Hi everyone and welcome to this online webinar on ECC refresher for nurses. My name's Elle Haskey and I am a registered veterinary nurse and I work in the emergency and critical care team at the Royal Veterinary College in London. So I get to see a variety of emergency patients coming through the emergency room, which needs stabilisation.

And then I get to follow some of these patients through and nurse them when they're in the intensive care unit, needing kind of that more critical care or more sort of ongoing close monitoring and observation. So what I am hoping to cover in this session, is that by the end, you should be able to define the principles of triage, you should be able to describe how to identify and treat shock. You should be able to list the effective ways to deliver oxygen therapy, you should be able to discuss the benefits of an emergency database and implement other commonly used stabilisation techniques.

Now emergency patients present often to the clinic and so I think as nurses, we need to feel confident in how we can play a really important role in these cases through the different aspects that we're gonna talk about today. Now every time you see this little symbol, so learning resource, there will be a link at the end, so you'll be able to go and read more about specific things that we're going to cover today, just because there's such a huge amount of information to get through in an hour. I'm also happy to receive questions after this session, and my email will be on the last slide.

Now, in the words of Florence Nightingale, the most important practical lesson that can be given to nurses is to teach them what to observe, and that's what we're gonna be touching on today. With the emergency patient, what we need to do is quite quickly try and carry out our patient assessments so that we can establish what might be a concern right there and then with the patient and identify any life-threatening injuries or issues. What we're then going to work to do is to try and stabilise that patient in a short period of time, if possible, to try and get their parameters back to more of a normal number or a normal level.

And we're gonna do that via stabilisation techniques, and as nurses, we need to be observing the patient really closely for a response to what, what we're doing to see if what we're doing is improving that patient and helping them out. We know with these sorts of patients, particularly the critical patients, they can change very, very quickly. They can decompensate very quickly.

And so again, coming back to monitoring and observing the patient and their trends can help us pick up things where maybe that patient's starting to decompensate. We can pick this up really quickly or early and try and instigate some form of support to try and prevent that patient tipping into that decompensatory stage. So observation is really, really important in this group of patients.

And I think where people go wrong is perhaps where we have that emergency patient come in, we assess them, we stabilise them, we get them looking a bit better and then maybe we think, oh well that's it, good, good, that patient's looking good now, and maybe we're not quite as observant of their clinical signs and all of a sudden. Something changes. So maybe this is a trauma patient, maybe they've been doing pretty well and responding OK to our treatment of their shock, their analgesia, but all of a sudden they spring in pneumothorax and actually because we're not observing them closely, they can then suddenly develop quite severe respiratory distress.

So what we need to make sure that we're doing with this group of patients is that we keep coming back to that clinical exam, we keep coming back to touching the patient, feeling their pulses, looking at their mucous membranes. And we have this closed level of observation. Now when any emergency presents to the clinic.

Often we are going to get a phone call, but not always. And the first interaction that we have with that owner or with that patient, we are going to instil the principles of triage. So this might be done over the phone if the owner has a concern that their patient is acutely unwell, then they're going to hopefully ring the clinic and be able to offer some advice with regards to whether we need to see that patient immediately, or actually whether we can maybe give that patient an appointment later on that day, or actually whether we can give the owner some advice and we can take slightly more of a watch and wait kind of mentality.

But our principles of triage are essentially to assess our major body systems. So to assess our neurological system, to assess our respiratory system, and to assess our cardiovascular system. Because typically speaking, without one of these three body systems working, we tend to die pretty quickly.

So what we want to do at that very sort of first initial patient interaction is to assess that patient's alertness. Ask the question, how are they breathing? Are they breathing OK?

Yes or no? If the answer is no. Obviously I'm gonna want to intervene more quickly with that patient.

And cardiovascular, how does that patient look? So if that patient is, you know, got a very abnormal heart rate or rhythm, either a very slow heart rate or a very fast heart rate, then that is gonna make me feel like we have to escalate that patient's, secondary survey, where we start to get a bit more information. Other important things with the emergency patient that we need to just think about during this time of triage is does that patient have any overt signs of pain, because that's something that we can generally treat quite easily and quite quickly.

I'm also going to try and assess that patient's behaviour as well, and I always ask owners, during my triage assessment of the patient, you know, is fluffy usually friendly in the veterinary environment? Because I don't want to get bitten, especially if this patient's painful or fearful or, or not feeling well. And the aim of my triage is to say at that very early stage, does this patient have any life threatening injuries?

And if so, I am going to scoot that patient straight out to my ready area where we're already hopefully going to be prepared for their arrival. We'll have some help, hopefully able to assist, where we can then start our secondary survey, where we get a little bit more information about that patient. Now the aim of our secondary survey is to look at each of our kind of body systems in in more detail than we do during triage.

Triage is. It's purely to flag, this patient is unstable and needs urgent attention now versus this patient is more stable and they can sit and wait for a period of time. The secondary survey is kind of like a full clinical exam, and I find it really helpful to work usually from the nose to the tail of the patient.

And I try and do my secondary survey as I do my triage exam in the same way every time so that I approach each patient in the same way and it helps me not to forget things or miss things out. And the secondary surveys is going to involve much more kind of hands-on examination where we want to, we're gonna touch the patient much more, we're gonna feel things like pulses, we're gonna feel things like mucous membranes to see if they're dry or moist. I'm going to use my eyes to look for obvious issues.

I'm going to also use my eyes to observe the way the patient's doing things, for example, observe the way they're breathing. What's their breathing pattern like, what's their breathing effort like? I'm gonna use my ears also to see if I can hear any abnormal noises.

Again, maybe linked with breathing. And smell. We will use our smell to some degree, but that might help us out, particularly maybe if this patient's a trauma patient or they've got some awful wounds, you know, you can sometimes have a look at that wound and it smells like grossly infected.

So we're going to tie in our senses to this secondary survey, and this acronym of a crash plan is really, really great way of working. Down our kind of patient's body system so that we, as we said, we don't forget anything. So we'll be looking for that finer detail each step of the way so we can start to pull together a list of patient concerns, and then therefore from that list, we can then prioritise what's the most urgent thing that we need to deal with with this emergency patient.

The other thing that we need to do quite early on with the patient is to try and get some form of capsule history. Now we might have been able to do this over the telephone, this might be a client that we know that's bonded to the clinic, and we might have been able to get some information prior to their arrival, which again will help us set up and be prepared for when they get here. It may well be that they're walking or we're not familiar with this client if we're covering the practises out of hours.

So we might need to get a bit more information here. And what we want to know is kind of the nature of the problems. So what has, what has brought that client to contact the clinic today?

What, what's their major concern with their pets? We want to know how long it's been going on for. So as we said, usually with this sort of emergency patient, it's often an acute situation, but it may well be that that something's been grumbling for longer with this patient, and it's actually now that, you know, the patient seems to be a bit worse that the owners opted to contact the clinic.

We want to know whether the patient has any concurrent health issues, so do they have anything else going on? Do they, are they on regular medication for something? If so, when was that last given?

How's their eating and drinking been, and how's their urinating and defecating been? And hopefully we're gonna be able to get a brief kind of capsule history in order to then help us start to piece together what we're finding on our, our secondary survey with regards to also the concerns that the the owner has to start building this problem list for the patient. Now once we've come up with our problem list and we've prioritise these concerns, we need to think about then how to stabilise the patient.

And what we're gonna do over the next er sort of series of slides is we're gonna look at some common emergency presentations and we're going to look at what maybe those concerns would be for that patient and how we're gonna go about stabilising them. And the aim is, is to kind of think about that first hour of that patient being with us as the golden hour. So what we want to do within this golden hour is we want to start instilling these stabilisation techniques so that we can start to, you know, if this patient has presented in shock, we can start to reverse this shock, or we can start to get this patient.

Feeling a little bit better, some of their numbers are a little bit more normal, and we're kind of pulling them back from disappearing down that slippery slope of compensatory shock into decompensatory shock. We also need to agree on sort of end resuscitation points during this stabilisation period, because if this patient's critically unwell, and they are already in that decompensatory stage when they present to us, it might not be that we can get things back to normal within that first hour, but it might be that we can get several steps closer to normal. So we need to sort of agree also on, on what our end resuscitation points are gonna be.

We need to make sure we've got really clear communication during this time. So as nurses, we're often going to be involved in that early triage stage of the patient. It may well be you carrying out that secondary survey, and we will need to make sure that we are communicating a vet and nurse team, really, really clearly.

So often we have to work quickly in these situations, especially if this patient is very sick or unstable on presentation, and we all need to know what what tasks each of us are doing. And we need to make sure we're clearly communicating, and again, coming back to that ongoing observation and monitoring of that patient, and we'll see this. This is kind of that nursing process where we assess the patient, we come up with a concern, we then implement something to manage that concern, and then we then come back and reassess.

So, you know, real good example of that endurance stabilisation is That patient's in shock. They've got a low blood pressure and a fast heart rate. We decide to give them a fluid bolus.

So the vet instructs you to do that. You go ahead and give you a fluid bolus, you come back, you recheck heart rate and blood pressure, and we're looking for a response to that fluid bolus. OK, so we're gonna be coming back to that observation and frequent monitoring of the patient.

Just to mention actually if I should pop back to this slide, all these things here on the right hand side are going to be the commonly utilised stabilisation techniques that we're gonna use, with the majority of our emergency patients, or at least we're going to give consideration to those. So oxygen therapy, analgesia, probably one IV catheter placements, grab an emergency database, thinking about whether the fluids are appropriate. There may be specific medications, given the situation, whether we can bring in fast scanning or focus point of care ultrasound to assist us in assessing that patient.

There may be some procedures that we carry out very early on, which could be life saving procedures such as braycentesis, and ultimately we're going to then try and work to address any other concerns that we have with that patient. And with each of the cases we use throughout this session, we're gonna come back to this list of stabilisation techniques and how we can apply them to that patient. So moving on to think about the emergency database, this is really, really helpful in this kind of group of patients.

And our emergency database usually consists of us taking a very small amount of blood from the patient in order to gain, I I guess quite a large amount of information quite early on. And this emergency database will give us a good sort of baseline and starting point. Now what we tend to do in the emergency department at the Royal Veterinary College is we tend to place our IV catheter and take a very small amount of blood from the IV catheter to save extra needles for the patient, and we can then run it.

To obtain the information here on the right. So PCV in total solids, blood glucose, lactate, we'll check electrolytes, urea and creatinine, and also a blood smear. So from probably about 0.3 to 0.4 of a mL of blood, we can gain all that information.

If we do have to stick this up needle stick this up patient, then we'll use off an insulin syringe just because it's a little bit less traumatic, and as we said, we only need a very small amount of blood. PCV and total solids is gonna be really helpful in that emergency patient to pick out patients that maybe are anaemic. If the patient's dehydrated, then we'll see their PCV and total solids both increase.

So using your total solids, which you can do on a urine refractometer, will give us a little bit more kind of bang for our buck, a bit more information when it comes to interpreting our PCV. Obviously, blood glucose can be abnormal in emergency presentation for a lot of different reasons. So thinking here, particular patient with maybe a concern about sepsis.

We can also see obviously patients on the flip side and having high blood glucose, maybe if they're in something like a diabetic ketoacidotic crisis. So again, useful to know at the start point. Our lactate is gonna give us an indication about perfusion.

So if our patients are in shock and a hypo perfused state, they've got, gone into a kind of an anaerobic respiration, which leads to the buildup of lactate, and so we can see an increase in lactate in these patients. So again, this might be something we can monitor as a trend, come back to, as we're stabilising the patient to look for a response to therapy and see that lactate come down as we restore perfusion. Electrolytes are often going to be abnormal in the critically unwell patient for a whole heap of reasons.

So things like our potassium, our sodium, think about our calcium, chloride, all of these things we can screen again early on because if these things are low, we can often supplement them to help that patient out. And if they're high, then we may well need to treat that patient in order to bring that electrolyte back down to help support the patient. By your ear or creatinine is going to give us a good baseline again about kind of the renal side of things.

So any patient which has had a period of sort of shock or hypotension, blood loss, things like that, is going to be at risk of their kidneys taking a little bit of a hit. So getting a baseline urine creatinine is going to be really useful in these patients. Again, trying to help us then build this concern, list of concerns for the patient that we can then address.

Over that kind of stabilisation period and and into the following hours or days for their supportive care for recovery. Again, a blood smear is gonna be really, really useful so that we can look at that in-house and just have a little look at things like white blood cells, platelets, red blood cells, again just to get a little bit more information about that patient on that start point. So if we first of all take the respiratory emergency patient.

We've got a patient here, so this is Jaffa. Jaffa is a 4 year male neuter domestic shorthair who's been found by the owner in the garden. And as you can see in the video, he's been presented because he's got some blood around his face and he's got some difficulty breathing.

So watching that video, you can see he's got kind of an increased abdominal effort. His respiratory rate is higher than we would want it to be. Obviously he's quite depressed in himself and he looks like he's working quite hard with his breathing.

So, you know, a fairly common presentation, a cat with respiratory distress. So what am I thinking when this patient arrives, we've carried out that secondary survey, we've got that capsule history, and I can see a patient looking like that on the table in front of me. I guess I'm gonna be thinking with the respiratory patient, where's the problem likely to be?

So if this is a patient with an upper respiratory tract issue, thinking here like a boas type patient, we often have often have an upper respiratory tract noise that we would hear with the breathing, so a stor or a strider, and these patients will be quite loud in their breathing. If patients have an upper airway problem, they also have an increased inspiratory phase to their breathing. Whereas patients with a lower airway problem have an increased expiratory phase.

So patients maybe with asthma, for example, find it harder to breathe out than in, whereas brachycephalic patients or patients with an upper airway obstruction, find it harder to breathe in than they do to breathe out. So I'm gonna be looking at the way that patient's breathing to try and think, is this an upper problem or is it a lower problem? Patients with plural space disease, so for example, a patient with a tho With a pneumothorax, will often have shorter, shallowy, more kind of choppy breathing when it starts to get quite bad.

I'm really thinking how I can reduce stress in this patient, so not being able to breathe, I imagine is probably pretty terrifying. And if you're a cat, it's probably already terrifying being at the vets. So what can I do to reduce stress?

Can I handle this patient gently? Can we maybe give this patient a little bit of sedation just to take the edge off, or if they're a trauma patient, could we give them an opioid to help settle them a little bit and take away some of the anxiety they have of not being able to breathe? I then want to think about what's the best way to give oxygen to this patient, so how can I do this in a way that stresses that patient even less.

I'm gonna be thinking again, could there be a cardiac aspect to this? So many cats that we see that present in respiratory distress can actually be obviously in heart failure. So I'm gonna be thinking, have I got anything on that secondary survey that's pointing the arrow for me that this is more of a cardiac issue maybe than a respiratory issue.

Given the history in this case here of trauma, I'm gonna be thinking it's probably more respiratory. And I'm then gonna think, how am I gonna observe an improvement in this patient? So whilst we're doing all these things and we're gonna be stabilising this patient, we're gonna be thinking here about the oxygen, getting analgesia on board because of the history of trauma potentially in the blood around the face.

I'm gonna need an IV catheter. I might need to do that in a very staged approach with this patient. I'll be thinking about CAT scan or pocus to get more information, thinking about procedures and other concerns with this patient, but what will I come back to to look for an an improvement?

So first of all, with our oxygen therapy, now thinking about on the right hand side of the slide, small cats, small dogs and cats, we'll be thinking here in this stabilisation period of probably going along the route of flow by or maybe oxygen with a mask. But oxygen kennels are great for these smaller patients because whilst we are Getting things prepared or whilst we are allowing that patient a period of time maybe to respond to some sedation or analgesia, we can pop them in the oxygen kennel so they can rest in the oxygen enriched environment and we can start to allow those drugs in time to work. In a severe case, we may actually have to take control of that patient's airway and intubate them in that emergency stabilisation period.

If we're thinking about our canine patients again in that stabilisation period, we'll be thinking about flow by or a mask similar to the the other smaller patients. We could also consider a crow collar, so where we have a buster collar and we cover the bottom 2/3 of clingfilm, or nasal prongs are a really, really great option in a, in a collapsed larger breed dog, because they can just sit in and it frees the person up from having to hold the oxygen tubing. If we're thinking slightly more oxygen for these patients, we might need to consider nasal catheters, which we would place and suture in, and these would deliver a higher inspired oxygen.

And again, we may need to intubate and take full charge of that patient's airway, particularly if this is something like a boas crisis. We next need to think about how well then is that patient oxygenating. So for me, if it's any patient in respiratory distress, I'm gonna give them oxygen first of all.

I'm then gonna come back to try and assess, you know, maybe how well are they oxygenating with the oxygen or how well are they oxygenating without. And we've got a number of different ways we can do that. So we can think about utilising pulse oximetry in that conscious patient, so we can pop it on a lip, pop it on an ear.

Even a skin fold and see if we can get a conscious reading to tell us how well that patient is saturating. We can think about doing an arterial blood gas sample, so this would be kind of I guess considered the most gold standard. It's not something though that we can do in every respiratory patient because we need them to sit in a certain way.

We need them to sit still in order to get that sample, and actually that might be more counterproductive in the patient that can't breathe very well. So whilst arterial blood gas sampling is gonna give us a definitive arterial oxygenation, it, it doesn't change the fact that if I'm looking at my patient and it looks like it can't breathe, it, it, it's probably not oxygenating very well. We've also got observation of the patient, and this, I think for me, certainly in this emergency sort of stabilisation period, this is, is where I go to more in terms of kind of trying to assess this patient's oxygenation.

I'll give this patient oxygen. We'll start our stabilisation techniques, and I'm gonna be coming back to observing that patient's breathing. Has their respiratory rate come down?

Has their effort improved? Do they look less stressed because they've had some analgesia or some sedation and therefore, it's slowed their breathing and increased their tidal volume. So I want to keep coming back to looking at how that patient is responding.

And if we see that that patient is oxygenating OK and we've had a positive response, we can start to scale back that oxygen a little bit, and again, keep coming back to monitoring and observing how that patient's doing. We'll also think about building in our FA scanning or our pocus, our point of care ultrasound. So we can look at scanning patients' thorax.

So we can do it in sort of two different sites. So we, can do this, or the vet can do this, nurses can do it too, around the heart area, so where you would do kind of pericardiocentesis sites or around kind of more the dorsal aspect of the thorax, so what we would call the chest tube site. And this can be done bedside with very minimal restraints, so I'm coming back to that stress reducing factors for this patient that can't breathe very well.

And what we're gonna be looking for here in this patient with respiratory distress is, do we have more evidence that we can see to point us in the direction of what might be going on. So. In a patient like Jaffa, who sustained a trauma and we're maybe worried about a pneumothorax, we would want to be looking to see if we could see a glide sign.

So a glide sign is where we see the lung and the plural lining sliding past each other called the glide sign. The absence of a glide sign is suggestive of a pneumothorax. We're also gonna listen to that patient's chest, remember, as part of our clinical exam.

And so if we have the absence of a glide sign, and we have really dull lung sounds, because we've got air trapped within the thorax, which means we can't hear the lung sounds very well, these are gonna be things that raise my suspicion for that patient having pneumothorax. If this patient's got more of a cardiac issue, then we're gonna see bee lines. So this is where we have these dark lines which come down our ultrasound screen.

And these are often associated with lung consolidation. So if we have a patient here where maybe they've got pulmonary edoema, we would be looking for the evidence of beelines, and we would then tie that into this patient exam. In the case of Jaffa, we detected a pneumothorax, and so we needed to then make sure that we did thoracentesis fairly and promptly to help improve his breathing.

So as we can see, he's had some analgesia, he's had some methadone, he's having flow by oxygen. We've clipped an area across his chest, and we're just using a little butterfly needle here. So this is one of the vets that's just doing a little needle, needle thorakicentesis.

And you'll see there that we're then gonna be getting some air out of this thorax. So it's just gone in in between the ribs round about the 8th 7th to 8th rib space, and what you'll see is we're then able to draw air and we've got our 3-way tap so that we can drain. And we'll consider this procedure in this sort of setting as a life saving procedure.

So thracocentesis can be both diagnostic, so we tap the patient to see what we get, and that helps us with our diagnosis. But it can also be therapeutic, so it makes that patient feel better. And in Jaffa's case, I think we drained quite a big volume.

It was around about 350 to 400 mL which immediately made his breathing better. I need to think now what other techniques have I got which we can instil for the dysneic patients. So we've touched on sedation already.

This is really helpful in that patient that's working themselves up into a frenzy, so particularly the BAS type crisis patient. We might also need to think about active cooling because the more the patient breathes and the more work that they're doing with their breathing, often the quicker their temperature starts to jump up. And so these patients can develop quite a profound hyperthermia quite quickly, and we'll have seen this in, in this kind of specifically in the brachycephalic group.

So we might need to think about active cooling of these patients, so dousing them down with tepid water, having some sedation on board, maybe getting a fan to blow cool air around, so that we can try and get that patient a little bit cooler. We might need to go with the minimal handling. So coming back to that, this near cat who's sitting on that knife edge, we have to take that staged approach.

Maybe we want that IV access and we actually clip the leg and put them back in the oxygen kennel. We get them back out 10 minutes later to pop some MLA on and we put them back in the kennel. And we go with the IM route of medication where we can and we allow the drugs some time to work.

What we don't want to do is get that patient out and restrain them, and we tip them over into a crisis. We can also think about patient positioning, so where possible, if we can encourage that patient to lie in a sternal type position, just allows both lung sides to sort of inflate and open, and it's gonna hopefully help them with their breathing a little bit. Equally, if that patient has a diaphragmatic rupture, maybe popping that patient on a slight angle, a little bit of gravity to help move the gut contents back down towards the, the abdominal contents back down towards the abdomen again might just help that patient's breathing a little bit.

We might also find that nebulization is helpful, so if this patient's got very, very kind of consolidated lungs, something maybe like an aspiration pneumonia, building some nebulization into their treatment plan might help them to sort of loosen those secretions and get things moving a little bit so they can cough up that consolidation. In terms of my ongoing monitoring, so we said we're gonna come back to observing the patient, so I want to be looking at this respiratory rate pattern and effort. How's this patient breathing now?

How have they responded to what we've done? Did we see an improvement and actually now they're refilling with their pneumothorax, so we're starting to see the respiratory rate go back up. How's that patient's response to their oxygen therapy?

So, do they look like they're breathing better for the oxygen that we're doing, or do we need to maybe think about increasing the amount of oxygen that they're inspiring? Do we need to be maybe a little bit more aggressive in our oxygen therapy plan? We can think also about whether we now could come back to measure the level of oxygenation if we haven't done that already.

So maybe popping that pulse oximeter on or maybe now the patient's looking a bit better, we might be able to take that arterial blood gas sample. The long term plan then needs to be when do we wean the oxygen, so again we're gonna keep coming back to how that patient's breathing. We're gonna want to make sure we've kind of got a baseline diagnosis that we're treating or we're managing, and then we can start to bring that oxygen level down to a point where we can wean them down to room air.

I'm gonna want to make sure I've got really close monitoring for a reoccurrence of a pneumothorax or a fusion, so that comes back to that respiratory rate pattern and effort monitoring. Go to keep an eye on my temperature in this group of patients, as we said, especially if they've had that crisis. So often with active cooling, we can take things the other way and they can end up hypothermic.

So just coming back to keep an eye on that temperature. And this group of patients may well need further workups, so they may well need radiographs, they might need CT, they might need even surgical intervention. But we're gonna be doing that once we've kind of got this patient over that initial stabilisation period.

We don't want to be pinning this patient down for radiographs if they are dysneic. We want to go with that bedside ultrasound, which is much more, you know, less restraint, and less stress for the patient. So moving on to another presentation that we see, here we've got a seizure in cat.

So this is Ricky, he's a 6 year ma due to domestic short hair, with a history of acute onset seizures. We've had several of these episodes at home, and the owner has brought him in because obviously she's concerned that he's seizuring. This cat doesn't really seem huge.

He's a little bit aware now as he looks like he's kind of coming out. And we're seeing this kind of that seizuring can cause a lot of facial twitching and y is hypersalivation. So kind of, I guess what we would see in a cat will kind of term this really as a, as a, if it was less obvious it might be more partial seizure looking at this cat that looks pretty convincingly like a seizure.

So what am I thinking when I have a patient like this present? Well, I'm gonna be thinking, you know, where's the problem? So when we see patients with either abnormal mentation or abnormal twitchy, sei like behaviour, this could be because of an intracranial issue.

So maybe this patient has something like idiopathic epilepsy, they've got a brain tumour, they've had maybe a head trauma. Or this could be an extracranial issue, so something like maybe a metabolic issue. So for example, any patient that presents in severe shock and hypo perfusion has a reduced perfusion to their brain that can make them obtunded and make them flat and less responsive.

So patients have a low blood glucose, for example, that can make them collapsed or quite flat and less responsive. So we want to be thinking about, you know, where, where might this problem be? And we'll use obviously our emergency database to help us look for things that are metabolic that could be contributing to this patient's abnormal behaviour or mentation or even seizure-like activity.

I need to think how's it gonna be best to manage these seizures in that emergency setting. Again, what's that patient's temperature, especially if it's a dog, especially if they've had lots of seizures when they, by the time they get to us. How am I gonna observe an improvement in this patient?

Is the patient responsive? So we could see that that cat there was, but that's not always the case with these patients. And again, have we got any evidence early on that we've got a concern for a raised intracranial pressure?

So in this group of patients, I'm gonna be thinking oxygen. I'm gonna be thinking I need IV access, gonna get that emergency database early on. We're gonna need to think potentially about specific anti-seizure medications, other procedures we might want to do, and then other concerns that we're gonna pick up based on that secondary survey.

Now it's important that we have a seizure plan and as we said, we kind of need to agree on what our kind of aim and goal is with this patient and also our kind of end resuscitation points. So for example here we've got some different sort of presentations. So we've obviously seen the seizure in cats.

We've also got this little taxxie here who's having partial seizures. So the Taxi is quite aware of what's going on. When I talked to him, you could.

Look and move his head around, so he knew I was there, but we can see he's got that very abnormal facial twitching to one side of his face. And what we need to agree on is at what point do we need to intervene? So at what point as the nurse looking after that patient, am I intervening to to break that cycle of seizures, or are we going to be tolerant of that behaviour because it's short and they're partial seizures, or do we want to intervene because we don't want it to wind up into a full seizure?

Equally, we see a lot of patients with kind of this tremoring type behaviour, so tremorogenic mycotoxin patients where they get into mouldy bread or mouldy food. Again, I'm really worried about all this sort of saying similar things with this patient, but actually, it's probably unlikely we're gonna stop this patient's tremors altogether, even if we give them quite a lot of sedation. So again, we might need to ride some of this out.

But usually, in terms of our anti-seizure plan, our first line therapy is gonna be injectable diazepam. We've got IV access. If we don't have IV access, then maybe go for a rectal diazepam.

So making sure we've got that out and ready prior to this patient arriving, making sure we've calculated what we think the dose is, and usually we pop it in a little rescue pack with a needle, and syringe, the vial of diazepam, and the saline flush. So we've got that that goes stay with the patient so that we can give it in an emergency. Then there's a number of different drugs that can be given, usually based on that patient case, and that comes down to the drug that the vet, working with that case wants to prescribe or feels is best suited, but we may give levetiracetam or we may give phenobarbitone.

And often with these drugs, we give these drugs as kind of a loading dose, so a higher dose, followed by subsequent lower doses. So the aim is to get these drugs in the blood system up to a therapeutic level so that we can break this seizure cycle. In severe cases where we've maybe got to this sort of 3rd line of anti-seizure medication, and we're progressing down this line and the patient's still seizuring, we may well have to give this patient something like propofol to anaesthetize them for a period of time, break that seizure cycle, and manage that patient from there.

Now if we have raised intracranial pressure, this could be secondary to trauma or this could be a patient where maybe they've had a bit of a bang on the head. So what can we do with this group of patients? Well, similar to this photo here, we can pop these patients on a 45 degree elevation, so a bit of gravity prevents blood pooling in their head.

We can give these patients some oxygen because we know at this point their brain's probably not being perfused very well. And what we want to monitor and observe in this patient is their heart rate and their blood pressure. So what happens with patients with raised intracranial pressure is if you have a brain tumour, for example, taking up space within your brain, your brain will shunt CSF out of your skull.

But if that brain tumour gets bigger and bigger and bigger, it starts to take up more space and therefore your skull. Restricts your brain and that tumour within that solid structure. So what happens is the brain starts to get squashed and we get areas of poor perfusion to the brain and the body's response to that is to increase blood pressure to try and reperfuse the brain.

And as the blood pressure goes up, obviously that's more blood that goes up towards the brain, which actually creates more pressure and actually then squashes the brain even further and worsens perfusion. And we start to see this blood pressure go up and up and up to try and combat this and maintain cerebral perfusion pressure and we see a vaguely mediated bradycardia. So if you have this patient, And their blood pressure is going up and their heart rate is going down, I would be very concerned about raising intracranial pressure.

So monitoring those things closely, keeping that patient elevated, and we may well have to think about agents such as hypertonic saline or Manitol to try and draw fluid out of that brain space, help reduce any cerebral edoema, to try and bring that raised intracranial pressure down. We might need to think about more aggressive management of hypothermia, especially if this patient has had status epilepticus. So we know that with the hypothermic patient, we can see end organ damage, so particularly damage to kind of the gastrointestinal tract, renal damage, liver damage, we can see coagulation abnormalities, and we can then see bacterial translocation from the gut.

So these patients, you know, if they have been seizuring a lot and we get that high rectal temperature, we've got to get those active cooling methods that we've sort of discussed already, underway quite promptly, reduce their activity. So again, we may well need to actually anaesthetize that patient, if it's really, really high, try and sedate them in order to then break that cycle so that we can get them cooler. If I'm thinking then about the ongoing monitoring and the ongoing observation of this seizure patient, again, we're gonna need to decide at what point are we intervening.

So what, what are we looking for with the seizure activity? What are we calling seizure activity? What are we happy to sit on and monitor versus at what point do I need to intervene?

And I need to know then what that seizure plan is. So am I going with that IV bolus of diazepam, or if that patient seizures again, do I need to give another dose of phenobarbitone, for example? So making sure we've got that plan, we've got that seizure pack prepared and ready with that patient, so it's there should the crisis strike.

Ongoing management of temperature, we can think about monitoring mentation with the modified Glasgow coma scale. So here we'll look at motor activity, which can range anywhere from a normal gait to absent spinal reflexes. We'll be looking at brain stem reflexes, so looking at a normal PLR.

Papillary light response and normal oculocephalic reflex. So your oculocephalic reflex is a physiological nystagmus, if you move your patient's head around the room, what you should see is that their eyes flicker as they follow around the room. Ranging through to unresponsive midriasis, so very big dilated, unresponsive pupils.

We'll also look at level of consciousness, so that can range from alert to comatose, not responsive to anything. And really what we do with this coma score is similar to a pain score. We'll score the patient for each of these three groups, and essentially the higher the score, the better the prognosis, the lower the score, the worse the prognosis.

We're gonna need to monitor the patient for that raised intracranial pressure, so coming back to blood pressure, coming back to heart rate, looking at that patient's mentation. And obviously if we do have to induce this patient into a coma or they have presented comatose, we're gonna need to manage that patient. So that patient probably will need intubated if they've got a reduced gag in order to protect their airway.

This patient will need to be hooked up to monitoring and have very close observations. We're gonna need to do all the things for this patient that this patient can't do for themselves. So eye care, oral care, keeping this patient clean and dry, turning this patient.

And if we're keeping this patient asleep for a period of time, we're then gonna need to start factoring in things like nutrition on top of this. Let's think about another common presentation. Let's take the trauma patients.

So I think this is quite a, a common presentation that we see. So this is Luther, he's a seven year male neutered greyhound who has presented following a road traffic accident. There's a concern that he's got a spinal fracture, hence why he's strapped down onto a stretcher and a table in the image on the left.

And he's also got some really nasty degloving type wounds to his hind legs. So, trauma patients can, you know, present from very, very mild to really quite severe. And these patients give us an enormous amount to think about from the get-go.

So I'm gonna be thinking with this patient, you know, are there any other injuries? So obviously I've got injuries I can see externally, but, you know, if this patient's had a trauma enough to fracture a spine, you know, what's their bladder doing? Have, have they got a pneumothorax?

Do they have pulmonary or myocardial contusions? How's their spleen? So I'm gonna be thinking here, what are their other injuries?

The other thing that's sometimes challenging with the trauma patient is other injuries don't become apparent until a little time later. So it might well be that actually we've got this list of concerns we're dealing with now with this patient, but actually in 24 hours we identify there's other issues that have now become apparent. I'm gonna be thinking about what's our initial womb plan management.

You know, is this patient in shock, and if so, how severe is that shock? How am I gonna observe an improvement in this patient? And again, is this patient painful?

This patient's probably going to be very, very painful if they've got a spinal fracture. Also, has this patient lost a lot of blood? Is that something else I'm gonna need to factor into this stabilisation?

So everything that we've had on this kind of prioritising concerns checklist, everything is gonna come into play in this type of patient because often there's a lot to think about. And this is your typical patient that is gonna present as an emergency in a state of shock. Now shock, we define shock as reduced oxygen delivery to tissues or or hypo perfusion.

And we can categorise shock in 4 different ways. So we can have cardiogenic shock, which is usually associated with kind of a heart disease, where the heart is unable to pump blood around the body. We've often got reduced contractility, reduced cardiac output, that leads to reduced tissue oxygen delivery.

In the trauma patient, we're going to be thinking more about hypovolemic shock. So this is where that patient has a reduced circulating blood volume, probably in this case because they've lost some blood, secondary to their trauma. And this reduced volume leads to reduced venous return back to the heart.

That means there's less stroke volume, so less blood coming out the other side of the heart, reduced cardiac output, and again, hypo perfusion. We can see patients with obstructive shock, so this is where there's a physical blockage to the blood flow in the vessels. So this could be something like maybe a pericardial effusion.

So the heart's actually fine and able to work, but the heart can't work because it's obstructed by the pericardial sac. Or for example, a patient maybe with a GDV where their stomach is twisted round, and we've got this physical blockage because it's twisted round and trapped the spleen in with it and we can't get blood flow to those areas. So this physical blockage means there's less return of blood to the heart.

Blood's trapped within that obstructed area as well. So again, we've got less stroke volume, less cardiac output, which leads to in time, reduced oxygen delivery. Lastly, we've got distributive shocks.

We think about this more in the seps SERS group of patients, so vasodilation, leaky blood vessels. We then start to see activation of the coagulation cascade, and what we see here in this group of patients is blood pools in the periphery. So because the patient's pooling blood because of vasodilation, we seem to have less blood typically circulating, which comes back round to the heart.

Leading on to the same knock-on effects which results in hypo perfusion. Now the signs that we're gonna be able to see in terms of that secondary survey and looking at these emergency patients that are gonna indicate the patient has cor perfusion. We are going to be looking for kind of vasoconstriction in the majority of those cases.

The sideline would be vasodilation in the distributive shock view for patients. But with vasoconstriction, we're going to see pale mucous membranes. We're going to see a very slow capillary refill time because that patient has vasoconstricted and sucked their blood into their major organs.

So they're protecting their kidneys, lungs, heart, and brain, and they've sucked the blood from their periphery into their core. These patients will have poor pulse quality. Remember, coming back to feeling pulses, feeling the patient.

They will be hypotensive on blood pressure, feel very cold because of that vasoconstriction. They'll have abnormal mentation often, and on that emergency database, these patients will have that increase in their blood lactate. Now remember shock is this spectrum where the patient presents in the early stages in that compensatory stage and if untreated and this hyper perfusion worsens and continues, the patient will move down to the decompensatory stage.

And the aim is, in this ECC emergency patient, to identify shock and jump in and treat it quickly. So we pull the patient back along this spectrum before they get to that decompensatory stage. Now, how do we treat hypo perfusion?

Well, if this is a cardiogenic cause, we want to assess cardiac function, and we're gonna give drugs to help improve cardiac output. So that's that patient in heart failure. We're gonna try and give them something such as aimabendin to try and help improve their cardiac output.

We're gonna try and deal with any congestive heart failure by giving them diuretics such as rosemide. Fluid therapy would be absolutely contraindicated in this group of patients. However, if the patient is in a hypovolemic, an obstructive or a distributive shock, fluid therapy is going to be our initial reach for thing.

With hypovolemic patients, we want to prevent any further growing blood loss, and we're gonna aim to replace circulating volume. With patients with an obstruction, we're gonna try and remove the obstruction, so that might be with the GDV we have to do that surgically, but in the meantime, we can give fluids to the patient to help increase preload, which helps therefore improve stroke volume and cardiac output and improve perfusion. If the patient is in distributive shock, we're gonna again try and identify the source.

That could be an anaphylaxis or a septic source. And again, we're gonna want to try and restore circulating volume with fluid therapy. We'll also consider whether we give those, that group of patients some drugs to help create a bit of vasoconstriction, because remember, distributive shock leads to vasodilation.

So we wanna help vasoconstrict their vessels a bit. So the aim with this hypovolemic patient, a bit like Luther, who's sustained this trauma, is to restore circulating volume to improve the perfusion, and we want to do that often with isotonic crystalloids. So we're gonna be thinking here about shock rate fluids.

So dogs really aiming for 80 to 90 mL per kilo as a total dose. Cats 50 to 55. Cats like to hide heart disease sometimes, so we're always a bit more cautious.

But we give this in incremental bonuses. So coming back to that nursing process, we're gonna give a bolus maybe 1015 mL per kilo in a dog, 5 to 10 in a cat, and we're gonna give that and we're gonna come back and we're gonna reassess these perfusion parameters. We're gonna administer hypertonic saline or consider that in very large breed dogs with an acute bleed because that will help to draw fluid from the interstitial space into the intravascular space, which will help to restore circulating volume quite quickly.

We can do this with our fluid pumps, and again if we've got large breed dogs, then we can consider things like these pressure cuffs or slam bags in order to get that big volume of fluids into the patient quickly. Again, if it's a really large breed dog, we could consider placing a second IV catheter in order to get two fluid bags running in at the same time. We're also going to make use of Thinking about our bedside ultrasound for abdominal ultrasound scanning in this trauma patient.

So we'll also use the thoracic scanning, which we've touched on already, especially if this trauma patient has signs of respiratory distress. But we're gonna want to scan the abdomen to look for any any evidence of free abdominal fluid. So that could be in the trauma patient's blood or urine.

It could be that they've got perforated gut. So we're gonna want to be able to scan the abdomen and look for any evidence of free abdominal fluid, and if we do have that, then we're gonna want to do, the vet's gonna want to do an abdominocentesis, which would be the sorry, which would be diagnostic to help us aid in what's, what's going on in the abdomen. And we're gonna scan with our ultrasound 4 areas, so we tend to scan up near the liver, down in the bladder and around by each kidney, in order to look for and identify free fluid which would show up on the image here as dark.

That can then be tapped to help us figure out what's going on. We're also gonna need to factor in wound management to this stabilisation plan. Now initially we said in as treating our hypovolemia, we're gonna stem bleeding, so that's applying pressure to that wound.

And the main aim during stabilisation is to just get that wound covered. So pack the wound if you need to with sterile lubricant, cover it with a sterile dressing, make sure that patient's got analgesia on board. For a wound like this in the image here, we'd want to get some antibiotics on board early on.

And we're gonna cover that wound whilst we stabilise the patient. Once that patient is then stable, we're then gonna come back to having an ongoing wound management plan. And that's gonna involve properly either sedating or anaesthetizing the patient so that we can fully fully look at the wound.

We can clip it all up properly, we can lavage it properly. We can assess the damage. We can work out whether there is anything we can do surgically there and then, or whether we're gonna need to manage that wound for several days with debridement techniques before we come back to try and close it, or whether we're gonna manage this as an open wound and wait for granulation to happen.

The main aim during stabilisation is to cover the wound and prevent further contamination whilst we stabilise the patient. The patient isn't gonna die of a degloving injury like this. It's gonna die because it's either got a pneumothorax or it's got hypo perfusion and it's in decompensatory shock.

So we'll come back to wound management once the patient's more stable. We're gonna get that analgesia early on board, so specifically, Luther's got this spinal fracture. Now in an ideal world, we want to be going with preemptive and multimodal analgesia, but that unfortunately does not fit with the nature of emergency and critical care.

If it's more with the critical care side, if we are gonna be coming back to, for example, addressing that wound, we could think about the use of a local ring block in that patient. But for the emergency presentation, we're gonna just need to get analgesia on early, early doors, and we'll be thinking here about opioids. We want to avoid non-steroidals, because we know that these patients are likely with this hypo perfusion, their gut is likely to have taken a hit, and they're going to be at risk of GI bleeding or ulceration if they've had really, really poor perfusion for a period of time.

So this group of patients, again from the renal side of things, we're going to avoid more steroidals. As I said, we can consider the use of local blocks, we can consider the use of things like our mla cream prior to aiding in that catheter placement. We can think about then making sure that we come back to that observation, we come back to that validated pain scale.

The feline Rimmer scale is, new, so some of you might not be aware of this yet, but you can download it on an app, which is absolutely brilliant, and definitely worth a look, for something that you can utilise in your feline patients because these patients can be quite challenging. We'll think about additional analgesics that we can use. So what else have we got?

Could we think about paracetamol in a canine patient? If this patient's also a little bit fractious and it's a cap, could we think about maybe some gabapentin on top of our opioids? And again, adjunct therapy.

So thinking here about cold therapy or warm therapy often doesn't cost us very much to do, just a little bit of time, but we can build that into our ongoing analgesia plan for the patient. Ongoing monitoring of this trauma patient, I want regular assessment of cardiovascular parameters. I want to make sure we've got that regular pain scoring and I'm, I'm, I'm, you know, comfortable and confident that we are really, you know, dealing with this patient's level of discomfort, in a, in a good way.

I'm going to monitor this patient then for the effects which we might see secondary to shock. So that GI upset where maybe they're likely to get diarrhoea, or this patient where maybe they could develop an acute kidney injury because they were really hypotensive for a long period of time. I'm gonna keep looking out for these additional injuries, as we said, remember with that trauma patient sometimes.

Actually, we don't see, for example, free fluid, and we think the patient's bladder seems intact and actually you realise 12 hours later, hang on a minute, this patient's had a lot of fluids and it's not peed. And actually we come back and refocus its abdomen and now it's got a uro abdomen because it did have a ruptured bladder. So looking for these additional injuries, just having sepsis at the back of our mind, any of these patients with wounds, especially, if they've been there for a while.

And really getting nutrition early doors on board for this group of patients. So these patients have a huge amount of recovery and healing after a trauma, and they need to have nutrition on board early on to help support them through that period. Lastly, I want to take a quick look at another common presentation that we see in the clinic, which is the toxin patient.

So this is Dizzy, Dizzy is a 6 year female spayed huskyros. Her owner has got horses and she spends a lot of time down at the yard. And the owner caught Dizzy eating rat bait about 20 minutes ago.

She has, she, she didn't ring, she just put Dizzy in the car, scooted straight down to the clinic, and you go and do your triage, and Dizzy's looking. Not so impressed to be having, you know, brought into the, into the veterinary clinic. So with a toxins patient like this, what am I gonna be thinking?

Well, we know that she's eaten it about 20 minutes ago because in this situation it was an observed exposure, but that's not always the case. I also want to know roughly how much has she eaten and of what, so we can try and ascertain how dangerous is this dose. In a rat bait toxicity patients, I'm gonna be thinking what's her clotting times doing because a lot of these toxins can lead to bleeding tendencies and hypercoagulation.

That's gonna lead me on to be thinking, OK, well, what blood products do we have available if she has been having some bleeding or at risk of bleeding? How am I gonna how will I observe an improvement in this patient? If she's already had some blood loss, how anaemic is she?

And again, how cardiovascularly stable is she if she's had some blood loss? So again thinking about these stabilisation techniques, this patient might need some oxygen therapy, we're gonna need IV access and that emergency database to help us rule out, you know, things like if she's anaemic or not. We're gonna need to probably add in our clotting time tests for this patient as part of that emergency database.

We're gonna be thinking about fluids, maybe extending that to blood, specific meds, fast scanning again, and other concerns. Now with any toxin exposure case. What we need to do is ascertain, you know, is this first of all, agent toxic to the patient?

Is it gonna cause a problem? If so, what problem are we likely to see? And also, what's the dose that we think that this patient's had, so that we can then decide on what's going to be the most appropriate course of action.

And time really is of the essence in this group of patients. So ideally knowing when they ate it is gonna be helpful. But even if it was, you know, in the last few hours, we will still often try and make that patient sick if it's safe to do so, in order to try and get rid of anything else that still might be in the stomach.

And we're also gonna want to know at that triage point of view and initial assessment, are we already seeing signs associated with that toxin ingestion. So the Veterinary Poisons Information Service is a wonderful resource, and they've got a huge amount of information, so. That would be our first point of contact, is to contact them and see what their recommendations are.

We want to obviously assess patients stability with our triage, but most of these patients, to be honest, are gonna jump jump your list of emergencies because of this, this time element. We're then gonna ideally, if the patient is not mentally depressed or inappropriate, we're gonna want to make this patient sick. Other things that we're gonna then think about doing is once we've made this patient sick, we'll be thinking about activated charcoal and whether that's appropriate.

And it really depends on the toxin that that patient has had, but activated charcoal will help to bind with toxins which undergo . Enteropathic recirculation. So where they cycle through the body several times from the liver to the gut and back again, we will catch them as they come back to the gut if that patient's had activated charcoal, and it will bind with them, bind with that toxin agent over repeated doses of activated charcoal being given.

We can also think about if there's an antidote or something that we can give either specifically to reverse the toxin or something that we can give to maybe help counteract the effects of the toxin. We might need to think about gastric lavage in some cases where we can't make them sick. So if their mentation's really inappropriate or they've had seizures, we could anaesthetize them, pump their stomach, gastric lavage, and again, excavate their stomach that way.

We need to keep coming back then to observation of that patient, so watching for the clinical signs developing if we haven't been able to successfully decontaminate them, thinking how long they might need to be hospitalised and really that depends on what they had, what was the dose, what we're likely to see, what we're seeing now. And again, whether we need any long term follow up in terms of long-lasting effects that we might see associated with the toxin that they've been exposed to. In particular, if it's something like the rat bait, which leads to coagulopathic issues, then we're gonna need to think about how we manage these patients.

So we can see primary, which is usually platelet coagulopathies, or we can see more secondary coagulopathies as we would with the rat bait and where we see kind of clotting factor, abnormalities. So these We need to have gentle handling, we need to be really, really cautious with needle sticks. We need to make sure we've got really acute observation of ongoing bleeding.

So if that's a primary coagulopathy with a platelet issue, we tend to see surface bleeds. So ecchymosis, petechiation, GI bleeding, whereas if this is a a clotting factor or a secondary coagulopathy, we tend to see these patients bleed into body cavities, so a hemothorax or a hemo abdomen. So this was a a rat baiter toxicity that presented with a hemoabdomen, and you can see that we've applied an abdominal pressure bandage to the abdomen whilst we're stabilising this patient.

We might need to give transfusions to these patients, and that might be that that's repeated several times over several days. And the other thing that we always try and just consider in the coagulopathic patient is an angio snap test. So you can see a patient present for, you know, any reason, and actually incidentally, we can find that they have, angiostrongylus.

So always just considering this in a patient which is coagulopathic. Now if this patient does have rat bait toxicity, they've been you know, ingested quite a large dose, we've maybe not been that successful in decontaminating them because they ate it a while ago, then this patient is gonna go on to develop hypercoagulation. And we're gonna think about stepping in to give blood products based on transfusion triggers.

So that comes back to what are we happy to tolerate with this patient. We're gonna think about this patient as an individual and make sure we're all on the same page and understanding what the transfusion triggers are for that individual. And our transfusion triggers usually are how cardiovascular stable is that patient?

So how well are they tolerating, you know, their anaemia, for example. We're gonna need to make sure before we give any blood products to any patient that they are blood typed, and we also will need to consider crossmatch, especially if they've had blood products before. But in an ideal world, we should probably be striving to both blood type and cross match all patients before all transfusions.

We want to then select the most appropriate product that we have and prepare it. We need to make sure we complete all our paperwork. Making sure we've got a patent IV catheter that's been flushed with saline before we start, and before we attach any of our blood products up.

Getting that baseline temperature pulse and respiration and blood pressure, and we tend to start our transfusions slowly and then increase the rate so that we can transfuse the whole lot over about 4 hours, either per bag or per syringe if we're doing a feline blood transfusion. In this sort of patient here, what we would probably be looking to do is to give fresh frozen plasma because or stored frozen plasma, because that would give the clotting factors that this rat bait toxicity patient needs. If this patient has bled a lot and is subsequently anaemic, we could give red blood cells.

Alternatively, we could give this patient whole blood if we had a donor available. Now, irrespective of the presentation of this emergency patient. We talked here a lot about kind of the stabilisation techniques and things to then consider monitoring when this patients then with us for the next sort of few hours or maybe our shift.

But we are gonna have to probably consider a number of other steps within that patient workup over the next hours or days depending on what's brought that patient to the clinic. And this is where we'll be thinking about more advanced imaging, maybe more clinical pathology stuff, so thinking about extra lab tests or getting samples that we can submit. We'll be thinking about other procedures.

So again, coming back to diagnostic procedures versus therapeutic procedures. Patients may well need surgery, and again, I can think of a number of emergency kind of situations. So your GDV patient or your caesarean, where actually you're gonna be thinking about emergency surgery and that needs to happen quite, quite quickly after this period of stabilisation, so we get this patient and make them the safest anaesthetic candidate we can for that emergency surgery.

We might need to obviously as we said, think about having an anaesthesia plan and also the tincture of time. So thinking with these patients actually sometimes we just allow a bit of time for waiting to see what happens. And then we can have that close observation and come back to that patient.

Now if that patient stays with us in the clinic and they're a critically unwell patient, then this is where Kirby's rule of 20 is the most brilliant checklist, that we can apply to these sick patients. So this is 20 different parameters and it can be really useful to print this out and stick it on the wall in the clinic of different things that we've kind of touched on along the way, during this session, but 20 different parameters that we can specifically apply to that critically unwell patient and that we can build into an individualised nursing care plan. We need to make sure communication is on point, and that is team communication and client communication.

As we said, these situations can be sometimes high pressured. We have to work quite quickly, and we need to make sure we've got this respectful and professional communication. So as nurses, we're there to advocate for the patients.

If you feel something is missing from our treatment plan or our stabilisation techniques, then we need to voice that. And equally, we're gonna be coming back to these observations and and back to this monitoring of trends, and so again, advocating something that's changed or something that you're worried about. Closed loop communication is particularly helpful in that moment of crisis because it helps us to prevent errors.

So this is where we communicate something and that thing is repeated back. Having these agreed goals and knowing what the aim is that we've talked about throughout this session. Notifiers can also be really, really helpful on our treatment sheets.

So this, these are set, so a bit like we said, kind of these end resuscitation points. At what point am I to worry? So for me, you know, maybe like if I have a patient with a respiratory rate over 40, that's a cat, that would alert me to then trigger me to alert the vet that that patient's respiratory rate is high.

Making sure we've got clear and concise notes, so again we're documenting what we've done, especially as we're working quickly and we're scheduling future treatment. We need to make sure the clients stay informed throughout what's going on and that we've also got consent for what we're doing. And again, just popping yourself in this owner's shoes.

It's really, really stressful when your pets unwell, so just being empathetic and caring, just trying to explain to them what's going to happen and what time frame, and that might fall down to you as a nurse to have this type of communication with the owner. So making sure that we can manage expectations and giving our progress updates as required. And again, signposting owners to useful information if they need to go away and read about something maybe if, you know, we're diagnosing their patient, for example, is diabetic.

So they can go away and and use a, you know, a, a good resource to educate themselves further. One other aspect of communication we do need to think about with these patients is structured handovers. So the ISA handover is endorsed by the World Health organisation, and it's one that's used in human healthcare.

And within this handover, we, we have these 5 different sections. We identify the patient, we talk. About the situation, why the patient's here, a bit about their background.

We then hand over our assessment, so our observations. We come back to that patient, a clinical assessment and my nursing assessment and observations of the animals. So what, what have I, you know, what's the trends been today?

We then finish that handover with a recommendation for the incoming shift so that then anything that's outstanding can be rectified and we've handed all that information over so that everything's clear and there's the opportunity to ask questions. So in summary, I think nurses play an enormous role in these sorts of patients, in the triage of these patients, in being prepared when they arrive, in assisting with these stabilisation techniques, in following these trends and monitoring these patients and observing things and, and coming back round with that nursing process to looking for a response to treatment. It's really important to have that clear lead so that we've got that communication and the agreed goals.

We're able to prioritise our concerns through our patient assessment, our triage and our secondary survey. As we said, coming back to the use of things like our scoring systems, which can help us to objectively score the patient in terms of things like pain or a coma score, and making sure that we advocate for our patients and we have this really clear communication. So hopefully now, by the end of this session, you are able to define the principles of triage, describe how to identify and treat shock, list the effective ways to deliver oxygen therapy, discuss the benefits of an emergency database and implement other commonly used stabilisation techniques.

As I mentioned, you can rewind the lecture or pause it here and make a note here of some of the useful resources that we have touched on throughout this session where you can go and read a little bit more should you want to. Otherwise, that ties this session up. If you do have any questions, then my email is here.

But otherwise, just remember the importance of coming back to that, that clinical exam of the patient, and, and really that close observation.