Managing emergencies in general practice

With the current workforce shortages, general practices are seeing more emergent cases and often have fewer options for transfer. While general practices are not stocked with the wide range of medications and diagnostics that emergency and specialty hospitals have, there are still many basic stabilization measures that can be taken in a general practice setting.

Just as veterinarians develop a systematic approach to the physical examination to ensure nothing is missed, we can develop a similar systematic approach to managing emergency presentations. Improving comfort with initial assessment and treatment of emergency cases can help to improve patient outcomes.

Triage

All team members should feel comfortable with patient triage. First, assess the ABCs:

• Airway – Is there an open airway?
• Breathing – What is the respiratory rate, effort, and pattern?
• Circulation – What is the heart rate and rhythm, pulse quality, capillary refill time, and blood pressure?

Any abnormalities in these systems should prompt action to initiate stabilization measures. Patients with concerning vital signs or who present in distress should be brought to the immediate attention of a veterinarian. Staff members should be familiar with normal vital signs and know that critical cats tend to be bradycardic and hypothermic. When in doubt, staff members should alert a doctor as it is better to overreact to a stable patient than underreact to an unstable patient.

Additional key areas to evaluate include neurologic status, palpation of the urinary bladder (especially in ADR cats), body temperature, and pain levels. A PCV, TS, blood glucose, and azo stick (if available) can provide helpful information from a small amount of blood. A full examination should be performed following stabilization of essential systems.

Initial stabilization

Veterinarians can work with the team to direct stabilization of the patient while a nurse or assistant obtains a full patient history. Initial stabilization efforts will depend on which systems are affected and may include oxygen therapy, intravenous fluid boluses, sedation, warming or cooling measures, administration of anticonvulsants, dextrose administration, control of active hemorrhage, and pain control.

If a patient presents with an occluded airway—which is uncommon in veterinary patients—establishing an open airway should be top priority. The external extraction technique (XXT), which is used to dislodge a ball or round object from the throat of an unconscious dog with a fully occluded airway, is helpful.

For patients presenting in respiratory distress, oxygen and sedation are typically the first-line stabilization measures. Handling and stress should be minimized for these patients. Many medications can be given IM until intravenous access can be obtained. Do not rush these patients into radiology to obtain a diagnosis. No patient should die in radiology!

Instead, look and listen to how the patient is breathing to direct therapy. For example, with a dog presenting with a heart murmur and crackles, the top differential would be heart failure and furosemide should be administered. For patients presenting with decreased or dull breath sounds and/or a paradoxical breathing pattern, pleural space disease should be suspected and thoracocentesis performed. Although this procedure can be intimidating, it is more likely that a patient will die from untreated pleural space disease than a negative thoracocentesis.

Cardiovascular stabilization begins with gaining intravenous access and providing fluid support. Fluid boluses should be given in small aliquots of isotonic crystalloids. Administration of smaller boluses followed by reassessment is now recommended. Generally, 10-20 mL/kg in cats and 20-30 mL/kg in dogs is a good starting place. It is important to have a resuscitation endpoint, which is a target heart rate, blood pressure, pulse quality and/or mentation. After the initial bolus, reassess parameters and repeat boluses until you reach the target endpoint. In trauma cases, where there is potential for internal hemorrhage, consider hypotensive resuscitation, which is a target systolic blood pressure of 90 mmHg.

Pain control is often needed but should be withheld until full neurologic assessment can be performed. NSAIDs should be avoided in patients with trauma and cardiovascular compromise because of potential for poor perfusion to the kidneys and GI tract. In an emergency clinic with a wide range of available medications, short-acting, full-mu opioids are preferred as they provide excellent pain control, doses can be titrated easily, and they can be withdrawn quickly to allow for reassessment of neurologic status as needed. Medications like injectable fentanyl are not often carried in general practice, so a full- or partial-mu agonist opioid can be administered. When in doubt about which medication to use, consult with your local emergency clinic prior to transfer.

If you are not able to stabilize a patient with the available equipment and medications in your clinic and the client wants continued care, refer the client when the pet is as stable as possible. Emergency veterinarians are often willing to get on the phone and help walk their general practice partners through stabilization measures for these patients to maximize the change of the patient arriving at their clinic alive.

Client communication

In an emergency, it is essential to gain a client’s trust quickly so that the team—which includes the veterinarian, nursing staff, and client—can make the best possible decisions for the pet. General practitioners often have an advantage with their existing clientele as they have an established relationship prior to an emergency presentation. Veterinary professionals should be clear and honest with the client about the patient status and what the team is doing to stabilize them early in the conversation. CPR orders should be obtained for all patients to allow quick action in the event the patient arrests.

Clients should be advised of recommended diagnostics and treatment as well as if transfer to an emergency of specialty hospital may be recommended. Planting the idea of transfer in the client’s mind early in the process can help to guide their decision-making. Be clear about the financial investment each step of the way, but always talk care first, money second.

Throughout the patient work-up, keep the client updated on the findings and on the prognosis. Some owners need to hear a poor prognosis multiple times or from multiple people before comprehending the reality of the situation, especially in an emergency.

Diagnostics and initial treatment

Once the patient is stable, consider performing some initial diagnostics and treatment prior to transfer. This can help to reduce costs to clients, may provide information that ultimately changes the recommendations for transfer, and clarify prognosis. Initial diagnostics may include bloodwork, radiographs, urinalysis, and collection of effusion samples for further testing. If your clinic does not have in-house laboratory equipment and you are sending the patient to another hospital for continued care, you can consider sending any blood drawn prior to administration of fluids or other medications with the client.

Consider initial treatment when possible, such as fluid therapy for dehydrated or hypovolemic pets and unblocking cats with urinary obstruction. By doing more in the primary care facility, you are helping improve the pet’s stability and comfort, reducing the client’s financial investment, and helping the emergency clinic that will have one less procedure to perform or test to run when the pet arrives.

Finding a balance between providing emergency care without derailing the entire schedule in a general practice setting can be challenging and clear communication with clients coming for regularly scheduled appointments about an ongoing emergency can help to manage expectations and decrease frustration around wait times.

Decision to transfer

The final step in the process is deciding to transfer the pet for continued care. Ultimately, the decision to transfer belongs to the client. The following questions should be considered prior to transfer:

• Will the patient benefit from continued, emergent care?
• Can the client afford continued care?
• Can the hospital where you intend to transfer the patient handle the case?

The first 2 questions require discussion with the client regarding patient prognosis, recommendations for care, and estimates of cost. Be honest with clients about the prognosis. Most clients would prefer to make the decision to euthanize their pet with their primary veterinarian, where the doctor and team are familiar. Some clients will not be ready to make the decision to euthanize until hearing the information again after arriving at the emergency facility, and this is okay too, as long as you have tried to share the information with them prior to transfer.

The final question requires practitioners to have knowledge of what local emergency and specialty hospitals can manage. For instance, a non-specialty emergency hospital is likely not the best place to transfer a down dog in need of back surgery. Developing a relationship with your local emergency and specialty hospitals can help to guide the decision of which clinic is best for an individual patient. Another consideration is potential for clinics to be at capacity of diverting patients, which has become much more common since the COVID-19 pandemic.

Call ahead to the hospital where you intend to send the pet to make sure that the clinic can take the pet, find out estimated wait times, and a general cost estimate. You can also ask to speak to an emergency doctor regarding what else you can or should do for a patient prior to transfer. Preparing clients for estimates, wait times, and expectations of the emergency visit (ie, will a needed ultrasound be available today or will the patient be hospitalized overnight before further testing?) can help reduce stress on arrival at the emergency clinic.

Before the patient leaves your hospital, provide copies of records and all diagnostic results to the referral hospital, including any medications administered and the time given. Anticipating potential complications that could occur during transport, especially if the owner has a large distance to cover, can be helpful. Consider giving sedation prior to travel if you have not already done so during your stabilization process. If portable oxygen is available, send it with patients in respiratory distress. If patients have been having seizures, a dose of rectal or intranasal diazepam can be sent with the client.

Ultimately, emergency cases can be very rewarding to manage, especially when you and your team are prepared with a plan prior to patient arrival.

Kate Boatright, VMD, a 2013 graduate of the University of Pennsylvania, is a practicing veterinarian and freelance speaker and author in western Pennsylvania. She is passionate about mentorship, education, and addressing common sources of stress for veterinary teams and recent graduates. Outside of clinical practice, Boatright is actively involved in organized veterinary medicine at the local, state, and national levels.