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How to do it(or more importantly . . .)
How To Do It at
Angell
A Guide for New Interns atAngell Animal Medical Center
2009-2010
INDEX
A
Addison’s................................................................................40Allergic Reactions..................................................................20Anesthesia/Analgesia.............................................................36Antibiotics................................................................................1Anti-emetics.............................................................................5Antitussives..............................................................................2Appetite Stimulants..................................................................2
B
Back/Spine..............................................................................17Bicarbonate Replacement.......................................................34Blood Gas...............................................................................14
C
Calcium Supplementation......................................................34Chest Tubes............................................................................13Coma Score............................................................................19COP........................................................................................30CPR.........................................................................................32CRIs........................................................................................29
D
Dermatology...........................................................................44DKA.......................................................................................42Dyspnea..................................................................................11Dystocia..................................................................................38
E
Emesis.....................................................................................23Exotics....................................................................................46
F
Fluid Rates..............................................................................31Free Water Deficit..................................................................30
G
Gastroprotectants......................................................................4GDV.......................................................................................39Gen Med Protocols.................................................................50Glaucoma................................................................................20Glucocorticoids.......................................................................37
H
Head Trauma..........................................................................18Hemoabdomen........................................................................41Hepatic Encephalopathy.........................................................21Hepatic Lipidosis....................................................................22Hypertonic Saline...................................................................30
I
IMHA/ITP..............................................................................35
N
NSAIDs....................................................................................3Nutritional Support...................................................................9
P
Paracentesis............................................................................15Potassium Replacement..........................................................34
R
Rabies Protocol.......................................................................47RBC Morphology...................................................................49
S
Seizures...................................................................................16
T
ToxicityAcetominophen..................................................................27Amphetamines...................................................................24Anticholinesterase..............................................................27Chocolate...........................................................................24Ethylene Glycol.................................................................28Lily.....................................................................................25NSAID...............................................................................28Permethrin..........................................................................25Rodenticide........................................................................25Xylitol................................................................................29
U
UO............................................................................................6URI Kitty................................................................................14Uroabdomen.............................................................................8
ANTIBIOTICS
AMOXICILLIN 10-22 MG/KG PO/12 50, 100, 150, 200, 400 MG TAB 50 MG/ML IN 15ML OR 30ML BOTTLES
CLAVAMOX 13.75 MG/KG PO BID FOR DOGS/CATS
62.5, 125, 250, 375 MG TABLETS 62.5 MG/ML IN 15ML BOTTLE
AMPICILLIN 10 –20 MG/KG IV, IM, SQ, PO/8 250, 500 MG CAPSULES 25, 50, 100 MG/ML ORAL SUSPENSION
CEFAZOLIN 10 – 33 MG/KG IV, SQ/8 INJECTABLE ONLY
CEFPODOXIME (SIMPLICEF) 5-10MG/KG PO Q24H
100, 200 MG TABLETS
CEPHALEXIN 22 MG/KG PO/8-12 H 250, 500 MG CAPSULES 250 MG/5 ML ORAL SUSPENSION
CLINDAMYCIN 5.5 – 11 MG/KG PO/12 (SOFT TISSUE)
11-33 MG/KG Q12H (OSTEOMYELITIS)12.5 MG/KG Q12H (TOXOPLASMA/NEOSPORA)
25, 75, 150 MG CAPS 25 MG/ML IN 20 ML BOTTLE “ANTIROBE”INJECTABLE
DOXYCYCLINE 5-10 MG/KG PO/IV12CAUTION IN PREGNANT/PEDIATRICS
50, 100MG TABLETS
5 MG/ML ORAL SUSPENSION IN 60ML BOTTLE INJECTABLE AVALIABLE
ENROFLOXACIN 5-20 MG/KG IV, PO/24 BE CAUTIOUS - MAXIMUM 5 MG/KG/DAY IN
CATS
DOGS START AT 10 MG/KG/24NOT FOR PREGNANT/PEDIATRICS
22.7, 68, 136MG TABLETS
17 MG/ML; 34 MG/ML ORAL SUSPENSION
INJECTABLE AVAILABLE
GENTAMICIN 5 MG/KG IV, IM, SQ Q24H
CAUTION IN PREGNANT/PEDIATRICS
(AMIKACIN 15-20 MG/LG IV, IM, SQ Q24H
50 MG/ML INJECTABLE ONLY
OTOTOXIC/NEPHROTOXIC
MUST CHECK URINE DAILY FOR CASTS
CHLOAMPHENICOL 50 MG/KG IV, PO Q8H INJECTABLE
250MG TABLETS
OWNERS MUST WEAR GLOVES—APLASTIC ANEMIA
METRONIDAZOLE 7.5 – 10 MG/KG PO/12-24, IV/12
TOXICITY SEEN IN DOGS >50 MG/KG/DAY
250, 500 MG TABLETS 50MG/ML ORAL SUSPENSION IN PHARMACY
INJECTABLE AVAILABLE
SULFADIMETHOXINE (ALBON) FOR COCCIDIOSIS
55MG/KG PO ONCE, THEN 27.5MG/KG PO/Q24H X 2-3 WK
125, 250, 500MG TABLETS
50MG/ML ORAL SUSPENSION
TIMENTIN 50 MG/KG IV/Q8H INJECTABLE ONLY
CIPROFLOXACIN 5 – 15 MG/KG PO/Q12H
NOT FOR PREGNANT/ PEDIATRICS
100, 250, 500, 750 MG TABS
INJECTABLE AVAILABLE, POOR ORAL ABSORPTION
- 1 -
ZITHROMAX 5 MG/KG/Q24H THEN CAN GO TO EOD AFTER 7 DAYS
50 MG/ML SUSPENSION
UNASYN
50 MG/KG Q8H INJ ONLY (BASICALLY INJ CLAVAMOX)
IMIPENEM
5-10 MG/KG Q8H IV SQ IM 250, 500, 750 MG
ALBON (SULFADIMETHOXINE)50 MG/KG ONCE PO; THEN 25 MG/KG FOR 10-
14 DAYS
50 MG/ML SOLUTION
AUGMENTIN (FOR THOSE EXAM ONLY OUTSIDE SCRIPTS)
13.75MG/KG
BASED ON JUST THE AMOXICILLIN CONCENTRATION
(250MG/5ML SOLUTION)TRIMETHOPRIM/SULFADIAZINE 30 MG/KG
PO/Q12H
30, 120, 480, 960, MG TABS
TRY TO AVOID USE IN DOBIES (OTHER BLK & TANS)—BM SUPPRESSION/HYPERSENSITIVITY RXN/ KCS
DERM ANTIBIOTICS
Cephalexin: 25-30 mg/kg q12h x 2-3 weeksClavamox: 22mg/kg q12h x 2-3 weeksClindamycin: 11mg/kg q12h x 2-3 weeksCefpodoxime (Simplicef): 5-10mg/kg q24h x2-3 weeks
APPETITE STIMULANTSCyproheptadine
(cats only) 2-4 mg/cat q12h (usually start at 2mg/cat)Mirtazipine
Cats: Give ¼ tablet PO q3d Dogs: <20 lb =3.75mg/day (1/4 15mg tab)
20-35 lb = 7.5mg/day (1/2 15 mg tablet) 40-60lbs = 15mg/day (1 tablet) >75lbs. = 22.5mg/day (1.5 tablets) >100lb =30mg/day (2 tablets)
AntitussivesHydrocodone
0.22 mg/kg PO q8-12h Liquid 1 mg/mL Tabs 5mg
Torbugesic 0.5 mg/kg PO q8-12h Tabs 5mg
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NSAIDs
Most NSAIDs work by inhibiting prostaglandin and thromboxane synthesis by decreasing cyclooxygenase levels. They offer analgesic, anti-inflammatory and antipyretic control. Some also decrease platelet aggregation, so don't use in patients with bleeding disorders (like Von Willebrands) and if possible, stop in patients a week before they are to have surgery. Most can cause significant GI ulceration and irritation if given in high doses or for prolonged periods of time.
Cautionary notes: DO NOT use in shock patients or hypotensive patients—control pain w/ opiods instead Do check liver and renal values prior to use—especially if an older animal
1) Aspirin - Use Ascriptin (325mg), Ecotrin or Bufferin; or baby aspirin (81mg) Dose for Dogs: Pain control: 10-25mg/kg PO BID-TID
Anti-inflammatory: 25-35mg/kg PO TIDDose for Cats: Pain control: 10mg/kgPO q24-48 hours. Be conservative!
Anti-inflammatory: 1 baby aspirin (81 mg) q48-72 for average sized cat
2) Carprofen – (Rimadyl) for dogs. Available in 25, 75, and 100mg. Dose: 1mg/pound PO/q12-24h with food. Dogs only. Injectable available.
3) Piroxicam - (Feldene)—dogs and cats Can be used for severe orthopedic pain but try another NSAID first Palliative Tx for TCC, OSA, prostate carcinoma Good for back and neck pain if NO NEURO deficits are noted Dose : 0.3mg/kgPO q24H for 2-4 weeks then q48hrs or try off for 2 weeks. They come in 1mg-
10mg capsules. Liquid can be compounded***Must be used with Cytotec (misoprostol) 3 mcg/kg q 12 hrs (not above 100 mcg/dog). Start this 8-12 hrs prior to Piroxicam if possible. Pregnant owners/staff should NOT handle.
4) Deracoxib (Deramaxx)—dogs—COX 2 specific—peri-operative pain/OA/DJD Dose for dogs : 3-4mg/kg PO/24 for up to 5 days post-op, then give 1-2mg/kg PO for
maintenance of chronic OA/DJD Anecdotally we’ve seen greater number of duodenal perforations w/ Deramaxx vs other
NSAIDS
5) Meloxicam (Metacam) – Good anti-inflammatory safe in cats (No Cytotec) Dogs: 0.2mg/kg PO on day 1, then 0.1mg/kg PO/24. Cats: 0.2mg/kg PO on day 1, then 0.1mg/kg PO/24 for 2 days, then 0.025mg/kg 2-3/week. EXAM ONLY: (big dogs)—can script out Mobic (human meloxicam)
o Tablets 7.5mg and 15mg or liquid (7.5mg/5mL)
**Orders to give NSAIDs in CCU must be signed off on by a staff clinician or resident **
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GASTROPROTECTANTS
Antacids Indications: Any disease that predisposes to GI ulceration: renal failure, mast cell disease, gastrinoma, vomiting, liver dz. OK to use for any animal that is vomiting.
General classes: Histamine H2 Rc antagonist and H+ pump inhibitor. Debated that H2 blockers lose efficacy after 72 hours. We use famotidine regularly here.
Famotidine (Pepcid): H2 blockerDose: 0.5 - 1mg/kg PO, IM, SQ, IV q12-24h Decrease to 0.25mg/kg q24h in renal disease
10 mg tablets (available over the counter), injectable 10 mg/m1
Cimetidine (Tagamet): H2 blocker. Inhibits cytochrome P450 system in the liver; slows metabolism of other drugs; use w/care in liver dz
Dose: 5-10 mg/kg PO, IM, or IV q6-8h
Ranitidine (Zantac): H2 blocker. Also has some prokinentic activityDose: 2 mg/kg PO or IV q8-12
Omeprazole (Prilosec): Proton pump inhibitor Most effective at decreasing gastric acid secretion, but also the most expensive
Dose: 0.5-1.0 mg/kg PO q12-24h (10 and 20mg capsules)—CANNOT SPLIT
Protonix (Pantoprazole) 1mg/kg IV SID (given over 20 minutes CCU protocol). Dogs only
Sucralfate (Carafate) Indications include GI ulcers/erosion and esophagitis (slurry) Attaches to injured gastric mucosa; heals ulcers and provides cytoprotective effect. May use a
loading dose of 3 to 6 grams in cases of severe bleeding. Works best on empty stomach so other oral meds should be given 1-2h before or after sucralfate.
May cause constipation. Dose : 0.25-1 g/dog q8h (small dogs 0.25g, large dogs 1g); 0.25g/cat; q8h
Misoprostol (Cytotec)—PGE1 analog May reduce NSAID induced ulceration (debated). Used concurrently with Piroxicam. Can cause
diarrhea and cramping. Pregnant staff/owners should NOT handle this drug. Dose : 3 mcg/kg PO q12h; not more than 100 mcg/dog/per dose
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ANTI-EMETICS
These are symptomatic therapy that DO NOT address the underlying problems and may MASK problems. Indicated if vomiting is contributing to morbidity, discomfort, excessive fluid or electrolyte losses.
Chlorpromazine (Thorazine) – a phenothiazine derivative Inhibits chemoreceptor trigger zone (CRTZ) Be very cautious with dehydrated or hypotensive patients as they cause vasodilation. Lowers seizure threshold (debated) Dose: 0.3 - 0.5 mg/kg IM, SQ q8h; (0.05 mg/kg IV q8 but avoid IV if possible)
Metoclopramide (Reglan) Inhibits CRTZ. Used to manage regurgitation/ileus Increases LES and pyloric sphincter tone and forward motility. Increases gastric tone and peristalsis. Dose should be reduced in severe renal dz due to renal excretion Contraindicated if GI obstruction; so take radiographs before starting this drug. Dose : 0.4-0.6 mg/kg PO SQ q8h; or 1-2mg/kg/day as a CRI
Dolansetron (Anzemet) - 5HT3 antagonist (works in CRTZ)Dose: 0.5-1.0 mg/kg q24h; IV, SQ, PO
Cerenia - binding of substance-P to the neurokinin-1 (NK-1) receptor in the vomiting center. It is an NK-1 receptor antagonist. It prevents both neural (central) and humoral (peripheral) causes of vomiting.
Dose (dogs): For acute vomiting: 1.0mg/kg SQ SID for 5 days or less 2.0mg/kg PO SID for 5 days or less
Motion sickness: at least 8 mg/kg PO q24h x 2 days Meclizine – inhibits CRTZ. Primarily used for motion sickness
Dose: Dogs – 4mg/kg PO SID or 25mg/dog PO SID
Mirtazapine – 5HT3 antagonist (works in CRTZ)Dose: Cats – 3.75mg PO q72h
Dogs – <20 lb =3.75mg/day (1/4 15mg tab) 20-35 lb = 7.5mg/day (1/2 15 mg tablet)
40-60lbs = 15mg/day (1 tablet) >75lbs. = 22.5mg/day (1.5 tablets) >100lb =30mg/day (2 tablets)
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THE BLOCKED CATSET UP
Sterile gloves; laceration pack Open ended and close ended Tomcat catheters Sterile lube +/- lidocaine gel 3-0 Nylon suture Sterile bowl may be handy Red rubber catheters: 5 Fr and 3.5 Fr Syringes: 12mL for UA and 35mL to flush bladder UCS and extension set Sterile saline, 250mL bottle Radiology—1 lateral rad (check U-cath placement and urinary stones)
Stable vs unstable Stable means little to no electrolyte disturbances, no arrhythmia or bradycardia, mentally appropriate,
may be mildly azotemic Unstable means moderate to severe electrolyte or acid base disturbances and/or if the cat is mentally
dull, bradycardic, hypothermic, shockyo Usually needs EKG and fluid bolus prior to unblocking
o Worry immediately about potassium >7 or if EKG shows tented T waves or bradycardia (HR <150)
Regular Insulin 0.1-0.25 U/kg Dextrose 0.5ml/kg Ca Gluconate 3ml/cat diluted 1:1 with 0.9% NaCl given over 10 minutes
Doctor must give
Drugs to unblock Hydromorphone (0.1mg/kg)/Valium (0.5mg/kg) Ketamine (4-6mg/kg)/Valium (0.5mg/kg) Sometimes need to top off w/ low dose propofol for complete relaxation (2-4 mg/kg) You may need to intubate cat, so be ready with ET tube and gas anesthesia Some sick cats are so dull no drugs are needed
Fluid orders IVF at least 2x maintenance if cat presented w/ moderate or severe azotemia SQ fluids OK in wards if no azotemia or minimal azotemia If insulin was given: Add dextrose to fluids and recheck BG in 2-4 hours
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IMPORTANT POST-OP ORDERS Submit urine for UA; aerobic C/S Recheck electrolytes w/in several hours if severe derangements on admit Change UCS q24h; empty and record volume q4-6h; check in/outs and adjust fluids accordingly Dr check bladder q8h SQ or IVF depending on finances and degree of electrolyte disturbance +/- prazocin (0.5 mg/cat PO q24h) or phenoxybenzamine (2.5 mg/cat PO q8h) if urethral spasms once
awake and BP OK Food and water OK once awake – ideally canned c/d or s/d Pain medication (buprenex) and E-collar always
HANDY TIPS If very gritty can try injecting lube or Vit C through catheter Add lidocaine to lube Can try ‘Slippery Sam’ catheter or frozen red rubbers for difficult cases Try threading a central line stylet thru red rubber for increased stiffness General anesthesia and benzodiazepines can ease catheter passage by increasing muscle relaxation
Debatable drugs to use Anti-inflammatories
o Dex SP—may be indicated if multiple attempts made to unblock or if penis is visibly inflamed. Dose: 0.1-0.2 mg/kg SQ, IM.
o Also may consider Meloxicam if NOT azotemic
Abs—rarely indicated unless positive culture or stones. Primary UTIs uncommon in male cats Cosequin—used long term for cystitis cats to help to help reduce bladder wall inflammation
UO DRUGS
Some drugs to think about using after unblocking depending on severity or urethral spasm or bladder tone.
1) Phenoxybenzamine or Prazocin - Both work by reducing internal urethral sphincter tone (alpha blockers). Good to try if they are straining or were very difficult to unblock. Don't use in cats with heart disease or low BPs. Side effects : Possible hypotension at higher doses and tachycardia, miosis and sometimes some GI
effects, nausea, depression. Phenoxybenzamine Dose: 2.5 – 10 mg PO/q8-24h; can take several days to start working Prazocin Dose : 0.5mg/CAT q24h – works faster, hypotension can be worse
o Can give up to q8h if needed, but usually start at q24h
2) Bethanechol - (Urecholine) Works as a cholinergic (mostly muscarinic) receptor stimulant. Increases detrusor muscle tone. Good for bladder atony. Contraindications : Outflow obstruction, post-bladder surgery, hyperthyroidism, GI obstruction or recent
GI surgery. Side Effects : Can cause vomiting and diarrhea, salivation and anorexia. Dose: 2.5-5 mg PO/q8-12h
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Uroabdomen
Causes: trauma, diseased bladder wall (neoplasia, cystitis, infection)Clinical signs:
Abdominal pain and distension Lethargy Shock (tachycardia, hypotension, prolonged CRT) Hypothermia or hyperthermia Not passing urine; or only urinating a little Hx that may be consistent (HBC, TCC, UO)
Diagnosis Positive abdominal tap for urine
Creatinine of abdominal fluid:serum is > 2:1 Potassium of abdominal fluid:serum is >1.4:1
Azotemia, hyperkalemia, acidosis (ARF) Contrast cystogram showing contrast leaking out of bladder/urethra
Treatment Treat initial signs of shock w/ fluids (0.9% NaCl) Place an indwelling urinary catheter Usually means an emergency Sx if diagnosed during the day If diagnosed after hours; best to establish drainage by placing peritoneal dialysis catheter
o Must be stable for heavy sedation/anesthesiao Call CC2 resident or chief resident overnight
Monitor INS/OUTS of both PD and urinary catheter Treat renal failure
o Fluids, Abs, GI protectants Prognosis can be good if drainage and definitive Tx are started early
- 8 -
NUTRITIONAL SUPPORTRemember Angell has a nutritionist—Dr Remillard.
Lipids This is an Angell phenomenon most of us had not seen before coming here. Good for short term, like while waiting for PN to be made, or to provide some calories in financial cases. Lipids should not be relied on as sole nutritional support. Lipids can also be used to bind lipid-soluble drugs in overdoses (Ivermectin). Lipid solution is 2kcal/mL.Dose: Kcal = 15 x BW in pounds/day for dogs.
Kcal = 20 x BW in pounds/day for cats.
Basic Caloric Requirement (RER)Dogs: (wt in kg)0.75 *70 = kcal/dCats: (wt in kg)0.75 *70 = kcal/d30 (BW in kg) + 70 = kcal/day (if<2 kg or >25 kg use 70 (wt in kg)0.75 )
The “not eating cat” ….Cyproheptadine (periactin) at 1-4 mg /cat q12-24h (can see behavioral side effects)Or can use Mirtazipine: 1/4 tablet (3.75mg) PO every 3 daysTry syringe feeding A/D slurry (may be tolerated or can cause food aversion)
Enteral Feeding “IF THE GUT WORKS, USE IT!” Stomach capacity: 10-15mL/kg if chronic anorexia; 45-90mL/kg when fully re-alimented
Tube Types: NE Tube
Usually done in CCU under minimal sedation Patient must have functional esophagus, stomach, and intestines. NE tube not appropriate if
vomiting. Used for short term feedings (only while in hospital) ALWAYS check position w/ rads before feeding Works only w/ liquid diets (Clinicare) Best tolerated as CRI
Esophagostomy Tube Done in surgery under full anesthesia. Placed for long term feedings. Check placement w/ lateral radiograph Provides longer nutritional support (weeks) and pet can go home w/ in place Uses larger tube - 12Fr red rubber or larger. Feed a gruel type diet
Gastrostomy Tube (“PEG” – percutaneous endoscopically-placed G-tube) Requires surgical, endoscopic or non-endoscopic placement. Can be left in for months but MUST be left in for at least 14 days to allow adhesion to form and thus
prevent leakage. G-tube allows the feeding of thicker blenderized food Jejunostomy Tube--indicated if it is necessary to bypass stomach. Requires surgical placement
- 9 -
Enteral Feeding Schedule: Liquid diets more likely to cause diarrhea; but less likely to plug tube; and must be used for tubes
smaller than 12Fr Gruel diets can only be used in larger tubes (12Fr or larger); a/d is easily mixed w/ water or Clinicare Bolus feeding
o Dosed q4-6h to accommodate 1/3 RER in first 24 hours; then increase by 1/3 every 24 hours
o Another rule of thumb: can start at 3-5mL/kg q2-4h and work up to 22-30mL/kg/feeding
CRI feedingo Can start w/ this initially or indicated if bolus feeding causes nausea or vomiting
o Start with 1/3 RER and increase to full calories by day 3
**** If vomiting/nausea occurs, decrease CRI by ½ or decrease bolus by ½ or skip next feeding or give bolus more slowly ****
Parenteral Nutrition Dr Remillard is a firm believer that there is no such thing as TPN, thus she refers to it as PN Order PN thru CC resident (usually CC2) or Cross trainer Central line required if osmolality of PN >600 mOsm/L Requires daily monitoring: electrolytes, glucose, phosphorus to avoid re-feeding syndrome Only start PN if it will be used for a minimum of 3 days; otherwise it is not worth the cost or nutritional
value to the patient Allow time for PN to be made when starting your animal and order extra bags when you need them—
order the day before you need them—difficult to get over the weekends There is no such thing as a nutritional emergency!
Metabolizable Energy (kcal/cup or kcal/can):
Dog CatDietHill’s adult maintenance canned 378 157-178Hill’s adult maintenance dry 365 488-495w/d canned 329 127-146w/d dry 243 278-281i/d canned 485 161i/d dry 379 483a/d 180 180m/d (canned/dry) -- 156/480k/d canned 496 183-200k/d dry 396 477Purina OM 189/266 150/321Purina NF 500/459 234/398Purina DM (canned/dry) -- 194/592
DYSPNEA
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Intrathoracic disease: pulmonary edema, pulmonary hemorrhage, pulmonary neoplasia, pleural effusion, tracheal compression by an enlarged heart, pneumothorax, smoke inhalation, feline asthma, PTE.
Extrathoracic causes: severe ascities, GDV, upper airway obstruction, laryngeal paralysis, brachycephalic syndrome, CNS disease
Metabolic cause: anemia, methemoglobinemia (Tylenol toxicity), hypokalemia, severe acidosis
Physical examination is key but can be difficult in extremely dyspneic, stressed animals. Pure inspiratory dyspnea tends to indicate upper respiratory obstruction (tracheal collapse, laryngeal paralysis) Inspiratory and expiratory dyspnea most likely lower airway disease
Triage Pearls for Dyspneic Animals Ask owners quickly if any heart failure, any medications Get resuscitation code Take back to O2 immediately Use breed/age clues to help narrow diagnosis: old retriever-lar par; young cat-asthma or CHF; small breed dog-
CHF or tracheal collapse
DO NOT STRESS THESE ANIMALSTreatments/diagnostics
IV catheter if possible Bloodwork
o Arterial blood gas if possible—usually only possible on dogs
o CCP to assess metabolic status
o Venous blood gas won’t give accurate PaO2; but will give useful PvCO2 information
Mild sedation can be very helpfulo Morphine 0.01-0.05 mg/kg IM
o Butorphanol 0.2-0.4 mg/kg
o Acepromazine 0.01-0.025 mg/kg
Radiographs: sometimes animal is not stable enough to obtain; but obviously most helpful
Pulmonary edema due to CHF: open mouth breathing; pulmonary crackles; pink fluid around mouth/nares; perihilar infiltrates; cardiomegaly; enlarged pulmonary vessels (look at VD 9-10th rib for vessel size)
2 mg/kg Furosemide IV if able; IM (repeat in an hour if NO improvement) Bolus dosing 2 mg/kg q8h or 0.25-0.5 mg/kg/h CRI can be used +/- sedation (morphine may have added benefit of decreasing preload) ¼ strip of Nitropaste in ear once BP >100 mmHg; OK to repeat q8h if BP normal In cats, should also assess rear limbs for signs of FATE (cold extremities, lack of FPs, cyanotic nail beds)
Pleural space disease: inspiratory/expiratory effort w/ no crackles; muffled heart and lung sounds; compression of lung lobes on films; pleural fissure lines; obscured cardiac silhouette
Thoracocentesis is needed for therapeutic and diagnostic purposeso Look at fluid for bacteria or neoplastic cells (submit for cytology and culture if indicated)
o Do PVC/TS on fluid to r/o hemothorax
o Chylous fluid—idiopathic or related to primary cardiac disease
o Hemothorax—trauma, neoplasia, coagulopathy (classic for cavitary bleeding due to rodenticide)
Perform PT/PTTo Pyothorax—requires a chest tube after initial stabilization; cats can be more sick from sepsis than from
pleural space issue; DO NOT rush cats to chest tube if hemodynamically unstable; cats do not usually require thoracotomy; dogs more likely to require thoracotomy
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Culture the effusion – anaerobic and aerobic Start Abs – Clavamox, Metronidazole, Ampicillin, Clindamycin post-tap +/- flush pleural cavity with saline +- intrapleural Abs
o Spontaneous pneumothorax will usually require chest tube; maybe a CT and eventually thoracotomy to locate leak (usually bleb or bulla) and repair it
Feline Asthma: Hx of coughing; expiratory sounds/expiratory dyspnea, may hear fine crackles, bronchial pattern on rads (railroad tracks and doughnuts); right middle lung lobe consolidation on rads
Dexamethasone 0.25 – 0.5 mg/kg IV, SQ, IM; or Prednisone 1-2mg/kg/q12-24h (remember if want to do a TTW then steroids will affect results)
Terbutaline 0.01 mg/kg IM or 1.25mg PO/12; or Aminophylline 20 mg/kg IM, SQ +/- sedation 2 puffs albuterol to start; OK to repeat 30 minutes to 2 hours if NO improvement Flovent is NOT an emergency inhaler—it takes a week to reach therapeutic effects
Upper airway disease: Laryngeal paralysis; tracheal collapse; obstruction Often present cyanotic and gasping Need immediate sedation w/ butorphanol or ace while on supplemental O2 Wait only a few minutes to determine if sedation is working—once sedation takes effect, less airway resistance
allows for adequate air flow and ventilation Sometimes brief intubation is needed—try to take moment to do a laryngeal exam if suspicious for lar par Dex SP 0.1-0.2 mg/kg IV can be helpful in reducing airway swelling that occurs due to increased airway
resistance If intubation is unsuccessful or multiple intubations needed—tracheostomy may be in order
Sometimes helpful to get CCU intern/resident/clinician to perform thoracocentesis and stabilize patient while you get the Hx. Do not feel like you are imposing, this what they are there for.
Other pathologies: Flail chest—stabilized with chest wrap or a small ‘raft’ of tongue depressors taped to the chest; chest tube may be
indicated PTE—predisposers include: liver, renal, Cushings, IMHA, ITP diseases; chest rads are usually normal or show
an area of ‘black lung’ due to small vessel size Non-cardiogenic pulmonary edema—electrocution, ARDS, upper airway obstruction; usually does not respond
well to furosemide; but is worth trying along with IVF and O2 Pericardial effusion/tamponade—may be seen on rads or be suggested by electrical alternans on EKG; requires
pericardiocentesis (use ECC US machine)
Indications for mechanical ventilation: PaO2 < 60 mmHg or PaCO2 > 60 mmHg on room airWhen in doubt call CC2 resident (day or night)—they are responsible for ventilating patients
CHEST TUBES
Unilateral or bilateral depends on lateralization of pathology, communicating mediastinum
- 12 -
Size: Largest possible that fits between ribs. Hints: Cat: 10Fr, Dog med: 12-16Fr, Dog lg: 16-20Fr -- Use heavy tranq or anesthetize/intubate to control airway
Pre-measure to determine 'internal' length (to reach the thoracic inlet) Position and prep
o In lateral recumbency, clip and surgically prep entire chest wall
Monitor SpO2 and EtCO2 continuously If continuous pneumothorax: remember to have someone suction while placing tube Place 1% Lidocaine local block into the 7th intercostal space at dorsal two thirds of chest regardless of
fluid or air; make sure skin, SQ, and intercostal muscles are blocked Grasp the skin along the lateral chest wall and pull it cranially, this eliminates the need to tunnel under
the skin prior to entering chest Make a small incision (but large enough to pass the tube) in the skin and SQ over the blocked site. If
tunneling of the tube in the SQ is needed, do it now, about 1-2 rib spaces cranially Enter the chest 2 ways:
o With one hand, firmly hold the stylet and tube against the chest wall, stabilizing it. With the other hand, you will have to smack on the end of the trocar to drive the tube through the intercostal muscles, pleura and into the pleural space. The best way to do this is with a series of smacks (only 1-2 should be needed and not too hard, but not too wimpy so that you don't get anywhere). You should feel the pleural 'POP'!
o Recommended: bluntly dissect down w/ a large hemostat and use the tip of the hemostat to ‘pop’ thru the pleura. Then guide the tip of the tube over the hemostat into the chest cavity.
When you think you're in, release the skin that was pulled forward and angle your chest tube so that it is now pointed toward the elbow.
Do NOT remove the stylet yet! Instead, hold the tube steady but pull the stylet out 1cm so that the tip of it is no longer exposed and will not damage intrathoracic structures when you feed the whole thing in
Now, slide your tube off the stylet as it feeds into the pleural space (cranioventral if fluid and craniodorsal if air) to your predetermined length
Now you can remove your stylet but make sure to clamp the tube near the end as you pull it at so that air doesn’t get sucked in
Place the chest adapter on the end. Attach syringe and suction any fluid or air until negative pressure is achieved. Clamp the tube w/ either a C-clamp or a special ‘toothless’ hemostat
Now, secure the skin to the tube with a purse string and use a chinese finger trap suture pattern or a piece of butterfly tape placed securely around the tube
Cover the insertion site with sterile gauze and betadine ointment. Apply chest wrap (cast padding, kling, vetrap, elasticon)
Check position of tube w/ radiographs (two views) Place E-collar Presence of the tube itself can lead to formation of nonseptic effusion of 1-2 ml/kg/day.
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The URI Kitty
Put in isolation (L-ward)IVF (if possible)Antibiotics – Zithromax (5mg/kg Q 24hr) or Doxy (not if young!!)+/- Synotic mixed with Chloramphenichol (1mg) and squirt up nose BID+/- L-Lysine 250mg PO BID+/- Interferon 30 IU/Cat (about 1/2ml) per day+/- Cyproheptadine 2mg PO BID+/- Sublingual Buprenex 0.015mg/cat q12-24+/- Teramycine OU q6Nutrition (syringe feed or consider E-tube)
Arterial Blood Gas Formulas** Needs to be taken on room air to use the equations below **
The A-a gradient
Allows you to assess pulmonary function independent of ventilation A-a = pAO2 – paO2
pAO2 = 150 -[(1.1)(pCO2)]Normal < 10
Gray zone 10-15
Abnormal > 15*** Must be at sea level on room air ***
PaO2/FiO2 Ratio
Allows you to assess the efficiency of lung oxygenation when breathing an oxygen concentration higher than room air
Normal = 500
Mild oxygenating inefficiency = 300-500
Moderate oxygenating inefficiency (ALI) = 200-300
Severe oxygenating inefficiency (ARDS) < 200
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PARACENTESIS
Thoracocentesis: Landmarks : ICS 7, 8, 9 Tap above costochondral junction for air; and at junction for fluid For pneumothorax—sometimes helpful to place in lateral recumbency to allow air to rise to top and tap at the
highest point on the chest at ICS 7, 8, 9 Cat: 21 gauge butterfly w or w/o extension set Dog: 22 gauge 1.5 inch needle w/ extension set; 3 way stopcock; 18 ga catheter, 14 ga needle for large dogs w/ a
significant amount of fluid to be removedPericardiocentesis:
Use lidocaine bleb under skin and into intercostal muscle +/- sedation (low dose torb/valium OK) Continuous EKG—electrical alternans often noted Position in LEFT lateral recumbency or sternal Technique
o 14 ga angiocatheter; w/ extension set, 3-way stopcock, and syringe
o Advance catheter into the RIGHT 4th ICS perpendicular to chest wall
o A blood flash may or may not be seen prior to aspiration
o Once blood is collected—wait a moment to monitor for clotting
Monitor for ventricular arrhythmias—give 2 mg/kg lidocaine slow IV if persistent VPCs noted Sometimes fluid bolus necessary after tap; try to avoid giving fluid bolus prior to tap due to decreased cardiac
contractility Clinical signs of tamponade may resolve even if very little fluid is removed; puncture of percicardium may cause
fluid to leak into pleural space—this is acceptable under the circumstancesAbdominocentesis:
Usually done for diagnostic purposes: septic abdomen; uroabdomen; hemoabdomen May be needed for therapeutic purposes if severe ascites is causing dsypnea Clip and prep area on midline; at umbilicus 22 ga needle (1.5 inch for large dogs); sometimes useful to use needle and syringe at the same time. May need 4
quadrant tap Get PCV/TS/BG/lactate of sample depending on the underlying cause. Look at a slide yourself. When indicated
submit for culture/cytology.
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SEIZURES
This is an emergency regardless of the cause. The goal is to STOP the seizures. Try to check glucose and calcium before starting treatment as they may be a cause but anticonvulsant Tx may still be needed.
Valuim: Dogs : 1.0 mg/kg IV for 3-4 doses; OR 2 mg/kg per rectum q20min up to 4x. Half-life of valium in dogs is 15-20
minutes; CRI 0.1-0.5 mg/kg IV Cats : valium can be used as a one time dose; but avoid valium due to risk of acute hepatic necrosis and long half
life of 15-20 hours; 0.5-1.0 mg/kg IV. Usually recommend starting w/ Phenobarbital.
Phenobarbital: Loading dose—
o Dogs : 12-18 mg/kg IV followed by 2-4 mg/kg q20min until control is achieved. Young pups usually require much larger doses for control.
o Cats : 6 mg/kg IV followed by 2 mg/kg q20min until control achieved
It takes at least 20 minutes from time of IV administration to exert anticonvulsant effect If animal already on Phenobarbital, skip loading dose and begin 2-4 mg/kg IV q20min Maintenance dose: 2 mg/kg q12h PO Oral loading: same as above
Pentobarbital: Use if Phenobarbital load does not stop seizures Draw up 18-24 mg/kg (should use much less than this!); give ¼ the dose very slowly over 1 minute, observe to
see if seizures stop; if not—then give another ¼ dose; and so on Since Phenobarbital and valium will potentiate the effect of pentobarbital, give the pentobarbital very slowly over
several minutes. Consider intubation and O2; may need to call in resident ON to monitor the patient if respiratory depression
occurs and ventilation is needed
Potassium bromide (KBr): Loading dose: 400 mg/kg PO or rectally; can split into 100 mg/kg doses x 4 Maintenance dose: 30-90 mg/kg split q12h
Other anticonvulsants: Zonisamide: starting dose 5-10 mg/kg PO q12h; no loading required Keppra: 20 mg/kg q8-12h PO, IV. Loading IV dose – 60 mg/kg Felbamate: 15-20 mg/kg PO q8h; last ditch effort; severe hepatic toxicity; (old dogs with brain tumors)
Other considerations: Assure ventilation once the seizure has stopped, intubate if necessary. Monitor ETCO2 if intubated and watch for
hypovolemia Check glucose and calcium before any treatment is administered
calcium gluconate if indicated (0.5 – 1.5 ml/kg of 10% solution IV diluted 1:1 with saline over 10 –15 minutes; doctor must monitor EKG to watch for arrhythmia)
50% dextrose 0.5-1mL/kg 1:1 NaCl Give dextrose if indicated: BG < 40; although seizure itself can elevate glucose
Prolonged seizure activity causes cerebral edema and increased intracranial pressure Consider steroids: 0.2 mg/kg DexSP IV Mannitol 20%: 1-2 grams/kg IV over 20 minutes
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Prolonged seizure activity causes hyperthermia; if T > 106, cool w/ cool water, cease cooling at 103 or hypothermia may result
Fluid Tx can be tricky. Prolonged seizure activity can predispose to fluid crossing the BBB. Monitor PCV/TS closely and use fluid judiciously if at all to prevent development of cerebral edema
Collect minimum date base: CBC/chemistry/UA/PT/PTT/BP Avoid hypotonic fluids (P56, 0.45% NaCl)
Back Emergencies/Spinal Trauma
Neurology service would prefer if you referred to these sections in the intranet version of the Intern Handbook for the information is too thorough to briefly cover here.
Solumedrol (MPSS, methylprednisolone sodium succinate): protocol is indicated if patient presents within 8 hours of acute spinal trauma. Initial dose: 30mg/kg IV slow (over 30 minutes)Then, 2hrs post-initial dose: 15mg/kg IVThen, 6hrs post-initial dose: 15mg/kg IVThen 15mg/kg IV/6 for 3 more doses, total of 24 hrs MPSS treatment.
Initial dose: 30mg/kg IV slow (over 30 minutes)Then, CRI at 5.4 mg/kg/hr over 24 hours
Polyethylene Glycol (PEG): protocol is also indicated if the patient presents within 8 hours of acute spinal trauma
Dose: 2ml/kg IV slowly over 40 minutes and then repeat in four hours.**Expensive so make sure you include it on your estimate** Protocol is often abbreviated or not started when a dog goes to surgery. Start gastroprotectants and IV fluids with the solumedrol. When patient with suspected spinal lesion presents late at night, serial neuro exams must be performed.
Neck pain in Dogs
Again, please refer to info in online intern handbook for full information on treating neck pain
Piroxicam Dose: 0.3mg/kgPO q24H for 2-4 weeks then q48hrs or try off for 2 weeks Comes in 1mg-10mg capsules. Liquid can be compounded
o Round down if dose is between mg sizes or give liquid
Should start helping in 24-72 hours and should be 100% pain-free by 5-7 days. Only give if no CP deficits
Misoprostol Dose: 3mcg/kg PO q12h Maximum dose 100mcg/dog Start this 8-12 hrs prior to Piroxicam if possible Pregnant owners/staff should NOT handle, wear gloves
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Head trauma
Diagnosis: Observed head trauma, loss consciousness, determine patient consciousness
PE:1) Keep cranial and cervical manipulation to the minimum until the extent of the injuries is determined.2) Check for airway integrity, respiratory pattern, otic and/or nasal hemorrhage, ocular injuries, dental trauma, etc. 3) Careful palpating the skull for fractures.4) Clinical signs of head trauma may include:
Depression/Dementia Traumatic injuries Circling, head tilt, nystagmus Proprioceptive deficits Opisthotonos Anisocoria Cranial nerve deficits Seizures Stupor, coma, and death
5) Check pupil size: Miotic pupils seen with cerebral and midbrain white matter injury. Rapid change in pupil size (from normal to miotic or mydriatic) is seen with rapid increase in intracranial pressure. Hippus (spasmodic irregular dilating/contracting of the pupil) is a sign of central vestibular disease.
6) Posture: Decerebrate rigidity (unconscious pet with four rigid limbs)- sign of midbrain nuclei upper motor neuron dysfunction. Decerebellar rigiditiy (rigid extension of the forelimbs). Aversive syndrome (when aroused pet will circle or adopt the posture of circling the head and neck towards the affected cerebral hemisphere)- unilateral cerebral or thalamic injuries.
7) Respiratory pattern: Hyperventilation with midbrain injury. Cheyne-Stokes breathing (periodic hyperpnea alternated with periods of apnea)- seen with tentorial herniation. Apnea with brainstem injury.
Treatment:1. Elevated head 20-30 degrees above body. Avoid pressure on neck. 2. Perform Modified Glasgow Coma Score. Should be repeated every few hours3. Monitor temperature, pulse and respiration. 4. Check for Arrhythmias (seen with brain stem lesions)5. Provide humidified oxygen 100ml/kg/min. AVOID nasal catheters because they can cause sneezing which in
turn can cause increased intracranial pressure. Some patients may need ventilation if Apneic6. If facial damage is severe and airways are compromised, consider transtracheal catheterization. 7. Avoid jugular catheters/blood draws because this increases ICP8. Treat for shock (For example: 4 mL/kg hypertonic saline; 10 mL/kg Hetastarch)9. Check mean arterial blood pressure. Try to keep it at around 80- 100mmHg.
Avoid hypertension by controlling pain (Opiates are recommended) If hypotension persists after treating for shock, consider Dobutamine (5ug/kg/min in dogs) or
Dopamine (5- 10ug/kg/min in dogs and cats). AVOID tachycardia. Gradually wean patients off these medications.
10. +/- Furosemide: In dogs: 1-2 mg/kg IV or IM q 6-12 hrs. In cats: 0.5- 1 mg/kg IV or IM q6-12hr. 11. Mannitol 1-2g/kg IV over 20 minutes. Repeat Mannitol as needed every 4 hrs. CONTRAINDICATED:
Dehydration, congestive heart failure, anuric renal failure, volume overloaded, hyperosmolar condition.12. If seizures: Diazepam 0.5- 1 mg/kg IV. Phenobarbital 2-4 mg/kg IV.13. AVOID: ketamine, corticosteroids and glucose-containing solutions. 14. DO NOT treat bradycardia w/ atropine (Cushing’s reflex – decreased HR, increased BP)
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Modified Glasgow Coma Score
Motor1. recumbent, hypotonia of muscles, depressed or absent spinal reflexes2. recumbent, constant extensor rigidity, opisthotonus3. recumbent, constant extensor rigidity4. Recumbent, intermittent extensor rigidity5. Hemiparesis, tetraparesis, or decerebrate activity6. Normal gait, normal spinal reflexes
Brain stem reflexes
1. Bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes2. Unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes3. Pinpoint pupils with reduced to absent oculocephalic reflexes4. Bilateral unresponsive meiosis with normal to reduced oculocephalic reflexes5. Slow pupillary light reflexes and normal to reduced oculocephalic reflexes6. Normal pupillary light reflexes and oculocephalic reflexes
Level of consciousness
1. Comatose, unresponsive to repeated noxious stimuli2. Semicomatose, responsive only to repeated noxious stimuli3. Semicomatose, responsive to auditory stimuli4. Semicomatose, responsive to visual stimuli5. Depression or delirium, capable of responding but response may be inappropriate6. Occasional periods of alertness and responsive to environment
Prognosis Severe – <8 Moderate - 9-12 Minor - >13
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GLAUCOMAThe mannitol protocol when used for glaucoma:
2g/kg IV over 30 minutes Withhold water during and for 4-6 hours after infusion Recheck IOP 4-6 hours after giving mannitol Can repeat this once within 24 hours if response not adequate (not normalized) Poor prognosis if pressures do not normalize with mannitol
**note – concurrent uveitis makes mannitol less effective for glaucoma treatment**can use xalatan 1 drop first and recheck IOP in 15 minutes (xalatan can be continued q12-24h)
DO NOT USE XALATAN IF SUSPECT UVEITIS**Other meds to use: timolol q12h, trusopt q8h, can also add methizolamide 2-5mg/kg PO q8h
ALLERGIC REACTIONS
MILD REACTION: wheals, facial edema Bug bites, chemical contact, mild vaccine reaction Benadryl (diphenhydramine): 2mg/kg IM Dexamethasone SP: 0.1-0.25 mg/kg IV +/- SQ fluids OK for owner to continue 2mg/kg PO q8-12h of Benadryl for 2-3 days
ANAPHYLAXIS: bradycardia, hypotension, circulatory collapse, bloody diarrhea, vomiting Benadryl/Dex SP Epinephrine: 0.01 mg/kg IV (can also SQ); this less than resuscitation dose; DO NOT be afraid to give Epi since
animals in circulatory collapse may not respond quickly enough w/o it IV fluids
TRANSFUSION REACTION: Varies from mild to lethal Febrile Non-hemolytic reaction: elevation in temp by 1-2 degrees
o Slow rate of transfusion by ½ o Stop if T keeps going upo Usually does not respond to dex or benadryl
Mild reaction IgE mediated: wheals and facial edema, maybe vomitingo Stop or slow rate by ½o Give benadryl IM and DexSP IM or IV
Acute hemolytic response: Fever, hypotension, bilirubinuria, tachycardia or bradycardiao STOP transfusion!o IV fluid bolus and continued fluid supporto Based on pathophysiology it should not be responsive to steroids or benadrylo Since ALL transfused cells become hemolyzed; the patient still requires a transfusiono Most predictably seen (and fatal) in Type B cats that receive Type A blood
TRALI: transfusion related acute lung injury Characterized by increased pulmonary capillary permeability Appears as non-cardiogenic pulmonary edema on radiographs Usually happens w/in 6 hours of transfusion Can resolve w/ time and O2 Tx
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HEPATIC ENCEPHALOPATHYSupportive Care
Question: Is your patient mentally alert enough to be treated with PO meds? If not, then start with IV and rectal meds.
If severely affected: Lactulose enema
o 0.5-1.0 ml/kg diluted 1:3 with water. This can be repeated q6h or as needed IV Fluids (in theory should avoid LRS; but is OK to use as IVF choice) Monitor BG and electrolytes Antibiotics:
o Neomycin: 22 mg/kg q8h POo Metronidazole: 7.5-10 mg/kg q12h IV (or PO); PO preferred for local control of GI urease-producing
bacteriao Ampicillin: 22 mg/kg q8h IVo If clinical signs suggestive of cerebral edema then give mannitol 1gm/kg over 20 minuteso Denosyl comes in 90’s and 225’s q24ho Vitamin K1: 2.5 mg/kg SQ, PO q24h
If stable:o Start with oral lactulose at 0.5-1.0 ml/kg PO q8h (increase dose until stools are soft) and Neomycin at 22 mg/kg q8h
PO o OK Diets for liver patients: k/d; l/d; Purina NFo Denosyl, Marin are adjunctive pro-liver medications
o Denosyl (SAMe) Up to 12 pounds (5.5 kg): one 90 mg tablet 12 to 25 pounds (5.5-11 kg): two 90 mg tablets (or one 225 mg tablet, if more convenient) 25 to 35 pounds (11-16 kg): one 225 mg tablet 35 to 65 pounds (16-29.5 kg): two 225 mg tablets 65-90 pounds (29.5 kg-41 kg): three 225 mg tablets
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Hepatic Lipidosis
Enteral support: quality and quantity (corner stone of Tx) Protein goal: 33-45%; (fat: 44-66%); avoid excessive CHO Iams Max calorie, Hill’s a/d, m/d, Purina DM, Clinicare Clinicare—needs omega 3 FA added Feed RER (at least); start feeding 1/3 RER on day 1; 2/3 on day 2; 3/3 on day 3 Monitor for re-feeding syndrome (there is a re-feeding blood panel)
o Low phosphorous, potassium and magnesium IV lipids if can’t get in a NE tube; or lipids in conjunction w/ NE tube
Medical Tx: L-carnitine: 250-500 mg/cat/day N acetyl cysteine (Mucomyst): 140mg/kg IV bolus; then 70 mg/kg IV q8-12h SAMe (once can take PO meds): 18 mg/kg PO q24h B vits (Cobalamin): 4mL B-complex per 1 L fluid (usual protocol is 2mL/1L)
o 250 mcg SQ often necessary Vitamin K: 0.5-1.5 mg/kg repeated 3 times at 12h intervals Vitamin E: 10 IU/kg/day Ursodeoxycholic acid (Actigal): 10-15mg/kg PO q24h
Helpful hints: Avoid dextrose IVF; in theory would want to avoid LRS (but in reality is OK IVF choice) Anesthesia medications to avoid—
o Oxymorphone, ketamineo Diazepam, etomidate (contain 35% propylene glycol—hemolysis)
Safe anesthesia protocols—o Butorphanol (0.05 mg/kg) w/ mask inductiono Fentanyl 5 mcg boluso Propofol 5mg/kg to effect (recent research shows that this actually fine)
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EMESIS
ASPCA Animal Poison Control Hotline: 1-888-426-4435
1. Induction of emesis in DOGS: Apomorphine: Start w/ ¼ tab for small dogs; ½ tab for big dogs (may need a whole tab). Place
in conjunctival sac. Should work w/in minutes. Rinse w/ saline when vomiting starts. Rinse thoroughly.
Premed dose of IM morphine often times works. Hydrogen peroxide (3%): 1-2ml/kg PO for up to three doses. If the patient does not vomit
within 15 minutes, give again at 0.25 ml/lb
2. Induction of emesis in CATS: Xylazine: 0. 44-1.1 mg/kg IM or SQ (can reverse with yohimbine 0.1 mg/kg IV)
In the surgery lockbox is large animal concentration; needs to be diluted for small animals CCU has also NO Apomorphine or Ipecac for cats Hydrogen peroxide: 1-2 mL/kg PO up to 3 doses
o Can cause GI bleeding in cats
Emetics are contraindicated in animals that are already vomiting, hypoxic, dyspneic, in shock, lack normal pharyngeal reflexes, seizuring, comatose, CNS-depressed, or in patients who have ingested strong alkaloids and petroleum products. Also rabbits and rodents.
Emetics generally remove about 80% of stomach contents. They should be followed with activated charcoal (30-60ml/10lbs) PO. [Consider an antiemetic after you have rinsed out/reversed the emetic, so the charcoal will not be aspirated!] If you mix the charcoal with a/d, a few animals will just eat it; this is much easier that forcing or tubing. In organophosphate or carbamate toxicosis, repeat charcoal q 4 hours.
Consider giving an osmotic or saline cathartic 30 min after activated charcoal (toxiban). Ex: sorbitol 3ml/kg PO
Animal Poison control is your friend! Invoice a call into SS. Gastric lavage:
o Sedate and intubate, place in lateral recumbency, pass a pre-measured stomach tube (this should remind you of decompressing a GDV dog)
Infuse warm water, 5-10ml/kg, through tube to moderately distend stomach, then allow fluid to drain (**Bread dough toxicosis: use cold water to stop active yeast**)
Turn patient to other side, continue infusing and draining until stomach is clear. Administer activated charcoal down tube, crimp and remove. Make sure patient is awake enough to guard airway, or leave the ET tube in.
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Toxicity
Basic idea is get them to vomit, activated charcoal to prevent further absorption, diurese with IVF (especially with NSAIDs), reverse what you can. Depending on what it is, heart rate, resp rate and BP monitoring might be indicated.
Poison Control 1-888-426-4435Chocolate toxicity:
Type of chocolate Caffeine (mg/oz) Theobromine (mg/oz)Baker’s 47mg 390-450mgSemi-sweet 22mg 130-138mgMilk 6mg 44-60mgWhite 0.85mg 0.25mg
Quick and dirty chocolate toxicity: 1oz/10# (milk); 1oz/3# (dark); 1oz/1# (baker’s)
Clinical signs: Caffeine: vomiting, restlessness, tachycardia, +/- arrhythmia, tachypnea, hyperthermia, tremors or seizures
o Reabsorbed thru bladder wall (IVF w/ walks q4h) Theobromine: vomiting, diarrhea, hyperactivity, hyperthermia, hypertension, bradycardia or tachycardia,
arrhythmia (esp VPCs), tremors or seizures Mild signs (>20 mg/kg); moderate (>40 mg/kg); severe (>60 mg/kg) LD 50 = 100-200 mg/kgTreatment: Decontamination
o Emesis if ingestion was w/in 2 hourso Gastric lavageo Activated charcoal—especially important b/c of the long half life in dogs
Symptom targeted treatmento Diazepam for tremors or seizureso Antiarrhythmic pathologic tachycardia (HR >200)
Β-blocker for sinus tachycardia HR > 200 (0.02 mg/kg propanolol PRN; can go up to 0.06 mg/kg every 20 minutes)
Lidocaine or procainamide for ventricular tachycardiaso Treat volume status before reaching for anti-arrhythmic agents!
Prognosis: Excellent if treated early Guarded if clinical signs cannot be controlled Fatal if massive ingestion left untreated
Amphetamines: Adderol type drugs DO NOT GIVE VALIUM!! USE ACEPROMAZINE!!
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Emesis and Charcoal
Apomorphine (conjunctival sac)Charcoal: 10 mL/kg PO
Anzemet SQ before giving +/- SQ fluids
Lilies (Easter, Tiger, Stargazer, Day, and Oriental) : All parts of the plant are toxic, and almost always fatal Toxic dose: only a few leaves Clinical signs: referable to ARF, polyuria progressing to oliguria/anuria and signs of renal failure
(vomiting/lethargy) Treatment: aggressive IVF/ u-cath (consider transferring to Tufts for dialysis if indicated), guarded
prognosisWhat to tell owners:
o Easter lily ingestion within 6 hours:- With emesis and fluid support, very good chance will not proceed into renal failure.- Will be in hospital for minimum 2-3 days.
o Easter lily ingestion >18 hours- Most likely will develop ARF if not in it already
o If ARF develops with normal urine production:- 50% chance will make it out of hospital- Expect 1-3 weeks in hospital.- Expect CRF
**Peace lily and Calla lilies are not nephrotoxic, but will cause GI irritation**
Permethrin Toxicosis: most common: Top Spot, Hartz, Biospot- in feline Clinical signs: generalized tremors Treatment:
o Bathe with mild dish detergent (Dawn or Palmolive)o Tremor control:
Methocarbamol (Robaxin) 50mg/kg PRN (can give up to 330mg/kg in 24 hours) Administer ½ dose rapidly (not to exceed 2ml/min) Give to effect (cat will relax; then give until desired effects)
Diazepam: 0.5- 1mg/kg IV for treatment of seizures. DO not exceed 4 mg/kg/DAY Pentobarbital: 2-4 mg/kg IV q6h Intubation with isoflurane may be necessary until activity is controlled
Supportive care:o Fluid and nutrition supporto Maintenance of normal body temperature.
Rodenticide: Vitamin K Antagonists: Warfarin, Brodifacoum, Bromodiolone, Diphacinone
Antagonism of factors II, VII, IX, X Clinical signs:
o May take 12-48h to appearo Cavitary/joint/GI hemorrhage/epistaxis
Diagnosis: Hx/signs; prolonged PT/PTT (PT prolonged first due to short ½ life of Factor VII Treatment:
o For non-clinical suspected or witnessed ingestion, induce emesis. If productive may choose to NOT give Vit K and have pet recheck PT in 48 hours. Otherwise treat for time outlined below:
o If pet is actively bleeding—give plasma (20 mL/kg), stabilize as needed Recheck PT/PTT after each plasma transfusion until normal, start vit K Continue orally at home for time outlined below. Recheck PT 48h after last vitamin K
doseo Vitamin K: Loading dose 5mg/kg SQ; followed by 2.5 mg/kg split q12h PO
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Phytonadione (oral vitamin K): 2.5 mg/kg PO q24h for 30d Pharmacy can compound as a liquid
o Duration of Tx: Warfarin—14 days Bromodiolone—21 days Diphacinone, Brodifacoum—30 days
Bromethalin—Diphenylamine neurotoxin Minimum lethal dose: Dogs: 2.5 mg/kg; Cats: 0.45 mg/kg Clinical signs
o Signs develop b/t 4h to 72 depending on amount ingestedo Signs can be non-specific: depression, anorexia, vomiting, tremorso Neuro signs vary: paresis, paralysis, hyperexcitability, tremors, hyperreflexia, seizures, death
Treatmento Decontamination
Emesis if ingestion < 60 minutes Activated charcoal w/ sorbital q4-8h for at least 2-3 days
Monitor Na+o Supportive care: directed at controlling clinical signs
Treating for cerebral edema Methocarbomal or diazepam for tremors Seizure control of choice
o Prognosis Dependent on severity of clinical signs Even mild signs can take up to 2 weeks to resolve
Cholecalciferol—vitamin D3 Minimum toxic dose: 0.5-3.0 mg/kg Pathophysiology: increases Ca++ and P levels Clinical signs
o Signs can be non-specific and include anorexia, vomiting, weakness, PU/PD, and mental dullness
o Renal failure: can occur w/in 24-48 hours w/ acute severe ingestion Diagnosis
o Hx and clinical signso Hypercalcemia, hyperphosphatemia, azotemiao Need to rule out the other reasons for hypercalcemia
Treatmento Decontamination
Emesis for known ingestion < 1 hour Activated charcoal w/ sorbital q6-8h for 48 hours
o Treat hypercalcemia Diuresis w/ 0.9% NaCl Furosemide 5 mg/kg IV bolus; then 5 mg/kg/h CRI or 2-4 mg/kg q12-8h IV, SQ, PO Prednisone 1-2 mg/kg q24h PO Phosphate binders Pamidronate 1-2 mg/kg IV over 24h (works quickly 24-48 hours)
Prognosiso Good if treated early and/or if hypercalcemia resolveso Soft tissue mineralization is almost irreversible and carries a guarded prognosis
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Acetominophen Minimum lethal dose: Dogs: 100 mg/kg; Cats: 60 mg/kg Clinical signs
o Dogs: referable to liver necrosis, nausea, vomiting, anorexia, depression Can also have methemoglobinemia, conjunctival swelling/facial edema
o Cats: referable to methemoglobinemia, cyanosis, ‘chocolate blood’, dyspnea, pigmenturia, facial edema (can also have hepatic necrosis at high doses)
Diagnosiso Hx and clinical signs (esp in cats)o Heniz bodies may be prominento NOVA Co-oximetry panel; <5% methemoglobin is normal; >30% MetHb poor Pxo Liver enzyme elevations; esp ALT and AST
Treatmento Decontamination—emesis and activated charcoalo Antidote: N-acteylcysteine (Mucomyst)
Provides cysteine for glutathione synthesis Dogs: 280 mg/kg IV or PO; then 140 mg/kg q4h for 3 days Cats: 140 mg/kg IV or PO; then 70 mg/kg q6h for 3 days
o Adjunctive Tx O2 Tx of limited value b/c metHb cannot bind O2 Blood transfusions only if patient has severe anemia, otherwise risk of volume overload
once the MetHb is corrected Denosyl—precursor to glutathione Cimetidine—p450 inhibitor—slows down metabolism of acetaminophen
5-10 mg/kg q6-8h Vitamin C—aids in conversion of MetHb to OxyHb
Simply add vitamin C as a Tx in fluids (nurses will do this) Monitoring with Co-oximetry—measure on presentation; then q24h during Tx; then 24h after last
Mucomyst treatment Prognosis
o metHb >30 % on Co-ox panel carries guarded prognosiso depends on onset of Tx and how sick the patient is on presentationo hepatic damage may take weeks/months to heal (if ever fully)
Anticholinesterase—organophosphate and carbamate Sources: commercial insecticides, some deworming products Minimum lethal dose: highly variable; can be as low as 1 mg/kg Clinical signs
o Can occur w/in 30 minutes after acute ingestion and predictably w/in 12h Neuron signs: mild—muscle weakness, depression
severe—tremors, ataxia, seizures Respiratory failure: bronchoconstriction and increased bronchial secretion
Diagnosiso Hx and clinical signso May see hypokalemia and hypermagnesemia
Treatmento Supportive care; +/- ventilatory supporto Pralidoxime chloride 2PAM
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o Anticholinergic—atropine
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Ethylene Glycol Minimum lethal dose: Dogs: 4.4-6.6 mL/kg; Cats: 1.5 mL/kg Clinical signs
o Stage I: CNS dysfunction: 30 min-12 hours post ingestiono Stage II: cardiac and pulmonary dysfunction: 12-24 h post ingestion
Tachycardia, tachypnea due to acidosis Increasing hypocalcemia
o Stage III: Renal failure: > 24 h post ingestion Oxalate crystals are deposited in renal tubules
Diagnosiso Hx and clinical signso EtGly test: tests only presence of EtGly and not the metabolites (not useful in Stage II or III)o CaOx crystalluria after 6 hours of ingestion—monohydrate crystalso Severe normochloremic metabolic acidosis (high AG); occurs w/in 3 hourso Renal failure
Treatmento Decontamination—emesis if 1-2 h since ingestion; gastric lavage 2-4 ho Antidotes
20% EtOH: alcohol dehydrogenase has higher affinity for EtOH than EtGly Dogs: 5.5 ml/kg IV q4h for 5 doses; then q6h for 5 doses Cats: 5 mL/kg IV q6h for 5 doses; then q8h for 4 doses Can use total dose as CRI over 48 hours
4-methylpyrazole (questionable efficacy in cats) 20 mg/kg loading dose; then 15 mg/kg at 12 and 24 hours; then 5 mg/kg at 36
hours If started soon enough, dogs can have almost full recovery in 24 hours after
initiation of 4-MP treatmento Dialysis—hemodialysis or peritoneal dialysis
Prognosiso Good for dogs treated w/in 8h of ingestion w/ 4-MPo Good for dogs and cats treated w/in 3h of ingestion w/ EtOHo Bad if renal failure is present at the time of diagnosis
NSAID Any NSAID including rimadyl, deramaxx, piroxicam, ibuprofen (particularly toxic) can cause
idiosyncratic liver toxicity (but usually associated w/ renal and GI signs) Ibuprofen toxic dose
o Dogs: 50 mg/kg GI signs, abdominal discomfort >150 mg/kg renal toxicity >400 mg/kg CNS signs, seizures, coma
o Cats: twice as sensitive as dogs Monitoring
o Baseline CBC/chemistry (at least a renal panel in $$ cases)o Q48h renal monitoringo +/- urinary catheter for ins and outs (if azotemic on presentation)
Treatmento Aggressive diuresis 2-3x maintenance minimumo GI protectants: misoprostol, carafate, pepcid/protonix
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Xylitol Sugar substitute (found in sugar-free candy, gums and other products) that promotes insulin release
cause severe hypoglycemia or hypokalemia. Can also cause hepatic necrosis Monitoring
o Monitor BG for the first 24 hourso Baseline liver values and 12-24h post ingestion
Treatmento Emesiso No activated charcoalo +/- dextrose supplementationo +/- liver protectants
Calculating CRIsNeed to know:-dose of drug-weight of pet in kg-rate of infusion (mL/h)-# hours the bag will last (at calculated rate)
Calculate dose in mg/hr: ex. 0.5 mg/kg/h x 10kg = 5 mg/hCalculate number of hours the bag will last at given rate = 500 mL bag at 10 mL/h will last 50 hoursCalculate the mg to add to bag: ex. 5mg of drug x 50h = 250mg drug in 500mL bag at 10 mL/h
Common CRI rates:Fentanyl (50mcg/mL): 3-8 mcg/kg/hMorphine (15 mg/mL): 0.1-0.2 mg/kg/hKetamine (100 mg/mL): 5-20 mcg/kg/min (higher intra-op, then taper post-op)Lidocaine (20 mg/mL): 50 mcg/kg/minLasix (50mg/mL): 0.25-1.0 mg/kg/h for heart failure, 0.1-0.66 mg/kg/hr for ARFDopamine (40 mg/mL): 5-20 mcg/kg/min (lower for Tx of anuria; higher for pressor support)Dobutamine (12.5 mg/mL): 2-10 mcg/kg/min (start slow, increase hourly as needed)Norepinephrine (1 mg/mL): 0.1-0.2 mcg/kg/minEpinephrine (1 mg/mL): 0.1-0.5 mcg/kg/minProcainamide (100 mg/mL): 25-50 mcg/kg/minPropofol (10 mg/mL): 0.1 mg/kg/min (anesthesia is often maintained at 0.4 mg/kg/min)Na nitroprusside (25 mg/mL): 1-10 mcg/kg/minFenoldopam (10 mg/mL): 0.5 mcg/kg/min (cat dose)
See compatibility book to see if these medications are light sensitive
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MLKM 0.1 mg/kg/hL 50 mcg/kg/minK 5 mcg/kg/min
Hypertonic SalineWe carry 7.2% hereProvides quick intravascular volume expansion w/o giving much volume due to the pull of the hypertonic solutionGive alone lasts 20-30 minutes; given with HES lasts 2-3 hoursGreat for resuscitating previously healthy normovolemic, hydrated patients (patients w/o pre-existing electrolyte changes)
HBC Hemoabdomen Trauma w/ obvious head injury (increased ICP) Arterial bleed Pulmonary contusions ‘High rise’ cats
3-5 mL/kg hypertonic saline followed by 5 mL/kg HES or (4 mL/kg hypertonic saline / 10 mL/kg HES)Hypertonic saline should not be given faster than 1 mL/kg/minute
Free Water Deficit Calculation
Wt (kg) x 0.6 x [(patients Na+/ normal Na+) – 1]
Replace deficit over 18-24 hours w/ hypotonic fluid (half strength saline of D5W). Usually use in combination with isotonic crystalloids to maintain intravascular and interstitial volume. Hypotonic fluids will shift into intracellular space, not good for intravascular volume expansion. For chronic dysnatremias do not decrease sodium more than 0.5 mEq/L/hr.
Osmolality Calculation: = 2(Na+) + (glucose/18) + (BUN/2.8)
Fluid Type Sodium Content (mEq/L)
Osmolality (mOsm/kg)
0.9% NaCl 154 308
LRS 130 312
Norm-R 140 296
0.9% NaCl 154 308
LRS 130 312
Norm-R 140 296
Colloid OSMOTIC Pressure
Normals: Cats 24.7 +/- 3.7 Dogs 19.95 +- 2.1
Requires whole blood in a green top tube.
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Contraindications: Dehydration Increased Na Hyperosmolar conditions (DKA) Renal failure CHF
FLUID RATES
CrystalloidsSQ dose: 20 mL/kg, about 100mL/10#Maintenance: few different formulas
60 mL/kg/d Dog (mLs/d): BW(kg)0.75 x 132; Cat (mLs/d): BW(kg)0.75 x 90 Puppy: 90-100 mLs/kg/d 100-120 mL/kg/d (rabbit)
Shock dose 90 ml/kg (dog); 40-60 mL/kg (cat) !!Tritrate to clinical response!!
Surgery maintenance 5-10 mL/kg/h
ColloidsHetastarch 6% in NaCl
5-10 mL/kg/d (cat) 10-20 mL/kg/d (dog) Reduce rate of crystalloids by ½ to 1/3
Pentastarch: dogs only: same dose as Hetastarch
Blood productsFresh whole blood: 1 unit ~450mL (dog); ~50-60 mL (cat)
20 mL/kg (dogs and cats) Emergency donors are listed in blood bank
Packed RBCs: 1 unit ~325mL (dog); ~25-30 mL (cat) 10 mL/kg over 0-4 hours Dogs OK to give more than 10 mL/kg if actively bleeding Aim for PCV > 25%
Fresh frozen plasma: 1 unit ~250-260 mL (dog); ~25 mL (cat) 10-20 mL/kg over 1-4 hours
Cryoprecipitate—DOGS only 1 unit/10 kgs Factor VIII, vWB, fibrinogen
Platelet concentrate—DOGS only (Frozen—must be thawed slowly) 1 unit/10 kg 1 unit ~100 mLs
Oxyglobin—hemoglobin glutamer (bovine) 10-15 mL/kg over 4 hours (dog) 5 mL/kg over 4 hours (cat)
Indications for Crossmatch Patient had a transfusion over 3 days ago or at any point in life Research shows every cat should ideally be cross matched even the 1st time Patients that autoagglutinate may not be able to be blood typed
Transfusion reaction: See all allergic rxn notes
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Low-Volume Fluid resuscitation
Hypertonic saline 4 mLs/kgHetastarch 5mLs/kg
Re-assess+/- start IVF
Reducing crystalloids for HES
HES: 10 mLs/kg – reduce by 40%15 mLs/kg – reduce by 50%20 mLs/kg – reduce by 60%
Basic CPR Instructions
Closed Chest CPR: Assess for breathing, heartbeatRespiratory arrest: intubate and begin manual ventilation @ 12 breaths/minCardiac arrest: begin chest compressions @ ~100 compressions/min (or more)Attach and assess ECG
Asystole -- epinephrine, atropine, repeat after several minutes. May try vasopressin (instead of the 2nd dose of epie). Do not defibrillate
Bradycardia – atropineVentricular fibrillation – defibrillate, vasopressin +/- magnesiumVentricular tachycardia – lidocaine or procanamide or sotalolPulseless electrical activity - vasopressin or epinephrine. Do not defibrillate
Address underlying disease process.
Open Chest CPR: indicated in lg dogs; dogs w/ pleural and pericardial disease(there should be an open chest CPR pack in CCU that includes instruments, rib spreaders, and vascular clamps)
Right lateral recumbencyVery quick clip & prepIncise skin of 5-6th intercostals spaceCut through intercostals muscles with scissors. Try to avoid the internal thoracic vessels ventrally. Halt
respirations while incising pleuraUse rib spreader to gain visualizationCut pericardial sac along apex to avoid the phrenic nerve. Exteriorize the heart Compress heart -apex to base. 60-80x/min (or more)Ventilate every 5th compression
Defibrillation: Do not give lidocaine if you plan to defibrillate because it increases your defibrillation thresholdExternal defib
3-5 Joules/kg (Plunket: 2 J/kg for under 7kg, 5J/kg for 8-40 kg and 5-10 J/kg for >40kg)Defib 2-3 times before resuming manual CPR, repeat defib at higher charge the next rnd
Cats and small dogs: 50 JMedium dogs: 100 JLarge dogs: 200J
Internal defib1-2 Joules/kgDefib; return to chest compressions; check rhythm after 60 seconds; repeat defib
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Atropine 1 mL/20#Epi 0.1 mL/20#
Drug Dosages:Atropine: 1ml/20# (0.04mg/kg)Calcium Gluconate: 0.5-1.5 ml/kg (dilute 1:1 with NaCl)Dopamine: 5 –15 mcg/kg/min (start at 10 for pressor support)Diazepam: 0.5 mg/kgDobutamine: 5-15 mcg/kg/minDoxapram: 1-5 mg/kg (1-2 drops under tongue of newborns)Epinephrine: 0.1 ml/20 lbsVasopressin (20 U/mL): 0.4-0.8 U/kg (0.4mL per 20#); CRI 0.1-0.4 mcU/kg/minLasix: 2-4 mg/kgLidocaine: 2mg/kg (ie 1ml/ 20lbs)Magnesium: 0.15-0.3 mEq/kgMannitol (post-resusicitation): 0.25 g/kg (give over 20 min)Phenylephrine (10 mg/mL): CRI 1-5 mcg/kg/minNaloxone (0.4 mg/mL): 1mL per 20# (0.04 mg/kg)Amiodarone: 5mg/kg, can repeat at 2.5mg/kg
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**Double dose of atropine, Triple dose of Epie if giving IT (and give 5-10ml 0.9% NaCl to increase volume)
Bicarbonate Replacement
Indicated if HCO3- is <12 or venous pH < 7.1
Considerations prior to giving bicarbonate:o PCO2: If PCO2 > 50; correct ventilatory problem FIRSTo Hydration/volume status: try fluid bolus and few hours of fluid replacement and recheck prior to
committing to bicarbonate Txo Bicarbonate deficit in mEq = 0.3 x (WT in kg) x (23 – measured HCO3
-) o NaHCO4 solution is 1 mL = 1 mEq
Give ¼ to ½ deficit IV over 20 minutes Can add additional ¼ deficit to IVF Recheck blood gas 4-6 hours later
o Can cause paradoxical CNS acidosis
Potassium Replacement
Estimated K+ losses Serum level Suggested K+in fluids (mEq/L)
Max CRI rate(ml/kg/hr)
Maintenance 3.6-5.0 20 25Mild 3.1-3.5 30 17
Moderate 2.6-3.0 40 12Severe 2.1-2.5 60 8
Life threatening <2.0 80 6K+ supplementation should not exceed 0.5 mEq/kg/hour. Recheck electrolytes!
-from Plunkett SJ, Emergency Procedures, 2nd Ed., p.476
CALCIUM SUPPLEMENTATION
Causes of hypocalcmeia: pancreatitis, eclampsia, UO, hypoparathyroidism, ethylene glycol toxicityClinical signs: seizures, altered behavior, hyperactivity, lethargy, muscle fasiculationsDiagnosis: iCa2+ < 0.8 and patient is showing clinical signs; +/- EKG changes; then consider supplementation
How to supplement: Initially 10 % calcium gluconate given as IV bolus at 0.5 to 1.5 ml/kg, diluted 1:1 with NaCl. Use a syringe
pump. This MUST be given by a doctor. Give over 10-20 minutes. Place the patient on an ECG during the bolus. Stop immediately if there is bradycardia. A CRI at 60-90/mg/kg/day or 6.5-9.75 ml/kg/day is usually necessary if clinical signs persist If stable enough to supplement orally, you can give calcium gluconate PO at 500-700 mg/kg/day or calcium
lactate at 400-600 mg/kg/day or calcium carbonate 100-150 mg/kg/day. o Tums – calcium carbonate
Recheck blood gas or ionized calcium 1 hr after bolus, and with every 4-8 hours of CRI of Ca2+
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IMMUNOSUPPRESSIVE PROTOCOL FOR IMHA and ITP
Prednisone (can do 0.25 mg/kg Dex SP IV BID 1st day if vomiting) 4 mg/kg/day for 7 days (optional loading dose)2 mg/kg/day for 3-4 weeks1.5 mg/kg/day for 4 weeks1 mg/kg/day for 4 weeks0.5 mg/kg/day for 4 weeks0.5 mg/kg q48h for 4 weeks
Azathioprine/Imuran 2 mg/kg/day for 4-30 days2 mg/kg/day q48h until patient reaches nadir of prednisone While on Imuran, check CBC 1 week after starting treatment then q3-4 weeks. Bone marrow suppression and pancreatitis is a concern.
Cyclosporine (Neoral)2-3 mg/kg q12h for at least 8 weeks, then stop
Want a trough level of 500ng/mlTrough is measured right before next dose is due
If patient has not received glucocorticoids then can give 0.3mg/kg Dexamethasone SP; if vomiting prevents oral administration use prednisolone acetate 3mg/kg SQ q24h.
hIVIG: 0.5-1.5 g/kg infused IV over 6-12 hours; can cause hypersensitivity reactionVincristine (platelet release): 0.5-0.7 mg/m2 IV
Your choices of immunosuppresants will vary greatly depending on the patient, disease you are treating, side effects and book-in doctor. Some cases that are mild can be treated with prednisone alone and monitored for response. However we tend to treat IMHA/ITP aggressively here, to the patient’s benefit, and most cases do end up on all 3 drugs. Remember that Neoral is very expensive in large animals. This is a guideline not an absolute recipe!! Recheck red cell counts, platelet counts and liver values. You may need to change the doses. Remember to prepare owners for the nasty side effects of prednisone. Consider tapering the pred dose sooner to preserve quality of life and owner’s sanity. Talk with internal medicine clinicians about adjustments.
Other immune-mediated conditions you may see and can treat with the same drugs as above:o Immune mediated polyarthritiso Granulomatous meningocephalitis (GME)o Myasthenia graviso Polymyositis
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Anesthesia/Analgesia
Premedications: Usually given IM or SQ ½-1 hour prior to procedure. In emergency setting may be given ½ IV and ½ IM. Generally
not recommended that all is given IV due to the drastic cardiovascular consequences of sudden tachycardia and hypotension.
Use of premeds prior to anesthesia helps reduce the amount of induction drug/anesthetic gas needed to keep a good anesthetic plane and also helps w/ recovery.
Usually consists of an opioid and sedative in various combinationso Hydromorphone: 0.05-0.2 mg/kgo Morphine: 0.1-0.5 mg/kgo Buprenorphine: 0.005-0.02 mg/kgo Butorphanol: 0.2-0.4 mg/kgo Fentanyl: 1-10 mcg/kg
Sedatives include:o Acepromazine: 0.01-0.05 mg/kgo Midalzolam/diazepam: 0.1-0.5 mg/kgo Dexdomitor: 5-20 mcg/kg IM for DOG; 30-60 mcg/kg IM for CAT
give ½ dose if going IV
Induction agents: Thiopental: 10-12 mg/kg IV to effect; usually given half to effect Diazepam/Ketamine: 1 mL of 1:1 or 2:1 volume mix per 5-10 kg; this boils down to 0.3-0.5 mg/kg diazepam/3-5
mg/kg ketamine IV Propofol: 4-6 mg/kg IV to effect Fentanyl: 20 mcg/kg IV; usually preceded by 0.1-0.3 mg/kg diazepam IV Fentanyl/Propofol: 5 mcg/kg : 2-4 mcg/kg to effect
Reversal agents:If necessary, reversal should be performed either IM, or only part IV, except in an emergency. Think about your reversal before you use it. If you are reversing an analgesic drug, will there be something left in the animal’s system to provide analgesia once the drug is reversed? If not, maybe you want to only partially reverse the drug, meaning give a lower dose, giving only part of the volume, give part IV, part IM. Also, think of the half life of the reversal agent—will it outlast the drug which it is reversing? Some reversal agents are simply not worth giving with the exception of an emergency situation.
Opioid Reversal: Naloxone: 0.02 mg/kg IM, SQ, IV Butorphanol (partial reversal): 0.05-0.2 mg/kg IM, SQ, IV
Diazepam/Midazolam Reversal: Flumazenil: 0.01 mg/kg IM, SQ, IV
Alpha-2 Agonist Reversal: Atipamezole (Antisedan): 0.04 mg/kg IM Yohimbine: 0.1 mg/kg IM
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Tramadol Synthetic opioid Of most benefit when pet is already on a steroid or NSAID and pain med is needed Dose dogs only: 2-4 mg/kg q8-12h PO
Fentanyl patches (2-4 mcg/kg): Cats: 12.5 or 25 mcg patch Dogs <7 kg: 25 mcg (12.5 mcg available for very small dogs) Dogs 7-25 kg: 50 mcg Dogs 25-35 kg: 75 mcg Dogs >35 kg: 100 mcg
Intra-wound Soaker catheter Lidocaine 2 mg/kg/h; made up as a 1, 1.5, or 2% solution
o whichever gives closest to 5 mL/h infusion
Prior to extubation; load catheter w/ 1.5 mg/kg bolus bupivicaine (give slowly) 1% solution:
o Remove 125mL saline from 250mL bag (0.9% NaCl). Replace w/ 125mLs 2% lidocaine; this provides 250mL 1% lidocaine; volumes can be adjusted.
1.5% solution:o Remove 187mLs saline from 250mL bag; replace with 187mLs 2% lidocaine
GLUCOCORTICOIDS
Duration of action
(hrs)
Mineralocorticoid Activity
Anti-inflammatory
Potency
Physiologic dose**
Anti-inflammatory
dose**
Immuno-suppressive
dose**
Shock dose**
Hydrocortisone 8 1-2 1 0.8 5-10 -- 50-150Predisone Na Succinate (Solu-Delta Cortef)
12-30 1 4 0.1-0.2 0.5 2 dog2-4 cat
--
Methylpred 12-36 0.75 5 0.16 1-3 -- --Methypred Na Succinate (Solu-Medrol)
18-36 0.75 5 0.16 0.5-2 11 30-35
Dexamethasone (Azium)
36072 0 25 0.02 0.1 0.25-0.3 4-6
Dexamethasone Na Phosphate
36-72 0 30 0.03 0.1 0.25-0.3 4-6
Triamcinolone 12-36 0 5 0.16 0.05-0.2 (dog)
0.25-0.5 (cat)
2-4 --
**Doses in mg/kg/day
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Dystocia
Signs of DystociaObvious maternal illness or pain (vocalization, biting at vulva)Malodorous or profusely hemorrhagic vaginal dischargeFailure to begin labor w/in:
- 24 hours of temperature dropping below 100- 60 days since onset of diestrus- 72 days since 1st breeding
Failure to deliver neonate in:- 30-60 minutes of strong contractions- 4-6 hours of last delivery (cats can rest 24 hours between births)- 15 minutes since the fetal membrane was visible- 4 hours since placental separation (green/clear discharge)
Failure to deliver entire litter w/in 12-24 hours (24-36 for cats)
Diagnostics: Pregnancy palpable at 15-28 days in dog; 21-28 days in cat One lateral abd rad—skeletal mineralization at day 45 AUS – can fine fetal heart beats at about day 25 Ionized Ca++ and blood glucose
Treatment: Fluids Oxytocin (NOT w/ obstruction)—5-20 units/dog; 5 units/cat (given at 20-60 minute intervals) Calcium gluconate should be given if Ca++ is low; but also should be given if Ca++ is normal and multiple doses
of oxytocin have not produced neonates Ca gluconate: 60-90 mg/kg/day
Normal parameters in neonates: HR: 200; RR: 15-35; T: 96-97; by week 1-2 should be about 100 MAP: 49 mmHg at 1 month (dogs) Eyes open: 12-14 days; Normal vision: 21-28 days; Menace: 7-19 days Testes descended: 4-6 weeks (dogs) Pain reflex present at birth Lab values: Lower—RBC, albumin, BUN, CREA; Higher—WBC, Ca, P, liver enzymes and bilirubin
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GDV
Signs:Abdominal distension (usually asymmetrically), dyspnea, unproductive vomiting, gagging, pale mucus membranes,
restlessness and discomfort. Can present flat out/severe shock. Not all are large breed, deep chested dogs, bull dogs.
Diagnosis:1. Right lateral radiographs of the abdomen (good to rule-out mesenteric torsions= grave prognosis)2. Metastatic check- especially if pet older than 5 yrs of age
***** Do at least #’s 1 and 2 plus get estimate okayed before calling the surgeon
Preoperative stabilization Place large bore catheter in one or both cephalic veins (avoid using saphenous veins). DO CCP/PCV/TS/ PT/PTT Bolus up to 90 ml/kg in ¼ to 1/3 increments IV fluid (Norm- R or LRS)
o 5 mL/kg HESo Don’t stop at one bolus if resuscitation parameters are not meto EKG monitor during stabilization. Sometimes V-arrhythmias are seen; but anti-arrhythmic
therapy is not always indicated at this time Decompression (try doing once pet is more stable and has received at least the 1st dose of shock fluids)
o Can trocarize w/o sedation using 14-16 gauge needle at the height of the gastric bubble on the RIGHT side behind the last rib
o Perform if in respiratory distress secondary to abdominal distentiono You will hear a hissing sound if you are in the right place. If blood appears (possibly hit the
spleen), remove your needle and re-direct. You can place pet in lateral recumbency in order to avoid ingesta in stomach
o If ingesta seen coming out of the needle or if the gas stops coming; pull needle out. If the HR rises quickly; STOP decompressing the patient—hypovolemic shock!
Consider Lidocaine (66 mcg/kg/min) for reperfusion injury (or N-acetylcysteine) Consider MLK pre-op or intra-op Get post resuscitated lactate (prior to Sx)
Passing orogastric tube:o Hydromorphone (0.05-0.1 mg/kg) IV or Torb (0.2-0.4 mg/kg), and diazepam (0.5 mg/kg) IV or
Ketamine (5 mg/kg)/ Diazepam (0.5 mg/kg)o Keep propofol to a minimum if usedo Place an endotracheal tube—reduces risk of aspiration
o +/- iso/ sevoo Place animal in sternal position. Keep head in an elevated position when passing the tube.o Mark stomach tube with tape by measuring the distance b/t the tip of the nose and costal arch of the last ribo Place a mouth gag (a 2 inch tape roll works well)o Lubricate the tube and use the soft tip to push the tube gently into the esophagus. Too much pressure on the
tube could cause the esophagus to rupture and create an iatrogenic pneumothoraxo Once in the stomach, using a funnel and pump infuse 500mLs-1L of warm water (until runs clear; usually 3-
5x). Massage abdomen gently. Lower the head/neck and tube and place end in a bucket. Allow water and ingesta to drain from the stomach. You can gently pull tube in and out of the mouth (siphon effect) a couple of inches in order to help ingesta to flow better
o Repeat gastric lavage until fluid drains clear. Remove the tube (remember to kink it as pulling out).o If thoracic rads were not taken before because patient was too unstable, you can attempt to do them now. If
you have not called surgeon yet, do it now. Most residents live at least 40mins away from Angell so plan appropriately so animal does not have wait for surgeon very long after being decompressed.
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*****Always listen to the CCU nurses they have done this procedure may times. If you are not able to decompress pet, call surgeon or critical care doctor for advice.
*****Ket/Val or Fentanyl induction more ideal than propofol
Post-operative care:o Vitals—TPR/BP q4h initiallyo CCP/PCV/TS, +/- PT/PTT (dilutional coagulopathy is common in this situation and may require plasma)o Adequate IVF necessary (1.5- 2 times maintenance) depending on HR, RR, CRT, pulses and blood pressure.
If low TS or BP consider Hetastarch 10-20/kg/day.o Blood products as neededo Adequate pain control hydromorphone 0.05- 0.1mg/kg IV q6h; Fentanyl CRI or MLK CRIo +/- Continuous EKG monitor to assess for VPC’s or V- tach. Treatment of these arrhythmias is dependent on
multiple factors including patient’s status- if symptomatic (weak, disoriented, syncopal), increased heart rate and blood pressure.
o Indications to treat V-tach R on T Multiform PVCs Poor hemodynamic status V-tach > 160 or a spontaneous HR >280
o Gastroprotectants: Pepcid 0.5 mg/kg IV q 12h or protonix 1 mg/kg IV q24h; +/- Sucralfate 1-2g/dog q 8hrs.o NPO for 8-12 hrs post op. Start with water. If not vomiting, feed small amounts of bland food e.g. w/d every
few hrs.o If gastric resection or splenectomy were performed, patients need to be monitored very closely. Prognosis for
these cases is worse. o Other things to consider in very ill patients:
o Central line (triple lumen); arterial lineo Plasma transfusion if indicatedo Peri-operative antibiotic therapy (cefazolin, timentin, ampicillin)
Addison’s
Shock dose IVF 0.9% NaCl (90 mL/kg) Hyperkalemia—give Ca gluconate Dexamethasone SP (will not affect ACTH stim)
o 0.25-0.5 mg/kg over 5-10 minuteso Then start prednisone 0.1 to 0.22mg/kg BID (after ACTH stim performed)
+/- DOCP 2.2 mg/kg IM q25 days ACTH stim (must be <4 cortisol to be Addison’s) Na:K ratio < 26 Continue IVF w/ 0.9% NaCl +/- GI protectants +/- Dextrose in IVF Recheck electrolytes frequently !!DO NOT CONFUSE W/ RENAL FAILURE!!
o Addisonians usually have a decreased heart rate o Also check USG – should be stable or elevated with Addison’s
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If needed: Trochar R side (16-18 ga)Where you hear a ping
Hemoabdomen
Etiology: Blunt trauma secondary to HBC, getting kicked or stepped on by large animal, penetrating wounds,
rupture vessels secondary to GDV or splenic torsion, NEOPLASIA (hemangiosarcoma), warfarin toxicity, or split ligature post spay or other abdominal surgery.
Diagnosis: Shock, pale mucus membranes, weak pulses, tachycardia, tachypnea, prolonged CRT Abdomen may be distended, fluctuant or tender (R/O GDV) Abdominocentesis (4 quadrant) reveals non-clotting blood in the abdominal cavity Met check- should be performed if no history of trauma or toxicity and high index of suspicion for neoplasia Abdominal ultrasound- check for possible metastasis. If possible check chest cavity for potential metastasis
to the heart. CBC, chemistry, PT, PTT, platelets, blood type, +/- UA (no cystocentesis)
STAT: PT/ PTT and blood type If overnight do a blood smear to look for platelets
Run EKG
Treatment:1. Initial PCV/TS, compare w/ abdominal fluid PCV/TS; then monitor PCV/TS after stabilization (30-60
minutes w/ lactate as well)2. Blood pressure- repeat as needed. Make sure the BP normalizes but DO NOT be over-zealous3. IVF—start with
o Crystalloids (shock dose for dogs: 90 ml/kg, and cats: 60ml/kg). Start with ¼ to 1/3 and recheck blood pressure.
o Alternative to isotonic crystalloids is hypertonic saline: 5 mL/kg followed by 5 ml/kg Hetastarch (or 4 mL/kg hypertonic saline / 10 mL/kg HES)
o Colloids (e.g. Hetastarch) may be necessary o 5 mL/kg bolus up to 20 mL/kg
4. Administer pRBC if the PCV is less than 25 and pet appears clinical (tachycardia, tachypnea, low BP, and weak pulses)
5. Consider abdominal wrap6. Exploratory laparotomy should be performed immediately if patient cannot be stabilized.
Prognosis:~75% of hemoabdomen’s are caused by cancer and >90% of those diagnosed w/cancer have HSA. Median survival time with splenectomy alone is 3 months and w/ splenectomy and chemotherapy survival time is about 6 months w/ HSA. (Hammond TW, Pesillo-Crosby SA . JAVMA 2: 32 (4), 2008)
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Stabilize before radiology!
Diabetes and Ketoacidosis
Admission –minimum data base 1. CBC, Profile, UA + C/S, venous blood gas, stat electrolytes
2. PCV, TS, AZO, BG 3. Dipstick urine for ketones
Admission –initial treatments1. Place saphenous or jugular catheter for blood drawing and fluid administration2. Place cephalic catheter for insulin drip Note: A double or triple lumen catheter can be used in lieu of the above catheters if the patient is stable enough to have one placed. If unable to place rehydrate first with a cephalic catheter 3. Bolus IV fluids (NaCl) to address serious dehydration4. After bolus IV fluids, start fluids for maintenance needs and dehydration5. Add minimum of 40mEq KCl/liter of fluids initially (+/- more K; +/- Phosphorus)6. Antibiotics (pending UA and urine CS)7. Warm hypothermic animals aggressively8. Start a regular insulin constant rate infusion (after a few hours of IVF; usually 2-6h)
If unable to place central line/client has financial concerns then use regular insulin protocol IM (q6h)
Regular Insulin CRI instructions Rate: Cat: 1unit regular insulin/kg/24 hours
Dog: 2 units regular insulin/kg/24 hours Administration:
Take a 250ml bag of 0.9% NaCl and remove 10ml. To the remaining 240ml, addthe calculated dose of regular insulin. Start the CRI at 10ml/hr (cats and dogs). Adjust the drip based on your blood sugar results.
If you are concerned about the total fluid volume being administered can double the insulin added and half the total fluid rate. If you do this you will need to half the amount you are increasing/decreasing the insulin CRI by.
BG Insulin CRI IV Fluids>400 Increase by 2ml/hr As is250-400 Increase by 1ml/hr As is125-250 As is As is75-125 Decrease by 1ml/hr add 2.5% dextrose<75 Decrease to 2ml/hr add 5% dextrose
**Do not always have to do insulin CRI (many times financial constraints will not allow this). Establish somewhat of a BG curve and use regular insulin IM q6h (BG q6h); tailor protocol to your patient.**
Notes: 1. Once dextrose is added to the IV fluids, do not remove dextrose until the animal is eating and drinking. Adjust your insulin drip to control the increase in blood sugar.2. Do not stop the insulin drip and switch to q12h insulin until negative ketones in urine or serum and the animal is
eating regularly. 3. If the animal is becoming hypoglycemic adjust the drip downwards but never stop the drip. NEVER stop the CRI as body needs the insulin to clear ketones (even with BG is low).
Can give dextrose bolus or feed and increase dextrose CRI4. Never flush the line through which the insulin drip is running. This means that all fluid administration and blood drawing is done through the other line.
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Daily Monitoring:o TPR/6 hours (minimum) first 24 hours.o BG/3 hours via saphenous or jugular cathetero PCV/TS every 24 hourso Urine dipstick for ketones every 24 hourso Electrolytes and phosphorus daily (renal panel downstairs)
Potassium:Pay particular attention to potassium. Even if the animal’s potassium looks normal initially, they are body depleted and will drop quickly after initiating insulin therapy. This can happen in a matter of hours.
If the potassium remains refractory to treatment, consider administering magnesium. Draw a magnesium level before supplementing.
Tumil K: 2-4 mEq/cat/day q12-24h (1/4 tsp = 2 mEq)
Magnesium Administration
Supplied as 4.06mEq/ml (check bottle)Dose: up to 1mEq/kg/day as a constant rate infusion administered in D5WIncompatible w/ sodium bicarbonate, hydrocortisone and dobutamine HCl
Phosphorus:o Like potassium, body stores of Phosphorus are often low (even if they appear normal at the outset). o Consequences of hypophosphatemia are hemolysis, skeletal muscle weakness, abnormal mentation,
difficulty breathing.o If hemolysis is noted on your daily PCV/TS or your PCV is declining, check the phosphorus
immediately and consider immediate supplementation while awaiting results.
Phosphorus administration:Supplied as Potassium Phosphate 3mM/ml phosphorus, 4.4mEq/ml potassiumDose: 0.03-.06mM/kg/hr for 6-12 hours, then stop and recheck phosphorus level.Calculate for the phosphorus and then add KCl to make up for additional potassium requirements.
Nutrition:If the patient is not eating, enteral or parenteral nutrition is necessary. Enteral nutrition is preferred if the patient is not vomiting. Do not hesitate to feed the patient by either means. The patient can still be regulated while receiving PPN. Please consult with Dr Remillard for nutritional needs.
Final Note: The presence of ketoacidosis is a signal that the animal has a secondary problem. Look for the other problem!! It can be as simple as an ear infection or UTI, or worse, hepatic lipidosis, pancreatitis, cholangiohepatitis, Cushing’s etc.
Approximate cost: $5000
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Dermatology Information
COMMON ORAL DERMATOLOGY DRUGSDRUG DOSE USE OTHER NOTESCephalexin 25-30 mg/kg q
12 hAntibiotic for pyoderma
One of the cheapest skin antibiotics
Chlorpheniramine 4-8 mg/DOG q 12 h2mg/CAT q 12 h
Antihistamine See below
Clavamox 20-25 mg/kg q 12 h
Antibiotic for pyoderma
Skin dose is higher than the UTI dose
Clindamycin 9-11 mg/kg q 12 hr
Antibiotic for pyoderma
Good choice especially for methicillin-resistant Staph
Convenia 8 mg/kg SQ or 0.045 ml/pound SQ
Antibiotic for pyoderma
Use only for pets that won’t take oral medications(lasts for 2 weeks)
Hydroxyzine 1-2 mg/kg q 8-12 hr
Antihistamine See below
Ketoconazole 5 mg/kg every 24 hr
Antifungal for yeast Do NOT use with high dose avermectins (ivermectin, milbemycin oxime, selamectin)
Prednisone 0.5 mg/kg q 24 hr for dogs1 mg/kg q 24 hr for cats
“Anti-Itchy” dose for dogs and cats
Some cats don’t respond well to prednisone, consider using another steroid. There is a STEROID CALCULATOR online (Google it) to help you calculate other steroid dosages.
Simplicef 5-10 mg/kg q 24 hr
Antibiotic for pyoderma
Fewer GI side effects than cephalexin
*Antihistamines work best for mild itching or before a severe allergy flare-up.*Malaseb, Chlorhexiderm, Oxydex or Etiderm shampoos can treat mild superficial pyodermas or can be used with an oral antibiotic. Superficial pyodermas should be treated for 3-4 weeks or 1 week beyond resolution of signs.*Malaseb pledgets or shampoo can treat mild Malassezia dermatitis or can be used with an oral antifungal. Use an oral antifungal like ketoconazole for severe Malassezia dermatitis or Malassezia dermatitis that is hard to treat topically.*Shampoo 1-2x a week. Educate clients about contact time and GIVE CLIENTS THE TOPICAL THERAPY HANDOUT.
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COMMON EAR MEDICATIONSEAR MEDICATION
INGREDIENTS WHEN TO USE
Conofite
Clotrimazole
Miconazole
Clotrimazole
Otitis externa fungal
Otomax Clotrimazole, gentamicin, betamethasone
Otitis externa fungal or bacterial (cocci or when small number of rods with little ear debris)Can be ototoxic
Tresaderm neomycin, dexamethasone, thiabendazole
Ear mitesOtitis externa fungalOtitis externa bacterial (cocci only)
Baytril otic Enrofloxacinsilver sulfadiazine
Otitis externa bacterial (rods)
Epi OticOticalm
Variety Ear cleaning 1-2x a week to minimize otic debrisGIVE CLIENTS THE EAR CLEANING HANDOUT
*Always recommend recheck ear cytology! Recheck ear cytology in 2-4 weeks.
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ExoticsBirds:Enrofloxacin 15mg/kg IM once, then 15mg/kg PO q 12hrsMetronidazole 50mg/kg PO q 12hrsDoxycycline 25 mg/kg PO q 12 hrs for 45 daysFluconazole 10mg/kg PO q 12 hrsItraconazole 10mg/kg PO q 24 hrs, African grey 5mg/kgDiazepam 0.5-1mg/kg IM/IVCaEDTA 30mg/kg IM undiluted or SQ diluted in NaCL q 12hrs for 5 days. Diurese concurrently and treat with MgSO4 PO q 12hrs to prevent further absorption of lead from GICagluconate 50-100mg/kg IM/SQ q 12hrsSQ fluids 25ml/kg SQ q 12 hrsCrop feeding: Kaytee Exact 25 ml/kg PO q 6-12 hrsMeloxicam: 0.2mg/kg BIDBuprenex: 0.02-0.05mg/kgSQ/8
Bleeding bird: iron dextran 10 mg/kg and SQ fluids
Rabbits:GI stasis:Cisapride 0.5mg/kg PO q 8-12 hrsMetoclopramide 0.5mg/kg PO q 6-12 hrsSimethicone 0.5-1 ml per rabbit PO q 6-12 hrsSQ fluids 100-120ml/kg/day divided q 8 hrsBuprenorphine 0.02-0.05mg/kg IM q 8 hrsCritical Care Herbivore 15ml/kg PO q 8 hrs
NO PROPOFOL!! (Apnea)Pre-med: Midazolam 0.5 mg/kg IM Butorphanol 0.2 mg/kg IMPost-op: Buprenorphine 0.04 mg/kg IM
Enrofloxacin 10mg/kg IM once then PO q 12 hrs Pen G 50.000-80.000 IU/kg SQ q 24 hrsThrimethroprim/Sulfa 30 mg/kg PO q 12 hrsChloramphenicol 50 mg/kg PO q 8-12 hrsAlbon 50 mg/kg PO once, then 25 mg/kg PO q 24 hrs for 10-20 daysMetronidazole 10 mg/kg PO for 14 days (Clostridium diarrhea)Oxybendazole 30 mg/kg PO q 24 hrs for 30 days (E. Cuniculli)Meclizine 2-12 mg/kg PO q 24 hrs (antitorticollis)Meloxicam 0.5mg/kg PO q12h; 7 days
Guinea Pig: Vitamin C 50-100mg/pig SQ q24
Ferrets:Insulinoma: Prednisone 0.25-0.5 mg/kg PO q 12 hrsDiazoxide 5-30 mg/kg PO q 12 hrs (if pred alone is not enough)Frequent feedingsHelicobacter protocol:Famotedine 0.5 mg/kg PO/IV q 24 hrsAmoxicillin 20 mg/kg PO/SQ q 12 hrsMetronidazole 10-20 mg/kg PO q 12 hrsSucralfate 125 mg per ferret PO q 6 hrs if melenaMonitor PCV if melenaProstatomegaly secondary to adrenal DZ
Lupron 0.1-0.2 mg/kg IM q 4 weeksOxyglobin 11-15 mg/kg over 4 hrsMeloxicam 0.2 mg/kg PO q24h, always give Famotidine with
Reptile:Very helpful website: Melissa Kaplan http://www.anapsid.org/Ceftazaidime dose: 20 mg/kg IM or SC q72hours – FRONT LEG ONLY
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Ferret insulinoma hypoglycemia
0.25-2.0 mLs Dextrose (50%) IV
Sedation:Buprenex 0.01-0.05 mg/kg and
Midazolam 0.3-0.1 mg/kg
RABIES PROTOCOLMANAGEMENT OF DOGS & CATS EXPOSED TO WILDLIFE
(Raccoon, skunk, fox, bat, woodchuck or any carnivorous wild animal)Exposure Category I f Dog or Cat is
Currently VaccinatedIf dog or cat isNOT Currently Vaccinated
Category 1Direct contact with or visible bite from a confirmed rabid animal(includes eating viscera)
1. Booster Immediately2. Notify local director of healthand local animal inspector3. Strict Confinement for 45 days
1. Euthanize, or2. If owner unwilling:a. Notify local director of healthand local animal inspectorb. Isolate for 3 months followedby 3 months strict confinementc. Vaccinate 1 month prior to release
Category 2Direct contact with or visible bite from a suspect rabid animal(includes eating viscera) which is unavailable for testing
1. Booster Immediately2. Notify local director of healthand local animal inspector3. Strict Confinement for 45 days
1. Euthanize, or2. If owner unwilling:a. Notify local director of health and local animal inspectorb. Strict confinement for 6 monthsc. Vaccinate 1 month prior to release
Category 3Wound of unknown origin suspected to be caused by another animal(e.g. cat abscesses)
1. Booster Immediately2. Notify local director of healthand local animal inspector3. Strict Confinement for 45 days
1. Euthanize, or2. If owner unwilling:a. Notify local director of health and local animal inspectorb. Strict confinement for 6 monthsc. Vaccinate 1 month prior to release
Category 4Exposure by proximity seen near or in close proximity to a confirmedrabid animal (no contact or wounds)
1. Booster Immediately2. Notify local director of healthand local animal inspector3. Strict Confinement for 45 days
1. Vaccinate immediately2. Notify local director of health and local animal inspectorb. Strict confinement for 6 months
Always wear gloves when handling saliva-contaminated wounds or fur.Always advise owner of rabies risk.Veterinarians must inform the local animal inspector of any potential rabies contact cases seen at their offices1. Do not vaccinate any unimmunized dog or cat in categories 1, 2 or 3.Timing of vaccination should follow above schedule2. If most recent rabies vaccination was administered within one month, it is not necessary to booster.3. Dog or cat should be examined by a veterinarian to assure there are no wounds.
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RABIES PROTOCOLMANAGEMENT OF DOGS & CATS EXPOSED TO OTHER DOMESTIC ANIMALS
(Wolf Hybrids and other exotic pets are considered to be wild animals)Exposure Category Exposed Dog or Cat is Currently Vaccinated Exposed Dog or Cat is NOT currently
vaccinatedCategory 1Visible bite or scratchfrom another domesticanimal which has beenavailable for quarantineidentified and
1. Notify local director of health and local animal inspector2. Biting animal will be placed under strict confinement for 10 days3. A) If biting animal is healthy at the end of 10 days, victim is not at risk for rabies 3. B) If the biting animal begins to exhibit signs compatible with rabies, biting animal should be euthanized and submitted for rabies4. A) If test results are negative, victim is not at risk for rabies4. B) If test results are positive,1. Booster victim immediately2. Notify local director of health and local animal inspector3. Strict confinement by owner for 45 days
1. Notify local director of health and local animal inspector2. Biting animal will be placed under strict confinement for 10 days3. A) If biting animal is healthy at the end of 10 days, victim is not atrisk for rabies - Vaccinate victim3. B) If the biting animal begins to exhibit signs compatible with rabies, biting animal should be euthanized and submitted for rabies4. A) If test results are negative, victim is not at risk for rabies, vaccinate victim4. B) If test results are positive,1. Notify local director of health and local animal inspector2. Euthanize, or Isolation for 3 months followed by 3 months strict confinement - vaccinateat 5 months
Category 2Visible bite or scratchfrom another domesticanimal which has NOT been identified and is NOT available for quarantine
1. Booster victim immediately2. Notify local director of health and local animal inspector3. Strict confinement by owner for 45 days
1. Notify local director of health and local animal inspector2. Strict confinement by owner for 6 months – vaccinate at 5 months
Any non-domestic animal biting a human needs to be reported to the Department of Public Health Protocol for ferrets is similar, but notification must be made to the Division of Fisheries and Wildlife Do not vaccinate any dog or cat which is under a 10-day quarantine Any animal euthanized while under a 10-day quarantine MUST be submitted for rabies testing If most recent rabies vax was within 30 days, it is not necessary to re-vaccinate
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RBC MORPHOLOGY AT-A-GLANCE
Morphology Appearance Significance & Assoc, Disease ConditionsRouleaux RBCs stuck together like
stack of coinsCan be normal in cats. Increased fibrinogen or increased globulins as in inflammation or lymphoproliferative disorders.
Agglutination Clumping of RBCs Immune mediated anemia; esp. IgM typePolychromasia Bluish erythrocytes Regenerative anemiaAnisocytosis Variation in RBC
diameterOccurs when macrocytes or microcytes are present.
Hypochromasia Increased central pallor Iron deficiency anemiaPoikilocytosis Abnormal shaped RBCs Common in cats; severe iron deficiency
anemia; oxidant injury; adriamycin toxicity; or dyserythropoiesis.
Echinocytes Evenly spaced spicules of similar size
Usually an artifact; also hypophosphatemia; rattlesnake envenomation; blood transfusion; uremia, PK deficiency; glomerulonephritis; neoplasia.
Acanthocyte Irregularly spaced spicules of variable size
Liver disease, RBC fragmentation disorders such as DIC, GN or hemangiosarcoma
Stomatocyte RBCs with a mouth Artifact; hereditary in Alaskan malamutes and schnauzers.
Schistocyte RBC fragments Microangiopathy-DIC, iron deficiency, liver disease, heart failure, GN, hemangiosarc., myelofibrosis, splenic disease.
Keratocyte Intact or ruptured vesicles on edge of RBC
Iron-deficiency anemia; liver disease; adriamycin toxicity; microangiopathy, MDS
Spherocyte Small, round, dense, lack central pallor
IMHA, iron deficiency, zinc tox, RBC parasites, bee sting, snake envenomation, transfusion of stored blood, fam. dyserythr.
Target cell and other leptocytes
Thin and floppy with folds or targets
Iron-deficiency anemia, liver disease, congenital dyserythropoiesis.
Eccentrocyte Hb poor area at edge Oxidant injury- onions, tylenol, Vit KHeinz bodies RBCs with noses Oxidant injury – large HBs; Cats can have
small HBs in diabetes, hyperthyroidism, lymphoma; also normal cats.
Ovalocyte Elliptical in shape Dogs – hereditary, GN, myelofibrosis, MDS; cats w/ bone marrow disease (ALL, myeloprolif), hepatic lipidosis, PSS, adriamyciin toxicity.
Dacrocytes Teardrop-shaped GN, hypersplenism, myeloproliferative ds.Basophilic stippling
Blue stippling due to ribosomes
Regenerative anemia; lead toxicity
Siderocyte Clustered blue dots- iron Lead tox, hemolytic anemia, drugs, dyserythropoiesis, myeloproliferative ds.
Howell-Jolly Nuclear remnant Regen. anemia, splenectomy; roids, vincrist.
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Vaccination protocol
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Flea/Tick Preventative
Active IngredientsLife cycle of
flea Any other parasites Formulation Side Effects Notes
Advantage Imidacloprid Larvae, Adults Lice Spot-on excessive salivation
Stays in epidermal lipid layerMinimal age dogs – 7 weeks, cats - 8 weeks
AdvantixImidacloprid, Permethrin Larvae, Adults
Ticks, mosquitos, Lice, ?Chyletiella Spot-on
Toxic in Cats; Permethrin washes off quickly (tick control not a month) +UV degrades Minimal age dogs – 7 weeks
Advantage-MultiImidacloprid, Moxidectin Larvae, Adults
Heartworm, mites (scabies), hookworms, roundworms, whipworms Spot-on
Not a good Tx for demodexMinimal age dogs – 7 weeks, cats – 9 weeks
Biospot (OTC)Permethrin, Methoprene Larvae, Adults Ticks, mosquitoes
Spot-on, spray, dip, collar Permethrin toxic to cats
Capstar Nitenpyram Adults No, Maggots? Tablet Safe
80min dog; 40min catsMinimal age dogs/ cats – 4 weeks, 2+ lbs
Flea Busters (OTC)
Boric acid (powder); surfactant (shampoo) eggs; adults No
Powder, shampoo
Sprinkle on carpet + vacuum - good 1yr
Frontline Fipronil Adults Lice, Chyletiella, ?Scabies Spray, Spot-on Toxic in Rabbits
Stays in sebacious glands - doesn't work w/sebacious adenititis
Frontline PlusFipronil; S-Methoprene
Larvae, Adults, Eggs Lice, Chyletiella, ?Scabies Spot-on Toxic in Rabbits
Stays in sebacious glands - doesn't work w/sebacious adenititisMinimal age dogs and cats – 8 weeks
Knockout Spray (OTC, Angell)
Permethrin, Pyriproxifen Larvae, Adults Lice, Chyletiella, Cockroaches Spray Toxic in Cats
(Program)/SentinelLufenuron / Milbemycin
Eggs (flea birth control)
Heartworm, hookworms, roundworms, whipworms
Tablet, Injectible q6m feline product None
3-4 mo until max efficacyMinimal age dogs – 4 weeks, cats - 6 weeks
Revolution Selamectin Adults, eggs Heartworm, mites, ticks Spot-on Caution in collie breeds
Resistant to bathingMinimal age dogs/ cats – 8 weeks
Preventic CollarAmitraz (Ticks only) Ticks No Collar Toxic if ingested
Heartworm, FLEA/TICK PREVENTATIVE SUMMARY
Heartgard Plus
Heartgard Plus (cats)
Interceptor Sentinel Revolution Frontline Plus Advantix Program Preventic
Approved for cats NO > 6 wks old NO NO > 6 wks old; or >5 lbs
> 8 wks old NOTOXIC
> 6 wks old NO
Approved for dogs > 6 wks old NO > 4 wks; or >2 lbs
> 4 wks; or > 2 lbs
> 6 wks old; or > 5 lbs
> 8 wks old > 7 wks old > 6 wks old > 12 wks old
Length of effectiveness 1 month 1month 1 month 1 month 1 month 1 month for ticks;3months for fleas
1 month 1 month 3 months
Method of Adminstration
Chewable Chewable Chewable—given w/ food
Chewable—given w/ food
Topical Topical Topical Chewable—given w/ food
Collar
HWP YES YES YES YES YES NO NO NO NO
Roundworm YES NO YES YES CATS ONLY
NO NO NO NO
Hookworms YES YES YES YES CATS ONLY
NO NO NO NO
Whipworms NO NO YES YES NO NO NO NO NO
Kills ticks NO NO NO NO DOGS ONLY
YES YES NO YES
Kills adult fleas NO NO NO NO YES YES YES NO NO
Kills flea larvae NO NO NO NO NO YES YES NO NO
Sterilizes flea eggs NO NO NO NO YES YES YES YES NO
Safe for pregnant pets YES YES YES YES YES NO NO YES NO
DEWORMING
Whipworms Tapeworms Roundworms Hookworms Giardia Coccidia OtherPyrantel pamoate (Strongid)
Toxacara canis/leonina
Ancyclostoma caninum; Unicinaria stenocephala
Physaloptera
Fenbendazole (Panacur)
Trichuris vulpis
Taenia pisiformis
Toxacara canis/leonina
Ancyclostoma caninum; Unicinaria stenocephala
Yes Capillaria; Filaroides; Paragonimus
Praziquantel (Droncit)
Dipylidium caninum; Taenia pisiformis
Echinococcus granulosis
Ivermectin (Heartgard)
Higher doses Higher doses Higher doses Dirofilaria immitis; Capillaria
Milbemycin(Revolution)
Trichuris vulpis
Toxacara canis
Ancyclostoma caninum
Dirofilaria immitis; Demodicosis
Metronidazole YesSulfadimethoxine (Albon)
Isospora
Strongid 1 mL/20# once; then repeat in 3 weeksPanacur 50mg/kg or based on weight q24h for 3- 5 days; then
repeat in 3 weeksAlbon 50 mg/kg once, then 25 mg/kg once daily for 2-3
weeksRevolution Sarcoptic mange: once q2 weeks; 3 doses
200mcg/kg PO SQ Ivermectin once a week for 3 weeks
