Ongoing Patient Evaluation in Emergency and Critical Conditions

Ongoing Patient Evaluation in Emergency and Critical Conditions

Stabilization is the beginning, not the end, of emergency care. The critical patient is dynamic — a patient that looked stable 20 minutes ago may be silently bleeding, developing a arrhythmia, or slipping into shock. The technician's job is continuous vigilance, not one-time assessment. Ongoing patient evaluation is what catches decompensation before it becomes arrest.

The Monitoring Cadence

The frequency of monitoring scales with the patient's stability:

A patient on a CRI of any vasoactive drug (dopamine, norepinephrine), insulin CRI (DKA), or dextrose CRI requires the tightest monitoring — often q15 min for the first hour, then q30 min.

Parameters to Track

The minimum vital sign set for any critical patient:

• Heart rate (HR) — dog: 60–140; cat: 140–220 (cats higher). Note trend more than absolute.
• Respiratory rate (RR) — dog: 10–30; cat: 20–40. Increased effort counts as much as increased rate.
• Temperature — 100–102.5°F. Hypothermia in cats and small dogs is often a shock sign.
• Mucous membrane color — pink is normal; pale = anemia/shock; brick-red = sepsis/distributive; cyanotic = hypoxia; icteric = hepatic/hemolytic.
• CRT — <2 seconds normal; >2 sec = poor perfusion; <1 sec flash = distributive.
• Pulse quality — femoral pulse strength, regularity, character (bounding vs thready).
• Mentation — bright, alert, responsive vs dull, depressed, stupor, comatose.
• Blood pressure — systolic >90 mmHg; MAP >60; direct arterial line for unstable patients.
• Urine output — 1–2 mL/kg/h normal; anuric patient is a crisis.
• Pain score — Glasgow Composite Measure or simple 0–4 scale.

Additional parameters for specific conditions:

• PCV/TS every 4–6 hours for hemorrhage or anemia
• Lactate — falling lactate indicates improving perfusion
• Blood glucose — q1–4 h on insulin/dextrose CRIs, neonates, septic patients
• Electrolytes (K+, Na+) — q4–6 h for blocked toms (urometer), DKA, Addisonian crisis
• ECG — continuous for arrhythmia patients (post-GDV, post-splenectomy, doxorubicin)
• SpO2 and EtCO2 — continuous for ventilated or respiratory patients

Trends Over Absolutes

This is the single most important concept in critical care evaluation. A snapshot tells you less than a trend does.

• A dog with HR 180 → 150 → 140 over 30 minutes is improving, even though 150 still looks 'high'.
• A dog with HR steady at 120 that suddenly jumps to 150 is deteriorating — investigate immediately (pain, hemorrhage, hypoxia).
• A cat with lactate 6 → 4 → 2.5 mmol/L over 2 hours has restoring perfusion; a cat with lactate steady at 4 mmol/L is not improving.
• A dog with PCV 25 → 22 → 20 is actively bleeding; do not wait for the absolute to fall below transfusion threshold before acting.

Trap: a single 'normal' value is reassuring but not conclusive. Always ask 'what was it 30 minutes ago?'

Re-evaluate After Every Intervention

Every intervention changes the patient's physiology. Each one must be followed by a targeted reassessment within a defined window:

Failure to reassess is the most common cause of 'sudden' decompensation — there is no sudden when you are monitoring correctly.

The Critical Care Record

The medical record is the legal record, the communication tool, and the patient safety net. The anesthetic record (covered in Chapter 15) and the critical care flowsheet share the same discipline: write what you observe, when you observe it, in real time. Do not rely on memory at the end of a shift.

A critical care flowsheet should capture:

• Time-stamped vital signs (every parameter, every interval)
• Every drug given: name, dose, route, time, ordering veterinarian
• Fluid type, rate, total volume in/out (input/output balance)
• Urine output, vomiting, diarrhea, food intake
• Diagnostic results (PCV/TS, BG, lactate, blood gas, electrolytes, imaging)
• Veterinarian orders and changes
• Phone communication with owner (time, content, consent)
• Reassessment notes after interventions

The flowsheet is also the handoff tool at shift change. A well-kept record lets the next technician pick up the trends without missing a beat; a poorly-kept record hides decompensation until it is too late.

Communication and Escalation

The technician is the veterinarian's eyes between examinations. Recognize the red flags that warrant immediate veterinarian notification:

• Sudden HR change (>20 bpm up or down)
• Systolic BP <80 mmHg or unrecordable
• Respiratory rate >40 with increased effort, or <8 (impending arrest)
• Temperature <98°F or >104°F
• Pale or cyanotic mucous membranes
• New arrhythmia on ECG
• Seizure activity
• Profound weakness or collapse
• Urine output <0.5 mL/kg/h

Escalate early. The cost of an unnecessary call is small; the cost of a missed decompensation is a patient.

Trap Callouts

Cats hide shock and cats hide pain. Use a multimodal assessment: CRT, pulse quality, mentation, blood pressure, and lactate together — never heart rate alone. A cat with HR 150 can still be in shock if CRT is 3 seconds and pulses are thready.

GDV is a true emergency that is medically stabilized first, then surgically corrected. Do not skip stabilization to rush to surgery, but also do not delay surgery once stabilized. Time to surgery is the single biggest survival determinant for GDV.

Trends over absolutes. A patient trending toward normal is improving even if the absolute value is still abnormal; a patient stable then worsening is deteriorating even if the absolute value is still 'normal'. Always ask 'what was it 30 minutes ago?'

Putting It Together

Ongoing evaluation is the discipline that turns a one-time resuscitation into sustained critical care. Monitor at the right cadence, track every parameter, watch the trend, reassess after every intervention, document in real time, and escalate the red flags. The technician who does this consistently is the technician whose critical patients survive.