Top 10 Tips + Tricks for the Emergency Room
TIP 1: TREATMENT TRUMPS DIAGNOSIS
Don’t get focused on trying to find the diagnosis right away, fix those life-threatening issues and you can work on getting a more solid diagnosis later on. – This is especially true of respiratory distress patients e.g. cats in congestive heart failure.
– They need immediate stabilisation (usually with sedation/oxygen), not something like an x-ray.
– Point of care ultrasound is a great alternative to an x-ray.
– Similarly, patients in hypovolemic shock need fluid boluses right away, not blood tests.
TIP 2: SPRING CONSIDERATIONS… ALLERGIC REACTIONS AND ANAPHYLAXIS
Antihistamines and steroids are not your first line of treatment for anaphylaxis. What they need is fluid boluses and adrenaline. – In springtime we see more allergic reactions and anaphylaxis.
– Anaphylaxis is very different from the usual swollen face, swollen eyes or hives that we see which may require antihistamines.
– Anaphylaxis is true cardiovascular collapse: it requires fluid boluses, adrenaline or epinephrine to help correct that cardiovascular collapse.
– Adrenaline is a great antihistamine in itself so it helps reverse anaphylaxis.
TIP 3: STAY SUTURES TO HELP UNBLOCK MALE CATS
During lockdown, we’re seeing more stressed cats, more cystitis, maybe even more urethral obstruction… – It can be useful to place stay sutures in the prepuce and use to extrude, straighten up the urethra and give you more free hands.
– This will help with passing the catheter, the flushing and whatever else you may need to do.
– Typically we extrude, find a good piece of the prepuce, put the stay suture through, clip off the needle, and put some clamps on the end.
TIP 4: USE OF NON-STEROIDALS IN GENERALISED TRAUMA
Avoid using non-steroidals, at least in the beginning. – In patients who have been involved in any sort of polytrauma, stick to opioids, ketamine and whatever else you may need at first. Non-steroidals can come later.
– We don’t know much about their renal microcirculation; the creatinine might be normal but that doesn’t mean there won’t be delayed damage.
– Non-steroidals can cause platelet disfunction and exacerbate bleeding.
– Non-steroidals are however appropriate for focal trauma.
TIP 5: RULING OUT A UROABDOMEN
If you have free fluid in the abdomen following trauma, you need to rule out a uroabdomen. – Even if you see a bladder on ultrasound/x-ray and it appears intact, this doesn’t mean there isn’t damage to the urogenital tract somewhere.
– Be safe: take a sample from the abdomen, check the creatinine and potassium levels and compare them to the levels in the blood.
– If the sample from the abdomen is significantly higher, you’ve got a high suspicion of a uroabdomen.
TIP 6: GET FRIENDLY WITH YOUR MICROSCOPE
Spend time looking at haematology samples and both spun and unspun cytology samples. – We do a lot of cytology and microscopy in the emergency room.
– If this isn’t something you do on a routine basis, then get comfortable by practising.
– If you come up with a routine to look at a blood smear in the same way each time then you’ll be happier with it. The more you see normal, the more comfortable you’ll be with recognising abnormal samples.
– Same with cytology samples: with free fluid in the abdomen you may take a smear, and when you look at it you just see neutrophils, then you spin it down and find there’s a lot of bacteria and intracellular bacteria. So, you can look at spun samples, un-spun samples, but just do it more!
TIP 7: OXYGEN DOES NOT FIX DISEASE
We worry that full examination of unstable respiratory distress patients is going to stress them out, so it’s great to give them a bit of sedation, diuretic, put them on oxygen, BUT… – If they have a pleural effusion, pericardial effusion, pneumothorax, pyothorax, they’re not going to get any better or they’re going to get worse without treatment.
– Don’t be tempted to put them on oxygen and leave them – make sure you come back quite quickly to re-evaluate them. Maybe do some point of care ultrasound.
– If there’s a high suspicion of some pleural disease, you could do some diagnostic thoracentesis and move on from there.
TIP 8: SLOW IS SMOOTH + SMOOTH IS FAST
When we’re in a high pressure situation, we may be more prone to mistakes. – Take time to forcibly slow yourself down a little bit and think about the steps you’re about to take.
– By slowing down we can ensure a smoother procedure, and if things are going smoothly we’re going to finish them up more quickly without having to repeat anything.
TIP 9: IT’S ALL ABOUT COMMUNICATION
It is your responsibility to be understood rather than your team’s responsibility to understand you. – In high pressure situations, make sure you are still communicating clearly and concisely with your team.
– If you’re communicating important information, you could ask your team to repeat it back to you or even write it down to ensure there are no errors.
TIP 10: ENSURING PATIENT COMFORT
– A lot of emergency patients require IV access quite quickly, but if they don’t then take time to clip up the leg and apply numbing agent.
– If you need any blood samples, get them out of the IV catheter rather than going for a second vessel.
– If you’ve got extremely stressed patients, consider sedation. Trazodone helps smooth anxiety, or use low doses of Medetomidine, Dexmedetomidine or Acepromazine on top of pain relief.