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k J.T. Vaughan Equine Conference Small Animal I Small Animal II Farm Animal Pharmacy
8:00
a.m
.
Welcome, Dean Calvin Johnson;
7:55-8:00 a.m.
Advanced Diagnostic Imaging in Equine Ophthalmology
8-8:50 a.m.McMullen, DVM
Mast Cell Tumors8-8:50 a.m.Matz, DVM
Welcome, Dean Calvin Johnson
8:55-9:00 a.m.
Food Animal Neurology: Neurologic Exam & Lesion Localization
8-8:50 a.m.Washburn, DVM
9:00
a.m
. Management of Hindlimb Gait Abnormalities
9-9:50 a.m.Caldwell, DVM
Wound Management & Bandaging9-9:50 a.m.Matz, DVM
Cats Are Not Dogs When it Comes to Dentistry
9-9:50 a.m.Bellows, DVM
Food Animal Neurology: Case Discussion
9-9:50 a.m.Washburn, DVM
10:0
0 a.
m. Neurologic Examination:
Choosing the Appropriate Diagnostic Test10:10-11 a.m.Mora, DVM
Feline Cardiomyopathies I: HCM Update 2020
10:10-11:00 a.m.Anderson, VMD
25 Surprising Hacks to Improve Your Dental Practice
10:10-11:00 a.m.Bellows, DVM
Welcome, Dean Calvin Johnson;
10:05-10:10 a.m.
FAMACHA: No it’s Not Spanish! 10:10-11:00 a.m.Washburn, DVM
Opioid Use and Control10:10-noonDuran, RPh
& Miller, RPh
11:0
0 a.
m. Lymphoma in Horses:
What We Know & Don’t Know11:10-noon
Groover, DVM
Feline Cardiomyopathies II: The “Other” Cardiomyopathies &
Treatment Controversies11:10-noon
Anderson, VMD
Demystifying Intraoral Radiology 11:10-noon
Bellows, DVM
Downer Bovids11:10-noon
Washburn, DVM
12:0
0 p.
m.
BREAK FOR LUNCH
1:00
p.m
. Equine Gastric Ulcer Syndrome (EGUS): Why is it Such
a Pain in the Gut?1-1:50 p.m.
Sanchez, DVM
Welcome, Dean Calvin Johnson;
12:55-1:00 p.m.
Systemic & Pulmonary Arterial Hypertension in Dogs & Cats
1-1:50 p.m.Anderson, VMD
Recognizing & Approaching Early Chronic Kidney Disease
1-1:50 p.m.Langston, DVM
Updates in the Standards of Failure in the Transfer of Passive Immunity
(FTPI) for Dairy & Beef Calves1-1:50 p.m.
Chamorro, DVM
* Florida Drug Dispensation &
Veterinary Pharmacy Laws & Rules1-4:00 p.m.Duran, RPh
& Miller, RPh
2:00
p.m
.
Equine Wound Management2-2:50 p.m.
Reyner, DVM
Canine Myocardial Disease 2-2:50 p.m.
Anderson, VMD
Don’t Let Hyperphosphatemia be Carved in Stone
2-2:50 p.m.Langston, DVM
Vaccination of Dams During Gestation or Early Vaccination of Calves:
Alternatives to Reduce BRD Preweaning
2-2:50 p.m.Chamorro, DVM
3:00
p.m
.
Three Critical Concepts for Utilizing Mare Assisted
Reproductive Technologies in Your Reproductive Practice
3:10-4:00 p.m.Lyman, DVM
ECGs for People in a Hurry3:10-4:00 p.m.
Anderson, VMD
Special Aspects of Chronic Kidney Disease:
Anemia & Hypertension3:10-4:00 p.m.
Langston, DVM
Spermiogram: The Good, the Bad, & the Ugly 3:10-3:35 p.m.Waters, DVM
Using the Intratesticular Route to Anesthetize Small Ruminants for Castration
3:35-4:00 p.m.R. Stockler, DVM
4:00
p.m
.
Burn Injury in Horses4:10-5:00 p.m.Hanson, DVM
Canine Degenerative Valve Disease: What Could
Possibly be New?4:10-5:00 p.m.
Anderson, VMD
Treating Chronic Kidney Disease4:10-5:00 p.m.
Langston, DVM
Maternally-Derived Antibodies Protect Young Beef Calves Against Experimental
Challenge with BRSV4:10-4:35 p.m.Martinez, DVM
Parasitic Otitis in an Adult Barzona Bull4:35-5:00 p.m.
Malmstrom, DVM
5:00
p.m
.
AWARDS RECOGNITION Bailey Distinguished Alumni, El Toro, and Vaughan Equine Achievement Awards
5-5:30 p.m.
2020 Annual Conference ScheduleThursday, October 22
= Sponsored by Royal Canin= Sponsored by Boehringer Ingelheim = Sponsored by Merck Animal Health = Sponsored by Seminole Wellness
* available in live format only, not included in on demand sessions
Trac
k J.T. Vaughan Equine Conference Small Animal I Small Animal II Farm Animal Technician Wellness
8:00
a.m
. Neurolocalization & the Differentials it Suggests,
Straight from the Horse’s Mouth
8-9:25 a.m.Wooldridge, DVM & Jukier,
DVM
Evidence-Based Decision-Making in Equine
Joint Disease 9:25-9:50 a.m.
Boorman, BVetMed
Proteinuria & Protein-Losing Nephropathy
8-8:50 a.m.Langston, DVM
Trichomoniasis Rule Change in Alabama8-8:50 a.m.
Frazier, DVM &Edmondson, DVM
Welcome, Dean Calvin Johnson;
7:55-8:00 a.m.
Non-Traditional Approach to Pain Management
8-8:50 a.m.Hodson, LVT
SOS: Saving Ourselves So We Can Save Others
(Compassion Fatigue)8-9:20 a.m.
Hulon, DVM
Resiliency: Thriving Beyond
Surviving9:30-10:50 a.m.
Hulon, DVM
9:00
a.m
. Fluid Therapy & Diuretics in Kidney Disease
9-9:50 a.m.Langston, DVM
Trace Mineral Challenges & Diagnostics in Beef Cattle
9-9:50 a.m.Tracy, DVM
Case Study: Conservative Management of Osteoarthritis
9-9:25 a.m.Hodson, LVT
Case Presentation: Water Works9:25-9:50 a.m.Streicher, VTS
10:0
0 a.
m. Synovial Sepsis:
Diagnosis & Treatment10:10-11:00 a.m.
Boone, DVM
Acute Uremia10:10-11:00 a.m.Langston, DVM
Colostrum Replacers: How & When to Use Them
10:10-11:00 a.m.J. Stockler, DVM
Nursing Care of the Traumatic Brain Injury Patient
10:10-10:35 a.m.Harris, DVM
Cardiopulmonary Resuscitation: Basic Life Support10:35-11:00 a.m.
Sender, DVM
11:0
0 a.
m. Industry Updates 2020:
What Happened? What’s Next?
11:10-noonSellers, MBA
Leptospirosis: An Update11:10-noon
Langston, DVM
Surgical Catheter Placement in Porcine Patients
11:10-11:35 a.m.Kennedy, DVM & Maxwell, DVM
Current Understanding of BVDV in Heterologous Hosts: Swine Edition
11:35-noonKennedy, DVM
Cardiopulmonary Resuscitation: Advanced Life Support
11:10-11:35 a.m.Henricksson, DVM
Post-Arrest Care of the Recently Resuscitated Patient
11:35-noonHung, DVM
Brain Biology 91111:10-noonHulon, DVM
12:0
0 p.
m.
BREAK FOR LUNCHNOON-1:00 P.M.
1:00
p.m
. Equine Abortion: How to Approach an Abortion in the Field
1-1:50 p.m.Johnson, DVM
* Management of Feline idiopathic Cystitis: Diet, Drugs & the
Environment1-1:50 p.m.
Westropp, DVM
Probiotics/FMT/Microbiome 1-1:50 p.m.
McMichael, DVMEvaluating Beef Cattle Lameness
1-2:50 p.m.Warner, DVM
Preventing the #1 Small Animal Disease
1-1:50 p.m.Bellows, DVM
2:00
p.m
. Updates on the Treatment of Respiratory Disease in Horses
2-2:50 p.m.Lascola, DVM
* Canine & Feline CaOx Urolithiasis2-2:50 p.m.
Westropp, DVM
Geriatric ECC Medicine2-2:50 p.m.
McMichael, DVM
Making Self-Care a Priority, Avoiding Compassion
Fatigue & Burnout2-2:50 p.m.Turner, LPC
3:00
p.m
.
Approach to Fever of Unknown Origin
3:10-3:35 p.m.Pfeifle, DVM
Renal Disease: What’s New?3:35-4:00 p.m.Kimura, DVM
* Diagnostics & Treatment for Canine UTI & Subclinical Bacteriuria
3:10-4:00 p.m.Westropp, DVM
Pediatric ECC Medicine3:10-4:00 p.m.
McMichael, DVM
Diagnosing & Treatment of Reproductive Injuries in
the Beef Bull3:10-4:00 p.m.Warner, DVM
Osteoarthritis in Small Animals: Tools for Monitoring Response to
Management 3:10-4:00 p.m.
McCarthy, BVSc
4:00
p.m
.
Regional Limb Perfusions in Horses
4:10-4:35 p.m.Zetterstrom, DVM
Diagnosis & Treatment of Equine Asthma: What’s New?
4:35-5:00 p.m.Ceriotti, DVM
* Canine Urinary Incontinence: Treatment
for the Leaky Dog4:10-5:00 p.m.
Westropp, DVM
Fun with Hypertonic Fluids4:10-5:00 p.m.
Kuo, DVM
Common Reproductive Problems Seen in Beef Cow Production
4:10-5:00 p.m.Warner, DVM
Emergency Triage & Stabilization Procedures
4:10-5:00 p.m. Zaccardi, CVT & Price, VTS
2020 Annual Conference ScheduleFriday, October 23
= Sponsored by Purina Pro Plan Veterinary Diets = Sponsored by Merck Animal Health = Sponsored by Seminole Wellness
* available in live format only, not included in on demand sessions
= Sponsored by Elanco
Trac
k
J.T. Vaughan Equine Conference Small Animal I Small Animal II Farm Animal
8:00
a.m
. The Colic Examination: Is There Anything New?
8-8:50 a.m.Bain, DVM
Juvenile Imaging of the Young Lame Canine Patient
8-8:50 a.m.Biller, DVM
Avoiding the Floodgates of Fluid Overload in Small Animal Patients
8-8:50 a.m.Gerken, DVM
Renal Dysfunction of Farm Animals8-8:50 a.m.
Washburn, DVM
9:00
a.m
. Critical Care in the Field: Case-Based Discussion
9-9:50 a.m.Bain, DVM
Interpretation of Thoracic Radiograph Involves More Than the Lungs & Heart
9-9:50 a.m.Biller, DVM
The Great Debate on Synthetic Colloids9-9:50 a.m.
Gerken, DVM & Kuo, DVM
Anemia: Disease & Treatment9-9:50 a.m.
Washburn, DVM
10:0
0 a.
m.
Update on Pain Management Options I10:10-11:00 a.m.
Taintor, DVM
Imaging of Gastrointestinal Obstruction10:10-11:00 a.m.
Biller, DVM
ER Menagerie I: Anything New?10:10-11:00 a.m.
Gerken, DVM & Kuo, DVM
Caseous Lymphadenitis in Small Ruminants10:10-11:00 a.m.Washburn, DVM
11:0
0 a.
m.
Update on Pain Management Options II11:10-noon
Taintor, DVM
Old Radiographic Techniques Revisited11:10-noonBiller, DVM
ER Menagerie II: Anything New?11:10-noon
Gerken, DVM & Kuo, DVM
Small Ruminant Case Discussions11:10-noon
Washburn, DVM
12:0
0 p.
m.
EVENT CONCLUSION
2020 Annual Conference ScheduleSaturday, October 24
= Sponsored by Merck Animal Health
1
Non-Traditional Approaches to Pain Management
Liz Hodson, BS, LVT, CCRP
Auburn University College of Veterinary Medicine
1220 Wire Road, Auburn, Alabama 36849
334-321-8515
Abstract-
This presentation will cover non-pharmacological options for pain management. Typically, pain is treated or managed with a combination of medications including NSAIDs and opioids. But there can be a risk of side effects that can compromise a patient’s overall health. A patient may not tolerate NSAID therapy though the effects of inhibiting inflammation are needed to decrease pain perception. We are going to examine non-traditional or non-pharmacological methods to aid in pain management. These techniques can be used in conjunction with pain medications to achieve a multimodal approach to pain management.
There are numerous non-pharmacological options to manage pain available including: thermal modalities, massage therapy, therapeutic laser, therapeutic ultrasound, electrical stimulation, extracorporeal shockwave, targeted pulsed electromagnetic field therapy, and acupuncture. The physiological effects and mechanisms of action will be discussed, as well as the indications and contraindications.
Key Words- Multimodal pain management, thermal therapies, massage, laser, acupuncture
This presentation will cover non-pharmacological options for pain management. Typically, pain is treated or managed with a combination of medications including NSAIDs and opioids. But there can be a risk of side effects that can compromise a patient’s overall health. A patient may not tolerate NSAID therapy though the effects of inhibiting inflammation are needed to decrease pain perception. We are going to examine non-traditional or non-pharmacological methods to aid in pain management. These techniques can be used in conjunction with pain medications to achieve a multimodal approach to pain management.
There are numerous non-pharmacological options to manage pain available including: thermal modalities, massage therapy, therapeutic laser, therapeutic ultrasound, electrical stimulation, extracorporeal shockwave, targeted pulsed electromagnetic field therapy, and acupuncture. By combining modalities and medications we are able to treat pain more effectively using a
2
Thermal modalities cover both cold and heat applications. They act in different ways and are used at different times, but they both help reduce pain.
Cryotherapy or icing as most of us call it, is often used after surgery. It is a superficial treatment meaning we place the ice pack in a towel on the skin and allow the cold to penetrate the body. The cooling effects only penetrate 1-4 cm of tissue depth and the depth depends on the adipose layer and blood supply. For this reason, cryotherapy is more efficient on distal limbs than on the truck of the body. When applying ice, you typically are going to treat the area for 10-20 minutes for maximum cooling but you need to be sure you are checking the temperature and color of the skin.
What are the physiological effects of cryotherapy and how do they translate into pain management? Cryotherapy causes vasoconstriction. When the blood vessels constrict, blood flow to the area decreases and since there is the vessels are technically smaller, pressure on nociceptors is decreased and that decreases pain. The vasoconstriction also aids in decreasing the edema of the surrounding tissues. Because there is less blood supply coming into the tissues, cryotherapy decreases enzyme-mediated tissue damage by minimizing the release of histamine and also slows the metabolic rate of the surrounding tissues. With the metabolic rate of the tissues slowed, the reaction rate related to acute inflammation also slows. Cryotherapy also decreases nerve conduction velocity, so pain signals in the area that are iced don’t get through as quickly. Because the nerve conduction is slowed and pain doesn’t travel as quickly through the nerves, it provides analgesia.
The analgesic response is medicated by the peripheral nervous system. The nerves in the limbs send signals to the brain to signal pain. Because the cold receptors in the area being iced are overstimulated and the nerve conduction is decreased, the pain signal is stopped at the spinal level and does not reach the brain. The term for this theory is Spinal Gate Control Theory of Pain Transmission. With the slowed signal conduction and the decreased metabolic rate of the tissues being iced, the refractory period of the cells increase and they are unable to transmit a pain signal for longer periods of time. The increased refractory period and slowed nerve conduction also allow for a decrease in reflexive muscle spasms. With fewer or weaker muscle spasms in the surrounding tissue, pain is reduced.
There are three physical mechanisms of cryotherapy which allow us to apply cryotherapy in various ways to reach our goal of decreasing pain. Conduction is the most commonly used mechanism in veterinary medicine. Typically ice packs, ice massage, or cold compresses are used. A good example of this is icing a limb or incision after surgery. Another mechanism is convection. An example of convection is an ice bath. This is not something we tend to do is veterinary medicine because it isn’t the most pleasant experience. The third mechanism is evaporation. A vapo-coolant spray is applied directly to the skin and heat is reduced in the area through evaporation. We don’t tend to use this in veterinary medicine because of the fur.
There are many reasons to use cryotherapy. Icing is used during the acute pain phase of soft tissue injuries. The acute pain phase is the first 72 hours following an injury. Icing an incision following surgery
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is an example of icing during the acute pain phase. It is also used to decrease edema to traumatized area. This occurs because of vasoconstriction. Cryotherapy can be used to help decrease pain in joints that is caused by chronic osteoarthritis. When there is osteoarthritis in a joint, there is a constant low-grade inflammation that causes pain and the ice helps to decrease the inflammation in the joint and slows the transduction of the pain sensation. Ice can also be used following physical rehabilitation to help with decreasing inflammation caused by exercise.
When applying cryotherapy there are some precautions that need to be taken. You should be very careful using ice on patients with cardiac conditions or high blood pressure because of the vasoconstriction that is induced. Also care should be use when applying ice to open wounds because the vasoconstriction can damage the delicate capillaries in the area. And when icing an area with superficial nerves, ice will not need to be applied as long since the nerves are closer to the skin and there is less insulation to protect the nerves. There are contraindications for cryotherapy that include cold hypersensitivity and altered skin sensation. It is possible to cause frost bite if you do not monitor the temperature and color of the skin appropriately.
The other thermal modality is heat therapy. There is superficial heating of the skin that penetrates 2cm deep. This is usually accomplished through warm packs or rice mamas. There is also deep heating that penetrates up to 5 cm deep and typically uses therapeutic ultrasound. When applying superficial heat the treatment time is 15-20 minutes every 4 to 6 hours. It is very important to monitor the skin temperature and color when using heat to avoid burns.
The physiological effects of heat therapy are opposite of cryotherapy. Heat therapy primarily causes vasodilation. This vasodilation allows for increased blood and lymph flow in the treated area. Because there is more blood flowing into the tissues, there is increased oxygenation of the tissues and leukocyte migration is increased. Since the cells and tissues are more active the metabolic rate of the cells increases as well. The heat also provides an element of relaxation that decreases muscle spasms in the tissues. With muscle spasms released, the soft tissue is able to move more freely and the tissue becomes flexible.
Heat therapy provides analgesia or pain relief primarily through vasodilation, but there is a cascade of events that must take place first. Heat increases the activity of cutaneous thermoreceptors. The increased activity in the thermoreceptors activates a release of bradykinin and nitrous oxide which causes the relaxation of smooth muscles in the surrounding blood vessels. With the smooth muscles in the blood vessels relaxed, vasodilation occurs. The relaxation of smooth muscles also allows for decreases in muscle spasms which leads to decreases in pain. Vasodilation is also caused by decreased sympathetic output. The heat also increases sensory and motor nerve conduction velocity which allows signals to travel more rapidly to the spinal cord. Heat increases soft tissue extensibility, most notably the collagen fibers in the soft tissue. With increased extensibility, the muscle is able to maintain a stretch completed during range of motion for longer periods of time and gradually lengthens the muscle fibers.
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Like in cryotherapy, there are three physical mechanisms of heat therapy which allow us to apply heat in various ways to reach our goal of decreasing pain. Conduction is the most commonly used mechanism in veterinary medicine. We typically use warm packs or warm water hydrotherapy. A good example of this is warm packing a seroma. Another mechanism is convection. An example of convection is a warm water bath or using a hair dryer to warm a patient. The third mechanism is radiation. Using UV lights or infrared lights to heat a patient are examples of radiation.
There are many reasons to use heat therapy. Warm packing is used during subacute inflammatory phase. The subacute inflammatory phase is 3-4 days following an injury. Warm packing an incision starting 3 days after surgery is an example of warm packing during the subacute inflammatory phase. Heat therapy can also be used to help relieve pain caused by chronic inflammation. The heat allows for vasodilation which brings more nutrient rich blood into the tissues and aids in relaxation. The relaxation of the smooth muscles also decreases muscle spasms that may be present. Heat is also beneficial following traumas such as sprains, strains, and myositis. The increased blood flow allows migration of cells needed to repair the damaged tissue. Another reason to use heat therapy is in cases of decreased joint range of motion. When a joint is unable to move in a normal manner, the supporting soft tissues become less extensible and are unable to stretch in properly. By heating the muscles, we are able to increase the extensibility of the collagen fibers in the muscles, allowing for a more complete stretch.
When applying heat therapy there are some precautions that need to be taken. You should be very careful using heat on patients that are pregnant. Also use caution in patients with cardiac insufficiency or impaired circulation because of the vasodilation that is caused by heat therapy. Patients that are extremely obese are sometimes unable to properly regulate their body temperature and caution should be used in these patients. Care should also be used in patients suffering from bursitis or tendonitis. These conditions benefit more from the application of cryotherapy. There are a number of contraindications for heat therapy which include: active hemorrhage (the application of heat would increase blood flow to the area), acute inflammation (cryotherapy should be used during the acute phase), thrombophlebitis or embolism (vasodilation would be detrimental to the patient’s overall health and wellbeing), or altered sensation to the skin (heat packs can cause serious burns if not monitored properly). Patients with malignancies or infection should not receive heat therapy due to the increased circulation in the area and the migration of cells in and out of the area being heated. Also, if a patient is febrile, the use of heat would only increase the patient’s temperature leading to a more serious or longer lasting fever.
Another approach to managing pain is the use of massage therapy. Massage therapy is a manual therapy that combines manipulation of soft tissue and stretching. It is beneficial to incorporate range of motion into a massage to allow increased stretching of the soft tissues surrounding joints. There are many benefits and physiological effects of massage therapy including increasing lymph and blood flow and maintaining soft tissue extensibility. It causes a natural release of endorphins which decreases anxiety and tension and increases relaxation.
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Massage is not just gently rubbing on a muscle, there are a number of techniques use for different tissue conditions to gain the desired results. It is important not to overwork the muscle because it can become bruised or sore to the touch.
Stroking is a technique that involves rubbing your hands on the animal moving from neck to tail. This allows you to assess the soft tissues and muscle tone. This is completed at the beginning of a massage and allows you to find specific areas of tension to focus on during the massage with other techniques.
Effleurage is a technique that involves working from the distal limb proximally. This aids in decreasing swelling and aids in drainage by using gentle pressure on the limb to manually move toxins towards lymph nodes. This technique is useful if a patient has swelling of the lower limb following surgery.
Petrissage is a technique used for deep tissue massage. It involves using kneading or wringing motion and skin rolling. This technique is used to compress underlying tissues.
Compression is a technique used to increase muscle tone is some muscles, typically the triceps and deltoids. In other muscles it is used to decrease muscle tone by increasing circulation in the tissues. To perform this technique, using the heel of your hand apply direct and constant pressure to the muscle belly and hold the pressure for 15 seconds. This can be repeated several times but do not overwork the muscle.
Holding and placing is a technique used to increase local circulation and relaxation in muscles that are in spasm. To complete this technique a hand is placed over the muscle that is in spasm and hold your hand there for several seconds. This traps heat in the specific muscles being covered.
Percussion is a clapping, hacking, or pounding a muscle using a cupped hand. This technique is used in areas of muscle weakness. It increases relaxation and generalized circulation.
There are two targeted massage therapies that are used for specific soft tissue issues. Trigger point therapy is one. A trigger point is a knot in the muscle, much like a tension knot in people often get in their necks. To complete this therapy, isolate the knot in the muscle. Place your fingers on either side of the knot and apply firm pressure to the knot and hold for 20 seconds. Release the knot for 10 seconds and repeat this 3-4 times. You can typically feel the knot melt away. If you have a knot in your neck you can easily try this on yourself.
The other targeted massage therapy is deep transverse friction massage or cross friction massage. This technique is less comfortable than other massage techniques. It is used to decrease scar tissue formation within the muscle. To complete this technique, massage at a 90 degree angle to the muscle belly, like strumming a guitar string. Complete ten strokes for 3-4 repetitions. After completing the strokes, finish with a gentle massage. It is important to not over work the muscle with this technique.
There are many indications for massage. It can be used: in patients with mechanical or postural changes due to compensatory injury following injury or surgery, to decrease scar tissue formation, or in patients with fatigue or muscle soreness. Massage aids in decreasing muscle tone and tension. It can be used in patients with low-grade inflammatory conditions like osteoarthritis or when an increase in blood flow is needed. It is also used frequently in canine and equine athletes to help in recovery following
6
completions and to improve their athletic performance. It is important to allow at least two hours between a workout and completing a massage.
There are also reasons for a patient not to receive a massage. If a patient is in shock it do not perform massage on a patient because it can lower the blood pressure further. Also, avoid massage in patients with a fever or acute inflammation or infectious disease because of the increase in circulation caused by massage. Patients with acute viral disease like Herpes should not receive massage because of the increased in circulation and decreased blood pressure. And if a patient has dermatologic condition do not massage them because of the possibility of introducing bacteria to the area, or spreading the bacteria to broken skin.
Therapeutic laser or photobiomodulation is a modality used to aid in pain management. It aids in modulating cellular function using light waves. There are Class 3b and Class 4 therapeutic lasers that vary in strength. The class 4 lasers are stronger and take less time to deliver the prescribed amount of Joules to the tissue. The wavelength of the laser determines how deep the energy is able to penetrate. There are superficial neurons within the treatment depth allowing the energy to act on the neurons and stimulate the physiologic effects.
There are many physiological effects including vasodilation and inhibition of inflammation. There is an increased release of endorphins and enkephalins leading to a decrease in pain. Photobiomodulation also promotes nerve recovery and wound healing through modulating cellular function and increasing blood flow to the area allowing for migration of cells and nutrients to the area being treated.
The exact mechanism of action of laser therapy is unknown. It is thought that laser therapy can influence pain perception either directly or indirectly by acting on nociceptors and modulating inflammation. It may suppress central sensitization resulting in a long-term depression of persistent pain with repeated treatments. On this case it is thought that if you continue to treat an area the effects of pain reduction will last longer between subsequent treatments. It also appears that sensory nerves are preferentially affected which causes inhibitory effects on pain receptors causing pain reduction.
There are many indications for therapeutic laser therapy. It is used for wound management to decrease healing time. It aids in pain management and decreases inflammation and edema. It often used for osteoarthritis and the pain associated with osteoarthritis. Because of the effects on nerve healing, it can be used in cases of neurologic dysfunction like degenerative myelopathy and nerve injury. It can be used for post-operative incision care as well as soft tissue injuries.
While there are many uses for therapeutic laser, there are contraindications and precautions that should be considered when deciding treatment options. Therapeutic laser should not be used in patients with neoplasia or open growth plates in puppies or open fontanels. A concern using laser in neoplasia patients is that it could possibly spread cancerous cells. Using laser in puppies or kittens can cause premature closure of growth plates. Laser should not be applied to pregnant abdomens or near eyes. The laser can cause blindness if the beam is direct towards the eye. Because the laser is a heat source, caution should be used when patients have dark skin, tattoos, or are taking medications that cause photosensitivity. It is also important for the patient and anyone in the area should wear special protective eyewear when the laser is in use. The laser should be applied in a grid pattern with the head constantly moving to avoid burns.
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Therapeutic ultrasound is another modality used in pain management. It is a deep penetrating heat that requires a coupling agent like ultrasound gel. Ultrasound uses one of two frequencies depending on the depth of the tissue that is being treated. A frequency of 1 mHz penetrates 2-5cm and causes enhanced cell proliferation. A frequency of 3.3 mHz penetrates 0.5-3cm. The intensity setting determines the rate of energy delivery. Typically the intensity is 0.5-5 W/cm2.
The physiological effects of therapeutic ultrasound are numerous. It increases collagen extensibility and soft tissue temperature allowing for improved stretching of the soft tissues in the limbs. Since it is a deep penetrating heat, it causes vasodilation and increases blood flow to the area being treated. It increases the pain threshold. When used in conjunction with topical anti-inflammatory drugs, it is able to drive the drug across the skin by phonophoresis.
Therapeutic ultrasound is used for musculoskeletal conditions like contracture. It is used in contracture to increase collagen extensibility allowing for more stretching and improving range of motion. It is beneficial in cases of scarring and soft tissue calcification. The frequency aids in disrupting scar tissue and calcification in soft tissue allowing muscle fibers to be manually massaged into a more normal position. It can decrease pain and muscle spasm through vasodilation. And is useful in treating subacute and chronic inflammation and wound healing.
There are many precautions and contraindications for using therapeutic ultrasound. Caution should be used when applying ultrasound over bony prominences due to a risk of burning. It is also not recommended to use during the acute inflammatory phase because of the heat and vasodilation it causes. Caution should also be used in patients with decreased circulation or sensation. It should not be used in patients with pacemakers or over the heart because it can alter the heart rhythm. It should not be used immediately after exercise or in patients with neoplasia or open growth plates because of vasodilation and premature closure of growth plates. It is very important to keep the ultrasound head moving and monitor the skin because of the risk of burning the patient.
TENS is electrical stimulation used for pain management. TENS stands for transcutaneous electric nerve stimulation. It uses low frequency (50-150 Hz) and low intensity that is gradually increased. There is no muscle contraction elicited. It is often used in humans after chiropractic adjustments. It feels like tingling or pins and needles. TENS is only used for pain control.
The physiologic effects of TENS are decreasing central sensation and primary hyperalgesia. It also causes a release of endogenous opiates leading to pain relief. TENS acts using the Gate Control Theory to provide pain relief. It stimulates faster sensory nerves with electrical impulses causing an overload of interneurons. This limits the ability of the sensory nerves to transmit pain signals to the brain. It basically causes overstimulation of the nerves and prevents pain signals from moving to the brain.
When using TENS caution should be used when applying the electrode pads in areas with decreased sensation or over sensitive skin. The pads can cause skin irritation if the patient has sensitive skin. Also be sure not to place the pads near ECG leads because it will interfere with the ECG readings. Electrodes should not be placed directly over the heart or the carotid sinus. The electric stimulation can adversely affect pacemakers and should not be used in patients with pacemakers. TENS should not be used in patients with a history of seizures and over areas of thrombosis, infection, or neoplasia.
8
Extracorporeal shockwave therapy is used in some cases for pain management. It uses radial or focused shockwaves to penetrate to deeper tissues. Radial shockwaves provide a broad field of treatment. Focused shockwaves have a more narrow field of effect. In older units heavy sedation or general anesthesia is required for administration. It can be very painful over lightly muscled areas.
The physiological effects of shockwave therapy include improving weight bearing and passive range of motion similar to using NSAIDs . It is particularly effective when used on the elbows, hips, and back. It alters nerve function in the treated areas producing analgesia. It increases cytokine and growth factor production allowing for increased healing in treated areas. It also increases endothelial nitric oxide synthase and upregulates bone morphogenetic protein expression which is why it can be beneficial in delayed union fractures.
The exact mechanism of action in Shockwave Therapy is unknown, but like TENS, it is believed that it works using the Gate Control Theory. It causes hyperstimulation of nociceptors and prevents pain signals from reaching the brain by promoting descending inhibition and modulation of sensory stimulus transmission. It also causes cell damage that prevents the membrane potentials required for signal transmission from being achieved.
Shockwave is beneficial in cases of osteoarthritis and controlling the pain associated with osteoarthritis. Because of its effects on growth factor production and bone morphogenetic protein expression, it can be used in delayed union fractures and non-union fractures. It is used in tendonopathies and ligament conditions because of the increase in cytokine and growth factor production it stimulates. It can be used in large wounds during the acute phase of the injury to aid in healing.
While shockwave therapy is beneficial in certain cases, it should be used with caution in young and developing with open growth plates. It can cause premature closure of growth plates and in some cases it can fracture small bones. It should not be used in immune mediated joint disease, infectious osteoarthritis, or diskosponylitis. Unstable fractures should not be treated with shockwave therapy because of the likelihood of displacing the fracture. It should also not be used in neurologic patients because of decreased sensation and the potential to cause injury. Never apply shockwave therapy over the lungs, heart, gravid uterus, brain or neoplasia. It is important that shockwave therapy can be painful and cause bruising and petechial over the treated areas.
Another modality used to treat pain is targeted Pulsed Electromagnetic Field therapy. A portable unit that is available through Assisi Animal Health is the Assisi Loop. It is a Non-steroidal anti-inflammatory device that is approved by the FDA. The device is placed over the area to be treated and turned on to run for 15 minutes. The treatment can be repeated up to four times a day but requires at least two hours between treatments.
The physiological effects of tPEMF include increased bone and tissue healing. It promotes ion transport across cell membranes which improves cell metabolism. It works on the Calcium ion channels and increases the binding of calcium to calmodulin leading to an acceleration in the nitric oxide cascade. It also stabilizes the intracellular calcium stores by altering formation of calcium channel proteins by decreasing mitochondrial free radicals leading to decreased inflammation.
TPEMF therapy is used to decrease pain and inflammation associated with osteoarthritis and hip dysplasia. It can also be used to decrease edema and spinal cord injuries. It is also beneficial in treating
9
pain and inflammation associated with surgery cystitis. The only contraindication associated with tPEMF therapy is pacemakers in the patient and the person administering the therapy.
Acupuncture is a modality used to manage not only pain but many other conditions. Acupuncture is traditional Chinese medicine that has been practiced for more than 2,000 years. It is used in a wide variety of animal patients, including: horses, cattle, dogs, cats, and birds, in addition to humans. There are specific acupuncture points that lie along meridians. Meridians are considered the energy channels of the body and there are 14 meridians and 361 specific acupuncture points.
The acupuncture points are stimulated by inserting needles into the points. The needles are a pointed filiform that comes in a variety of gauges. The acupuncture needles do not cut the tissue rather they separate the tissues. Inserting the needles is not typically painful.
There are many physiological effects associated with acupuncture. Stimulating acupuncture points activates A-alpha and A-beta nerve fibers causing a release of beta-endorphins. Through stimulating nerve fibers serotonins are activated and there is a release of endogenous opioids. The stimulation also activates the pain inhibitory pathway that leads to pain relief. Acupuncture also regulates blood pressure and stimulates the immune system leading to an increase in white blood cells and T-lymphocytes in circulation.
Acupuncture is used to achieve many goals to aid in the overall health is patients. It is used to release physical and emotional stress. Typically patients receiving acupuncture relax quickly and will sometimes fall asleep during their treatment. It activates and controls immune and anti-inflammatory mechanisms. It can be used to accelerate tissue healing by increasing white blood cells and T-lymphocytes in circulation and stimulating the immune system. Often times it is used for pain relief that is caused by the release of serotonin and endorphins.
There are many types of acupuncture or methods to perform acupuncture. Dry needling is the most common method. Needles are inserted into specific acupuncture points and allowed to sit in place for 10 to 20 minutes. Moxibustion is used to activate acupuncture points through heating the points. It is performed by burning Chinese ragweed over the point with or without inserting a needle into the point. Never touch the burning moxa to the skin and caution should be used in the summer because the purpose of moxibustion is to increase the heat in the body. It should also be completed in a well ventilated area because of the strong smell associated with the smoke.
Electro-acupuncture is more effective than dry needling and is used to continuously stimulate acupuncture points for a prolonged period of time. An electrical current is delivered through the needles with the frequency and amplitude being controlled. The frequency is adjusted based on the condition that is being treated. The treatment is typically between 10 and 30 minutes. This is done in conjunction with dry needling.
Aqua-acupuncture is the process of injecting a solution into an acupuncture point to provide repeated stimulation of the acupuncture point. As the solution is absorbed, the pressure in the acupuncture point changes causing a repeated stimulation of the acupuncture point. Vitamin B12, saline, and sterile water are commonly used in aqua-acupuncture.
Hemo-acupuncture is used to release heat from the patient. A hypodermic needle is inserted into acupuncture points along blood vessels. When the patient bleeds, heat is released from the body.
10
Acupressure is a technique that does not use needles to apply pressure to acupuncture points. Digital pressure is applied to acupuncture points with five to ten minutes of constant pressure. This technique removes the need for needles and still allows the points to be stimulated. Though it is not as effective, it can still stimulate the points to gain benefits.
There are many pain conditions that are treated with acupuncture. It is used to release trigger points and musculoskeletal pain. It is beneficial in geriatric patients with chronic lameness, osteoarthritis pain, lumbosacral, cervical, and thoracolumbar pain. It can also be used for more acute conditions related to exercise injury like biceps tenosynovitis. It can also be used for pain associated with colic in horses. Caution should be used in patients that are weak, debilitated, or pregnant. It is important to start with fewer points being stimulated and build the number based on how the patient responds. Electo-acupuncture should not be used in patients with seizures and pacemakers. Patients with neoplasia should not receive acupuncture in points near the tumor.
In conclusion, when managing pain in patients it is beneficial to use a multimodal approach. By incorporating different modalities into the plan, it is sometimes possible to decrease the amount of pain medications based on the patient’s response. It is important to manage a patient’s pain to improve their overall quality of life.
References-
Huisheng Xei, Carolina Orthiz-Umpierre: Journal of the American Animal Hospital Associaltion, July/August 2006, vol. 42:244-248.
Darryl L Millis, David Levine: Canine Rehabilitation and Physical Therapy, ed. 2. Philadelphia, Elsevier, 2014.
Nuno E. O. F. Silva, Stelio P. L. Luna, et.al.:Can Vet J, September 2017, vol. 58:941-951.
Case Study: Conservative Management of Osteoarthritis
Liz Hodson, BS, LVT, CCRP
Physical Rehabilitation
Auburn University College of Veterinary Medicine
Auburn, Alabama
334-707-0515
Abstract-
This lecture is a case study of a patient with osteoarthritis that was medically managed using
medications, supplements, physical rehabilitation, and acupuncture. The case will include the
initial evaluations, physical rehabilitation plan, and outcome.
Key Words: Osteoarthritis, conservative management, acupuncture
The case that is presented is that of a twelve year old female spayed Australian Shepherd that
was diagnosed with osteoarthritis of bilateral coxofemoral joints caused by hip dysplasia and of
the left stifle. The patient had previously been treated using non-steroidal anti-inflammatories
that had caused elevated liver enzymes in the past. The owner opted to pursue conservative
management of the patient’s symptoms. The owner was interested in incorporating physical
rehabilitation and acupuncture into the management plan.
The patient presented with a two year history of weakness and stiffness in the hind limbs. The
onset of the symptoms was slow and progressive in nature and were most obvious following
prolonged rest periods or intense exercise. Initial medical management of symptoms included
the use of medications and joint supplements.
On presentation the patient’s vitals were within normal limits. A soft tissue mass was noted on
the lateral left shoulder and there was saliva staining on the fore limbs, chest, and left axilla.
The orthopedic exam revealed an abnormal gait in the pelvic limbs with a prominent hip sway.
The patient failed the sit test, she rolled to her hip instead of having a square seated position.
On palpation the left and right forelimbs had decreased carpal flexion and pain on carpal flexion.
The left pelvic limb showed decreased stifle extension with pain on tibial thrust testing and
crepitus in the stifle. There was also pain on hip extension and crepitus on left hip abduction
and iliopsoas pain. On the right pelvic limb crepitus of the stifle was palpated, pain was elicited
on hip extension and crepitus of the hip with abduction. Right iliopsoas pain was also noted.
Diagnostics were completed including a blood chemistry to recheck liver enzymes. The blood
chemistry was normal with the exception of ALK_PHOS. Sedated radiographs of the pelvis and
left stifle were performed and showed severe hip dysplasia with severe osteoarthritis of the hips
and mild osteoarthritis of the left stifle.
Following the diagnosis of osteoarthritis, a treatment plan was developed that included referral
to the physical rehabilitation service for evaluation for physical rehabilitation and acupuncture.
The patient continued taking pain medications for two weeks before presenting to the physical
rehabilitation service.
On presentation to the physical rehabilitation service a detailed history was taken and the
evaluation was completed. The patient was overweight and diet modifications were discussed.
The owner’s goals for physical rehabilitation and acupuncture were to improve the patient’s
comfort and decrease medications if able. The patient was typically active and swam daily but
her level of activity had gradually decreased.
The patient’s gait was described as having a mild truncal sway and scuffing bilateral hind feet.
There was a slight circumduction of the hind limbs with a mild lameness in bilateral hind limbs.
She also had a low head carriage. Her seated limb position was square in the hind limbs with
her weight shifted forward and her elbows were adducted. While standing, she was noted to be
cow hocked and slightly post-legged in her hind limbs. Her weight was shifted forward and she
was offloading her hind limbs.
During palpation a number of abnormalities were found. In her forelimbs decreased carpal
flexion was noted bilaterally. A medial buttress was palpated on bilateral stifles. Severe muscle
atrophy was noted in bilateral hind limbs with hair loss on caudal thighs bilaterally. There were
numerous trigger points in her neck and shoulders and pain was elicited over the lumbar region.
She was determined to be ambulatory with mild hind limb lameness and severe muscle atrophy.
Because of the distance the owner would be required to travel, an at-home exercise plan was
developed with in-hospital rehabilitation sessions to be completed twice monthly in conjunction
with her acupuncture sessions. The at-home exercise plan included leash walks, ramps, weight
shifting, sit to stands, and massage. The length of sessions and repetitions would be gradually
increased as the patient was able.
The physical rehabilitation sessions that were completed in hospital included massage, passive
range of motion, underwater treadmill, and a variety of therapeutic exercises. Acupuncture
sessions were completed at the time of physical rehabilitation sessions. To date, nine
acupuncture and physical rehabilitation sessions have been completed over six months. The
patient is currently receiving joint supplements but is no longer taking pain medications. She is
more playful and social and has increased functional ability. Her overall quality of life has
improved. She continues acupuncture and physical rehabilitation.
Following the case presentation, there will be time for questions.
1
Water Works! A case presentation of Erythema Multiforme
Missy Streicher, CVT, VTS (Dermatology)
Auburn University College of Veterinary Medicine
Abstract:
Erythema Multiforme (EM) is a cutaneous pattern stemming from a hypersensitivity reaction to a
variety of antigens that induce an immune response against the keratinocytes (skin cells). The
causative agents can be drugs, infections (viral, bacterial), neoplasia or idiopathic. Often drugs
are the instigating factor and a thorough drug history is of utmost importance when faced with an
acute onset of skin lesions. This presentation will highlight a case of Erythema Multiforme
admitted through Auburn University’s Dermatology Service, discuss cutaneous adverse drug
reaction symptoms which include EM, diagnostics, and supportive therapies to consider when
managing patients with severe skin lesions.
Keywords:
Erythema Multiforme, Adverse Drug Reaction (ADR), Cutaneous Adverse Drug Reaction
(CADR), Apoptosis
Adverse drug reaction (ADR) is an unintended effect on a patient due to use of a therapeutic
drug. In dermatology, a patient presenting with an ADR that primarily affects the skin is known
as a cutaneous adverse drug reactions (CADR). CADR occurs with variable severity and likely
occurs more commonly than reported as symptoms may be mild or since lesions may look like
other skin conditions, their appearance is discounted as a flare up of the previously noted
condition. CADR may also be referred to as drug eruption, drug allergy or dermatitis
medicamentosa. Any drug, at any time, whether given orally, inhaled, by injection, or applied
2
topically may cause the drug eruption. The most common documented drugs that trigger the
reaction are a variety of antibiotics with those in the sulfonamide class (especially trimethoprim
sulfa or TMS) being the most often implicated. Other types of drugs that are known to cause
drug eruptions are topical medications with various active ingredients (shampoo, ointments,
creams), anti-parasitics but any drug can be the trigger. Additionally, the drug reaction can occur
after the drug is administered for the first time, a few days after discontinuing a drug, or the
patient is maintained on a prescription for years and then cause the ADR. However, most
reactions occur 1-3 weeks after starting a therapy. There are breed predilections in adverse drug
events. Rottweilers and Dobermans are known to have sulfonamide reactions. Poodles, Bichon
Frise, Yorkshire Terriers, Silkie Terriers and Maltese are more predisposed to injection induced
reactions, particularly rabies vaccines causing vasculitis and scarring at the injection site.
Miniature schnauzers are prone for developing a reaction called superficial necrolytic dermatitis
two to three days after shampooing/grooming which is painful and potentially life threatening.
The clinical findings on physical exam can mimic dermatologic lesions associated with a variety
of diagnoses. On the human side, a very distinct target lesion is noted when diagnosing EM but
that lesion is not often noted in veterinary medicine. A careful medication history is a must
when presented these cases.
Although the exact pathogenesis is unknown, the immune system is involved in producing the
lesions but there is not proof that the immune system is the main cause of causing the eruption.
For this reason, CADR is often categorized and treatment of the condition may include drugs
used for treating immune mediated diseases. A patient with Erythema Multiforme presents to
the veterinarian with acute symmetrical cutaneous inflammation. The skin lesions noted on
physical exam are those of folliculitis such as macules and papules and progress to urticarial
3
plaques and vesicles that ulcerate. The patient may be systemically ill and be febrile, depressed
and anorexic. Skin lesions will appear in the axillary and inguinal regions, pinnae and foot pads
which may slough. The mucocutaneous junctions and oral cavity can ulcerate adding to the
patient being reluctant to eat. Some patients exhibit pain particularly if the lesions progress and
get secondarily infected. While the definitive diagnosis of CADR on histopathology of skin
biopsies is not made but rather describe the lesions and with the history of receiving a suspected
medication and upon removal of the drug see clinical improvement. With Erythema Multiforme,
the pathologist will report epidermal apoptosis (cell death) with the skin cells being shrunk or
smaller in appearance and lymphocytes gathering around the dead cells which is called
lymphocytic satellitosis. Again, this is coupled with a solid drug history and improvement of
clinical signs with discontinuation of suspected contributive antigen. Therefore, the diagnosis of
Erythema Multiforme is actually the reaction pattern described by the pathologist from a
hypersensitivity that is usually triggered by drugs, but could also occur from bacterial infections,
parvo virus, food, neoplasia, or be idiopathic. In other words, a cutaneous adverse drug reaction
can cause Erythema Multiforme but not always. Identification and elimination of the most likely
causative agents along with supportive care and potentially immunosuppression are indicated
with both CADR and EM. In the case of the patient diagnosed with EM in this presentation,
supportive therapies were an integral part of his successful care.
References:
Miller WH, Griffin CE, Campbell KL. Small Animal Dermatology, 7th ed. St. Louis, MO.
Elsevier. Muller & Kirk. 2013
Hnilica KA, Patterson AP. Small Animal Dermatology, A Color Atlas and Therapeutic Guide,
4th ed. St. Louis, MO. Elsevier. 2017
4
Nursing Management for Traumatic Brain Injury
Stephanie Harris, DVM, Resident, Small Animal Emergency and Critical Care
Kendon Kuo, DVM, MS, DACVECC, Associate Clinical Professor
Kathy Gerken, DVM, MS, DACVECC, Assistant Clinical Professor
Auburn University College of Veterinary Medicine
1220 Wire Road
Auburn, AL 36849
Traumatic brain injury is a common presentation within the emergency setting and can occur
secondary to bite wounds, vehicular trauma, crushing injuries, missile injuries, or inadvertent or
purposeful attacks from humans. The initial insult of traumatic brain injury occurs before the
patient arriving at this hospital, and the healthcare team’s focus should be on minimizing the
effects of the secondary insult. Both the veterinarian and nursing staff can work together to
ameliorate the effects of the second injury stage, which often can lead to death. Preventing the
increase of intracranial pressure and maintaining adequate cerebral perfusion are the mainstays
of care for the head trauma patient.
Keywords: traumatic brain injury, head trauma, Cushing response, Monroe-Kellie doctrine,
Modified Glasgow Coma Scale, intracranial pressure
I. Basic physiology and understanding
a. The difference between head trauma and traumatic brain injury (TBI) is subtle
and it is important to distinguish between the two. Head trauma describes overt
trauma we can visualize on a patient, such as abrasions, lacerations, puncture
wounds, or bleeding. TBI describes the injury that occurs to the brain as a
consequence of head trauma. Often the healthcare team must rely on neurologic
exams and vital parameters to assess the extent of brain damage.1 In human
medicine, it is common to assess TBI with either a CT or MRI scan; however, this
is often a cost-limiting diagnostic in veterinary medicine and is not necessary
unless there is the potential need for surgical planning (e.g. penetrating wounds or
depressed skull fractures).
b. TBI can be divided into initial and primary injury categories
i. Primary injury: the direct mechanical injuries that occurred and effects are
immediate.1
ii. Secondary injury: occurs minutes to days after primary injury and is a
consequence of physical and biochemical changes that occur after the
primary injury. The healthcare team can try and prevent or at least
ameliorate secondary injuries with specific nursing and treatments.
Ultimately the healthcare team’s goal is to achieve adequate perfusion to
the brain and preventing an increase of pressure within the skull. Failing to
achieve adequate perfusion or prevent increased intracranial pressure
(ICP) can lead to cell ischemia and brain death.1
c. Cerebral blood flow
i. In health, the brain is able to control (“autoregulate”) its blood flow when
the body’s systemic blood pressure is within a range of 50-150 mm Hg.
However, in states of illness or if the blood pressure is outside of this
reference range, then the body loses its ability to regulate the blood flow to
the brain, which can result in further brain damage.2
ii. The Monroe-Kellie doctrine states that the skull is a rigid compartment
with three components: the brain, the blood, and cerebrospinal fluid
(CSF). Normally the body tightly regulates these components to achieve a
balanced equilibrium. If one compartment increases, then another must
decrease; otherwise, intracranial hypertension will occur.2
iii. Increased pressure within the brain or inadequate perfusion will result in
lack of oxygen and ultimately cell death.2
II. Nursing management
a. Advocate for pain management! A patient may not have a normal mentation or
may appear sedated, but this does not mean they aren’t painful, which can cause
increased blood pressure and consequently increased intracranial pressure.
b. Position the patient in the best way to achieve adequate perfusion to the brain,
minimizing increased pressure at the same time. Laying the patient at a slant with
the head elevated at 30 degrees will allow adequate venous drainage. Be sure not
to have neck bent which can also cause increased ICP
c. No jugular venipuncture should be performed as this can increase ICP.
Additionally, avoid neck leads or tight collars that could apply pressure to the
jugular veins.
d. Until spinal trauma can be ruled out, minimize manipulation of the spine. Further
agitation to spinal trauma can result in fatal consequences.
III. Common therapeutics to be familiar with
a. Hypertonic saline – pulls fluid from the interstitial space and the brain
parenchyma, allowing for decreased ICP.
i. Must be given over 10-15 minutes otherwise can cause hypotension
b. Mannitol
i. An osmotic diuretic; also pulls water from the interstitial space, decreasing
cerebral volume and relieving increased ICP
ii. Must be warmed as crystals can form
1. Use a filter to eliminate accidental administration of crystals
intravenously
iii. Also, give over 15-20 minutes
c. Midazolam (diazepam)
i. Head trauma patients are at increased susceptibility for having seizures
and so it is prudent to have a dose ready in case a seizure event occurs.
d. IV fluids – achieve adequate perfusion, but need to be cautious about increasing
fluid volume, which would subsequently increase ICP
IV. Monitoring
a. Heart rate – low heart rate should signal the need to check blood pressure and
ensure the patient is not having a Cushing response
b. Blood pressure – High blood pressure. This should prompt double-checking the
heart rate and ensuring the patient is not having Cushing’s response. If high blood
pressure and high heart rate are present concurrently, ensure that pain is
adequately controlled.
c. Cushing’s response – this occurs as the body’s last-ditch effort to decrease
intracranial pressure and indicates brain herniation, often holding a guarded to
grave prognosis. This is classified by high blood pressure (>180 mm Hg) and a
low HR (<80 bpm). The heart rate drops dramatically in an attempt to lower the
systemic blood pressure, thereby lowering the intracranial pressure.2
d. Respiratory rate and depth
i. The brainstem is responsible for respiratory drive and if this is affected,
then intubation and breathing for the patient may be needed
1. If concern for lack of respiratory drive, one should frequently
check gag reflex
2. Want to keep ETCO2 on the lower end as higher ETCO2 causes
vasodilation and more blood pooling within the brain = more
pressure
e. Modified Glasgow Coma Scale3
i. Assesses motor activity, brainstem reflexes, and level of consciousness
1. Motor activity
2. Brainstem reflexes
3. Level of consciousness
4. MCGS Score
a. 3-8, grave prognosis
b. 9-14, guarded prognosis
c. 15-18, good prognosis
References:
1. Burkitt, J.M and Davis, H. Advanced Monitoring Procedures for Small Animal
Emergency and Critical Care. Care of the Patient with Intracranial Disease. Pg 789-798.
Authors Holowaychuk, Marie K. and Ostenkamp, Sara M.
2. Platt S. Coma scales. In: D Silverstein, K Hopper, eds. Small Animal Critical Care
Medicine. 2nd ed. St. Louis, MO: Elsevier Saunders; 2015: 422! 425.
3. Platt SR, Radaelli ST, McDonnell JJ. The prognostic value of the modified Glasgow
Coma Scale in head trauma in dogs. J Vet Intern Med. 2001;15(6):581-584.
1
Cardiopulmonary Resuscitation - Basic Life Support
David Sender, DVM
Resident, Emergency & Critical Care
Kendon Kuo, DVM, MS, DACVECC, Associate Clinical Professor
Katherine Gerken, DVM, MS, DACVECC, Assistant Clinical Professor
Auburn University
1220 Wire Road, Auburn, AL 36849
334.844.4690
Abstract
Basic life support includes the rapid recognition of cardiopulmonary arrest, management of the
airway, ventilation support, and chest compressions. When a patient is found unresponsive, a
quick 5-15 second exam is performed to identify cardiopulmonary arrest. If there are any doubts,
cardiopulmonary arrest should be assumed, and chest compressions should be started right away.
Two major theories have been proposed to explain how blood is pumped during cardiopulmo-
nary resuscitation: the cardiac pump theory and the thoracic pump theory. These two models can
be employed depending on the body conformation of the patient. Chest compressions are per-
formed for two-minute cycles at a rate of 100-120 beats per minute to compress the chest one-
third to one-half the width of the chest with each compression. Proper positioning of the person
performing chest compressions is of great importance to ensure the most effective compressions
are being performed. Manual ventilation, whether it is performed through intubation or with a
2
bag-mask, is performed at a rate of ten breaths per minute with a rapid inspiration time of one
second.
Keywords: Cardiopulmonary resuscitation, basic life support, compressions
Cardiopulmonary resuscitation - Basic life support
Basic life support (BLS) in veterinary medicine involves rapid recognition of cardiopulmonary
arrest (CPA), maintenance of the airway, ventilation, and chest compressions1. A recent study
showed 53% of clients at a veterinary teaching hospital think CPR at a veterinary clinic is similar
to CPR in people and includes some form of compression and artificial breathing2. The 2012 RE-
COVER guidelines provide evidence-based recommendations for dogs and cats with CPA, and
readers here are referred to these guidelines for a more complete review of current literature and
recommendations for BLS. The RECOVER guidelines make specific recommendations based on
human and animal studies to standardize CPR efforts to improve outcomes of veterinary patients
undergoing CPA. Unfortunately, awareness of these RECOVER guidelines is still incomplete
among general practitioners3.
When an unresponsive patient is identified, a rapid assessment of the airway and breathing is rec-
ommended first. The patient is typically placed in lateral recumbency for evaluation and initia-
tion of chest compressions. Rapid assessment of the airway, breathing, and circulation (ABC)
should be completed in 5-15 seconds or less. Palpation of pulses is not recommended as human
studies have shown unreliability of this technique and may delay the initiation of BLS. Several
human studies have shown that delays in initiation of BLS lead to decreased survival rates4 while
3
minimal adverse effects are caused by the initiation of unnecessary compressions in people that
have not undergone CPA1,6.
The first part of the rapid assessment is of the airway. A brief inspection, including pulling out
the tongue, is performed to evaluate for obvious upper airway obstruction. If an obstruction is
identified and can be removed, the patient should then be further evaluated to confirm CPA. Af-
ter evaluating the airway, breathing is assessed by either feeling for air movement around the
mouth and nose or by visualizing chest expansion. If no breathing is noted, CPA should be as-
sumed, and chest compressions should be started.
Chest compressions are performed in right or left lateral recumbency (or dorsal recumbency if
the patient is a barrel-chested dog). There are two main theories described to explain how chest
compressions lead to blood flow during CPR. The cardiac pump theory suggests direct compres-
sions of the heart allows for blood to be pumped out of the left ventricle and into the aorta during
compression followed by filling of the heart chambers and coronary perfusion during recoil. The
thoracic pump theory supposes blood from the thoracic cavity is pumped into circulation as the
intrathoracic pressure increases during compressions due to compression of the aorta and col-
lapse of the vena cava. During recoil, the decrease in intrathoracic pressure allows blood to flow
from the periphery into the thorax and lungs, thereby suggesting the heart is a passive conduit for
blood flow. Veterinary patient conformation is variable, and some patients may benefit from the
cardiac pump technique while others will benefit more from the thoracic pump technique. Most
medium to giant breed dogs have chests that are rounded and are too large to allow for direct
compression of the heart. Therefore, chest compressions in these patients should be performed at
4
the widest part of the chest in lateral recumbency to utilize the thoracic pump model. Cats, small
dogs, and dogs with keel-shaped chests (such as greyhounds, and Salukis) have a size and/or
conformation that generally allows for direct compression of the heart, so chest compressions on
these animals should be performed directly over the heart with animals in lateral recumbency.
Dogs with barrel-shaped chests generally benefit more from being placed in dorsal recumbency
with chest compressions performed directly over the sternum to employ the cardiac pump tech-
nique by compressing the heart between the sternum and spine6.
The person performing chest compressions should be positioned on the dorsal (spine-side) of the
patient. One hand is placed on top of the other with fingers interlocked, and the heel of the palm
is placed on the area of compression while the elbows are locked in extension. The rescuer’s
shoulders should be directly in line with their hands, and the weight of the body is used to
strengthen compressions. Attempts should be made to compress the chest one-third to one-half
the width of the chest. If the patient is a cat or small dog, their chest walls are generally compli-
ant enough to allow compression of the heart using a single-hand technique with the rescuer’s
thumb on one side of the chest and the four fingers on the other side (called the circumferential
technique). Regardless of the compression technique, the rescuer should be on the spine-side of
the patient to prevent inadvertently pushing the patient further away from the rescuer (assuming
the patient is in lateral recumbency). Compressions are performed at a rate of 100-120 beats per
minute4. Many songs, such as “Stayin’ Alive” by the Bee Gees and “I Will Survive” by Gloria
Gaynor, have beats between 100-120 beats per minute and can be used to improve the timing of
compressions. Common pitfalls that must be avoided include the following: too rapid or too slow
of a compression rate, arms bent at the elbow during compressions, a participant positioned too
5
low to the patient so as adequate compressions cannot be performed, compressions exceeding
one-half the width of the chest (causing unnecessary thoracic trauma) or less than one-third the
width of the chest (inadequate compressions), not allowing full recoil of the chest between each
compression, or standing on the sternum-side of the animal, which will lead to the participant in-
advertently pushing the patient away with each compression.
Performing successful chest compressions can be a physically demanding and exhausting pro-
cess—especially in larger dogs—and there are many studies showing rescuer fatigue and de-
creased depth of compressions after anywhere between 1 and 10 minutes of compression. How-
ever, it takes one minute of continuous compressions to reach maximal blood flow7. With these
results in mind, the RECOVER guidelines suggest performing uninterrupted chest compressions
at two-minute intervals with minimal delay between intervals.
In addition to chest compressions, interposed abdominal compressions can be performed in pa-
tients that do not have intra-abdominal disease8. However, the timing of abdominal compressions
can be difficult and may negatively impact the quality of chest compressions.
While chest compressions are being performed, it is also important to provide ventilation be-
cause prolonged hypoxia decreases cerebral perfusion pressure and leads to metabolic acidosis.
All efforts should be made to intubate the patient without disrupting chest compressions. In a few
different studies, Yannopoulos, et al showed a ventilation rate of 10 breaths per minute improved
outcomes in porcine CPA models9,10. If intubation is not available, patients should be ventilated
6
mouth-to-snout at a 30:2 compression/ventilation ratio. A bag-mask may also be utilized4. Respi-
rations should be performed with a rapid inspiration time of 1 second whether that is performed
with a ventilation machine or a bag-mask4.
Conflicts of interest: The author has no conflicts of interest to declare.
7
References:
1. Hopper, K, Epstein, S, Fletcher D, et al. RECOVER evidence and knowledge gap analy-
sis on veterinary CPR. Part 3: Basic life support. JVECC. 2012;22(S1);S26-S43.
2. Oberholtzer J, Hofmeister E. Perception of small animal cardiopulmonary resuscitation of
owners presenting to a small animal teaching clinic including a large first opinion service.
JVECC. 2020;30(4);411-417.
3. Gillespie I, Fletcher D, Stevenson M, et al. The Compliance of Current Small Animal
CPR Practice With RECOVER Guidelines: An Internet-Based Survey. Front Vet Sci.
2019;6.
4. Fletcher D, Bolle M, Brainard B, et al. RECOVER evidence and knowledge gap analysis
on veterinary CPR. Part 7: Clinical guidelines. JVECC. 2012;22(S1);102-S131.
5. White L, Rogers J, Bloomindale M, et al. Dispatcher-assisted cardiopulmonary resuscita-
tion: risks for patients not in cardiac arrest. Circulation 2010;121(1):91-97
6. Drobatz K, Hopper K, Rozanski E, et al. Textbook of Small Animal Emergency Medi-
cine. Hoboken, NJ: John Wiley and Sons, Inc.; 2019.
7. Kern K, Hilwig R, Berg R, et al. Efficacy of chest compression-only BLS CPR in the
presence of an occluded airway. Resuscitation. 1998;39(3);179-188.
8. Linklater A. Cardiopulmonary Resuscitation – Emergency Medicine And Critical Care –
Veterinary Manual. [online] Veterinary Manual. 2020 [cited 31 August 2020]. Available
from: https://www.merckvetmanual.com/emergency-medicine-and-critical-care/specific-
diagnostics-and-therapy/cardiopulmonary-resuscitation
8
9. Yannopoulos D, Sigurdsson G, McKnite S, et al. Reducing ventilation frequency com-
bined with an inspiratory impedance device improves CPR efficiency in swine model of
cardiac arrest. Resuscitation. 2004;61(1);75-82.
10. Lurie K, Yannopoulos D, McKnite S, et al. Comparison of a 10-breaths-per-minute ver-
sus a 2-breaths-per-minute strategy during cardiopulmonary resuscitation in a porcine
model of cardiac arrest. Respiratory Care. 2008;53(7);862-870.
1
Cardiopulmonary Resuscitation - Advanced Life Support
Andrea Henriksson, DVM
Resident, Emergency & Critical Care
Kendon Kuo, DVM, MS, DACVECC, Associate Clinical Professor
Katherine Gerken, DVM, MS, DACVECC, Assistant Clinical Professor
Auburn University College of Veterinary Medicine
1220 Wire Road, Auburn, AL 36849
Abstract
Advanced life support (ALS) is an important part of cardiopulmonary resuscitation (CPR) but
should be implemented secondary to high-quality basic life support (BLS). The most important
parts of ALS include the administration of vasopressors, such as epinephrine, and anticholinergic
medications such as atropine. Appropriate reversal drugs (atipamezole, naloxone, or flumazenil)
should be administered to any animal that has received recent sedation or analgesic drugs. The
preferred administration route is intravenously (IV), but intraosseous (IO), or intratracheal (IT)
can also be used if necessary. Intravenous fluids are only recommended in hypovolemic animals,
and steroids and bicarbonate are not recommended in the vast majority of patients.
Electrocardiogram (ECG) and capnograph are the two most useful monitoring device. ECG is
necessary to determine the type of cardiac rhythm and therefore a crucial tool to determine if
defibrillation is indicated. Open-chest CPR should be considered in certain patients with
intrathoracic disease, obesity, or patients that have abdominal surgery performed. However,
2
open-chest CPR should only be performed is appropriate care and treatments can be provided in
case of return of spontaneous circulation (ROSC).
Keywords
Cardiopulmonary resuscitation, advanced life support,
Cardiopulmonary resuscitation - Advanced life support
Advanced life support (ALS) consists of the administration of drugs (vasopressors,
anticholinergics, reversals), correction of acid-base and electrolytes, and defibrillation. ALS is an
important part of cardiopulmonary resuscitation (CPR) but should not never be prioritized over
high-quality basic life support (BLS). Without appropriate BLS, ALS is unlikely to be
successful.
A minimum of 3-4 people should be available for appropriate ALS to be performed. One
of these people should take the role as the leader of the CPR. Studies have shown in human
medicine that the outcome of the patient is not affected if the leader is a physician or a nurse. The
same is likely true in veterinary medicine and anyone confident with previous experience can
lead the CPR. The role of the team leader is to oversee, monitor time, and record all events
during the CPR. It is important to use closed-loop-communication. This means that all
instructions should be repeated back to the person giving the instructions to reduce the risk of
misunderstandings.
Intravenous (IV) access is crucial to deliver drugs. For the sake of time, this should be
performed by one of the most experienced people of the team. If adequate people available, two
people can attempt vascular access simultaneously (for example in cephalic vein and saphenous
3
vein). Do not hesitate to perform a cut down of the skin if necessary. If IV access is not
successful or if the patient is pediatric, an intraosseous (IO) catheter can be attempted.
Everything that can be administered IV can also be administered via an IO catheter. The third
route of administration is intratracheal, and drugs like naloxone, atropine, vasopressin, lidocaine,
and epinephrine can be administered via this route (mnemonic: NAVLE). (1) Drugs that are
being administered via the intratracheal route should be diluted and administered via a red rubber
catheter (or similar) to assure that the drug gets delivered to the airways and doesn’t stay inside
the endotracheal tube.
Vasopressors, such as epinephrine and vasopressin, are commonly used during CPR.
Epinephrine can be given at a high dose (0.1mg/kg) as well as a low dose (0.01mg/kg). The
higher dose has been associated with a higher chance of ROSC, but the overall mortality is not
improved. The reason is unclear but may be due to its overwhelming adrenergic effects. High
dose epinephrine is therefore not recommended unless there is prolonged CPR (>10min).
Vasopressin (0.8U/kg) is used less commonly than epinephrine due to its significantly higher
price. Studies have not shown that this drug is inferior or superior to epinephrine and can
therefore be considered during CPR. Compared to epinephrine, vasopressin works at lower pH
levels and could therefore be a good choice if resuscitation efforts are prolonged or the patient is
profoundly acidotic. Atropine (0.04mg/kg) is an anticholinergic drug that suppresses the
parasympathetic nervous system so that the sympathetic nervous system dominates. It has been
useful in animals that arrest due to high vagal tone; however, no clear benefit or harm has been
shown in other patients. Atropine should therefore also be considered during CPR especially in
patients with arrest due to high vagal tone. Administration of vasopressors and anticholinergics
are recommended every 4 min during CPR. They are typically given at the time of every other
4
BLS cycle. Other drugs that should be considered are reversal drugs, including naloxone (reverse
opioids), atipamezole (reverse alpha-2 agonists), and flumazenil (reverse benzodiazepines).
These drugs should be administered IV if any sedation or analgesia has recently been given to
the animal. It is important to remember that the half-life of any drug can be significantly
prolonged in critically ill animals and if there are any concerns about residual drug
concentrations reversal should be given multiple times. (2)
The two most important monitoring devices are the electrocardiogram (ECG) and
capnograph. (3) A capnograph is a useful tool not only to monitor the quality of CPR but can
also be a helpful tool to confirm correct endotracheal tube placement. The capnograph measures
carbon dioxide in the expired air (ETCO2). In an arrested individual, the carbon dioxide of the
blood will be high. However, since the perfusion of the body is poor the CO2 is not being carried
to the lungs and is therefore not expired and the ETCO2 in a dead patient will be low. During
high-quality CPR, blood is being circulated in the body and carbon dioxide is being brought to
the lungs and exchanged. A high reading of ETCO2 is therefore an indicator of good quality CPR
and the patient has a higher chance of return of spontaneous circulation (ROSC). (4) A low
ETCO2 indicates that perfusion is poor, or that the patient is not well-ventilated. In a patient that
is experiencing ROSC, a sudden spike in ECTO2 will be seen on the capnograph. This is due to
the perfusion suddenly increasing and more carbon dioxide from the periphery of the body is
being circulated to the lungs and expired.
ECG is also important for monitor arrhythmias during CPR. The four types of cardiac
rhythms that are seen during cardiac arrest include asystole, pulseless electrical activity (PEA),
ventricular fibrillation (VF), and pulseless ventricular tachycardia (PVT). (1) It is important to
diagnose the type of rhythm because PVT and VF require defibrillation, while asystole and PEA
5
do not. Assessment of the rhythm should be performed in between every other BLS cycle and
should not prolong the shift between two cycles for more than a few seconds. All members of the
CPR team should view the ECG reading, and the leader should call out the type of arrhythmia. If
there are any disagreements regarding the type of arrhythmia, the next cycle should continue
without delaying BLS while a discussion is held to diagnose the arrhythmia.
During VF and PVT, random myocardial cells are firing and the heart is no longer led by
the pacemaker cells of the sinoatrial node. In these types of arrhythmias, defibrillation is
indicated. The goal of defibrillation is to depolarize as many of the cells as possible and stop
them from firing so that the heart can return to being paced by the cells of the sinoatrial node.
Successful defibrillation means that the rhythm will return to sinus rhythm or asystole.
Defibrillation should be performed in dorsal recumbency with placing two paddles on either side
of the chest at the level of the heart. Gel should be used to achieve good contact with the skin.
Alcohol should be avoided due to the risk of fire. The person handling the paddles should make
everyone aware that the patient is about to be defibrillated by yelling “clear”, before delivering
the shock. Regardless if the defibrillation is successful or not, a new cycle of cardiac
compressions and ventilation should be resumed immediately after defibrillation and the cardiac
rhythm should be evaluated again at the end of that cycle. If still a shockable rhythm, another
defibrillation should be performed. Each defibrillation dose may be increased by approximately
50% after each shock up to a maximum dose of 10 J/kg. (3)
The timing of the defibrillation is important. After cardiac arrest, the heart enters an
“electric phase”. During this time enough energy substrates are present to make defibrillation
successful. Between 4-10 minutes the heart is in a “circulatory phase” where the heart is
suffering from ischemia and no energy substrates are available. It is therefore important to notice
6
that if the arrest was not immediately witnessed, or it is known that the patient has been dead for
> 4 minutes, one full cycle (2 minutes) of BLS should be performed before defibrillation is
performed. This delay of defibrillation can improve myocardial ischemia and improve the
chances of a successful outcome. After 10 minutes of arrest, the heart enters a “metabolic phase”
and the chances for effective defibrillation are significantly decreased. (5) If a defibrillator is not
available when needed, no ideal other options exist. Anti-arrhythmic drugs such as amiodarone
or lidocaine can be considered but have a lower success rate than defibrillation. As a last-ditch
effort, a precordial thump can also be considered but has no evidence for a successful effect.
Other treatments such as steroids, IV fluids, and/or bicarbonate are not indicated in the majority
of patients. (2) Unless the patient has an underlying condition that requires steroids, the use of
glucocorticoids is not recommended and does not improve the change or survival. IV fluids are
only indicated if there is a high suspicion that the patient is severely hypovolemic. IV fluids
should not be administered in a euvolemic patient because IV fluids increase cardiac preload.
This increases the pressure in the right atrium which can decrease coronary perfusion (since the
coronary arteries exit the aorta and enter the right atrium). Bicarbonate can cause severe
metabolic derangements. Inside the body, bicarbonate is converted to carbon dioxide which can
accumulate to dangerous levels in patients that are not able to ventilate adequately. Some studies
show that the administration of bicarbonate even worsens the outcome if given during early
cardiac arrest. Therefore, it should be used very cautiously during CPR and only given if there is
confirmed severe metabolic acidosis on blood gas.
Open-chest CPR can be considered in certain patients. Direct compression of the heart
will increase cardiac output but is a high-risk and very invasive procedure. Open-chest CPR
should not be attempted unless the clinic can offer appropriate surgical and critical care of the
7
patient in the case of ROSC. Patients, where open-chest CPR can be considered, include patients
with an intrapleural or pericardial disease such as pneumothorax, pleural effusion, pericardial
effusion, or diaphragmatic hernia. (2, 6) Patients that have any thoracic wall defects, such as flail
chest, or are severely obese or of a large breed also benefit from direct cardiac compression.
Open-chest CPR should be considered in patients during intraabdominal surgery. When
performing open-chest CPR, the skin and intercostal muscles should quickly be transected with
scissors or scalpel at the level of the heart (4-5th intercostal space). If needed retractors can be
used to keep the ribs spread apart. The pericardium should be removed and attention should be
brought to the phrenic nerve so that this is not injured. Depending on the size of the patient,
either one or two hands can be used to massage the heart. The heart should be gently massaged
from the bottom to the top without using fingertips and nails that could damage the heart. If
ROSC is achieved, the patient required surgical lavage of the thorax and closure of the chest
wall.
References
1. Waxman C. Recover CPR for veterinary nurses. Veterinary Nursing Journal
2019;34(8):207-212.
2. Fletcher D, Boller M, Brainard B, et al. RECOVER evidence and knowledge gap analysis
on veterinary CPR. Part 7: Clinical guidelines. JVECC 2012;22(S1);102–S131.
3. Fletcher D, Boller M. Cardiopulmonary Resuscitation in the Emergency Room. In:
Drobatz KJ, Hopper K, Rozanski E, Silverstein DC, editors. Textbook of Small Animal
Emergency Medicine. Hoboken, NJ: Wiley & Sons; 2019. p.967-973.
8
4. Hogen T, Cole S, Drobatz K. Evaluation of end-tidal carbon dioxide as a predictor of
return of spontaneous circulation in dogs and cats undergoing cardiopulmonary
resuscitation. JVECC 2018;00(0):1–10.
5. Weisfeldt M, Becker L. Resuscitation After Cardiac Arrest A 3-Phase Time-Sensitive
Model. JAMA 2002; 288(23):3035-8.
6. Fletcher D, Boller M. Cardiopulmonary Resuscitation. In: Silverstein D, Hopper K,
editors. Small animal critical care medicine. 2nd ed. St. Louis: Elsevier Saunders; 2014.
p. 11-16.
Proceedings – Post-Cardiac Arrest Care of the Recently Resuscitated Patient
Wan-chu (Ellan) Hung, DVM (SA Emergency and Critical Care Resident)
Kendon Kuo, DVM, MS, DACVECC and Katherine Gerken, DVM, MS, DACVECC (Faculty)
Auburn University College of Veterinary Medicine
1220 Wire Road
Auburn, AL 36849
334.844.4690
Abstract
When cardiopulmonary resuscitation is successful, post-arrest care becomes the next
obstacle to overcome. Even with good return of spontaneous circulation, many patients are not
able to be discharged from the hospital due to recurrence of arrest or comorbidities depreciating
quality of life. Post-arrest care should focus on stabilizing the patient hemodynamically and
cardiovascularly, while addressing the underlying cause of arrest. This can be achieved with a
number of interventions which should be tailored to the specific patient’s needs.
In small animal medicine, despite the return of spontaneous circulation (ROSC) rate after
cardiopulmonary resuscitation (CPR) to be reported at 35 – 58%, the survival-to-discharge rate
remains low as 5 – 6%1,2. This discrepancy between the rates of ROSC and survival-to-discharge
points out the significant role of post-arrest care in veterinary CPR, which may greatly affect
outcomes.
In patients that attain ROSC, they can sustain a lethal post-cardiac arrest (PCA)
syndrome, which is a combination of cardiac ischemia, anoxic brain injury, multi-organ failure
secondary to ischemia and reperfusion, and the pre-existing underlying disease3,4. The goals for
post-cardiac arrest (PCA) care are to maintain spontaneous circulation and support adequate
perfusion to vital organs to attenuate further damage and prevent re-arrest. Because of the
complexity and variability of the patients, there is no universal therapy for post-cardiac arrest
syndrome. The therapeutic intervention must be tailored to the individual patient’s needs.
Research of post-cardiac arrest care in small animals is scarce, and most of the current
recommendations are based on human literature. Post-cardiac arrest care mainly includes four
parts, which are 1) hemodynamic optimization strategies, 2) control of respiratory function, 3)
mild therapeutic hypothermia (MTH) therapy, and 4) other supportive strategies.
Hemodynamic optimization strategies
The cardiovascular dysfunction after CPR can be attributed to cardiac ischemia,
reperfusion injury, increased vascular permeability secondary to systemic inflammation, and
microcirculatory dysfunction. Clinically, hypotension and arrhythmias may be observed.
Because persistent cardiovascular dysfunction can cause ongoing tissue hypoxia and organ
damage, early hemodynamic optimization is recommended. The interventions for this include
those which optimize tissue oxygen delivery (e.g. intravenous fluid therapy, inotropic and
vasoactive drug administration, red blood cell transfusion if anemic) and those which reduce
tissue oxygen demand (e.g. sedation, mechanical ventilation)5. The patient needs to be closely
monitored for cardiac arrhythmias, blood pressures, blood lactate, central venous oxygen
saturation (ScvO2), and arterial oxygen saturation. Sometimes central venous pressure can be
utilized as well, though this has fallen out of favor more recently. Cardiac arrhythmias should be
addressed properly with adequate antiarrhythmic medication and electrolyte balance.
Control of respiratory function
Identification and normalization of abnormal blood oxygen, carbon dioxide, and pH
levels are crucial steps in PCA care. Low blood oxygen levels can decrease tissue oxygen uptake
and worsen tissue hypoxia. Elevated blood carbon dioxide levels can affect cerebral blood flow,
which may lead to elevated intracranial pressure and consequently neurological signs (e.g.
seizure, coma). On the other hand, low blood carbon dioxide levels can cause cerebral
vasoconstriction and subsequent cerebral hypoxia. As a result, targeting normocapnia is vital
(PaCO2 of 32 – 43 mm Hg in dogs and 26 – 36 mm Hg in cats) in PCA care. Clinically, arterial
blood gases and end-tidal carbon dioxide levels (ETCO2) can be used to assess if the patient has
adequate ventilation. If the patient is unable to ventilate properly, mechanical ventilation is
required to maintain adequate gas exchange and normal acid-base homeostasis. Although oxygen
is essential in tissue oxygenation, it is also the major source of reactive oxygen species (ROS).
Excessive ROS can cause cell damage, lipid peroxidation, and protein alteration. Based on both
human literature and a study in dogs, it is recommended to titrate the oxygen supplementation to
maintain normoxemia, with the target oxygen saturation (SpO2) of 94-96% or partial pressure of
oxygen (PaO2) 80 – 100 mmHg. Hyperoxemia or hypoxemia should both be avoided.
Mild therapeutic hypothermia (MTH) therapy
Mild therapeutic hyperthermia (MTH) has been shown to provide a neuroprotective
effect in patients after ROSC. The proposed mechanisms of MTH on neuroprotection include a
decrease in cell metabolism and reduced production of ROS, a decrease in cerebral metabolism,
and suppression of seizure activity. In veterinary medicine, it is recommended to initiate MTH
on dogs and cats that remain comatose right after ROSC and keep the patient’s core body
temperature between 89.6° to 93.2° F for 24 – 48 hours, followed by slow rewarming (0.45° -
0.9° F per hour)6. Because MTH can induce shivering, which may in turn increase tissue
metabolism and oxygen consumption, it is recommended to sedate the patient and initiate
mechanical ventilation at the same time of MTH therapy. An alternative to MTH, since most
small animal patients remain hypothermic after CPR, is to allow the patient to rewarm to normal
body temperature slowly at the rate of 0.45° to 0.9° F per hour6.
Other supportive strategies
Some other drug therapies are used in an attempt to improve the outcome of PCA care,
including corticosteroids, hyperosmotic therapy, and anti-seizure medications.
The use of the corticosteroid in the PCA care is still controversial. So far, the clinical
trials in human medicine have failed to demonstrate any benefit of corticosteroid therapy in PCA
care. As a result, routine corticosteroid administration during PCA care is not recommended.
However, in patients that are hemodynamically unstable and not responsive to fluid therapy,
inotropes, and/or vasopressors, may benefit from the administration of hydrocortisone (1 mg/kg
followed by either 1 mg/kg q 6 h or CRI at the rate of 0.15 mg/kg/h) for possible relative adrenal
insufficiency.
In patients that attained ROSC, cerebral edema may occur and can present with seizure,
abnormal mentation, decerebrate posture, cranial nerve deficits, and Cushing reflex. Currently,
there are not many studies investigating mannitol or hypertonic saline administration in PCA
care, but based on the utility of both drugs in treating cerebral edema, they can be considered in
PCA patients with neurological signs that are consistent with cerebral edema. Prophylactic
administration of barbiturates (e.g. phenobarbital) should also be considered, especially in those
patients who remain comatose or sedated, because non-convulsive seizure activity (i.e. can only
be identified on the electroencephalography) may be present and can lead to an increase in
cerebral metabolism and oxygen demand.
The concept of bundle therapies has been employed in the treatment of several complex
diseases with positive outcomes and should be considered in PCA care. Bundle therapy describes
a group of evidence-based therapies that are implemented together to provide a greater benefit
for the patients and lead to better outcomes. In PCA care, early hemodynamic optimization,
respiratory care, neuroprotective strategies including MTH, seizure prophylaxis, and
hyperosmotic therapy are reasonable bundle components.
1. Hofmeister EH, Brainard BM, Egger CM, Kang S. Prognostic indicators for dogs and
cats with cardiopulmonary arrest treated by cardiopulmonary cerebral resuscitation at a
university teaching hospital. J Am Vet Med Assoc. 2009;235(1):50-57.
doi:10.2460/javma.235.1.50
2. McIntyre RL, Hopper K, Epstein SE. Assessment of cardiopulmonary resuscitation in
121 dogs and 30 cats at a university teaching hospital (2009-2012). J Vet Emerg Crit
Care (San Antonio). 2014;24(6):693-704. doi:10.1111/vec.12250
3. Smarick SD, Haskins SC, Boller M, Fletcher DJ; RECOVER Post-Cardiac Arrest Care
Domain Worksheet Authors. RECOVER evidence and knowledge gap analysis on
veterinary CPR. Part 6: Post-cardiac arrest care. J Vet Emerg Crit Care (San Antonio).
2012;22 Suppl 1:S85-S101. doi:10.1111/j.1476-4431.2012.00754.x
4. Fletcher DJ, Boller M. Updates in small animal cardiopulmonary resuscitation. Vet Clin
North Am Small Anim Pract. 2013;43(4):971-987. doi:10.1016/j.cvsm.2013.03.006
5. Silverstein, D. C., & Hopper, K. (2014). Chapter 4: Post-cardiac arrest care. In
Small animal critical care medicine (Second ed., pp. 17-25). St. Louis, Missouri:
Elsevier.
6. Fletcher, D.J., Boller, M., Brainard, B.M., Haskins, S.C., Hopper, K., McMichael, M.A.,
Rozanski, E.A., Rush, J.E. and Smarick, S.D. (2012), RECOVER evidence and
knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. Journal of
Veterinary Emergency and Critical Care, 22: S102-S131. doi:10.1111/j.1476-
4431.2012.00757.x
PREVENTING THE #1 SMALL ANIMAL DISEASE
Jan Bellows, DVM
Diplomate, American Veterinary Dental College
Diplomate, American Board of Veterinary Practitioners
ALL PETS DENTAL, Weston, Florida
954-349-5800
Abstract
The most common of all small animal diseases is periodontal disease which is caused by plaque.
Prevention of plaque using dental chews is easy and can be very effective. The challenge is
figuring out how to choose a chew or other form of periodontal disease prevention that is safe,
effective and tailored to the client and patient.
Keywords: Chews, periodontal disease prevention, VOHC, plaque, tartar, calculus
The gold standard to prevent the accumulation of plaque and calculus is daily tooth brushing. Less
than 2% of the pet owning public brush their pet’s teeth daily, which leave 98% that, do not. Many
caring pet owners have chosen manufactured chews as a way to keep their dog’s oral cavity
healthy. There is little to no oversight on what can be printed on a box unless there is a medical
claim such as “prevents gingivitis, and periodontal disease” which is regulated by the FDA.
Essentially any words can be used to describe claims (whitens teeth, freshens breath, decreases
mouth odor) and herein lies the conundrum, how can we assist our caring pet guardians make wise
decisions on the right commercial chews to choose?
How are chews mass-produced?
Commercial dental chews are produced by an extrusion process, baking or through injection
molding.
In the extrusion process, raw materials are first ground to the correct particle size. The dry mix is
passed through a pre-conditioner, where other ingredients may be added, and steam is injected to
start the cooking process. The preconditioned mix is then passed through an extruder, forced
through a die and cut to the desired length. The cooking process takes place within the extruder,
which can induce both protein denaturation and starch gelatinization. Sometimes, a catalyst is
added when producing texturized vegetable chews.
Baked chews uses is the same process of manufacturing crackers and cookies. Textures are
typically brittle and crunchy which will usually not give the needed texture to have an
efficacious mechanical effect. Chemicals such as sodium hexametaphosphate a calculus
sequestrant, can be added to the baked product.
Injection molding is typically used where the same chew is being created thousands or even
millions of times in succession by injecting material in liquid form into a mold. The process
works by heating small pellets of material into a molten liquid and then forcing the hot liquid
through a nozzle and into a mold whose internal cavity is the negative of whatever part is being
created. The molten parts are cooled and then removed from the mold by ejector pins.
Chew Efficacy
The Veterinary Oral Health Council (VOHC) accepts products that decrease accumulation of
plaque and/or calculus by at least 20% (and considered safe).
The FDA is the regulatory agency for veterinary products, and was involved in the discussions
that lead to the development of the VOHC. With the FDA’s help, a system was created that helps
consumers understand product claims for dental products that reduce plaque and calculus
accumulation. The testing methodology is based on proving that there is decreased plaque and
calculus accumulation compared to controls of at least an average of 20% in two tests with each
at least greater than 15%.
Chew safety
Clients and veterinarians must be concerned with safety. Many of the products that claim
mechanical plaque and calculus control are unfortunately so hard that chewing can result in tooth
fracture with pulp exposure or create a gastrointestinal obstruction. To further define what is
acceptable hardness or texture, research is being conducted on how much pressure it takes to
fracture dog’s a tooth. As veterinarians we must advise against feeding bones, nylon chews,
antlers, or any product that does not easily bend, compress or dissolve when placed in a fluid
environment. Additionally, other parameters must be considered including stiffness and surface
abrasiveness. Each of these contributes to the behavior of the product when chewed.
Those products that claim control of plaque through chemical means must also be safe from a
medical standpoint for the dog or cat to ingest. Excessive protein, preservatives, and ingredients
such as grain alcohol and arsenic (as a preservative) in dental treats may cause injury.
Digestibility (product solubility) is also important to consider. Dog treats that are swallowed
whole, or in part, should degrade rapidly in the canine digestive system to prevent dangerous
blockage. The VOHC is considering standardized digestibility tests to accompany future chew
submissions.
Mechanical / chemical / and combined chew methods of plaque/calculus accumulation delay
Non- mechanical forms of plaque control include chemicals and natural ingredients to decrease the
formation of plaque, the adhesion of plaque on the tooth surface and to decrease the formation of
calculus through crystal growth inhibition preventing mineralization of plaque and the transition of
plaque into calculus.
Anti-plaque agents include oils of thymol, menthol, eucalyptol, methyl salicylate, cinnamon, and
clove. Anti-plaque chemicals include Lauryl sulphate, Tricolosan, Zinc, and Glucose oxidase and
delmopinol. Delmopinol is an active anti-plaque surfactant agent with an antimicrobial effect.
The clinical efficacy of delmopinol is partially due to a reduction of surface-associated glucan
synthesis that lowers the cohesion of the dental plaque.
Pyrophosphates are anti-calculus agents including polypyrophospate (sodium hexametaphosphate,
SHMP). SHMP decreases the accumulation of calculus by binding to salivary calcium reducing
the calcification of plaque into calculus. Tripolyphosphate and tetrasodium polyphosphate are
also in this group of mineral deposition inhibitors. Zinc also inhibits plaque and crystal growth.
Additional reading
Harvey CE, Shofer FS, Laster L. Correlation of diet, other chewing activities and periodontal
disease in North American client-owned dogs. J Vet Dent 1996; 13:101-105.
Lage A, Lausen N, Tracy R, Allred E. Effect of chewing rawhide and cereal biscuit on removal
of dental calculus in dogs. JAVMA 1990; 197:213-219.
Duke A. How a chewing device affects calculus build-up in dogs. Vet Med 1989;
November:1110-1114.
Gorrel C. The role of a ‘dental hygiene chew’ in maintaining periodontal health in dogs. J Vet
Dent 1996; 13:31-34.
Gorrel C, Warrick J, Bierer TL. Effect of a new dental hygiene chew on periodontal health in
dogs. J Vet Dent 1999; 16:77-81.
Johnson, RB. Recent dental advances for companion animals through dietary means, in
Proceedings. TNAVC January 2002. Orlando, FL; 179-180.
Cox, ER, Lepine, AJ. Use of polyphosphates in canine diets to control tartar. J Dent Res 2002;
81:A349 (Abstr.).
Stookey GK, Warrick JM, Miller LL, Katz BP: Hexamethaphosphate-coated snack biscuits
significantly reduce calculus formation in dogs J Vet Dent 12(1) 27-30, 1996.
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MAKING SELF CARE A PRIORITY AND AVOIDING COMPASSION FATIGUE AND BURNOUT Mary-Catherine Turner Licensed Professional Counselor Auburn University 1180 Wire Road Veterinary Education Center, Room 135 334-844-5123 334-844-6110 (fax) [email protected] Burnout and compassion fatigue are common concerns with individuals who work in health care, veterinary health care especially. Those who attended the American Veterinary Medical Association conference reported that stress, burnout, and compassion fatigue were the most important wellness concerns that were prevalent in the veterinary community. These same individuals reported there are not resources readily available to those in veterinary medicine professions to address these concerns. The unique circumstances in veterinary medicine contribute to increased risk of burnout in veterinary related professions. Individuals who chose their profession as one in veterinary health care are usually those with increased compassionate and empathetic personalities and attributes. Witnessing another person’s painful traumatic experiences and encountering illness and death on a daily basis can lead to compassion fatigue. Compassion fatigue by definition is exhaustion due to the demands of being empathic and helpful to others who are suffering. Continuously experiencing compassion fatigue can lead to burnout which can be the end point for some individuals in their chosen profession. The ways to address, manage, and decrease compassion fatigue that leads to burnout starts in the workplace. Developing resources with individuals and as a team to address the symptoms associated with burnout and compassion fatigue is vital to performance and wellbeing. Individuals have a responsibility to care for themselves as well as care for their professional responsibilities in the healthiest way. Developing a self-care action plan can assist in identifying and addressing your needs and ways to incorporate a plan into daily routine. Building resilience is imperative in veterinary professions to manage and avoid compassion fatigue and burnout. Keywords: self-care, compassion fatigue, burnout, wellness, mental health Compassion fatigue is exhaustion due to the demands of being empathetic and helpful to others who are suffering. Veterinary professionals are susceptible to compassion fatigue due to dealing with death and dying on a daily basis. Research shows that veterinary professionals deal with ethical decisions three to five times per week, this large load of moral stress can lead to compassion fatigue and burnout. Burnout is the end point in the veterinary profession for some individuals. Signs and symptoms of compassion fatigue are many, the following are a few examples: sadness and apathy, difficulty concentrating, lack of self-care, mental and physical exhaustion and isolation from others. Stress can lead to distress or negative wellbeing. Eustress or positive stress, is the action enhancing stress that keeps individuals motivated for life. The balance of these is very important to effective functioning in daily life. Self-care is an important addition to build resilience and assessing a self-care plan can assist in identifying and addressing your needs to add into your daily routine. Self-care is the act of caring for yourself, is any
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activity we do deliberately to care for our mental, emotional, and physical health. Self-care and addressing this need is just as important as completing job responsibilities. Personal strategies for self-care may include lifestyle changes, adopting a healthier lifestyle, reduction of working hours, and ensuring adequate sleep. Incorporating things like adequate nutrition and sleep, physical activity, and active relaxation to routine can assist in building resilience. Awareness of compassion fatigue and burnout are also key to avoiding these. Developing a self-care action plan begins by addressing strengths and areas for growth in this area. Targeting each area of mental, emotional, and physical health by developing positive coping strategies in each area. References
1. Lloyd C, Campion D. Occupational stress and the importance of self-care and resilience: focus on veterinary nursing. Irish Veterinary Journal. 2017;70(1).
2. Parker K, Ragsdale J. Effects of Distress and Eustress on Changes in Fatigue from Waking to Working. Applied Psychology: Health and Well-Being. 2015;7(3):293-315.
3. Cake M, Bell M, Bickley N, Bartram D. The Life of Meaning: A Model of the Positive Contributions to Well-Being from Veterinary Work. Journal of Veterinary Medical Education. 2015;42(3):184-193.
4. Cake M, McArthur M, Matthew S, Mansfield C. Finding the Balance: Uncovering Resilience in the Veterinary Literature. Journal of Veterinary Medical Education. 2017;44(1):95-105.
5. Kogan L, Wallace J, Schoenfeld-Tacher R, Hellyer P, Richards M. Veterinary Technicians and Occupational Burnout. Frontiers in Veterinary Science. 2020;7.
6. Work and compassion fatigue [Internet]. American Veterinary Medical Association. 2020 [cited 11 September 2020]. Available from: https://www.avma.org/resources-tools/wellbeing/work-and-compassion-fatigue
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Emergency Triage and Stabilization Procedures
Sharon F. Price LVT, VTS (ECC)
Auburn University College of Veterinary Medicine
1220 Wire Rd. Auburn, Al 36849
(334) 844-4690
Quickly obtaining and interpreting baseline results in an emergency is critical. This includes
temperature, pulse, respiration, Quick Assessment Test (QAT), blood pressure,
electrocardiogram, capillary refill time and pulse oximetry.
Keywords: Emergency, Triage, Blood Pressure, Pulse Oximetry, baseline results
Triage
Triage is from the French word to sort. It is used to classify emergencies based on the severity of
illness, meaning you would treat the most critical patient first rather than in order of arrival. The
veterinary nurse is usually the first to evaluate the animals upon arrival at the hospital. If
multiple animals arrive within a few minutes of one another, you need to quickly assess each
animal and decide which have the most critical issues and which would be able to wait safely.
Obtain a brief history of why the animal is presenting and any previous illnesses. A quick initial
exam can be done by listening and watching the animals breathing, feeling for pulses, and
checking the mucous membrane color. A complete exam can be performed later. The decision
of who is more emergent can be based on respiratory, cardiac and neurological assessment.
These can then be further broken down into ABCDs: A-airway, B-breathing, C-circulation, and
D-decreased mentation/central nervous system. Some examples of an emergent animal that
would need to be seen immediately are severe respiratory distress, cardiovascular compromise,
and active seizures.
Physical Exam
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Start with the airway and breathing. Does anything seem to be obstructing the airway? Are
there any noises on inspiration or expiration? Is the effort normal or forced? The normal
inspiration expiration (I:E) ratio is 1:2, where an animal’s expiration is twice as long as the
inspiration. On expiration, the diaphragm relaxes, so exhalation should be relaxed and without
force. Sometimes noises and breathing patterns can help localize the abnormality. Animals with
upper airway obstruction, such as tracheal collapse, tracheal foreign body, or laryngeal paralysis,
may breathe with an increased effort on inspiration. Increased effort on expiration can indicate
lower airway pathology, such as pneumonia. Also, stertor or stridor may account for the noises
heard without a stethoscope. Stertor is a low-pitched noise that sounds like a snore and is caused
by vibrations in the upper airways. Stertor is common in brachycephalic breeds due to elongated
soft palates, stenotic nares, and everted saccules, all of which can cause loud snorting noises on
inspiration. Stridor is a high-pitched sound like wheezing and is caused by the restriction of
airflow as in tracheal collapse (increased inspiration) and laryngeal paralysis (increased effort on
inspiration and sometimes expiration). Count a respiratory rate. Is it normal (12-40 rpm), slow,
or fast and shallow? Is the patient open mouth breathing? Patients often adapt their respirations
to minimize the work of breathing. Auscultate the patient for increased, decreased, or absent lung
sounds. It may be challenging to recognize abnormal lung sounds, but by listening to all lung
fields, you may notice one field is more increased or decreased than the others. Increased lung
sounds may indicate pneumonia, with or without crackles. Crackles from aspiration pneumonia
are commonly auscultated in the right cranial and left middle lung lobes first and sound like
cellophane paper on inspiration. Are there decreased or absent lung sounds ventrally? This could
indicate pleural effusion. Absent lung sounds dorsally can indicate pneumothorax. If any of
these evaluations are abnormal, minimize stress to the patient and administer either flow by
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oxygen or place the animal in an oxygen cage. If you are not sure, a brief delivery of oxygen is
not going to hurt. Mild sedation may also be necessary.
Pulse oximetry is a noninvasive way of measuring oxygen saturation by using light absorption.
It measures the amount of hemoglobin carrying oxygen and reads it as a percentage called a
SpO2. Pulse oximeters function best over a strong arterial pulse. Pulse oximetry can be used on
the upper lip or toe web with the clip probe or by use of a flat probe on any artery, such as the
femoral, dorsal metatarsal, or the coccygeal arteries. Any area you choose should be free of fur
or debris to obtain an accurate reading. Adding a small amount of lube will help with contact if
using the flat probe. Many factors can affect SpO2, such as movement, any pigmentation other
than pink (dark coloration of the skin, anemia, or icterus), or decreased perfusion. A normal
SpO2 reading is 98-100% and any reading < 95% should warrant supplementation with oxygen.
Just like any other measured parameter, it should be interpreted with the other clinical findings.
It is vital to make sure the heart rate (HR) reading on the machine matches the patient’s actual
HR and that there is a strong pulse reading on the graph. If it does not match, the number should
not be trusted. Some oximeters also have a pulse waveform that can aid in accuracy. If you get
a reading in the 80% range and the patient is not cyanotic, the results are probably inaccurate.
Next, evaluate the cardiovascular system and circulation. The pulse quality should be assessed.
The pulse wave is formed by the difference in systolic and diastolic pressures. Palpate femoral
pulses while also auscultating the heart for synchrony. If you auscultate a heartbeat with a
missed pulse being palpated, this could indicate pulse deficits. Pulse deficits are an indicator of a
cardiac arrhythmia such as ventricular premature contractions. An ECG can confirm the
arrhythmia and if further treatment is indicated. Are the femoral pulses strong, weak, or
shallow? A weak pulse is due to poor cardiac output, caused by hypovolemia, decreased heart
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contractility, tachycardia, or arrhythmias. Can you palpate a dorsal pedal pulse? This is located
proximal to the metatarsals 3-4th digit (below the hock). Palpation of the dorsal pedal pulse
usually indicates a systolic blood pressure (SBP) of at least 80-90 mmHg and palpation of the
femoral pulse indicates SBP of at least 50-60 mmHg or greater. Although, sometimes in the case
of sepsis where the vessels and arteries are dilated, you may be able to palpate femoral and
dorsal pedal pulses but be unable to get a doppler reading. While listening to the heart, you
should also note if there are any murmurs (turbulent blood flow) which could indicate anemia or
underlying heart disease. Absent or decreased heart sounds could indicate pericardial effusion.
Heart rate should be evaluated with all of the other physical exam findings. Bradycardia (<60
dog, <160 cat) may indicate atrioventricular (AV) conduction disturbance (2nd or 3rd-degree heart
block), hyperkalemia (feline urinary obstruction), severe hypothermia, toxicity, or increased
intracranial pressure. Severe bradycardia could indicate the decompensatory phase of shock and
can cause a further decrease in cardiac output and a drop in the blood pressure. Tachycardia
(>160 large breed dog, >180 small breed dog, >240 cat) may be caused by anxiety/fear, fever,
pain, volume loss (fluids or blood), hypoxemia, or sepsis. An increased heart rate can be a
compensatory mechanism for a decrease in cardiac output. Once the compensatory mechanisms
in the body are exhausted, the patient will begin to decompensate quickly. Continuous
monitoring of the heart rate, blood pressure, temperature, and pulse quality is crucial. Heart rates
greater than two times the average rate will also lead to decreased ventricular filling and
therefore decreased cardiac output.
Mucous membrane (MM) color should be medium pink, which is a result of oxygenated
hemoglobin in red blood cells in the capillary bed. Red or injected MM occurs in cases of
vasodilation (sepsis or heatstroke). White or pale MM is a sign of vasoconstriction, as with pain,
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shock, or anemia. Blue or cyanotic MM can be caused by hypoxemia. Yellow or icteric MM is
common in hepatic disease, bile duct obstruction, or hemolysis.
Capillary refill time (CRT) is the time it takes for the color to return to the gums when pressure
is applied. This should be 1-2 seconds and reflects perfusion to the peripheral tissue. It is better
to use the gums for obtaining a CRT rather than the lip, since you may cause tension on the lip
when pulled upward, which could affect refill time. This also applies when checking the MM
color, when pulling the lip away, the tension could also blanch the color from the lip, giving a
false impression of anemia. A prolonged CRT is associated with poor perfusion as with
dehydration, hypovolemia, vasoconstriction, pain, or shock. A fast CRT (< 1 sec) is
characteristic of vasodilation, as with hyperthermia or cardiac disease.
Blood pressure (BP) is the pressure exerted by the circulating blood on the walls of the blood
vessels. Direct or indirect methods can be used to monitor BP. Direct blood pressure monitoring
is the gold standard and measures the systolic (100-160 mmHg), diastolic (60-100 mmHg), and
mean arterial pressures (80-120 mmHg). The direct method is more accurate but requires
advanced technical skills compared to indirect methods. It involves the placement of an arterial
catheter connected to a fluid-filled transducer, a pressure bag, and a monitoring system. A more
common way to measure BP is indirectly using a doppler or an oscillometric machine. The
Doppler is an ultrasonic flow monitor that measures blood pressure by placing a probe over a
peripheral artery. A liberal amount of coupling gel is placed on the concave side of the probe, the
probe with the gel is then placed parallel over an artery until a clear pulse is audible. The probe
is attached to a monitor, which amplifies the sound of the blood flow under the probe. A blood
pressure cuff is placed proximal to the probe and is attached to a sphygmomanometer and
inflated until the swishing sound is no longer audible (occlusion of the artery). It is not
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necessary to squeeze the sphyg- as high as it will go, usually only 30 to 40 mmgh beyond where
the flow signal is lost is sufficient. The cuff is then deflated until the sound returns, which is the
reentry of blood into the artery. The first sound heard is the systolic pressure. Doppler can only
measure systolic pressure, but its ease of use makes it the most common method used in
hospitals. A doppler reading of less than 100mmhg in cats is closer related to the mean arterial
pressure. In short haired animals, you do not have to clip the fur over the artery but in furry
animals, I find that it is much easier to clip the fur to obtain good contact with the gel and artery.
If you do not clip the fur, you can use alcohol to wet down the fur and part it away from the
artery. The alcohol can sometimes help dilate the artery and make it easier to find. An
oscillometric machine gives a reading of HR, systolic, diastolic, and mean arterial pressures
(MAP). It measures blood pressure by detecting oscillations of the arterial wall and calculates a
reading based on wall motion. Many devices can be set to cycle for repeated measurements.
Movement by the animal, low perfusion, and arrythmias can give incorrect readings. Always
confirm the heart rate with the animal’s actual HR. If needed for serial readings of BP, you can
first obtain a reading with a doppler and then compare the systolic reading with that of the
oscillometer. What sized cuff should you use? The cuff’s width should be 40% of the limb
circumference in the dog and 30% in the cat. If the limb measures an in between size, use the
wider sized cuff. A cuff that is too large, will result in an inaccurate low reading and a cuff too
small, will result in an inaccurate high reading. The cuff should also be snug around the limb.
Too tight = high readings and too loose = low readings. The cuff size and site of reading should
be consistent. Trends are sometimes just important as the reading. You should obtain 5 readings
(doppler or oscillometric) and average the readings. The cuff should be at the level of the right
atrium. A blood pressure measured in a standing animal will be overestimated and by raising the
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leg with the cuff above the heart can underestimate the reading. Some animal’s limbs are not
made for blood pressure cuffs (dachshund). In these animals, the tail can be used. The tail can
also be used in cats, as they sometimes tolerate this better. Also, a dog that refuses to sit or lie
down, the tail can also be used, as it will be closer to the level of the heart.
Temperature is also very important, normothermia is considered 99.5-102.5°F. Severe
hyperthermia of 105°F or greater can cause brain damage, vasodilation, cardiac arrhythmia’s
coagulation disturbances, and sloughing of the gut just to name a few. Active cooling should be
initiated by wetting the animal down, using a fan, placing the animal on a steel exam table, and
most importantly administration of IV fluids. Continue to monitor the temperature every 5-10
minutes. Stop active cooling, once the temperature is 103.5°F, to avoid rebound hypothermia.
Severe hypothermia (95°F or less) can cause cardiac arrythmias, decreased immune function, and
vasoconstriction. When rewarming, always monitor closely and stop active warming in the
99.5°F range. If busy, always set a timer to remind yourself to recheck the temperature, so not to
overheat animal.
Mentation should be evaluated for alertness and responsiveness. Is the mentation appropriate for
the environment? The level of consciousness may be altered in traumatic brain injury after being
hit by a car, seizures, or from a toxicity. Level of consciousness can be described as alert, dull,
obtunded, stupor, or coma.
Initial database
Quick Assessment Test (QATs) is a term for simple test’s that are obtained for any animal upon
intake to your clinic. At Auburn our QATs include: PCV (35-45%), TP (6-8 g/dL), BG (80-120
mg/dL), and Lactate (< 2.5 mmol/L). These tests can be done quickly and with only a small
amount of blood by using the stylet from the intravenous catheter when first placed. These
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baseline results help determine a patient’s current status and help guide further treatments.
Packed cell volume (PCV) and total protein (TP) should be evaluated together. They are a means
of monitoring an animal’s hydration status and blood loss. An increase in both, PCV and TP, are
consistent with hemoconcentration and dehydration. A decrease in TP (<6 mg/dL) with a normal
PCV is indicative of acute hemorrhage. With acute blood loss, the PCV may initially be normal
due to splenic contractions. With a decrease in PCV and TP could indicate chronic blood loss.
Total protein can be high, due to dehydration, and low due to fluid loss through vomiting and
diarrhea. Blood glucose (BG) may be low in neonates, animals with sepsis, or insulin overdose,
which would warrant dextrose administration. Hyperglycemia may be present in diabetics or due
to stress in cats. When using the point of care (handheld) blood glucose analyzer’s the glucose
may be high or low depending on the hematocrit. You may obtain a false low BG reading with
hemoconcentration (high PCV) and vice versa, a false high BG reading may be obtained with a
low PCV. There was a study done using the Alpha®TRAK 2 (zoetis), where very
hemoconcentrated samples had a lower ratio of plasma to react with the reagent and produced
false low glucose readings. With hemodilute samples, there is more plasma to react with the test
reagent and resulted in false high readings. I have found this to be true in cases where the PCV
was in the 60-80% range, or with PCV in 12% range. If you think the low or high BG reading is
due to hemoconcentration or hemodilution, you can measure a glucose on the plasma. Also, a
formula is available through the study to use for a corrected glucose.
Blood lactate is a measurement of tissue perfusion and is due to the formation of lactic acid
during anaerobic metabolism. This measurement may be high due to seizures, hypovolemia, or
gastric dilation volvulus (GDV). Lactate concentration can be an indicator of disease severity. It
should normalize with appropriate therapy such as fluids, oxygen, blood transfusion, control of
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seizures, or correction of GDV. Failure of the lactate to decrease, could indicate a poor
prognosis.
In an ideal world all animals would present to the hospital at spaced out intervals. If you work
in general practice, maybe you have emergencies once in a while but at an emergency or
specialty practice it seems like all the animals present at the same time. Being able to quickly
assess which conditions to treat first is crucial. I hope this presentation helps you to understand
what the different results indicate, and how they may relate to different emergency situations.
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References
Breton AN. Triage and initial assessment of the emergency patient. In: Norkus CL, editor.
Veterinary technician’s manual for small animal emergency and critical care. Iowa:
Blackwell; 2012. p. 6-24.
Davis H. Triage. In: Creedon JM, Davis H, editors. Advanced monitoring and procedures for
small animal emergency and critical care. Iowa: Blackwell; 2012. p. 6, 9.
Macintire DK, Drobatz KJ, Haskins SC, et al. Manual of small animal emergency and critical
care medicine. Iowa: Blackwell; 2006.
Reinke EL. Evaluation and triage of the critically ill patient. In: Silverstein DC, Hopper K,
editors. Small animal critical care medicine. 2nd edition. St. Louis: Saunders; 2015. p. 2.
Hackett TB. Physical examination and daily assessment of the critically ill patient. In:
Silverstein DC, Hopper K, editors. Small animal critical care medicine. 2nd edition. St. Louis:
Saunders; 2015. p. 6-9.
Farry T. Monitoring the critical patient. In: Norkus CL, editor. Veterinary technician’s
manual for small animal emergency and critical care. Iowa: Blackwell; 2012. p. 65-67, 72-
74.
Paul AH, Shiel RE, Juvet F, et al. Effect of hematocrit on accuracy of two point-of-care
glucometers for use in dogs. In: Vetgirl, 2020. How accurate are point-of-care glucometeres
in hemodiluted and hemoconcentrated canine blood samples?. [podcast].©2020Vetgirl, LLC;
[11 October 2020]. Available from: <http://vetgirlontherun.com/podcasts/.
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Emergency Triage and Stabilization Procedures
Christina M. Zaccardi, CVT [email protected]
Auburn University College of Veterinary Medicine 1220 Wire Rd. Auburn, Al 36849 (334) 844-6015
Abstract- In an ideal emergency situation, there is a specialized team to triage, assess, and
stabilize the patient in a quick and efficient manner. Since the nature of an emergency is far
from ideal, it becomes imperative for all team members to have a basic understanding on how to
obtain baseline data, perform basic tasks essential in critical care, and communicate results with
their doctors. Nursing tasks include but are not limited to: obtaining consent along with patient
data and relevant history from owners, initial triage and assessment of the patient, and their
initial stabilization. Today we will briefly cover some vital nursing tasks involved in stabilizing
an emergency patient to promote quality patient care and a functional nursing team.
Key Words- Catheter, emergency, shock, and stabilization
Most tasks must be done simultaneously in order to provide necessary care. As one team member
is working on triage and gathering critical data another should be working on stabilization. Just
as patients are prioritized based on severity, some nursing tasks must be prioritized above others.
Proper administration of critical drugs and fluid therapy is heavily based on the patient weight.
Therefore, an accurate patient weight in kilograms should be the first task performed. If not
possible then nurses should be prepared to confidently estimate the weight. There is no exact
science to this, and accuracy comes with practice. Being familiar with the weight standard of one
or two common breeds from each size group from a reputable resource such as the American
Kennel Club will go a long way on honing this skill. Nurses should also be prepared to convert
weight from pounds to kilograms if need be. As soon as the situation permits, an accurate
weight must be obtained.
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Securing a patient intravenous catheter (IVC) is the most critical nursing task and should be
performed first in most emergencies. Though you normally have four legs with veins to choose
from occasionally they will not be viable. Knowing how and when to place an IVC in a central
vein or perform an advance technique such as a cut down or intraosseous catheterization may be
your patients only option. With familiarization and practice, these techniques can be mastered by
almost any nurse.
Since time is short and technical skill is high, most catheter placements are in a peripheral vein
on a leg. Many factors must be quickly considered when doing so. First, pick the site that
promotes the best fluid and drug administration. Ideally, they should be placed in the least
damaged front leg. Remember that the nature of the emergency, body condition, and physical
confirmation will all effect the viability of a vein. Short legged animals such as dachshunds or
munchkin cats may physically lack the real estate to place the most desirable catheter. If the
patient has extensive trauma such as road rash, morbid obesity, or poor skin then a rear leg may
provide the most reliable vein. If perfusion is an issue such as with possible GDV or saddle
thrombus patients then rear leg veins are not a viable option. Being aware of patient condition,
physical limitations of the presenting complaint, anatomical landmarks, and all vain options will
give you the most opportunities for success.
When your patient is hemodynamically compromised (unable to place a peripheral catheter) you
can always attempt to gain venous access through the jugular vein. After placing the peripheral
catheter, it can be secured by splitting the tape in half to create butterfly wings similar to a
butterfly needle. The catheter wings can now be secured by either staples or suture. Do not tape
around the neck as you would with a peripheral vein. After wrapping the neck with cast padding
and vet wrap, finish securing the catheter and T-port by taping them to the vet wrap. Neonates
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and dull or lethargic patients usually tolerate a jugular catheter well if secured properly. Once the
patient becomes more stable, then it will need to be replaced with a peripheral catheter.
Once a site has been chosen, quickly shave and prep your site. This does not need to be pretty by
any means. Ultimately, you will have to balance good patient care and immediate need based on
the severity of the situation. However, taking the time to be through will pay off in the long run.
The limb should be shaved completely around with wide margins above and below the actual
intended puncture site. This provides three critical benefits. First, it is the most sanitary for
preparation, placement, and maintenance of the catheter. Second, it provides the best
visualization for the main and any accessory veins. Third, it provides the best surface for tape to
stick to the skin. A fringe benefit is that your patient appreciates the tape removal far better than
ripping off their fur.
Once you have shaved, clean the site. If you patient is practically bloody, filthy, or flaky you will
need to take the extra time to remove that grime. Failing to do so not only makes your job harder
but will be a possible source of infection for your patient if they survive the immediate
emergency. Quickly use your scrub to remove the bulk of the grime before your actual scrub for
catheter placement. Next, perform a quick scrub of the puncture site using aseptic technique and
alternating between a premixed surgical scrub and alcohol. You can never scrub too much but
you can scrub too little. Performing at least three complete passes helps ensures that no matter
how chaotic the situation that you are providing good nursing care. Do not spend excessive time
cleaning the site. If time doesn't allow for complete aseptic cleaning (animal presents while
coding), you can always shave and do minimal cleaning of the site. Once the patient becomes
more stable, replace the catheter with appropriate aseptic technique.
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If you have not already, quickly rip your tape to secure the catheter and flush your T-port. There
is no one right way to tape in a catheter but there are plenty of wrong ways. If your tape job does
not occlude the vein or ports, keeps the catheter straight, and secures it then it is a successful tape
job. Once your patient is stable you can always go back and retape the catheter to meet your
practice standards. Every catheter should be finished off with a cast padding and vet wrap
placement above and below the access port to ensure stability, cleanliness, and good patient care.
However, as soon as the catheter has been secured then fluid and drug administration should
begin if the situation dictates. Do not delay critical care for the sake of cast padding and vet
wrap.
Size matters and when it comes to the actual catheter, and bigger is better. The goal is to place
the biggest bore size with the shortest length to ensure the quickest drug and fluid delivery.
Reality is that you need the largest catheter that you can place and secure. Severe dehydration,
shock, or odd body confirmation may force you to place a smaller gauge then you would
normally place. Do not be afraid to drop a size if the vein or patient is proving to be
uncooperative. A patient small catheter is better than no catheter.
Do not forget that your unflushed catheter needle and or catheter cap will contain enough blood
sample to obtain Quick Assessment Tests (QAT) data. This not only saves time, frustration, and
material but will keep your remaining veins integrity intact for future treatments.
Most critical emergency patients suffer from shock upon presentation. Without the diligent
observation and intervention provided by the nursing team, their condition can rapidly
deteriorate. Nurses are normally tasked with executing treatment, diagnostic testing, and
providing the supportive care as the attending veterinarian develops further treatments, interprets
15
data, and communicates with owners. Being vigilant of the patients' fragile state and
communicating changes is vital to their overall survival.
Common tasks nurses are charged with as the veterinarian continues their assessment include
oxygen therapy, thermo regulation, wound management, fluid therapy, and drug administration
along with continued observation and reassessment of the patient. As silly as it sounds, we must
always ensure that our patient is still beathing and that their heart is still beating at all times.
Often in the chaos of stabilization we develop tunnel vision with treatment. When possible, there
should be a nurse charged with patient observation. They can often carry out oxygen therapy,
thermo regulation, basic wound management, and reassessment in conjunction with observation.
When staffing or situation does not permit, then it is critical that the attending nurse make
regular checks of the patients' status. It is much easier to treat a live patient then a dead one.
Fluid therapy and drug administration should be carried out by a separate dedicated nurse when
possible. By having one dedicated nurse, critical mistakes can often be avoided such as over or
under dosing. This also allows for accurate and efficient record management, communication,
and product utilization. Though rare, proper management of too many helpers is just as vital as
not enough and should be planned for in advanced. By identifying the nurse responsible for drug
and fluid administration at the start of an event will reduce stress and provide better care overall.
Knowing the products you have on hand, how to administer them, and the common dosing
allows the nurse to carry out the doctors’ orders efficiently and independently. Confidents and
knowledge come with time and practice. It is never a bad idea to review emergency fluid
therapy.
Isotonic crystalloids such as Norm-R, LRS, and 0.9% NaCl have electrolytes similar to that of
plasma. Large volumes of these fluids stay in the vascular space for about 30 minutes making
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them safer to administer in shock boluses. Total shock dose is equivalent to the estimated blood
volume of the patient (60-90 mL/kg (90 mL/kg) for dogs and 45-60 mL/kg (60 mL/kg) for cats).
The total shock dose is typically administered in ¼ increment boluses over 15min with patient
reassessment to include mentation, temperature, pulse, respiration, capillary refill time, and
blood pressure assessed between each bolus. Boluses are delivered to effect and each assessment
should be communicated to your attending veterinarian as they are performed. Any sudden
changes in patent condition during administration should also be immediately reported. Typical
bolus dose is 10-20 mL/kg bases on severity of the situation.
Hypertonic crystalloids such as hypertonic saline and 7.5% NaCl have a greater osmolality than
plasma. This draws water into the intravascular space from the interstitial and intracellular space
(water follows salt) resulting in increased volume in the intravascular space. This is particularly
helpful for animals where rapid vascular expansion is needed or in cases where small volumes
are preferred such as traumatic brain injuries and seizers. The primary adverse effect is
immediate hypernatremia. This makes it contraindicated in dehydrated patients and should be
used with extreme caution in cardiac patient. Typical dose is 3-5 mL/kg (4 mL/kg) over 10 min
and is given after several boluses of crystalloid fluids to help counter the hypernatremia.
Performing all the tasks involved with stabilizing a patient can overwhelm even the most
seasoned nursing team. Stress can escalate the situation putting the team on edge making
members prone to mistakes and outbursts. Through education and practice, tasks can be
prioritized and delegate quickly and efficiently to promote the best outcome while maintaining a
cohesive team dynamic. All emergencies have an element of fear and panic. It is each of our
responsibilities to rise to these challenges to promote the health and welfare of our patients.
Thank you for your time.
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References
· Davis H. Triage. In: Creedon JM, Davis H, editors. Advanced monitoring and procedures for
small animal emergency and critical care. Iowa: Blackwell; 2012.
· Macintire DK, Drobatz KJ, Haskins SC, et al. Manual of small animal emergency and critical
care medicine. Iowa: Blackwell; 2006.
· Farry T. Monitoring the critical patient. In: Norkus CL, editor. Veterinary technician’s manual
for small animal emergency and critical care. Iowa: Blackwell; 2012.
