Veterinary Review Questions Part 2

12. What is evaluated/investigated in a pleural effusion to find the underlying cause? transu/exudate For example: - - color/smell protein leucocytes cytology If the PCV of pleural effusion is 25%, then it is most likely  hemothorax Pleural effusion with neutrophils and intracellular bacteria is most likely causing pyothorax 13. Kirby`s Rule of 20 Kirby`s Rule of 20 (taking care of stationary critically ill patient) 1. fluid balance 2. oxygenation/ventilation 3. blood pressure 4. heart rate, rhythm 5. glucose 6. temperature 7. albumin 8. electrolytes 9. mentation/attitude 10.RBC 11.GI motility and mucosal integrity 12.nutrition 13.renal function 14.coagulation 15.immune system/antibiotic dosage 16.drug dosages 17.pain control 18.nursing care and patient mobilization 19.wound care and bandage change 20.tender loving care 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 o airways o breathing o circulation o dysfunction supportive care and treatment o monitoring and supportive care o fluid therapy o cardiovascular support o gastrointestinal support o neurological support o analgesia/sedation o 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 o tepid water and liquid dish degreasing soap o clipping caustic, acidic or alkaline toxicities o gentle decontamination with tepid water o do not scrub! Do not use high pressure water sprays! o do not “neutrilize”! risk of hypothermia with cooling o increases the effect of pyretroids and pyrethrins on CNS not too warm water o vasodilation Gastrointestinal decontamination - - before considering emesis o complete history consider o time frame o underlying med. problems o symptomatic patients o corrosive vs caustic agent o hydrocarbons: gasoline, kerosine, motor oil etc be aware of possible complications o aspiration pneumonia o hematemesis o caustic or corrosive injury to esophagus, oropharynx or GIT Emesis - the earlier the better o mainly useless after 4h (1-2h ideal) except: o large wads of xylitol gum o large amounts of chocolate o grapes and raisins o massive ingestion that can cause concretion (fish oil capsules, ironvitamins) o ingestions that can form a bezoar or foreign body (blood or bone meal; fire starter logs) o drugs that delay gastric emptying (e.g opioids) Emesis at home - - - 3% hydrogen peroxide o direct gastric irritation o 1-2ml/kg; do not exceed 50ml o induction in 5-10min table salt o no longer recommended by veterinarians nor human doctors o risk of hypernatremia 7% Syrup of Ipepac o no longer recommended by veterinarians nor human doctors o severe hematemesis, lethargy, diarrhea, depression Emesis at clinic - Ropinirol Apomorphine Xylazine Dexmedetomidine Gastric lavage - - - when o o o o 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 o risk of sedation o aspiration pneumonia o hypoxemia o mechanical injury contraindications o corrosive agent o hydrocarbon agent o 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 o management of potentially life-threatening clinical signs, symptomatic and supportive care o 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). o 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 o 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 o 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. o 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. o Vitamin K1: 3–5 mg/kg twice per day. Duration of treatment depends on the specific rodenticide. o 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 o after that: signs of AKI; polyuria, oliguria, anuria, dehydration, diarrhea, depression o CNS signs (cats): ataxia, head pressing, disorientation, tremors, seizures o 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 o dermal application: paresthesia, ear twitching, paw/tail licking, hiding, hyperexcitability o cats: weakness, tremors, shaking, ataxia, seizures, paralysis, death o dogs: nervousness, rubbing application site, agitation, shaking of legs, mild muscle fasciculation - treatment: o intravenous fluid support to maintain electrolyte balance o thermoregulation o decontamination by washing o benzodiazepines for seizure control o intravenous lipid emulsion (off-label use) o 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 o erythrocytes, platelets, coag. Factors, plasma proteins o use within 8h or refrigerate Packed Red Blood Cells (pRBCs) o PCV 70-80% - o in refrigerator, standing position frozen plasma (FP) o freeze Blood transfusion - - dogs o more than 12 DEA groups o most common DEA 1  positive or negative o blood typing o DEA 1 negative considered as universal donor cats o A, B, AB o have naturally occurring alloantibodies o 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: o temperature o heart rate; pulse rate, o respiratory rate, o mucous membrane color o general demeanor after 30 minutes- no signs of transfusion reaction o 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: o hemothorax o 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 o 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: o dopamine 2-2,5mikrogr/kg/min antibiotics: o use when needed 19. Common injuries in trauma (body regions) Injuries by body regions Head - - - skull o fractures o intracranial injuries-TBI mouth o lip avulsion o tongue injuries o tooth fractures o jaw fractures o symphysis luxation o joint luxation o palate eyes o proptosis o 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 o spleen o liver traumatic hernia urinary tract injuries o uroabdomen o kidney rupture/hematoma o urethra injuries  inguinal and penile injuries Fractures - front o o o limbs radius- ulna fractures elbow joint lux humeral fracture - o scapula fracture hind libs o pelvic fractures o femoral fracture o hip luxation o distal bone fractures Traumatic nerve injuries - brachial plexus avulsion caudal gluteal nerve damage sciatic nerve damage tibial nerve damage causes: o fractures o bite wounds o gunshots Spinal injuries - spinal cord contusion vertebral luxation, fracture cats more blunt