Small Animal Emergency an.d Critical . Care Mediéine Douglass K. Macintire Kenneth J. Drobatz I Steven c. Haskins -:-----:=l - William D. Saxon 6.3 6. UD7bU¿~ MANUAL OF SMALL ANIMAL EMERGENCY AND CRITICAL CARE MEDICINE DOUGLASS K. MACINTIRE, MS, DVM Diplomate ACVIM and ACVECC Director ofIntensive Care College of Veterinary Medicine Department of Small Animal Surgery and Medicine Aubum University Aubum, Alabama KENNETH J. DROBATZ, DVM, MSCE Diplomate ACVIM and ACVECC Director, Trauma Emergency Service Veterinary Hospital, University ofPennsylvania Philadelphia, Pennsylvania STEVEN C. HASKINS, MS, DVM Diplomate ACVA and ACVECC Direct01; Small Animal Intensive Care Unit Veterinary Medical Teaching Hospital University of Califomia Davis, Califa mia WILLlAM D. SAXON, DVM Diplomate ACVIM and ACVECC Telemedicine Consultant, IDEXX Graton, Califomia r-.------w" ..-.-... 0.: UNIVEi<:SiD,'¡J LA SALLE BIBLIOTECA P.T. Blackwell f/J Publishing BI8L¡O"~CA UNIVERSiDAD DE LA SALLE INGRESO 0'1- Oc)uhre ?ºQl 000 .f;d...;W.;L~,"-,---->,"-,,_.~~-- :CMPRADC A DONADO PC ~ __~_. ,,--- ~AN,::;"0', ©2006 Blackwell Publishing Iled''-k¡'J~Lª~;r:;~-:;-;;.- ;AC~:f:D' ©2005 Lippincott Williarns (SrWilkins Allrights reserved I'RECIO . __ ~ REGiSTRO ..LP2 '1L3 ) Blackwell Publishing Professional 2121 State Avenue, Ames, Iowa 50014, USA Orders: 1-800-862-6657 Office: 1-515-292-0140 Fax: 1-515-292-3348 Web site: www.blackwellprofessional.com Blackwell Publishing Ltd 9600 Garsington Road, Oxford OX4 2DQ, UK TeL:+44 (0)1865 776868 Blackwell Publishing Asia 550 Swanston Street, Carlton, Victoria 3053, Australia TeL:+61 (0)383591011 Authorization to photocopy iterns forinternal or personal use, or the internal or personal use ofspecific clients, is granted byBlackwell Publishing, provided that the base feeispaid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA01923. For those organizations that have been granted aphotocopy license by CCC, aseparate system ofpayrnents has been arranged. The feecodes for users of the Transactional Reporting Service are ISBN-13:978-0-397-58463-5; ISBN-lO:0-397-58463 6/2006. Printed inthe United States ofAmerica Library of Congress Cataloging-in-Publication Data Macintire, Douglass K Manual ofsmall animal emergency and critical care medicine /Douglass K Macintire, KennethJ Drobatz, Steven C.Haskins. p. cm. ISBN-13:978-0-397-58463-5 ISBN-lO:0-397-58463-6 LVeterinary emergencies-Handbooks, manuals, etc. 2.Veterinary critical care-Handbooks, manuals, etc. LDrobatz, KennethJ n.Haskins, Steve C.IlI. Title. SF778.M33 2004 636.089'6025-dc22 2004048529 The last digit is the print number: 98 765 43 CONTENTS PART1:L1FESUPPORT INITIAL STABILlZATION, MONITORING ANO INTENSIVE CARE OF THECRITICALLY ILL PATlENT 1. ApPROACH TO THEEMERGENCY PATIENT 3 11.Guidelines forAnesthesia in Critical Patients 38 1.Triage-Derivedfrom 111.SpecificDrugsUsedin Critical French Word "ToSort" 3 Patients 39 11.Identification ofLife-Threatening IV.Anesthesia Concerns and Protocols for Problems: Initial Examination 3 Common Conditions 43 111.Secondary Snrveyofthe Patient 8 V.Anesthetic Dosages for Healthy Patients 44 VI.Injectable DrugCombinations for Short 2. EMERGENCY ROOM REAOINESS 12 Procedures 48 VII.Pain Management in Critical Patients 48 1.The Importance ofReadiness 12 11.Eqnipment Recommendations 12 111.Recommended Supplies 13 6. 55 FLUIO THERAPY IV.Recommended Drugs 14 l. Crystalloid Solutions 55 3: CAROIOPULMONARy-CEREBRAL 11.Colloid Solutions 58 RESUSCITATlON (CPCR) 16 111.SpecificConditions Requiring Fluid Therapy 61 1.Definition 16 11.Predisposing Factors 16 III. Clinical Signs 16 7. MONITORING CRITICAL PATlENTS 71 IV.Prognosis/General Recommendations 16 V.Treatment 16 l. Cardiovascular Monitoring 71 11.Respiratory Monitoring 79 111.UrologicMonitoring 83 4. SHOCK 27 IV.Metabolic Monitoring 84 V.Neurologic Monitoring 87 l. Defmition 27 11.Categories ofShock 27 111.Treatment ofShock 29 8. NUTRITIONAL SUPPORT OF CRITICAL 89 PATIENTS 5. ANESTHETIC PROTOCOLS FORSHORT PROCEDURES 38 l. AcuteMalnutrition 89 11.Methods and Procedures ofProviding 1.OverviewofAnesthetic Drugs Enteral Nutrition 90 Usedin Critical Patients 38 111.Parenteral Nutrition 105 X CONTENTS PART11:SPECIFIC PROTOCOlS ANO PROCEOURES FOR EMERGENCY CONOITIONS 9. RESPIRATORV EMERGENCIES 115 11.Diagnostic and Monitoring Procedures 296 111.Management ofSpecificConditions 300 1.GeneralApproachIMethods ofOxygenDelivery 1I5 11.Upper Airway Obstruction 16. REPROOUCTIVE EMERGENCIES 334 (Pharynx,Larynx, Trachea) 118 111.Plenral SpaceDisease 128 l. Clinical Signs,Diagnosis 334 IV.LowerAirway Disease 144 11.Diagnostic and Monitoring Procednres 335 V.Parenchymal Disease 150 111.Management ofSpecificConditions 335 VI.Cyanosis 155' VII.Mechanical Ventilation 156 17. PEDIATRIC EMERGENCIES 341 10. CAROIAC EMERGENCIES 160 1.Resuscitation ofNeonates (Birth to 2weeks) 341 1.Clinical Signs 160 11.Diseases ofInfant Animals 11.Diagnosis 160 (2-6 weeks) 346 111.Diagnostic and Monitoring Procedures 161 111.Diseases ofJuvenile Animals IV.Management ofSpecificConditions 167 (6-12 weeks) 349 11. GASTROINTESTINAL EMERGENCIES 189 18. OCULAR EMERGENCIES 353 1.Clinical Signs,Diagnosis 189 l. Clinical Signs,Diagnosis 353 11.Diagnostic and Monitoring Procednres 189 11.Diagnostic and Monitoring Procedures 353 111.Management ofSpecificConditions 194 111.Management ofSpecificConditions 356 12. UROLOGIC EMERGENCIES 226 19. DERMATOLOGIC EMERGENCIES 373 1.Clinical Signs, Diagnosis 226 1.Clinical Signs, Diagnosis 373 11.Diagnostic and Monitoring Procedures 226 11.Diagnostic and Monitoring Procednres 374 111.Management ofSpecificConditions 235 111.Management ofSpecificConditions 375 13. NEUROLOGIC EMERGENCIES 251 20. TOXICOLOGIC EMERGENCIES 384 1.Clinical Signs, Diagnosis 251 11.Diagnostic and Monitoring Procedures 251 1.Clinical Signs,Diagnosis 384 111.Management ofSpecificConditions 254 11.Diagnostic and Monitoring Procednres 384 111.Management ofSpecificConditions 387 14. HEMATOLOGIC EMERGENCIES 279 21. MISCELLANEOUS EMERGENCIES 402 l. Clinical Signs,Diagnosis 279 11.Diagnostic and Monitoring Procedures 281 l. Reat Illness 402 111.Management ofSpecificConditions 286 11.Rypothermia 404 111.Frostbite 406 15. IV.Near Drowning 408 ENOOCRINE ANO METABOLlC EMERGENCIES 296 V.Insect and Spider Bites 409 VI. Snakebites 412 1.Clinical Signs, Diagnosis 296 VII.Electrocution 414 XI CONTENTS ApPENDICES 41 7 Appendix G.Normal Valuesfor Oxygenand Hemodynamic Parameters 429 Appendix A.Calibration Tablesfor the Schiotz Appendix H.Toxicology 432 Tonometer 417 Appendix l. Transfusion Guide 436 Appendix B.Normal Valnesfor the Canine AppendixJ. DrugFormulary 438 and FelineElectrocardiogram 418 Appendix K.Guidelines forAnesthesia in Animals with Critical Problems 485 Appendix C.CPCRGuidelines 419 Appendix D.Common Equations 421 Appendix E.Constant Rate Infusions 422 489 Appendix F.Conversion Tables 427 INDEX Life Support and Initial Stabilization, Monitoring and Intensive Care of the Critically 11P1atient APPROACH TO THE EMERGENCY PATIENT l. TRIAGE-DERIVED FROM FRENCH WORD c. Asecondary, more exhaustive physical and MEANING "TO SORT" laboratory examination can be completed once the life-threatening problems have been stabi A. Method used to classify patients according to lized (see box, p. 7) urgency ofneed foremergency care d. Semicomprehensive examinations should be repeated at regular intervals to keep pace with B. Allows rapid identification and treatment of the changing condition ofthe patient. Just be life-threatening problems cause something was not aproblem at the time C. Stable patients must wait tobe treated; those of the last examination doesnot mean that itis with life-threatening problems are seen without not aproblem now. delay. 2. Determine whether the animal is attempting to D.Allanimals should be evaluated byeither a breathe. veterinarian or aveterinary technician within a. Ifnot, clear the airway, intubate, and venti 1minute after arrival at the emergency hospital. late with 100%oxygen. b. Ifunable to intubate, perform emergency E. Patients with life-threatening problems tracheostomy (p. 118). (Table 1-1) can be taken directly to the emergency c. Apnea is asign ofacentral nervous system treatment area for immediate therapy; stable pa tients canwait with the owner. (CNS) lesion or aperipheral problem with the neuromuscular axis. 3. Ifthe animal isbreathing, isit effective? a. Administer supplemental oxygen (p. 115) 11.IDENTIFICATION OF L1FE·THREATENING PROBLEMS: INITIAL EXAMINATION while completing physical examination. b. Classify the breathing pattern (see box, p.6). A. Primary survey, assessment ofbreathing and c. Normal respiratory rate is 16-30bpm. If vital signs respirations arelabored, lung sounds areabsent 1. When the emergency or trauma patient is first or increased, or animal is cyanotic or tachyp presented, perform arapid primary evaluation neic, see "Respiratory Emergencies" (p. 115). with special attention to the ABCs(Airway, d. Life-threatening respiratory insufficiency Breathing, Circulation). can exhibit any ofthe following signs: a. This examination should concentra te on ab 1) Orthopaedic stance-extended head and normalities that might be an immediate risk to neck the lifeofthe patient (Table 1-1). 2) Apnea b. Life-threatening abnormalities should be 3) Restlessness or anxiety stabilized without delay. 4) Open-mouth breathing; gasping 4 PART 1: CHAPTER l/APPROACH TO THE EMERGENCY PATIENT It j"~ TPARBOLBELE1M.1S IDENTIFIED ATTRIAGE THATREQUIRE IMMEDIATE ATTENTION Cardiovascular Head trauma Cardiac arrest (no pulse, no auscultable History of toxin ingestion heartbeat) Acute paraparesis/paraplegia Pale mucous membranes Slow capillary refill time (>2seconds) Urinary Weak, thready, or absent pulses lnability to urinate Active Hemorrhage History ofethylene glycol ingestion Brick-red membranes, capillary refill Large, painful bladder on palpation < 1second, bounding pulses No palpable bladder posttrauma > > Tachycardia (dog 180; cat 250) Bradycardia (dog <60, cat <150) Other > Pulse deficits, arrhythmias Hyperthermia (T 105°F), heat stroke Collapse Dystocia Snake bite Respiratory Poisonings Rapid, shallow respirations Profuse vomiting or diarrhea Upper airway obstruction Burns Labored breathing, gasping, open mouth Fractures breathing Automobile-related injuries Cyanosis Fall from height Pulmonary crackles and wheezes on Dehiscence ofabdominal surgical wound auscultation Frostbite Chest trauma-rib fractures, penetrating chest Drowning wounds, flail chest Smoke inhalation Electrocution Neurologic Organ prolapse Seizures or history ofseizures Gastric distension Stupor Ocular emergencies-glaucoma, proptosis Coma Recent toxin ingestion 5) Cyanosis 3) "Muddy" or brown membranes can occur 6) Paco2 above 80 mm Hg with sepsis or acetaminophen toxicity (cats). 7) Pao2 below 60 mm Hg (21%inspired 4) Hyperemic (brick red) membranes occur oxygen at sea level) with hyperdynamic shock, cyanide or car a) Sa 02below 90 (as measured with pulse bon monoxide toxicity, heatstroke, or other oximetry) hypermetabolic states (pheochromocytoma, b) The ratio 01Paoz topercentage inspired "thyroid storm") oxygen is <3while breathing enriched in b. Assess capillary refill time (CRT) spired oxygen 1) This should be performed by applying pressure to cause blanching of pink oral 4. After stabilizing airway and breathing, evaluate mucous membranes and counting the num other vital signs. ber of seconds for the pink color to return. a. Evaluate mucous membrane color. It is better to perform this test on the gums 1) Pale membranes can occur with anemia, rather than the lips, because tension on the shock, pain, or poor perfusion. lip may affect refill time. It is difficult or im 2) Blue membranes indica te cyanosis, possible to perform on animals with dark which can occur with impaired respiration, pigmented gums. methemoglobinemia (acetaminophen, 2) Assessment of CRT provides a crude in nitrates), shunt, or congenital heart defect. dication of hydration status and peripheral (See "Cyanosis," p. 155.) perfusion. 5 MANUAL OF SMALL ANIMAL EMERGENCY ANO CRITIC'AL CARE MEDICINE 11I I11"1 TTRAEBALTEME1N.T2 PRIORITIES IN .EMERGENCY PATlENTS A-Airway and arterial bleeding Provide patent airway, 100%02 Apply pressure to areas ofactive hemorrhage B-Breathing Auscult cl).est,characte.rize breatqing Pi'lHern.•.• Perform thoracocentesis or emergency tracheostomy ifindicated C-Cireulation Place IV catheter, obtain samples for pcvrrs, BUN, glucose, Na, K,blood gases, ::'::coagulation tests and blood smear, urinalysis Treat for shock ifcardiac failure is ruled out as the cause ofpoor perfusion Fluid guidelines for shock Crystalloid resuscitation-hypovolemic shock Dog, 90mUkglh-Administer in 25%increments and assess patient response Cat, 60 mUkglh-Administer asabove Acure blood loss, PCV <20% 20 mUkg fresh whole blood transfusion Shock with head trauma or pulmonary contusions Minimize crystalloid fluid, 10-20 mUkg IVmaximum 7.5%hypertonic saline, 5mUkg IV Small-volume resuscitation with colloids Give 5mUkg hetastarch or dextran 70q5-10 min until HR, color, pulses, and BPimprove (generally up to 20 mUkg) Monitor pcvrrs q20-30 min in trauma patients Place abdominal compression bandage ifdropping PCV indicates internal hemorrhage. Transfusion ::'::surgery for uncontrollable hemorrhage D-Disability assessment Neurologic examination Brain, spinal cord, peripheral nerves Rule out lesions with poor prognoses Treat head trauma or spinal cord injury Musculoskeletal examination Antibiotics, cleaning, debridement for open fractures Splint, stabilize distallimb fractures Bandage, clean lacerations Radiograph when stable E-Evaluate for abdominal injuries, uriuary traet trauma, oliguria Abdominocentesis, diagnostic peritoneallavage, radiographs, ultrasound Radiographic contrast studies Monitor urine output 3) Normal CRT = 1.0-1.5seconds striction, hypothermia, pain, exogenous 4) Rapid CRT «1.0 second) is characteristic catecholamines, hypoxia, or shock. CRT > ofhyperdynamic shock or hypermetabolic 3 seconds indicates serious peripheral states (hyperthermia, sepsis, hyperthyroidism). vasoconstriction and poor perfusion. 5) Slow CRT (>1.5 seconds) is associated e. Determine pulse quality with poor perfusion-dehydration, hypov 1) Palpable femoral pulse estimates mean olemia, cardiac disease, peripheral vaso con- blood pressure of at least 50mm Hg. A