First aid and other emergencies

Chapter 3


First aid and other emergencies




First aid is the first important action that is carried out when an animal suffers an accident. What is done to the animal will influence whether it lives or dies and will have an effect on its subsequent treatment and recovery.


Under the Veterinary Surgeons Act 1966, anyone may carry out first aid providing that it is:



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:



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:




(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:



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





Procedure: Treatment of asphyxia



1. Action: Clear any obstruction from the mouth and the pharynx.


    Rationale: Obstructions may include clotted blood, saliva, vomit and solid material such as balls and wet leaves (if animal has drowned). A useful tip is to use the handle of a large spoon to lever out the obstruction without being bitten.


2. Action: Loosen the collar.


    Rationale: To facilitate breathing, but do not remove the collar as the animal may suddenly recover and run off. A dog running around without its collar is a stray.


3. Action: If water or a foreign body blocks the trachea then perform the Heimlich manoeuvre to remove the obstruction – hold the animal up by its hind legs or, if the animal is too big, hang it upside down over a table (Fig. 3.1). Administer a sharp punch to the abdominal wall, above the xiphisternum angled down towards the diaphragm.



    Rationale: This aim of this technique is to force foreign material from the trachea. The obstructing material may move down the trachea towards the pharynx in response to the pull of gravity.


4. Action: Repeat up to four times.


    Rationale: Repeating the procedure more than four times may cause damage.


5. Action: If attempts to remove the blockage fail then establish an emergency airway by pushing a wide gauge hypodermic needle through the ventral midline of the neck and into the trachea.


    Rationale: This will act as an airway until a proper tracheotomy can be performed.



Tracheotomy vs tracheostomy


A tracheotomy creates a temporary opening in the trachea in an animal with an upper airway obstruction allowing air to enter the trachea distal to the site of the blockage. If a tube is then placed in the stoma created by the tracheotomy this is then termed a tracheostomy. The procedures are usually performed as an emergency under local anaesthetic or sedation – dyspnoeic patients may present an anaesthetic risk. Aseptic preparation of the surgical site should be carried out (see Ch. 9), but if the animal is about to die it need not be done – provide antibiotic cover later on when the situation has improved.


The animal will present with increased inspiratory effort, dyspnoea, cyanosis, open mouth breathing and orthopnea. If the condition is acute, i.e. the animal is close to death, then a wide gauge hypodermic needle can be pushed through the ventral midline of the trachea as a temporary measure.


A tracheotomy may also be used to remove obstructions or to collect samples.



Procedure: Tracheotomy



1. Action: Position the patient in dorsal recumbency with the neck extended and raised up over a pad.


    Rationale: This helps to deviate the trachea ventrally.


2. Action: Clip up and prepare the caudal mandibular area, ventral neck and cranial thorax aseptically.


    Rationale: Ensure that the area is larger than you might expect as this gives you room for manoeuvre.


3. Action: Make a midline incision in the ventral cervical area of the neck and extend it from the larynx to the sternum.


    Rationale: To allow adequate exposure.


4. Action: Separate the overlying sternohyoid muscles along their midline and retract them laterally.


    Rationale: To provide a good view of the trachea and the proposed site.


5. Action: Blunt dissect the peritracheal connective tissue from the ventral surface of the trachea


    Rationale: To facilitate entry into the trachea.


6. Action: Do not traumatize the vital structures running on either side of the trachea (i.e. recurrent laryngeal nerve, carotid artery, jugular vein and thyroid vessels). Also look out for the oesophagus.


    Rationale: Keep in the midline and you should avoid these structures.


7. Action: Fix the trachea between your forefinger and thumb and make a horizontal or vertical midline incision through the wall of the trachea.


    Rationale: To create an opening into the trachea.


8. Action: Place sutures around the adjacent tracheal cartilages and use them to pull the edges of the incision apart.


    Rationale: To elevate the cartilages and separate the edges, allowing inspection of the tracheal lumen.


9. Action: Use suction to clear debris, blood and secretions from the lumen.


    Rationale: To remove any blockage.


10. Action: If possible find the source of the blockage and remove it.


    Rationale: This may not always be possible.


11. Action: If the airway is now clear the opening can be closed:



    Rationale: Make sure that the suture line is more or less airtight to prevent air under-running the tissues as the animal inspires. This will gradually improve as the wound heals.



Procedure: Temporary tracheostomy



1. Action: Prepare the patient as above and follows steps 1 to 7 (Fig. 3.2).



    Rationale: The procedure is very similar, except that a tracheostomy tube is placed so that the stoma created stays open for a longer period and the site is more prescribed.


2. Action: If placing a tracheostomy tube the tracheal incision should be horizontal and between the 3rd / 4th or 4th / 5th tracheal cartilages. Do not extend the length of the incision more than half of the circumference of the trachea (Fig. 3.2).


    Rationale: To allow room for the flange of the tube to be placed comfortably below the larynx. The tube is unlikely to be dislodged by movement of the neck.


    If the incision is too long there is a risk of bisecting the trachea completely.


3. Action: An alternative incision can be made vertically between the 3rd and 5th cartilages.


    Rationale: It may be more difficult to place the tracheostomy tube using this approach.


4. Action: Using suction remove blood and other debris from the trachea.


    Rationale: To facilitate inspiration and clean up the surgical site.


5. Action: Select a tube that is non-reactive and that is no larger than half the size of the trachea. If the patient is to be placed on a respirator a cuffed tube must be used.


    Rationale: To prevent a reaction and to reduce resistance within the trachea. Use of a cuffed tube prevents breathing around the tube.


6. Action: Place a suture around the tracheal ring distal to the incision (Fig. 3.2).


    Rationale: This will be used to assist in opening the trachea prior to tube placement.


7. Action: Using a pair of closed artery forceps, depress the cartilage cranial to the opening.


    Rationale: To facilitate introduction of the tube.


8. Action: At the same time, using the suture around the distal cartilage, pull it up and insert the tube (Fig. 3.2).


    Rationale: This opens the incision making it easier to insert the tube. If there are difficulties the tracheal incision can be widened or a small ellipse of cartilage can be resected.


9. Action: Oppose the sternohyoid muscles with a continuous suture.


    Rationale: To close the dead space and to hold the tube in place.


10. Action: Close the subcutaneous tissues and the skin as normal (see Ch. 10).


    Rationale: To close the dead space and to hold the tube in place.


11. Action: Secure the tube by suturing it to the skin or by tying a gauze bandage around it and tying that around the patient’s neck.


    Rationale: The patient must be checked regularly to make sure that the tube is still in place and the site is not becoming infected (Box 3.2).



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).



    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 image–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).



    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.



    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).






Procedure: Control of haemorrhage



1. Action: Place the animal on a stable table or on a surface that is at a comfortable height for you.


    Rationale: If the animal feels secure it will be less likely to try and escape. If the procedure takes some time you must feel comfortable and have easy access to the animal.


2. Action: Ask an assistant to restrain the animal so that you can reach the affected part of the body without the animal moving too much or biting you.


    Rationale: The animal may resent the wound being touched. Your assistant should be able to react quickly to prevent the animal moving or trying to escape.


3. Action: Wash your hands thoroughly with a surgical scrub.


    Rationale: It is important not to introduce infection into the wound, but as the wound is not sterile there is no need to scrub up.


4. Action: Assess what type of haemorrhage you are presented with (Table 3.1).


    Rationale: The extent of the haemorrhage depends on which blood vessels are severed and determines your treatment.


5. Action: As quickly as possible stop the bleeding using one of the first aid measures described in Table 3.2.


    Rationale: It is vital that the animal loses as little blood as possible. The method depends on where you are, for example, in the surgery or in the ‘field’.


6. Action: Once the bleeding has stopped, or is showing signs of stopping, assess the animal’s condition. Check for signs of shock and treat if necessary (see later procedure).


    Rationale: Blood loss may lead to hypovolaemic shock. Treatment must be instigated as soon as possible to prevent death.


7. Action: Monitor the animal closely. If blood soaks through the bandage, place another one over the top. Do not remove the original bandage.


    Rationale: If you remove the original bandage you may remove the blood clot and start the bleeding again.


8. Action: Once the animal’s condition is stable, place it in a quiet warm kennel and check every 15 minutes.


    Rationale: Overexcitement may start the bleeding again.


9. Action: When the bleeding has stopped and the animal is stable, treatment to repair the wound can be carried out.


    Rationale: It may be necessary to anaesthetize the animal – this should not be done until you are certain that the animal is out of danger and anaesthesia no longer poses a risk.

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Jul 24, 2016 | Posted by in SMALL ANIMAL | Comments Off on First aid and other emergencies

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