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Examination and Treatment of Critical Care Patients
Examination and Treatment of Critical Care Patients
Tibor NÉMETH, Tibor NÉMETH, DVM, PhD, CertSACSDVM, PhD, CertSACSTibor NÉMETH, Tibor NÉMETH, DVM, PhD, CertSACSDVM, PhD, CertSACS
Examination and Treatment of Critical Care Patients
Examination and Treatment of Critical Care Patients
Definition:Definition:„cases requiring sudden / urgent „cases requiring sudden / urgent emergency diagnosis and treatment, emergency diagnosis and treatment, otherwise patient may get worse or come otherwise patient may get worse or come to death within in a relatively short time”to death within in a relatively short time”
Definition:Definition:„cases requiring sudden / urgent „cases requiring sudden / urgent emergency diagnosis and treatment, emergency diagnosis and treatment, otherwise patient may get worse or come otherwise patient may get worse or come to death within in a relatively short time”to death within in a relatively short time”
Conditions Requiring Critical Care
(Poly)Traumatisation(Poly)TraumatisationAcute Respiratory Distress (ARD)Acute Respiratory Distress (ARD) ShockShock „Acute Abdomen”„Acute Abdomen”CNS emergenciesCNS emergenciesAcute urinary obstructions Acute urinary obstructions Emergencies in anesthesiaEmergencies in anesthesia
(Poly)Traumatisation(Poly)TraumatisationAcute Respiratory Distress (ARD)Acute Respiratory Distress (ARD) ShockShock „Acute Abdomen”„Acute Abdomen”CNS emergenciesCNS emergenciesAcute urinary obstructions Acute urinary obstructions Emergencies in anesthesiaEmergencies in anesthesia
Conditions Requiring Emergency Care
Respiratory SystemConditions Requiring Emergency Care
Respiratory System
- Complete blockage (foreign body obstruction) - Severe leakage (penetrating wound of larynx or
trachea) - Pneumothorax (open, tension) - Hemothorax - Severe pulmonary oedema - Pulmonary hemorrhage - Diaphragmatic hernia
- Complete blockage (foreign body obstruction) - Severe leakage (penetrating wound of larynx or
trachea) - Pneumothorax (open, tension) - Hemothorax - Severe pulmonary oedema - Pulmonary hemorrhage - Diaphragmatic hernia
Conditions Requiring Emergency Care
Cardiovascular SystemConditions Requiring Emergency Care
Cardiovascular System
Permanent, external major blood loss cannot be stopped by compression bandage
Acute major bleeding into the pleural or peritoneal cavity
Acute cardiac tamponade (hemopericardium)
Permanent, external major blood loss cannot be stopped by compression bandage
Acute major bleeding into the pleural or peritoneal cavity
Acute cardiac tamponade (hemopericardium)
Conditions Requiring Emergency Care
Gastrointestinal TractConditions Requiring Emergency Care
Gastrointestinal Tract
Major obstruction of intestinal vascular supply (mesenteric
Intestinal volvulus GDV Leakage of the colon, small intestine, stomach,
esophagus,gallbladder, pancreas (in this order)
Complete obstruction of pyloric antrum, esophagus, small intestine, colon, biliary duct
Major obstruction of intestinal vascular supply (mesenteric
Intestinal volvulus GDV Leakage of the colon, small intestine, stomach,
esophagus,gallbladder, pancreas (in this order)
Complete obstruction of pyloric antrum, esophagus, small intestine, colon, biliary duct
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Conditions Requiring Emergency Care
Central Nervous SystemConditions Requiring Emergency Care
Central Nervous System
Deepening coma due to head injury Impressive skull fracture Acute intervertebral discus prolaps Vertebral fracture or luxation with
paralysis
Deepening coma due to head injury Impressive skull fracture Acute intervertebral discus prolaps Vertebral fracture or luxation with
paralysis
Conditions Requiring Emergency Care
Urinary TractConditions Requiring Emergency Care
Urinary Tract
Obstructions Rupture/leakage Renal and prostatic abscessation
Obstructions Rupture/leakage Renal and prostatic abscessation
Conditions Requiring Emergency Care
Musculoskeletal SystemConditions Requiring Emergency Care
Musculoskeletal System
Open fractures
Severe muscular laceration
Rupture/severance of tendon
Fractures involving joints
Open fractures
Severe muscular laceration
Rupture/severance of tendon
Fractures involving joints
Conditions Requiring Emergency Care
Skin and Subcutaneous TissuesConditions Requiring Emergency Care
Skin and Subcutaneous Tissues
Severe, bleeding wounds Severe burns Severe wound infection Snakebite envenomation
Severe, bleeding wounds Severe burns Severe wound infection Snakebite envenomation
Examination of Critical Care Patients
Question:Question:–– Why does a critical care patient take specific Why does a critical care patient take specific
place and have particular importance inplace and have particular importance in surgical surgical diagnostics and therapy?diagnostics and therapy?
Answer:Answer:–– The order of examination and therapeutical The order of examination and therapeutical
methods are different than in „ordinary” casesmethods are different than in „ordinary” cases–– The diagnosis and the therapy overlap each The diagnosis and the therapy overlap each
other in order to gain timeother in order to gain time–– Two phases (primary and secondary survey) Two phases (primary and secondary survey)
Question:Question:–– Why does a critical care patient take specific Why does a critical care patient take specific
place and have particular importance inplace and have particular importance in surgical surgical diagnostics and therapy?diagnostics and therapy?
Answer:Answer:–– The order of examination and therapeutical The order of examination and therapeutical
methods are different than in „ordinary” casesmethods are different than in „ordinary” cases–– The diagnosis and the therapy overlap each The diagnosis and the therapy overlap each
other in order to gain timeother in order to gain time–– Two phases (primary and secondary survey) Two phases (primary and secondary survey)
Examination of Critical Patients
Examination of Critical Patients
I., Primary Survey reveal the direct life-threatening condition check and stabilise circulation, respiration and CNS
II., Secondary Survey determine other organic disorders which need management
long term patent monitoring
I., Primary Survey reveal the direct life-threatening condition check and stabilise circulation, respiration and CNS
II., Secondary Survey determine other organic disorders which need management
long term patent monitoring
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I. Primary Survey
1. AnamnesisI. Primary Survey
1. Anamnesis (brief quetions - brief answers) - What happened? - When did it happen? - What kind of symptoms ...?--------------------------------------------------------- - Have the symptomes been improving or deteriorating? - What about the general behavior, consciousness...? - Did the animal urinate and when? - When did the animal eat? - What about weight bearing? - Has the animal received any sort of treatment?
(brief quetions - brief answers) - What happened? - When did it happen? - What kind of symptoms ...?--------------------------------------------------------- - Have the symptomes been improving or deteriorating? - What about the general behavior, consciousness...? - Did the animal urinate and when? - When did the animal eat? - What about weight bearing? - Has the animal received any sort of treatment?
I. Primary Survey
2. Assessment of the circulationI. Primary Survey
2. Assessment of the circulation
- check whether or not there is current bleeding - check-up of the mucous membranes
(pale, anemic, dark-red) - CRT - venous refill time (ext. jugular vein) - pulse rate, quality
(frequent, poorly palpable) - non palpable femoral pulse blood pressure 70
mmHg
- check whether or not there is current bleeding - check-up of the mucous membranes
(pale, anemic, dark-red) - CRT - venous refill time (ext. jugular vein) - pulse rate, quality
(frequent, poorly palpable) - non palpable femoral pulse blood pressure 70
mmHg
I. Primary Survey
2. Assessment of the circulationI. Primary Survey
2. Assessment of the circulation - shock index: pulse rate / syst. blood pressure
normal: 75/120 = 0,6danger of shock: 100/100 = 1,0 (8-10%) shock: 180/70 = 2,6 ( 12%)
- body temperature (hypo-, hyperthermia) - temperature of the extremities - basic examination of the heart
(auscultation, percussion) - taking blood sample for acid-base, hematological
and biochemical evaluation
- shock index: pulse rate / syst. blood pressurenormal: 75/120 = 0,6danger of shock: 100/100 = 1,0 (8-10%) shock: 180/70 = 2,6 ( 12%)
- body temperature (hypo-, hyperthermia) - temperature of the extremities - basic examination of the heart
(auscultation, percussion) - taking blood sample for acid-base, hematological
and biochemical evaluation
I. Primary Survey
3. Assessment of respirationI. Primary Survey
3. Assessment of respiration
- coughing, hematoptoe, epistaxis - type, rate volume of ventillation
(hypo-, hyperventillation) - type of dyspnoe
(inspired, expired, combined) - colour of conjunctiva (cyanosis) - visualisation and palpation of the thorax (open
wound, fractured ribs, enlargements along the thoracic wall, chest-resonance)
- coughing, hematoptoe, epistaxis - type, rate volume of ventillation
(hypo-, hyperventillation) - type of dyspnoe
(inspired, expired, combined) - colour of conjunctiva (cyanosis) - visualisation and palpation of the thorax (open
wound, fractured ribs, enlargements along the thoracic wall, chest-resonance)
I. Primary Survey
3. Assessment of respirationI. Primary Survey
3. Assessment of respiration
- auscultation of respiration (basic sounds, amplified sounds, fluid-like sounds, lack of sounds)
- percussion on the thorax (position of the lungs, line of the diaphragm, normal, tympanic, dull sound)
- X-ray - diagnostic puncture (if necessary)
- auscultation of respiration (basic sounds, amplified sounds, fluid-like sounds, lack of sounds)
- percussion on the thorax (position of the lungs, line of the diaphragm, normal, tympanic, dull sound)
- X-ray - diagnostic puncture (if necessary)
I. Primary Survey
4. Assessment of CNSI. Primary Survey
4. Assessment of CNS - status of consciousness
(conscious,unconscious, apathic) - sense of direction
(central or periferial ataxia) - sense of reaction
(hyper-, hyporeactivity) - reflectory perception
(corneal, pupillary, spinal reflexes) - sensory perception
(hyperaesthesia, paraesthesia)
- status of consciousness (conscious,unconscious, apathic)
- sense of direction (central or periferial ataxia)
- sense of reaction (hyper-, hyporeactivity)
- reflectory perception (corneal, pupillary, spinal reflexes)
- sensory perception (hyperaesthesia, paraesthesia)
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II. Secondary Survey
1. Examination of the abdomenII. Secondary Survey
1. Examination of the abdomen
- inspection (hernias, penetrating wounds, formal deviation)
- auscultation (gastric and intestinal sounds) - palpation (painfulness, check the normal abdominal
contents, palpation of the urinary bladder, pay attention on possibly free abdominal fluid)
- percussion (gas filled ventricule, horizontal dullness)
- inspection (hernias, penetrating wounds, formal deviation)
- auscultation (gastric and intestinal sounds) - palpation (painfulness, check the normal abdominal
contents, palpation of the urinary bladder, pay attention on possibly free abdominal fluid)
- percussion (gas filled ventricule, horizontal dullness)
II. Secondary Survey
1. Examination of the abdomenII. Secondary Survey
1. Examination of the abdomen
- urethral catheterisation (physical examination of urine, sample for laboratory evaluation)
- diagnostic puncture (blood, urine, chyme)
- X-ray - Ultrasonography CT, MR
- urethral catheterisation (physical examination of urine, sample for laboratory evaluation)
- diagnostic puncture (blood, urine, chyme)
- X-ray - Ultrasonography CT, MR
II. Secondary Survey2. Examination of the
musculosceletal system
II. Secondary Survey2. Examination of the
musculosceletal system
- check spinal reflexes / neurologic examination (skin, tendineal and defensive reflexes)
- examination of joints and bones (compound fractures)
- check tendons and muscles -examination of motion
- check spinal reflexes / neurologic examination (skin, tendineal and defensive reflexes)
- examination of joints and bones (compound fractures)
- check tendons and muscles -examination of motion
II. Secondary Survey
3. Patient monitoringII. Secondary Survey
3. Patient monitoring
General observation Evaluation of laboratory results
- acid-base data- hematological and biochemical results
Recheckings of the clinical status regularly Modification of the treatment (if necessary)
General observation Evaluation of laboratory results
- acid-base data- hematological and biochemical results
Recheckings of the clinical status regularly Modification of the treatment (if necessary)
VIDEOVIDEOVIDEOVIDEO
Treatment of critical care Treatment of critical care patientspatients
Treatment of critical care Treatment of critical care patientspatients
Stabilisation of circulationStabilisation of circulation
Stabilisation of respirationStabilisation of respiration
Stabilisation of CNSStabilisation of CNS
Stabilisation of circulationStabilisation of circulation
Stabilisation of respirationStabilisation of respiration
Stabilisation of CNSStabilisation of CNS
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Stabilisation of circulationStabilisation of circulationStabilisation of circulationStabilisation of circulation
See: ShockSee: Shock See: ShockSee: Shock
Stabilisation of respiration I.Stabilisation of respiration I.Stabilisation of respiration I.Stabilisation of respiration I.
ProvisionProvision of patent of patent airwaysairways OxygenOxygen –– supportsupport ((maskmask, , tubetube, , stomastoma)) RemovalRemoval of of anyany fluid fluid oror secretionsecretion fromfrom
airwaysairways ((suctionsuction)) RemovalRemoval of air of air oror fluid fluid fromfrom thethe pleuralpleural
spacespace ((thoracocentesisthoracocentesis, , drainagedrainage) )
ProvisionProvision of patent of patent airwaysairways OxygenOxygen –– supportsupport ((maskmask, , tubetube, , stomastoma)) RemovalRemoval of of anyany fluid fluid oror secretionsecretion fromfrom
airwaysairways ((suctionsuction)) RemovalRemoval of air of air oror fluid fluid fromfrom thethe pleuralpleural
spacespace ((thoracocentesisthoracocentesis, , drainagedrainage) )
PTX Pleural effusion
Thoracocentesis
videovideo
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Stabilisation of respiration II.Stabilisation of respiration II.Stabilisation of respiration II.Stabilisation of respiration II.
Fluid Fluid therapytherapy ((hypotensivehypotensive resuscresusc.).)
DiureticsDiuretics ((furosemidefurosemide))
BronchusBronchus--dilatorsdilators ((aminophyllinaminophyllin))
MucolyticsMucolytics ((NN--acetylcysteinacetylcystein))
((CorticosteroidsCorticosteroids???)???)
Fluid Fluid therapytherapy ((hypotensivehypotensive resuscresusc.).)
DiureticsDiuretics ((furosemidefurosemide))
BronchusBronchus--dilatorsdilators ((aminophyllinaminophyllin))
MucolyticsMucolytics ((NN--acetylcysteinacetylcystein))
((CorticosteroidsCorticosteroids???)???)
Stabilisation of CNSStabilisation of CNSStabilisation of CNSStabilisation of CNS
ToTo decreasedecrease intracranialintracranial and/and/oror spinalspinalpressurepressure
DiureticsDiuretics ((mannitolmannitol, , hypertonichypertonic solutionsolution))
((CorticosteroidsCorticosteroids ??? ??? no no effecteffect !!!)!!!)
ToTo decreasedecrease intracranialintracranial and/and/oror spinalspinalpressurepressure
DiureticsDiuretics ((mannitolmannitol, , hypertonichypertonic solutionsolution))
((CorticosteroidsCorticosteroids ??? ??? no no effecteffect !!!)!!!)
Thank you for your Thank you for your attention!attention!
Thank you for your Thank you for your attention!attention!
