ADVERSITY

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ADVERSITY

• Lifes challenges are not supposed to paralyze
  you, they are supposed to help you discover who
  you are.
• - Bernice Johnson Reagon

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Emergency Procedures
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Normal PE
Area Organs
Cranial ventral abdomen Liver, stomach, pancreas
Cranial dorsal abdomen Kidneys, stomach, pancreas
Mid-ventral abdomen Spleen, small bowel
Mid-dorsal abdomen Kidneys, ureters, retroperitoneal space
Caudal ventral abdomen Bladder, uterus
Caudal dorsal abdomen Colon, sub-lumbar lymph nodes, prostate, uterus
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Use belts and your hands
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ABCD

• A Establish airway
• B Breathe for animal
• C Maintain circulation with thoracic
  compressions and IV fluids
• D Disability

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Triage of Emergency Patients

• 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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Mucous membrane
Color Interpretation Causes
PINK Adequate circulation and perfusion Normal circulatory system
WHITE OR PALE PINK Anemia, decreased peripheral perfusion, vasoconstriction Anemia ( blood loss, inc. destruction, dec. production) shock
BLUE OR GREY Hypoxemia, anemia Respiratory embarrassment, blood loss
DARK RED, BRICK RED Increased peripheral perfusion cyanide toxicity Fever, sepsis, systemic inflammatory response, smoke inhalation/ cyanide toxicity
BROWN Methemoglobenemia Acetaminophen, ibuprofen
YELLOW (ICTERIC) Hyperbilirubinemia Hemolysis, hepatic/ biliary disease
PATECHIA Coagulation disorder Thrombocytopenia, decreased platelet function
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Triage of Emergency Patients

• 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

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Breathing Airway patent

• NO
• Clear airway use suction
• Intubate
• Ventilate (dont over ventilate drive CO2 down)
• 10/12/min
• lt 20 cm H2O

• YES
• Provide flow-by air

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Triage of Emergency Patients

• Vital signs (taken after initial assessment)
• HR, pulse rate (same as HR?), strength
• RR
• mm color, CRT
• Temp
• BP
• High HR, high BP? pain
• High HR, low BP ? hypovolemic shock
• Baseline data
• ECG
• Chem panel, CBC

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Triage of Emergency Patients

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

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Triage of Emergency Patients

• Events
• 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 Prognosis)
• Any other underlying medical conditions/medication
  s

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Triage of Emergency Patients

• 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)

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Triage of Emergency Patients

• Control hemorrhage
• External counterpressure using body wrap of
  pelvic limbs, pelvis, and abdomen
• Insert urinary catheter 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 gt5 mm Hg, stop removal infuse more
  fluids
• If BP continues to drop, reapply wrap

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Triage of Emergency Patients
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SHOCK RECOGNITION AND TREATMENT

• SHOCK is inadequate tissue perfusion resulting in
  poor oxygen delivery
• Cardiogenic
• Distributive
• Obstructive
• Hypovolemic

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Shock

• Types of Shock
• Cardiogenicresults from heart failure
• ? blood pumped by heart
• HCM, DCM, valvular insufficiency/stenosis
• Distributiveblood flow maldistribution
  (Vasodilation)
• Sepsis, anaphylaxis ??arteriole resistance ?loss
  of fluid from vessels to interstitial spaces
  ??BP? ? blood return to heart
• Obstructivephysical obstruction in circ system
• HW disease ? heart pumping against the adult worm
  blockage
• Gastric torsion ??blood return to heart
• Hypovolemicdecreased intravascular volume
• Most common in small animals
• Blood loss, dehydration from excessive
  vomiting/diarrhea, effusion of fluid into 3rd
  spaces

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Hypovolemic Shock

• Pathophysiology of hypovolemic shock
• ?blood vol ??venous return, ?vent filling
  ??stroke vol, ?CO ??BP
• Stage I Compensation
• Baroreceptors detect hypotension (?BP)
• 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
• Renin (kidney)?angiotensin (blood)?aldosterone
  (adrenals) reflex
• ? Na and water retention ? ? intravascular vol
  (?BP)
• PE findings
• Tachycardia
• Prolonged cap refill time
• Pale mm

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Hypovolemic Shock

• Pathophysiology of hypovolemic shock
• Stage II Decompensation
• 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

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Shock

• Treatment the goal of therapy is to improve O2
  delivery
• O2 supplementation (If pulse ox lt 93)
• Face mask
• O2 cage/hoods
• Transtracheal/nasal insufflation
• Venous access
• Cephalic
• Saphenous
• Jugular
• Intraosseous

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Oxygen supplementation
NASAL CANNULA
FACE MASK
OXYGEN HOOD
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Fluid Administration
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Shock

• Treatment
• Fluid resuscitation (O2 delivery is improved by
  ?CO)
• 1. Crystalloids
• Isotonic solutions (electrolytes Na, Cl-, K,
  bicarbonate)
• Examples (body fluid280-300 mOsm/L)
• Lactated Ringers (273 mOsm/L)
• Normal saline (0.9) (308 mOsm/L)
• Dose Dog 80-90 ml/kg/hr
• Cat 50-55 ml/kg/hr
• Hypertonic solutionswhen lg vol of fluid cannot
  be administered rapidly enough
• Examples7.5 saline
• Causes fluid shift from intracellular 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
• Examples5 Dex in water (252 mOsm/L)

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Shock

• Treatment
• Fluid resuscitation (O2 delivery is improved by
  ?CO)
• 2. Colloids
• Large molecular wt solutions that do not leave
  vascular system
• Better blood volume expanders than crystalloids
• 50-80 of infused volume stays in blood vessels
• Examples
• Whole blood
• Plasma
• Dextran 70

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Shock

• Rx (continued)
• Sympathomimetics
• Use only after adequate fluid administration if
  BP and tissue perfusion have not returned to
  normal
• Dopamine (Inotropin)
• 0.5-3.0 µg/kg/min
• Dilation of renal, mesenteric, coronary vessels
• 3.0-7.5 µg/kg/min
• ? contractility of heart
• ? HR
• gt7.5µg/kg/min
• Vasoconstriction
• Dobutamine (Dobutrex)
• 5-15 µg/kg/min
• ? contractility of heart (min effect on HR)

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Shock

• Monitoring
• Hemodynamic/metabolic sequelae of shock are
  continually changing
• Physical Parameters
• Respiratory
• Color of mm
• RR
• 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 volume

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Shock

• Monitoring
• Physiologic Monitoring Parameters
• O2 Saturation
• Pulse oximetrynoninvasive
• Normal Hb saturations (SpO2)gt95
• SpO2lt90--serious hypoxemia
• Arterial BPa product of CO, vascular capacity,
  blood volume
• If one is subnormal, the other 2 try to
  compensate to maintain BP

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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 lt35 mm Hg ? hyperventilation
• PaCO2 gt45 mm Hg ? hypoventilation
• PaO2 Tells how well patient is being oxygenated
• PaO2 lt90 mm Hg ? hypoxemia
• pH tells acid/base status of patient
• lt7.35 ? acidosis
• gt7.45 ? alkalosis

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VISION

• It is a terrible thing to see and have no
  vision.
• -Helen Keller

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CPCR

• CARDIOPULMONARY CEREBROVASCULAR RESUSCITATION

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Cardiopulmonary Arrest and Resuscitation (CPR)

• Cardiopulmonary Arrest (CPA) sudden cessation of
  effective ventilation and circulation.
• Causes
• Anesthesia
• Trauma head trauma
• Infections (e.g. pneumonia)
• Heart disease arrhythmia
• Autoimmune disease
• Malignancy

Hypoxemia, shock, anemia
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Cardiopulmonary Resuscitation

• Resuscitation Team Members
• Should be 3-5 members
• Team leaderVeterinarian 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 teams effectiveness
• Teams should practice on a regular basis to stay
  sharp

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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

Agonal breaths, apnea, collapse, fixed gaze, no
palpable pulase
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Cardiopulmonary Resuscitation

• 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 Ringers, 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
• ? Surgeons gloves

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Emergency Drugs in Dogs
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Emergency Drugs in Cats
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CPR

• Basic Life Support
• A -- Establishment of an Airway.
• B -- Breathing support.
• C -- Circulation support.
• Advanced Life Support
• D -- Diagnosis and Drugs.
• E -- Electrocardiography.
• F -- Fibrillation control.
• Prolonged Life Support
• G -- Gauging a patient's response.
• H -- Hopeful measures for the brain
• I -- Intensive care.

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Cardiopulmonary Resuscitation

• 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 (6-10 breaths/ min)
• Chest compressions in between breaths if working
  alone
• 1 to 2 times per second (80 times per minute for
  a large dog and 120 times for a small dog or cat)
• 10 compression for every 2 breaths (or 51)

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CPR

• http//www.youtube.com/watch?vVJGlsYHI9cU

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Cardiopulmonary Resuscitation Intubation
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Cardiopulmonary Resuscitation

• Basic Life Support (Phase I)
• Circulation
• External cardiac compression
• Lateral recumbencyone/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

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Cardiopulmonary Resuscitation

• 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 7th and 8th 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

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Cardiopulmonary Resuscitation

• 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

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Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)
• Add 2 priorities to ABC--D E (administer
• Drugs, Electricaldefibrillate)
• Drugs
• Fluids
• Lactated Ringers is standard (do not use
  Dextrose)
• Initial dose Dogs40 ml/kg
• (rapidly IV) Cats20 ml/kg
• Atropineparasympatholytic effects
• (blocks parasympathetic effects)
• 0.02-0.04 mg/kg
• ?HR
• ?secretions
• Epinephrineadrenergic effects
• 0.02-0.2 mg/kg
• Arterial and venous vasoconstriction? ?BP

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Common arrhythmias electrical mechanical
dissociation, (no pulse), asystole (flatline),
ventricular tachcardia, bradycardia
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Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)
• Add 2 priorities to ABC--D E (administer Drugs,
  Electricaldefibrillate)
• Drugs (continued)
• 2 Lidocaine (Used to treat cardiac arrhythmias)
• Dogs 1-2 mg/kg
• Cats 0.5-1.0 mg/kg
• Sodium bicarb (For metabolic acidosis)
• 0.5 mEq/kg per 5 min or cardiac arrest
• Vasopressin (ADH)
• 0.8 U/kg

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CPR
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Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)
• Add 2 priorities to ABC--D E (administer Drugs,
  Electricaldefibrillate)
• Drugs (continued)
• Route of drug administration
• Jugular veinclose to heart drugs will get to
  heart quicker
• Cephalic, saphenousfollow drugs with 10-30 ml
  saline flush
• Intraosseousintramedullary cannula into femur,
  humerus, wing of ilium, tibial crest
• Intratrachealfor limited of drugs atropine,
  lidocaine, epinephrine
• Intracardiaclast resort several complications
  can occur
• Depends on
• Speed of access
• Technical ability
• Difficulties encountered
• Rate of drug delivery

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Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)
• Add 2 priorities to ABC--D E (administer Drugs,
  Electricaldefibrillate)
• ElectricalDefibrillate
• Purposeeliminate 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

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Cardiopulmonary Resuscitation
DEFIBRILLATORS
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Cardiopulmonary Resuscitation
VENTRICULAR FIBRILLATION
NORMAL EKG
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Cardiopulmonary Resuscitation

• 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 patients
• Dogs 3.8
• Cats 2.3

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CPR
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EDUCATION

• Education is what survives after what has been
  learned has been forgotten.
• - B.F. Skinner

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Anaphylaxis/Allergic reactions

• Rare, 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

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Anaphylaxis/Allergic reactions

• 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

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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

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Heat Stroke (Hyperthermia)

• Requires immediate treatment
• Dogs do not cool as well as humans (dont sweat)
• Evaporate fluid from mouth, tongue, pharynx)
• Mortality 50 64
• 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 (takes 45- 60
  days to acclimatize)

AN ENLARGED TONGUE HANGING FREELY FROM THE MOUTH
IS A CLEAR SIGNAL TO REST AND COOL
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Heat Stroke

• Signs
• Rapid, frantic, noisy breathing
• Tongue/mm bright red, thick saliva
• Vomiting/diarrheamay be bloody
• Rectal temp gt105
• Unsteady/stagger
• 107 108 energy for cellular
• functions ceases Coma/death

Prevention
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Heat Stroke

• Complications
• Multi-system organ failure
• Denatures proteins
• Hypotension
• Lactic acidosis
• Decreased oxygen delivery
• Electrolyte abnormalities gt cerebral edema and
  death
• Coagulopathies gt DIC
• If survives the first 24 hrs, prognosis is more
  favorable

Prognosis nucleated RBC
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Heat Stroke

• TREATMENT Mild cases move dog to a/c building or
  car
• Temp gt104º, immerged in cool water, hose down,
  fan, wet cloths
• Temp gt106º, cool water enema (cool to 103º)
• Temp gt109 leads to multiple organ failure
• STOP COOLING EFFORTS AT 104º
• IV fluids
• Corticosteroids

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Emergency Drugs in Cats
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Emergency Drugs in Dogs
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Pain Management

• Misconceptions about animal pain
• Animals do not experience pain
• Pain doesnt 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

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Pain Management

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

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Pain Management

• 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

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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 skills
  in injections, blood draw

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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

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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
• ? analgesia and sedation
• S depression, excitement, anxiety
• ?
• Side effects
• Vomiting, constipation, excitement, bradycardia,
  panting
• Metabolized by liver excreted by kidneys
• Use caution with hepatic, renal disease

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Pain Management

• Opioids
• Morphine sulfate (great for orthopedic
  emergencies)
• Used for max analgesia/sedation
• Inexpensive
• Side-effects systemic hypotension, vomiting
• Cats particularly sensitive
• Oxymorphone
• 10x potency of morphine
• Much more expensive less resp depression and GI
  stimulation
• Side-effects depression, sensory
  hypersensitivity
• Hydromorphone
• Similar effects of Oxymorphone
• More widely available, less expensive than
  Oxymorphone

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Pain Management

• Opioids
• Fentanyl citrate
• Extremely potent
• Rapid onset, short duration when administered IM
  or IV
• Transdermal patch
• 3-day duration
• Shave hair, apply to the skin
• Butorphanol Tartrate
• ? agonist µ antagonist
• Analgesic effect questionable (gt1 h) good
  sedative (2 h)
• More expensive than morphine
• Less vomiting, resp. depression
• Buprenorphine
• Partial mu agonist
• 30x potency of morphine longer duration
• good absorption via buccal mucosa

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Pain Management

• Opioids
• Antagonists
• Naloxone HCl
• Reversal occurs within 1-2 min
• Can be used to reverse anesthesia (Inovar-Vet)

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PERSEVERANCE

• Sometimes the best way out is through.

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TOXICOLOGIC EMERGENCIES
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Toxicologic Emergencies

• Signs will vary depending on character of toxic
  compound
• Toxicity can result from exposure via many routes
• Ingestion
• Inhalation
• Skin contact
• Injection

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Toxicologic Emergencies

• Top 10 Toxicoses (2005)
• Human medication (ibuprofen, acetominophen,
  anti-depressants)
• Insecticidesflea and tick
• Rodenticidesanticoagulants
• Veterinary medication
• Household cleanersbleach, detergents
• Plantssago palm, lily, azalea
• Herbicides
• Chocolatehighest in food category
• Home improvement productssolvents, adhesives,
  paint, wood glue
• Fertilizers

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Toxicologic Emergencies

• HISTORY
• ASSESS
• STABILIZE
• Administer oxygen
• Control seizures
• Correct cardiovascular abnormalities
• DECONTAMINATION
• Emetics
• Activated charcoal
• Gastointestinal protectants
• CONTROL CLINICAL SIGNS
• GOOD NURSING CARE
• PREVENT FURTHER EXPOSURE

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Toxicologic Emergencies external exposure

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

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TO VOMIT OR NOT TO VOMIT?

• VOMIT
• Acetone
• Alcohol
• Amphetamines, opiates, cocaine, heroin
• Arsenic
• Snail or rat bait
• Marijuana, tobacco, cigarettes/cigars
• Pesticides and insecticied i.e. malathion,
  dichlorvos, diazonon
• House plants and sago plants
• Lead
• Pine oil
• Choclate
• Xylitol containing food items

• DO NOT VOMIT
• Petroleum distillates
• Sharp objects
• Bread dough
• Commercial or industrial cleaners
• Alkali/ caustic cleaners
• Bleach
• Burnt lime
• Volatile substances i.e. gasoline or paint
  thinner
• Unknown chemicals
• Fertilizers
• Lye (NaOH/ caustic soda)
• Gorilla glue
• Strychine

87
Toxicologic Emergencies

• Ingestion
• Induce vomitingif chemical not caustic animal
  conscious, not seizing
• Syrup of ipecac, apomorphine, Xylazine, H2O2 (not
  reliable), salt (not recommmended)
• Dilute caustic substances with milk, water
• Gastric lavagelarge bore stomach tube light
  anesthesia w/ endotracheal tube
• Administer absorbentsactivated charcoal inhibits
  GI absorption
• Give orally or via stom tube
• Enemas/cathartics to eliminate toxins more rapidly

88
Toxicological Emergencies
ACTIVATED CHARCOAL WITH OR WITHOUT A CATHARTIC
89
Toxicologic Emergencies

• Methylxanthines (caffeine,
• theobromine, theophylline
• Found in coffee, tea, chocolate,
• other stimulants
• Toxic Dose of caffeine and theobromine in dogs
  100-200 mg/kg (other sources 250-500mg)
• Milk Chocolate44-60 mg/oz
• Dark chocolate-150 mg/oz
• Baking Chocolate390-450 mg/oz

90
Toxicologic Emergencies

• Clinical signs of methylxanthine/chocolate
  toxicosis (caffeine, theobromine)
• Increased HR, RR
• Anxiety
• Vomiting/diarrhea
• Seizures, coma
• Cardiac arrhythmias
• Treatment
• Induce vomiting
• Activated charcoal
• Control seizues
• Fluid therapy

91
Toxicologic Emergencies

• Rodenticides
• 1. Anticoagulants (warfarin, pindone,
  bromadiolone, brodifacoum)
• Work by binding Vit K, which inhibits synthesis
  of factors II, VI, IX, X
• This effect occurs within 6-40 h in a dog effect
  may last 1-4 wk

92
Toxicological Emergencies

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

93
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94
Toxicologic Emergencies

• Rodenticides
• CholecalciferolVit D3 used in Quintox, rampage,
  Rat-Be-Gone
• -causes Ca reabsorption from bone, intestine,
  kidneys causing hypercalcemia (gt11.5 mg/dl) and
  cardiotoxicity
• Clinical signs (12-36 h after ingestion)
• Kidney failure
• Anorexia
• Vomiting
• Tissue mineralization
• Cardiovascular abnormalities
• Muscle weakness
• arrhythmias

95
Toxicological Emergencies

• Diagnosis
• Hx of exposure
• Usually discovered on routine Chem panel (?blood
  Ca)
• Treatment
• 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

96
Toxicologic Emergencies

• Rodenticides
• 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 (gt24 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

97
Toxicologic Emergencies

• Acetaminophen
• Common OTC drug for analgesia
• Toxic dose Dog160-600 mg/kg
• Cat50-60 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
• Pxpoor
• 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

98
Toxicological Emergencies
causing the blood to be dark brown in color
99
Toxicologic Emergencies

• Metals
• Lead toxicity more common in dogs than cats
• Source
• Lead paint (prior to 1970s) 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

100
Toxicologic Emergencies

• Metals
• Lead toxicity
• Dx
• Large nucleated RBCs basophilic stipling
• Blood lead conc gt35 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

101
Toxicologic Emergencies

• Metals
• 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

102
Toxicologic Emergencies

• Ethylene Glycol (antifreeze sweet taste)
• Lethal dose Cat1.5 ml/kg
• Dog6.6 ml/kg
• Signs (onset within 12 h of ingestion)
• CNS depression, ataxia (may appear intoxicated)
• Vomiting
• PD/PU
• Seizures, coma, death
• Acute renal failure
• Dx
• Hx, signs
• Ethylene Glycol Poison Testan 8 min test used in
  cats and dogs
• Calcium oxalate crystals
• Rx
• Emesis, adsorbents if ingestion within 3 h of
  presentation
• IV fluids, NaBicarb for acidosis
• Ethanol inhibits ethylene glycol metabolism Dogs
  (Cats) 20 ethanol5.5 (5.0) ml/kg q6h x 5,
  then q8h x 4
• 4-methylpyrazole has been shown to be effective

103
Toxicological Emergencies
THE PROBLEM
THE SOLUTION
104
Toxicologic Emergencies

• 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

105
Toxicologic Emergencies

• 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

106
Toxicologic Emergencies

• Insecticides
• Pyrethrins, Pyrethroids, Permethrins
• 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

107
Toxicologic Emergencies

• 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, and flys
• Signs
• Salivation
• Lacrimation
• Urinary incontinence
• Diarrhea
• Dyspnea
• Emesis, gastrointestinal cramping
• -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

108
Toxicologic Emergencies

• 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
• 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

109
Dumb Cane (Dieffenbachia)

• aka Mother-in-laws tongue
• Oral irritation intense burning, excess
  salivation

110
Split Leaf Philodendron

• Oxalate crystals like Dieffenbachia
• Oral irritation intense burning, excess
  salivation

111
Lily of the Valley

• Contains cardiac glucosides
• Cardiac arrythmias, death

112
Azalea (Rhododendron)

• Hypotension, cardiovascular collapse, death

113
Sago Palm

• ALL PARTS OF THE PLANT ARE TOXIC
• Coagulopathy
• Liver failure

114
Toxicologic Emergencies

• 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)

115
References

• Alleice Summers, Common Diseases of Companion
  Animals
• Texas A and M University, 2nd Annual Canine
  Paramedicine Conference, May 2011
• http//veterinarymedicine.dvm360.com/vetmed/Articl
  eStandard/Article/detail/670169