Let the fun begin Or Passez le bon temp

Let the fun begin Or Passez le bon temp
Emergency Procedures Let the fun begin Or Passez le bon temp

Triage of Emergency Patients
Triage—to sort (Fr); most critical seen first Should be done by RVT in busy practice; receptionist should not do it Initial exam (by RVT) Wear gloves Animal muzzled (use discretion) Minimize movement of patient Initial Assessment (30-60 sec; from rostral direction) Mentation (level of consciousness) A Alert V Verbally responsive P responsive to painful stimuli U Unresponsive Extend head/neck to provide clear airway; check for patency Breathing/respiratory pattern (shallow, labored, rapid, obstructed) Abnormal body/limb posture (fracture, paralysis) Presence of blood or other material around patient

Initial Assessment (continued) Breathing/respiratory pattern Total/Partial blockage of airways (Requires immediate Rx) Exaggerated inspirations Nasal flare, open mouth, extended head/neck Cyanosis Breathing assessment Watch chest wall movement Auscult lungs bilaterally to r/o hemo- or pneumothorax

Vital signs (taken after initial assessment) HR, pulse rate (same as HR?), strength RR mm color, cap refill Temp BP High HR, high BP→ pain High HR, low BP → hypovolemic shock Baseline data ECG (lead II) Chem panel, CBC

Resuscitation (treatment to restore life/health) Analgesics for pain once airway patency and heart beat are established (these are critical for life) Control hemorrhage Pressure bandages (sterile gauze, laparotomy pads, towels) If bleed thru, do not remove initial bandage, apply another on top On distal extremity, BP cuff can be placed proximal to wound (avoid tourniquet if possible) External counterpressure using body wrap of pelvic limbs, pelvis, and abdomen Insert urinary cath to monitor urine output Use towels, cotton rolls, duct tape, etc Monitor respirations (diaphragm/abdominal breathing compromised) Leave on until hemodynamically stable (6-24 h) Monitor BP during removal If BP drops >5 mm Hg, stop removal; infuse more fluids If BP continues to drop, reapply wrap

History (mnemonic) A Allergies M Medications P Past History L Lasts (meals, defecation, urination, medication) E Events (What is the problem now?) How long since injury Cause of injury (HBC, dog fight, gunshot) Evidence of loss of consciousness Blood loss? Deterioration/improvement since accident (good indicator of Px) Any other underlying medical conditions/medications

Shock What is shock? General Public Medically Psychological
Poor O2 delivery to tissues, esp brain

Shock Types of Shock: Cardiogenic—results from heart failure
↓ blood pumped by heart HCM, DCM, valvular insufficiency/stenosis Distributive—blood flow maldistribution (Vasodilation) From psychological shock Sepsis, anaphylaxis →↓arteriole resistance →loss of fluid from vessels to interstitial spaces →↓ blood return to heart →↓BP Obstructive—physical obstruction in circ system HW disease →↓blood pumped by heart Gastric torsion →↓blood return to heart Hypovolemic—decreased intravascular volume Most common Blood loss, dehydration from vom/dia

Shock Pathophysiology (of hypovolemic shock)
↓blood vol →↓venous return, ↓vent filling →↓stroke vol, ↓CO →↓BP Compensation—Baroreceptors detect hypotension (↓BP) Sympathetic reflex—(Epi, Norepi, cortisol released from adrenals) ↑ HR, contractility Constriction of arterioles (↑BP) to skin (cold, clammy), muscles, kidneys, GI tract; not brain, heart Renin (kidney)→angiotensin (blood)→aldosterone (adrenals) reflex ↑ Na+ and water retention → ↑ intravascular vol (↑BP)

Shock Recognition History PE findings Trauma Vom/dia
Stage I (compensated shock) Tachycardia Prolonged cap refill time Pale mm Stage II (decompensated shock) Delayed cap refill time Muddy mm (loss of pink color, more brown than pink) BP is dropping Altered mental state Stage III (irreversible shock) PE findings worsen; cannot revive; death will occur

Shock Rx (the goal of therapy is to improve O2 delivery)
O2 supplementation Face mask O2 cage/hoods Transtracheal/nasal insufflation Venous access Cephalic Saphenous Jugular Intraosseous ulna

Shock Rx (continued: remember the goal of therapy is to improve O2 delivery) Fluid resuscitation (O2 delivery is improved by ↑CO) 1. Crystalloids Isotonic solutions (crystalloids; Na+, Cl-, K+, bicarb) Examples (body fluid= mOsm/L) Lactated Ringer’s (273 mOsm/L) Normal saline (0.9%) (308 mOsm/L) Dose: Dog ml/kg/hr Cat ml/kg/hr Hypertonic solutions—when lg vol of fluid cannot be administered rapidly enough Examples—7.5% saline Causes fluid shift from intracellular space→ interstitial space→ intravascular space →↑vascular vol →↑venous return → ↑CO Also causes vasodilation → ↑ tissue perfusion Dose: 4-6 ml/kg over 5 min Hypotonic solutions should never be used for hypovolemic shock Examples—5% Dex in water (252 mOsm/L)

Shock Rx (continued: remember the goal of therapy is to improve O2 delivery) Fluid resuscitation (O2 delivery is improved by ↑CO) 2. Colloids— Large molecular wt solutions that do not leave vascular system Better blood vol expanders than crystalloids 50-80% of infused vol stay in blood vessels Examples Whole blood Plasma Dextran 70

Shock Rx (continued) Sympathomimetics
Use only after adequate fluid administration if BP and tissue perfusion have not returned to normal Dopamine (Intropin®) μg/kg/min Dilation of renal, mesenteric, coronary vessels μg/kg/min ↑ contractility of heart ↑ HR >7.5μg/kg/min Vasoconstriction Dobutamine (Dobutrex®) 5-15 μg/kg/min ↑ contractility of heart (min effect on HR)

Shock Monitoring Physical Parameters
Hemodynamic/metabolic sequelae of shock are continually changing Physical Parameters Respiratory Color of mm RR and Tidal Vol adequate? Breathing efforts smooth? Breathing pattern regular? Auscultation normal? Cardiovascular HR normal? ECG normal? Cap refill time (1-2 sec) Urine production? (1-2 ml/kg/hr) Weak pulse? → ↓stroke vol

Shock Monitoring Physiologic Monitoring Parameters O2 Saturation
Pulse oximetry—noninvasive Normal: Hb saturations (SpO2)>95% SpO2<90%--serious hypoxemia Arterial BP—a product of CO, vascular capacity, blood volume If one is subnormal, the other 2 try to compensate to maintain BP

Shock Monitoring Laboratory Parameters Hematocrit (PCV)
Increase →dehydration Decrease →blood loss Electrolytes (what is that?) Proper balance needed for proper cell function Fluid therapy may alter the balance; supplement fluid as needed Arterial pH and blood gases PaCO2 tells how well patient is ventilating PaCO2 <35 mm Hg → hyperventilation PaCO2 >45 mm Hg → hypoventilation PaO2 Tells how well patient is being oxygenated PaO2 <80 mm Hg → hypoxemia pH tells acid/base status of patient <7.35 → acidosis >7.45 → alkalosis

Cardiopulmonary Resuscitation (CPR)
Cardiopulmonary Arrest (CPA)—Heart stops, breathing stops Causes Anesthesia Dogs Trauma Infections (GI, pneumonia) Heart disease Autoimmune disease Malignancy Cats Infectious diseases

Cardiopulmonary Resuscitation
Resuscitation Team Members Should be 3-5 members Team leader—Veterinarian or RVT with most experience All members have several responsibilities Provide ventilation Chest compression Establish IV line Administer drugs Attach monitoring equipment Record resuscitation efforts Monitor team’s effectiveness Teams should practice on a regular basis to stay sharp

Facilities Adequate room for entire team and equipment O2 source Good lighting Crash cart with all needed Rx (should be checked at beginning of each shift) Defibrillators Electrocardiogram Suction Table to perform chest compression Grated surgery prep table not solid enough for chest compression Use board underneath patient Recognition RVT should ID patients at risk and observe any deterioration Preventing an arrest is easier than treating one

Standard Emergency Supplies (on crash cart) Pharmaceuticals --Venous access supplies Atropine ● Butterfly cath Epinephrine ● IV caths Vasopressin ● IV drip sets 2% lidocaine (w/o epi) ● Bone marrow needles Na+ bicarb ● Syringes Ca++ chloride or gluconate ● Hypodermic needles (var sizes) Lactated Ringer’s, hypertonic saline, ● Adhesive tape dextran 70, hetastarch ● Tourniquet Airway access supplies --Miscellaneous supplies Laryngoscope ● Gauze pads (3 x 3) Endotracheal tubes (variety of sizes) ● Stethoscope Lubricating jelly ● Minor surgery pack Roll gauze ● Suture material ● Scalpel blades ● Surgeon’s gloves

Basic Life Support (Phase I) Remember the priorities (ABC; Airway, Breathing, Circulation) Establish patent Airway Endotracheal tube Tracheostomy tube for upper airway obstruction Suction to remove blood, mucus, pulmonary edema fluid, vomit Artificial ventilation (Breathing) Ambu-Bag Anesthetic machine Ventilate once every 3-5 sec Chest compressions in between breaths

Cardiopulmonary Resuscitation Entubation

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

Basic Life Support (Phase I) Circulation Internal cardiac compression More effective than external compression ↑CO, ↑BP, higher survival rate Indications Rib fractures Pleural effusion Pneumothorax If not responsive after 5 min of external cardiac compression Preparation Clip hair ASAP, no surgical scrub Incision at 4th or 5th intercostal space With a gloved hand, compress heart between fingers and palm (Do not puncture heart with finger tips or twist heart) After spontaneous beating returns, flush chest cavity with saline, perform sterile scrub of skin and close

Basic Life Support (Phase I) Assessing effectiveness (must be done frequently) Improved color of mm Palpable pulse during cardiopulmonary resuscitation (difficult) If efforts are not effective, do something differently Use different hand Change person performing compression Ventilate with every 2nd or 3rd chest compression Compress chest where it is widest in lg breed dogs Apply counter-pressure to abdomen (hand, sandbag) Prevents posterior displacement of diaphragm and increases intrathoracic pressure

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) Drugs Fluids Lactated Ringer’s is standard (do not use Dextrose) Initial dose: Dogs—40 ml/kg (rapidly IV) Cats—20 ml/kg Atropine—parasympatholytic effects (blocks parasympathetic effects) mg/kg ↑HR ↓secretions Epinephrine—adrenergic effects mg/kg Arterial and venous vasoconstriction→ ↑BP

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) Drugs (continued) 2% Lidocaine (Used to treat cardiac arrhythmias) Dogs: 1-2 mg/kg Cats: mg/kg Magnesium Sulfate or Chloride (For refractory ventricular fibrillation) 30 mg/kg over 2 min period Sodium bicarb (For metabolic acidosis) 0.5 mEq/kg per 5 min or cardiac arrest Vasopressin (ADH) (vasodilator) 0.8 U/kg

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) Drugs (continued) Route of drug administration Jugular vein—close to heart; drugs will get to heart quicker Cephalic, saphenous—follow drugs with ml saline flush Intraosseous—intramedullary cannula into femur, humerus, wing of ilium, tibial crest Intratracheal—for limited # of drugs: atropine, lidocaine, epinephrine Intracardiac—last resort; several complications can occur Depends on Speed of access Technical ability Difficulties encountered Rate of drug delivery

Advanced Life Support (Phase II) Add 2 priorities to ABC--D E (administer Drugs, Electrical—defibrillate) Electrical—Defibrillate Purpose—eliminate asynchronous electrical activity in heart muscles by depolarizing all cardiac muscle fibers; hopefully, the fibers will repolarize uniformly and start beating with coordinated contractions Paddles (with electrical gel) placed on each side of chest Yell “CLEAR” before discharging electrical current Start with low charge and increase as needed External: 3-5 J/kg Internal: J/kg normal ECG Ventricular fibrillation

Prolonged Life Support (Phase III) Once heart is beating on its own, monitor the following: HR and rhythm Antiarrhythmic drugs Correct electrolyte abnormalities BP Peripheral perfusion Color of mm Cap refill time urine output RR and character of breathing Adequate breathing Auscultory sounds Mental status Improving or deteriorating UC Davis study: survival rate at 1 wk for cardiac resuscitation patients Dogs: 3.8% Cats: 2.3%

Allergic Reactions

Anaphylaxis/Allergic reactions
Rare, life-threatening reactions to something injected or ingested Untreated, it results in shock, resp/cardiac failure, and death IgE Antibodies to allergen bind to mast cells; on subsequent exposure, the Ag-Ab reaction causes massive release of histamine and other inflammatory mediators Histamine → vasodilation → ↓BP Initiating factors Insects Vaccines Antibiotics Certain hormones Other medications Foods Re-exposure

Signs Sudden onset of vom/diarrhea Shock Gums are pale Limbs are cold HR rapid, weak Face scratching (early sign) Respiratory distress Collapse Seizures Coma Death

Rx (this is an extreme emergency) Eliminate cause Epinephrine H1 antihistamines (Diphenhydramine) IV fluids Corticosteroids Oxygen Prevention There is no way to predict what will bring on an anaphylactic reaction the first time Always inform vet if animal has had previous reaction to vaccine Owners should have an ‘epi-pen’ with them at all times

Heat Stroke Signs Rapid, frantic, noisy breathing
Tongue/mm bright red, thick saliva Vomiting/diarrhea—may be bloody Rectal temp up to 106º Unsteady/stagger Coma/death Prevention

Heat Stroke (Hyperthermia)
Requires immediate treatment Dogs do not cool as well as humans (don’t sweat) Causes Left in hot car Water deprivation Obesity/older Chained without shade in hot weather Muzzled under a hot dryer Short-nosed breed (esp Pug, Bulldog)/heavy coat Heart/Resp disease or any condition that impairs breathing or ability to cool body Lack of acclimatization/exercise

Heat Stroke Rx (cells break down at 107º)
Mild cases: move dog to a/c building or car Temp>104º, immerged in cool water, hose down Temp>106º, cool water enema (cool to 103º) STOP COOLING EFFORTS AT 103º IV fluids Corticosteroids

Heat Stroke Complications Can affect all organs in the body
Denatures proteins Hypotension Lactic acidosis Decreased oxygen delivery Electrolyte abnormalities => cerebral edema and death Coagulopathies => DIC If survives the first 24 hrs, prognosis is more favorable

Pain Management Misconceptions about animal pain
Animals do not experience pain Pain doesn’t really affect how animal responds to treatment Signs of pain are too subjective to be assessed Pain is good because it limits activity Analgesia interferes with accurate assessment of treatment Pain management not major concern in LA (except horses) Pain shows weakness/fragility (Lab vs Collie) Fresh ideas about animal pain Analgesia increases chance of recovery in critically ill Pain associated with diagnostic test should be minimized Morally correct thing to do

Pain Management

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

Pain Management Sequelae to untreated pain Neuroendocrine responses
Excessive release of pit, adr, panc hormones Cause immunosuppression and disturbances of growth, development, and healing Cardiovascular compromise ↑BP, HR, intracranial pressure Coagulopathies ↑platelet reactivity, DIC Long-term recumbency Decubital ulcers Poor appetite/nutrition Hypoproteinemia→slow healing

Pain Management Pain Relief
Nonpharmacologic interventions (differentiate pain vs stress) Give relief from: Boredom, Thirst, Anxiety, Need to urinate/defecate Clean bedding/padding Reduce light/sound Stroking pet, calming speech Owner visits (±) Minimize painful events (reduce #, improve skill [inject, blood draw]

Pain Management Questions the Vet Tech must continually ask (you are in charge of pain meds) Is patient at acceptable comfort level Are there any contraindications to giving pain meds What is the appropriate (safe, effective) med for this patient

Pain Management Drug Options
Nonsteroidal Antiinflammatory Drugs (NSAIDs) Most widely used Extremely effective for acute pain Most effective when used preemptively (before tissue injury) Usually not adequate to manage surgical pain COX-2 NSAIDs do not cause damage to stomach lining Opioids Most commonly used in critically injured animals Rapid onset of action; effective; safe 4 types of receptors μ: analgesia, sedation, and resp depression Κ: analgesia and sedation Δ: some analgesia, resp depression Σ: depression, excitement, anxiety Side effects Vomiting, constipation, excitement, bradycardia, panting Metabolized by liver; excreted by kidneys Use caution with hepatic, renal disease

Pain Management Opioids Morphine sulfate (the gold standard)
Used for max analgesia/sedation Inexpensive Side-effects: systemic hypotension, vomiting Cats particularly sensitive Dose: Dogs— mg/kg SQ, IM; mg/kg IV Cats— mg/kg SQ, IM Oxymorphone 10x potency of morphine Much more expensive; less resp depression and GI stimulation Side-effects: depression, sensory hypersensitivity Dose: mg/kg IV, IM Hydromorphone Similar effects of Oxymorphone More widely available, less expensive than Oxymorphone Dose: Dog— mg/kg SQ, IM Cat— mg/kg SQ, IM

Pain Management Opioids Fentanyl citrate Butorphanol Tartrate
Extremely potent Rapid onset, short duration when administered IM or IV Transdermal patch 3-day duration Shave hair Butorphanol Tartrate Κ agonist; μ antagonist Analgesic effect questionable (>1 h); good sedative (~2 h) More expensive than morphine Less vomiting, depression Dose Dog— mg/kg SQ, IM; mg/kg IV (Half that dose in Cat) Buprenorphine 30x potency of morphine; longer duration; transmucosal absorption Dose: Dog/cat— mg/kg SQ, IM, IV, buccal mucosa

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

Toxicologic Emergencies
Signs will vary depending on character of toxic compound Anxiety (marijuana) Seizures Unresponsive, Coma Toxicity can result from exposure via many routes Ingestion—most common; usually accidental (angry neighbor?) Inhalation Skin contact—animals should be washed to remove toxin Injection—either o.d. in vet hosp or recreational drug use Equipment List: Basic equip: IV cath, fluids, bandages, ECG, O2, crash cart Emetics Activated charcoal Stomach tubes Valium, muscle relaxers

Top 10 Toxicoses (2005) Human medication—painkillers, NSAIDs, antidepressants Insecticides—flea and tick Rodenticides—anticoagulants Veterinary medication—NSAIDs, HW Household cleaners—bleach, detergents Plants—sago palm, lily, azalea Herbicides— Chocolate—highest in food category Home improvement products—solvents, adhesives, paint, wood glue Fertilizers

Hx—as thorough as possible May not know Legal issues Rx Treat clinical signs Seizures valium, phenobarbital Anxiety valium Coma IV fluids Induce vomiting (if animal is able) Some poisons release toxic gases Zinc phosphide (gopher bait) releases phosphine gas (well vent room) Wear gloves to prevent topical exposure to you Be cautious of abnormal behavior Biting

Prevent Further Damage Ocular exposure Rinse eyes with copious saline for min Chemical burns treated with lubricating ointment and suture lids closed Use corticosteroids only if corneal epithelium is intact Topical exposure Bathe with mild detergent (liquid dish soap) Bather should wear protective clothing (gloves, goggles) If toxic substance is a powder, vacuum before bathing

Ingestion Induce vomiting—if chemical not caustic; animal conscious, not seizuring ipecac, apomorphine, Xylazine, H2O2 [not reliable], salt [not recom], soapy water [not recom]) Dilute caustic substances with milk, water Gastric lavage—large bore stomach tube; light anesthesia w/ endotrach tube Administer absorbents—activated charcoal inhibits GI absorption Give orally or via stom tube Enemas/cathartics to eliminate toxins more rapidly

Specific toxicities Methylxanthines—↑HR, ↑RR, mild diuretic Ex: caffeine, theobromine, theophylline Found in: coffee, tea, stimulants, chocolate Chocolate (theobromine tox) -Found in cocoa bean, colas, tea -Contains all 3 methylxanthines -Theobromine toxic to dogs and cats; cats more finicky -Toxic Dose: mg/kg; Milk Chocolate—44 mg/oz, Baking Chocolate—390 mg/oz

Clinical Signs anxiety, vom/dia, ↑HR, cardiac arrhythmias, incontinence, ataxia, muscle tremors, abd pain, hematuria, seizures, cyanosis, coma Rx induce vom, gastric lavage, carcoal, cathartics Diazepam to control seizures frequent bladder catheterizations—methylxanthines can be resorbed

Specific toxicities Methylxanthines 2. Caffeine -found in coffee, tea, chocolate, colas, stimulant drugs -Lethal dose: 140 mg/kg Clinical signs vomiting, diuresis, restlessness/hyperactivity, ↑HR, ↑RR, ataxia, seizures, arrhythmias, death not common Rx—same as theobromine

Specific toxicities Rodenticides 1. Anticoagulants (warfarin, pindone, bromadiolone, brodifacoum, chlorphacinone, difethialone, diphacinine, coumafuryl, dicoumarol, difenamarol) Work by binding Vit K, which inhibits synthesis of prothrombin (Factor II) and other clotting factors This effect occurs within 6-40 h in a dog; effect may last 1-4 wk Clinical signs (occur after depletion of clotting factors) Lethargy Vom/dia with blood; melena Anorexia Ataxia Dyspnea Epistaxis, schleral hemorrhage, pale mm Rx Vit K: 3-5 mg/kg PO for up to 21 d depending on anticoagulant used Induce vomiting; activated charcoal Whole blood transfusion if anemic

Specific toxicities Rodenticides Cholecalciferol—Vit D3; used in Quintox, rampage, Rat-Be-Gone -causes Ca++ reabsorption from bone, intestine, kidneys causing hypercalcemia (>11.5 mg/dl) and cardiotoxicity Clinical signs (12-36 h after ingestion) Anorexia Vomiting Muscle weakness Constipation Dx Hx of exposure Usually discovered on routine Chem panel (↑blood Ca++) Rx Induce vom/activated charcoal if ingestion occurred with 2 h Furosemide x 2-4 wk; increases Ca++ excretion in urine Prednisone x 2-4 wk; decreases Ca++ reabsorption from bones/intesine Calcitonin to lower blood Ca++ concentration

Specific toxicities Rodenticides Bromethalin -uncoupler of oxidative phosphorylation in CNS (stops production of ATP) -Causes cerebral edema -found in Assault, Vengence, Trounce -Toxic Dose Dog: 4.7 mg/kg Cats: 1.8 mg/kg Clinical signs (>24 h after ingestion of high dose; 1-5 d--low dose) Excitement, tremors, seizures Depression, ataxia Rx (will take 2-3 wk to know if animal will survive) Purge GI tract if exposure recent Reduce cerebral edema with Mannitol and glucocorticoids Seizure control with Diazepam and Phenobarbital

Specific toxicities Acetaminophen Common OTC drug for analgesia Toxic dose: Dog— mg/kg Cat—50-60 mg/kg (2 doses in 24 h is almost always fatal) Clinical signs (starts within 1-2 h of ingestion) Vomiting, salivation Facial and paw edema Depression Dyspnea Pale mm Cyanosis due to methemoglobinemia Px—poor Rx Induce vom/activated charcoal Antidote: N-Acetylcysteine (loading dose of mg/kg PO, IV, then at 70 mg/kg PO, IV QID x 2-3 d

Specific toxicities Metals Lead toxicity more common in dogs than cats Source Lead paint (prior to 1970’s) is primary source Batteries, linoleum, plumbing supplies, ceramic containers, lead pipes, fishing sinkers, shotgun pellets Clinical signs (Usually involves signs of GI and nervous systems) Anorexia Vom/dir Abd pain -CNS signs do not show initially Blindness, seizures, ataxia, tremors, unusual behavior

Specific toxicities Metals Lead toxicity Dx Large # nucleated RBC’s; basophilic stipling Blood lead conc >35 μg/ml Rx Remove lead from GI tract (cathartic, Sx) Chelators (to bind the Pb in blood stream and hasten its removal) -Calcium EDTA (ethylene diamine tetra acetic acid) -Penicillamine IV fluids for dehydration and to speed removal via kidneys Diazepam, Phenobarbital to control seizures

Specific toxicities Metals Zinc Toxicosis Usually from ingested pennies, galvanized metal, zinc oxide ointment Clinical signs Vomiting CNS depression Lethargy Dx Hx of exposure Rx Remove metal objects endoscopically or surgically IV fluid therapy Ca EDTA chelation

Specific toxicities Ethylene Glycol (antifreeze; sweet taste) Lethal dose: Cat—1.5 ml/kg Dog—6.6 ml/kg Signs (onset within 12 h of ingestion) CNS depression, ataxia (may appear intoxicated) Vomiting PD/PU Seizures, coma, death Dx Hx, signs Ethylene Glycol Poison Test—an 8 min test used in cats and dogs Rx Emesis, adsorbents if ingestion within 3 h of presentation IV fluids, NaBicarb for acidosis Ethanol inhibits ethylene glycol metabolism (keep animal drunk) Dogs (Cats): 20% ethanol—5.5 (5.0) ml/kg q6h x 5, then q8h x 4 4-methylpyrazole has been shown to be effective

Specific toxicities Snail Bait (Metaldehyde, methiocarb) Metaldehyde mechanism unknown Methiocarb is a carbamate and parasympathomimetic Signs Hypersalivation Incoordination Muscle fasciculations Hyperesthesia Tachycardia Seizures Rx Emesis and absorbents Pentobarbital, muscle relaxants to control CNS hyperactivity

Specific toxicities Garbage Toxicity Common in dogs; not in cats Enterotoxin-producing bacteria include Strep, Salmonella, Bacillus Signs (within min to h after ingestion) Anorexia, lethargy Vom/dia Ataxia, tremors Enterotoxic shock can cause death Rx IV Fluid therapy Broad-spec antibiotics Intestinal protectants Muscle relaxers or Valium may be needed to control tremors Corticosteroids to counter endotoxic shock

Specific toxicities Insecticides Pyrethrins and Pyrethroids Common ingredients of flea/tick sprays, dips, shampoos, etc If used according to instructions, toxicity rarely occurs; if overused, toxicity can result Signs Hypersalivation Vom/dia Tremors, hyperexcitability or lethargy Later, dyspnea, tremors, seizures can occur Rx Bathe animal to remove excess Induce vomiting/charcoal/cathartics for ingestion Diazepam may be necessary for mild tremors Methocarbamol, a muscle relaxer, for moderate-severe tremors Atropine for hypersalivation and bradycardia

Specific toxicities Insecticides Organophosphates and Carbamates Inhibit cholinesterase activity (break down of Ach is inhibited) Highly fat-soluble; easily absorbed from skin and GI tract Found in dips, sprays, dusts, etc for fleas and ticks Signs Salivation Vom/dia Muscle twitching Miosis -May progress to Seizures, coma, resp depression, death Rx Bathe animal Charcoal if ingested Atropine ( mg/kg; half IV, half IM or SQ) Praloxime chloride (20 mg/kg BID till signs subside)—reactivates cholinesterase

Specific toxicities Plant Toxicity Most common in confined and juvenile animals Usually from ornamental, indoor plants Severity varies with plants ID scientific plant name (florist, greenhouse) Araceae family (most from this family) Dumb cane, split-leaf philodendron Contain calcium oxalate crystals and histamine releasers Signs Hypersalivation, oral mucosal edema, local pruritis -Large amount of plant may cause: Vomiting, dysphagia, dyspnea, abd pain, vocalization, hemorrhage Rx Rinse mouth with milk or water to remove Ca Oxalate crystals GI decontamination (protectants) may be needed

Dumb Cane (Dieffenbachia)
aka Mother-in-law’s tongue Oral irritation; intense burning, excess salivation

Sago Palm Coagulopathy Liver failure

Split Leaf Philodendron
Oxalate crystals like Dieffenbachia Oral irritation; intense burning, excess salivation

Lily of the Valley Contains cardiac glucosides
Cardiac arrythmias, death

Azalea (Rhododendron)
Hypotension, cardiovascular collapse, death

Phone advice to give owners (legal issues) Protect yourself from exposure before handling animal Gloves, protective clothing Protect yourself from animal because poisoned animals may act strangely Protect animal from further exposure by removing pet from source Bring sample of vomit, feces, urine Bring container/package that toxin was in and a sample of the toxin (plant material, rat bait, etc)

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