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ADVERSITY “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon.

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Presentation on theme: "ADVERSITY “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon."— Presentation transcript:

1 ADVERSITY “Life’s challenges are not supposed to paralyze you, they are supposed to help you discover who you are.” - Bernice Johnson Reagon

2 Emergency Procedures

3 Normal PE AreaOrgans Cranial ventral abdomenLiver, stomach, pancreas Cranial dorsal abdomenKidneys, stomach, pancreas Mid-ventral abdomenSpleen, small bowel Mid-dorsal abdomenKidneys, ureters, retroperitoneal space Caudal ventral abdomenBladder, uterus Caudal dorsal abdomenColon, sub-lumbar lymph nodes, prostate, uterus

4 Use belts and your hands

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

6 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

7 Mucous membrane ColorInterpretationCauses PINKAdequate circulation and perfusion Normal circulatory system WHITE OR PALE PINKAnemia, decreased peripheral perfusion, vasoconstriction Anemia ( blood loss, inc. destruction, dec. production) shock BLUE OR GREYHypoxemia, anemiaRespiratory embarrassment, blood loss DARK RED, BRICK REDIncreased peripheral perfusion: cyanide toxicity Fever, sepsis, systemic inflammatory response, smoke inhalation/ cyanide toxicity BROWNMethemoglobenemiaAcetaminophen, ibuprofen YELLOW (ICTERIC)HyperbilirubinemiaHemolysis, hepatic/ biliary disease PATECHIACoagulation disorderThrombocytopenia, decreased platelet function

8 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

9 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

10 Triage of Emergency Patients – Vital signs (taken after initial assessment) Vital signs 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

11 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?)

12 Triage of Emergency Patients – Events How long since injury Cause of injury (HBC, dog fight, gunshot) Evidence of loss of consciousness Blood loss? Deterioration/improve ment since accident (good indicator of Prognosis) Any other underlying medical conditions/medications

13 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)

14 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

15 Triage of Emergency Patients

16 SHOCK: RECOGNITION AND TREATMENT SHOCK is inadequate tissue perfusion resulting in poor oxygen delivery – Cardiogenic – Distributive – Obstructive – Hypovolemic

17 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 3 rd spaces

18 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

19 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

20 Shock Treatment: the goal of therapy is to improve O 2 delivery – O 2 supplementation (If pulse ox < = 93%) Face mask O 2 cage/hoods Transtracheal/nasal insufflation – Venous access Cephalic Saphenous Jugular Intraosseous

21 Oxygen supplementation FACE MASK NASAL CANNULA OXYGEN HOOD

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23 Fluid Administration

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25 Shock Treatment – Fluid resuscitation (O 2 delivery is improved by ↑CO) 1. Crystalloids Isotonic solutions (electrolytes: Na +, Cl -, K +, bicarbonate) – Examples (body fluid= mOsm/L) » Lactated Ringer’s (273 mOsm/L) » Normal saline (0.9%) (308 mOsm/L) – Dose: Dog ml/kg/hr Cat 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)

26 Shock Treatment – Fluid resuscitation (O 2 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

27 Shock Rx (continued) – Sympathomimetics Use only after adequate fluid administration if BP and tissue perfusion have not returned to normal Dopamine (Inotropin®) – μg/kg/min » Dilation of renal, mesenteric, coronary vessels – 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)

28 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

29 Shock Monitoring – Physiologic Monitoring Parameters O 2 Saturation – Pulse oximetry—noninvasive – Normal: Hb saturations (SpO 2 )>95% » SpO 2 <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

30 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 – Pa CO2 tells how well patient is ventilating » Pa CO2 <35 mm Hg → hyperventilation » Pa CO2 >45 mm Hg → hypoventilation – Pa O2 Tells how well patient is being oxygenated » Pa O2 <90 mm Hg → hypoxemia – pH tells acid/base status of patient – <7.35 → acidosis – >7.45 → alkalosis

31 VISION “It is a terrible thing to see and have no vision.” -Helen Keller

32 CPCR CARDIOPULMONARY CEREBROVASCULAR RESUSCITATION

33 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

34 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

35 Cardiopulmonary Resuscitation Facilities – Adequate room for entire team and equipment – O 2 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

36 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

37 Emergency Drugs in Dogs

38 Emergency Drugs in Cats

39 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.

40 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)

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44 CPR cU cU

45 Cardiopulmonary Resuscitation Intubation

46 Basic Life Support (Phase I) – Circulation External cardiac compression – Lateral recumbency—one/both hands on thorax over heart (4 th -5 th intercostal space) – In larger patients, arms extended, elbows locked – In small patients, thumb and first 2 fingers to compress chest – Rate of compression: /min Cardiopulmonary Resuscitation

47 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 7 th and 8 th 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

48 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 2 nd or 3 rd 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

49 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) – mg/kg – ↑HR – ↓secretions Epinephrine—adrenergic effects – mg/kg – Arterial and venous vasoconstriction→ ↑BP

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

51 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: mg/kg Sodium bicarb (For metabolic acidosis) – 0.5 mEq/kg per 5 min or cardiac arrest Vasopressin (ADH) – 0.8 U/kg

52 CPR

53 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 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

54 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: J/kg

55 Cardiopulmonary Resuscitation DEFIBRILLATORS

56 Cardiopulmonary Resuscitation NORMAL EKG VENTRICULAR FIBRILLATION

57 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%

58 CPR

59 EDUCATION “Education is what survives after what has been learned has been forgotten.” - B.F. Skinner

60 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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62 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

63 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

64 Heat Stroke (Hyperthermia) Requires immediate treatment Dogs 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 days to acclimatize) AN ENLARGED TONGUE HANGING FREELY FROM THE MOUTH IS A CLEAR SIGNAL TO REST AND COOL

65 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

66 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

67 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

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69 Emergency Drugs in Cats

70 Emergency Drugs in Dogs

71 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

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

73 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

74 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]

75 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

76 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

77 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

78 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

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

80 PERSEVERANCE “Sometimes the best way out is through.”

81 TOXICOLOGIC EMERGENCIES

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

83 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

84 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

85 Ocular exposure Rinse eyes with copious saline for 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

86 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 vomiting—if chemical not caustic; animal conscious, not seizing – Syrup of ipecac, apomorphine, Xylazine, H 2 O 2 (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

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: mg/kg; (other sources: mg) Milk Chocolate—44-60 mg/oz Dark chocolate-150 mg/oz Baking Chocolate— 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

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94 Toxicologic Emergencies – Rodenticides 2.Cholecalciferol—Vit D 3 ; 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

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 3.Bromethalin -uncoupler of oxidative phosphorylation in CNS (stops production of ATP) -Causes cerebral edema -found in Assault, Vengence, Trounce -Toxic DoseDog: 4.7 mg/kg Cats: 1.8 mg/kg Clinical 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

97 Toxicologic Emergencies Acetaminophen Common OTC drug for analgesia Toxic dose:Dog— 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 of 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 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

100 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

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:Cat—1.5 ml/kg Dog—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

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 ( 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-law’s 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, 2 nd Annual Canine Paramedicine Conference, May /ArticleStandard/Article/detail/670169


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