ADVERSITY“Life’s challenges are not supposed to

paralyze you, they are supposed to help you discover who you are.”

- Bernice Johnson Reagon

Emergency Procedures

Normal PE

Area OrgansCranial 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

Use belts and your hands

ABCD

• A = Establish airway

• B = Breathe for animal

• C = Maintain circulation with thoracic compressions and IV fluids

• D = Disability

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

Mucous membraneColor 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

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

Breathing – Airway patent

• NO– Clear airway: use suction

– Intubate

– Ventilate (don’t over ventilate drive CO2 down)

• 10/12/min

• < 20 cm H2O

• YES– Provide flow-by air

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

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?)

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/medications

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)

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 >5 mm Hg, stop removal; infuse

more fluids» If BP continues to drop, reapply wrap

Triage of Emergency Patients

SHOCK: RECOGNITION AND TREATMENT

• SHOCK is inadequate tissue perfusion resulting in poor oxygen delivery– Cardiogenic

– Distributive

– Obstructive

– Hypovolemic

Shock

• Types of Shock:– Cardiogenic—results from heart failure

• ↓ blood pumped by heart• HCM, DCM, valvular insufficiency/stenosis

– Distributive—blood flow maldistribution (Vasodilation)• Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from

vessels to interstitial spaces →↓BP→ ↓ blood return to heart– Obstructive—physical obstruction in circ system

• HW disease → heart pumping against the adult worm blockage• Gastric torsion →↓blood return to heart

– Hypovolemic—decreased intravascular volume• Most common in small animals• Blood loss, dehydration from excessive vomiting/diarrhea,

effusion of fluid into 3rd spaces

Hypovolemic Shock

• Pathophysiology of hypovolemic shock↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP

• Stage I: Compensation– Baroreceptors detect hypotension (↓BP)

a. 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

b. Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex- ↑ Na+ and water retention → ↑ intravascular vol (↑BP)

– PE findings– Tachycardia– Prolonged cap refill time– Pale mm

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

Shock

• Treatment: the goal of therapy is to improve O2 delivery– O2 supplementation (If pulse ox < = 93%)

• Face mask

• O2 cage/hoods

• Transtracheal/nasal insufflation

– Venous access• Cephalic

• Saphenous

• Jugular

• Intraosseous

Oxygen supplementation

FACE MASK

NASAL CANNULA

OXYGEN HOOD

Fluid Administration

Shock

• Treatment– Fluid resuscitation (O2 delivery is improved by ↑CO)

1. Crystalloids • Isotonic solutions (electrolytes: Na+, Cl-, K+, bicarbonate)

– Examples (body fluid=280-300 mOsm/L)» Lactated Ringer’s (273 mOsm/L)» Normal saline (0.9%) (308 mOsm/L)

– Dose: Dog 80-90 ml/kg/hr Cat 50-55 ml/kg/hr

• Hypertonic solutions—when lg vol of fluid cannot be administered rapidly enough– Examples—7.5% 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– Examples—5% Dex in water (252 mOsm/L)

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

Shock

• Rx (continued)– SympathomimeticsUse 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

– >7.5μg/kg/min» Vasoconstriction

• Dobutamine (Dobutrex®)– 5-15 μg/kg/min– ↑ contractility of heart (min effect on HR)

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

Shock

• Monitoring – Physiologic Monitoring Parameters

• O2 Saturation– Pulse oximetry—noninvasive

– Normal: Hb saturations (SpO2)>95%

» SpO2<90%--serious hypoxemia

• Arterial BP—a product of CO, vascular capacity, blood volume– If one is subnormal, the other 2 try to compensate to maintain BP

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 <35 mm Hg → hyperventilation» PaCO2 >45 mm Hg → hypoventilation

– PaO2 Tells how well patient is being oxygenated» PaO2 <90 mm Hg → hypoxemia

– pH tells acid/base status of patient– <7.35 → acidosis– >7.45 → alkalosis

VISION“It is a terrible thing to see and

have no vision.”-Helen Keller

CPCRCARDIOPULMONARY CEREBROVASCULAR

RESUSCITATION

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

Cardiopulmonary Resuscitation

• Resuscitation Team Members– Should be 3-5 members

• Team leader—Veterinarian 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 team’s effectiveness

• Teams should practice on a regular basis to stay sharp

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

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 Ringer’s, 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● Surgeon’s

gloves

Emergency Drugs in Dogs

Emergency Drugs in Cats

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.

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 5:1)

CPR

• http://www.youtube.com/watch?v=VJGlsYHI9cU

Cardiopulmonary Resuscitation Intubation

• Basic Life Support (Phase I)– Circulation

• External cardiac compression– Lateral recumbency—one/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

Cardiopulmonary Resuscitation

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

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

Cardiopulmonary Resuscitation• Advanced Life Support (Phase II)

Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate)

– Drugs• Fluids

– Lactated Ringer’s is standard (do not use Dextrose)» Initial dose: Dogs—40 ml/kg (rapidly IV) Cats—20 ml/kg

• Atropine—parasympatholytic effects (blocks parasympathetic effects)

– 0.02-0.04 mg/kg– ↑HR– ↓secretions

• Epinephrine—adrenergic effects– 0.02-0.2 mg/kg– Arterial and venous vasoconstriction→ ↑BP

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

Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)Add 2 priorities to ABC--D E (administer Drugs, Electrical—

defibrillate)

– 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

CPR

Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate)

– Drugs (continued)• Route of drug administration

– Jugular vein—close to heart; drugs will get to heart quicker– Cephalic, saphenous—follow drugs with 10-30 ml saline flush– Intraosseous—intramedullary cannula into femur, humerus, wing of ilium,

tibial crest– Intratracheal—for limited # of drugs: atropine, lidocaine, epinephrine– Intracardiac—last resort; several complications can occur

• Depends on– Speed of access– Technical ability– Difficulties encountered– Rate of drug delivery

Cardiopulmonary Resuscitation

• Advanced Life Support (Phase II)Add 2 priorities to ABC--D E (administer Drugs, Electrical—

defibrillate)

– Electrical—Defibrillate• Purpose—eliminate 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

Cardiopulmonary Resuscitation

DEFIBRILLATORS

Cardiopulmonary Resuscitation

NORMAL EKG VENTRICULAR FIBRILLATION

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 patientsDogs: 3.8%Cats: 2.3%

CPR

EDUCATION“Education is what survives after what has been learned has been

forgotten.”- B.F. Skinner

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

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

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

Heat Stroke (Hyperthermia)Requires immediate treatmentDogs do not cool as well as humans (don’t 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

Heat Stroke

• Signs– Rapid, frantic, noisy breathing

– Tongue/mm bright red, thick saliva

– Vomiting/diarrhea—may be bloody

– Rectal temp >105°

– Unsteady/stagger

– 107 – 108: energy for cellular

functions ceases = Coma/death

Prevention

Heat Stroke

• Complications– Multi-system organ failure

– Denatures proteins

– Hypotension

– Lactic acidosis

– Decreased oxygen delivery

– Electrolyte abnormalities => cerebral edema and death

– Coagulopathies => DIC

– If survives the first 24 hrs, prognosis is more favorable

Prognosis: nucleated RBC

Heat Stroke

• TREATMENT Mild cases: move dog to a/c building or car

– Temp >104º, immerged in cool water, hose down, fan, wet cloths

– Temp >106º, cool water enema (cool to 103º)

– Temp >109° leads to multiple organ failure

STOP COOLING EFFORTS AT 104º

– IV fluids

– Corticosteroids

Emergency Drugs in Cats

Emergency Drugs in Dogs

Pain Management

• Misconceptions about animal pain– Animals do not experience pain– Pain doesn’t 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

Pain Management

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

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

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]

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

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– Κ: analgesia and sedation – Σ: depression, excitement, anxiety– Δ

• Side effects– Vomiting, constipation, excitement, bradycardia, panting

• Metabolized by liver; excreted by kidneys– Use caution with hepatic, renal disease

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

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• Κ agonist; μ antagonist• Analgesic effect questionable (>1 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

Pain Management

• Opioids– Antagonists

• Naloxone HCl – Reversal occurs within 1-2 min

– Can be used to reverse anesthesia (Inovar-Vet)

PERSEVERANCE

“Sometimes the best way out is through.”

TOXICOLOGIC EMERGENCIES

Toxicologic Emergencies

• Signs will vary depending on character of toxic compound

• Toxicity can result from exposure via many routes– Ingestion

– Inhalation

– Skin contact

– Injection

Toxicologic Emergencies

• Top 10 Toxicoses (2005)– Human medication (ibuprofen, acetominophen, anti-

depressants)– Insecticides—flea and tick– Rodenticides—anticoagulants– Veterinary medication– Household cleaners—bleach, detergents– Plants—sago palm, lily, azalea– Herbicides– Chocolate—highest in food category– Home improvement products—solvents, adhesives, paint,

wood glue– Fertilizers

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

• 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)

Toxicologic Emergencies: external exposure

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

Toxicologic Emergencies

• Ingestion • Induce vomiting—if 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 lavage—large bore stomach tube; light anesthesia w/ endotracheal tube

• Administer absorbents—activated charcoal inhibits GI absorption– Give orally or via stom tube

• Enemas/cathartics to eliminate toxins more rapidly

Toxicological Emergencies

ACTIVATED CHARCOAL WITH OR WITHOUT A CATHARTIC

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 Chocolate—44-60 mg/ozDark chocolate-150 mg/oz

Baking Chocolate—390-450 mg/oz

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

Toxicologic Emergencies

–Rodenticides1. 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

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

Toxicologic Emergencies

– Rodenticides2. Cholecalciferol—Vit D3; used in Quintox,

rampage, Rat-Be-Gone-causes Ca++ reabsorption from bone, intestine, kidneys

causing hypercalcemia (>11.5 mg/dl) and cardiotoxicity• Clinical signs (12-36 h after ingestion)

– Kidney failure» Anorexia» Vomiting» Tissue mineralization

– Cardiovascular abnormalities» Muscle weakness» arrhythmias

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

Toxicologic Emergencies– Rodenticides

3. 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/kgClinical signs (>24 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

Toxicologic Emergencies

• Acetaminophen• Common OTC drug for analgesia• Toxic dose: Dog—160-600 mg/kg

Cat—50-60 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

• Px—poor• 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

Toxicological Emergencies

causing the blood to be dark brown in color

Toxicologic Emergencies

– Metals• Lead toxicity more common in dogs than cats

– Source» Lead paint (prior to 1970’s) 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

Toxicologic Emergencies

– Metals• Lead toxicity

– Dx» Large # nucleated RBC’s; basophilic stipling » Blood lead conc >35 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

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

Toxicologic Emergencies• Ethylene Glycol (antifreeze; sweet taste)

• Lethal dose: Cat—1.5 ml/kgDog—6.6 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 Test—an 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% ethanol—5.5 (5.0)

ml/kg q6h x 5, then q8h x 4 – 4-methylpyrazole has been shown to be effective

Toxicological Emergencies

THE PROBLEMTHE SOLUTION

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

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

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

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

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

Dumb Cane (Dieffenbachia)• aka Mother-in-law’s tongue

• Oral irritation; intense burning, excess salivation

Split Leaf Philodendron• Oxalate crystals like Dieffenbachia

• Oral irritation; intense burning, excess salivation

Lily of the Valley• Contains cardiac glucosides

• Cardiac arrythmias, death

Azalea (Rhododendron) • Hypotension, cardiovascular collapse, death

Sago Palm

• ALL PARTS OF THE PLANT ARE TOXIC

• Coagulopathy

• Liver failure

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)

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/ArticleStandard/Article/detail/670169