Manual of Small Animal Emergency and Critical Care Medicine (Manual of Small Animal Emergency & Critical Care Medicine)

517 Pages·2004·54.93 MB·English

by  Douglass K. Macintire

Small Animal
Emergency
an.d Critical .
Care Mediéine
Douglass K. Macintire
Kenneth J. Drobatz
I Steven c. Haskins
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William D. Saxon
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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
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UNIVEi<:SiD,'¡J LA SALLE
BIBLIOTECA P.T.
Blackwell
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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