Emergency Procedures Let the fun begin Or Passez le bon temp

Emergency Procedures

Let the fun begin

Or

Passez le bon temp

Triage of Emergency PatientsTriage—to sort (Fr); most critical seen first

Should be done by RVT in busy practice; receptionist should not do it

• Initial exam (by RVT)– Wear gloves– Animal muzzled (use discretion)– Minimize movement of patient– Initial Assessment (30-60 sec; from rostral direction)

• Mentation (level of consciousness)– A Alert– V Verbally responsive– P responsive to painful stimuli– U Unresponsive

» Extend head/neck to provide clear airway; check for patency

• Breathing/respiratory pattern (shallow, labored, rapid, obstructed)

• Abnormal body/limb posture (fracture, paralysis)

• Presence of blood or other material around patient

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– Initial Assessment (continued)• Breathing/respiratory pattern

– Total/Partial blockage of airways (Requires immediate Rx)

» Exaggerated inspirations

» Nasal flare, open mouth, extended head/neck

» Cyanosis

– Breathing assessment

» Watch chest wall movement

» Auscult lungs bilaterally to r/o hemo- or pneumothorax

Triage of Emergency Patients

– Vital signs (taken after initial assessment)• HR, pulse rate (same as HR?), strength• RR• mm color, cap refill• Temp• BP

– High HR, high BP→ pain

– High HR, low BP → hypovolemic shock

– Baseline data• ECG (lead II)• Chem panel, CBC


• Resuscitation (treatment to restore life/health)– Analgesics for pain once airway patency and heart beat are

established (these are critical for life)– Control hemorrhage

• Pressure bandages (sterile gauze, laparotomy pads, towels)– If bleed thru, do not remove initial bandage, apply another on top– On distal extremity, BP cuff can be placed proximal to wound (avoid

tourniquet if possible)

• External counterpressure using body wrap of pelvic limbs, pelvis, and abdomen

– Insert urinary cath to monitor urine output– Use towels, cotton rolls, duct tape, etc– Monitor respirations (diaphragm/abdominal breathing compromised)– Leave on until hemodynamically stable (6-24 h)– Monitor BP during removal

» If BP drops >5 mm Hg, stop removal; infuse more fluids» If BP continues to drop, reapply wrap


• History (mnemonic)

– A Allergies– M Medications– P Past History– L Lasts (meals, defecation, urination, medication)– E Events (What is the problem now?)

• How long since injury• Cause of injury (HBC, dog fight, gunshot)• Evidence of loss of consciousness• Blood loss?• Deterioration/improvement since accident (good indicator of

Px)• Any other underlying medical conditions/medications


Shock

• What is shock?– General Public

• Psychological

– Medically • Poor O2 delivery to tissues, esp brain

Shock• Types of Shock:

– Cardiogenic—results from heart failure • ↓ blood pumped by heart• HCM, DCM, valvular insufficiency/stenosis

– Distributive—blood flow maldistribution (Vasodilation)• From psychological shock• Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from

vessels to interstitial spaces →↓ blood return to heart →↓BP

– Obstructive—physical obstruction in circ system• HW disease →↓blood pumped by heart• Gastric torsion →↓blood return to heart

– Hypovolemic—decreased intravascular volume• Most common• Blood loss, dehydration from vom/dia

Shock• Pathophysiology (of hypovolemic shock)

– ↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP

1. Compensation—Baroreceptors detect hypotension (↓BP)a. Sympathetic reflex—(Epi, Norepi, cortisol released from adrenals)

- ↑ HR, contractility

- Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart

b. Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex- ↑ Na+ and water retention → ↑ intravascular vol (↑BP)

Shock • Recognition

– History• Trauma• Vom/dia

– PE findings• Stage I (compensated shock)

– Tachycardia– Prolonged cap refill time– Pale mm

• Stage II (decompensated shock)– Tachycardia– Delayed cap refill time– Muddy mm (loss of pink color, more brown than pink)– BP is dropping– Altered mental state

• Stage III (irreversible shock)– PE findings worsen; cannot revive; death will occur

Shock

• Rx (the goal of therapy is to improve O2 delivery)

– O2 supplementation• Face mask

• O2 cage/hoods

• Transtracheal/nasal insufflation

– Venous access• Cephalic• Saphenous• Jugular• Intraosseous

ulna

Shock • Rx (continued: remember the goal of therapy is to improve O2 delivery)

– Fluid resuscitation (O2 delivery is improved by ↑CO)

1. Crystalloids • Isotonic solutions (crystalloids; Na+, Cl-, K+, bicarb)

– Examples (body fluid=280-300 mOsm/L)

» Lactated Ringer’s (273 mOsm/L)

» Normal saline (0.9%) (308 mOsm/L)

– Dose: Dog 80-90 ml/kg/hr

Cat 50-55 ml/kg/hr

• Hypertonic solutions—when lg vol of fluid cannot be administered rapidly enough

– Examples—7.5% saline

– Causes fluid shift from intracellular space→ interstitial space→ intravascular space →↑vascular vol →↑venous return → ↑CO

– Also causes vasodilation → ↑ tissue perfusion

– Dose: 4-6 ml/kg over 5 min

• Hypotonic solutions should never be used for hypovolemic shock– Examples—5% Dex in water (252 mOsm/L)

Shock • Rx (continued: remember the goal of therapy is to improve O2 delivery)

– Fluid resuscitation (O2 delivery is improved by ↑CO)

2. Colloids—• Large molecular wt solutions that do not leave vascular system• Better blood vol expanders than crystalloids• 50-80% of infused vol stay in blood vessels• Examples

– Whole blood

– Plasma

– Dextran 70

Shock • Rx (continued)

– SympathomimeticsUse only after adequate fluid administration if BP and tissue

perfusion have not returned to normal• Dopamine (Intropin®)

– 0.5-3.0 μg/kg/min

» Dilation of renal, mesenteric, coronary vessels

– 3.0-7.5 μg/kg/min

» ↑ contractility of heart

» ↑ HR

– >7.5μg/kg/min

» Vasoconstriction

• Dobutamine (Dobutrex®)– 5-15 μg/kg/min

– ↑ contractility of heart (min effect on HR)

Shock • Monitoring Hemodynamic/metabolic sequelae of shock are continually changing

– Physical Parameters• Respiratory

– Color of mm

– RR and Tidal Vol adequate?

– Breathing efforts smooth?

– Breathing pattern regular?

– Auscultation normal?

• Cardiovascular – HR normal?

– ECG normal?

– Color of mm

– Cap refill time (1-2 sec)

– Urine production? (1-2 ml/kg/hr)

– Weak pulse? → ↓stroke vol

Shock

• Monitoring – Physiologic Monitoring Parameters

• O2 Saturation– Pulse oximetry—noninvasive

– Normal: Hb saturations (SpO2)>95%

» SpO2<90%--serious hypoxemia

• Arterial BP—a product of CO, vascular capacity, blood volume

– If one is subnormal, the other 2 try to compensate to maintain BP

Shock • Monitoring

– Laboratory Parameters• Hematocrit (PCV)

– Increase →dehydration

– Decrease →blood loss

• Electrolytes (what is that?)– Proper balance needed for proper cell function

– Fluid therapy may alter the balance; supplement fluid as needed

• Arterial pH and blood gases– PaCO2 tells how well patient is ventilating

» PaCO2 <35 mm Hg → hyperventilation

» PaCO2 >45 mm Hg → hypoventilation

– PaO2 Tells how well patient is being oxygenated

» PaO2 <80 mm Hg → hypoxemia

– pH tells acid/base status of patient

– <7.35 → acidosis

– >7.45 → alkalosis

Cardiopulmonary Resuscitation (CPR)

Cardiopulmonary Arrest (CPA)—Heart stops, breathing stops

• Causes• Anesthesia

– Dogs• Trauma• Infections (GI, pneumonia)• Heart disease• Autoimmune disease• Malignancy

– Cats• Trauma • Infectious diseases

• Resuscitation Team Members– Should be 3-5 members

• Team leader—Veterinarian or RVT with most experience• All members have several responsibilities

– Provide ventilation

– Chest compression

– Establish IV line

– Administer drugs

– Attach monitoring equipment

– Record resuscitation efforts

– Monitor team’s effectiveness

• Teams should practice on a regular basis to stay sharp

Cardiopulmonary Resuscitation

• Facilities– Adequate room for entire team and equipment

– O2 source

– Good lighting– Crash cart with all needed Rx (should be checked at beginning of each

shift)• Defibrillators

• Electrocardiogram

• Suction

– Table to perform chest compression• Grated surgery prep table not solid enough for chest compression

– Use board underneath patient

• Recognition– RVT should ID patients at risk and observe any deterioration– Preventing an arrest is easier than treating one


• Standard Emergency Supplies (on crash cart)– Pharmaceuticals --Venous access supplies

• Atropine ● Butterfly cath

• Epinephrine ● IV caths

• Vasopressin ● IV drip sets

• 2% lidocaine (w/o epi) ● Bone marrow needles

• Na+ bicarb ● Syringes

• Ca++ chloride or gluconate ● Hypodermic needles (var sizes)

• Lactated Ringer’s, hypertonic saline, ● Adhesive tape

dextran 70, hetastarch ● Tourniquet

– Airway access supplies --Miscellaneous supplies• Laryngoscope ● Gauze pads (3 x 3)

• Endotracheal tubes (variety of sizes) ● Stethoscope

• Lubricating jelly ● Minor surgery pack

• Roll gauze ● Suture material

● Scalpel blades

● Surgeon’s gloves


• Basic Life Support (Phase I)– Remember the priorities (ABC; Airway, Breathing, Circulation)

• Establish patent Airway– Endotracheal tube

– Tracheostomy tube for upper airway obstruction

– Suction to remove blood, mucus, pulmonary edema fluid, vomit

• Artificial ventilation (Breathing)» Ambu-Bag

» Anesthetic machine

– Ventilate once every 3-5 sec

– Chest compressions in between breaths


CPR

• http://www.youtube.com/watch?v=VJGlsYHI9cU

http://www.youtube.com/watch?v=VJGlsYHI9cU

http://www.youtube.com/watch?v=VJGlsYHI9cU

Cardiopulmonary Resuscitation Entubation

• Basic Life Support (Phase I)– Circulation

• External cardiac compression– Lateral recumbency—one/both hands on thorax over heart (4th-5th

intercostal space)

– In larger patients, arms extended, elbows locked

– In small patients, thumb and first 2 fingers to compress chest

– Rate of compression: 80-120/min


• Basic Life Support (Phase I)– Circulation

• Internal cardiac compression– More effective than external compression

» ↑CO, ↑BP, higher survival rate– Indications

» Rib fractures» Pleural effusion» Pneumothorax» If not responsive after 5 min of external cardiac compression

– Preparation» Clip hair ASAP, no surgical scrub» Incision at 4th or 5th intercostal space» With a gloved hand, compress heart between fingers and palm (Do

not puncture heart with finger tips or twist heart)» After spontaneous beating returns, flush chest cavity with saline,

perform sterile scrub of skin and close


• Basic Life Support (Phase I)– Assessing effectiveness (must be done frequently)

• Improved color of mm• Palpable pulse during cardiopulmonary resuscitation (difficult)• If efforts are not effective, do something differently

– Use different hand

– Change person performing compression

– Ventilate with every 2nd or 3rd chest compression

– Compress chest where it is widest in lg breed dogs

– Apply counter-pressure to abdomen (hand, sandbag)

» Prevents posterior displacement of diaphragm and increases intrathoracic pressure


CPR

• Advanced Life Support (Phase II)Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate)

– Drugs• Fluids

– Lactated Ringer’s is standard (do not use Dextrose)

» Initial dose: Dogs—40 ml/kg

(rapidly IV) Cats—20 ml/kg

• Atropine—parasympatholytic effects (blocks parasympathetic effects)– 0.02-0.04 mg/kg

– ↑HR

– ↓secretions

• Epinephrine—adrenergic effects– 0.02-0.2 mg/kg

– Arterial and venous vasoconstriction→ ↑BP



– Drugs (continued)• 2% Lidocaine (Used to treat cardiac arrhythmias)

– Dogs: 1-2 mg/kg

Cats: 0.5-1.0 mg/kg

• Magnesium Sulfate or Chloride (For refractory ventricular fibrillation)

– 30 mg/kg over 2 min period

• Sodium bicarb (For metabolic acidosis)

– 0.5 mEq/kg per 5 min or cardiac arrest

• Vasopressin (ADH) (vasodilator)

– 0.8 U/kg



– Drugs (continued)• Route of drug administration

– Jugular vein—close to heart; drugs will get to heart quicker

– Cephalic, saphenous—follow drugs with 10-30 ml saline flush

– Intraosseous—intramedullary cannula into femur, humerus, wing of ilium, tibial crest

– Intratracheal—for limited # of drugs: atropine, lidocaine, epinephrine

– Intracardiac—last resort; several complications can occur

• Depends on– Speed of access

– Technical ability

– Difficulties encountered

– Rate of drug delivery



– Electrical—Defibrillate• Purpose—eliminate asynchronous electrical activity in heart muscles

by depolarizing all cardiac muscle fibers; hopefully, the fibers will repolarize uniformly and start beating with coordinated contractions

• Paddles (with electrical gel) placed on each side of chest• Yell “CLEAR” before discharging electrical current• Start with low charge and increase as needed

– External: 3-5 J/kg

– Internal: 0.2-0.4 J/kg

normal ECG Ventricular fibrillation


• Prolonged Life Support (Phase III)– Once heart is beating on its own, monitor the following:

• HR and rhythm – Antiarrhythmic drugs– Correct electrolyte abnormalities

• BP• Peripheral perfusion

– Color of mm– Cap refill time– urine output

• RR and character of breathing– Adequate breathing– Auscultory sounds

• Mental status• Improving or deteriorating

UC Davis study: survival rate at 1 wk for cardiac resuscitation patientsDogs: 3.8%Cats: 2.3%


Allergic Reactions

Anaphylaxis/Allergic reactionsRare, life-threatening reactions to something injected or ingested

Untreated, it results in shock, resp/cardiac failure, and death

IgE Antibodies to allergen bind to mast cells; on subsequent exposure, the Ag-Ab reaction causes massive release of histamine and other inflammatory mediators

Histamine → vasodilation → ↓BP

• Initiating factors– Insects– Vaccines– Antibiotics– Certain hormones– Other medications– Foods

Re-exposure

• Signs– Sudden onset of vom/diarrhea– Shock

• Gums are pale• Limbs are cold• HR rapid, weak

– Face scratching (early sign)– Respiratory distress– Collapse – Seizures– Coma– Death

Anaphylaxis/Allergic reactions

• Rx (this is an extreme emergency)– Eliminate cause– Epinephrine– H1 antihistamines (Diphenhydramine)– IV fluids– Corticosteroids – Oxygen

• Prevention– There is no way to predict what will bring on an anaphylactic reaction the

first time– Always inform vet if animal has had previous reaction to vaccine– Owners should have an ‘epi-pen’ with them at all times

Anaphylaxis/Allergic reactions

Heat Stroke

• Signs– Rapid, frantic, noisy breathing– Tongue/mm bright red, thick saliva– Vomiting/diarrhea—may be bloody– Rectal temp up to 106º– Unsteady/stagger– Coma/death

Prevention

Heat Stroke (Hyperthermia)Requires immediate treatment

Dogs do not cool as well as humans (don’t sweat)

• Causes– Left in hot car– Water deprivation– Obesity/older– Chained without shade in hot weather– Muzzled under a hot dryer– Short-nosed breed (esp Pug, Bulldog)/heavy coat– Heart/Resp disease or any condition that impairs

breathing or ability to cool body– Lack of acclimatization/exercise

Heat Stroke• Rx (cells break down at 107º)

– Mild cases: move dog to a/c building or car– Temp>104º, immerged in cool water, hose down– Temp>106º, cool water enema (cool to 103º)

STOP COOLING EFFORTS AT 103º– IV fluids– Corticosteroids

Heat Stroke

• Complications– Can affect all organs in the body

– Denatures proteins

– Hypotension

– Lactic acidosis

– Decreased oxygen delivery

– Electrolyte abnormalities => cerebral edema and death

– Coagulopathies => DIC

– If survives the first 24 hrs, prognosis is more favorable

Pain Management• Misconceptions about animal pain

– Animals do not experience pain– Pain doesn’t really affect how animal responds to treatment– Signs of pain are too subjective to be assessed– Pain is good because it limits activity– Analgesia interferes with accurate assessment of treatment– Pain management not major concern in LA (except horses)– Pain shows weakness/fragility (Lab vs Collie)

• Fresh ideas about animal pain – Analgesia increases chance of recovery in critically ill– Pain associated with diagnostic test should be minimized– Morally correct thing to do

Pain Management

Pain Management• Signs

– Vocalization– ↑HR– ↑RR– Restlessness, abnormal posturing, unwilling to move– ↑ Body temperature– ↑BP– Inappetence– Aggression– Facial expression, trembling– Depression, insomnia

• Sequelae to untreated pain– Neuroendocrine responses

• Excessive release of pit, adr, panc hormones– Cause immunosuppression and disturbances of growth, development,

and healing

– Cardiovascular compromise• ↑BP, HR, intracranial pressure

– Coagulopathies• ↑platelet reactivity, DIC

– Long-term recumbency• Decubital ulcers

– Poor appetite/nutrition• Hypoproteinemia→slow healing

Pain Management

• Pain Relief– Nonpharmacologic interventions (differentiate pain vs stress)

• Give relief from:– Boredom, Thirst, Anxiety, Need to urinate/defecate

• Clean bedding/padding• Reduce light/sound• Stroking pet, calming speech• Owner visits (±)• Minimize painful events (reduce #, improve skill [inject, blood draw]

Pain Management

• Questions the Vet Tech must continually ask (you are in charge of pain meds)– Is patient at acceptable comfort level– Are there any contraindications to giving pain meds– What is the appropriate (safe, effective) med for this patient

Pain Management

• Drug Options– Nonsteroidal Antiinflammatory Drugs (NSAIDs)

• Most widely used• Extremely effective for acute pain• Most effective when used preemptively (before tissue injury)• Usually not adequate to manage surgical pain• COX-2 NSAIDs do not cause damage to stomach lining

– Opioids• Most commonly used in critically injured animals

– Rapid onset of action; effective; safe

• 4 types of receptors– μ: analgesia, sedation, and resp depression– Κ: analgesia and sedation – Δ: some analgesia, resp depression– Σ: depression, excitement, anxiety

• Side effects– Vomiting, constipation, excitement, bradycardia, panting

• Metabolized by liver; excreted by kidneys– Use caution with hepatic, renal disease

Pain Management

• Opioids – Morphine sulfate (the gold standard)

• Used for max analgesia/sedation

• Inexpensive

• Side-effects: systemic hypotension, vomiting

• Cats particularly sensitive

• Dose: Dogs—0.5-2.2 mg/kg SQ, IM; 0.1-0.5 mg/kg IV

Cats—0.1-0.5 mg/kg SQ, IM

– Oxymorphone• 10x potency of morphine

• Much more expensive; less resp depression and GI stimulation

• Side-effects: depression, sensory hypersensitivity

• Dose: 0.05-0.1 mg/kg IV, IM

– Hydromorphone• Similar effects of Oxymorphone

• More widely available, less expensive than Oxymorphone

• Dose: Dog—0.1-0.2 mg/kg SQ, IM

Cat—0.05-0.1 mg/kg SQ, IM

Pain Management

• Opioids – Fentanyl citrate

• Extremely potent• Rapid onset, short duration when administered IM or IV• Transdermal patch

– 3-day duration– Shave hair

– Butorphanol Tartrate• Κ agonist; μ antagonist• Analgesic effect questionable (>1 h); good sedative (~2 h)

– More expensive than morphine– Less vomiting, depression

• Dose Dog—0.2-0.8 mg/kg SQ, IM; 0.1-0.4 mg/kg IV (Half that dose in Cat)

– Buprenorphine• 30x potency of morphine; longer duration; transmucosal absorption• Dose: Dog/cat—0.01-0.03 mg/kg SQ, IM, IV,

buccal mucosa

Pain Management

Pain Management• Opioids

– Antagonists• Naloxone HCl

– Reversal occurs within 1-2 min

– Can be used to reverse anesthesia (Inovar-Vet)

Toxicologic Emergencies• Signs will vary depending on character of toxic compound

– Anxiety (marijuana)– Seizures– Unresponsive, Coma

• Toxicity can result from exposure via many routes– Ingestion—most common; usually accidental (angry neighbor?)– Inhalation– Skin contact—animals should be washed to remove toxin– Injection—either o.d. in vet hosp or recreational drug use

• Equipment List:– Basic equip: IV cath, fluids, bandages, ECG, O2, crash cart– Emetics– Activated charcoal– Stomach tubes– Valium, muscle relaxers

• Top 10 Toxicoses (2005)– Human medication—painkillers, NSAIDs, antidepressants– Insecticides—flea and tick– Rodenticides—anticoagulants– Veterinary medication—NSAIDs, HW– Household cleaners—bleach, detergents– Plants—sago palm, lily, azalea– Herbicides—– Chocolate—highest in food category– Home improvement products—solvents, adhesives, paint,

wood glue– Fertilizers

Toxicologic Emergencies

• Hx—as thorough as possible– May not know– Legal issues

• Rx– Treat clinical signs

• Seizures valium, phenobarbital• Anxiety valium• Coma IV fluids

– Induce vomiting (if animal is able)• Some poisons release toxic gases

– Zinc phosphide (gopher bait) releases phosphine gas (well vent room)

– Wear gloves to prevent topical exposure to you– Be cautious of abnormal behavior

• Biting


• Prevent Further Damage– Ocular exposure

• Rinse eyes with copious saline for 20-30 min• Chemical burns treated with lubricating ointment

and suture lids closed– Use corticosteroids only if corneal epithelium is

intact– Topical exposure

• Bathe with mild detergent (liquid dish soap)• Bather should wear protective clothing (gloves,

goggles)• If toxic substance is a powder, vacuum before

bathing



– Ingestion • Induce vomiting—if chemical not caustic; animal conscious, not

seizuring– ipecac, apomorphine, Xylazine, H2O2 [not reliable], salt [not recom],

soapy water [not recom])

• Dilute caustic substances with milk, water

• Gastric lavage—large bore stomach tube; light anesthesia w/ endotrach tube

• Administer absorbents—activated charcoal inhibits GI absorption– Give orally or via stom tube

• Enemas/cathartics to eliminate toxins more rapidly

• Specific toxicities– Methylxanthines—↑HR, ↑RR,

mild diuretic• Ex: caffeine, theobromine,

theophylline• Found in: coffee, tea, stimulants,

chocolate1. Chocolate (theobromine tox)

-Found in cocoa bean, colas, tea-Contains all 3 methylxanthines-Theobromine toxic to dogs and cats; cats

more finicky-Toxic Dose: 250-500 mg/kg; Milk

Chocolate—44 mg/oz,

Baking Chocolate—390 mg/oz



Clinical Signs

anxiety, vom/dia, ↑HR, cardiac arrhythmias, incontinence, ataxia, muscle tremors, abd pain, hematuria, seizures, cyanosis, coma

Rx

induce vom, gastric lavage, carcoal, cathartics

Diazepam to control seizures

frequent bladder catheterizations—methylxanthines can be resorbed

• Specific toxicities– Methylxanthines

2. Caffeine

-found in coffee, tea, chocolate, colas, stimulant drugs

-Lethal dose: 140 mg/kg

Clinical signs

vomiting, diuresis, restlessness/hyperactivity, ↑HR, ↑RR, ataxia, seizures, arrhythmias, death not common

Rx—same as theobromine


• Specific toxicities– Rodenticides

1. Anticoagulants (warfarin, pindone, bromadiolone, brodifacoum, chlorphacinone, difethialone, diphacinine, coumafuryl, dicoumarol, difenamarol)

– Work by binding Vit K, which inhibits synthesis of prothrombin (Factor II) and other clotting factors

– This effect occurs within 6-40 h in a dog; effect may last 1-4 wk

• Clinical signs (occur after depletion of clotting factors)– Lethargy– Vom/dia with blood; melena– Anorexia– Ataxia– Dyspnea – Epistaxis, schleral hemorrhage, pale mm

• Rx– Vit K: 3-5 mg/kg PO for up to 21 d depending on anticoagulant used– Induce vomiting; activated charcoal– Whole blood transfusion if anemic



2. Cholecalciferol—Vit D3; used in Quintox, rampage, Rat-Be-Gone-causes Ca++ reabsorption from bone, intestine, kidneys causing

hypercalcemia (>11.5 mg/dl) and cardiotoxicity

• Clinical signs (12-36 h after ingestion)– Anorexia– Vomiting– Muscle weakness– Constipation

• Dx– Hx of exposure– Usually discovered on routine Chem panel (↑blood Ca++)

• Rx– Induce vom/activated charcoal if ingestion occurred with 2 h– Furosemide x 2-4 wk; increases Ca++ excretion in urine– Prednisone x 2-4 wk; decreases Ca++ reabsorption from bones/intesine– Calcitonin to lower blood Ca++ concentration



3. Bromethalin-uncoupler of oxidative phosphorylation in CNS (stops production of ATP)

-Causes cerebral edema

-found in Assault, Vengence, Trounce

-Toxic Dose Dog: 4.7 mg/kg

Cats: 1.8 mg/kg

Clinical signs (>24 h after ingestion of high dose; 1-5 d--low dose)– Excitement, tremors, seizures

– Depression, ataxia

• Rx (will take 2-3 wk to know if animal will survive)– Purge GI tract if exposure recent

– Reduce cerebral edema with Mannitol and glucocorticoids

– Seizure control with Diazepam and Phenobarbital


• Specific toxicities– Acetaminophen

• Common OTC drug for analgesia• Toxic dose: Dog—160-600 mg/kg

Cat—50-60 mg/kg (2 doses in 24 h is almost always fatal)

• Clinical signs (starts within 1-2 h of ingestion)– Vomiting, salivation– Facial and paw edema– Depression– Dyspnea– Pale mm– Cyanosis due to methemoglobinemia

• Px—poor• Rx

– Induce vom/activated charcoal– Antidote: N-Acetylcysteine (loading dose of140-280 mg/kg PO, IV, then

at 70 mg/kg PO, IV QID x 2-3 d


• Specific toxicities– Metals

• Lead toxicity more common in dogs than cats– Source

» Lead paint (prior to 1970’s) is primary source» Batteries, linoleum, plumbing supplies, ceramic containers,

lead pipes, fishing sinkers, shotgun pellets– Clinical signs (Usually involves signs of GI and nervous systems)

» Anorexia» Vom/dir» Abd pain

-CNS signs do not show initially» Blindness, seizures, ataxia, tremors, unusual behavior



• Lead toxicity– Dx

» Large # nucleated RBC’s; basophilic stipling » Blood lead conc >35 μg/ml

– Rx» Remove lead from GI tract (cathartic, Sx)» Chelators (to bind the Pb in blood stream and hasten its

removal)

-Calcium EDTA (ethylene diamine tetra acetic acid)

-Penicillamine» IV fluids for dehydration and to speed removal via kidneys» Diazepam, Phenobarbital to control seizures



• Zinc Toxicosis– Usually from ingested pennies, galvanized metal, zinc oxide

ointment

• Clinical signs– Vomiting– CNS depression– Lethargy

• Dx– Hx of exposure– Clinical signs

• Rx– Remove metal objects endoscopically or surgically– IV fluid therapy– Ca EDTA chelation



• Specific toxicities– Ethylene Glycol (antifreeze; sweet taste)

• Lethal dose: Cat—1.5 ml/kgDog—6.6 ml/kg

• Signs (onset within 12 h of ingestion)– CNS depression, ataxia (may appear intoxicated)– Vomiting– PD/PU– Seizures, coma, death

• Dx– Hx, signs– Ethylene Glycol Poison Test—an 8 min test used in cats and dogs

• Rx– Emesis, adsorbents if ingestion within 3 h of presentation– IV fluids, NaBicarb for acidosis– Ethanol inhibits ethylene glycol metabolism (keep animal drunk)

» Dogs (Cats): 20% ethanol—5.5 (5.0) ml/kg q6h x 5, then q8h x 4 – 4-methylpyrazole has been shown to be effective


• Specific toxicities– Snail Bait (Metaldehyde, methiocarb)

– Metaldehyde mechanism unknown

– Methiocarb is a carbamate and parasympathomimetic

• Signs– Hypersalivation

– Incoordination

– Muscle fasciculations

– Hyperesthesia

– Tachycardia

– Seizures

• Rx– Emesis and absorbents

– Pentobarbital, muscle relaxants to control CNS hyperactivity


• Specific toxicities– Garbage Toxicity

– Common in dogs; not in cats– Enterotoxin-producing bacteria include Strep, Salmonella, Bacillus

• Signs (within min to h after ingestion)– Anorexia, lethargy– Vom/dia– Ataxia, tremors– Enterotoxic shock can cause death

• Rx– IV Fluid therapy– Broad-spec antibiotics– Intestinal protectants– Muscle relaxers or Valium may be needed to control tremors– Corticosteroids to counter endotoxic shock


• Specific toxicities– Insecticides

• Pyrethrins and Pyrethroids– Common ingredients of flea/tick sprays, dips, shampoos, etc– If used according to instructions, toxicity rarely occurs; if

overused, toxicity can result

• Signs– Hypersalivation– Vom/dia– Tremors, hyperexcitability or lethargy– Later, dyspnea, tremors, seizures can occur

• Rx– Bathe animal to remove excess– Induce vomiting/charcoal/cathartics for ingestion– Diazepam may be necessary for mild tremors– Methocarbamol, a muscle relaxer, for moderate-severe tremors– Atropine for hypersalivation and bradycardia


• Specific toxicities– Insecticides

• Organophosphates and Carbamates– Inhibit cholinesterase activity (break down of Ach is inhibited)– Highly fat-soluble; easily absorbed from skin and GI tract– Found in dips, sprays, dusts, etc for fleas and ticks

• Signs– Salivation– Vom/dia– Muscle twitching– Miosis-May progress to – Seizures, coma, resp depression, death

• Rx– Bathe animal– Charcoal if ingested– Atropine (0.2-0.4 mg/kg; half IV, half IM or SQ)– Praloxime chloride (20 mg/kg BID till signs subside)—reactivates

cholinesterase


• Specific toxicities– Plant Toxicity

– Most common in confined and juvenile animals

– Usually from ornamental, indoor plants

– Severity varies with plants

– ID scientific plant name (florist, greenhouse)

• Araceae family (most from this family) – Dumb cane, split-leaf philodendron

– Contain calcium oxalate crystals and histamine releasers

• Signs– Hypersalivation, oral mucosal edema, local pruritis

-Large amount of plant may cause:

– Vomiting, dysphagia, dyspnea, abd pain, vocalization, hemorrhage

• Rx– Rinse mouth with milk or water to remove Ca Oxalate crystals

– GI decontamination (protectants) may be needed


Dumb Cane (Dieffenbachia)• aka Mother-in-law’s tongue• Oral irritation; intense

burning, excess salivation

Sago Palm

• Coagulopathy• Liver failure

Split Leaf Philodendron• Oxalate crystals like Dieffenbachia• Oral irritation; intense burning, excess salivation

Lily of the Valley• Contains cardiac glucosides• Cardiac arrythmias, death

Azalea (Rhododendron) • Hypotension, cardiovascular collapse, death

• Phone advice to give owners (legal issues)– Protect yourself from exposure before handling animal

• Gloves, protective clothing

– Protect yourself from animal because poisoned animals may act strangely

– Protect animal from further exposure by removing pet from source

– Bring sample of vomit, feces, urine– Bring container/package that toxin was in and a sample of

the toxin (plant material, rat bait, etc)


Documents

Emergency Procedures Let the fun begin Or Passez le bon temp