what could be some Presenting Complaints of an emergency resp case?
dyspnea, open mouth breathing, ADR, lethargy, tachypnea, anorexia, Vomiting/Gagging (happens in cats with resp dz..weird), exercise intolerance, collapse, fever, cyanosis
Is this normal?
No. CAT PANTING=BAD
what are some things you might note on clinical exam for presenting resp. emergency?
Lacerations/signs of trauma, None to sucking chest wounds, Restlessness, Anxiety, frantic bh, Gasping/shallow breaths, unconsciousness, Seizure like activity, fever, tachycardia, Use of accessory muscles (Abdominal press/restrictive component), Discoloration of mucous membranes (pale/cyanotic), Poor refill time, SQ emphysema
what did she mention about the wording of a "sucking chest wound"?
pressure pushes...but dec pressure on inside, so pressure on outside pushes in... pressure pushes, not sucks.
Why can an animal be weird calm or super frantic when there is bad resp distress?
all they care about is breathing, and that is all they are focusing on
what is some valuable info Auscultation can tell you about your resp pt? (what might you be able to hear?)
Increased adventitial sounds, Increased heart sounds, Muffled heart sounds, Referred upper airway noise, Bronchial vs. vesicular, Crackles and wheezes
***what should you know about taking rads in your ER resp pt?
THEY ARE ALREADY STRUGGLING TO BREATHE-- DONT STRESS THEM OUT BY FORCING THEM ON THE RAD TABLE. hold off on rads until a more reasonable time
**when is the only time you SHOULDNT give a ER resp pt OXYGEN?
....if they are on fire. So literally like always.
thoracocentesis before or after rads?
Which patient (based on presentation/CS) WOULD you want to do a thoracocentesis on, and which pt would you NOT?
WOULD IF: they have SHORT AND SHALLOW breathing-- means chest isnt able to expand bc there is shit in there. This is worth doing a thoracocentesis on. You would NOT do one (at least immediately) on a patient with full chest excursions and huge breaths
when might sedation/anxiolytics be useful to give to a resp ER pt?
laryngeoparalysis dogs-- so stressed theyre making it worse-- use ace to chill them out a bit and they will start to breathe a bit better
giving O2 does what to the partial pressure in the blood? How does this affect other gases in the body, and what dz is this good for?
O2 delivery increases the partial pressure in the blood. Which means it Decreases pp of other gases in blood. This is good for pneumothorax! Other gases will diffuse down gradient out of chest back into lungs and out
why is giving O2 good for penumothorax?
dec partial pressure of other gasses in the blood, so if have pneumothorax, allows other gasses to diffuse out of pleural space and into vasculature so it can get taken away (and uh, provides O2 when they arent good at breathing))
(whatever you gotta do) What are some various ways to deliver O2 to a ER resp pt?
Flow by, O2 hood-plastic bag 85-90%, O2 collar-80%, Nasal cath-40-50%, transtracheal, O2 cage (% is what percent O2 they are able to provide)
(basically anything) Conditions benefiting from O2 (list)
Why might you see Attenuation of vascular pattern?
Because lungs don’t extend to chest wall anymore
Rounded lung margins (scalloping of lung lobes)--> do you usually see this acutely or chronically? what might cause this?
what might cause ER resp problems with enlarged vessels on rads?
what are some soft tissue masses you might see on rads?
what are some cystic structures you might see on rads?
explain what Attenuation of vascular pattern on rads might tell you
(attenuation= dec ability to see them) (so, dont see vessels going all the way out- they are stopping short) Because lungs don’t extend to chest wall anymore--> air/something is pushing on them--> pressure on vessels causes them to collapse--> now you cant see them
this is a bulla- dilated balloon area of the lungs. commonly rupture---> pneumothorax
wuts going on here? what imaging modality is this?
This is a CT of hyro and pneumothorax (A= pneumo and B=hydro)
**WHERE do you do your thoracocentesis? (# ribs and location near ribs)
7th to 9th Intercostal space, at the CRANIAL edge of the rib (nn and vv are on the caudal border) (think about dog running through woods, runs into stick, want important shit BEHIND rib so stick just bounces off front of rib and it's fine)
how do you prep and perform the thoracocentesis?
(7-9th ICS, Cr border) clip and clean the skin, you can consider a local block (if you have time). Make sure beveled angle is flat to lungs (less chance of accidentally popping lungs- so poke in, bevel down, and then flatten out needle so you arent going down into lung). You might feel a "pop" when you enter in the pleural space.
what are the tools/instruments you will need for performing a thoracentesis?
needle attached to extension set, then 3 way stop cock, and then syringe.
how is US useful for thoracocentesis?
not only can it help guide your needle in, but it can help guide you to pockets of air or fluid you might wanna suck up
what is happening in flail chest. if its on one side do you want that side up or down when pt laying?
2 or more ribs broken- paradoxical breathing pattern where they breath in- mos of chest goes out, but that chunk is pulled IN by inc in intraplural pressure. opposite for exhaling. Want flair chest side DOWN bc other side is fxn better so give that side the room to expand!
pneumothorax can lead to wha pH balance?
acidotic- both bc lactic acid and bc too much CO2
Pneumothorax--> open vs closed?
CLOSED example: bulla-- rupture. dont have hole to outside world, but do have chest space air and not outside. OPEN= open to where? open to the outside! stabbed in chest with kitchen knife.
3 ways pneumothorax can occur?
Traumatic, spontaneous, iatrogenic
what kinda disorder is a pneumothorax?
what's going on here?
those whiteish blobs in the center are actually the LUNGS. This is a penumothorax-- air pressing down on lungs. causes short, shallow breaths bc they can't expand their lungs.
you notice on your rads that the contents of the mediastinum are oddly easy to see. what are you thinking?
easier to see bc AIR in the mediastinum-- suspect pneumothorax.
what are some signs/problems associated with pneumothorax?
which is more common- open or closed pneumothorax?
ex of things that can cause open pneumothorax
Stab, gunshot, bites (open hole to the outside)
ex of thigns that can cause closed penumothorax
impact (Chest compressed with a closed glottis- think holding your breath right before a car crash- your lung is the weak point, that is what will rupture), Pneumomediastinum, Pericardial effusion, Rib fractures
Spontaneous pneumothorax- is this a 1* or 2* condition?
could be either- depends on evidence of pulm dz or not. Look at lungs to see if dz to see if 1*
Spontaneous pneumothorax- who tends to get this?
Deep chested large breeds, huskies
which is the type of penumothorax which can progressively get worse and they can suddenly die on the table if you aren't paying attention?
what should you know about closed/traumatic/tension pneumothorax?
driving down the road, see car about to collide with you, brace for impact and hold your breath-- close glottis and get hit-- lung is weak spot, lung ruptured. This is a tension pneumothorax (can happen if you bag animals too much)
if you have an pneumothorax you might be able to also see air where?
why lactic acidosis in pneumothorax?
anaerobic metabolism happening bc lung cells dont have any O2
explain tension pneumothorax. What do these guys die from?
working like a "one way valve" where Inspiration sucks in expiration closes valve. This Increases intrathroacic pressure, which Decreases venous return— blood pooling in capacitance vessels…which leads to SHOCK—these guys will die while you take radiographs!
(she talked about blebs and bulla generally and mentioned how grass awns migrate and then kinda moved on) what are some things that can cause a spontaneous pneumothorax?
(1) Cavitary lesions (blebs, bulla, Pneumatoceles, Cysts-sterile or parasitic, Abscesses/granulomas) (2) Foreign bodies (awns/sticks/quills) (also on slide as causes: Pneumonia, Heartworms, Chronic granulomatous infections, neoplasia, asthma)
(not read in class by on slides) what is a bleb and what is a bulla?
Blebs-air accumulation in visceral pleura. Bullae-result of destruction, dilation, and convergence of contiguous alveoli, secondary to obstruction of small airways (right middle more often involved)
5 big things that you do that cause iatrogenic pneumothorax?
(1) FNA (2) intubation- ESP CATS! can be from traumatic intubation, or overinflation of the cuff (pressure necrosis), Moving with out disconnecting tubing, Extubation with out decuffing (3) Manual ventilation (4) Chronic effusions (chylothorax, pyothorax, malig effusions) (5) Chest taps/tubes
so you see this rad which shows effusion in lungs. how do you know what the effusion is?
TAP TAP TAP
what are some things which can be effusions/causes of effusions?
Blood, pus, chylous/pseudochylous, neoplastic
when you tap a chest effusion, you should be saving several samples for...
Cytology and culture, test for cholesterol if you think its chyle
what does chylothorax look like grossly? upon cytological exam?
looks like milk...see lymphocytes and fat droplets
what can neoplastic effusions look like?
look like anything- cancer does whatever it wants.
WHEN do you want to place a chest tube?
If …thoracocentesis not enough--> negative pressure unattainable, >10 ml/kg in 12 hours, repeated taps have been necessary
if you are getting ____ per ___ hr with thoracocentesis, you should consider a chest tube
>10 ml/kg in 12 hours
what should the size of the chest tube be?
about the size of the mainstem bronchus
**WHERE do you put a CHEST TUBE?
10th-11th ICS at the skin, then tunnel under skin 3-4 ICS cranial and THEN pop it in with some pressure. Then advance tube off stylet. The tunneling creates another seal for safety- if it falls out of hole, skin closes over it. Then stick a xmas tree adapter on it.
how do you secure a chest tube once you have placed it?
Purse string and Chinese finger trap, Xmas tree adapter, 3 way stopcock, bandage an e collar
(didnt mention in class) if you take rads where should the chest tube be sitting?
Cranioventral pleural space to level of 2nd rib
ANY compression on lungs can lead to what problems?
(so want lungs to work and be free)
some bloodwork and other lab tests you can do....
(1) CBC/CHEM: can be normal to consistent with 1* dz (2) Blood gasses (esp might wanna do if wanna checkHypoxemia or Respiratory acidosis) (3) heartworm tests (ELISA, smear) (4) Baermann sedimentation (lungworms)
what might you see on an ECG which might indicate you should be a little more aggressive with your tx bc it is a sign of stress? what are some other problems you might see?
Stress--> S-T segment changes. Also might see Arrhythmias, tachy and bradycardia
you DONT want BP to go below but and above what?
DONT WANT IT TO GO below 80 and above 150...so also check for low pulse pressures and check for weak doppler flow
why might you want to be checking temps in diff parts of the body?
If >10* difference in temp (like between rectal and toe web) might indicate poor perfusion to the hind limbs (saddle thrombus)
concerned w what temp? pulseox? CVP (central venous pressue)?
>104* temp, pulseox <92, CVP <3
what kinda urine output should you be concerned with?
low urine output
what are some things you can do for treatment?
OXYGEN (duh), Thoracocentesis, thoracostomy tube, thoracotomy with lobe resection....
how do you usually tx Traumatic pneumothorax?
can usually just tap
how do you usually treat spontaneous pneumothorax?
usually sx! (bc problem in lung like a bulla that is the problem) (recurrance 0-25% vs 50-100% with taps or tubes) or thorascopically
when do you know to take the chest tube out? (amount)
take out if you're getting 2-4ml/kg/day (this is how much the tube produces by being in there)
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