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How to do it

(or more importantly . . .)

How To Do It
at

Angell
A Guide for New Interns at Angell Animal Medical Center 2009-2010

INDEX

A
Addisons................................................................................46 Allergic Reactions...................................................................22 Anesthesia/Analgesia..............................................................42 Anti-emetics..............................................................................5 Antibiotics.................................................................................1 Antitussives...............................................................................2 Appetite Stimulants...................................................................2

H
Head Trauma...........................................................................20 Hemoabdomen........................................................................47 Hepatic Encephalopathy.........................................................23 Hepatic Lipidosis....................................................................24 Hypertonic Saline...................................................................34

I
IMHA/ITP...............................................................................41

B
Back/Spine..............................................................................19 Bicarbonate Replacement.......................................................40 Blood Gas...............................................................................16

N
NSAIDs.....................................................................................3 Nutritional Support.................................................................10

C
Calcium Supplementation.......................................................40 Chest Tubes.............................................................................14 Coma Score.............................................................................21 COP.........................................................................................34 CPR.........................................................................................38 CRIs........................................................................................33

P
Paracentesis.............................................................................17 Potassium Replacement..........................................................40

R
Rabies Protocol.......................................................................53 RBC Morphology...................................................................55

S
Seizures...................................................................................18

D
Dermatology...........................................................................50 DKA........................................................................................48 Dyspnea..................................................................................12 Dystocia..................................................................................44

T
Toxicity....................................................................................... Acetominophen..................................................................29 Amphetamines...................................................................26 Anticholinesterase..............................................................29 Chocolate...........................................................................26 Ethylene Glycol..................................................................31 Lily.....................................................................................27 NSAID...............................................................................31 Permethrin..........................................................................27 Rodenticide........................................................................27 Xylitol................................................................................33

E
Emesis.....................................................................................25 Exotics....................................................................................52

F
Fluid Rates..............................................................................36 Free Water Deficit..................................................................34

G
Gastroprotectants......................................................................4 GDV........................................................................................45 Gen Med Protocols.................................................................56 Glaucoma................................................................................22 Glucocorticoids.......................................................................43

U
UO.............................................................................................6 URI Kitty................................................................................16 Uroabdomen..............................................................................9

ANTIBIOTICS
AMOXICILLIN 10-22 MG/KG PO/12 50, 100, 150, 200, 400 MG TAB 50 MG/ML IN 15ML OR 30ML BOTTLES CLAVAMOX 13.75 MG/KG PO BID FOR DOGS/CATS 62.5, 125, 250, 375 MG TABLETS 62.5 MG/ML IN 15ML BOTTLE AMPICILLIN 10 20 MG/KG IV, IM, SQ, PO/8 250, 500 MG CAPSULES 25, 50, 100 MG/ML ORAL SUSPENSION CEFAZOLIN 10 33 MG/KG IV, SQ/8 INJECTABLE ONLY CEFPODOXIME (SIMPLICEF) 5-10MG/KG PO Q24H 100, 200 MG TABLETS CEPHALEXIN 22 MG/KG PO/8-12 H 250, 500 MG CAPSULES 250 MG/5 ML ORAL SUSPENSION CLINDAMYCIN 5.5 11 MG/KG PO/12 (SOFT TISSUE) 25, 75, 150 MG CAPS 11-33 MG/KG Q12H (OSTEOMYELITIS) 25 MG/ML IN 20 ML BOTTLE ANTIROBE 12.5 MG/KG Q12H (TOXOPLASMA/NEOSPORA) INJECTABLE DOXYCYCLINE 5-10 MG/KG PO/IV12 50, 100MG TABLETS CAUTION IN PREGNANT/PEDIATRICS 5 MG/ML ORAL SUSPENSION IN 60ML BOTTLE
INJECTABLE AVALIABLE

ENROFLOXACIN 5-20 MG/KG IV, PO/24 22.7, 68, 136MG TABLETS BE CAUTIOUS - MAXIMUM 5 MG/KG/DAY IN CATS 17 MG/ML; 34 MG/ML ORAL SUSPENSION DOGS START AT 10 MG/KG/24 INJECTABLE AVAILABLE NOT FOR PREGNANT/PEDIATRICS GENTAMICIN 5 MG/KG IV, IM, SQ Q24H 50 MG/ML INJECTABLE ONLY CAUTION IN PREGNANT/PEDIATRICS OTOTOXIC/NEPHROTOXIC (AMIKACIN 15-20 MG/LG IV, IM, SQ Q24H MUST CHECK URINE DAILY FOR CASTS CHLOAMPHENICOL 50 MG/KG IV, PO Q8H INJECTABLE 250MG TABLETS OWNERS MUST WEAR GLOVESAPLASTIC ANEMIA METRONIDAZOLE 7.5 10 MG/KG PO/12-24, IV/12 250, 500 MG TABLETS TOXICITY SEEN IN DOGS >50 MG/KG/DAY 50MG/ML ORAL SUSPENSION IN PHARMACY
INJECTABLE AVAILABLE

SULFADIMETHOXINE (ALBON) FOR COCCIDIOSIS 125, 250, 500MG TABLETS 55MG/KG PO ONCE, THEN 27.5MG/KG PO/Q24H X 2-3 50MG/ML ORAL SUSPENSION
WK

TIMENTIN 50 MG/KG IV/Q8H

INJECTABLE ONLY

CIPROFLOXACIN 5 15 MG/KG PO/Q12H 100, 250, 500, 750 MG TABS NOT FOR PREGNANT/ PEDIATRICS INJECTABLE AVAILABLE, POOR ORAL ABSORPTION ZITHROMAX 5 MG/KG/Q24H THEN CAN GO TO EOD 50 MG/ML SUSPENSION AFTER 7 DAYS UNASYN INJ ONLY (BASICALLY INJ CLAVAMOX) 50 MG/KG Q8H IMIPENEM 250, 500, 750 MG 5-10 MG/KG Q8H IV SQ IM

ALBON (SULFADIMETHOXINE) 50 MG/ML SOLUTION 50 MG/KG ONCE PO; THEN 25 MG/KG FOR 10-14
DAYS

AUGMENTIN (FOR THOSE EXAM ONLY OUTSIDE BASED ON JUST THE AMOXICILLIN CONCENTRATION SCRIPTS) (250MG/5ML SOLUTION) 13.75MG/KG TRIMETHOPRIM/SULFADIAZINE 30 MG/KG PO/Q12H 30, 120, 480, 960, MG TABS TRY TO AVOID USE IN DOBIES (OTHER BLK & TANS) BM SUPPRESSION/HYPERSENSITIVITY RXN/ KCS

DERM ANTIBIOTICS
Cephalexin: 25-30 mg/kg q12h x 2-3 weeks Clavamox: 22mg/kg q12h x 2-3 weeks Clindamycin: 11mg/kg q12h x 2-3 weeks Cefpodoxime (Simplicef): 5-10mg/kg q24h x2-3 weeks

APPETITE STIMULANTS
Cyproheptadine (cats only) 2-4 mg/cat q12h (usually start at 2mg/cat) Mirtazipine Cats: Give tablet PO q3d Dogs: <20 lb =3.75mg/day (1/4 15mg tab) 20-35 lb = 7.5mg/day (1/2 15 mg tablet) 40-60lbs = 15mg/day (1 tablet) >75lbs. = 22.5mg/day (1.5 tablets) >100lb =30mg/day (2 tablets)

Antitussives
Hydrocodone 0.22 mg/kg PO q8-12h Liquid 1 mg/mL Tabs 5mg Torbugesic 0.5 mg/kg PO q8-12h Tabs 5mg

NSAIDs
Most NSAIDs work by inhibiting prostaglandin and thromboxane synthesis by decreasing cyclooxygenase levels. They offer analgesic, anti-inflammatory and antipyretic control. Some also decrease platelet aggregation, so don't use in patients with bleeding disorders (like Von Willebrands) and if possible, stop in patients a week before they are to have surgery. Most can cause significant GI ulceration and irritation if given in high doses or for prolonged periods of time. Cautionary notes: DO NOT use in shock patients or hypotensive patientscontrol pain w/ opiods instead Do check liver and renal values prior to useespecially if an older animal

1) Aspirin - Use Ascriptin (325mg), Ecotrin or Bufferin; or baby aspirin (81mg)

Dose for Dogs: Dose for Cats:

Pain control: 10-25mg/kg PO BID-TID Anti-inflammatory: 25-35mg/kg PO TID Pain control: 10mg/kgPO q24-48 hours. Be conservative! Anti-inflammatory: 1 baby aspirin (81 mg) q48-72 for average sized cat

2) Carprofen (Rimadyl) for dogs. Available in 25, 75, and 100mg.

Dose: 1mg/pound PO/q12-24h with food. Dogs only. Injectable available.


3) Piroxicam - (Feldene)dogs and cats

Can be used for severe orthopedic pain but try another NSAID first Palliative Tx for TCC, OSA, prostate carcinoma Good for back and neck pain if NO NEURO deficits are noted Dose: 0.3mg/kgPO q24H for 2-4 weeks then q48hrs or try off for 2 weeks. They come in 1mg10mg capsules. Liquid can be compounded ***Must be used with Cytotec (misoprostol) 3 mcg/kg q 12 hrs (not above 100 mcg/dog). Start this 812 hrs prior to Piroxicam if possible. Pregnant owners/staff should NOT handle. 4) Deracoxib (Deramaxx)dogsCOX 2 specificperi-operative pain/OA/DJD Dose for dogs: 3-4mg/kg PO/24 for up to 5 days post-op, then give 1-2mg/kg PO for maintenance of chronic OA/DJD Anecdotally weve seen greater number of duodenal perforations w/ Deramaxx vs other NSAIDS 5) Meloxicam (Metacam) Good anti-inflammatory safe in cats (No Cytotec) Dogs: 0.2mg/kg PO on day 1, then 0.1mg/kg PO/24. Cats: 0.2mg/kg PO on day 1, then 0.1mg/kg PO/24 for 2 days, then 0.025mg/kg 2-3/week. EXAM ONLY: (big dogs)can script out Mobic (human meloxicam) o Tablets 7.5mg and 15mg or liquid (7.5mg/5mL) **Orders to give NSAIDs in CCU must be signed off on by a staff clinician or resident **

GASTROPROTECTANTS
Antacids Indications: Any disease that predisposes to GI ulceration: renal failure, mast cell disease, gastrinoma, vomiting, liver dz. OK to use for any animal that is vomiting.
General classes: Histamine H2 Rc antagonist and H+ pump inhibitor. Debated that H2 blockers lose efficacy after 72 hours. We use famotidine regularly here.

Famotidine (Pepcid): H2 blocker Dose: 0.5 - 1mg/kg PO, IM, SQ, IV q12-24h Decrease to 0.25mg/kg q24h in renal disease 10 mg tablets (available over the counter), injectable 10 mg/m1 Cimetidine (Tagamet): H2 blocker. Inhibits cytochrome P450 system in the liver; slows metabolism of other drugs; use w/care in liver dz Dose: 5-10 mg/kg PO, IM, or IV q6-8h Ranitidine (Zantac): H2 blocker. Also has some prokinentic activity Dose: 2 mg/kg PO or IV q8-12 Omeprazole (Prilosec): Proton pump inhibitor Most effective at decreasing gastric acid secretion, but also the most expensive Dose: 0.5-1.0 mg/kg PO q12-24h (10 and 20mg capsules)CANNOT SPLIT Protonix (Pantoprazole) 1mg/kg IV SID (given over 20 minutes CCU protocol). Dogs only Sucralfate (Carafate) Indications include GI ulcers/erosion and esophagitis (slurry) Attaches to injured gastric mucosa; heals ulcers and provides cytoprotective effect. May use a loading dose of 3 to 6 grams in cases of severe bleeding. Works best on empty stomach so other oral meds should be given 1-2h before or after sucralfate. May cause constipation. Dose: 0.25-1 g/dog q8h (small dogs 0.25g, large dogs 1g); 0.25g/cat; q8h Misoprostol (Cytotec)PGE1 analog May reduce NSAID induced ulceration (debated). Used concurrently with Piroxicam. Can cause diarrhea and cramping. Pregnant staff/owners should NOT handle this drug. Dose: 3 mcg/kg PO q12h; not more than 100 mcg/dog/per dose

ANTI-EMETICS
These are symptomatic therapy that DO NOT address the underlying problems and may MASK problems. Indicated if vomiting is contributing to morbidity, discomfort, excessive fluid or electrolyte losses. Chlorpromazine (Thorazine) a phenothiazine derivative Inhibits chemoreceptor trigger zone (CRTZ) Be very cautious with dehydrated or hypotensive patients as they cause vasodilation. Lowers seizure threshold (debated) Dose: 0.3 - 0.5 mg/kg IM, SQ q8h; (0.05 mg/kg IV q8 but avoid IV if possible) Metoclopramide (Reglan) Inhibits CRTZ. Used to manage regurgitation/ileus Increases LES and pyloric sphincter tone and forward motility. Increases gastric tone and peristalsis. Dose should be reduced in severe renal dz due to renal excretion Contraindicated if GI obstruction; so take radiographs before starting this drug. Dose: 0.4-0.6 mg/kg PO SQ q8h; or 1-2mg/kg/day as a CRI Dolansetron (Anzemet) - 5HT3 antagonist (works in CRTZ) Dose: 0.5-1.0 mg/kg q24h; IV, SQ, PO Cerenia - binding of substance-P to the neurokinin-1 (NK-1) receptor in the vomiting center. It is an NK-1 receptor antagonist. It prevents both neural (central) and humoral (peripheral) causes of vomiting. Dose (dogs): For acute vomiting: 1.0mg/kg SQ SID for 5 days or less 2.0mg/kg PO SID for 5 days or less Motion sickness: at least 8 mg/kg PO q24h x 2 days Meclizine inhibits CRTZ. Primarily used for motion sickness Dose: Dogs 4mg/kg PO SID or 25mg/dog PO SID Mirtazapine 5HT3 antagonist (works in CRTZ) Dose: Cats 3.75mg PO q72h Dogs <20 lb =3.75mg/day (1/4 15mg tab) 20-35 lb = 7.5mg/day (1/2 15 mg tablet) 40-60lbs = 15mg/day (1 tablet) >75lbs. = 22.5mg/day (1.5 tablets) >100lb =30mg/day (2 tablets)

THE BLOCKED CAT


SET UP Sterile gloves; laceration pack Open ended and close ended Tomcat catheters Sterile lube +/- lidocaine gel 3-0 Nylon suture Sterile bowl may be handy Red rubber catheters: 5 Fr and 3.5 Fr Syringes: 12mL for UA and 35mL to flush bladder UCS and extension set Sterile saline, 250mL bottle Radiology1 lateral rad (check U-cath placement and urinary stones)

Stable vs unstable Stable means little to no electrolyte disturbances, no arrhythmia or bradycardia, mentally appropriate, may be mildly azotemic Unstable means moderate to severe electrolyte or acid base disturbances and/or if the cat is mentally dull, bradycardic, hypothermic, shocky o Usually needs EKG and fluid bolus prior to unblocking o Worry immediately about potassium >7 or if EKG shows tented T waves or bradycardia (HR <150) Regular Insulin 0.1-0.25 U/kg Dextrose 0.5ml/kg Ca Gluconate 3ml/cat diluted 1:1 with 0.9% NaCl given over 10 minutes Doctor must give Drugs to unblock Hydromorphone (0.1mg/kg)/Valium (0.5mg/kg) Ketamine (4-6mg/kg)/Valium (0.5mg/kg) Sometimes need to top off w/ low dose propofol for complete relaxation (2-4 mg/kg) You may need to intubate cat, so be ready with ET tube and gas anesthesia Some sick cats are so dull no drugs are needed Fluid orders IVF at least 2x maintenance if cat presented w/ moderate or severe azotemia SQ fluids OK in wards if no azotemia or minimal azotemia If insulin was given: Add dextrose to fluids and recheck BG in 2-4 hours

IMPORTANT POST-OP ORDERS Submit urine for UA; aerobic C/S Recheck electrolytes w/in several hours if severe derangements on admit Change UCS q24h; empty and record volume q4-6h; check in/outs and adjust fluids accordingly Dr check bladder q8h SQ or IVF depending on finances and degree of electrolyte disturbance +/- prazocin (0.5 mg/cat PO q24h) or phenoxybenzamine (2.5 mg/cat PO q8h) if urethral spasms once awake and BP OK Food and water OK once awake ideally canned c/d or s/d Pain medication (buprenex) and E-collar always HANDY TIPS If very gritty can try injecting lube or Vit C through catheter Add lidocaine to lube Can try Slippery Sam catheter or frozen red rubbers for difficult cases Try threading a central line stylet thru red rubber for increased stiffness General anesthesia and benzodiazepines can ease catheter passage by increasing muscle relaxation Debatable drugs to use Anti-inflammatories o Dex SPmay be indicated if multiple attempts made to unblock or if penis is visibly inflamed. Dose: 0.1-0.2 mg/kg SQ, IM. o Also may consider Meloxicam if NOT azotemic Absrarely indicated unless positive culture or stones. Primary UTIs uncommon in male cats Cosequinused long term for cystitis cats to help to help reduce bladder wall inflammation UO DRUGS Some drugs to think about using after unblocking depending on severity or urethral spasm or bladder tone. 1) Phenoxybenzamine or Prazocin- Both work by reducing internal urethral sphincter tone (alpha blockers). Good to try if they are straining or were very difficult to unblock. Don't use in cats with heart disease or low BPs. Side effects: Possible hypotension at higher doses and tachycardia, miosis and sometimes some GI effects, nausea, depression. Phenoxybenzamine Dose: 2.5 10 mg PO/q8-24h; can take several days to start working Prazocin Dose: 0.5mg/CAT q24h works faster, hypotension can be worse o Can give up to q8h if needed, but usually start at q24h 2) Bethanechol- (Urecholine) Works as a cholinergic (mostly muscarinic) receptor stimulant. Increases detrusor muscle tone. Good for bladder atony. Contraindications : Outflow obstruction, post-bladder surgery, hyperthyroidism, GI obstruction or recent GI surgery. Side Effects: Can cause vomiting and diarrhea, salivation and anorexia.

Dose: 2.5-5 mg PO/q8-12h

Uroabdomen
Causes: trauma, diseased bladder wall (neoplasia, cystitis, infection) Clinical signs: Abdominal pain and distension Lethargy Shock (tachycardia, hypotension, prolonged CRT) Hypothermia or hyperthermia Not passing urine; or only urinating a little Hx that may be consistent (HBC, TCC, UO) Diagnosis Positive abdominal tap for urine Creatinine of abdominal fluid:serum is > 2:1 Potassium of abdominal fluid:serum is >1.4:1 Azotemia, hyperkalemia, acidosis (ARF) Contrast cystogram showing contrast leaking out of bladder/urethra Treatment Treat initial signs of shock w/ fluids (0.9% NaCl) Place an indwelling urinary catheter Usually means an emergency Sx if diagnosed during the day If diagnosed after hours; best to establish drainage by placing peritoneal dialysis catheter o Must be stable for heavy sedation/anesthesia o Call CC2 resident or chief resident overnight Monitor INS/OUTS of both PD and urinary catheter Treat renal failure o Fluids, Abs, GI protectants Prognosis can be good if drainage and definitive Tx are started early

NUTRITIONAL SUPPORT
Remember Angell has a nutritionistDr Remillard.

Lipids This is an Angell phenomenon most of us had not seen before coming here. Good for short term, like while waiting for PN to be made, or to provide some calories in financial cases. Lipids should not be relied on as sole nutritional support. Lipids can also be used to bind lipid-soluble drugs in overdoses (Ivermectin). Lipid solution is 2kcal/mL. Dose: Kcal = 15 x BW in pounds/day for dogs. Kcal = 20 x BW in pounds/day for cats. Basic Caloric Requirement (RER) Dogs: (wt in kg)0.75 *70 = kcal/d Cats: (wt in kg)0.75 *70 = kcal/d 30 (BW in kg) + 70 = kcal/day (if<2 kg or >25 kg use 70 (wt in kg)0.75 ) The not eating cat . Cyproheptadine (periactin) at 1-4 mg /cat q12-24h (can see behavioral side effects) Or can use Mirtazipine: 1/4 tablet (3.75mg) PO every 3 days Try syringe feeding A/D slurry (may be tolerated or can cause food aversion) Enteral Feeding IF THE GUT WORKS, USE IT! Stomach capacity: 10-15mL/kg if chronic anorexia; 45-90mL/kg when fully re-alimented Tube Types: NE Tube Usually done in CCU under minimal sedation Patient must have functional esophagus, stomach, and intestines. NE tube not appropriate if vomiting. Used for short term feedings (only while in hospital) ALWAYS check position w/ rads before feeding Works only w/ liquid diets (Clinicare) Best tolerated as CRI Esophagostomy Tube Done in surgery under full anesthesia. Placed for long term feedings. Check placement w/ lateral radiograph Provides longer nutritional support (weeks) and pet can go home w/ in place Uses larger tube - 12Fr red rubber or larger. Feed a gruel type diet Gastrostomy Tube (PEG percutaneous endoscopically-placed G-tube) Requires surgical, endoscopic or non-endoscopic placement. Can be left in for months but MUST be left in for at least 14 days to allow adhesion to form and thus prevent leakage. G-tube allows the feeding of thicker blenderized food Jejunostomy Tube--indicated if it is necessary to bypass stomach. Requires surgical placement

Enteral Feeding Schedule: Liquid diets more likely to cause diarrhea; but less likely to plug tube; and must be used for tubes smaller than 12Fr Gruel diets can only be used in larger tubes (12Fr or larger); a/d is easily mixed w/ water or Clinicare Bolus feeding o Dosed q4-6h to accommodate 1/3 RER in first 24 hours; then increase by 1/3 every 24 hours o Another rule of thumb: can start at 3-5mL/kg q2-4h and work up to 22-30mL/kg/feeding CRI feeding o Can start w/ this initially or indicated if bolus feeding causes nausea or vomiting o Start with 1/3 RER and increase to full calories by day 3 **** If vomiting/nausea occurs, decrease CRI by or decrease bolus by or skip next feeding or give bolus more slowly **** Parenteral Nutrition Dr Remillard is a firm believer that there is no such thing as TPN, thus she refers to it as PN Order PN thru CC resident (usually CC2) or Cross trainer Central line required if osmolality of PN >600 mOsm/L Requires daily monitoring: electrolytes, glucose, phosphorus to avoid re-feeding syndrome Only start PN if it will be used for a minimum of 3 days; otherwise it is not worth the cost or nutritional value to the patient Allow time for PN to be made when starting your animal and order extra bags when you need them order the day before you need themdifficult to get over the weekends There is no such thing as a nutritional emergency!

Metabolizable Energy (kcal/cup or kcal/can):


Dog Diet Hills adult maintenance canned Hills adult maintenance dry w/d canned w/d dry i/d canned i/d dry a/d m/d (canned/dry) k/d canned k/d dry Purina OM Purina NF Purina DM (canned/dry) 378 365 329 243 485 379 180 -496 396 189/266 500/459 -Cat 157-178 488-495 127-146 278-281 161 483 180 156/480 183-200 477 150/321 234/398 194/592

DYSPNEA
Intrathoracic disease: pulmonary edema, pulmonary hemorrhage, pulmonary neoplasia, pleural effusion, tracheal compression by an enlarged heart, pneumothorax, smoke inhalation, feline asthma, PTE. Extrathoracic causes: severe ascities, GDV, upper airway obstruction, laryngeal paralysis, brachycephalic syndrome, CNS disease Metabolic cause: anemia, methemoglobinemia (Tylenol toxicity), hypokalemia, severe acidosis Physical examination is key but can be difficult in extremely dyspneic, stressed animals. Pure inspiratory dyspnea tends to indicate upper respiratory obstruction (tracheal collapse, laryngeal paralysis)

Inspiratory and expiratory dyspnea most likely lower airway disease

Triage Pearls for Dyspneic Animals Ask owners quickly if any heart failure, any medications Get resuscitation code Take back to O2 immediately Use breed/age clues to help narrow diagnosis: old retriever-lar par; young cat-asthma or CHF; small breed dogCHF or tracheal collapse DO NOT STRESS THESE ANIMALS Treatments/diagnostics IV catheter if possible Bloodwork o Arterial blood gas if possibleusually only possible on dogs o CCP to assess metabolic status o Venous blood gas wont give accurate PaO2; but will give useful PvCO2 information Mild sedation can be very helpful o Morphine 0.01-0.05 mg/kg IM o Butorphanol 0.2-0.4 mg/kg o Acepromazine 0.01-0.025 mg/kg Radiographs: sometimes animal is not stable enough to obtain; but obviously most helpful

Pulmonary edema due to CHF: open mouth breathing; pulmonary crackles; pink fluid around mouth/nares; perihilar infiltrates; cardiomegaly; enlarged pulmonary vessels (look at VD 9-10th rib for vessel size)

2 mg/kg Furosemide IV if able; IM (repeat in an hour if NO improvement) Bolus dosing 2 mg/kg q8h or 0.25-0.5 mg/kg/h CRI can be used +/- sedation (morphine may have added benefit of decreasing preload) strip of Nitropaste in ear once BP >100 mmHg; OK to repeat q8h if BP normal

In cats, should also assess rear limbs for signs of FATE (cold extremities, lack of FPs, cyanotic nail beds) Pleural space disease: inspiratory/expiratory effort w/ no crackles; muffled heart and lung sounds; compression of lung lobes on films; pleural fissure lines; obscured cardiac silhouette Thoracocentesis is needed for therapeutic and diagnostic purposes o Look at fluid for bacteria or neoplastic cells (submit for cytology and culture if indicated) o Do PVC/TS on fluid to r/o hemothorax o Chylous fluididiopathic or related to primary cardiac disease o Hemothoraxtrauma, neoplasia, coagulopathy (classic for cavitary bleeding due to rodenticide)

Perform PT/PTT o Pyothoraxrequires a chest tube after initial stabilization; cats can be more sick from sepsis than from pleural space issue; DO NOT rush cats to chest tube if hemodynamically unstable; cats do not usually require thoracotomy; dogs more likely to require thoracotomy Culture the effusion anaerobic and aerobic Start Abs Clavamox, Metronidazole, Ampicillin, Clindamycin post-tap +/- flush pleural cavity with saline +- intrapleural Abs o Spontaneous pneumothorax will usually require chest tube; maybe a CT and eventually thoracotomy to locate leak (usually bleb or bulla) and repair it Feline Asthma: Hx of coughing; expiratory sounds/expiratory dyspnea, may hear fine crackles, bronchial pattern on rads (railroad tracks and doughnuts); right middle lung lobe consolidation on rads

Dexamethasone 0.25 0.5 mg/kg IV, SQ, IM; or Prednisone 1-2mg/kg/q12-24h (remember if want to do a TTW then steroids will affect results) Terbutaline 0.01 mg/kg IM or 1.25mg PO/12; or Aminophylline 20 mg/kg IM, SQ +/- sedation 2 puffs albuterol to start; OK to repeat 30 minutes to 2 hours if NO improvement Flovent is NOT an emergency inhalerit takes a week to reach therapeutic effects

Upper airway disease: Laryngeal paralysis; tracheal collapse; obstruction Often present cyanotic and gasping Need immediate sedation w/ butorphanol or ace while on supplemental O2 Wait only a few minutes to determine if sedation is workingonce sedation takes effect, less airway resistance allows for adequate air flow and ventilation Sometimes brief intubation is neededtry to take moment to do a laryngeal exam if suspicious for lar par Dex SP 0.1-0.2 mg/kg IV can be helpful in reducing airway swelling that occurs due to increased airway resistance If intubation is unsuccessful or multiple intubations neededtracheostomy may be in order Sometimes helpful to get CCU intern/resident/clinician to perform thoracocentesis and stabilize patient while you get the Hx. Do not feel like you are imposing, this what they are there for. Other pathologies: Flail cheststabilized with chest wrap or a small raft of tongue depressors taped to the chest; chest tube may be indicated

PTEpredisposers include: liver, renal, Cushings, IMHA, ITP diseases; chest rads are usually normal or show an area of black lung due to small vessel size Non-cardiogenic pulmonary edemaelectrocution, ARDS, upper airway obstruction; usually does not respond well to furosemide; but is worth trying along with IVF and O2 Pericardial effusion/tamponademay be seen on rads or be suggested by electrical alternans on EKG; requires pericardiocentesis (use ECC US machine)

Indications for mechanical ventilation: PaO2 < 60 mmHg or PaCO2 > 60 mmHg on room air When in doubt call CC2 resident (day or night)they are responsible for ventilating patients

CHEST TUBES
Unilateral or bilateral depends on lateralization of pathology, communicating mediastinum Size: Largest possible that fits between ribs. Hints: Cat: 10Fr, Dog med: 12-16Fr, Dog lg: 16-20Fr -Use heavy tranq or anesthetize/intubate to control airway Pre-measure to determine 'internal' length (to reach the thoracic inlet) Position and prep o In lateral recumbency, clip and surgically prep entire chest wall Monitor SpO2 and EtCO2 continuously If continuous pneumothorax: remember to have someone suction while placing tube Place 1% Lidocaine local block into the 7th intercostal space at dorsal two thirds of chest regardless of fluid or air; make sure skin, SQ, and intercostal muscles are blocked Grasp the skin along the lateral chest wall and pull it cranially, this eliminates the need to tunnel under the skin prior to entering chest Make a small incision (but large enough to pass the tube) in the skin and SQ over the blocked site. If tunneling of the tube in the SQ is needed, do it now, about 1-2 rib spaces cranially Enter the chest 2 ways: o With one hand, firmly hold the stylet and tube against the chest wall, stabilizing it. With the other hand, you will have to smack on the end of the trocar to drive the tube through the intercostal muscles, pleura and into the pleural space. The best way to do this is with a series of smacks (only 1-2 should be needed and not too hard, but not too wimpy so that you don't get anywhere). You should feel the pleural 'POP'! o Recommended: bluntly dissect down w/ a large hemostat and use the tip of the hemostat to pop thru the pleura. Then guide the tip of the tube over the hemostat into the chest cavity. When you think you're in, release the skin that was pulled forward and angle your chest tube so that it is now pointed toward the elbow. Do NOT remove the stylet yet! Instead, hold the tube steady but pull the stylet out 1cm so that the tip of it is no longer exposed and will not damage intrathoracic structures when you feed the whole thing in Now, slide your tube off the stylet as it feeds into the pleural space (cranioventral if fluid and craniodorsal if air) to your predetermined length Now you can remove your stylet but make sure to clamp the tube near the end as you pull it at so that air doesnt get sucked in Place the chest adapter on the end. Attach syringe and suction any fluid or air until negative pressure is achieved. Clamp the tube w/ either a C-clamp or a special toothless hemostat Now, secure the skin to the tube with a purse string and use a chinese finger trap suture pattern or a piece of butterfly tape placed securely around the tube Cover the insertion site with sterile gauze and betadine ointment. Apply chest wrap (cast padding, kling, vetrap, elasticon) Check position of tube w/ radiographs (two views) Place E-collar Presence of the tube itself can lead to formation of nonseptic effusion of 1-2 ml/kg/day.

The URI Kitty


Put in isolation (L-ward) IVF (if possible) Antibiotics Zithromax (5mg/kg Q 24hr) or Doxy (not if young!!) +/- Synotic mixed with Chloramphenichol (1mg) and squirt up nose BID +/- L-Lysine 250mg PO BID +/- Interferon 30 IU/Cat (about 1/2ml) per day +/- Cyproheptadine 2mg PO BID +/- Sublingual Buprenex 0.015mg/cat q12-24 +/- Teramycine OU q6 Nutrition (syringe feed or consider E-tube)

Arterial Blood Gas Formulas


** Needs to be taken on room air to use the equations below **
The A-a gradient Allows you to assess pulmonary function independent of ventilation A-a = pAO2 paO2 pAO2 = 150 -[(1.1)(pCO2)] Normal < 10 Gray zone 10-15 Abnormal > 15 *** Must be at sea level on room air *** PaO2/FiO2 Ratio Allows you to assess the efficiency of lung oxygenation when breathing an oxygen concentration higher than room air Normal = 500 Mild oxygenating inefficiency = 300-500 Moderate oxygenating inefficiency (ALI) = 200-300 Severe oxygenating inefficiency (ARDS) < 200

PARACENTESIS
Thoracocentesis: Landmarks : ICS 7, 8, 9 Tap above costochondral junction for air; and at junction for fluid For pneumothoraxsometimes helpful to place in lateral recumbency to allow air to rise to top and tap at the highest point on the chest at ICS 7, 8, 9 Cat: 21 gauge butterfly w or w/o extension set Dog: 22 gauge 1.5 inch needle w/ extension set; 3 way stopcock; 18 ga catheter, 14 ga needle for large dogs w/ a significant amount of fluid to be removed Pericardiocentesis: Use lidocaine bleb under skin and into intercostal muscle +/- sedation (low dose torb/valium OK) Continuous EKGelectrical alternans often noted

Position in LEFT lateral recumbency or sternal Technique o 14 ga angiocatheter; w/ extension set, 3-way stopcock, and syringe o Advance catheter into the RIGHT 4th ICS perpendicular to chest wall o A blood flash may or may not be seen prior to aspiration o Once blood is collectedwait a moment to monitor for clotting

Monitor for ventricular arrhythmiasgive 2 mg/kg lidocaine slow IV if persistent VPCs noted Sometimes fluid bolus necessary after tap; try to avoid giving fluid bolus prior to tap due to decreased cardiac contractility Clinical signs of tamponade may resolve even if very little fluid is removed; puncture of percicardium may cause fluid to leak into pleural spacethis is acceptable under the circumstances Abdominocentesis: Usually done for diagnostic purposes: septic abdomen; uroabdomen; hemoabdomen May be needed for therapeutic purposes if severe ascites is causing dsypnea

Clip and prep area on midline; at umbilicus 22 ga needle (1.5 inch for large dogs); sometimes useful to use needle and syringe at the same time. May need 4 quadrant tap Get PCV/TS/BG/lactate of sample depending on the underlying cause. Look at a slide yourself. When indicated submit for culture/cytology.

SEIZURES
This is an emergency regardless of the cause. The goal is to STOP the seizures. Try to check glucose and calcium before starting treatment as they may be a cause but anticonvulsant Tx may still be needed. Valuim:

Dogs: 1.0 mg/kg IV for 3-4 doses; OR 2 mg/kg per rectum q20min up to 4x. Half-life of valium in dogs is 15-20 minutes; CRI 0.1-0.5 mg/kg IV Cats: valium can be used as a one time dose; but avoid valium due to risk of acute hepatic necrosis and long half life of 15-20 hours; 0.5-1.0 mg/kg IV. Usually recommend starting w/ Phenobarbital.

Phenobarbital: Loading dose o Dogs: 12-18 mg/kg IV followed by 2-4 mg/kg q20min until control is achieved. Young pups usually require much larger doses for control. o Cats: 6 mg/kg IV followed by 2 mg/kg q20min until control achieved It takes at least 20 minutes from time of IV administration to exert anticonvulsant effect If animal already on Phenobarbital, skip loading dose and begin 2-4 mg/kg IV q20min Maintenance dose: 2 mg/kg q12h PO Oral loading: same as above

Pentobarbital: Use if Phenobarbital load does not stop seizures Draw up 18-24 mg/kg (should use much less than this!); give the dose very slowly over 1 minute, observe to see if seizures stop; if notthen give another dose; and so on Since Phenobarbital and valium will potentiate the effect of pentobarbital, give the pentobarbital very slowly over several minutes. Consider intubation and O2; may need to call in resident ON to monitor the patient if respiratory depression occurs and ventilation is needed Potassium bromide (KBr): Loading dose: 400 mg/kg PO or rectally; can split into 100 mg/kg doses x 4 Maintenance dose: 30-90 mg/kg split q12h Other anticonvulsants: Zonisamide: starting dose 5-10 mg/kg PO q12h; no loading required Keppra: 20 mg/kg q8-12h PO, IV. Loading IV dose 60 mg/kg Felbamate: 15-20 mg/kg PO q8h; last ditch effort; severe hepatic toxicity; (old dogs with brain tumors) Other considerations: Assure ventilation once the seizure has stopped, intubate if necessary. Monitor ETCO2 if intubated and watch for hypovolemia Check glucose and calcium before any treatment is administered calcium gluconate if indicated (0.5 1.5 ml/kg of 10% solution IV diluted 1:1 with saline over 10 15 minutes; doctor must monitor EKG to watch for arrhythmia) 50% dextrose 0.5-1mL/kg 1:1 NaCl Give dextrose if indicated: BG < 40; although seizure itself can elevate glucose Prolonged seizure activity causes cerebral edema and increased intracranial pressure Consider steroids: 0.2 mg/kg DexSP IV Mannitol 20%: 1-2 grams/kg IV over 20 minutes

Prolonged seizure activity causes hyperthermia; if T > 106, cool w/ cool water, cease cooling at 103 or hypothermia may result Fluid Tx can be tricky. Prolonged seizure activity can predispose to fluid crossing the BBB. Monitor PCV/TS closely and use fluid judiciously if at all to prevent development of cerebral edema Collect minimum date base: CBC/chemistry/UA/PT/PTT/BP Avoid hypotonic fluids (P56, 0.45% NaCl)

Back Emergencies/Spinal Trauma


Neurology service would prefer if you referred to these sections in the intranet version of the Intern Handbook for the information is too thorough to briefly cover here.
Solumedrol (MPSS, methylprednisolone sodium succinate): protocol is indicated if patient presents within 8 hours of acute spinal trauma. Initial dose: 30mg/kg IV slow (over 30 minutes) Then, 2hrs post-initial dose: 15mg/kg IV Then, 6hrs post-initial dose: 15mg/kg IV Then 15mg/kg IV/6 for 3 more doses, total of 24 hrs MPSS treatment. Initial dose: 30mg/kg IV slow (over 30 minutes) Then, CRI at 5.4 mg/kg/hr over 24 hours Polyethylene Glycol (PEG): protocol is also indicated if the patient presents within 8 hours of acute spinal trauma Dose: 2ml/kg IV slowly over 40 minutes and then repeat in four hours. **Expensive so make sure you include it on your estimate** Protocol is often abbreviated or not started when a dog goes to surgery. Start gastroprotectants and IV fluids with the solumedrol. When patient with suspected spinal lesion presents late at night, serial neuro exams must be performed.

Neck pain in Dogs


Again, please refer to info in online intern handbook for full information on treating neck pain Piroxicam Dose: 0.3mg/kgPO q24H for 2-4 weeks then q48hrs or try off for 2 weeks Comes in 1mg-10mg capsules. Liquid can be compounded o Round down if dose is between mg sizes or give liquid Should start helping in 24-72 hours and should be 100% pain-free by 5-7 days. Only give if no CP deficits Misoprostol Dose: 3mcg/kg PO q12h Maximum dose 100mcg/dog Start this 8-12 hrs prior to Piroxicam if possible Pregnant owners/staff should NOT handle, wear gloves

Head trauma
Diagnosis: Observed head trauma, loss consciousness, determine patient consciousness PE: 1) 2) 3) 4) Keep cranial and cervical manipulation to the minimum until the extent of the injuries is determined. Check for airway integrity, respiratory pattern, otic and/or nasal hemorrhage, ocular injuries, dental trauma, etc. Careful palpating the skull for fractures. Clinical signs of head trauma may include: Depression/Dementia Traumatic injuries Circling, head tilt, nystagmus Proprioceptive deficits Opisthotonos Anisocoria Cranial nerve deficits Seizures Stupor, coma, and death 5) Check pupil size: Miotic pupils seen with cerebral and midbrain white matter injury. Rapid change in pupil size (from normal to miotic or mydriatic) is seen with rapid increase in intracranial pressure. Hippus (spasmodic irregular dilating/contracting of the pupil) is a sign of central vestibular disease. 6) Posture: Decerebrate rigidity (unconscious pet with four rigid limbs)- sign of midbrain nuclei upper motor neuron dysfunction. Decerebellar rigiditiy (rigid extension of the forelimbs). Aversive syndrome (when aroused pet will circle or adopt the posture of circling the head and neck towards the affected cerebral hemisphere)- unilateral cerebral or thalamic injuries. 7) Respiratory pattern: Hyperventilation with midbrain injury. Cheyne-Stokes breathing (periodic hyperpnea alternated with periods of apnea)- seen with tentorial herniation. Apnea with brainstem injury. Treatment:

1. Elevated head 20-30 degrees above body. Avoid pressure on neck.


2. 3. 4. 5. Perform Modified Glasgow Coma Score. Should be repeated every few hours Monitor temperature, pulse and respiration. Check for Arrhythmias (seen with brain stem lesions) Provide humidified oxygen 100ml/kg/min. AVOID nasal catheters because they can cause sneezing which in turn can cause increased intracranial pressure. Some patients may need ventilation if Apneic 6. If facial damage is severe and airways are compromised, consider transtracheal catheterization. 7. Avoid jugular catheters/blood draws because this increases ICP 8. Treat for shock (For example: 4 mL/kg hypertonic saline; 10 mL/kg Hetastarch) 9. Check mean arterial blood pressure. Try to keep it at around 80- 100mmHg. Avoid hypertension by controlling pain (Opiates are recommended) If hypotension persists after treating for shock, consider Dobutamine (5ug/kg/min in dogs) or Dopamine (5- 10ug/kg/min in dogs and cats). AVOID tachycardia. Gradually wean patients off these medications. 10. +/- Furosemide: In dogs: 1-2 mg/kg IV or IM q 6-12 hrs. In cats: 0.5- 1 mg/kg IV or IM q6-12hr. 11. Mannitol 1-2g/kg IV over 20 minutes. Repeat Mannitol as needed every 4 hrs. CONTRAINDICATED: Dehydration, congestive heart failure, anuric renal failure, volume overloaded, hyperosmolar condition. 12. If seizures: Diazepam 0.5- 1 mg/kg IV. Phenobarbital 2-4 mg/kg IV.

13. AVOID: ketamine, corticosteroids and glucose-containing solutions. 14. DO NOT treat bradycardia w/ atropine (Cushings reflex decreased HR, increased BP)

Modified Glasgow Coma Score


Motor 1. 2. 3. 4. 5. 6. recumbent, hypotonia of muscles, depressed or absent spinal reflexes recumbent, constant extensor rigidity, opisthotonus recumbent, constant extensor rigidity Recumbent, intermittent extensor rigidity Hemiparesis, tetraparesis, or decerebrate activity Normal gait, normal spinal reflexes

Brain stem reflexes 1. 2. 3. 4. 5. 6. Bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes Unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes Pinpoint pupils with reduced to absent oculocephalic reflexes Bilateral unresponsive meiosis with normal to reduced oculocephalic reflexes Slow pupillary light reflexes and normal to reduced oculocephalic reflexes Normal pupillary light reflexes and oculocephalic reflexes

Level of consciousness 1. 2. 3. 4. 5. 6. Comatose, unresponsive to repeated noxious stimuli Semicomatose, responsive only to repeated noxious stimuli Semicomatose, responsive to auditory stimuli Semicomatose, responsive to visual stimuli Depression or delirium, capable of responding but response may be inappropriate Occasional periods of alertness and responsive to environment

Prognosis Severe <8 Moderate - 9-12 Minor - >13

GLAUCOMA The mannitol protocol when used for glaucoma:


2g/kg IV over 30 minutes Withhold water during and for 4-6 hours after infusion Recheck IOP 4-6 hours after giving mannitol Can repeat this once within 24 hours if response not adequate (not normalized) Poor prognosis if pressures do not normalize with mannitol

**note concurrent uveitis makes mannitol less effective for glaucoma treatment **can use xalatan 1 drop first and recheck IOP in 15 minutes (xalatan can be continued q12-24h) DO NOT USE XALATAN IF SUSPECT UVEITIS **Other meds to use: timolol q12h, trusopt q8h, can also add methizolamide 2-5mg/kg PO q8h

ALLERGIC REACTIONS
MILD REACTION: wheals, facial edema Bug bites, chemical contact, mild vaccine reaction Benadryl (diphenhydramine): 2mg/kg IM Dexamethasone SP: 0.1-0.25 mg/kg IV +/- SQ fluids OK for owner to continue 2mg/kg PO q8-12h of Benadryl for 2-3 days ANAPHYLAXIS: bradycardia, hypotension, circulatory collapse, bloody diarrhea, vomiting Benadryl/Dex SP Epinephrine: 0.01 mg/kg IV (can also SQ); this less than resuscitation dose; DO NOT be afraid to give Epi since animals in circulatory collapse may not respond quickly enough w/o it IV fluids TRANSFUSION REACTION: Varies from mild to lethal Febrile Non-hemolytic reaction: elevation in temp by 1-2 degrees o Slow rate of transfusion by o Stop if T keeps going up o Usually does not respond to dex or benadryl Mild reaction IgE mediated: wheals and facial edema, maybe vomiting o Stop or slow rate by o Give benadryl IM and DexSP IM or IV Acute hemolytic response: Fever, hypotension, bilirubinuria, tachycardia or bradycardia o STOP transfusion! o IV fluid bolus and continued fluid support o Based on pathophysiology it should not be responsive to steroids or benadryl o Since ALL transfused cells become hemolyzed; the patient still requires a transfusion o Most predictably seen (and fatal) in Type B cats that receive Type A blood TRALI: transfusion related acute lung injury Characterized by increased pulmonary capillary permeability Appears as non-cardiogenic pulmonary edema on radiographs Usually happens w/in 6 hours of transfusion Can resolve w/ time and O2 Tx

HEPATIC ENCEPHALOPATHY
Supportive Care Question: Is your patient mentally alert enough to be treated with PO meds? If not, then start with IV and rectal meds.

If severely affected: Lactulose enema o 0.5-1.0 ml/kg diluted 1:3 with water. This can be repeated q6h or as needed IV Fluids (in theory should avoid LRS; but is OK to use as IVF choice) Monitor BG and electrolytes Antibiotics: o Neomycin: 22 mg/kg q8h PO o Metronidazole: 7.5-10 mg/kg q12h IV (or PO); PO preferred for local control of GI urease-producing bacteria o Ampicillin: 22 mg/kg q8h IV o If clinical signs suggestive of cerebral edema then give mannitol 1gm/kg over 20 minutes o Denosyl comes in 90s and 225s q24h o Vitamin K1: 2.5 mg/kg SQ, PO q24h If stable: o Start with oral lactulose at 0.5-1.0 ml/kg PO q8h (increase dose until stools are soft) and Neomycin at 22 mg/kg q8h PO o OK Diets for liver patients: k/d; l/d; Purina NF o Denosyl, Marin are adjunctive pro-liver medications o Denosyl (SAMe) Up to 12 pounds (5.5 kg): one 90 mg tablet 12 to 25 pounds (5.5-11 kg): two 90 mg tablets (or one 225 mg tablet, if more convenient) 25 to 35 pounds (11-16 kg): one 225 mg tablet 35 to 65 pounds (16-29.5 kg): two 225 mg tablets 65-90 pounds (29.5 kg-41 kg): three 225 mg tablets

Hepatic Lipidosis
Enteral support: quality and quantity (corner stone of Tx) Protein goal: 33-45%; (fat: 44-66%); avoid excessive CHO Iams Max calorie, Hills a/d, m/d, Purina DM, Clinicare Clinicareneeds omega 3 FA added Feed RER (at least); start feeding 1/3 RER on day 1; 2/3 on day 2; 3/3 on day 3 Monitor for re-feeding syndrome (there is a re-feeding blood panel) o Low phosphorous, potassium and magnesium IV lipids if cant get in a NE tube; or lipids in conjunction w/ NE tube Medical Tx: L-carnitine: 250-500 mg/cat/day N acetyl cysteine (Mucomyst): 140mg/kg IV bolus; then 70 mg/kg IV q8-12h SAMe (once can take PO meds): 18 mg/kg PO q24h B vits (Cobalamin): 4mL B-complex per 1 L fluid (usual protocol is 2mL/1L) o 250 mcg SQ often necessary Vitamin K: 0.5-1.5 mg/kg repeated 3 times at 12h intervals Vitamin E: 10 IU/kg/day Ursodeoxycholic acid (Actigal): 10-15mg/kg PO q24h

Helpful hints: Avoid dextrose IVF; in theory would want to avoid LRS (but in reality is OK IVF choice) Anesthesia medications to avoid o Oxymorphone, ketamine o Diazepam, etomidate (contain 35% propylene glycolhemolysis) Safe anesthesia protocols o Butorphanol (0.05 mg/kg) w/ mask induction o Fentanyl 5 mcg bolus o Propofol 5mg/kg to effect (recent research shows that this actually fine)

EMESIS ASPCA Animal Poison Control Hotline: 1-888-426-4435


1. Induction of emesis in DOGS: Apomorphine: Start w/ tab for small dogs; tab for big dogs (may need a whole tab). Place in conjunctival sac. Should work w/in minutes. Rinse w/ saline when vomiting starts. Rinse thoroughly. Premed dose of IM morphine often times works. Hydrogen peroxide (3%): 1-2ml/kg PO for up to three doses. If the patient does not vomit within 15 minutes, give again at 0.25 ml/lb 2. Induction of emesis in CATS: Xylazine: 0. 44-1.1 mg/kg IM or SQ (can reverse with yohimbine 0.1 mg/kg IV) In the surgery lockbox is large animal concentration; needs to be diluted for small animals CCU has also NO Apomorphine or Ipecac for cats Hydrogen peroxide: 1-2 mL/kg PO up to 3 doses o Can cause GI bleeding in cats Emetics are contraindicated in animals that are already vomiting, hypoxic, dyspneic, in shock, lack normal pharyngeal reflexes, seizuring, comatose, CNS-depressed, or in patients who have ingested strong alkaloids and petroleum products. Also rabbits and rodents. Emetics generally remove about 80% of stomach contents. They should be followed with activated charcoal (30-60ml/10lbs) PO. [Consider an antiemetic after you have rinsed out/reversed the emetic, so the charcoal will not be aspirated!] If you mix the charcoal with a/d, a few animals will just eat it; this is much easier that forcing or tubing. In organophosphate or carbamate toxicosis, repeat charcoal q 4 hours. Consider giving an osmotic or saline cathartic 30 min after activated charcoal (toxiban). Ex: sorbitol 3ml/kg PO Animal Poison control is your friend! Invoice a call into SS. Gastric lavage: o Sedate and intubate, place in lateral recumbency, pass a pre-measured stomach tube (this should remind you of decompressing a GDV dog) Infuse warm water, 5-10ml/kg, through tube to moderately distend stomach, then allow fluid to drain (**Bread dough toxicosis: use cold water to stop active yeast**) Turn patient to other side, continue infusing and draining until stomach is clear. Administer activated charcoal down tube, crimp and remove. Make sure patient is awake enough to guard airway, or leave the ET tube in.

Toxicity
Basic idea is get them to vomit, activated charcoal to prevent further absorption, diurese with IVF (especially with NSAIDs), reverse what you can. Depending on what it is, heart rate, resp rate and BP monitoring might be indicated. Poison Control 1-888-426-4435 Chocolate toxicity: Emesis and Charcoal Type of chocolate Bakers Semi-sweet Milk White Caffeine (mg/oz) 47mg 22mg 6mg 0.85mg Theobromine (mg/oz) 390-450mg 130-138mg 44-60mg 0.25mg Apomorphine (conjunctival sac) Charcoal: 10 mL/kg PO Anzemet SQ before giving +/- SQ fluids

Quick and dirty chocolate toxicity: 1oz/10# (milk); 1oz/3# (dark); 1oz/1# (bakers) Clinical signs: Caffeine: vomiting, restlessness, tachycardia, +/- arrhythmia, tachypnea, hyperthermia, tremors or seizures o Reabsorbed thru bladder wall (IVF w/ walks q4h) Theobromine: vomiting, diarrhea, hyperactivity, hyperthermia, hypertension, bradycardia or tachycardia, arrhythmia (esp VPCs), tremors or seizures Mild signs (>20 mg/kg); moderate (>40 mg/kg); severe (>60 mg/kg) LD 50 = 100-200 mg/kg Treatment: Decontamination o Emesis if ingestion was w/in 2 hours o Gastric lavage o Activated charcoalespecially important b/c of the long half life in dogs Symptom targeted treatment o Diazepam for tremors or seizures o Antiarrhythmic pathologic tachycardia (HR >200) -blocker for sinus tachycardia HR > 200 (0.02 mg/kg propanolol PRN; can go up to 0.06 mg/kg every 20 minutes) Lidocaine or procainamide for ventricular tachycardias o Treat volume status before reaching for anti-arrhythmic agents! Prognosis: Excellent if treated early Guarded if clinical signs cannot be controlled Fatal if massive ingestion left untreated Amphetamines: Adderol type drugs DO NOT GIVE VALIUM!! USE ACEPROMAZINE!!

Lilies (Easter, Tiger, Stargazer, Day, and Oriental) : All parts of the plant are toxic, and almost always fatal Toxic dose: only a few leaves Clinical signs: referable to ARF, polyuria progressing to oliguria/anuria and signs of renal failure (vomiting/lethargy) Treatment: aggressive IVF/ u-cath (consider transferring to Tufts for dialysis if indicated), guarded prognosis What to tell owners: o Easter lily ingestion within 6 hours: - With emesis and fluid support, very good chance will not proceed into renal failure. - Will be in hospital for minimum 2-3 days. o Easter lily ingestion >18 hours - Most likely will develop ARF if not in it already o If ARF develops with normal urine production: - 50% chance will make it out of hospital - Expect 1-3 weeks in hospital. - Expect CRF **Peace lily and Calla lilies are not nephrotoxic, but will cause GI irritation** Permethrin Toxicosis: most common: Top Spot, Hartz, Biospot- in feline Clinical signs: generalized tremors Treatment: o Bathe with mild dish detergent (Dawn or Palmolive) o Tremor control: Methocarbamol (Robaxin) 50mg/kg PRN (can give up to 330mg/kg in 24 hours) Administer dose rapidly (not to exceed 2ml/min) Give to effect (cat will relax; then give until desired effects) Diazepam: 0.5- 1mg/kg IV for treatment of seizures. DO not exceed 4 mg/kg/DAY Pentobarbital: 2-4 mg/kg IV q6h Intubation with isoflurane may be necessary until activity is controlled Supportive care: o Fluid and nutrition support o Maintenance of normal body temperature. Rodenticide: Vitamin K Antagonists: Warfarin, Brodifacoum, Bromodiolone, Diphacinone Antagonism of factors II, VII, IX, X Clinical signs: o May take 12-48h to appear o Cavitary/joint/GI hemorrhage/epistaxis Diagnosis: Hx/signs; prolonged PT/PTT (PT prolonged first due to short life of Factor VII Treatment: o For non-clinical suspected or witnessed ingestion, induce emesis. If productive may choose to NOT give Vit K and have pet recheck PT in 48 hours. Otherwise treat for time outlined below: o If pet is actively bleedinggive plasma (20 mL/kg), stabilize as needed Recheck PT/PTT after each plasma transfusion until normal, start vit K

Continue orally at home for time outlined below. Recheck PT 48h after last vitamin K dose o Vitamin K: Loading dose 5mg/kg SQ; followed by 2.5 mg/kg split q12h PO Phytonadione (oral vitamin K): 2.5 mg/kg PO q24h for 30d Pharmacy can compound as a liquid o Duration of Tx: Warfarin14 days Bromodiolone21 days Diphacinone, Brodifacoum30 days BromethalinDiphenylamine neurotoxin Minimum lethal dose: Dogs: 2.5 mg/kg; Cats: 0.45 mg/kg Clinical signs o Signs develop b/t 4h to 72 depending on amount ingested o Signs can be non-specific: depression, anorexia, vomiting, tremors o Neuro signs vary: paresis, paralysis, hyperexcitability, tremors, hyperreflexia, seizures, death Treatment o Decontamination Emesis if ingestion < 60 minutes Activated charcoal w/ sorbital q4-8h for at least 2-3 days Monitor Na+ o Supportive care: directed at controlling clinical signs Treating for cerebral edema Methocarbomal or diazepam for tremors Seizure control of choice o Prognosis Dependent on severity of clinical signs Even mild signs can take up to 2 weeks to resolve Cholecalciferolvitamin D3 Minimum toxic dose: 0.5-3.0 mg/kg Pathophysiology: increases Ca++ and P levels Clinical signs o Signs can be non-specific and include anorexia, vomiting, weakness, PU/PD, and mental dullness o Renal failure: can occur w/in 24-48 hours w/ acute severe ingestion Diagnosis o Hx and clinical signs o Hypercalcemia, hyperphosphatemia, azotemia o Need to rule out the other reasons for hypercalcemia Treatment o Decontamination Emesis for known ingestion < 1 hour Activated charcoal w/ sorbital q6-8h for 48 hours o Treat hypercalcemia Diuresis w/ 0.9% NaCl Furosemide 5 mg/kg IV bolus; then 5 mg/kg/h CRI or 2-4 mg/kg q12-8h IV, SQ, PO

Prednisone 1-2 mg/kg q24h PO Phosphate binders Pamidronate 1-2 mg/kg IV over 24h (works quickly 24-48 hours)

Prognosis o Good if treated early and/or if hypercalcemia resolves o Soft tissue mineralization is almost irreversible and carries a guarded prognosis

Acetominophen Minimum lethal dose: Dogs: 100 mg/kg; Cats: 60 mg/kg Clinical signs o Dogs: referable to liver necrosis, nausea, vomiting, anorexia, depression Can also have methemoglobinemia, conjunctival swelling/facial edema o Cats: referable to methemoglobinemia, cyanosis, chocolate blood, dyspnea, pigmenturia, facial edema (can also have hepatic necrosis at high doses) Diagnosis o Hx and clinical signs (esp in cats) o Heniz bodies may be prominent o NOVA Co-oximetry panel; <5% methemoglobin is normal; >30% MetHb poor Px o Liver enzyme elevations; esp ALT and AST Treatment o Decontaminationemesis and activated charcoal o Antidote: N-acteylcysteine (Mucomyst) Provides cysteine for glutathione synthesis Dogs: 280 mg/kg IV or PO; then 140 mg/kg q4h for 3 days Cats: 140 mg/kg IV or PO; then 70 mg/kg q6h for 3 days o Adjunctive Tx O2 Tx of limited value b/c metHb cannot bind O2 Blood transfusions only if patient has severe anemia, otherwise risk of volume overload once the MetHb is corrected Denosylprecursor to glutathione Cimetidinep450 inhibitorslows down metabolism of acetaminophen 5-10 mg/kg q6-8h Vitamin Caids in conversion of MetHb to OxyHb Simply add vitamin C as a Tx in fluids (nurses will do this) Monitoring with Co-oximetrymeasure on presentation; then q24h during Tx; then 24h after last Mucomyst treatment Prognosis o metHb >30 % on Co-ox panel carries guarded prognosis o depends on onset of Tx and how sick the patient is on presentation o hepatic damage may take weeks/months to heal (if ever fully) Anticholinesteraseorganophosphate and carbamate Sources: commercial insecticides, some deworming products Minimum lethal dose: highly variable; can be as low as 1 mg/kg Clinical signs o Can occur w/in 30 minutes after acute ingestion and predictably w/in 12h Neuron signs: mildmuscle weakness, depression severetremors, ataxia, seizures

Respiratory failure: bronchoconstriction and increased bronchial secretion Diagnosis o Hx and clinical signs o May see hypokalemia and hypermagnesemia Treatment o Supportive care; +/- ventilatory support o Pralidoxime chloride 2PAM o Anticholinergicatropine

Ethylene Glycol Minimum lethal dose: Dogs: 4.4-6.6 mL/kg; Cats: 1.5 mL/kg Clinical signs o Stage I: CNS dysfunction: 30 min-12 hours post ingestion o Stage II: cardiac and pulmonary dysfunction: 12-24 h post ingestion Tachycardia, tachypnea due to acidosis Increasing hypocalcemia o Stage III: Renal failure: > 24 h post ingestion Oxalate crystals are deposited in renal tubules Diagnosis o Hx and clinical signs o EtGly test: tests only presence of EtGly and not the metabolites (not useful in Stage II or III) o CaOx crystalluria after 6 hours of ingestionmonohydrate crystals o Severe normochloremic metabolic acidosis (high AG); occurs w/in 3 hours o Renal failure Treatment o Decontaminationemesis if 1-2 h since ingestion; gastric lavage 2-4 h o Antidotes 20% EtOH: alcohol dehydrogenase has higher affinity for EtOH than EtGly Dogs: 5.5 ml/kg IV q4h for 5 doses; then q6h for 5 doses Cats: 5 mL/kg IV q6h for 5 doses; then q8h for 4 doses Can use total dose as CRI over 48 hours 4-methylpyrazole (questionable efficacy in cats) 20 mg/kg loading dose; then 15 mg/kg at 12 and 24 hours; then 5 mg/kg at 36 hours If started soon enough, dogs can have almost full recovery in 24 hours after initiation of 4-MP treatment o Dialysishemodialysis or peritoneal dialysis Prognosis o Good for dogs treated w/in 8h of ingestion w/ 4-MP o Good for dogs and cats treated w/in 3h of ingestion w/ EtOH o Bad if renal failure is present at the time of diagnosis NSAID Any NSAID including rimadyl, deramaxx, piroxicam, ibuprofen (particularly toxic) can cause idiosyncratic liver toxicity (but usually associated w/ renal and GI signs) Ibuprofen toxic dose o Dogs: 50 mg/kg GI signs, abdominal discomfort >150 mg/kg renal toxicity >400 mg/kg CNS signs, seizures, coma o Cats: twice as sensitive as dogs Monitoring o Baseline CBC/chemistry (at least a renal panel in $$ cases) o Q48h renal monitoring o +/- urinary catheter for ins and outs (if azotemic on presentation) Treatment o Aggressive diuresis 2-3x maintenance minimum

o GI protectants: misoprostol, carafate, pepcid/protonix

Xylitol Sugar substitute (found in sugar-free candy, gums and other products) that promotes insulin release cause severe hypoglycemia or hypokalemia. Can also cause hepatic necrosis Monitoring o Monitor BG for the first 24 hours o Baseline liver values and 12-24h post ingestion Treatment o Emesis o No activated charcoal o +/- dextrose supplementation o +/- liver protectants

Calculating CRIs
Need to know: -dose of drug -weight of pet in kg -rate of infusion (mL/h) -# hours the bag will last (at calculated rate)

MLK M 0.1 mg/kg/h L 50 mcg/kg/min K 5 mcg/kg/min

Calculate dose in mg/hr: ex. 0.5 mg/kg/h x 10kg = 5 mg/h Calculate number of hours the bag will last at given rate = 500 mL bag at 10 mL/h will last 50 hours Calculate the mg to add to bag: ex. 5mg of drug x 50h = 250mg drug in 500mL bag at 10 mL/h Common CRI rates: Fentanyl (50mcg/mL): 3-8 mcg/kg/h Morphine (15 mg/mL): 0.1-0.2 mg/kg/h Ketamine (100 mg/mL): 5-20 mcg/kg/min (higher intra-op, then taper post-op) Lidocaine (20 mg/mL): 50 mcg/kg/min Lasix (50mg/mL): 0.25-1.0 mg/kg/h for heart failure, 0.1-0.66 mg/kg/hr for ARF Dopamine (40 mg/mL): 5-20 mcg/kg/min (lower for Tx of anuria; higher for pressor support) Dobutamine (12.5 mg/mL): 2-10 mcg/kg/min (start slow, increase hourly as needed) Norepinephrine (1 mg/mL): 0.1-0.2 mcg/kg/min Epinephrine (1 mg/mL): 0.1-0.5 mcg/kg/min Procainamide (100 mg/mL): 25-50 mcg/kg/min Propofol (10 mg/mL): 0.1 mg/kg/min (anesthesia is often maintained at 0.4 mg/kg/min) Na nitroprusside (25 mg/mL): 1-10 mcg/kg/min Fenoldopam (10 mg/mL): 0.5 mcg/kg/min (cat dose) See compatibility book to see if these medications are light sensitive

Hypertonic Saline
We carry 7.2% here Provides quick intravascular volume expansion w/o giving much volume due to the pull of the hypertonic solution Give alone lasts 20-30 minutes; given with HES lasts 2-3 hours Great for resuscitating previously healthy normovolemic, hydrated patients (patients w/o pre-existing electrolyte changes) HBC Contraindications: Hemoabdomen Dehydration Trauma w/ obvious head injury (increased ICP) Increased Na Arterial bleed Hyperosmolar conditions (DKA) Pulmonary contusions Renal failure High rise cats CHF 3-5 mL/kg hypertonic saline followed by 5 mL/kg HES or (4 mL/kg hypertonic saline / 10 mL/kg HES) Hypertonic saline should not be given faster than 1 mL/kg/minute

Free Water Deficit Calculation


Wt (kg) x 0.6 x [(patients Na+/ normal Na+) 1] Replace deficit over 18-24 hours w/ hypotonic fluid (half strength saline of D5W). Usually use in combination with isotonic crystalloids to maintain intravascular and interstitial volume. Hypotonic fluids will shift into intracellular space, not good for intravascular volume expansion. For chronic dysnatremias do not decrease sodium more than 0.5 mEq/L/hr. Osmolality Calculation: = 2(Na+) + (glucose/18) + (BUN/2.8)
Fluid Type 0.9% NaCl LRS Norm-R 0.9% NaCl LRS Norm-R Sodium Content (mEq/L) 154 130 140 154 130 140 Osmolality (mOsm/kg) 308 312 296 308 312 296

Colloid OSMOTIC Pressure


Normals:

Cats 24.7 +/- 3.7 Dogs 19.95 +- 2.1

Requires whole blood in a green top tube.

FLUID RATES

Low-Volume Fluid resuscitation

Crystalloids Hypertonic saline 4 mLs/kg SQ dose: 20 mL/kg, about 100mL/10# Hetastarch 5mLs/kg Maintenance: few different formulas Re-assess 60 mL/kg/d 0.75 0.75 +/- start IVF Dog (mLs/d): BW(kg) x 132; Cat (mLs/d): BW(kg) x 90 Puppy: 90-100 mLs/kg/d 100-120 mL/kg/d (rabbit) Shock dose 90 ml/kg (dog); 40-60 mL/kg (cat) !!Tritrate to clinical response!! Surgery maintenance Reducing crystalloids for HES 5-10 mL/kg/h Colloids Hetastarch 6% in NaCl 5-10 mL/kg/d (cat) 10-20 mL/kg/d (dog) Reduce rate of crystalloids by to 1/3 Pentastarch: dogs only: same dose as Hetastarch

HES: 10 mLs/kg reduce by 40% 15 mLs/kg reduce by 50% 20 mLs/kg reduce by 60%

Blood products Fresh whole blood: 1 unit ~450mL (dog); ~50-60 mL (cat) 20 mL/kg (dogs and cats) Emergency donors are listed in blood bank Packed RBCs: 1 unit ~325mL (dog); ~25-30 mL (cat) 10 mL/kg over 0-4 hours Dogs OK to give more than 10 mL/kg if actively bleeding Aim for PCV > 25% Fresh frozen plasma: 1 unit ~250-260 mL (dog); ~25 mL (cat) 10-20 mL/kg over 1-4 hours CryoprecipitateDOGS only 1 unit/10 kgs Factor VIII, vWB, fibrinogen Platelet concentrateDOGS only (Frozenmust be thawed slowly) 1 unit/10 kg 1 unit ~100 mLs Oxyglobinhemoglobin glutamer (bovine) 10-15 mL/kg over 4 hours (dog) 5 mL/kg over 4 hours (cat) Indications for Crossmatch Patient had a transfusion over 3 days ago or at any point in life Research shows every cat should ideally be cross matched even the 1st time Patients that autoagglutinate may not be able to be blood typed Transfusion reaction: See all allergic rxn notes

Basic CPR Instructions

Closed Chest CPR: Assess for breathing, heartbeat Respiratory arrest: intubate and begin manual ventilation @ 12 breaths/min Cardiac arrest: begin chest compressions @ ~100 compressions/min (or more) Attach and assess ECG Asystole -- epinephrine, atropine, repeat after several minutes. May try vasopressin (instead of the 2nd dose of epie). Do not defibrillate Bradycardia atropine Ventricular fibrillation defibrillate, vasopressin +/- magnesium Ventricular tachycardia lidocaine or procanamide or sotalol Pulseless electrical activity - vasopressin or epinephrine. Do not defibrillate Address underlying disease process. Open Chest CPR: indicated in lg dogs; dogs w/ pleural and pericardial disease (there should be an open chest CPR pack in CCU that includes instruments, rib spreaders, and vascular clamps) Right lateral recumbency Very quick clip & prep Incise skin of 5-6th intercostals space Cut through intercostals muscles with scissors. Try to avoid the internal thoracic vessels ventrally. Halt respirations while incising pleura Use rib spreader to gain visualization Cut pericardial sac along apex to avoid the phrenic nerve. Exteriorize the heart Compress heart -apex to base. 60-80x/min (or more) Ventilate every 5th compression Defibrillation: Do not give lidocaine if you plan to defibrillate because it increases your defibrillation threshold External defib 3-5 Joules/kg (Plunket: 2 J/kg for under 7kg, 5J/kg for 8-40 kg and 5-10 J/kg for >40kg) Defib 2-3 times before resuming manual CPR, repeat defib at higher charge the next rnd Cats and small dogs: 50 J Medium dogs: 100 J Large dogs: 200J Internal defib 1-2 Joules/kg Defib; return to chest compressions; check rhythm after 60 seconds; repeat defib

Atropine 1 mL/20# Epi 0.1 mL/20#

Drug Dosages: **Double dose of atropine, Atropine: 1ml/20# (0.04mg/kg) Triple dose of Epie if giving Calcium Gluconate: 0.5-1.5 ml/kg (dilute 1:1 with NaCl) IT (and give 5-10ml 0.9% Dopamine: 5 15 mcg/kg/min (start at 10 for pressor support) NaCl to increase volume) Diazepam: 0.5 mg/kg Dobutamine: 5-15 mcg/kg/min Doxapram: 1-5 mg/kg (1-2 drops under tongue of newborns) Epinephrine: 0.1 ml/20 lbs Vasopressin (20 U/mL): 0.4-0.8 U/kg (0.4mL per 20#); CRI 0.1-0.4 mcU/kg/min Lasix: 2-4 mg/kg Lidocaine: 2mg/kg (ie 1ml/ 20lbs) Magnesium: 0.15-0.3 mEq/kg Mannitol (post-resusicitation): 0.25 g/kg (give over 20 min) Phenylephrine (10 mg/mL): CRI 1-5 mcg/kg/min Naloxone (0.4 mg/mL): 1mL per 20# (0.04 mg/kg) Amiodarone: 5mg/kg, can repeat at 2.5mg/kg

Bicarbonate Replacement
Indicated if HCO3- is <12 or venous pH < 7.1 Considerations prior to giving bicarbonate: o PCO2: If PCO2 > 50; correct ventilatory problem FIRST o Hydration/volume status: try fluid bolus and few hours of fluid replacement and recheck prior to committing to bicarbonate Tx o Bicarbonate deficit in mEq = 0.3 x (WT in kg) x (23 measured HCO3-) o NaHCO4 solution is 1 mL = 1 mEq Give to deficit IV over 20 minutes Can add additional deficit to IVF Recheck blood gas 4-6 hours later o Can cause paradoxical CNS acidosis

Potassium Replacement
Estimated K+ losses Suggested K+ Max CRI rate in fluids (mEq/L) (ml/kg/hr) Maintenance 3.6-5.0 20 25 Mild 3.1-3.5 30 17 Moderate 2.6-3.0 40 12 Severe 2.1-2.5 60 8 Life threatening <2.0 80 6 K+ supplementation should not exceed 0.5 mEq/kg/hour. Recheck electrolytes! Serum level

-from Plunkett SJ, Emergency Procedures, 2nd Ed., p.476

CALCIUM SUPPLEMENTATION
Causes of hypocalcmeia: pancreatitis, eclampsia, UO, hypoparathyroidism, ethylene glycol toxicity Clinical signs: seizures, altered behavior, hyperactivity, lethargy, muscle fasiculations Diagnosis: iCa2+ < 0.8 and patient is showing clinical signs; +/- EKG changes; then consider supplementation How to supplement: Initially 10 % calcium gluconate given as IV bolus at 0.5 to 1.5 ml/kg, diluted 1:1 with NaCl. Use a syringe pump. This MUST be given by a doctor. Give over 10-20 minutes. Place the patient on an ECG during the bolus. Stop immediately if there is bradycardia. A CRI at 60-90/mg/kg/day or 6.5-9.75 ml/kg/day is usually necessary if clinical signs persist If stable enough to supplement orally, you can give calcium gluconate PO at 500-700 mg/kg/day or calcium lactate at 400-600 mg/kg/day or calcium carbonate 100-150 mg/kg/day. o Tums calcium carbonate Recheck blood gas or ionized calcium 1 hr after bolus, and with every 4-8 hours of CRI of Ca2+

IMMUNOSUPPRESSIVE PROTOCOL FOR IMHA and ITP


Prednisone (can do 0.25 mg/kg Dex SP IV BID 1st day if vomiting) 4 mg/kg/day for 7 days (optional loading dose) 2 mg/kg/day for 3-4 weeks 1.5 mg/kg/day for 4 weeks 1 mg/kg/day for 4 weeks 0.5 mg/kg/day for 4 weeks 0.5 mg/kg q48h for 4 weeks Azathioprine/Imuran 2 mg/kg/day for 4-30 days 2 mg/kg/day q48h until patient reaches nadir of prednisone While on Imuran, check CBC 1 week after starting treatment then q3-4 weeks. Bone marrow suppression and pancreatitis is a concern. Cyclosporine (Neoral) 2-3 mg/kg q12h for at least 8 weeks, then stop Want a trough level of 500ng/ml Trough is measured right before next dose is due If patient has not received glucocorticoids then can give 0.3mg/kg Dexamethasone SP; if vomiting prevents oral administration use prednisolone acetate 3mg/kg SQ q24h. hIVIG: 0.5-1.5 g/kg infused IV over 6-12 hours; can cause hypersensitivity reaction Vincristine (platelet release): 0.5-0.7 mg/m2 IV Your choices of immunosuppresants will vary greatly depending on the patient, disease you are treating, side effects and book-in doctor. Some cases that are mild can be treated with prednisone alone and monitored for response. However we tend to treat IMHA/ITP aggressively here, to the patients benefit, and most cases do end up on all 3 drugs. Remember that Neoral is very expensive in large animals. This is a guideline not an absolute recipe!! Recheck red cell counts, platelet counts and liver values. You may need to change the doses. Remember to prepare owners for the nasty side effects of prednisone. Consider tapering the pred dose sooner to preserve quality of life and owners sanity. Talk with internal medicine clinicians about adjustments.

Other immune-mediated conditions you may see and can treat with the same drugs as above: o Immune mediated polyarthritis o Granulomatous meningocephalitis (GME) o Myasthenia gravis o Polymyositis

Anesthesia/Analgesia Premedications:
Usually given IM or SQ -1 hour prior to procedure. In emergency setting may be given IV and IM. Generally not recommended that all is given IV due to the drastic cardiovascular consequences of sudden tachycardia and hypotension. Use of premeds prior to anesthesia helps reduce the amount of induction drug/anesthetic gas needed to keep a good anesthetic plane and also helps w/ recovery. Usually consists of an opioid and sedative in various combinations o Hydromorphone: 0.05-0.2 mg/kg o Morphine: 0.1-0.5 mg/kg o Buprenorphine: 0.005-0.02 mg/kg o Butorphanol: 0.2-0.4 mg/kg o Fentanyl: 1-10 mcg/kg Sedatives include: o Acepromazine: 0.01-0.05 mg/kg o Midalzolam/diazepam: 0.1-0.5 mg/kg o Dexdomitor: 5-20 mcg/kg IM for DOG; 30-60 mcg/kg IM for CAT give dose if going IV

Induction agents:
Thiopental: 10-12 mg/kg IV to effect; usually given half to effect Diazepam/Ketamine: 1 mL of 1:1 or 2:1 volume mix per 5-10 kg; this boils down to 0.3-0.5 mg/kg diazepam/3-5 mg/kg ketamine IV Propofol: 4-6 mg/kg IV to effect Fentanyl: 20 mcg/kg IV; usually preceded by 0.1-0.3 mg/kg diazepam IV Fentanyl/Propofol: 5 mcg/kg : 2-4 mcg/kg to effect

Reversal agents:
If necessary, reversal should be performed either IM, or only part IV, except in an emergency. Think about your reversal before you use it. If you are reversing an analgesic drug, will there be something left in the animals system to provide analgesia once the drug is reversed? If not, maybe you want to only partially reverse the drug, meaning give a lower dose, giving only part of the volume, give part IV, part IM. Also, think of the half life of the reversal agentwill it outlast the drug which it is reversing? Some reversal agents are simply not worth giving with the exception of an emergency situation. Opioid Reversal: Naloxone: 0.02 mg/kg IM, SQ, IV Butorphanol (partial reversal): 0.05-0.2 mg/kg IM, SQ, IV Diazepam/Midazolam Reversal: Flumazenil: 0.01 mg/kg IM, SQ, IV Alpha-2 Agonist Reversal: Atipamezole (Antisedan): 0.04 mg/kg IM Yohimbine: 0.1 mg/kg IM

Tramadol
Synthetic opioid Of most benefit when pet is already on a steroid or NSAID and pain med is needed Dose dogs only: 2-4 mg/kg q8-12h PO

Fentanyl patches

(2-4 mcg/kg): Cats: 12.5 or 25 mcg patch Dogs <7 kg: 25 mcg (12.5 mcg available for very small dogs) Dogs 7-25 kg: 50 mcg Dogs 25-35 kg: 75 mcg Dogs >35 kg: 100 mcg

Intra-wound Soaker catheter


Lidocaine 2 mg/kg/h; made up as a 1, 1.5, or 2% solution o whichever gives closest to 5 mL/h infusion Prior to extubation; load catheter w/ 1.5 mg/kg bolus bupivicaine (give slowly) 1% solution: o Remove 125mL saline from 250mL bag (0.9% NaCl). Replace w/ 125mLs 2% lidocaine; this provides 250mL 1% lidocaine; volumes can be adjusted. 1.5% solution: o Remove 187mLs saline from 250mL bag; replace with 187mLs 2% lidocaine

GLUCOCORTICOIDS
Duration of action (hrs) 8 12-30 12-36 18-36 36072 36-72 12-36 Mineralocorticoi d Activity 1-2 1 0.75 0.75 0 0 0 Antiinflammatory Potency 1 4 5 5 25 30 5 Physiologic dose** 0.8 0.1-0.2 0.16 0.16 0.02 0.03 0.16 Antiinflammatory dose** 5-10 0.5 1-3 0.5-2 0.1 0.1 0.05-0.2 (dog) 0.25-0.5 (cat) Immunosuppressive dose** -2 dog 2-4 cat -11 0.25-0.3 0.25-0.3 2-4 Shock dose** 50-150 --30-35 4-6 4-6 --

Hydrocortisone Predisone Na Succinate (SoluDelta Cortef) Methylpred Methypred Na Succinate (SoluMedrol) Dexamethasone (Azium) Dexamethasone Na Phosphate Triamcinolone

**Doses in mg/kg/day

Dystocia
Signs of Dystocia Obvious maternal illness or pain (vocalization, biting at vulva) Malodorous or profusely hemorrhagic vaginal discharge Failure to begin labor w/in: - 24 hours of temperature dropping below 100 - 60 days since onset of diestrus - 72 days since 1st breeding Failure to deliver neonate in: - 30-60 minutes of strong contractions - 4-6 hours of last delivery (cats can rest 24 hours between births) - 15 minutes since the fetal membrane was visible - 4 hours since placental separation (green/clear discharge) Failure to deliver entire litter w/in 12-24 hours (24-36 for cats) Diagnostics: Pregnancy palpable at 15-28 days in dog; 21-28 days in cat One lateral abd radskeletal mineralization at day 45 AUS can fine fetal heart beats at about day 25 Ionized Ca++ and blood glucose Treatment: Fluids Oxytocin (NOT w/ obstruction)5-20 units/dog; 5 units/cat (given at 20-60 minute intervals) Calcium gluconate should be given if Ca++ is low; but also should be given if Ca++ is normal and multiple doses of oxytocin have not produced neonates Ca gluconate: 60-90 mg/kg/day Normal parameters in neonates: HR: 200; RR: 15-35; T: 96-97; by week 1-2 should be about 100 MAP: 49 mmHg at 1 month (dogs) Eyes open: 12-14 days; Normal vision: 21-28 days; Menace: 7-19 days Testes descended: 4-6 weeks (dogs) Pain reflex present at birth Lab values: LowerRBC, albumin, BUN, CREA; HigherWBC, Ca, P, liver enzymes and bilirubin

GDV
Signs: Abdominal distension (usually asymmetrically), dyspnea, unproductive vomiting, gagging, pale mucus membranes, restlessness and discomfort. Can present flat out/severe shock. Not all are large breed, deep chested dogs, bull dogs. Diagnosis: 1. Right lateral radiographs of the abdomen (good to rule-out mesenteric torsions= grave prognosis) 2. Metastatic check- especially if pet older than 5 yrs of age ***** Do at least #s 1 and 2 plus get estimate okayed before calling the surgeon Preoperative stabilization Place large bore catheter in one or both cephalic veins (avoid using saphenous veins). DO CCP/PCV/TS/ PT/PTT Bolus up to 90 ml/kg in to 1/3 increments IV fluid (Norm- R or LRS) o 5 mL/kg HES o Dont stop at one bolus if resuscitation parameters are not met o EKG monitor during stabilization. Sometimes V-arrhythmias are seen; but anti-arrhythmic therapy is not always indicated at this time Decompression (try doing once pet is more stable and has received at least the 1st dose of shock fluids) o Can trocarize w/o sedation using 14-16 gauge needle at the height of the gastric bubble on the RIGHT side behind the last rib o Perform if in respiratory distress secondary to abdominal distention o You will hear a hissing sound if you are in the right place. If blood appears (possibly hit the spleen), remove your needle and re-direct. You can place pet in lateral recumbency in order to avoid ingesta in stomach o If ingesta seen coming out of the needle or if the gas stops coming; pull needle out. If the HR rises quickly; STOP decompressing the patienthypovolemic shock! Consider Lidocaine (66 mcg/kg/min) for reperfusion injury (or N-acetylcysteine) Consider MLK pre-op or intra-op Get post resuscitated lactate (prior to Sx) Passing orogastric tube: o Hydromorphone (0.05-0.1 mg/kg) IV or Torb (0.2-0.4 mg/kg), and diazepam (0.5 mg/kg) IV or Ketamine (5 mg/kg)/ Diazepam (0.5 mg/kg) o Keep propofol to a minimum if used o Place an endotracheal tubereduces risk of aspiration o +/- iso/ sevo o Place animal in sternal position. Keep head in an elevated position when passing the tube. o Mark stomach tube with tape by measuring the distance b/t the tip of the nose and costal arch of the last rib o Place a mouth gag (a 2 inch tape roll works well) o Lubricate the tube and use the soft tip to push the tube gently into the esophagus. Too much pressure on the tube could cause the esophagus to rupture and create an iatrogenic pneumothorax o Once in the stomach, using a funnel and pump infuse 500mLs-1L of warm water (until runs clear; usually 35x). Massage abdomen gently. Lower the head/neck and tube and place end in a bucket. Allow water and ingesta to drain from the stomach. You can gently pull tube in and out of the mouth (siphon effect) a couple of inches in order to help ingesta to flow better o Repeat gastric lavage until fluid drains clear. Remove the tube (remember to kink it as pulling out). o If thoracic rads were not taken before because patient was too unstable, you can attempt to do them now. If you have not called surgeon yet, do it now. Most residents live at least 40mins away from Angell so plan

appropriately so animal does not have wait for surgeon very long after being decompressed. *****Always listen to the CCU nurses they have done this procedure may times. If you are not able to decompress pet, call surgeon or critical care doctor for advice. *****Ket/Val or Fentanyl induction more ideal than propofol

If needed: Trochar R side (16-18 ga) Where you hear a ping

Post-operative care: o VitalsTPR/BP q4h initially o CCP/PCV/TS, +/- PT/PTT (dilutional coagulopathy is common in this situation and may require plasma) o Adequate IVF necessary (1.5- 2 times maintenance) depending on HR, RR, CRT, pulses and blood pressure. If low TS or BP consider Hetastarch 10-20/kg/day. o Blood products as needed o Adequate pain control hydromorphone 0.05- 0.1mg/kg IV q6h; Fentanyl CRI or MLK CRI o +/- Continuous EKG monitor to assess for VPCs or V- tach. Treatment of these arrhythmias is dependent on multiple factors including patients status- if symptomatic (weak, disoriented, syncopal), increased heart rate and blood pressure. o Indications to treat V-tach R on T Multiform PVCs Poor hemodynamic status V-tach > 160 or a spontaneous HR >280 o Gastroprotectants: Pepcid 0.5 mg/kg IV q 12h or protonix 1 mg/kg IV q24h; +/- Sucralfate 1-2g/dog q 8hrs. o NPO for 8-12 hrs post op. Start with water. If not vomiting, feed small amounts of bland food e.g. w/d every few hrs. o If gastric resection or splenectomy were performed, patients need to be monitored very closely. Prognosis for these cases is worse. o Other things to consider in very ill patients: o Central line (triple lumen); arterial line o Plasma transfusion if indicated o Peri-operative antibiotic therapy (cefazolin, timentin, ampicillin)

Addisons
Shock dose IVF 0.9% NaCl (90 mL/kg) Hyperkalemiagive Ca gluconate Dexamethasone SP (will not affect ACTH stim) o 0.25-0.5 mg/kg over 5-10 minutes o Then start prednisone 0.1 to 0.22mg/kg BID (after ACTH stim performed) +/- DOCP 2.2 mg/kg IM q25 days ACTH stim (must be <4 cortisol to be Addisons) Na:K ratio < 26 Continue IVF w/ 0.9% NaCl +/- GI protectants +/- Dextrose in IVF Recheck electrolytes frequently !!DO NOT CONFUSE W/ RENAL FAILURE!! o Addisonians usually have a decreased heart rate o Also check USG should be stable or elevated with Addisons

Hemoabdomen
Etiology: Blunt trauma secondary to HBC, getting kicked or stepped on by large animal, penetrating wounds, rupture vessels secondary to GDV or splenic torsion, NEOPLASIA (hemangiosarcoma), warfarin toxicity, or split ligature post spay or other abdominal surgery. Diagnosis: Shock, pale mucus membranes, weak pulses, tachycardia, tachypnea, prolonged CRT Abdomen may be distended, fluctuant or tender (R/O GDV) Abdominocentesis (4 quadrant) reveals non-clotting blood in the abdominal cavity Met check- should be performed if no history of trauma or toxicity and high index of suspicion for neoplasia Abdominal ultrasound- check for possible metastasis. If possible check chest cavity for potential metastasis to the heart. CBC, chemistry, PT, PTT, platelets, blood type, +/- UA (no cystocentesis) STAT: PT/ PTT and blood type If overnight do a blood smear to look for platelets Run EKG Stabilize before radiology! Treatment: 1. Initial PCV/TS, compare w/ abdominal fluid PCV/TS; then monitor PCV/TS after stabilization (30-60 minutes w/ lactate as well) 2. Blood pressure- repeat as needed. Make sure the BP normalizes but DO NOT be over-zealous 3. IVFstart with o Crystalloids (shock dose for dogs: 90 ml/kg, and cats: 60ml/kg). Start with to 1/3 and recheck blood pressure. o Alternative to isotonic crystalloids is hypertonic saline: 5 mL/kg followed by 5 ml/kg Hetastarch (or 4 mL/kg hypertonic saline / 10 mL/kg HES) o Colloids (e.g. Hetastarch) may be necessary o 5 mL/kg bolus up to 20 mL/kg 4. Administer pRBC if the PCV is less than 25 and pet appears clinical (tachycardia, tachypnea, low BP, and weak pulses) 5. Consider abdominal wrap 6. Exploratory laparotomy should be performed immediately if patient cannot be stabilized. Prognosis: ~75% of hemoabdomens are caused by cancer and >90% of those diagnosed w/cancer have HSA. Median survival time with splenectomy alone is 3 months and w/ splenectomy and chemotherapy survival time is about 6 months w/ HSA. (Hammond TW, Pesillo-Crosby SA . JAVMA 2: 32 (4), 2008)

Diabetes and Ketoacidosis Admission minimum data base


1. CBC, Profile, UA + C/S, venous blood gas, stat electrolytes 2. PCV, TS, AZO, BG 3. Dipstick urine for ketones Admission initial treatments 1. Place saphenous or jugular catheter for blood drawing and fluid administration 2. Place cephalic catheter for insulin drip Note: A double or triple lumen catheter can be used in lieu of the above catheters if the patient is stable enough to have one
placed. If unable to place rehydrate first with a cephalic catheter

3. 4. 5. 6. 7. 8.

Bolus IV fluids (NaCl) to address serious dehydration After bolus IV fluids, start fluids for maintenance needs and dehydration Add minimum of 40mEq KCl/liter of fluids initially (+/- more K; +/- Phosphorus) Antibiotics (pending UA and urine CS) Warm hypothermic animals aggressively Start a regular insulin constant rate infusion (after a few hours of IVF; usually 2-6h) If unable to place central line/client has financial concerns then use regular insulin protocol IM (q6h)

Regular Insulin CRI instructions


Rate: Cat: 1unit regular insulin/kg/24 hours Dog: 2 units regular insulin/kg/24 hours Administration: Take a 250ml bag of 0.9% NaCl and remove 10ml. To the remaining 240ml, add the calculated dose of regular insulin. Start the CRI at 10ml/hr (cats and dogs). Adjust the drip based on your blood sugar results. If you are concerned about the total fluid volume being administered can double the insulin added and half the total fluid rate. If you do this you will need to half the amount you are increasing/decreasing the insulin CRI by. BG >400 250-400 125-250 75-125 <75 Insulin CRI Increase by 2ml/hr Increase by 1ml/hr As is Decrease by 1ml/hr Decrease to 2ml/hr IV Fluids As is As is As is add 2.5% dextrose add 5% dextrose

**Do not always have to do insulin CRI (many times financial constraints will not allow this). Establish somewhat of a BG curve and use regular insulin IM q6h (BG q6h); tailor protocol to your patient.**
Notes: 1. Once dextrose is added to the IV fluids, do not remove dextrose until the animal is eating and drinking. Adjust your insulin drip to control the increase in blood sugar. 2. Do not stop the insulin drip and switch to q12h insulin until negative ketones in urine or serum and the animal is eating regularly. 3. If the animal is becoming hypoglycemic adjust the drip downwards but never stop the drip. NEVER stop the CRI as body needs the insulin to clear ketones (even with BG is low). Can give dextrose bolus or feed and increase dextrose CRI 4. Never flush the line through which the insulin drip is running. This means that all fluid administration and blood drawing is done through the other line.

Daily Monitoring: o TPR/6 hours (minimum) first 24 hours. o BG/3 hours via saphenous or jugular catheter o PCV/TS every 24 hours o Urine dipstick for ketones every 24 hours o Electrolytes and phosphorus daily (renal panel downstairs) Potassium: Pay particular attention to potassium. Even if the animals potassium looks normal initially, they are body depleted and will drop quickly after initiating insulin therapy. This can happen in a matter of hours. If the potassium remains refractory to treatment, consider administering magnesium. Draw a magnesium level before supplementing. Tumil K: 2-4 mEq/cat/day q12-24h (1/4 tsp = 2 mEq)

Magnesium Administration
Supplied as 4.06mEq/ml (check bottle) Dose: up to 1mEq/kg/day as a constant rate infusion administered in D5W Incompatible w/ sodium bicarbonate, hydrocortisone and dobutamine HCl Phosphorus: o Like potassium, body stores of Phosphorus are often low (even if they appear normal at the outset). o Consequences of hypophosphatemia are hemolysis, skeletal muscle weakness, abnormal mentation, difficulty breathing. o If hemolysis is noted on your daily PCV/TS or your PCV is declining, check the phosphorus immediately and consider immediate supplementation while awaiting results. Phosphorus administration: Supplied as Potassium Phosphate 3mM/ml phosphorus, 4.4mEq/ml potassium Dose: 0.03-.06mM/kg/hr for 6-12 hours, then stop and recheck phosphorus level. Calculate for the phosphorus and then add KCl to make up for additional potassium requirements. Nutrition: If the patient is not eating, enteral or parenteral nutrition is necessary. Enteral nutrition is preferred if the patient is not vomiting. Do not hesitate to feed the patient by either means. The patient can still be regulated while receiving PPN. Please consult with Dr Remillard for nutritional needs. Final Note: The presence of ketoacidosis is a signal that the animal has a secondary problem. Look for the other problem!! It can be as simple as an ear infection or UTI, or worse, hepatic lipidosis, pancreatitis, cholangiohepatitis, Cushings etc. Approximate cost: $5000

Dermatology Information
COMMON ORAL DERMATOLOGY DRUGS DRUG DOSE USE OTHER NOTES Cephalexin 25-30 mg/kg q Antibiotic for One of the cheapest skin 12 h pyoderma antibiotics Chlorpheniramine 4-8 mg/DOG q Antihistamine See below 12 h 2mg/CAT q 12 h Clavamox 20-25 mg/kg q Antibiotic for Skin dose is higher than 12 h pyoderma the UTI dose Clindamycin 9-11 mg/kg q 12 Antibiotic for Good choice especially hr pyoderma for methicillin-resistant Staph Convenia 8 mg/kg SQ or Antibiotic for Use only for pets that 0.045 ml/pound pyoderma wont take oral SQ medications (lasts for 2 weeks) Hydroxyzine 1-2 mg/kg q 8Antihistamine See below 12 hr Ketoconazole 5 mg/kg every Antifungal for yeast Do NOT use with high 24 hr dose avermectins (ivermectin, milbemycin oxime, selamectin) Prednisone 0.5 mg/kg q 24 Anti-Itchy dose Some cats dont respond hr for dogs for dogs and cats well to prednisone, 1 mg/kg q 24 hr consider using another for cats steroid. There is a STEROID CALCULATOR online (Google it) to help you calculate other steroid dosages. Simplicef 5-10 mg/kg q 24 Antibiotic for Fewer GI side effects hr pyoderma than cephalexin *Antihistamines work best for mild itching or before a severe allergy flare-up. *Malaseb, Chlorhexiderm, Oxydex or Etiderm shampoos can treat mild superficial pyodermas or can be used with an oral antibiotic. Superficial pyodermas should be treated for 3-4 weeks or 1 week beyond resolution of signs. *Malaseb pledgets or shampoo can treat mild Malassezia dermatitis or can be used with an oral antifungal. Use an oral antifungal like ketoconazole for severe Malassezia dermatitis or Malassezia dermatitis that is hard to treat topically. *Shampoo 1-2x a week. Educate clients about contact time and GIVE CLIENTS THE TOPICAL THERAPY HANDOUT.

EAR MEDICATION Conofite Clotrimazole Otomax

COMMON EAR MEDICATIONS INGREDIENTS WHEN TO USE Miconazole Clotrimazole Clotrimazole, gentamicin, betamethasone neomycin, dexamethasone, thiabendazole Enrofloxacin silver sulfadiazine Variety Otitis externa fungal or bacterial (cocci or when small number of rods with little ear debris) Can be ototoxic Ear mites Otitis externa fungal Otitis externa bacterial (cocci only) Otitis externa bacterial (rods) Otitis externa fungal

Tresaderm Baytril otic Epi Otic Oticalm

Ear cleaning 1-2x a week to minimize otic debris GIVE CLIENTS THE EAR CLEANING HANDOUT *Always recommend recheck ear cytology! Recheck ear cytology in 2-4 weeks.

Exotics
Birds:
Enrofloxacin 15mg/kg IM once, then 15mg/kg PO q 12hrs Metronidazole 50mg/kg PO q 12hrs Doxycycline 25 mg/kg PO q 12 hrs for 45 days Fluconazole 10mg/kg PO q 12 hrs Itraconazole 10mg/kg PO q 24 hrs, African grey 5mg/kg Diazepam 0.5-1mg/kg IM/IV CaEDTA 30mg/kg IM undiluted or SQ diluted in NaCL q 12hrs for 5 days. Diurese concurrently and treat with MgSO4 PO q 12hrs to prevent further absorption of lead from GI Cagluconate 50-100mg/kg IM/SQ q 12hrs SQ fluids 25ml/kg SQ q 12 hrs Crop feeding: Kaytee Exact 25 ml/kg PO q 6-12 hrs Meloxicam: 0.2mg/kg BID Buprenex: 0.02-0.05mg/kgSQ/8 Bleeding bird: iron dextran 10 mg/kg and SQ fluids Rabbits: GI stasis: Cisapride 0.5mg/kg PO q 8-12 hrs Metoclopramide 0.5mg/kg PO q 6-12 hrs Simethicone 0.5-1 ml per rabbit PO q 6-12 hrs SQ fluids 100-120ml/kg/day divided q 8 hrs Buprenorphine 0.02-0.05mg/kg IM q 8 hrs Critical Care Herbivore 15ml/kg PO q 8 hrs NO PROPOFOL!! (Apnea) Pre-med: Midazolam 0.5 mg/kg IM Butorphanol 0.2 mg/kg IM Post-op: Buprenorphine 0.04 mg/kg IM Guinea Pig: Vitamin C 50-100mg/pig SQ q24 Ferrets: Insulinoma: Prednisone 0.25-0.5 mg/kg PO q 12 hrs Diazoxide 5-30 mg/kg PO q 12 hrs (if pred alone is not enough) Frequent feedings Ferret insulinoma hypoglycemia Helicobacter protocol: Famotedine 0.5 mg/kg PO/IV q 24 hrs 0.25-2.0 mLs Dextrose (50%) IV Amoxicillin 20 mg/kg PO/SQ q 12 hrs Metronidazole 10-20 mg/kg PO q 12 hrs Sedation: Sucralfate 125 mg per ferret PO q 6 hrs if melena Buprenex 0.01-0.05 mg/kg and Monitor PCV if melena Midazolam 0.3-0.1 mg/kg Prostatomegaly secondary to adrenal DZ Lupron 0.1-0.2 mg/kg IM q 4 weeks Oxyglobin 11-15 mg/kg over 4 hrs Meloxicam 0.2 mg/kg PO q24h, always give Famotidine with Reptile:Very helpful website: Melissa Kaplan http://www.anapsid.org/ Ceftazaidime dose: 20 mg/kg IM or SC q72hours FRONT LEG ONLY Enrofloxacin 10mg/kg IM once then PO q 12 hrs Pen G 50.000-80.000 IU/kg SQ q 24 hrs Thrimethroprim/Sulfa 30 mg/kg PO q 12 hrs Chloramphenicol 50 mg/kg PO q 8-12 hrs Albon 50 mg/kg PO once, then 25 mg/kg PO q 24 hrs for 10-20 days Metronidazole 10 mg/kg PO for 14 days (Clostridium diarrhea) Oxybendazole 30 mg/kg PO q 24 hrs for 30 days (E. Cuniculli) Meclizine 2-12 mg/kg PO q 24 hrs (antitorticollis) Meloxicam 0.5mg/kg PO q12h; 7 days

RABIES PROTOCOL
MANAGEMENT OF DOGS & CATS EXPOSED TO WILDLIFE (Raccoon, skunk, fox, bat, woodchuck or any carnivorous wild animal) Exposure Category I f Dog or Cat is If dog or cat is Currently Vaccinated NOT Currently Vaccinated Category 1 1. Booster Immediately 1. Euthanize, or Direct contact with or visible bite 2. Notify local director of health 2. If owner unwilling: from a confirmed rabid animal and local animal inspector a. Notify local director of health (includes eating viscera) 3. Strict Confinement for 45 days and local animal inspector b. Isolate for 3 months followed by 3 months strict confinement c. Vaccinate 1 month prior to release Category 2 1. Booster Immediately 1. Euthanize, or Direct contact with or visible bite 2. Notify local director of health 2. If owner unwilling: from a suspect rabid animal and local animal inspector a. Notify local director of health and (includes eating viscera) which is 3. Strict Confinement for 45 days local animal inspector unavailable for testing b. Strict confinement for 6 months c. Vaccinate 1 month prior to release Category 3 1. Booster Immediately 1. Euthanize, or Wound of unknown origin 2. Notify local director of health 2. If owner unwilling: suspected to be caused by another and local animal inspector a. Notify local director of health and animal 3. Strict Confinement for 45 days local animal inspector (e.g. cat abscesses) b. Strict confinement for 6 months c. Vaccinate 1 month prior to release Category 4 1. Booster Immediately 1. Vaccinate immediately Exposure by proximity seen near 2. Notify local director of health 2. Notify local director of health and or in close proximity to a and local animal inspector local animal inspector confirmed 3. Strict Confinement for 45 days b. Strict confinement for 6 months rabid animal (no contact or wounds) Always wear gloves when handling saliva-contaminated wounds or fur. Always advise owner of rabies risk. Veterinarians must inform the local animal inspector of any potential rabies contact cases seen at their offices 1. Do not vaccinate any unimmunized dog or cat in categories 1, 2 or 3. Timing of vaccination should follow above schedule 2. If most recent rabies vaccination was administered within one month, it is not necessary to booster. 3. Dog or cat should be examined by a veterinarian to assure there are no wounds.

RABIES PROTOCOL MANAGEMENT OF DOGS & CATS EXPOSED TO OTHER DOMESTIC ANIMALS
(Wolf Hybrids and other exotic pets are considered to be wild animals) Exposed Dog or Cat is Currently Vaccinated Exposed Dog or Cat is NOT currently vaccinated Category 1 1. Notify local director of health and local 1. Notify local director of health and local Visible bite or scratch animal inspector animal inspector from another domestic 2. Biting animal will be placed under strict 2. Biting animal will be placed under strict animal which has been confinement for 10 days confinement for 10 days available for quarantine 3. A) If biting animal is healthy at the end of 10 3. A) If biting animal is healthy at the end identified and days, victim is not at risk for rabies of 10 days, victim is not at 3. B) If the biting animal begins to exhibit signs risk for rabies - Vaccinate victim compatible with rabies, biting animal should be 3. B) If the biting animal begins to exhibit euthanized and submitted for rabies signs compatible with rabies, biting animal 4. A) If test results are negative, victim is not at should be euthanized and submitted for risk for rabies rabies 4. B) If test results are positive, 4. A) If test results are negative, victim is 1. Booster victim immediately not at risk for rabies, vaccinate victim 2. Notify local director of health and local 4. B) If test results are positive, animal inspector 1. Notify local director of health and local 3. Strict confinement by owner for 45 days animal inspector 2. Euthanize, or Isolation for 3 months followed by 3 months strict confinement vaccinate at 5 months Category 2 1. Booster victim immediately 1. Notify local director of health and local Visible bite or scratch 2. Notify local director of health and local animal inspector from another domestic animal inspector 2. Strict confinement by owner for 6 months animal which has NOT 3. Strict confinement by owner for 45 days vaccinate at 5 months been identified and is NOT available for quarantine Exposure Category Any non-domestic animal biting a human needs to be reported to the Department of Public Health Protocol for ferrets is similar, but notification must be made to the Division of Fisheries and Wildlife Do not vaccinate any dog or cat which is under a 10-day quarantine Any animal euthanized while under a 10-day quarantine MUST be submitted for rabies testing If most recent rabies vax was within 30 days, it is not necessary to re-vaccinate

RBC MORPHOLOGY AT-A-GLANCE


Morphology Rouleaux Agglutination Polychromasia Anisocytosis Hypochromasia Poikilocytosis Echinocytes Appearance RBCs stuck together like stack of coins Clumping of RBCs Bluish erythrocytes Variation in RBC diameter Increased central pallor Abnormal shaped RBCs Evenly spaced spicules of similar size Irregularly spaced spicules of variable size RBCs with a mouth RBC fragments Intact or ruptured vesicles on edge of RBC Small, round, dense, lack central pallor Thin and floppy with folds or targets Hb poor area at edge RBCs with noses Elliptical in shape Significance & Assoc, Disease Conditions Can be normal in cats. Increased fibrinogen or increased globulins as in inflammation or lymphoproliferative disorders. Immune mediated anemia; esp. IgM type Regenerative anemia Occurs when macrocytes or microcytes are present. Iron deficiency anemia Common in cats; severe iron deficiency anemia; oxidant injury; adriamycin toxicity; or dyserythropoiesis. Usually an artifact; also hypophosphatemia; rattlesnake envenomation; blood transfusion; uremia, PK deficiency; glomerulonephritis; neoplasia. Liver disease, RBC fragmentation disorders such as DIC, GN or hemangiosarcoma Artifact; hereditary in Alaskan malamutes and schnauzers. Microangiopathy-DIC, iron deficiency, liver disease, heart failure, GN, hemangiosarc., myelofibrosis, splenic disease. Iron-deficiency anemia; liver disease; adriamycin toxicity; microangiopathy, MDS IMHA, iron deficiency, zinc tox, RBC parasites, bee sting, snake envenomation, transfusion of stored blood, fam. dyserythr. Iron-deficiency anemia, liver disease, congenital dyserythropoiesis. Oxidant injury- onions, tylenol, Vit K Oxidant injury large HBs; Cats can have small HBs in diabetes, hyperthyroidism, lymphoma; also normal cats. Dogs hereditary, GN, myelofibrosis, MDS; cats w/ bone marrow disease (ALL, myeloprolif), hepatic lipidosis, PSS, adriamyciin toxicity. GN, hypersplenism, myeloproliferative ds. Regenerative anemia; lead toxicity Lead tox, hemolytic anemia, drugs, dyserythropoiesis, myeloproliferative ds. Regen. anemia, splenectomy; roids, vincrist.

Acanthocyte Stomatocyte Schistocyte Keratocyte Spherocyte Target cell and other leptocytes Eccentrocyte Heinz bodies Ovalocyte

Dacrocytes Basophilic stippling Siderocyte Howell-Jolly

Teardrop-shaped Blue stippling due to ribosomes Clustered blue dots- iron Nuclear remnant

Vaccination protocol

Feline vaccinations FVRCP R shoulder SQ

Rabies (Purevax R hind SQ

Flea/Tick Preventative
Life cycle of flea Larvae, Adults Larvae, Adults Lice Ticks, mosquitos, Lice, ? Chyletiella Heartworm, mites (scabies), hookworms, roundworms, whipworms Ticks, mosquitoes No, Maggots?

Active Ingredients Advantage Advantix Imidacloprid Imidacloprid, Permethrin Imidacloprid, Moxidectin Permethrin, Methoprene Nitenpyram Boric acid (powder); surfactant (shampoo) Fipronil

Any other parasites

Formulation Spot-on Spot-on

Side Effects excessive salivation Toxic in Cats; Permethrin washes off quickly (tick control not a month) +UV degrades

Notes Stays in epidermal lipid layer Minimal age dogs 7 weeks, cats - 8 weeks Minimal age dogs 7 weeks Not a good Tx for demodex Minimal age dogs 7 weeks, cats 9 weeks

Advantage-Multi Biospot (OTC) Capstar

Larvae, Adults Larvae, Adults Adults

Spot-on Spot-on, spray, dip, collar Tablet Permethrin toxic to cats Safe

80min dog; 40min cats Minimal age dogs/ cats 4 weeks, 2+ lbs

Flea Busters (OTC) Frontline

eggs; adults Adults

No Lice, Chyletiella, ?Scabies

Powder, shampoo Spray, Spot-on Toxic in Rabbits

Frontline Plus Knockout Spray (OTC, Angell) (Program)/Sentinel Revolution Preventic Collar

Fipronil; S-Methoprene Permethrin, Pyriproxifen Lufenuron / Milbemycin Selamectin Amitraz (Ticks only)

Larvae, Adults, Eggs Larvae, Adults Eggs (flea birth control) Adults, eggs Ticks

Lice, Chyletiella, ?Scabies Lice, Chyletiella, Cockroaches Heartworm, hookworms, roundworms, whipworms Heartworm, mites, ticks No

Spot-on Spray Tablet, Injectible q6m feline product Spot-on Collar

Toxic in Rabbits Toxic in Cats None Caution in collie breeds Toxic if ingested

Sprinkle on carpet + vacuum good 1yr Stays in sebacious glands doesn't work w/sebacious adenititis Stays in sebacious glands doesn't work w/sebacious adenititis Minimal age dogs and cats 8 weeks

3-4 mo until max efficacy Minimal age dogs 4 weeks, cats - 6 weeks Resistant to bathing Minimal age dogs/ cats 8 weeks

Heartworm, FLEA/TICK PREVENTATIVE SUMMARY


Heartgard Plus NO > 6 wks old 1 month Chewable YES YES YES NO NO NO NO NO YES Heartgard Plus (cats) > 6 wks old NO 1month Chewable YES NO YES NO NO NO NO NO YES Interceptor NO > 4 wks; or >2 lbs 1 month Chewable given w/ food YES YES YES YES NO NO NO NO YES Sentinel NO > 4 wks; or > 2 lbs 1 month Chewable given w/ food YES YES YES YES NO NO NO NO YES Revolution > 6 wks old; or >5 lbs > 6 wks old; or > 5 lbs 1 month Topical YES CATS ONLY CATS ONLY NO DOGS ONLY YES NO YES YES Frontline Plus > 8 wks old > 8 wks old 1 month for ticks; 3months for fleas Topical NO NO NO NO YES YES YES YES NO Advantix NO TOXIC > 7 wks old 1 month Topical NO NO NO NO YES YES YES YES NO Program > 6 wks old > 6 wks old 1 month Chewablegiven w/ food NO NO NO NO NO NO NO YES YES Preventic NO > 12 wks old 3 months Collar NO NO NO NO YES NO NO NO NO

Approved for cats Approved for dogs Length of effectiveness Method of Adminstration HWP Roundworm Hookworms Whipworms Kills ticks Kills adult fleas Kills flea larvae Sterilizes flea eggs Safe for pregnant pets

DEWORMING
Whipworms Pyrantel pamoate (Strongid) Fenbendazole (Panacur) Praziquantel (Droncit) Ivermectin (Heartgard) Milbemycin (Revolution) Metronidazole Sulfadimethoxine (Albon) Higher doses Trichuris vulpis Trichuris vulpis Taenia pisiformis Dipylidium caninum; Taenia pisiformis Higher doses Toxacara canis Higher doses Ancyclostom a caninum Yes Isospora Tapeworms Roundworms Toxacara canis/leonina Toxacara canis/leonina Hookworms Ancyclostom a caninum; Unicinaria stenocephala Ancyclostom a caninum; Unicinaria stenocephala Giardia Coccidia Other Physaloptera

Yes

Capillaria; Filaroides; Paragonimus Echinococcu s granulosis Dirofilaria immitis; Capillaria Dirofilaria immitis; Demodicosis

Strongid Panacur Albon Revolution

1 mL/20# once; then repeat in 3 weeks 50mg/kg or based on weight q24h for 3- 5 days; then repeat in 3 weeks 50 mg/kg once, then 25 mg/kg once daily for 2-3 weeks Sarcoptic mange: once q2 weeks; 3 doses 200mcg/kg PO SQ Ivermectin once a week for 3 weeks

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