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Approach to the Patient in the Critical Care Setting
Sarah Allen, DVM, DACVECC

Massachusetts Veterinary Referral Hospital, Woburn, MA, USA

Patients presenting to a veterinary emergency room rep- sequence. The exam may need to be performed in multi-
resent a diverse array of illness and injury, ranging from ple phases to allow for patient comfort and safety.
mild to life threatening. The use of a triage system allows Due to the critical condition of these patients, initial
these patients to be systematically evaluated and prior- exam time should be spent on evaluating critical sys-
itized based on presenting signs, history, and initial vital tems, particularly airway and breathing, heart and circu-
parameters. While no triage system is perfect, success is lation, and neurologic status. For patients in respiratory
enhanced when staff are well trained. Every facility and distress, brief attempts at an exam may need to be inter-
emergency team should have a standard triage system, spersed between periods of rest in an oxygen chamber.
appropriately trained staff to perform triage, and a relia- Observation of the patient’s respirations with attention
bly equipped area to allow for efficient and prompt care to chest wall and abdominal movement may also provide
of these patients’ needs. information as to the cause of distress. Emphasis should
A clinician’s relationship with a critical patient often be placed on thoracic auscultation to help discern the
begins upon presentation to the hospital or, in the case of cause of distress, noting stridor, air movement or
a referral center, upon admission to the intensive care increased/decreased lung sounds. If the patient is not
unit (ICU). As the direct definition of the word “critical” breathing or is ineffectively moving air, intubation and
states, a critical patient is one that is at a stage of disease manual ventilation is required.
when an abrupt change for better or worse may be The heart should be ausculted while peripheral pulses
expected, or that has an illness or condition involving are palpated. If heartbeat and pulses are absent, CPR
danger of death. Due to this unstable position, these must be instituted immediately (see Chapter 37). If the
patients require intense and continuous assessment and heart is beating and pulses are absent or irregular, fur-
care and may benefit from consultation with a critical ther investigation and intervention are required to
care specialist. restore effective circulation. During heart auscultation,
the heart rate and rhythm should be noted and heart
sounds should be evaluated for presence of murmurs or
Physical Exam muffled nature.
The patient’s neurologic status should be evaluated
A thorough initial physical exam, as well as frequent and continuously monitored for alterations or deteriora-
sequential exams, should be performed with the goal of tion. Particularly with trauma, signs of spinal cord injury
promptly identifying current and evolving problems. should be sought and appropriate stabilization initiated
Advanced diagnostics may become necessary in order to prior to further manipulation of the patient. If traumatic
fully illuminate clinical findings but should never be used brain injury is suspected, efforts to increase cerebral per-
in place of a physical exam. While each clinician should fusion and decrease intracranial pressure (ICP) should
have a routine by which they approach an exam, it may be instituted, including blood pressure support, head
be required that the order of the exam be varied in criti- elevation, and minimal jugular vein occlusion. Judicious
cally ill patients, based on each patient’s current condi- IV fluid therapy is recommended to restore blood pres-
tion and stability. Care must be taken to ensure that all sure to a minimum of a systolic of 90 mmHg or a mean of
systems are assessed due to possible variation in exam 60 mmHg.

Clinical Small Animal Internal Medicine Volume I, First Edition. Edited by David S. Bruyette.
© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/bruyette/clinical