5 simple ways to support your emergency patients
Our medical patients can present to us for routine appointments due to illness, but we’ll see many patients as emergencies, too.
Diseases like diabetic ketoacidosis, acute kidney injury, toxin ingestions, asthma, pneumonia, pleural space disease, and even severe vomiting and diarrhoea will often present as an emergency (usually on a Friday night, or a weekend!)
When these patients arrive, it’s usually down to us nurses to perform an initial assessment, determine how stable the patient is, and discuss our findings with the veterinary surgeon (potentially pulling them out of their consultation if we think the patient is too unstable to wait).
In this post, I’m going to share 5 ways to support your medical emergency patients. By the end of it you should feel more confident triaging and nursing those emergencies!
If you want to know more about how to support medical emergencies and complex medical patients, don’t forget to join me on November 14th for a free medical nursing workshop! Save your spot below, and DM me on Instagram and let me know if you’re coming along!
Preparation is key when nursing medical emergencies
Get as much information about the case as you can at the time the appointment is booked. If your reception team deals with emergency bookings or takes the call, make sure there is a practice protocol in place where the clinical team knows the main presenting signs, and an ETA (think 24 hours in A&E, “trauma, red phone” style but a lot less scary…)
What to get ready
Once you’ve got your ETA, get everything you think you’ll need for your patient. Depending on the case, this should include:
An oxygen source
Monitoring equipment (a stethoscope, watch or clock, thermometer, blood pressure monitor and pulse oximeter +/- an ECG if one is available)
Equipment for intravenous access
Equipment for minimum database blood sampling (glucometer, lactate metre if one is available or venous blood gas if available in your practice, PCV and total solids, blood smear, plus tubes for full biochemistry and haematology testing)
Ultrasound if available, for point-of-care scanning
Equipment for intravenous fluid therapy administration, in case this is required
Potentially the crash trolley or box, depending on the individual case
This equipment should be prepared in a central area of the hospital, where the patient can quickly be taken and assessed, and where equipment and consumables are within easy reach. Depending on the size of your practice, this may be a separate triage area or ER, or your prep room.
A triage form is a really useful tool to have on-hand in your emergency area or prep room. This can be used to record all of your assessment findings, and given to the vet who can add instructions for emergency medications they’d like you to administer, or tests they’d like you to perform. Once you’ve finished triaging your patient, that information can be transferred to the patient’s hospital sheet, or scanned onto their record.
Let’s talk triage
When your patient arrives, it’s time to perform your triage assessment. This should begin with a major body systems assessment, before moving on to a more generalised assessment.
Our major body systems are those that, if affected, pose a threat to that patient’s life - the cardiovascular, respiratory and neurological systems. Some sources describe the renal system as a major body system, too.
When these systems have been assessed, any dysfunction found must be immediately stabilised before moving onto a full-body assessment. This generalised assessment or ‘secondary survey’ also includes collection of minimum database samples and point-of-care ultrasound scanning where available.
When performing a triage assessment, always make sure you get consent from your client. This is vital as any emergency stabilisation, intravenous access, or sampling will need to be performed before the veterinary surgeon has a consultation with the client or asks them to sign a consent form.
I like to say something along the lines of “I’m just going to take Fluffy to our treatment area to perform a triage exam, and make sure there’s nothing we need to do right now. Once this is completed the veterinary surgeon will come and speak to you. We sometimes need to take a small blood sample or place an intravenous line as part of this assessment. Do I have your permission to do that if needed?”
This way, you can go ahead and perform your full triage assessment, ensuring there are no delays in stabilising your patient.
Triaging the cardiovascular system
The first major body system we’ll look at is the cardiovascular system. This includes anything affecting the patient’s heart rate or rhythm, arterial blood pressure, pulse or delivery of blood and oxygen to the tissues.
It will be affected by anything that reduces intravascular volume (causing hypovolaemic shock), reduces return of blood to the heart (causing distributive shock), and anything that affects how well the heart can actually pump blood (cardiogenic shock), as well as other things like anaphylaxis and sepsis.
We commonly see these changes in medical patients - secondary to things like severe gastrointestinal fluid losses, anaemia, haemorrhage, cardiac disease, systemic inflammation or infection to name just a few.
To evaluate the patient’s cardiovascular status, we firstly need to assess their:
Heart rate
We may see tachycardia initially as the body tries to compensate for the reduced blood volume, by pumping it around the body faster. As this progresses, the body loses this compensatory mechanism and bradycardia results.
Heart rhythm
Arrhythmias may impair contractility and the delivery of blood around the body.
Pulse rate
This should match the heart rate; if there are discrepancies these are known as pulse deficits. We often see these in patients with arrhythmias.
Pulse quality
Palpate a peripheral pulse such as the dorsal pedal pulse. Can you palpate a pulse wave there? Does the pulse feel normal? Are the pulses weak, bounding or thready? If you can’t palpate a peripheral pulse, go for a larger, more central artery such as the femoral. How do the pulses compare there?
Mucous membranes
Are these pink, pale pink, or pale? If they are paler, this could indicate reduced numbers of red blood cells, or a reduction in the amount of blood actually getting to the gums.
Is there evidence of jaundice indicating haemolysis or liver dysfunction? Do the mucous membranes feel moist, tacky or dry? If they are tacky or dry, this indicates dehydration (not hypovolaemia!)
Capillary refill time
This may not be possible to assess in pale patients. Is the refill time 2 seconds or less? Delays indicate reduced perfusion of the peripheral tissues.
Arterial blood pressure
Hypotension is common in patients with cardiovascular compromise - either because the patient has a lower stroke volume (the amount of blood pumped out of the heart per beat) or because they have a lower systemic vascular resistance (the blood vessels have dilated, meaning the blood flows through them at a lower pressure).
What next?
Once you’ve assessed these parameters, it’s time to think about stabilisation. If you have evidence of hypovolaemia, we treat this by giving a fluid bolus under the vet’s direction. We usually give volumes of around 5-20ml/kg over a 5-20 minute period, depending on the individual patient.
If the patient is not fluid depleted (aka can’t be managed with boluses, as they would cause volume overload), we generally treat with medications that increase cardiac contractility (these are known as positive inotropes, like dobutamine), or improve vascular tone (these are known as vasopressors, like noradrenaline).
Dealing with the respiratory system
The respiratory system is often a real pain to manage when it goes wrong - because these patients are usually on a knife edge, balancing reduced oxygen availability with an increased demand for oxygen (due to things like stress and illness).
The good news is that a lot of our respiratory assessment can take place from a distance to minimise this stress. We firstly want to assess:
Respiratory rate, pattern and effort
What is their respiratory rate in breaths/minute? Is their breathing short, rapid and shallow, or slower and deeper? Is their effort increased, and if so is this during inspiration, expiration or both?
Position
Look at the patient generally. How do they seem? Are they able to sit or lie down? Are they remaining in sternal recumbency or moving around? Are they extending their neck or appearing ‘hungry’ for air?
We will often see orthopnoea in these patients - they will adapt their body position to try and make breathing easier. They may stand or remain in sternal recumbency. Their elbows are often abducted away from their chest to allow expansion. When looking at their neck, you’ll often see this is extended, which straightens their trachea.
Auscultation
If you can (if your patient will tolerate it without becoming too stressed), listen to the trachea and the chest. We want to listen to all lung fields on both sides of the chest, for a couple of breaths. Make a note of any abnormal sounds (like wheezes, crackles or clicks), where you hear these, and when (inspiration or expiration).
Oxygen saturation
If you’re able to measure this without the patient becoming distressed, try and assess their oxygen saturation. It should be above 95% on room air (21% O2); any hypoxia should be stabilised by providing oxygen (either by flow-by, prongs/catheters or an oxygen kennel, depending on the individual patient).
You’ve assessed your patient’s breathing. What next?
Respiratory emergencies really benefit from a hands-off, less is more approach. We often find that a little sedation (with something like butorphanol, for example) and some time in oxygen can really help these patients.
We do not want to rush them to x-ray - the stress of this can very easily tip these patients over the edge! A thoracic point-of-care ultrasound (POCUS) is a great option in respiratory patients and can easily be performed by veterinary nurses.
This allows us to look for free fluid or air in the chest, and look at the lungs themselves for evidence of pneumonia or consolidation.
We can then plan our next steps - for example, thoracocentesis if a patient has pleural space disease.
Assessing and managing the neurological system
I’ll let you in on a secret - when I worked in general practice, I hated managing neurological patients. We never saw them, because they were pretty much the only patients that we referred elsewhere. But the reality is the neurological system doesn’t have to be scary.
We also see lots of neurological abnormalities in our medical patients - they don’t just have to have a brain tumour or be a spinal patient to need a neurological assessment!
When assessing your patient’s neurological function, you want to ask yourself 3 questions:
Can they walk?
Are they ambulatory? If so, is their movement normal, or are they:
Ataxic (wobbly)
Paretic (weak)
Paralytic (paralysed - not drunk, that’s ataxic!!)
Circling
If there are any abnormalities with their movement, is this on all 4 limbs, only the pelvic or thoracic limbs (paraparesis), or only the left or right side (hemiparesis)
What’s their mentation like?
Are they able to interact with their surroundings and stimuli in a normal way? Are they alert? Are they less reactive to normal stimuli (dull or obtunded)? Are they only reactive to painful stimuli (stuporous)? Or are they unconscious and not reactive even to painful stimuli (comatose)?
We often see changes to mentation in our patients - due to things like hypovolaemia and shock, toxin ingestion, electrolyte disturbances and infectious diseases.
Is there seizure activity?
Is the patient seizuring or at risk of seizures? If so, are those seizures generalised (whole body) or focal (showing signs such as facial twitching only)?
Managing neurological abnormalities
Once you’ve performed your neurological assessment, it’s time to think about nursing care. This will vary depending on the underlying reason for the neurological abnormalities, and includes:
Correcting fluid, acid-base and electrolyte abnormalities
Making a seizure plan with the clinician, and ensuring this is available on the patient’s kennel, along with anticonvulsants, syringes and flush
If the patient has increased intracranial pressure (e.g. due to cerebral haemorrhage or oedema, or a cerebral mass), the administration of mannitol or hypertonic saline under veterinary direction
Managing and assessing renal emergencies
We see a lot of renal abnormalities as emergencies - either due to toxin ingestion (think lilies and ethylene glycol), urethral or ureteral obstructions, or even rupture of the urethra, ureter or urinary bladder. We may also see our more chronic renal patients as emergencies, for example during end-stage renal failure.
These patients require an overall assessment of their cardiovascular, respiratory and neurological systems. There is usually evidence of cardiovascular compromise (shock; dehydration). Patients with severe acute kidney injury may be anuric, and unable to tolerate intravenous fluids without getting volume overload - this is something we need to bear in mind when stabilising these patients.
Patients with acute kidney injury are also often hyperkalaemic, which has significant effects on the heart. Potassium directly affects the heart muscle, causing arrhythmias. When you place an ECG on a hyperkalaemic patient, you’ll see progressive signs including:
Spiked or ‘tented’ T waves
Bradycardia
Missing P waves
Wide and bizarre QRS complexes
These wide, bizarre QRS complexes progress into ‘sine waves’, which look like exaggerated wavy lines. If this progresses, asystole results.
Hyperkalaemia can be treated in an emergency with intravenous fluid therapy, glucose, or a combination of glucose and neutral insulin. The glucose and insulin drive the potassium into the cells, reducing levels in the bloodstream.
Calcium gluconate can also be given in an emergency to protect the heart from the dangerous effects of the potassium.
Depending on the patient’s presenting signs and the cause of their renal emergency, our goals of stabilisation are:
To keep the patient comfortable (urinary obstructions and traumatic bladder ruptures are very painful!)
To restore the circulating volume
To correct acid-base and electrolyte abnormalities
Before further diagnostics or procedures (such as urethral catheterisation) are performed.
Other considerations in the medical emergency patient
Other considerations in our emergency patients include pain, securing intravenous access and minimum database testing, alongside the generalised (whole-body) assessment.
Pain should be assessed in all patients after completing the major body systems assessment, and analgesia given under veterinary direction at the earliest opportunity possible.
IV access should be secured as soon as possible. The exception to this is in many respiratory distress patients, who will not tolerate restraint for IV catheter placement. These patients are already struggling to meet their oxygen demands, so stress and restraint should be minimised. It may be more appropriate to administer intramuscular anxiolytics and wait for these to take effect before catheterisation is attempted.
During catheterisation, I like to collect samples from the IV for emergency minimum database testing. These tests help guide treatment and stabilisation decisions, and help plan further diagnostics once the patient is stable. Tests to run as part of a minimum database often include:
Venous blood gas
Blood glucose
Lactate
Renal values (BUN and creatinine)
Packed cell volume
Total solids
The preparation of a blood smear (which can be examined during or after initial stabilisation, to avoid delaying this)
Once the initial assessment and stabilisation is complete, it’s time to look at the rest of our patient. You can use the mnemonic ACRASHPLAN to ensure you’ve covered every body system:
A = Airway
C = Cardiovascular
R = Respiratory
A = Abdomen
S = Spine (and tail)
H = Head
P = Pelvis
L = Limbs
A = Arteries (and veins)
N = Nerves
Once this is complete, you’ve got a good idea of how quickly your patient needs further treatment and diagnostics, and stabilised the most life-threatening injuries.
As you can see, there is a lot to think about in our medical emergency patients - but by making sure you’re prepared in advance, looking at the major body systems first, and including point-of-care diagnostics and minimum database testing, you’ll take a lot of the stress out of their care!
Want to know more about supporting emergency medical patients? Make sure you join me for the medical nursing workshop on November 14th! Save your spot here, and let me know when you’re in! I can’t wait to see you there.
References
McBride, D. 2017. Triage and assessment of the emergency patient. [Online]. VIN. Available from: https://www.vin.com/apputil/content/defaultadv1.aspx?pId=20539&catId=113426&id=8506304
Poli, G. 2021. Triage, pt 1: secondary survey. [Online]. Vet Times. Available from: https://www.vettimes.co.uk/triage-pt-1-primary-survey/
Poli, G. 2021. Triage, pt 2: secondary survey. [Online]. Vet Times. Available from: https://www.vettimes.co.uk/triage-pt-2-secondary-survey/
Rogers, E. A. Undated. Triage and initial assessment [Online] Penn Veterinary School. Available from: https://www.vet.upenn.edu/docs/default-source/penn-annual-conference/pac2016-proceedings/vet-tech-track/triage-initial-assessment--elisa-rogers.pdf?sfvrsn=e65f19ba_3
