Table Of Content

A Color Handbook of Small Animal Emergency and Critical Care Medicine Elizabeth A Rozanski DVM, DACVIM (Internal Medicine), DACVECC Tufts University, North Grafton, Massachusetts, USA John E Rush DVM, MS, DACVIM (Cardiology), DACVECC Tufts University, North Grafton, Massachusetts, USA MANSON PUBLISHING/ THE VETERINARY PRESS This book is dedicated to the memory of Jeff Proulx, DVM, DACVECC. Copyright © 2007 Manson Publishing Ltd ISBN: 978-1-84076-073-6 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means without the written permission of the copyright holder or in accor- dance with the provisions of the Copyright Act 1956 (as amended), or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 33–34 Alfred Place, London WC1E 7DP, UK. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. A CIP catalog record for this book is available from the British Library. For full details of all Manson Publishing titles please write to: Manson Publishing Ltd, 73 Corringham Road, London NW11 7DL, UK. Tel: +44(0)20 8905 5150 Fax: +44(0)20 8201 9233 Website: www.mansonpublishing.com Commissioning editor: Jill Northcott Project manager: Ayala Kingsley Copy editor: Joanna Brocklesby Proof reader: John Forder Book design and layout: Ayala Kingsley, diacriTech Colour reproduction: Tenon & Polert Colour Scanning Ltd, Hong Kong Printed by: New Era Printing Co Ltd, Hong Kong CONTENTS 3 Contributors . . . . . . . . . . . . 5 CHAPTER 4 CHAPTER 8 Abbreviations . . . . . . . . . . . 6 Hematological Neurological Preface . . . . . . . . . . . . . . . . 8 emergencies emergencies Blood loss anemia . . . . . . . . . 80 Seizures . . . . . . . . . . . . . . . 137 PART I Hemolytic anemia . . . . . . . . 84 Traumatic brain injury . . . . 141 Emergency medicine Nonregenerative Paralysis and paresis . . . . . . 144 anemia . . . . . . . . . . . . . . 86 Overview of emergency Vestibular syndrome . . . . . . 148 medicine . . . . . . . . . . . . . 10 Thrombocytopenia/ Mental alteration . . . . . . . . 151 thrombocytopathia . . . . . 87 Acquired coagulopathy . . . . . 90 CHAPTER 1 CHAPTER 9 Shock Metabolic CHAPTER 5 emergencies Hypovolemic shock . . . . . . . 14 Toxicological Sepsis/septic shock . . . . . . . . 17 Diabetic ketoacidosis . . . . . 157 emergencies Cardiogenic shock . . . . . . . . 19 Hypoglycemia . . . . . . . . . . 161 Overview . . . . . . . . . . . . . . . 92 Hypoadrenocorticism Poisonous plants . . . . . . . . . . 95 (Addison’s disease) . . . . 164 CHAPTER 2 Ethylene glycol . . . . . . . . . . . 96 Disorders of calcium . . . . . . 167 Cardiac Anticoagulant emergencies rodenticides . . . . . . . . . . . 97 CHAPTER 10 Cardiopulmonary Acetaminophen resuscitation . . . . . . . . . . 22 (paracetamol) . . . . . . . . . 99 Trauma Congestive heart failure in the Chocolate . . . . . . . . . . . . . . 100 Vehicular trauma . . . . . . . . 172 dog . . . . . . . . . . . . . . . . . 28 Tremorgenic Degloving wounds . . . . . . . 174 Congestive heart failure in mycotoxicosis . . . . . . . . 100 Bite wounds . . . . . . . . . . . . 175 the cat . . . . . . . . . . . . . . . 34 Pyrethrin and pyrethroids . . 102 Gunshot and Cardiac arrhythmias . . . . . . . 39 stab wounds . . . . . . . . . 178 Pericardial effusion . . . . . . . . 52 CHAPTER 6 Emergency fracture Arterial thromboembolism . . . 56 management . . . . . . . . . 180 Gastrointestinal Syncope . . . . . . . . . . . . . . . . 60 emergencies Vomiting . . . . . . . . . . . . . . 104 CHAPTER 11 CHAPTER 3 Reproductive Acute diarrhea . . . . . . . . . . 107 Respiratory emergencies Gastrointestinal emergencies obstruction . . . . . . . . . . 109 Dystocia . . . . . . . . . . . . . . . 184 Respiratory distress . . . . . . . . 66 Gastric dilatation–volvulus . . 111 Pyometra . . . . . . . . . . . . . . 187 Upper airway obstruction . . . 68 Gastrointestinal Neonatal emergencies . . . . . 189 Pneumonia . . . . . . . . . . . . . . 69 hemorrhage . . . . . . . . . . 114 Male reproductive Feline asthma . . . . . . . . . . . . 71 Pancreatitis . . . . . . . . . . . . . 118 emergencies . . . . . . . . . 191 Pulmonary thromboembolism . . . . . 73 CHAPTER 7 CHAPTER 12 Noncardiogenic pulmonary Renal Environmental edema . . . . . . . . . . . . . . . 74 emergencies emergencies Pneumothorax . . . . . . . . . . . 75 Acute renal failure . . . . . . . 123 Bites and stings . . . . . . . . . . 194 Pyothorax . . . . . . . . . . . . . . . 77 Dialysis . . . . . . . . . . . . . . . . 128 Heatstroke . . . . . . . . . . . . . 201 Pulmonary neoplasia . . . . . . 78 Chronic renal failure . . . . . . 130 Hypothermia . . . . . . . . . . . 205 Urethral obstruction . . . . . 132 Smoke inhalation . . . . . . . . 206 Burn injury . . . . . . . . . . . . . 208 PART 2 CHAPTER 17 Critical care Nutritional support of the critically ill patient Care of critically ill animals . . . . . . . . . . . 212 Nutritional assessment . . . . 248 Goals of nutritional support . . . . . . . . . . . . 249 CHAPTER 13 Nutritional plan . . . . . . . . . 249 Monitoring critical care patients Enteral nutrition . . . . . . . . 250 Monitoring of cardiac Parenteral nutrition . . . . . . 251 function . . . . . . . . . . . . 214 Monitoring and Monitoring of respiratory reassessment . . . . . . . . . 252 function . . . . . . . . . . . . 218 Special nutrients . . . . . . . . . 256 Summary . . . . . . . . . . . . . . 256 CHAPTER 14 Anesthesia and analgesia CHAPTER 18 for critical care patients Techniques General anesthetic Vascular access . . . . . . . . . . 258 approach to the critically ill patient . . . . . . . . . . . . 222 Urinary catheterization . . . . 262 Anesthetic and analgesic Supplemental oxygen . . . . . 263 agents . . . . . . . . . . . . . . 227 Thoracocentesis . . . . . . . . . 264 Analgesia for critically Thoracostomy tube ill patients . . . . . . . . . . . 229 placement . . . . . . . . . . . 265 Summary . . . . . . . . . . . . . . 229 Pericardiocentesis . . . . . . . . 266 Abdominocentesis . . . . . . . 267 CHAPTER 15 Tracheostomy . . . . . . . . . . 268 Fluid therapy Transtracheal aspirate . . . . . 269 Determining the need Epidural analgesia . . . . . . . . 271 for fluid therapy . . . . . . . 232 Esophagostomy tube Choosing the appropriate placement . . . . . . . . . . . 272 fluid type . . . . . . . . . . . . 233 Robert Jones bandage . . . . 275 Appropriate routes for fluid therapy . . . . . . . . . 236 Determining the rate Appendices and duration of 1. Conversion tables . . . . . . 277 fluid therapy . . . . . . . . . 236 2. Calculation of a Fluid additives . . . . . . . . . . 237 continuous rate Monitoring and possible infusion . . . . . . . . . . . . . 280 complications . . . . . . . . 238 3. Intensive care unit Summary . . . . . . . . . . . . . . 238 drug formulary . . . . . . . 282 CHAPTER 16 Index . . . . . . . . . . . . . . . 293 Transfusion medicine for critical care patients Blood products . . . . . . . . . . 240 Synthetic blood substitutes . . . . . . . . . . . 242 Blood types . . . . . . . . . . . . 242 Administration . . . . . . . . . . 244 CONTRIBUTORS 5 Elizabeth Armitage-Chan, Ari Jutkowitz, VMD, Scott P. Shaw, DVM, VetMB, MA, MRCVS, DACVECC DACVECC DACVA Michigan State University Tufts University Royal Veterinary College East Lansing, MI North Grafton, MA London, UK (Section editor – Environmental, Jana Norris, DVM, DACVS Reproductive, and Mark Acierno, DVM, Veterinary Surgical and Toxicology) DACVIM (Internal Diagnostic Specialists Medicine) Clarksburg, NJ Jennifer Waldrop, DVM, Louisiana State University DACVECC Baton Rouge, LA Massachusetts Veterinary Therese O’Toole, DVM, Referral Hospital DACVIM Jonathan Bach, DVM, Tufts University Woburn, MA DACVIM, DACVECC North Grafton, MA University of Wisconsin Thomas Walker, DVM, (Section editor – Renal, Madison, WI Metabolic, and Neurological) DACVECC Tufts VETS Søren Boysen, DVM, April Paul, DVM Walpole, MA DACVECC Tufts VETS University of Montreal Megan Whalen, DVM Walpole, MA St. Hyacinthe, Quebec Tufts University North Grafton, MA Elizabeth A. Rozanski, DVM, Daniel Chan, DVM, MRCVS, DACVECC, DACVIM DACVN, DACVECC (Internal Medicine) Kimberly Winters, DVM, Royal Veterinary College Tufts University DACVIM London, UK North Grafton, MA Tufts VETS (Section editor – Monitoring, (Section editor – Respiratory and Walpole, MA Nutrition) Hematological) Benjamin Davidson, BVSc, John E. Rush, DVM, MS, DACVECC DACVIM (Cardiology), New York City Veterinary DACVECC Specialists Tufts University New York, NY North Grafton, MA (Section editor – Cardiology) Armelle deLaforcade-Buress, DVM, DACVECC Tufts University North Grafton, MA (Section editor – Gastrointestinal, Trauma) 6 GLOSSARY OF ABBREVIATIONS 5DW 5% dextrose in water CV system cardiovascular system ACD acid–citrate–dextrose CVD central vestibular disease ACE angiotensin-convering enzyme CVP central venous pressure ACR anticoagulant rodenticide DC direct current ACT activated clotting time DEA dog erythrocyte antigen ACTH adrenocorticotropic hormone DIC disseminated intravascular coagulation ALP alkaline phosphatase DKA diabetic ketoacidosis ALT alanine aminotransferase DOCP desoxycorticosterone pivolate aPTT activated partial thromboplastin time DPL diagnostic peritoneal lavage ARDS acute respiratory distress ECG electrocardiogram syndrome EEG electroencephalogram ARF acute renal failure EMD electromechanical dissociation ASA American Society of EMG electromyography Anesthesiologists FCE fibrocartilagenous embolism AST aspartate aminotransferase FDP fibrin(ogen) degradation products AT antithrombin FeLV feline leukemia virus ATP adenosine triphosphate FFA free fatty acid AV atrioventricular FFP fresh frozen plasma BMBT buccal mucosal bleeding time FiO fraction of inspired oxygen 2 bpm beats per minute FIP feline infectious peritonitis BPH benign prostatic hypertrophy FIV feline immunodeficiency virus BUN blood urea nitrogen FLUTD feline lower urinary tract disease cAMP cyclic adenosine monophosphate FP frozen plasma CBC complete blood count Fr French gauge cGMP cyclic guanosine monophopshate ga gauge CHF congestive heart failure GABA gamma aminobutyric acid CNS central nervous system GDV gastric dilatation–volvulus CO carbon dioxide 2 GFR glomerular filtration rate COP colloid osmotic pressure GGT gamma-glutamyl transpeptidase CPA cardiopulmonary arrest GI gastrointestinal CPDA-1 citrate–phosphate–dextrose– HGE hemorrhagic gastroenteritis adenine hpf high-power field CPR cardiopulmonary resuscitation IM intramuscularly (used in CRF chronic renal failure describing dosages of medication) CRH corticotropin-releasing hormone ITP immune-mediated CRI continuous rate infusion thrombocytopenia CRRT continuous renal replacement IV intravenously (used in describing therapy dosages of medication) CRTZ chemoreceptor trigger zone IVIG intravenous immunoglobulin C-section Cesarean section IVP intravenous pyelography CSF cerebrospinal fluid MAH malignancy-associated CT computed tomography hypercalcemia 7 MRI magnetic resonance imaging U units NCPE noncardiogenic pulmonary edema UO urethral obstruction NPO non per os (nothing by mouth) US United States NSAID nonsteroidal anti-inflammatory V–Q ventilation–perfusion drug OHE ovariohysterectomy PaCO partial pressure of arterial 2 carbon dioxide PaO partial pressure of arterial oxygen 2 PCV packed cell volume PEG percutaneous endoscopic gastrostomy PES primary epileptic seizure PGF Prostaglandid F 2 2 PIVKA proteins induced by vitamin K absence or antagonism PO per os (by mouth) PPN partial parenteral nutrition pRBC packed red blood cells PT prothrombin time PTE pulmonary thromboembolism PTH parathyroid hormone PTH-rP parathyroid hormone related protein PTT partial thromboplastin time PU/PD polyuria/polydipsia PVD peripheral vestibular disease RER resting energy requirement RES reactive epileptic seizure SaO arterial oxygen saturation 2 SC subcutaneously (used in describing dosages of medication) SES structural epileptic seizure SI small intestinal SIRS systemic inflammatory response syndrome SpO arterial oxygen hemoglobin 2 saturation SVT Supraventricular tachycardia TBSA total body surface area TLI trypsin-like immunoreactivity TPN total parenteral nutrition TT thrombin time 8 PREFACE Emergency and critical care is one of the fastest growing fields of veterinary medicine. Veterinarians engaged in emergency veterinary medical practice must be able to recognize and manage a dizzying array of diseases. Virtually every life-threatening disease can present for emergency evaluation, and the emergency clinician must be prepared to successfully manage all cases. This requires a strong working knowledge of many specialty areas, including internal medicine, neurology, cardiology, oncology, anesthesia, and many other fields. The emergency clinician must be prepared to make a quick assessment or diagnosis, and then follow these decisions with action regarding surgery, diagnostics, and medical interventions. The appropriateness of these actions can mean the difference between life and death for the animal. In contrast, the critical care veterinary clinician often has a good working knowledge of the primary disease, and some therapy has typically been initiated by the time the critical care veterinarian becomes involved. The criticalist is required to recognize subtle changes in the clinical course of animals, often in a stressful 24-hours-a-day environment, and to take corrective action before severe systemic disease becomes irreversible. Clinical decisions regarding seemingly small items, such as fluid therapy, antibiotics or analgesics, can have a profound impact on patient outcome. The best criticalist uses a combination of years of experience, a solid understanding of pathophysiology of all organ systems, and acute clinical acumen. This manual is intended to complement comprehensive textbooks of emergency and critical care medicine, and other texts which provide the required fundamental basics of pathophysiology, pharmacology, surgery, or internal medicine. Certain diseases occur commonly, and certain predictable dilemmas arise in the intensive care unit. Some diseases or clinical problems can be best demonstrated or described with accompanying illustrations. The main aim of the book is to discuss management of the common clinical conditions and scenarios that we encounter in our clinical practice, with the hope that these will also be common dilemmas for the reader. There can be many successful approaches in clinical medicine, especially in a rapidly developing field like emergency and critical care, and our biases in the medical and surgical approach to certain diseases will undoubtedly show. We have included figures or illustrations for situations where an image can do greater justice to the topic than a lengthy textual description and have highlighted key information in tabular form. The aim is to bring this information into a small manual which might be a ready resource for clinicians actively engaged in the field. We hope that you will find this manual on the counter or desk more often than on the bookshelf. PART I 9 Emergency medicine