The role of the veterinary technician in traumatic emergencies is pivotal to the survival of the incoming patient. The physical exam must be quick, thorough, and concise. Utilization of all technical skills from careful visualization, palpation, and auscultation is of the utmost importance. The use of emergency equipment is also useful, but should not be a substitute for a proper physical exam. The following outline summarizes a systemic approach to the most common traumatic emergency, the hit-by-car (HBC).
The airway should always be evaluated immediately upon arrival of the HBC. As a rule of thumb, one must remove the most immediate threats of life first, the whole concept behind triage. If a patient presents breathing, note that this does not ensure a patent airway. Before any action is taken, visually watch both the respiratory effort and respiratory pattern. Are chest expansions adequate? Keep in mind that the patient just received a traumatic injury, rode in an automobile, and is now surrounded by strangers. The first evaluation of the respiratory system, therefore, although diagnostic, should be repeated after several minutes to several hours. Examples of common respiratory patterns secondary to trauma include abdominal breathing, paradoxical breathing, and shallow or poor chest expansions.
Note that these are patterns of respirations. They do not indicate a number. Tachypnea (elevation of the respiratory rate) is simply a number. It does not mark a pattern of respiration, or the effort of respiration. In traumatic injuries such as the HBC, most patients will be tachypnic from stress alone. Therefore, it is by the pattern of the respirations that can characterize the nature of the injury. For example, abdominal breathing can indicate a diaphragmatic hernia, severe pulmonary contusions, pneumothorax, hemothorax, severe pain, or may indicate a metabolic abnormality such as acidosis secondary to poor perfusion. Paradoxical breathing can indicate a diaphragmatic hernia as well as blunt chest trauma, or can suggest a more severe diagnosis such as a cervical injury. Shallow or poor chest expansion can be a sign of shock, severe pneumothorax or hemothorax, an obstructive airway, atelectasis, pain, or pulmonary parenchymal contusions. In any situation, if abnormal respiratory patterns are present, minimize the stress to the patient and administer oxygen therapy in the least stressful route. Evaluate other clinical signs of respiratory insufficiency such as mucus membrane color and pulse quality, to further assess the patient's immediate needs. Again, counting the number of respirations is important, but not as critical as characterizing the pattern. Recommended oxygen therapy is listed as follows: mask: 3-5 lpm, oxygen cage at least 40%, and intranasal catheter insufflation at 50-100ml/kg/min.A quick, simple evaluation of the mucus membranes should also be a part of the check of the respiratory system. Note that in any traumatic injury, frequent evaluation of the membrane color is indicated. If a patient presents with normal, pink membranes but abnormal respiratory rate and pattern, the patient may not be hemodynamically stable. Repeat analysis of the membranes is essential. Note that pale membranes are an indication of a variety of incidences, from anemia to pain to hypoventilation. Again, note the respiratory pattern and respiratory effort to make a proper assessment of the patient's status in a timely fashion. Similarly, white mucus membranes, although abnormal, may not necessarily indicate a problem with the airway or respiratory system. White membranes may mean severe pain, hypothermia, shock, or ongoing blood loss. However, in addition to an abnormal respiratory pattern and rate/effort, the white membranes may suggest hypoventilation and the technician must administer oxygen in the least stressful route immediately. Cyanosis, or blue mucous membranes, indicates severe decompensation and respiratory shut down. Immediate action should be taken to reoxygenate the patient in the best effective manner.
Auscultation is the next step in evaluating the respiratory system. The patient should be sternal (if possible) and elimination of environmental noise for proper evaluation. If-possible, the patient should be refrained from panting or open mouth breathing, in order to auscult lung parenchyma and not referred airway noise. Frequent findings in the HBC patient auscultation include harsh lung sounds, decreased or absence of lung sounds, or guttural sounds in the thoracic area. Harsh lung sounds can be heard either ventrally or dorsally, either on inspiration or expiration, and may be isolated to the side of impact. Observe the respiratory pattern, respiratory effort, mucous membrane color, and utilize tools such as pulse oximetry or arterial blood gas analysis only as an extension to the physical exam findings. Administer oxygen if harsh lung sounds are present despite normal pulse oximeter values if the patient has any abnormal respiratory patterns or increased effort to ensure adequate oxygen exchange. Radiograph the thorax once the patient has been thoroughly evaluated and is not appear stressed. Thoracocentesis should not be attempted initially if there is no evidence of a pneumothorax on radiographs and the patient has a normal respiratory rate and effort.
You can provide basic medical care at the scene of the injury. Remember that any animal that is injured or in pain may bite or scratch. Injured animals must be approached carefully, and you should first take precautions for your own safety. Using a muzzle is often a prudent safety measure; one can be easily made from a piece of cloth or a ready-made muzzle can be included in the first aid kit. Never muzzle a dog with chest injuries or a dog with a short nose (brachycephalic breeds like Pugs), and never leave a muzzled dog alone.
If your pet is not breathing, you may need to perform mouth-to-nose resuscitation and chest compressions. Request instructions from your veterinarian or pet emergency hotline. To perform mouth-to-nose resuscitation, close the animal’s mouth, place your lips over the animal’s nostrils, and initially give 3 to 4 strong breaths (see Emergency Care for Dogs and Cats : Cardiopulmonary-Cerebral Resuscitation). If the animal does not start breathing on its own, breathe for the animal 10 to 12 times per minute. If you cannot detect a heartbeat, perform 5 chest compressions to 1 quick breath. Continue this pattern until the animal starts breathing on its own, or you get to veterinary assistance. Of course, in this situation, someone else will have to drive during transport.
Bleeding requires immediate first aid. Press down firmly on the bleeding area with your fingers or the palm of your hand, and then apply a firm, but not tight, bandage. Any long pieces of fabric or gauze can be used. Often washcloths and hand towels are enough when applied with mild pressure. If the original bandage becomes soaked with blood, do not remove it; simply place additional material on top and continue to apply pressure. These bandages can be secured in place using duct or packaging tape.
Burns can be difficult to evaluate because the fur makes it hard to examine the injury. Large deep burns, chemical burns, and electrical burns need immediate attention, as do burns involving the airway or face. Use cold water on the affected area, and cover the burn with a nonstick dressing.
Dogs or cats that are choking may cough forcefully, drool, gag, or paw at their mouth. They may also hold their mouth open and show signs of agitation. If you think your pet is choking, do not stick your fingers in its mouth because you can easily be bitten or push the object further in. Instead, you can try to dislodge the object by thumping the animal between the shoulder blades or by applying several quick, squeezing compressions on both sides of the ribcage.
Do not remove foreign objects that have penetrated the skull, chest, or abdomen. Prevent the object from moving or penetrating further. If an arrow has penetrated the abdomen, do not let the shaft of the arrow move during transport. It may be necessary to stabilize the shaft of the arrow just outside the body and, holding it firmly, cut the shaft off.
Heat stroke is another emergency. Normal rectal temperature for cats and dogs is about 101.5°F to 102°F (38.6°C to 38.9°C). Signs of heat stroke include skin that is hot to the touch, vomiting, drooling, rapid panting, distress, loss of coordination, collapse, and unconsciousness. Remove the animal from the heat. Use cool water, ice packs, or wet towels to cool the head and body. Offer small amounts of water after the pet has begun to cool down. Do not immerse the animal in cold water.
Hypothermia (overexposure to cold) usually results when an animal has been lost or outside in very cold weather for a long time after another accident or injury, such as a car accident. Signs of hypothermia include slow pulse, shallow breathing, disorientation, collapse, and unconsciousness. Shivering is not a usual sign of hypothermia in pets. If the animal is wet, first dry it thoroughly, and then place wrapped warm (not hot) water bottles around the body. White, numb skin may be frozen or frostbitten. Thaw the area slowly; do not rub it or apply snow or warm water.
Dogs or cats that have neck or throat injuries caused by strangulation, such as hanging by their collar, should be taken to the veterinarian immediately. Remove the collar and use a makeshift harness from rope or an extra leash to control the animal.
Moving an Injured Animal
When moving or transporting an injured animal, minimize motion of its head, neck, and spine. A flat, firm surface of wood, cardboard, or thick fabric can be used to provide support. If the animal acts confused or disoriented after trauma, keep the head level or slightly elevated during transport. Avoid any jerking or thrashing motions, and prevent anything from pushing on the neck or jugular veins. Placing cats in boxes can minimize stress during transport. The box should have holes large enough so that you can see the cat.