Calmly handling emergency patients

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Adesola Odunayo, DVM, MS, DACVECC, a professor of emergency and critical care at the University of Florida’s College of Veterinary Medicine, kicked off the third and final day of the 2024 Fetch dvm360 Conference in Atlantic City, New Jersey, with her keynote session, “From Chaos to Calm: Mastering Emergency Medicine Excellence.”¹ Over the course of the presentation, Odunayo provided a comprehensive overview of her 7 keys to dealing with emergency scenarios in a calm manner, with skill and confidence. Her key points are applicable to patients being managed in practice or stabilized for transfer to a referral hospital.

“Emergency cases and chaos go hand in hand,” Odunayo said as she began her lecture. “[Emergency room cases] are not very different from what you’re going to see in general practice. I cannot say that there aren’t days where I feel stressed out, they definitely happen, but… the goal today will be to make things a little bit less chaotic for you in your practice.”

Vascular access

The first point that Odunayo focused on was the significance of establishing vascular access early on in an emergency. “When emergency cases come in, I see vascular access as the lifeline of the patient,” Odunayo said. “We want to try to get an [intravenous] catheter in the patient as quickly as possible so that we can administer fluids, medication, pain medication, anti-seizure medication.”

Odunayo explained canines and felines that present in severe respiratory distress are the ones that need vascular access. The same is true for patients who have a history of seizures or tremors, and those that are critically ill. To get venous access in a patient, it is critical to minimize stress, especially for cats in respiratory distress, as Odunayo pointed out. She shared that she sometimes utilizes an oxygen cage and would consider intramuscular sedation, as well as analgesic drugs for patients in severe pain.

Peripheral access should be prioritized, when possible, with the only exception being pediatric patients. She recommended use of the cephalic and lateral saphenous veins, while consciously trying to avoid placing a central vessel reclusively. When cats present in shock, she said she prioritizes placing the catheter in a medial saphenous vein.

Fluid therapy

Fluids are the most utilized drugs in veterinary medicine. It’s crucial to have an intentional fluid prescription plan, because it can be easy to forget that fluids are drugs. Odunayo referenced the common “prescriptions” of 2x, 3x, or 4x maintenance, saying that these are not true prescriptions, but arbitrary volumes that hold no real significance. The drawback to this method of fluid treatments is the strong likelihood that the patient is receiving too much or too little fluids.

Instances where fluid therapy should be implemented are in cases of hypovolemia, poor perfusion, and shock, in conditions including:

• Tachycardia/bradycardia
• Weak distal pulses
• Prolonged capillary refill time
• Pale mucous membranes
• Cold extremities
• Hypotension
• Hypothermia (especially common in cats)

Dehydration should be treated intentionally with a prescription fluid plan. For more information on fluid therapy, Odunayo references the 2024 AAHA Fluid Therapy Guidelines for Dogs and Cats.²

Rapid airway control

Respiratory distress is a common presentation in both general practice and the emergency room. There are well established methods for managing these cases that can be very effective, including sedation, oxygen supplementation, thoracocentesis, bronchodilators, and diuretics. There will be cases in which patients do not respond to these methods of supportive care, in which case Odunayo advised turning to airway control, and intubating the patient. She admitted that there are cases where this is the first thing she does, when the patient presents in exceptionally poor shape. As a result of the control over the patient’s airway achieved through intubation, the emergency room tends to calm down, and diagnostics become easier to attain.

“I would say this is probably the most common indication to intubate a patient,” she said. “Just looking at that animal and saying, ‘you are going to die or stop breathing if I don’t do something.’”

She also pointed to use of the pulse oximeter. Although, she implied that the pulse oximeter can be somewhat unreliable, based on the consistency of the plethysmograph, she reiterated the importance of rapid intubation, with intravenous access, a fast-acting induction drug, and positive pressure ventilation. Dogs and cats who are intubated because of an upper-airway obstruction are the exceptions, not requiring positive pressure ventilation, she noted.

Inserting needles into body cavities

This point can be lifesaving for patients. Odunayo estimated that 80% of cats that present with respiratory distress have chests full of fluid, or pleural effusion. She shared that she is able to effectively treat the majority of cats once she can identify the pleural effusion. She advised attendees not to be afraid of using needles, especially into sensitive organs like the heart, and offered her own personal technique.

“I always palpate 2 ribs,” she said. “I personally like to go right in between 2 ribs… you want to be running perpendicular to the ribs. Once you get into the pleural space… it’s helpful to redirect the needle so that it’s now parallel to the ribs. [This way], once you’ve evacuated the chest and the lungs start to expand, you’re less likely to hit the lungs.”

Analgesia, always

Odunayo explains that there is never a good reason to withhold analgesia. She said that the reason she feels so strongly about analgesia in the ICU, is directly correlated to mortality, because pain releases a lot of catecholamines, which have a negative impact on healing. Opioid can be used, which provide excellent analgesia, have a minimal effect on the cardiovascular system, are reversible, and offer a simple method for multimodal analgesia. Although, opioid usage can result in ileus, urinary retention, respiratory depression, and vomiting. Additionally, she recommends the use of the Feline Grimace Scale, which is available in the form of a smartphone app.

Point of care ultrasounds

Odunayo expressed that point of care ultrasounds have changed the landscape of emergency and critical care medicine. These ultrasounds are quick, efficient, and wildly available, saving clients time and money. There are numerous applications for point of care ultrasounds in practice, including pleural and pericardial effusion, pulmonary infiltrates, pneumothorax, pulmonary hypertension, and left atrial enlargement, among others.

An open mind

The final point that Odunayo included in her presentation involves the importance of keeping an open mind and considering all possibilities. It’s crucial to avoid tunnel vision and to remain open to all differentials. Before arriving at any conclusions, it should be established whether or not the history and presenting complaint fit with the diagnostic findings. Additionally, clients should have the opportunity to decline diagnostic tests.

“You never want to make assumptions,” Odunayo said. “You always want to do the diagnostics and make sure you’re on the right track.”

References

1. Odunayo A. From Chaos to Calm: Mastering Emergency Medicine Excellence. Presented at: Fetch dvm360 Conference; October 14-16, 2024; Atlantic City, NJ.
2. 2024 AAHA Fluid Therapy Guidelines for Dogs and Cats. American Animal Hospital Association. Accessed October 16, 2024. https://www.aaha.org/resources/2024-aaha-fluid-therapy-guidelines-for-dogs-and-cats/