or D-dimers
• prolonged prothrombin time
• low fibrinogen concentration

• treat underlying cause
• transfusions if bleeding or invasive procedures
• heparin therapy (?)
• aim for early recognition and rapid, aggressive therapy

outside the blood

if a vessel is damaged, coagulation is initiated

interacts with VIIa to stimulate common pathway

thrombin (IIa)

formed from prothrombin (II) upon activation of X and V

• Initiation
• TF and VIIa separated by vascular endothelium
• bind upon vascular damage
• complex with Ca (donates positive charge)
• activates more VII, also IX, X on TF-bearing cell
• X activates V (prothrombinase complex)
• this cleaves II to thrombin
• Amplification
• thrombin leaves TF-bearing cell, binds to platelet
• platelet releases granules and changes shape
• XI, V, XIII activated, vWF free to facilitate platelet adhesion
• positive feedback mech for thrombin
• propagation
• granules recruit more platelets, provide phospholipid surface for more coag. 
• XI activates IX, IX binds with VIII to form Xase
• X binds with V to form more thrombinase
• thrombin activates fibrinogen into monomers, stabilizes.

• tissue plasminogen activator released by damaged endothelium 
• activates plasminogen (free floating from liver, then incorporated into a clot) a few days after clot formation. 
• plasmin causes release of t-PA and u-PA, which are inhibited by PAI-1 and 2
• TAFI (thromain-activatable fibrinolysis inhibitor) inhibits plasmin-mediated fibrin breakdown to prevent immediate breakdown

• TFPI-inhibits tissue factor pathway/initiation by inhibiting X, IX, and TF-VII
• thrombomodulin-activates protein C when binding to thrombin, which activates TAFI (procoag)
• protein C-inactivates V and VIII. vitamin K dependent. enhanced by protein S. inhibits PAI-1--> enhances t-PA and u-PA-->fibrinolysis
• APC (activated protein C)- also anti-inflammatory, especially during sepsis
• Antithrombin-inhibits X and thrombin, IX, and TF-VII, enhanced by heparin-like GAGs

II, VII, IX, X

protein protein C

• thrombin generation with depression of inhibitory mechanisms such as antithrombin and protein C. impaired fibrin degradation due to hi PAI-1
• septic patients seem to have reduced circulating antithrombin and protein C

1. platelet count
2. platelet function testing (aggregometry)
3. BMBT-cannot distinguish thrombocytopathy from endothelial dysfunction
4. vWF analysis
1. I-reduced conc in circulation (most common)
2. II-abnormal dysfunction
3. III- absolute lack

• petechiae, ecchymoses due to thrombocytopenia
• mucosal bleeding 

PT-VII, X, V, prothrombin/thrombin, fibrinogen/fibrin

PTT-XII, XI, IX, VIII, X, V, prothrombin/thrombin, fibrinogen/fibrin

ACT-

early vit K antagonist intoxication or early liver failure

(since factor VII is the only PT-specific factor and does not cause phenotypic coagulopathies)

• check VIII (hemophilia A)
• check IX (hemophilia B)
• check XII (Hageman factor deficiency)
• check wVF 

global assessment of hemostasis, including platelets in characterization of clot strength

thromboelastography

1. R: time from start of test to inital clot formation
2. K: time from initial clot formation until 20mm
3. MA: maximum amplitude
4. α: angle of center line and tangent
5. LY30: rate of amplitude reduction 30 min after MA

on a TEG, what do the following suggest?

• shortened R or k, or increased alpha or MA
• increased alpha, MA, prolonged R, or k
• increased LY30

hypercoagulability

hypocoagulability

hyperfibrinolysis

• hypercoagulatibilty
• vascular endothelial dysfunction
• blood stasis/turbulence

cancer

inflammation-->endothelial dysfunction

malaise-->immobility (stasis)

neoplasia

IMHA

PLE, PLN

liver disease

SIRS

iatrogenic (catheters, corticosteroids)

systemic inflammatory response syndrome

§  Risk factor for thrombosis

§  Sepsis

§  Pancreatitis (not infection, but inflammation)

§  Hi temp, hi HR, leukocytosis, etc.

§  Proinflam mediators, endothelial injury, tissue factor expression, thrombin production. increase coag and inflammation.

§  Increased PAI-1, increased TAFIα, reduced protein C. decreased fibrinolysis

1. pulmonary thromboembolism (silent killer)
2. large vein thrombosis (ascites, CV collapse) portal, splenic, caval
3. arterial thromboembolism (cats with HCM-hindlimb paralysis with aortic trifucation thrombus)

• prevent furhter clot accumulation with anticoags and antiplatelet drugs
• enhance fibrinolysis
• surgical thrombectomy

surgery

trauma

immobility

cancer

increasing age

acute medical illness

obesity

IMHA, Cushing's, sepsis, parvo

• anticoagulants-target secondary hemostasis, prevent thrombin/fibrin formation
• unfractioned heparin-potentiate antithrombin
• low MW heparins-inhibit factor X
• warfarin-vit K antagonism, prevents prothrombin, VII, IX, X, proteins C and S
• antiplatelet drugs (aspirin, ADP-receptor antagonist, GP IIb, IIIa receptor antagonists)
• mechanical-early and frequent ambulation, passive range of motion, massage

name the muscles of inspiration

• diaphragm
• external intercostals (ribs pulled cranioventrally)
• scalene, sternomastoids, alae nasi

• should be needed during normal tidal breathing!
• elasticity of lung and chest wall should naturally recoil
• when needed: abdominal wall 

·         Butorphanol is 1^st choice

o   Rapid onset

o   Multiple routes of admin

o   Minimal cardiac or resp effects

o   Reversible

·         Laryngeal paralysis

·         Tracheal collapse

·         Foreign bodies

·         Polyps

·         Brachycephalic airway syndrome

·         Feline bronchial disease (asthma)

·         Chronic bronchitis

·         Primary cardiac disease

o   Very young and very old

o   Small breed dogs

o   Maine coon cats

o   Presence of murmur or arrhythmia (more obvious in dogs)

o   History of coughing (dogs)

o   Give furosemide

·         Non-cardiac disease       

o   Any age or breed

o   History of vomiting or recent anesthesia

o   Coughing (cats or dogs)

o   Severe, concurrent disease

o   Give bronchodilators

• alveolar (air bronchograms)
• bronchial (circles and lines)
• interstitial (cottony, indistinct)

• expiratory dyspnea, wheezes, open-mouth breathing, cyanosis.
• oxygen rich environment, terbutaline, aminophylline, or theophylline, or albuterol
• if those do not work, corticosteroids can be administered

• pleural effusion
• d/t: hemothorax, pyothorax, chylothorax, neoplastic effusions, FIP, heart disease, lung lobe torsion, diaphragmatic hernia
• pneumothorax
• diaphragmatic hernia
• listen for borborygmi heard over lung fields, take rads if possible

• nothing. if stabilized and sedated, cage-rest and the blood components should be resorbed
• if not stable, can drain partially
• Check clotting profile since rodenticide toxicity is a common cause

1. decreased effective circulation volume
2. ineffective heart pumping
3. loss of vasomotor tone

1. hypovolemic
1. large amount of IV fluid loss due to hemorrhage or protracted v/d
2. cardiogenic
1. systolic failure-dec. contractility
2. diastolic failure-alterted filling
3. bradyarrhythmia-dec. rate
3. distributive
1. loss of vasomotor tone
2. maldistribution of blood volume (sepsis, anaphylaxis)
4. obstructive
1. impedance of major vessels
2. decreased blood flow (pericardial effusion, GDV)

mentation

mm

CRT

heart rate

pulse quality

temperature

urine production

lactate

BP (tho may seem normal d/t increased SVR)

1. compensatory
2. early decompensatory
3. late decompensatory

1. increased sympathetic tone (positive inotropy, chronotropy, vasocontriction, RAAS activation)
2. RAAS activation
3. ADH release

• Renin release

• B1 receptor

• Baroreceptors

• from juxtaglomerlular cells, triggered by prostaglandins from Macula Densa

• trigger Angiotensinogen-->ANGI in liver

• ANG I

• ANG I --> ANG II by ACE in lungs

• ANG II

• Vasoconstriction

• Water and salt retention

• Norepinephrine release

• ADH release stimulated by:

• Hypovolemia

• Osmolality

• ANG II

• Effects

• Water retention (V2 receptor)

• Vasoconstriction (V1 receptor)

1. anaerobic metabolism
2. redistribution of blood flow
3. oxygen consumption becomes delivery dependent

1. metabolic needs can no longer be met
2. autoregulatory escape
3. cell death
4. organ dysfunction
5. reversal is much for difficult to impossible

·         Bradycardia

·         Hypotension

·         Hypothermia

inotropic support

vasodilation

NO fluids

calculate them, but only administer 1/4 volume as isotonic crystalloid and immediately reassess

colloids:  5-15 (dog) or 2-5 (cat) ml/kg increments

go slooooowly in cats

20ml/kg total dose

4-7 ml/kg dogs

2-4 ml/kg cats

• α-1 responsiveness is decreased
• can contribute to bradycardia, which won't be responsive to atropine
• cats especially at risk

• septic shock: sepsis with hypotension in the face of adequate volume replacement 
• sepsis: systemic inflammatory response to infection

multiple organ dysfunction syndrome:

dysfunction of >2 organ systems secondary to SIRS

1. infection
2. SIRS
3. sepsis
4. severe sepsis
5. septic shock
6. MODS

2/4 required for SIRS diagnosis

• HR              >120
• resp rate     >20
• Temp          <100 OR >102.6
• WBC           <6000 OR >16,000

3/4 required for SIRS diagnosis

• HR              <140 OR >225
• resp rate     >40
• Temp          <100 OR >104
• WBC           <5000 OR >19,000

• bacterial LPS binds to macrophages
• CD-14 helps bind to TLR's and other adhesion molecules
• leads to production of inflammatory mediators (TNF-α, IL-1, 6, etc). 
• overwhelming production of these mediators leads to sepsis and inflammation overwhelms anti-inflammatory processes. 
• leads to coag, CV instability, vasc permeability, vasodilation, and MODS

• signs of systemic inflammation
• Hx, PE
• blood gas, CBC, chem
• UA with sediment and culture
• imaging
• cytology/biopsy
• culture!

• CBC
• leukocytes with left shift
• anemia
• thrombocytopenia
• Chem
• changes reflect underlying cause
• hyperbilirubinemia
• hyperglycemia-->hypoglycemia
• hypoalbuminemia

·         GI tract leakage in 30-70% of these cases

o   Neoplasia

o   Foreign bodies

o   Post operative leak

o   NSAID induced ulcers

o   Translocation

§  Urinary

§  Respiratory (aspiration)

§  Wounds

§  Catheters

§  Hospital vs community acquired

§  Cytology

·         Intracellular bacteria

§  Glucose

·         >20mg/dl lower in effusion vs blood (used up nutrition for bacteria)

§  Lactate

·         2mmol/l higher in effusion vs blood (waste product)