Tuesday, September 3, 2013

Three things I learned: common mistakes in the emergency room (ER)

 
Why I love webinars: because Hero lounges on my desk while I learn. Everyone wins!
I’ve been trialling the services of VetGirl, a subscription-based pod-casting, webinaring, veterinary continuing education provider. Last week I enrolled in a webinar on Common Mistakes to Avoid in the ER, with Dr Justine Lee.

I enjoy Justine’s candour and style. She started the webinar by admitting that she was not an A student, she shares her worst experiences (they are, after all, probably the things that we learn from most) and her passion for ER is as palpable as a grade 6 heart murmur.

She discussed what she considered to be the top ten mistakes that are made in emergency situations. So I’m picking three that I found helpful.

  1. Not doing enough chest radiographs (in dogs): this is especially important in geriatric patients. Dr Lee agreed that thoracic radiographs are often a low-yield test but the impact of a positive met-check changes everything. If the patient won’t allow a DV or VD at least two opposite laterals gives a reasonable indication of the presence of mets. Of course in dyspnoeic cats we should possibly be performing less thoracic radiographs (more TFAST and chest taps). Dr Lee has discussed this in more detail in a previous webinar.
  2. Using shock rates of fluids: the textbooks cite shock rates as 60-90ml/kg which is almost the blood volume of the animal and really is overdoing it – especially in cats. Dr Lee recommends bolusing smaller amounts (1/4 to 1/3 of shock rates) over a variable time period (e.g. if it’s a cat with a gallop rhythm this might be given over an hour; if it’s an unstable GDV it might be administered over 20 minutes). This can be repeated several times.
  3. Using the wrong dose of steroids: older textbooks recommend 4-6mg/kg of dexamethasone sodium phosphate for just about everything including shock. But dex SP is 8-15x stronger than pred. Dr Lee recommends treating animals with IV fluids, blood products and vasopressors for shock, and if dex SP must be used, less of it (e.g. 0.01mg/kg q12hr IV for anti-inflammatory effect and 0.25mg/kg q12hr IV).
For more information about VetGirl, check out the site here.

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