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BSAVA Manual of BSAVA Manual of Canine and Feline B S Emergency and Critical Care A Canine and Feline V Second edition A Edited by Lesley G. King and Amanda Boag M Emergency and a n u Emergency care is one of a Critical Care the most important areas l o of veterinary medicine. f Building on the success of C the bestselling first edition, a Second edition the international editors and n authors have revised and i n updated the Manual to reflect e the continued growth in knowledge in this vital area. a n d The Manual remains a highly practical resource. A new chapter on vascular access details the placement and maintenance of intravenous, arterial and intraosseous F e catheters. Other new chapters feature: l electrolyte abnormalities and acid–base i n imbalance; and transfusion medicine. e The growing body of knowledge and E range of techniques in analgesia is m reflected in a new stand-alone chapter. Medical and surgical treatments for e gastrointestinal emergencies have r g also been separated to allow a clearer e picture. To aid fast access to practical n information, techniques such as tube c placement are now found within y the relevant chapters. Additional a photographs and illustrations serve to n increase useability still further. d C r i CONTENTS t i Triage of the emergency patient; Vascular access; Assessment and diagnosis of shock; Fluid therapy; c Electrolyte and acid–base imbalance; Cardiovascular emergencies; General approach to dyspnoea; a Renal and urinary tract emergencies; Neurological emergencies; Ophthalmological emergencies; l Approach to gastrointestinal emergencies; Acute abdominal and gastrointestinal surgical emergencies; C Haematological emergencies; Transfusion medicine; Reproductive and paediatric emergencies; Endocrine emergencies; Acute management of orthopaedic and external soft tissue injuries; a Dermatological emergencies; Toxicological emergencies; Cardiopulmonary–cerebral resuscitation; r e Anaesthesia and sedation of the critical patient; Analgesia in the critical patient; Nutritional support of the critical patient; Antibiotic therapy in the critical patient; Imaging techniques for the critical patient; 2 Nursing care of the critical patient; Index. n d Edited by Also available from the BSAVA: e Lesley G. King d BSAVA Manual of Canine n and Amanda and Feline Anaesthesia and Analgesia, 3rd edition Boag 6 1 S Edited by Tanya Duke-Novakovski, UB P Marieke de Vries and Chris Seymour 91 9 3 3991 Emergency Covers Spread.indd 1 Covers Placed.indd 1 1182//1102//22001166 1111::5059 BSAVA Manual of Canine and Feline Emergency and Critical Care Second edition Editors: Lesley G. King MVB DipACVECC DipACVIM School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA and Amanda Boag MA VetMB DipACVIM DipACVECC FHEA MRCVS Department of Veterinary Clinical Science, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Published by: British Small Animal Veterinary Association Woodrow House, 1 Telford Way, Waterwells Business Park, Quedgeley, Gloucester GL2 2AB A Company Limited by Guarantee in England. Registered Company No. 2837793. Registered as a Charity. First published 1999 Second edition 2007 Reprinted 2011, 2014, 2015, 2017 Copyright © 2017 BSAVA All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in form or by any means, electronic, mechanical, photocopying, recording or otherwise without prior written permission of the copyright holder. A catalogue record for this book is available from the British Library. ISBN 978 0 905214 99 3 e-ISBN 978 1 910443 09 5 The publishers, editors and contributors cannot take responsibility for information provided on dosages and methods of application of drugs mentioned or referred to in this publication. Details of this kind must be verified in each case by individual users from up to date literature published by the manufacturers or suppliers of those drugs. Veterinary surgeons are reminded that in each case they must follow all appropriate national legislation and regulations (for example, in the United Kingdom, the prescribing cascade) from time to time in force. Printed in India by Imprint Digital 3991PUBS16 Printed on ECF paper made from sustainable forests i Page i Emergency.indd 1 12/12/2016 11:04 Other titles in the BSAVA Manuals series: Manual of Canine & Feline Abdominal Imaging Manual of Canine & Feline Abdominal Surgery Manual of Canine & Feline Advanced Veterinary Nursing Manual of Canine & Feline Anaesthesia and Analgesia Manual of Canine & Feline Behavioural Medicine Manual of Canine & Feline Cardiorespiratory Medicine Manual of Canine & Feline Clinical Pathology Manual of Canine & Feline Dentistry Manual of Canine & Feline Dermatology Manual of Canine & Feline Endocrinology Manual of Canine & Feline Endoscopy and Endosurgery Manual of Canine & Feline Fracture Repair and Management Manual of Canine & Feline Gastroenterology Manual of Canine & Feline Haematology and Transfusion Medicine Manual of Canine & Feline Head, Neck and Thoracic Surgery Manual of Canine & Feline Musculoskeletal Disorders Manual of Canine & Feline Musculoskeletal Imaging Manual of Canine & Feline Nephrology and Urology Manual of Canine & Feline Neurology Manual of Canine & Feline Oncology Manual of Canine & Feline Ophthalmology Manual of Canine & Feline Radiography and Radiology: A Foundation Manual Manual of Canine & Feline Rehabilitation, Supportive and Palliative Care: Case Studies in Patient Management Manual of Canine & Feline Reproduction and Neonatology Manual of Canine & Feline Surgical Principles: A Foundation Manual Manual of Canine & Feline Thoracic Imaging Manual of Canine & Feline Ultrasonography Manual of Canine & Feline Wound Management and Reconstruction Manual of Canine Practice: A Foundation Manual Manual of Exotic Pet and Wildlife Nursing Manual of Exotic Pets: A Foundation Manual Manual of Feline Practice: A Foundation Manual Manual of Ornamental Fish Manual of Practical Animal Care Manual of Practical Veterinary Nursing Manual of Psittacine Birds Manual of Rabbit Medicine Manual of Rabbit Surgery, Dentistry and Imaging Manual of Raptors, Pigeons and Passerine Birds Manual of Reptiles Manual of Rodents and Ferrets Manual of Small Animal Practice Management and Development Manual of Wildlife Casualties For further information on these and all BSAVA publications, please visit our website: www.bsava.com ii Prelims Emergency.indd 2 23/04/2015 09:39 Contents List of contributors v Foreword vii Preface viii 1 Triage of the emergency patient 1 Andrew J. Brown and Kenneth J. Drobatz 2 Vascular access 8 Sophie Adamantos and Amy Alwood 3 Assessment and diagnosis of shock 17 Janet Aldrich 4 Fluid therapy 30 Amanda Boag and Dez Hughes 5 Electrolyte and acid–base balance 46 Amanda Boag 6 Cardiovascular emergencies 57 Rebecca L. Stepien and Adrian Boswood 7 General approach to dyspnoea 85 Lori S. Waddell and Lesley G. King 8 Renal and urinary tract emergencies 114 Karol A. Mathews 9 Neurological emergencies 130 Charles H. Vite and Sam N. Long 10 Ophthalmological emergencies 147 Deborah C. Mandell 11 Approach to gastrointestinal emergencies 159 Kate Murphy and Sheena M. Warman 12 Acute abdominal and gastrointestinal surgical emergencies 174 David Holt and Dorothy Brown 13 Haematological emergencies 192 Susan G. Hackner 14 Transfusion medicine 215 Gillian Gibson 15 Reproductive and paediatric emergencies 228 Gary C.W. England and Marco Russo iii Prelims Emergency 3 4/4/07, 4:54 PM 16 Endocrine emergencies 241 Barbara J. Skelly 17 Acute management of orthopaedic and external soft tissue injuries 251 Matthew J. Pead and Sorrel J. Langley-Hobbs 18 Dermatological emergencies 269 Petra J. Roosje 19 Toxicological emergencies 278 Robert H. Poppenga 20 Cardiopulmonary–cerebral resuscitation 295 Edward Cooper and William W. Muir 21 Anaesthesia and sedation of the critical patient 309 Richard Hammond 22 Analgesia in the critical patient 320 Daniel Holden 23 Nutritional support of the critical patient 327 Karyl J. Hurley and Kathryn E. Michel 24 Antibacterial therapy in the critical patient 339 Reid P. Groman and Dawn Merton-Boothe 25 Imaging techniques for the critical patient 356 Frances Barr 26 Nursing care of the critical patient 372 Emily Savino, Elisa A. Petrollini and Dez Hughes Appendix Conversion tables 383 Index 384 iv Prelims Emergency 4 4/4/07, 4:54 PM Contributors Sophie Adamantos BVSc CertVA DipACVECC MRCVS Department of Veterinary Clinical Science, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Janet Aldrich DVM DipACVECC Veterinary Medical Teaching Hospital, University of California – Davis, One Shields Avenue, Davis, CA 95616, USA Amy J. Alwood DVM Allegheny Veterinary Emergency, Trauma and Specialty, 4224 Northern Pike, Monroeville, PA 15146, USA Frances Barr MA VetMB PhD DVR DipECVDI MRCVS Department of Clinical Veterinary Science, University of Bristol, Langford House, Langford, Bristol BS40 5DU Amanda Boag MA VetMB DipACVIM DipACVECC FHEA MRCVS Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Adrian Boswood MA VetMB DVC DipECVIM ILTM MRCVS Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Andrew J. Brown MA VetMB DipACVECC MRCVS Department of Small Animal Clinical Studies, College of Veterinary Medicine, Michigan State University, East Lansing, MI 48824, USA Dorothy Cimino Brown DVM MSCE DipACVS School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Edward Cooper VMD Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, USA Kenneth J. Drobatz DVM DipACVECC DipACVIM School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Gary C.W. England BVetMed PhD DVetMed DVR DVRep DipECAR DipACT ILTM FRCVS School of Veterinary Medicine and Science, University of Nottingham, College Road, Loughborough LE12 5RD Gillian R. Gibson VMD DipACVIM MRCVS Wingrave Veterinary Surgery, 84 Mulgrave Road, Sutton, SM2 6LZ Reid P. Groman DVM DipACVIM School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Susan G. Hackner BVSc DipACVIM DipACVECC MRCVS Veterinary Specialty Consulting, Washington, DC 20007, USA Richard Hammond BSc BVetMed PhD DVA DipECVA MHEA MRCVS School of Veterinary Medicine and Science, University of Nottingham, College Road, Loughborough LE12 5RD Daniel Holden BVetMed DVA DipECVA CertSAM MRCVS The County Veterinary Clinic,137 Kingston Road, Taunton, Somerset TA2 7SR David Holt BVSc DipACVS School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Dez Hughes BVSc DipACVECC MRCVS Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Karyl J. Hurley DVM DipACVIM DipECVIM Waltham Centre for Pet Nutrition, Freeby Lane, Waltham-on-the-Wolds, Leicestershire LE14 4RS Lesley G. King MVB DipACVECC DipACVIM School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA v Prelims Emergency 5 4/4/07, 4:54 PM Sorrel J. Langley-Hobbs MA BVetMed DSAS(O) DipECVS MRCVS Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES Sam N. Long BVSc PhD DipECVN MRCVS School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Deborah C. Mandell VMD DipACVECC School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Karol A. Mathews DVM DVSc DipACVECC University of Guelph, Ontario Veterinary College, Guelph, Ontario, N1G 2W1, Canada Dawn Merton-Boothe DVM DipACVIM College of Veterinary Medicine, Auburn University, 109 Greene Hall, Auburn, AL 36849, USA Kathryn E. Michel DVM MS DipACVN School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA William W. Muir DVM PhD DipACVECC College of Veterinary Medicine, Department of Veterinary Clinical Sciences, 601 Tharp Street, Columbus, OH 43210-1089, USA Kate Murphy BVSc (Hons) DSAM DipECVIM-CA MRCVS Department of Clinical Veterinary Science, University of Bristol, Langford, Bristol BS40 5DU Matthew Pead BVetMed PhD CertSAO ILTM MRCVS Department of Veterinary Clinical Science, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA Elisa A. Petrollini CVT VTS (ECC) School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Robert H. Poppenga DVM PhD DipABVT CAHFS Toxicology Laboratory, School of Veterinary Medicine, University of California, West Health Sciences Drive, Davis, CA 95616, USA Petra J. Roosje DVM PhD DipECVD Division of Clinical Dermatology, Department of Clinical Veterinary Medicine, Vetsuisse Faculty, University of Berne, Lä nggassstrasse 128, 3012 Berne, Switzerland Marco Russo DVM PhD MRCVS Department of Clinical Science, Section of Clinical Obstetrics, Faculty of Veterinary Medicine, University of Naples, Italy Emily Savino CVT VTS (ECC) School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Barbara J. Skelly MA VetMB PhD DipACVIM DipECVIM-CA MRCVS Department of Veterinary Medicine, University of Cambridge, Madingley Road, Cambridge CB3 0ES Rebecca L. Stepien DVM MS DipACVIM Section of Veterinary Medicine, University of Wisconsin–Madison, 2015 Linden Drive W., Madison, WI 53706-1102, USA Charles H. Vite DVM PhD DipACVIM School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Lori S. Waddell DVM DipACVECC Department of Clinical Sciences, School of Veterinary Medicine, University of Pennsylvania, 3900 Delancey Street, Philadelphia, PA 19104-6010, USA Sheena M. Warman BSc BVMS DSAM DipECVIM-CA MRCVS Department of Clinical Veterinary Science, University of Bristol, Langford, Bristol BS40 5DU vi Prelims Emergency 6 4/4/07, 4:54 PM Foreword The Editors have asked me to write a Foreword for this edition of the BSAVA Manual of Canine and Feline Emergency and Critical Care. I am happy to do so and feel that it is quite an honour. For several years now I have been exclusively involved in emergency medicine and critical care and most striking to me is the amount of new knowledge that has accumulated in this area of veterinary medicine. When I was in veterinary school I can remember only two books specifically dedicated to emergency medicine. That has obviously changed, along with the development of the Veterinary Emergency and Critical Care Society, the American College of Veterinary Emergency and Critical Care, the British Association of Veterinary Emergency Care, the European Veterinary Emergency and Critical Care Society, and numerous residencies and internships specifically designed for education in emergency and critical care. It is extremely exciting to be a part of this emerging new specialty. As with any new specialty, the individuals involved are extremely passionate about what they do and show great willingness to spread the ‘Emergency Medicine and Critical Care Gospel’. This book captures that zeal and information in an extremely practical and useful format. Anyone that valued the last edition will not be disappointed. Those who went without the first version should make this a ‘must-have’ for their veterinary library. As with the last edition, this book is truly international with an excellent mix of authors from both sides of ‘the pond’, providing a broad perspective of emergency and critical care that no other book can boast. The credentials of the chapter authors are impressive and Lesley King and Amanda Boag have done a wonderful job in putting together a cohesive and extremely readable and useful manual that you will want to keep readily available for when that next emergency case comes in. You know and I know, it can happen at any time and this book can be there for you in that time of need! Kenneth J. Drobatz March 2007 vii Prelims Emergency 7 4/4/07, 4:54 PM Preface It is our great pleasure to present the newest edition of the BSAVA Manual of Small Animal Emergency and Critical Care. The specialty of emergency and critical care has continued to develop rapidly since publication of the first edition, with this second edition presenting updates, expansions and new illustrations of the material from the first book. Several important new chapters have also been added covering topics vital to the emergency practitioner, such as vascular access, electrolyte and acid–base balance, transfusion therapy, medical approach to gastrointestinal emergencies, analgesia in critical patients, and antibiotic therapy. This Manual is intended as a quick and easy reference for practitioners who handle emergency and critical cases on a routine or even not-so- routine basis. We hope that the material is accessible and practical, even in a crisis! In addition, the book is intended to act as a useful resource for residents and specialists in the field of emergency and critical care. The editors would like to express our sincere gratitude to each of the contributing authors. These contributors are truly leaders in their fields, both nationally and internationally. Without their efforts it would not have been possible to put together this Manual, which spans the breadth of our knowledge in this vast field. We must also acknowledge the incredible contributions of everyone in the BSAVA office, who all worked tirelessly to make this manual as perfect as it can be! In particular, Marion and Sabrina deserve special mention for their persistence, timeliness and attention to detail. Finally, the editors would like to acknowledge the help and support that we have received from our families and friends, as we worked to bring this project to fruition. Without their constant encouragement and support it would be difficult to achieve any of our goals in life. We hope that this Manual proves to be useful, helps you to save some lives, and sparks or fuels your interest in the exciting and dynamic field of emergency and critical care. Sincerely, Lesley G. King Amanda Boag April 2007 viii Prelims Emergency 8 4/4/07, 4:54 PM Chapter 1 Triage of the emergency patient 1 Triage of the emergency patient Andrew J. Brown and Kenneth J. Drobatz Introduction • Respiratory distress • Neurological abnormalities Triage can be defined as the evaluation and allocation • Protracted vomiting of treatment to patients according to a system of priori- • Slow or rapid heart rate ties designed to maximize the number of survivors. • Bleeding from body orifices All stages of emergency evaluation are important • Weakness, pale mucous membranes to the successful management of the critically ill • Rapid and progressive abdominal patient: telephone triage, waiting room triage, primary distension survey and treatment, secondary survey and the • Inability to urinate emergency plan. Critically ill patients have little physio- • Severe coughing logical reserve to tolerate mistakes of omission or • Toxin ingestion commission. Anticipation and prevention of problems • Collapse before they occur is one of the cornerstones of opti- • Extreme pain. mal emergency and critical care medicine. Always assume the worst and treat for it, while maintaining Transport and preparation the philosophy ‘above all, do no harm’. Owners often want to administer first aid to their pets. In instances where the problem is clearly determined and relatively simple, advice can often be given over Telephone triage the telephone. Relying on an owner’s interpretation of the animal’s problems can be risky, however. If The initial contact between a client and the veterinary there is any doubt about what is occurring, the owner surgery or hospital is often via the telephone. The in- should be advised to bring the pet to the clinic for formation obtained from this conversation may assist definitive evaluation. in triage of the patient, may help in diagnosis, and If trauma has occurred, the patient should be may provide information regarding first aid treatment placed on a board or some type of support struc- for the pet. ture. Fractured limbs can sometimes be stabilized The immediate aim of telephone triage is to deter- for transport by wrapping a roll of newspaper around mine whether the patient needs to be examined by the limb or taping or tying a board or piece of card- the veterinary surgeon immediately and what the board to the leg. The joints above and below the frac- owner should do for the pet before coming to the sur- ture should be stabilized. Splints should be applied gery. The owner should be calmed if necessary, so with care, since it is often difficult for the owner to that concise and accurate information can be obtained. determine the location of the fracture. If done incor- Questions should be directed at determining: rectly, splinting has the potential to cause further damage. If doubt exists, the animal should be placed • The nature of the injury in a confined space or in an area where movement • How the animal is breathing is minimized. Direct pressure or careful application • The colour of the mucous membranes of a tourniquet can control active haemorrhage. • The level of consciousness Owners should be warned that animals that are in • The presence and severity of bleeding pain, traumatized, neurologically damaged or fright- • The presence and severity of wounds ened should be carefully approached and muzzled • The ability of the animal to ambulate if possible. Even the friendliest of pets can become • The presence of obvious fractures aggressive under these circumstances. • The severity of vomiting and diarrhoea if Clients may be extremely upset and should be present calmed prior to bringing their pet in. Clear directions • The ability to urinate should be given to the owner for the drive to the • The degree of abdominal distension clinic, and time of arrival should be estimated. The • Whether there is coughing. hospital personnel should be notified about the nature of the emergency and the estimated time of arrival, Patients with the following should be brought to so that any special preparations may be undertaken the hospital without delay: if necessary. 1 Ch01 Emergency 1 4/4/07, 1:40 PM