First aid and other emergencies

What must happen afterwards is that the animal is handed over to a veterinary surgeon for further treatment. It is illegal for a layperson to keep the animal and continue treatment as this becomes an act of veterinary surgery requiring diagnosis, possible surgery and the prescribing of medication. Failure to do this may cause suffering, which will contravene the Animal Welfare Act 2006.

In many cases it will be a member of the public who administers first aid out in the ‘field’ (e.g. road traffic accident or a cut paw) but in some cases such as haemorrhage or anaesthetic arrest, which may occur within the practice, it will be the veterinary surgeon who is first on the scene. Obviously the chances of survival of the animal will be greatly increased by the degree of knowledge and experience of the person dealing with it; however, whoever this person is, the basic rules of first aid should be followed.

First of all, keep calm and don’t panic – always ensure your own safety first. You will not be able to help the animal if you are injured. Levels of panic can be significantly reduced by knowledge and training and adhering to a well-rehearsed routine.

Now remember the acronym ABC:

• Airway – ensure that the animal has a clear airway allowing the passage of oxygen into the respiratory system and then into the circulatory system.

• Breathing – make sure that the animal is making some form of respiratory effort.

• Circulation – check that the heart is beating, i.e. there is a pulse, and look at the colour of the mucous membranes; a healthy pink colour will indicate oxygen is reaching the tissues.

When an animal is about to suffer cardiopulmonary arrest and requires resuscitation it is important to be able to recognize the clinical signs (Box 3.1) and to have a strict routine for cardiopulmonary cerebral resuscitation (CPCR). In an emergency everything seems to happen at once and successful treatment requires a trained ‘crash’ team who have defined roles and understand their responsibilities. The procedures that must be carried out by this team are:

Box 3.1 Signs of cardiopulmonary arrest or impending death

• Loss of consciousness

• Absence of respiratory movements or agonal (gasping) breathing

• Either a very weak rapid pulse or lack of a pulse or heartbeat

• Fixed dilated pupils

• Lack of corneal or palpebral reflexes

• Cornea begins to dull

• Loss of control of the bowel and bladder

• Intubation of the patient and attachment to an anaesthetic machine

• Provision of oxygen and manual compression of the reservoir bag if necessary

• External cardiac massage

• Placement of an intravenous catheter for the administration of fluids

• Attachment to an ECG machine to monitor progress and to assist in the provision of appropriate medication.

(In order to avoid repetition some procedures that may also be used as a first aid procedure or as continuing treatment are included in other chapters:

• Bandaging and stabilization of limbs – see Chapter 4

• Wound management – see Chapter 4

• Fluid therapy – see Chapter 7

• Anaesthetic emergencies – see Chapter 8.

Look inside the front cover for a life support algorithm.)

Procedure: Assessing the emergency patient

The steps in this assessment must, of necessity, be as rapid as possible and they will run into each other, making you feel that the steps must be carried out simultaneously. This may add to your feeling of panic but, in order not to forget anything, it is important to stick to a rigid protocol and remember the rules of Airway, Breathing, Circulation.

1. Action: Ensure that the environment is safe for you and the animal.

Rationale: Do not attempt to rescue or treat an animal if there is any risk to you (e.g. electrocution, traffic, fire, radiation, falling masonry).

2. Action: Stand back from the animal and observe for a moment.

Rationale: You must remain calm and in control. Touching the animal may destroy some evidence (see Ch. 2). Try to calm the owners or people around the animal as they may be panicking.

3. Action: Make sure that the animal is restrained appropriately. You may need to ask someone to help you. If the animal is breathing normally you may have to apply a tape muzzle (see Ch. 1).

Rationale: The first reaction of an animal that is frightened and in pain is to bite and / or to run away. Never apply a tape muzzle to an animal that is having trouble breathing.

4. Action: Examine the airway to ensure that it is patent.

Rationale: The animal may be trying to breathe, but this will be difficult if the airway is blocked

5. Action: If necessary remove any blockage (e.g. blood clot, saliva, rubber ball).

Rationale: Both clotted blood and saliva can create as effective a blockage as a solid object such as a ball.

6. Action: Position the animal in such a way as to facilitate breathing (e.g. in lateral recumbency with the head extended, tongue pulled forward, loosen the collar). If the animal has been drowned, place the head lower than the rest of the body.

Rationale: In this position the airway should remain open. Never remove the collar as the animal may suddenly recover and run away and it will then be without its collar. Placing the head lower than the body enables water to drain out of the airway.

7. Action: Check that the animal is breathing. If necessary start artificial respiration (refer to later procedure).

Rationale: Lack of oxygen to the brain will kill the animal or cause irreparable brain damage within a matter of minutes.

8. Action: Check that the animal has a heartbeat. If necessary start cardiac massage (refer to later procedure).

Rationale: If the heart is not beating, oxygen will not be pumped around the body to supply the brain and other vital organs.

9. Action: Check the patient’s capillary refill time, colour of mucous membrane, pulse and respiratory rate and body temperature. Record these parameters.

Rationale: These parameters will provide an indication of the animal’s condition and provide a starting point on which to base your assessment as the animal’s condition improves.

10. Action: Once the patient is stable and not going to die immediately, check for haemorrhage and take steps to control it (refer to later procedure).

Rationale: Haemorrhage must be dealt with quickly as severe blood loss will kill the animal within a few minutes or cause it to go into shock.

11. Action: Assess the animal for signs of shock and treat appropriately (refer to later procedure).

Rationale: In severe cases shock will set in rapidly and treatment must be instigated as soon as possible.

12. Action: Examine the animal for fractures and immobilize them (refer to Ch. 4).

Rationale: The presence of a fracture is not generally life threatening, but it will cause pain and the condition may be made worse by movement.

13. Action: Check the animal for all other wounds and provide a temporary dressing as appropriate.

Rationale: To prevent the entry of infection before you can clean, debride and provide proper wound dressings (refer to Ch. 4).

14. Action: Administer the appropriate medication (e.g. antibiotics and analgesics).

Rationale: Antibiotics will prevent sepsis and analgesia will help the animal to stabilize.

15. Action: Once you are satisfied that the animal is safe to move, take it to the surgery, or, if in the surgery, place it in a warm, quiet secure kennel and keep under observation.

Rationale: The first few minutes after an incident are vital, but once the animal is stable most wounds and immobilized fractures can be left for a short time while the animal begins to recover and poses less of an anaesthetic risk.

Airway and breathing

Box 3.2 Care of the tracheostomy tube

• Monitor the patient at regular intervals throughout the 24-hour period.

• Do not use fluffy bedding or cat litter in the kennel as this may become sucked into the tube and block it.

• Do not feed sloppy, dry or flaky food as this may block the tube.

• Never put a collar on the patient.

• Make sure that the patient does not occlude the tube when it is sleeping.

• Before starting or finishing any procedure, i.e. cleaning or checking, administer 100% oxygen for 5 minutes to the patient.

• Clean the tube every 2–3 hours to prevent it blocking up with discharge and to prevent infection.

• Clean around the entry site of the tube with surgical scrub and then dry.

NB Tracheostomy tubes used in emergency situations are not usually left in for more than a day or two. A permanent tracheostomy is achieved by the creation of a permanent stoma within the trachea and overlying skin, which may remain for life or until such time as the stoma is closed surgically.

Procedure: Artificial respiration

In some instances (e.g. out in the ‘field’) there may not be equipment available to intubate an animal so artificial respiration should be done by this method. Assume there is no damage to the chest wall. (For artificial respiration in an intubated patient refer to Ch. 8.) If there is damage to the chest wall, artificial respiration should be done by the mouth to nose method described below.

1. Action: Place the animal in right lateral recumbency with its head and neck extended, and pull the tongue forwards (Fig. 3.3).

Figure 3.3 The recovery position.

Rationale: This position allows maximum air intake.

2. Action: Pull the front legs forward.

Rationale: In order to prevent the musculature of the shoulder and upper limb from obscuring the site at which pressure should be applied.

3. Action: Check that there are still no respiratory movements.

Rationale: Moving the animal sometimes stimulates spontaneous respiration.

4. Action: Place the palm of your hand in the middle of the chest (Fig. 3.3).

Rationale: Your hand will be directly over the majority of the lung field and will be used to force air into and out of the chest.

5. Action: Apply steady firm downward pressure and then release.

Rationale: The elasticity of the rib cage makes the ribs spring back up, drawing air down the trachea.

6. Action: Apply the pressure at –1-second intervals depending on the size of the animal.

Rationale: The smaller the animal the faster is the respiration rate.

7. Action: Check the animal at regular intervals for signs of respiration.

Rationale: You may find it easier to ask an assistant to do this while you continue to administer artificial respiration.

8. Action: Continue until the animal begins to breathe on its own.

Rationale: Continue artificial respiration for about 30 minutes; if the animal is still not breathing it may be pronounced dead.

9. Action: As soon as the animal starts to breathe provide oxygen.

Rationale: If you are not in the surgery this can be difficult, but if in the surgery you should intubate and provide oxygen through a circuit. If intubation is impossible then provide oxygen by mask.

10. Check the animal every 5 minutes during its recovery and extend the time intervals as it regains consciousness.

Rationale: Relapses can occur.

Procedure: Mouth to nose resuscitation

This is used to stimulate breathing when the chest wall is damaged.

1. Action: Place the animal in right lateral recumbency with its head and neck extended, and pull the tongue forwards.

Rationale: This position allows maximum air intake.

2. Action: Grasp the nose firmly in the right hand so that the thumb and fingers curl around the nose and mouth, and hold the mouth closed (Fig. 3.4).

Figure 3.4 Mouth to nose resuscitation – holding the nose.

Rationale: This creates an airtight seal.

3. Action: Place the left hand under the lower jaw (Fig. 3.4).

Rationale: This supports the lower jaw.

4. Action: If possible use a facemask, a handkerchief or some form of cloth to blow through.

Rationale: To prevent the potential transfer of pathogens.

5. Action: Place your mouth over the animal’s nostrils forming a seal with your lips.

Rationale: To maximize the effect of your expiratory effort.

6. Action: Blow down the nose at 1-second intervals turning your head away after each expiration.

Rationale: To avoid inhaling the animal’s expired air and mucus. Your expired air contains carbon dioxide, which acts as a respiratory stimulant for the animal.

7. Action: Do not overinflate the lungs particularly if the animal is neonatal (i.e. resuscitation after a caesarean section). Use just enough force to raise the chest slightly.

Rationale: Lung damage can occur as a result of sudden overinflation, especially in young animals.

8. Action: Periodically check for signs of respiration.

Rationale: You may find it easier to ask an assistant to do this while you continue to administer mouth to nose respiration.

9. Action: Repeat the procedure until spontaneous respiration begins.

Rationale: Continue for 20–30 minutes. If there is no response the animal may be pronounced dead.

10. Action: As soon as the animal starts to breathe provide oxygen.

Rationale: If you are not in the surgery this can be difficult, but if in the surgery you should intubate and provide oxygen through a circuit. If intubation is impossible, provide oxygen by mask.

11. Action: Check the animal every 5 minutes during its recovery and extend the time intervals as it regains consciousness.

Rationale: Relapses can occur.

Circulation

Procedure: Cardiac massage

This procedure should be started as soon as possible after the lack of a pulse or a heartbeat has been detected as lack of oxygen to the brain and other tissues will very quickly result in permanent damage and / or death.

1. Action: Place the animal in right lateral recumbency.

Rationale: In this position there is easier access to the heart for massage and for monitoring.

2. Action: Locate the position of the heart.

Rationale: The heart lies between the 3rd rib and caudal border of the 6th rib.

3. Action: Using the heel of your hand, place it over the heart (Fig. 3.5a). Apply rhythmic pressure using enough force to depress the chest wall by 1–3 cm depending on the size of the animal.

Figure 3.5 Technique used for cardiac massage in (A) a dog and (B) a cat.

Rationale: This force will reach the heart wall and compress the muscle.

4. Action: Place your other hand under the animal’s chest to support it (Fig. 3.5A).

Rationale: You can also place a firm sandbag under the chest to provide something to push against.

5. Action: In feline patients or in very small dogs you can apply pressure by placing the thumb and forefinger around the sternum (Fig 3.5B).

Rationale: As the animal is small your hand should fit around the sternum to reach the appropriate part of the chest wall.

6. Action: The ideal rate of chest compressions is 100 per minute giving equal time to compression and relaxation.

Rationale: Singing ‘Nellie the Elephant’ will provide the appropriate beat to your compressions.

7. Action: Give a breath every 5th or 6th compression.

Rationale: If the animal is intubated, squeeze the bag; if you are out in the ‘field’ breathe into the animal’s nose as described above.

8. Action: Every 3–4 minutes check for signs of a returning heartbeat.

Rationale: Look for improved mucous membrane colour, restoration of a pulse, decreased capillary refill time and reduction in pupil size.

9. Action: If cardiac function returns then stop chest compressions.

Rationale: You may cause damage to the heart if chest compressions continue while the heart is beating.

10. Action: If cardiac function does not return, assess the condition of the patient and then consider open-chest compressions.

Rationale: This cannot be carried out in the ‘field’. If the animal is in the surgery this procedure can be considered but the prognosis is poor (see Ch. 8 – Anaesthetic emergencies).

Control of haemorrhage

Any loss of blood can potentially be life threatening and should be taken seriously. Table 3.1 describes the types of haemorrhage and Table 3.2 describes the range of first aid treatments. Methods used to control haemorrhage are temporary and once haemorrhage has ceased the bandage should be removed and the wound cleaned and treated by suturing or by rebandaging (see Ch. 4 for bandaging techniques and Ch. 10 for suturing techniques).

Table 3.1

Types of haemorrhage

Type	Clinical signs	Treatment
Arterial	Blood is bright red and pumps out in spurts. Bleeding point is usually easy to identify.	Very serious and a significant volume may be lost rapidly. Stop immediately using digital pressure until a more permanent method is put in place.
Venous	Blood is darker red and flows in a steady stream. Bleeding point is usually easy to identify.	Serious; stop as soon as possible by digital pressure or a pressure bandage.
Capillary	Multiple pinpoint haemorrhages. Blood oozes from the wound with little force. Commonly seen in surgical incisions.	Less serious, but capillary ooze for a long period may result in significant blood loss. Stop by means of a pressure bandage.
Mixed	Combination of the types described above. This is the most common type.	Depends on the extent of the haemorrhage.

Table 3.2

Range of first aid treatment for haemorrhage

Treatment	Method	Comment
Direct digital pressure	With a clean finger and thumb apply pressure to either side of the wound. Avoid pushing bone fragments or foreign bodies deeper into the wound.	Quick and easy, but only a temporary measure until a pressure bandage is applied.
Pressure bandage	Place sterile swab over the wound and apply pressure using a conforming bandage. If wound involves the neck or chest, make sure that breathing is not impeded.	Deep wounds may need packing with sterile gauze to spread the pressure. If wound includes a penetrating foreign body or bone fragments, place a ring pad over it before placing the bandage.
Pressure points	These are sites where pressure can be applied to a major artery by pushing it against a bone, thus stopping the blood supply to the area distal to it. Common sites are the brachial, femoral and coccygeal arteries.	Sites are not easy to locate. Venous bleeding still continues. Apply a pressure bandage or tourniquet as soon as possible.
Tourniquet	Ready-made or improvised strap is applied to a limb proximal to the injury and tightened. Pressure should be just enough to stop bleeding.	Never leave a tourniquet in place for longer than 15 minutes as tissue damage will occur. Relieve pressure for 1 minute then retighten.