Veterinary Triage Questions PDF

**Review questions/topics** 1. Triage categories (examples) **Triage --** classification of patients to determine priority of need and optimal order in which they should be treated - RED - immediate - life-threatening - ORANGE - very urgent - potentially life-thr...

**Review questions/topics** 1. Triage categories (examples) **Triage --** classification of patients to determine priority of need and optimal order in which they should be treated - RED - immediate - life-threatening - ORANGE - very urgent - potentially life-threatening - YELLOW - urgent - not life-threatening - GREEN - standard - not emergency situation Examples: RED -- severe respiratory distress, circulatory shock, **neurological seizing currently**, unresponsive, rapid abdominal distension, hypoglycemia, rectal temp over 41 under 36,7 ORANGE -- moderate respiratory distress, subcut emphysema, **uncontrollable major hemorrhage**, arterial thromboembolism signs, pale MM with absence of shock, altered conciuousness, cluster seizures, evisceration, proptosis of eye, toxin or foreign body ingestion, labor, urethral obstruction, severe pain YELLOW -- mild respiratory distress, uncontrollable minor hemorrhage, acute spinal neurological deficit, head tilt, **open fracture**, medium to large skin wound, possible foreign body, persistent vomiting, melena, red urine without stranguria, moderate pain, moderate dehydration, severe pruritus, anorexia in pup, rectal temp 40-40,4 GREEN -- local inflammation, stranguria, **vomiting**, mild pain or pruritus, one seizure, swelling, rectal temp 39-39.9 2. Triage clinical examination: respiratory, cardiovascular, nervous system (normal vs abnormal) Primary triage - **A**irways - **B**reathing - **C**irculation - **D**isability MBSA (major body system assessment) - respiratory system - cardio-vascular system - nervous system - urinary/reproductive system - other parameters/changes Respiratory system - in order to detect hypoxemia and hypoventilation - open airways - stertor/stridor - respiratory rate and pattern - \+ mucous membranes - auscultation - palpation of thorax - tachypnea: - hypoxemia - hypovolemia - pain - abdominal enlargement - scared/frightened Cardiovascular system - in order to identify hypoperfusion: - color of mucous membranes - capillary refill time (CRT) - heart rate - pulse-presence/quality - femoral pulse - dorsal metatarsal pulse - heart auscultation Parameters of shock Color of mucous membranes Neurological system - central nervous system - mentality - cranial nerves - movement - pain/deep pain - changed mental status - stupor (voi reagoida isoon stimuliin) vs coma (ei reagoi mihinkään) - anisocoria (unequal size eye pupils) - seizures - acute paralysis/paresis - deep pain Primary stabilization - IV catheter - oxygen therapy - fluid therapy - analgesia Diagnostics - blood sample: - PCV/TS - Glycose - Lactate - Blood gases - UREA - Blood smear - Electrolytes - diagnostics: - SpO2 - NIBP (non invasive blood pressure) - EKG - aFAST/tFAST 3. Fluid therapy: calculation in patients (dehydration, daily needs, ongoing losses) **Fluid therapy** - aims: - maintain adequate perfusion in body - restoring fluid balance/treatment of dehydration - restoring electrolyte balances - restoring normal blood circulation and cardiac function in shock and hypovolemia - **dehydration**: loss of fluids in interstitial space - hypovolemia: insufficient amount of blood in bloodstream (intravascular space) Fluid therapy calculation - for rehydration - infusion = - body weight (kg) \* dehydration % \*10 =ml - \+ daily requirement - +/- continuing losses - daily requirement, rule of thumb: - dogs: 2-6ml/kg/h - cats: 2-3ml/kg/h Potassium supplementation - potassium supplementation in hypokalemia: - normal potassium in blood: 3,5-5,5mmol/l - 1 mEq/L= 1mmol/L - do not exceed 0,5mEq (mmol)/kg/h 4. Stabilization of the hypovolemic patient with fluid therapy Hypovolemic shock (decreased intravascular volume) - low volume/hypotensive resuscitation: isotonic crystalloids - aiming mean blood pressure 60-90 mmHg - fluid rate: 15-20ml/kg within 10-15min - repeated up to 4 times - if isotonic crystalloids do not work: - add colloids: - dogs: 5-10ml/kg - cats: 1-5ml/kg - hypertonic fluids: Do not use in hypernatremia and severe dehydration! - dogs: 4-5ml/kg - cats: 2-4ml/kg - if blood loss due to active bleeding -- try to stop it - consider blood products 5. Calculation of glucose solutions Glucose supplementation - in hypoglycemia - small breeds - glycose/dextrose 5% - in blood metabolizes to water, has no electrolytes - could be used in heatstroke, diabetes insipidus - usually make fluid yourself - isotonic fluid + glucose solution (10-40%) - X(volume to add) = concentration of gly solution you want (%) \* volume of isotonic fluid (ml) / concentration of glycose solution you have 6. Advantages and disadvantages of oxygen delivery methods **Oxygen therapy** - prolonged hypoxemia and poor tissue oxygen delivery may result in multiple organ failure and therefore should be treated immediately - use if respiratory distress symptoms, pulse oximetry under 95%, PaO2 less than 80mmHg Non-invasive methods: - Flow-by oxygen - oxygen hose near mouth or nostrils - flow rate of 2-3 L /min provides FiO2 of 25% - well tolerated by most patients, especially cats - one of simplest techniques - short term administration - Oxygen mask - can be used in any patient who lying still and/or tolerates mask - more suitable in short term oxygen administration - 2-6 L/min flow recommended (patient size) - possible to reach 40-50%FiO2 - minimal equipment required - needs supervision - Oxygen hood or self-made cage - easily made in hospital - leave 2-5 cm from top open to allow humidity and CO2 elimination - not tolerated by all patients - temperature inside collar area may increase rapidly - maintenance flow 2-5L/min - FiO2 obtained is 30-40% - Oxygen cage - suitable for patients suffering for severe stress and not tolerating other methods (cats) - FiO2 40-50% - disadvantages- cost - hyperthermia can develop easily - possible lack of patient access Invasive methods: - Nasal prongs - human nasal prongs can be used - well tolerated by most dogs - easily dislodged - unknown FiO2 - possibly higher than flow by oxygen - Nasal catheter - if O2 is needed more than 24h - simple to place and requires minimal equipment - catheter should be changed every 24-48h - flow rates 50-150ml/kg can provide FiO2 30-70% - higher flow can be irritating and cause sneezing - humification is needed - Trans-tracheal oxygen - catheter is inserted through cricothyroid ligament or caudal to it (between 3-5 ring) - needs experience - may need sedation - aseptic technique - O2 flow rates of 50 ml/kg/min provide FiO2 40-60% - risks associated with sedation and infection - lesions or damage of trachea - Tracheostomy tube - needs experience - need sedation - aseptic technique - risks associated with pneumomediastinum, infection and dislodging 7. Different types of shock (examples) **Shock** - broadly defined as imbalance between oxygen delivery to tissues and oxygen consumption by tissues - most commonly classified by hemodynamic effects (circulatory): - hypovolemic - cardiogenic - obstructive - distributive - non-circulatory: - hypoxic - metabolic - multiple types can co-exist - several clinical stages of shock are recognized -- based on extent of physiological compensation    Hypovolemic shock - most common form - causes: - hemorrhagic - internal vs external - non-hemorrhagic - internal vs external - dehydration vs hypovolemia Shock stages, causes Distributive shock - maldistribution of blood flow - vasodilatation - SIRS- systemic inflammatory response syndrome - infectious and non-infectious causes - trauma - pancreatitis - burns... - sepsis - anaphylactic shock Obstructive shock - physical obstruction to blood flow - to or from the heart or great blood vessels - may be accompanied by cardiogenic shock - causes: - GDV - pericardial tamponade - dirofilariosis - tension pneumothorax - pulmonary or aortic thromboembolism Cardiogenic shock - occurs when cardiac output is reduced - causes: - cardiac diseases - arrhythmias - valvular insufficiencies - prognosis guarded - treatment is aimed for increasing cardiac output Non-circulatory types - **hypoxic** - decreased oxygen content in arterial blood - causes: - anemia (e.g.IMHA) - aspiration pneumonia - lung contusion - carbon monoxide poisoning - paracetamol toxicosis - **metabolic** - reduced cellular aerobic metabolism - causes: - severe hypoglycemia - sepsis - cyanide toxicity 8. Stabilization of respiratory distress patient Stabilization-Based on your DDX list - OXYGEN - analgesia/sedation - inhalative drugs - furosemide - antibacterial treatment and fluid therapy Oxygen - treat and prevent hypoxia - choose method that animal is ok with - if needed intubate/tracheostomy Analgesia and sedation - butorphanol: 0.1-0.4mg/kg (0.2mg/kg) IM/IV/SC - midazolam: 0.1-0.3mg/kg (0.1mg/kg) IM/IV/SC - others: - acepromazine - A2-agonists - ketamine - propofol Inhalation drugs - salbutamol (albuterol sulfate): Ventolin 100μg/dose - bronchodilator - cat/dog: one puff q30min up to 4-6h - used in acute cases - fluticasone: Flixotide inhaler 50μg/dose - inhaled glucocorticosteroids - cat one puff q12 - dog 2-4 puffs q12 - needs time to work; systemic hormone treatment Furosemide - diuretic - indication - cardiogenic lung edema - cardiogenic edema - 1-4 (-8)mg/kg IM/IV - max 12mg/kg/q24 - CRI 0,66-1mg/kg/h Antibiotics and fluid therapy - they are not always needed Other things - temperature - thoracocentesis - tracheostomy - lavaging stomach 9. Obstructive diseases of the upper and lower respiratory tract, Diseases of the lung parenchyma Upper airway obstructive diseases - laryngeal paralysis - tracheal collapse - brachycephalic syndrome - polyps - foreign bodies - neoplasia Lower airway obstructive diseases - asthma -- allergic cause - Siamese and Burmese - coughing cat - risk for secondary pneumothorax - chronic bronchitis Lung parenchymal diseases - aspiration pneumonia - anesthesia - megaesophagus - infectious - parasitic - bacterial - viral - lung edema - cardiogenic - non-cardiogenic - neurogenic (seizures, head trauma, electrocution) - post-obstructive (choking, laryngeal paralysis) - due to systemic disease (sepsis, shock) - primary lung damage (pneumonia, lung torsion, smoke inhalation) - accumulation of fluid in alveoli and pulmonary interstitium - aim is to differentiate cardiac from non-cardiac - cardiac - more common (especially in cats) - left-sided failure and elevated pulmonary venous pressure - on auscultation: - crackles; heart murmur; gallop rhytm - ER Treatment: oxygen, furosemide, butorphanol/acepromazine 10. Indications for thoracocentesis If suspected pleural effusions or pneumothorax, diagnostic/treatment - dog: pyothorax, chylothorax, cardiac insufficiency, neoplasia, diaphragmatic hernia - cat: cardiac insufficiency, systemic disease, neoplasia, FIP, chylothorax, diaphragmatic hernia 11. Possible causes of hemo, chylo, and pyothorax Chylothorax - milky white chylomicron rich fluid within the thoracic cavity (usually exudate rather than transudate, PP \>2g/l or 30 g/l), cell count below 10000 cells/mcg, over 5000, gravity over 1.018 - Cause: cardiac disease (cats), idiopathic, neoplasia, trauma Pyothorax - yellowish, turbid fluid, SG \ 14. Advantages/disadvantages of feeding tubes (naso-oesophagus; oesophagus) Nasoesophageal (-gastric) tube - 3,5-8 Fr - easy to place; requires local anesthetic - generally well tolerated - short term (up to 14 days) - liquid diet only - contraindications: facial trauma, coagulopathy, respiratory disease - always verify correct placement with x-ray! - complications: sneezing, aspiration pneumonia, vomiting, tube migration, esophageal irritation, inflammation and scarring, tube clogging, epistaxis Esophagostomy tube - 12---22 Fr (cat vs large breed dog) - animals tolerate well - can be used for long period (weeks, months) - wider selection of diets - in patients with facial/oral diseases - requires general anesthesia - verify the correct placement by x-ray! - complications: cellulitis or infection of placement site, displacement during vomiting or regurgitation, clogging of tube - more severe: pneumothorax, pneumomediastinum, damage to vascular structures or nerves in cervical region (rare) 15. Decontamination of toxicosis Emergency management - ABCD - airways - breathing - circulation - dysfunction - supportive care and treatment - monitoring and supportive care - fluid therapy - cardiovascular support - gastrointestinal support - neurological support - analgesia/sedation - other Ocular decontamination - physiological saline (e.g. contact lens solution) - tepid water - 15-20min - maximize decontamination - reduce secondary injury to cornea - immediate veterinary care is needed - prevent rubbing/Elizabethan collar Dermal decontamination - prevent transdermal absorption - prevent oral re-exposure secondary to grooming - eyes! - protect yourself and instruct owner - oil-based toxicities - tepid water and liquid dish degreasing soap - clipping - caustic, acidic or alkaline toxicities - gentle decontamination with tepid water - do not scrub! Do not use high pressure water sprays! - do not "neutrilize"! - risk of hypothermia with cooling - increases the effect of pyretroids and pyrethrins on CNS - not too warm water - vasodilation Gastrointestinal decontamination - before considering emesis - complete history - consider - time frame - underlying med. problems - symptomatic patients - corrosive vs caustic agent - hydrocarbons: gasoline, kerosine, motor oil etc - be aware of possible complications - aspiration pneumonia - hematemesis - caustic or corrosive injury to esophagus, oropharynx or GIT Emesis - the earlier the better - mainly useless after 4h (1-2h ideal) - except: - large wads of xylitol gum - large amounts of chocolate - grapes and raisins - massive ingestion that can cause concretion (fish oil capsules, iron-vitamins) - ingestions that can form a bezoar or foreign body (blood or bone meal; fire starter logs) - drugs that delay gastric emptying (e.g opioids) Emesis at home - 3% hydrogen peroxide - direct gastric irritation - 1-2ml/kg; do not exceed 50ml - induction in 5-10min - table salt - no longer recommended by veterinarians nor human doctors - risk of hypernatremia - 7% Syrup of Ipepac - no longer recommended by veterinarians nor human doctors - severe hematemesis, lethargy, diarrhea, depression Emesis at clinic - Ropinirol - Apomorphine - Xylazine - Dexmedetomidine Gastric lavage - when to consider - symptomatic patient with changed mental status - need for controlled decontamination - material large in size - large toxic ingestions of tablets/capsules approaching LD 50 (lethal dose 50%) - complications - risk of sedation - aspiration pneumonia - hypoxemia - mechanical injury - contraindications - corrosive agent - hydrocarbon agent - sharp objects Activated charcoal (AC) - act as an absorbent and prevent systemic absorption - 1-5g/kg - often with cathartic - ideally should not mix with food - toxicant must come in direct contact with AC - toxicant must be in the stomach - it has to bind with AC - currently ideal timeframe 0-60min post-ingestion binds poorly with: alcohol, sugar alcohol (sorbitol), glycols, strong acids, strong bases, metals, lithium, sodium, iron, lead, arcenic 16. Toxicosis (chocolate, rat poison, lily, permethrin): clinical signs, principles of treatment **Chocolate** - signs usually 6-12h after ingestion: vomiting, diarrhea, tachycardia, arrythmias, hypertension, ataxia, muscle tremors, seizures, hyperexcitability, PU/PD, urinary incontinence, tachypnea, respiratory failure, hypokalemia, death - treatment - management of potentially life-threatening clinical signs, symptomatic and supportive care - stabilization: - antivonculsant - diazepam or midazolam (0.25--0.5 mg/kg IV) for tremors and/or mild seizures - barbiturates or other general anaesthetics for severe and/or continued seizures - tachyarrhythmias: - Propranolol (0.02--0.06 mg/kg IV q 6 hours) or metoprolol (0.2--0.4 mg/kg PO q 12 hours). - refractory ventricular tachyarrhythmias: - Lidocaine (1--2 mg/kg IV once, followed by a CRI of 25--75 μg/kg/min). - bradyarrhythmias: - Atropine (0.01--0.02 mg/kg). - Ater stabilization, or prior clinical signs (caffeine in 1--2 hours, chocolate in 6 hours post-ingestion): - induced emesis, via apomorphine or hydrogen peroxide - if the patient is sedated because of seizure activity, gastric lavage may be considered - after decontamination of agent: - activated charcoal 1--2 g/kg PO once with a cathartic (sorbitol) then q 6--8 hours without a cathartic for 24--48 hours - Urinary catheterization or frequent urination (q 2--4 hours) recommended to decrease potential reabsorption of methylxanthines across bladder wall **Rat poison** - signs usually 36-72h after exposure: lethargy, weakness, anemia, dyspnea, coughing, hemoptysis, bleeding into cavities/joints, hemorrhage, abdominal distension, CNS signs (seizures, paralysis), sudden death due hypovolemic shock - treatment - Induced vomiting (e.g. hydrogen peroxide) is effective within 4--8h of ingestion. If vomiting is not successful or contraindicated, oral vitamin K1 should be started. - Asymptomatic patients: start prophylactic vitamin K1 or monitor patient's PT. If PT is normal at 72h, no treatment is needed. If PT increases, start vitamin K1 treatment. PT monitoring should not occur while administering vitamin K1, can lead to false readings. - Vitamin K1: 3--5 mg/kg twice per day. Duration of treatment depends on the specific rodenticide. - Symptomatic patients: stabilization, oxygen treatment and blood or plasma transfusions. Oral vitamin K1 treatment. Hospitalization until PT normalizes. **Lily** - signs 6-12h after ingestion: early signs vomiting, anorexia, lethargy - after that: signs of AKI; polyuria, oliguria, anuria, dehydration, diarrhea, depression - CNS signs (cats): ataxia, head pressing, disorientation, tremors, seizures - rare: pancreatitis - treatment - Wash off animal contaminated with pollen - Induce vomiting (before symptoms start): α 2 agonist (dexmedetomidine, xylazine) in cats, apomorphine in dogs - IV-fluid therapy: at least for 48-72 hours, isotonic crystalloids, initially at 2-3x maintenance for 48 hours then adjust accordingly to patient's needs - Carbodote (activated charcoal) for binding toxins & cathartic for increasing bowel movements (if not dehydrated / diarrhea) - Other treatment considerations: diazepam (seizures), gastroprotectants, antiemetics, analgesics **Permethrin** - signs in minutes up to hours - dermal application: paresthesia, ear twitching, paw/tail licking, hiding, hyperexcitability - cats: weakness, tremors, shaking, ataxia, seizures, paralysis, death - dogs: nervousness, rubbing application site, agitation, shaking of legs, mild muscle fasciculation - treatment: - intravenous fluid support to maintain electrolyte balance - thermoregulation - decontamination by washing - benzodiazepines for seizure control - intravenous lipid emulsion (off-label use) - methocarbamol to reduce tremors 17. Diagnostics of abdominal fluid **aFAST identified free fluid.** **Which clinical signs/changes would animal have in case of hemoabdomen? What finding we expect from effusion?** Clinical signs are bloated belly, low BP, pale gums, weakness, distressed breathing, subcutaneous bruising, shock and collapse. The effusion fluid is usually red in colour. Most importantly PCV is measurable (usually \1%) and RBC count is over 0.5-1 million/uL. In effusion the specific gravity, total cell counts, total protein, and cytologic findings are similar to values in peripheral blood. **How would you diagnose uroabdomen from effusion?** With creatinine, it is ≥ 2:1 peritoneal to venous. BUN is not used since it is not reliable, it is small molecule and diffuses freely. Initially there is low protein and cell count but becomes exudative with time. **What findings in effusion can be seen in septic peritonitis?** Glucose can be used. In case of septic peritonitis, the glucose ≥ 20 mg/dL less than the venous glucose. Also lactate is ≥ 2mmol/L greater than the venous lactate. Also total nucleated cell count can be used with cut off of 3000/uL, but then there should be differentiated if they are of inflammatory or neoplastic nature. **How to diagnose from effusion gallbladder rupture?** Bile is yellow-brown material either free or withing macrophages or as white bile (aggregates of streaks of mucus). Confirmed by measurement of bilirubin in fluid, and it should be ≥ 2x higher in peritoneal to venous. In cases of ruptured mucocele with white bile, total bilirubin is usually less than in serum. 18. First line stabilization of trauma patient Oxygen! - its aim is to increase fraction of inspired oxygen (FiO2) - to improve PaO2(partial pressure of arterial O2) - to improve hemoglobin saturation - to increase oxygen delivery to tissues - to avoid hypoxemia, tissue hypoxia and lactic acidosis Methods Fluid therapy - isotonic fluids - colloids - blood products - hypertonic fluids Blood transfusion - indications - anemia - coagulopathy - thrombocytopenia - hypoproteinemia What we can use? - whole blood - erythrocytes, platelets, coag. Factors, plasma proteins - use within 8h or refrigerate - Packed Red Blood Cells (pRBCs) - PCV 70-80% - in refrigerator, standing position - frozen plasma (FP) - freeze Blood transfusion - dogs - more than 12 DEA groups - most common DEA 1 - positive or negative - blood typing - DEA 1 negative considered as universal donor - cats - A, B, AB - have naturally occurring alloantibodies - blood typing extremely important! Blood transfusion Blood transfusion rate - start at 0.5--1 ml/kg/hour for first 15 minutes - increase to 2 ml/kg/hour for further 15 minutes - monitor: - temperature - heart rate; pulse rate, - respiratory rate, - mucous membrane color - general demeanor - after 30 minutes- no signs of transfusion reaction - 5--10 ml/kg/hour for the rest of the transfusion - transfusion must be complete within 4 hours Side effects Autotransfusion - autologous blood transfusion - used: - hemothorax - hemoperitoneum - do it as sterile as you can! - use blood filter! Xenotransfusion - can be beneficial - few adverse reactions - low risk of infection (FIV;FeLV) - low volume of blood needed - clinical improvement for 2-4 days Analgesia and anesthesia - analgesia - opioids: - methadone 0,1-0,2mg/kg (1mg/kg) 4-6h; CRI 0,12mg/kg/h - fentanyl 10-50 mikrogr/kg; prefer CRI - butorphanol 0,1-0,5mg/kg; sedatsion vs analgesia - CRI Other drugs - vasopressors: - dopamine 2-2,5mikrogr/kg/min - antibiotics: - use when needed 19. Common injuries in trauma (body regions) **Injuries by body regions** Head - skull - fractures - intracranial injuries-TBI - mouth - lip avulsion - tongue injuries - tooth fractures - jaw fractures - symphysis luxation - joint luxation - palate - eyes - proptosis - eyelid lacerations Thorax - lung contusion - pneumothorax - hemothorax - rib fractures - pneumomediastinum - diaphragmatic hernia - concurrent head trauma in every 4th patient Arrhythmias - sinus tachycardia - VPC- ventricular premature contractions  - accelerated idioventricular rhythm - ventricular tachycardia  Abdomen - hemoperitoneum - spleen - liver - traumatic hernia - urinary tract injuries - uroabdomen - kidney rupture/hematoma - urethra injuries - inguinal and penile injuries Fractures - front limbs - radius- ulna fractures - elbow joint lux - humeral fracture - scapula fracture - hind libs - pelvic fractures - femoral fracture - hip luxation - distal bone fractures Traumatic nerve injuries - brachial plexus avulsion - caudal gluteal nerve damage - sciatic nerve damage - tibial nerve damage - causes: - fractures - bite wounds - gunshots Spinal injuries - spinal cord contusion - vertebral luxation, fracture cats more blunt 20. Head trauma vs traumatic brain injury **Head trauma vs TBI** - head trauma - epistaxis - ocular or aural hemorrhage - wounds and fractures to head/jaw - +/- neurological deficits - TBI - abnormal mentation, LOC (level of consciousness) - abnormal PLR - anisocoria - absent gag reflex - irregular breathing pattern - decerebrate rigidity - modified ATT and MGCS provide very valuable information regarding prognosis Management - correct any perfusion or hydration deficits -- consider saline 0.9% - treat any suspected ICP with mannitol or HTS - provide supplemental oxygen - administer pain relief -- pure opioid is preferred; for example, methadone or fentanyl constant rate infusion - 15° to 30° degree cranial body elevation - avoid any pressure on jugular region - assess Modified Glasgow Coma Scale on presentation, then 30 minutes, 60 minutes then every 4 hours - constant monitoring of vital parameters, pulse oximetry, partial pressure of carbon dioxide (or end-tidal CO2) and blood pressure - consider not actively rewarming patient if it is mildly hypothermic - mechanical ventilation, if hypercapnia is present greater than 50mmHg, and patient is not improving and all other options have failed. - blood transfusion if PCV less than 25 Clinical signs indicating ↑ICP - vomiting - altered mentation - cushing reflex - hypertension - bradycardia - changed breathing pattern - anisocoria Hypertonic vs mannitol - hypertonic fluid - decreases fluid in the tissues - 4ml/kg dog - 2ml/kg cat - slowly IV 10-15 min - osmotic diuretic - 0.25mg/kg -1mg/kg IV - 20 min - every 4h if needed 21. GDV Gastric dilatation and volvulus (GDV) - life-threatening condition - risk factors: - occurrence in the previous family - deep chest - age - fast eating/feeding once a day - dry food (they expand in stomach) - nervous / fearful temperament - looseness or agenesis of gastric ligaments - causes changes throughout the body: - cardiovascular changes: - compression of portal vein and caudal vein - venous blood return to heart is inhibited, blood pressure lowers - compression of portal vein causes swelling and distension the GI system; volume of blood in vessel decreases - oxygen supply decreases - toxemia - bacterial translocalization - production of free radicals -- direct toxic damage to tissues - tissue hypoxemia and death - lactic acid production -- anaerobic metabolism GDV -- diagnosis - anamnesis - xray - thorax as well - aspiration pneumonia - lactate (numbers as indicators... but not only thing that we think) - ≤ 6 mmol/L -- 99% survival - ≥ 6 mmol/L -- 58 % survival - ≥ 9 mmol/L -- 1% survival - more important is decrease in lactate levels post-op - if drop is more than 50%, then prognosis is good (this is better indicator) - check this quite fast after surgery (or after anesthesia) Stabilization - shock - hypovolemic (because BP low) - obstructive (because stomach so big) - distributive (physical obstruction, blood cannot be distributed around body) - fluid therapy: - treatment of shock: isotonic +/- colloid solutions (shock boluses to big dogs, isotonic first choice) - monitor HR, BP, MM, temp (every 15min at least) - hypotensive - dopamine 3 -- 10 μg/kg min CRI - dobutamine 5 -- 15 μg/kg min CRI - antibiotics (because toxemia) - broad spectrum - prior to surgery (and continue in surgery) - cefazolin 20 -- 22 mg/kg IV - antiarrhythmics - ventricular arrhythmias (EKG would be good, if there is not EKG do not use..) - start prior to surgery - lidocaine 1 -- 2 mg/kg IV - analgesia - methadone (usually first) - fentanyl - FLK - antiemetics - gastric lavage if possible - with tube - decreasing bloat (if the animal is critical, helps to decrease pressure, based on general state) - biggest IV catheters to left side but find the place where you feel the stomach - peritonitis is smaller risk than dying Anesthesia and surgery  small area of necrosis, ok you can use the invagination technique  gastropexy, can be done preventatively Post -- op - monitor hydration, BP - vasopressors / positive inotropes if necessary - MAP above 60 mmHg - oxygen therapy - monitoring for arrhythmias -- intervention if necessary - analgesia - FLK / methadone - do not use NSAIDs (because GI side effects!) - gastroprotectants - feeding (as soon as possible, small amounts, more frequent) - no opioid to home - usually causes inappetence, if very painful fentanyl patch - maybe paracetamol These are in lectures 6 and 7. 22. C-section 23. Approach to GI tract emergencies General approach - thorough history (age, sex, breed etc) - acuteness - vomiting vs regurgitation - diarrhea / constipation - feeding - vaccination and dehelmintation - toxins / foreign bodies Diagnostic approach - clinical examination - x -ray - ultrasound - blood samples - hematology, PCV/PP - biochemistry - specific rapid tests Acute abdomen - acute abdomen can be caused by: - abdominal pain - pain in lumbar and / or sacrum region - the sooner the underlying cause is diagnosed and treated, it is less likely that complications will develop (sepsis, SIRS, MODS -- multiorgan disease syndrome) **Bloody diarrhea** - **hemorrhagic gastroenteritis / acute hemorrhagic diarrhea syndrome (AHDS)** - very acute bloody diarrhea, +/- bloody vomiting - often accompanied by severe hypovolemic shock - small breeds have a predisposition - blood samples - strong hemoconcentration - low TP - increased LAC - treatment - fluid therapy, shock boluses if necessary - antiemetics - gastroprotectants - +/- antibiotics - feeding - **parvovirus** - infectious disease (unvaccinated animals) - acute vomiting / diarrhea - blood samples - neutropenia - hypoalbuminemia - rapid test Parvo antigen - severe hypovolemic shock / dehydration - antiemetics, gastroprotectants, antibiotics - feeding **Pancreatitis, inflammation of pancreas** - clinical symptoms are non-specific - vomiting - painful abdomen - inappetence - +/- diarrhea - history often includes change in diet or fatty food - blood samples: - dehydration - ALT, ALP, CHOL, TBIL - pre-renal azotemia - specific snap tests - neutrophilia - diagnostic Imaging - x-ray - opacity of cranial abdominal region - enlargement of the pyloric and duodena angle - displacement of stomach to left - ultrasound - peritoneal fluid around the pancreas - hyperechoic peri-pancreatic region - hypoechoic pancreas - in uncomplicated cases, clinical improvement will be seen in 48h - treatment - fluid therapy - antiemetics - +/- antibiotics - feeding, feeding tube if necessary - cats -- triaditis - IBD - hepatitis - pancreatitis **Foreign bodies** - **in esophagus** - regurgitation, vomiting, coughing, breathing difficulties - risk for esophageal perforation - spasm of the muscle layer of the esophagus, necrosis of the mucosa - complications - mediastinitis and pleuritis - pyothorax - endoscopy preferred - surgery - **in stomach / intestinal tract** - anamnesis - is foreign body likely, is some toy or object missing / has been chewed up etc. - diagnostics - xray - +/- contrast - ultrasound - treatment either surgical or endoscopy **Intussusception** - invagination of portion of intestinal tract into lumen of adjacent section of bowel - typical types: ileocolic in dogs and jejunojejunal in cats - generally \