The secondary survey of emergency patients is the process of obtaining significant and thorough historical information, performing a complete physical examination, and collecting general diagnostic information. These data are used to direct the formulation of a specific diagnostic, therapeutic, and monitoring plan.
The history should be recorded in a concise format. The presenting complaint is obtained from the owner, who can provide information such as when the animal was last completely normal. A chronology of the daily progression of abnormalities since the onset of signs can be useful. Background information includes past medical problems, toxicities, medications, drug and food sensitivities, blood transfusions, travel history, the date of last vaccinations, and other preventive care. Other organ systems not seemingly involved should also be historically evaluated. Details of the specific disease process are obtained and may help direct diagnostics and care.
A complete physical examination should be performed, working from head to tail. Particular attention is given to heart and lung auscultation for abnormalities, and to abdominal, rectal, and joint palpation for pain or enlargements. A complete neurologic and orthopedic examination is often warranted. Acute abdominal pain requires localization of the pain and auscultation of the abdomen for bowel sounds to localize the problem to the reticuloendothelial, reproductive, urinary, or GI systems; the peritoneal space; or the muscle, skin, nerves, or fat around the abdominal wall. Fever of unknown origin directs examination to the peritoneal cavity and to the reproductive, urinary, pulmonary, and cardiovascular systems.
An initial minimum database should consist of a PCV, total solids, glucose, and BUN. Other important diagnostics include urinalysis (before fluid administration), venous or arterial blood gas, an electrolyte panel, a CBC, and a serum chemistry panel. When coagulation disorders are suspected or surgery is anticipated, blood smears to estimate platelet number, buccal bleeding time to evaluate platelet function, and a clotting profile such as an activated clotting time or prothrombin time and activated partial thromboplastin time are warranted. Thromboelastography has emerged as a method to identify risk of hypercoagulation and hyperfibrinolysis.
A deficit in any of the first three components of the primary survey (ie, airway, breathing, circulation) will quickly result in anaerobic metabolism due to poor oxygen delivery to the tissues. This can rapidly result in a type A lactic acidosis. Lactate can be accurately, easily, and rapidly measured with several point-of-care analyzers. Normal lactate values in dogs and cats are < 2 mmol/L. Lactate levels normalize rapidly with treatment of the underlying condition of poor oxygen delivery to the tissues and is associated with improved survival. Lactate can be used along with other parameters as an endpoint of resuscitation in hypovolemic animals. Initial increases in blood lactate have been reported to be associated with an increase in complications and mortality in certain diseases in small animals. Resolving hyperlactatemia is associated with improved outcome.
Various scoring systems such as the animal trauma triage score may provide some useful prognostic information. The modified Glasgow Coma Scale is a useful monitoring tool for patients with neurologic injury; the composite Glasgow Pain Scale will identify patients in need of analgesia.
Key Points
A primary survey is essential to identify patients that require rapid intervention to avoid rapid deterioration.
Airway, Breathing, Circulation, level of consciousness and level of pain should all be rapidly evaluated.
Identification of the etiology of shock along with rapid correction with IV fluids and vasopressor agents is essential.
Damage control techniques are used for patients with hemorrhage.
Monitoring patients for response to therapy and need for additional intervention is key.
A secondary survey should be performed for identification of, and therapy for, the underlying etiology along with concurrent illness or injury.
For More Information
Also see pet health content regarding emergency care for dogs and cats and emergency care for horses.
