Veterinary Technician's Daily Reference Guide: Canine and Feline

Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition

Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition Candyce M. Jack, LVT Sequim, Washington

Patricia M. Watson, LVT Redmond, Washington

Mark S. Donovan, DVM Consulting Editor Seattle, Washington

First Edition first published 2003 Second Edition first published 2008 © 2008, Candyce M. Jack and Patricia M. Watson Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has been merged with Wiley’s global Scientific, Technical, and Medical business to form Wiley-Blackwell. Editorial Office 2121 State Avenue, Ames, Iowa 50014-8300, USA For details of our global editorial offices, for customer services, and for information about how to apply for permission to reuse the copyright material in this book, please see our website at www.wiley.com/wiley-blackwell. Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by Blackwell Publishing, provided that the base fee is paid directly to the Copyright Clearance Center, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payments has been arranged. The fee codes for users of the Transactional Reporting Service are ISBN-13: 978-0-8138-1204-5/2008. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. Library of Congress Cataloguing-in-Publication Data Jack, Candyce M. Veterinary technician’s daily reference guide: canine and feline / Candyce M. Jack, Patricia M. Watson; consulting editor, Mark S. Donovan. – 2nd ed. p. ; cm. Rev. ed. of: Veterinary technician’s daily reference guide: canine and feline / Candyce M. Jack, Patricia M. Watson; consulting editor, Mark S. Donovan. C2003. Includes bibliographical references and index. ISBN 978-0-8183-1204-5 (alk, paper) 1. Veterinary medicine–Handbooks, manuals, etc. I. Watson, Patricia M. II. Jack, Candyce M. Veterinary technician’s daily reference guide. III. Title. [DNLM: 1. Veterinary Medicine–methods–Handbooks. 2. Animal Technicians– Handbooks. 3. Cat Diseases–Handbooks. 4. Dog Diseases–Handbooks. SF 748 J12v 2008] SF748.J33 2008 636.089–dc22 2007050954 A catalogue record for this book is available from the U.S. Library of Congress. Set in Berling-Roman by SNP Best-set Typesetter Ltd Printed in Singapore by Markono Print Media Pte Ltd 1 2008

This book is dedicated to all the licensed veterinary technicians who are doing their best for the advancement of the field and devoting themselves to providing the best possible care to their animal patients. A special thanks to our medical editor, Dr. Mark Donovan, for his commitment to our goal and his perseverance to ensure the book presented advanced and accurate information. Patricia Special thanks for family, co-workers, and friends who are consistently supporting me to new levels of learning and opportunity. Each of you and your pets are a part of this book and I am grateful for your constant support. Thanks to my coauthor, whose insight, energy, dedication to the veterinary field, and perseverance has made this second edition a reality. And finally, I dedicate this book in special remembrance of my beloved Einstein (1991–2006), whose teeth are immortalized within the pages of this book. Candyce With heartfelt gratitude, I thank Dede for her patience and friendship, Linda for her continuous support of my endeavors, Megan for teaching me “you can’t push the river,” and, most important, my incredibly supportive family for the sacrifices they have made to allow me to complete this project.

Table of Contents Figure List Preface Acknowledgments Contributors

xvii xxi xxiii xxiii

Section One: Anatomy

3

Chapter 1:

5

Anatomy Anatomy Overall Musculature Skeletal Internal Organs Circulatory System Nervous System Urogenital Eye Ear

6 6 6 7 8 9 10 11 13 13

Section Two: Preventative Care

15

Chapter 2:

Preventative Care and Vaccinations

17

Physical Examinations Preliminary Examination Physical Examination Pediatric Physical Examination Normal Parturition Care and Feeding of Orphaned Puppies and Kittens Geriatric Physical Examination Cardiac Examination Pulmonary Examination Abdominal Examination Otoscopic Examination Regional Lymph Node Examination Neurologic Examination Orthopedic Examination Vaccinations Guidelines to Follow When Vaccinating an Animal

18 19 20 23 26 27 28 30 32 33 33 34 34 36 37 37

Chapter 3:

Canine Transmissible Diseases Coronavirus, Distemper Hepatitis, Infectious Tracheobronchitis Leptospirosis, Lyme Disease Parvovirus, Rabies Canine Vaccination Protocol Feline Transmissible Diseases Feline Calicivirus Feline Infectious Peritonitis Feline Panleukopenia Virus, Feline Immunodeficiency Virus Feline Leukemia Virus, Feline Rhinotracheitis Virus Feline Vaccination Protocol Animal Care Client Education: Home Dental Care Grooming Bathing Nail Trimming Anal Sac Expression Ear Cleaning and Flushing

38 38 39 41 42 44 44 44 46 47

Nutrition

57

General Nutrition Daily Caloric Requirement Worksheet for a Healthy Animal General Life Stage Feeding Guidelines Body Condition Scoring System Disease Nutritional Requirements Obesity Management

58

49 51 51 52 53 53 54 54 55

59 60 62 64 68

Section Three: Diagnostic Skills

69

Chapter 4:

Laboratory

71

Blood Chemistries Blood Collection, Handling, Storage, and Transport Tips

74 74 vii

Blood Collection Tubes Blood Chemistries Bone Marrow Evaluation Bone Marrow Collection, Handling, Storage, and Transport Tips Supplies for Bone Marrow Collection Smear Techniques Evaluation Bone Marrow Evaluation Cell Type Identification Interpretation Cytology Cytology Collection, Handling, Storage, and Transport Tips Collection Techniques FNB Needle and Syringe Selection Smear Techniques Evaluation Cytologic Criteria of Malignancy Figure 4.4: Cytologic Criteria of Malignancy Specific Tumor Cells Interpretation Fecal Cytology Vaginal Cytology Classifying Vaginal Cells Staging the Estrus Cycle Function Tests Hematology Complete Blood Count Hemacytometer Use Calculating a Differential Evaluation RBC Alterations and Morphology WBC Morphology WBC Alterations WBC Left Shift Platelet Morphology Platelet Alterations Coagulation Tests Coagulation Screening Coagulation Tests Blood Transfusions Crossmatching viii

TABLE OF CONTENTS

75 76 83

Blood Typing Immunology and Serology Tests Microbiology Microbiology Collection, Handling, Storage, and Transport Tips Collection Techniques Specimen Storage Most Commonly Used Culture Media Culture Media Inoculation and Incubation Evaluation of Culture Growth Staining Solutions and Procedures Staining Problems Bacteria Identification Fungi Identification Parasitology Fecal Collection, Handling, Storage, and Transport Tips Endoparasite Examination Methods Fecal Flotation Solutions Blood Parasite Examination Methods Ectoparasite Examination Methods Figure 4.35: Relative Size of Parasite Eggs Endoparasites Ectoparasites Urinalysis Urine Collection, Handling, Storage, and Transport Tips Urine Examination/Urinalysis Gross Examination Preparation Chemistry Strip Examination Sediment Examination Reporting of Bacteria and Sperm Sediment Examination Urine Artifacts

83 84 84 85 85 86 88 88 88 88 89 90 91 92 93 94 95 96 97 97 98 98 104 105 108 108 108 108 112 113 114 115 115 115 115 116 119 119

Chapter 5:

120 120 122 122 123 124 125 126 127 127 130 130 133 134 134 134 137 138 139 139 139 145 147 147 147 148 149 149 150 151 151 155

Imaging

157

Radiology Radiographic Equipment Radiographic Exposure and Image Factors Radiographic Technique Chart Example 1: Veterinary X-Ray Technique Guide

159 160 161 161 162

Example 2: Veterinary X-Ray Technique Chart Evaluating Radiograph Technique Exposure Evaluation Density Evaluation Scale of Contrast Evaluation Radiographic Alterations Radiographic Artifacts Radiographic Positioning Directional Terms Positional Terms Soft Tissue Positioning Thorax Abdomen and Pharynx Head Positioning Skull Zygomatic Arch Tympanic Bullae Temporomandibular Joint Nasal Cavities and Sinuses Nasal Cavities and Sinuses (continued) Spine Positioning Cervical Thoracic–Lumbar Sacrum–Caudal Shoulder and Forelimb Positioning Scapula–Shoulder Humerus Elbow Radius/Ulna and Carpus Metacarpus/Phalanges Pelvis and Hindlimb Positioning Pelvis Femur, Stifles, and Tibia/Fibula Tarsus and Metatarsals Radiographic Contrast Studies Types of Contrast Media Fistula Contrast Studies Fistulography Abdominal Contrast Studies Peritoneography Gastrointestinal Tract Contrast Studies Esophagography and Gastrography Upper and Lower Gastrointestinal Study

163 164 164 164 164 166 167 167 168 168 169 169 169 170 170 171 172 172 173 173 174 174 175 175 176 176 176 177 178 178 179 179 180 181 181 182 183 183 183 183 184 184 185

Head Contrast Studies Dacryocystorhinography, Rhinography, and Sialography Spinal and Joint Contrast Studies Myelography and Epidurography Discography and Arthrography Urethra Contrast Studies Urethrography, Canine Urethrography, Feline Vaginal Contrast Studies Vaginography Urinary Tract Contrast Studies Cystography Cystography (continued) Additional Imaging Techniques Computer Tomography and Echocardiography Fluoroscopy Magnetic Resonance Imaging and Nuclear Medicine Ultrasonography Basic Scanning Technique Sites for Ultrasound Scanning

187 187 188 188 189 190 190 191 192 192 193 193 194 195 195 196 196 197 198 198

General Medicine

201

Cardiopulmonary Asthma and Brachycephalic Airway Syndrome Bronchitis and Cardiomyopathy, Hypertrophic Cardiomyopathy, Dilated Cardiomyopathy, Restrictive and Congenital Heart Disease Endocardiosis and Heartworm Disease Congestive Heart Failure Hypertension and Myocarditis Pneumonia and Pleural Effusion Rhinitis/Sinusitis and Tracheal Collapse Dermatology Acne Acral Lick Dermatitis, Atopy, and Flea Allergy Dermatitis Food Hypersensitivity and Otitis Externa Pyoderma

204 204 205 208

Color Plate Chapter 6:

TABLE OF CONTENTS

210 211 214 215 217 219 220 220 222 224 225 ix

Endocrinology and Reproduction Abortion and Diabetes Insipidus Diabetes Mellitus Dystocia and Eclampsia Hyperadrenocorticism and Hyperparathyroidism Hyperthyroidism and Hypoadrenocorticism Hypoparathyroidism, Hypothyroidism, and Mastitis Pregnancy and Pyometra Gastroenterology Anal Sac Disease, Cholangitis, and Cholangiohepatitis Constipation and Megacolon Diarrhea Exocrine Pancreatic Insufficiency and Gastric Dilatation-Volvulus Hepatic Disease/Failure Hepatic Lipidosis and Inflammatory Bowel Disease Megaesophagus Pancreatitis and Peritonitis Protein-Losing Enteropathy and Vomiting Hematology Anemia and Disseminated Intravascular Coagulation Thrombocytopenia and von Willebrand’s Disease Infectious Diseases Brucellosis and Erhlichiosis Rocky Mountain Spotted Fever and Salmon Poisoning Tetanus and Toxoplasmosis Musculoskeletal Arthritis Cruciate Disease and Hip Dysplasia Osteochondrosis and Osteomyelitis Patellar Luxation and Panosteitis Neurology Encephalitis and Epilepsy Intervertebral Disc Disease and Meningitis Myasthenia Gravis and Myelopathy Vestibular Disease and Wobbler Syndrome Oncology Neoplasia Histiocytoma, Mammary Gland Neoplasia, and Mast Cell Tumor Various Neoplasias x

TABLE OF CONTENTS

227 227 228 230 231 233 235 237 238

Ophthalmology Anterior Uveitis and Cataracts Conjunctivitis and Entropion Cilia Disorders and Glaucoma Keratitis and Keratoconjunctivitis Sicca Lens Luxation and Prolapsed Gland of the Third Eyelid Urology Cystic Calculi, Feline Lower Urinary Tract Disease, and Pyelonephritis Renal Failure Urinary Tract Obstruction and Urinary Tract Infection

238 240 241 243 245 246 248 249 251 253 253 254 256 256 258 259 261 261 263 264 266 267 267 269 271 272 273 273 275 277

Chapter 7:

284 284 285 287 288 290 292 292 294 296

Emergency Medicine

299

Emergency Medicine Emergency Supplies Telephone Assessment and Emergency Transportation Recommendations Inducing Vomiting At-Home Triage Primary Survey Hemostasis Cardiopulmonary Cerebrovascular Resuscitation (CPCR) Secondary Survey Shock Cardiovascular Emergencies Environmental Emergencies Gastrointestinal Emergencies Hematologic Emergencies Metabolic and Endocrine Emergencies Neonatal Emergencies Neonatal Resuscitation Post-Cesarean Neurologic Emergencies Ophthalmic Emergencies Renal and Urinary Emergencies Reproductive and Genital Emergencies Respiratory Emergencies Toxicologic Emergencies Toxins Trauma Emergencies

301 301 304 305 306 306 307 308 309 310 312 313 314 315 316 317 317 318 319 320 321 322 323 324 326

Section Four: Patient Care Skills

327

Chapter 8:

Patient Care

329

Patient Monitoring Blood Pressure Blood Pressure Procedure Blood Pressure Results Central Venous Pressure Blood Gas Analysis Blood Gas Analysis Arterial Blood Gas Interpretation Acid-Base Disturbances Electrocardiogram ECG Procedure ECG Leads ECG Interpretation Figure 8.1 Normal Canine Electrocardiogram Heart Rate Calculation Common Rhythm Abnormalities Figure 8.2 Atrial Premature Contraction/Complex Figure 8.3 ST-Segment Elevation Figure 8.4 Ventricular Premature Contraction/ Complex ECG Problems and Artifacts Heat Administration Recumbent Patient Care Drug Administration Injections Intravenous Catheter Placement Peripheral and Jugular Arterial and Intraosseous Monitoring and Maintenance Chemotherapy Administration Toxicity Client Education: Monitoring Chemotherapy Response Insulin Therapy Client Education: Insulin Administration Client Education: Monitoring Insulin Response Client Education: Monitoring for Hypoglycemia Fluid Therapy Hydration Assessment

332 332 332 333 334 335 335 337 337 338 338 339 340 341 342 343 344 344 344 345 346 347 348 348 349 349 350 351 352 352 353 356 357 357 358 359 359 360

Chapter 9:

Calculating Fluid Requirements Routes of Fluid Administration Commonly Used Fluids Fluid Additives Calculating Drip Rates Monitoring Fluid Therapy Blood Transfusions Blood Types Blood Collection Blood Products Blood Administration Blood Transfusion Reactions Oxygen Therapy Oxygen Administration Routes of Oxygen Administration Oxygen Hood and Nasal Catheter Transtracheal Catheter and Tracheostomy

361 362 363 365 365 366 367 368 369 371 373 374 375 375 376 376 377

Pain Management

379

Pain Management Pain Assessment Pain Scales Instructions for Using the CSU Acute Pain Scale Pain Levels Associated With Surgical Procedures, Injuries, and Illness Behaviors Suggesting Pain and Anxiety Nondrug Approach to Decrease Pain and Anxiety Pain Management Drugs Pain Management Techniques Constant Rate Infusions Setting Up a Morphine/Lidocaine/Ketamine Constant Rate Infusion

380 381 381

Chapter 10: Wound Care

382 383 384 386 386 392 392 393

395

Wound Treatment and Bandaging Wound Healing Process Classification of Wounds Factors Affecting the Healing Process Wound Care TABLE OF CONTENTS

396 396 397 398 399 xi

Wound Cleaning Solutions Topical Wound Medications Wound Bandaging Bandage Care Bandaging Basic Bandage Robert Jones Bandage Chest/Abdominal Bandage Distal Limb Splint Casts Ehmer Sling 90–90 Flexion Velpeau Sling Hobbles Chapter 11: Parenteral Nutrition Nutritional Support Tips on Encouraging Oral Nutrition Enteral Nutrition Coax Feeding and Orogastric Tube Nasoesophageal/Nasogastric Tube Esophagostomy Tube Gastrotomy Tube Without Gastropexy Gastrotomy Tube With Gastropexy Jejunostomy Tube Enteral Nutrition Administration Parenteral Nutrition Parenteral Nutrition Parenteral Nutrition Administration Worksheet for Calculating Total Parenteral Nutrition (TPN) Worksheet for Calculating Peripheral or Partial Parenteral Nutrition (PPN)

Chapter 12: Medical Procedures Gastrointestinal Procedures Stomach Tube and Gastric Lavage Gastrointestinal Tube Placement Verification Abdominocentesis and Diagnostic Peritoneal Lavage Enema, Warm Water xii

TABLE OF CONTENTS

401 402 403 404 405 405 406 407 408 408 409 410 410 411 413 414 414 414 414 415 417 418 419 420 421 422 423 424 425 426

427 428 428 429 429 430

Ophthalmic Procedures Schirmer Tear Test, Fluorescein Sodium Stain, and Tonometry Respiratory Procedures Thoracocentesis and Thoracostomy Tube Placement Nebulization, Coupage, and Metered-Dose Inhalers Urogenital Procedures Urine Collection Urine Collection Devices Urinary Catheterization Urinary Catheter Maintenance

430 430 431 431 432 434 434 435 435 436

Section Five: Anesthesia and Anesthetic Procedures

437

Chapter 13: Anesthesia

439

Guidelines for Safe Anesthesia Preanesthetic Preanesthetic Evaluation Case-Based Anesthesia Preanesthetic Drugs Anesthesia Anesthetic Administration Anesthetic Machine Machine Setup Anesthetic Breathing Systems Anesthetic Administration General Anesthesia Induction Endotracheal Intubation Figure 13.1 Endotracheal Intubation Endotracheal Complications Perioperative Patient Care Intermittent Positive-Pressure Ventilation (IPPV) Anesthetic Monitoring Stages of Anesthesia Anesthesia Monitoring Postanesthesia Recovery Postanesthetic Monitoring Local and Regional Anesthesia Ventilation

441 442 442 444 451 451 451 451 451 452 453 453 454 455 456 456 456 458 458 458 460 466 466 467 470 474

General Information Administration Anesthetic Drugs Preanesthetic Drugs Anticholinergic Drugs Atropine and Glycopyrrolate Phenothiazines Acepromazine Maleate Benzodiazepines Diazepam and Midazolam α2-Agonists Xylazine and Medetomidine Opioids Butorphanol and Buprenorphine Fentanyl and Hydromorphone Morphine Sulfate and Oxymorphone HCl Injectable Induction Anesthetics Barbituates Thiobarbituates and Methylated Barbituates Cyclohexamines Ketamine and Tiletamine Propofol Propofol (continued) Etomidate Etomidate (continued) Inhalant Anesthetics Halothane and Isoflurane Sevoflurane Chapter 14: Dentistry Dentistry Anatomy Figure 14.1: Dentition: Canine and Feline Figure 14.2: Cross Section of a Triple-Rooted Tooth Figure 14.3: Skeletal Structure: Canine and Feline Figure 14.4: Cross Section of Facial Structures: Canine and Feline Dental Instruments and Equipment Hand-held Instruments Figure 14.5: Hand-held Non-mechanical Dental Instruments Instrument Maintenance

474 475 477 477 477 478 478 479 480 480 481 482 484 485 486 487 488 488 489 490 491 492 492 493 494 494 495 496 497 499 499 499 500 500 501 501 501 502 502

Sharpening Technique Mechanical Instruments Dental Prophylaxis Dental Cleaning Procedure Dental Charting Figure 14.6: Sample of Patient’s Dental Health Chart Common Dental Disorders Anatomical Disorders Pathologic Disorders Dental Radiology Equipment Technique Chart Radiographic Film Radiographic Techniques Radiographic Positioning Extractions General Extraction Procedures Local Dental Nerve Blocks Chapter 15: Surgery

503 503 504 504 506 509 510 510 511 512 512 512 513 513 514 517 517 518 521

Instrument Packs Preoperative Protocol Surgical Procedures Abdominal Surgery Abdominal Hernia, Anal Sacculectomy, and Colotomy Enterotomy, Gastric-Dilatation Volvulus, and Gastrotomy Intestinal Resection and Anastomosis and Hepatectomy Aural Surgery Aural Hematoma and Lateral Ear Canal Resection Integumentary Surgery Abscess and Laceration Mass Removal and Onychectomy Neurologic Surgery Disc Fenestration, Dorsal Laminectomy, and Hemilaminectomy Ophthalmic Surgery Cataracts, Ectropion, and Entropion Conjunctival Flap and Enucleation TABLE OF CONTENTS

523 524 525 525 526 528 529 530 530 531 532 533 534 535 536 537 538 xiii

Glaucoma and Nictitating Membrane Flap Replacement Prolapse of the Gland of the Third Eyelid and Traumatic Proptosis Orthopedic Surgery Cranial Cruciate Ligament Repair, Femoral Head Ostectomy, and Fracture Repair Patellar Luxation, Total Hip Replacement, and Triple Pelvic Osteotomy Reproductive Tract Surgery Cesarean Section, Orchiectomy, and Ovariohysterectomy Postoperative Care of Neonates and Dam Thoracic Surgery Diaphragmatic Hernia, Laryngeal Paralysis, and Sternotomy Thoracotomy and Tracheal Collapse Urogenital Tract Surgery Cystotomy and Urethrostomy, Perineal Urethrostomy, Scrotal, and Urethrostomy, Prescrotal Suture Techniques Suture Patterns Knot Tying Postoperative Care Protocol Standard Postoperative Care Instructions Preventing Self-Trauma Alternative Surgical Options Endoscopy: Flexible Gastrointestinal and Rigid Laser Surgery Radiation Therapy: Teletherapy, Brachytherapy and Systemic Therapy Temperature Therapy: Hyperthermia and Cryosurgery

538 539 539 540 541 542 542 544 544 545 546 547 547 548 548 548 549 550 550 550 551 551 552 553 554

Section Six: Complementary and Alternative Veterinary Medicine and Pharmacology

555

Chapter 16: Complementary and Alternative Veterinary Medicine

557

Complementary and Alternative Veterinary Medicine (CAVM) Physical Therapy and Rehabilitation Traditional Chinese Medicine

558 558 562

xiv

TABLE OF CONTENTS

Ayurveda and Chiropractic Flower Essences and Homeopathy Laser Therapy Magnetic Field Therapy Western Herbal Medicine Chapter 17: Pharmacology Pharmacology Basic Calculations Drug Cross-Reference Antifungal Drugs Anti-infective Drugs Aminoglycosides, Cephalosporins, and Chloramphenicol Fluoroquinolones, Lincosamides, and Metronidazole Penicillin, Sulfonamides, and Tetracyclines Antiparasitic Drugs Antinematodals Antinematodals (continued) Anticestodals Ectoparasitics Ectoparasitics (continued) Cancer/Chemotherapy Drugs Alkylating Agents Anthracycline Antibiotics Antimetabolites Enzyme, Immunomodulating, Synthetic Hormone, and Vinca Alkaloid Cardiovascular Drugs Antianemics Antiarrhythmics Anticoagulants and Calcium Supplements Contractility Enhancers and Positive Inotropic Agents Diuretics Vasodilators Dermatologic Drugs Antiseborrheics Antipruritics/Antihistamines Gastrointestinal Drugs Antidiarrheals Antiemetics

563 564 565 565 566 567 570 570 571 574 575 575 576 577 578 578 579 579 580 580 581 581 582 583 584 585 585 586 587 588 589 590 591 591 591 592 592 593

Antiulcer Agents Emetics Enzyme, Laxatives, and Lubricants Protectants and Stool Softener Hepatic Drugs Supplements Metabolic Drugs Adrenal Cortex Pancreatic Pancreatic (continued) Parathyroid and Thyroid Musculoskeletal Drugs Anti-inflammatory Drugs Nonsteroidal Anti-inflammatory Drugs Nonsteroidal Anti-inflammatory Drugs (continued) Nonsteroidal Anti-inflammatory Drugs (continued) Protectant, Muscle Relaxer, and Supplement Neurologic Drugs Appetite Stimulator and Cholinergics Autonomic Nervous System: Adrenergic Agents: Alpha Stimulators Central Nervous System: Anticonvulsants Euthanasia Agents and Muscle Relaxers Analgesics Analgesic/Anticonvulsant, NMDA Antagonist, and Narcotic Agonist Analgesic: Opioids Analgesic: Opioids (continued) Behavioral: Antidepressants Ophthalmic Drugs Adrenergic Agonist, Carbonic Anhydrase Inhibitors, and Immunosuppressant Miotics, Mydriatics/Cycloplegics, Topical Anesthetics, and Stains

594 595 596 597 598 598 599 599 600 601 601 602 602 603 604 605 605 606 606 607 607 608 609 610 611 612 613 613 613

Otic Drugs Topical Anti-infectives Renal/Urinary Drugs Acidifers, Adrenergic Agent. and Alkalinizing Agent Alpha-Adrenergic Agent, Antibacterial/Acidifer, Anabolic Steroid, and Cholinergic Enzyme Inhibitor and Tricyclic Antidepressant Reproductive System Drugs Androgens, Estrogens, and Gonadotrpins Oxytocin, Progestins, and Prostaglandin Respiratory Drugs Antitussives Bronchodilators and Mucolytics Stimulants Toxicologic Drugs Chelating Drugs and Synthetic Alcohol Dehydrogenase Inhibitor Appendix

615 615 616 616 617 618 619 619 620 621 621 622 623 624 624 625 625 625 626 626 627 627 628

Metric Units Weights Liquid Measure Length Kilograms to Body Surface Area Temperature Conversion Disinfectants Glossary Abbreviations Bibliography Index

631 647 651 661

614

TABLE OF CONTENTS

xv

Figure List Chapter 1: Anatomy Figure 1.1 Overall Figure 1.2 Regional Lymph Nodes Figure 1.3 Musculature: Lateral View Figure 1.4 Skeletal: Lateral View Figure 1.5 Skeletal: Dorsal View Figure 1.6 Internal Organs: Left Lateral View Figure 1.7 Internal Organs: Right Lateral View Figure 1.8 Internal Organs: Ventral View Figure 1.9 Circulation: Dorsal View of Heart Figure 1.10 Circulation: Internal View of Heart Figure 1.11 Circulation: Heart Valves Figure 1.12 Circulatory: Lateral View Figure 1.13 Nervous System: Lateral View of Brain Figure 1.14 Nervous System: Lateral View Figure 1.15 Urogenital: Ventral View, Female Figure 1.16 Urogenital: Ventral View, Male Figure 1.17 Urogenital: Lateral View, Male Figure 1.18 Eye Figure 1.19 Ear

6 6 6 7 7 8 8 8 9 9 10 10 10 11 11 12 12 13 13

Chapter 3: Nutrition Table 3.2 Body Condition Score

61

Chapter 4: Laboratory Figure 4.4 Cytologic Criteria of Malignancy Figure 4.35 Relative Size of Parasite Eggs

93 139

Chapter 5: Imaging Table 5.4 Scale of Contrast Evaluation Table 5.7 Directional terms

165 168

Chapter 8: Patient Care Figure 8.1 Normal Canine Electrocardiogram Figure 8.2 Atrial Premature Contraction/Complex Figure 8.3 ST-Segment Elevation Figure 8.4 Ventricular Premature Contraction/Complex

341 344 344 344

Chapter 10: Wound Care Box 10.3 Basic Bandage Box 10.4 Robert Jones Bandage Box 10.5 Chest/Abdominal Bandage Box 10.6 Distal Limb Splint Box 10.7 Casts Box 10.8 Ehmer Sling Box 10.9 90–90 Flexion Box 10.10 Velpeau Sling Box 10.11 Hobbles

405 406 407 408 408 409 410 410 411

Chapter 13: Anesthesia Figure 13.1 Endotracheal Intubation

455

Chapter 14: Dentistry Figure 14.1 Dentition: Canine and Feline Figure 14.2 Cross Section of a Triple-Rooted Tooth Figure 14.3 Skeletal Structure: Canine and Feline Figure 14.4 Cross Section of Facial Structures: Canine and Feline Figure 14.5 Hand-held Nonmechanical Dental Instruments Figure 14.6 Sample of a Patient’s Dental Health Chart Table 14.10 Radiographic Positioning

499 500 500 501 502 509 514

Color Plate Anatomy Figure 1.6 Internal Organs: Left Lateral View Figure 1.7 Internal Organs: Right Lateral View Figure 1.8 Internal Organs: Ventral View Figure 1.9 Circulatory: Dorsal View of Heart Figure 1.10 Circulatory: Internal View of Heart Figure 1.12 Circulatory: Lateral View Figure 1.14 Nervous System: Lateral View Bone Marrow Figure 4.1 Canine Bone Marrow Figure 4.2 Canine Bone Marrow Figure 4.3 Maturation Stages of Megakaryocytes Tumor Cytology Figure 4.5 Histiocytoma

CP-1 CP-1 CP-1 CP-1 CP-2 CP-2 CP-2 CP-3 CP-3 CP-3 CP-4 xvii

Figure 4.6 Lymphoma Figure 4.7 Mast Cell Tumor Fecal Cytology Figure 4.8 Clostridium Figure 4.9 Giardia Figure 4.10 Campylobacter Figure 4.11 Spirochetes Figure 4.12 Yeast Hematology Figure 4.13 Canine Blood Smear Figure 4.14 Canine Distemper Figure 4.15 Feline Blood Smear Figure 4.16 Canine Blood Smear Figure 4.17 Feline Blood Smear Figure 4.18 Feline Blood Smear Figure 4.19 Canine Blood Smear Figure 4.20 Canine Blood Smear Figure 4.21 Babesia canis Figure 4.22 Cytauxoon felis Figure 4.23 Neutrophils Figure 4.24 Lymphocytes Figure 4.25 Monocytes Figure 4.26 Canine Blood Smear Figure 4.27 Eosinophils Figure 4.28 Basophils Figure 4.29 Canine Blood Smear Figure 4.30 Feline Blood Smear Figure 4.31 Canine Blood Smear Figure 4.32 Canine Blood Smear Figure 4.33 Blood Smear Ear Cytology Figure 4.34 Malessezia Endoparasites Figure 4.36 Ancylostoma caninum Figure 4.37 Ancylostoma tubaeforme Figure 4.38 Crytosporidium Figure 4.39 Didylidium caninum Figure 4.40 Dirofilaria immitis Figure 4.41 Echinococcus granulosus Figure 4.42 Giardia Figure 4.43 Isospora spp. Figure 4.44 Taenia spp. Figure 4.45 Toxocara canis xviii

FIGURE LIST

CP-4 CP-4 CP-4 CP-5 CP-5 CP-5 CP-5 CP-6 CP-6 CP-6 CP-6 CP-7 CP-7 CP-7 CP-7 CP-8 CP-8 CP-8 CP-8 CP-9 CP-9 CP-9 CP-9 CP-10 CP-10 CP-10 CP-10 CP-11 CP-11 CP-11 CP-11 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12 CP-12

Figure 4.46 Figure 4.47 Figure 4.48 Figure 4.49 Ectoparasites Figure 4.50 Figure 4.51 Figure 4.52 Figure 4.53 Figure 4.54 Figure 4.55 Figure 4.56 Figure 4.57 Figure 4.58 Urinalysis Figure 4.59 Figure 4.60 Figure 4.61 Figure 4.62 Figure 4.63 Figure 4.64 Figure 4.65 Figure 4.66 Figure 4.67 Figure 4.68 Figure 4.69 Figure 4.70 Figure 4.71 Figure 4.72 Figure 4.73 Figure 4.74 Figure 4.75 Figure 4.76 Figure 4.77 Figure 4.78 Figure 4.79 Figure 4.80 Figure 4.81 Figure 4.82 Figure 4.83 Figure 4.84 Figure 4.85 Figure 4.86

Toxocara cati Toxoplasma gondii Trichuris vulpis Uncinaria stenocephala

CP-13 CP-13 CP-13 CP-13

Cheyletiella Ctenocephalides canis Demodex canis Dermacentor variabilis Linognathus setosus Otodectes cynotis Rhipicehpalus sanguineus Sarcoptes scabiei canis Trichodectes canis

CP-13 CP-13 CP-13 CP-13 CP-14 CP-14 CP-14 CP-14 CP-15

Bacteria Bacteria Bacteria White Blood Cells White Blood Cells Epithelial Cells Epithelial Cast Fatty Cast Granular Cast Hyaline Cast Red Blood Cell Cast White Blood Cell Cast Waxy Cast Amorphous Phosphate Crystals Amorphous Urate Crystals Amorphous Biurate Crystals Bilirubin Crystals Calcium Carbonate Crystals Calcium Oxalate Dihydrate Crystals Cystine Crystals Leucine Crystals Sulfonamide Crystals Triple Phosphate Crystals Tyrosine Crystals Uric Acid Crystals Renal Epithelial Cells Squamous Epithelial Cells Transitional Epithelial Cells

CP-15 CP-16 CP-16 CP-16 CP-16 CP-17 CP-17 CP-17 CP-17 CP-18 CP-18 CP-18 CP-19 CP-19 CP-19 CP-19 CP-20 CP-20 CP-20 CP-20 CP-20 CP-20 CP-21 CP-21 CP-21 CP-21 CP-21 CP-21

Figure Figure Figure Figure

4.87 4.88 4.89 4.90

Epithelial Cells and Lipid Droplets Capillaria plica Starch Granules Yeast

CP-22 CP-22 CP-22 CP-22

Pain Scales Figure 9.1 CSU Canine Acute Pain Scale Figure 9.2 CSU Feline Acute Pain Scale

CP-23 CP-24

FIGURE LIST

xix

Preface This second edition of Veterinary Technician’s Daily Reference Guide: Canine and Feline continues from the success of the first edition. As our profession continues to grow and demand more of veterinary technicians, this reference guide has done the same. With the obvious inclusion of updated medical information, this second edition contains an expansive amount of more in-depth skill descriptions allowing the technician to reach an even higher level of care. Its purpose is not to present ideas for the first time but rather to refresh or expand the veterinary technician’s current knowledge. This manual provides the link between the formal learning environment and the daily clinical setting. The goals are to increase confidence and technical skill and to allow veterinary technicians to provide clear client education. This book covers all areas of the veterinary technology profession pertinent to canines and felines, from the basics of physical examinations to advanced skills of chemotherapy administration. We are confident that the veterinary technician will find a daily need for this invaluable resource. In the end, it is our goal that this book will facilitate improved care for patients and the owners who rely on experienced veterinary technicians.

SUMMARY OF KEY FEATURES Comprehensive Guide. This book was written as a quick reference guide. Its purpose is to assist an already trained and licensed veterinary technician throughout the work day—providing a refresher for a seldom-taken radio-

graph, for example, or a pharmacology reminder to help answer a client’s question. The veterinary technology student will also find this book useful as a supplement to more in-depth textbooks as they finish training and join the workforce. Unique Chart and Table Format. The format of this book uses charts and tables for the efficient retrieval of pertinent information. As a result, very little prose text has been included. This unique format leads technicians straight to the answers they need to perform a task quickly. Extensive Art Program. The art program, which includes more than 200 illustrations and photographs, will provide visual assistance to the technician performing laboratory tests, dentistry, client education, and much more. The color insert makes the artwork very clear and easy to use. Expansive Indexing. A comprehensive table of contents and references at the beginning and throughout each chapter will ease the movement through this information-rich text. It is our expectation that this book will be of great assistance to the veterinary technician. Use of this book should result in enhanced performance of a veterinary technician’s duties and, therefore, improved care for patients. Candyce Jack, LVT Patricia Watson, LVT

xxi

Acknowledgments We would like to express our heartfelt thanks to all the people who gave support and guidance during the forming of this book. We also appreciate the professional courtesy extended by Phoenix Laboratory, DentaLabels, Wiley-Blackwell, American Society of Anesthesiologists, Dr. Peter Hellyer, Dr. Narda Robinson, Tara Raske, International Veterinary Association of

Pain Management, Greg deBoer, Anne Rains, Dr. David Stansfield, Novartis, Dr. James H. Meinkoth, Oklahoma State University, Gary Averbeck, Dr. Robert K. Ridley, Kansas State University, and Dr. Jay R Georgi, Dr. Daniel Chan, and Mikki Cook, LVT, Hill’s Pet Nutrition, Animal Emergency and Trauma Center.

Contributors Dina Andrews, DVM, PhD, Dip. ACVP Lisa Coyne, LVT Cindy Elston, DVM J. Michael Harter, DVM Joyce Knoll, VMD, PhD, Dip. ACVP Brita Kraabel, DVM Bob Kramer, DVM, Dip. ACVR Veronica Martin, LVT Linda Merrill, LVT, VTS (Small Animal Internal Medicine)

Kathryn Michel, DVM, MS, Dip. ACVN Jeb Mortimer, DVM Richard Panzer, DVM, MS Patrick Richardson, DVM Nancy Shaffran, CVT, VTS (ECC) Stuart Spencer, DVM Cheryl Stockman, MT (ASCP) Laura Tautz-Hair, LVT, VTS (ECC) Sandy Willis, DVM, MVSc, Dip. ACVIM

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Veterinary Technician’s Daily Reference Guide: Canine and Feline Second Edition

Section

One

Anatomy

Chapter

1

1

Anatomy Anatomy 6 Figure 1.1. Overall 6 Figure 1.2. Regional Lymph Nodes 6 Musculature 6 Figure 1.3. Musculature: Lateral View 6 Skeletal 7 Figure 1.4. Skeletal: Lateral View 7 Figure 1.5. Skeletal: Dorsal View 7 Internal Organs 8 Figure 1.6. Internal Organs: Left Lateral View 8 Figure 1.7. Internal Organs: Right Lateral View 8 Figure 1.8. Internal Organs: Ventral View 8 Circulatory System 9 Figure 1.9. Circulatory: Dorsal View of Heart 9 Figure 1.10. Circulatory: Internal View of Heart 9

Figure 1.11. Circulatory: Heart Valves 10 Figure 1.12. Circulatory: Lateral View 10 Nervous System 10 Figure 1.13. Nervous System: Lateral View of Brain Figure 1.14. Nervous System: Lateral View 11 Urogenital 11 Figure 1.15. Urogenital: Ventral View, Female 11 Figure 1.16. Urogenital: Ventral View, Male 12 Figure 1.17. Urogenital: Lateral View, Male 12 Eye 13 Figure 1.18. Eye 13 Ear 13 Figure 1.19. Ear 13

10

5

1

ANATOMY For a veterinary technician to be able to accurately complete many of his or her daily tasks, a clear understanding of the anatomy of the canine and feline body is needed. The following diagrams show the basic layout of the body systems, highlighting the areas of interest that are most commonly accessed in daily medicine practices ranging from the correctly positioned radiograph to a single-stick venipuncture.

Overall See Skill Box 2.6 Regional Lymph Node Examination, page 34.

Figure 1.2 Regional lymph nodes.

Musculature Sternocephalicus Cleidocervicalis External Trapezius abdominal Latissimus oblique dorsi

Middle gluteal Superficial gluteal Biceps femoris

Deltoids

Cleidobrachialis

Figure 1.1 Overall.

Pectoralis major Triceps

Sartorius Deep Gracilis pectoral Pectoralis minor Semitendinosus

Figure 1.3 Musculature: lateral view.

6

SECTION ONE: ANATOMY

Gastrocnemius

Skeletal

1

See Skill Box 2.8 Orthopedic Examination, page 36. Orbit

Zygomatic arch

Zygomatic arch Atlas Axis Cervical Spinous Iliac Thoracic process Lumbar crest Ilium Ischial tuberosity Greater trochanter

Maxilla

Mandible Spine of scapula Scapula

Wing of atlas

Axis

T1

Sacrum Ischium Costal arch

Ribs Humerus Ulna

Spine of scapula

Scapula

Xyphoid Patella Sternum Fibula Ulna

Radius Carpus Metacarpus

Femur

Atlas

Tibia Tarsus Metatarsus

L1 Phalanges

Figure 1.4 Skeletal: lateral view.

Iliac crest Ilium Greater trochanter of femur

Sacrum

Ischial tuberosity

Figure 1.5 Skeletal: dorsal view.

CHAPTER 1 / ANATOMY

7

1

Internal Organs

Esophagus

See Skill Box 2.4 Abdominal Examination, page 33. See Color Plates 1.6–1.8. CP-1.

Trachea

Lung

Heart Uterine horn Ovary

Ureter Colon

Right kidney

Lungs

Anus

Diaphragm

Liver

Liver

Gall bladder Common bile duct Liver Duodenum Pancreas Transverse colon Ascending colon Cecum

Liver Heart Greater omentum (covering small intestines)

Urinary bladder

Figure 1.6 Internal organs: left lateral view.

Rectum Esophagus Trachea

Lungs

Spleen

Stomach

Liver

Thymus

Ureter

Small intestines Urinary bladder

Figure 1.7 Internal organs: right lateral view.

SECTION ONE: ANATOMY

Spleen Jejunum Ileum

Descending colon

Mesentery

Anal gland

Left kidney

Heart (cardiac notch)

8

Lesser omentum Stomach Greater omentum (cut)

Colon

Figure 1.8 Internal organs: ventral view.

Circulatory System

Left subclavian artery

See Skill Box 2.2 Cardiac Examination, page 30. See Color Plates 1.9, 1.10, and 1.12. CP-1, 2.

1

Aorta Superior vena cava

Left subclavian artery

Superior vena cava

Right auricle

Right atrium

Aortic arch Pulmonary arteries Left atrium

Pulmonary veins

Left auricle

Right atrium

Tricuspid valve Right ventricle

Pulmonary veins Left ventricle

Apex

Inferior vena cava

Coronary artery Right ventricle Apex

Semilunar valves of aorta

Left atrium

Figure 1.9 Circulatory: dorsal view of heart.

Bicuspid valve Left ventricle

Chordae tendineae Ventral papillary muscle

Figure 1.10 Circulatory: internal view of heart.

CHAPTER 1 / ANATOMY

9

1

Figure 1.12 Circulatory: lateral view.

Nervous System See Color Plate 1.14. CP-2.

Epithalamus

Corpus collosum

Figure 1.11 Circulatory: heart valves. Cerebellum

Olfactory bulb Optic chiasm

Spinal cord

Thalamus Medulla oblongata

Hypothalamus

Pituitary

Figure 1.13 Nervous system: lateral view of brain.

10

Urogenital

Vagosympathetic trunk Brachial plexus

Lumbo-sacral plexus

1

See Skill Box 2.4 Abdominal Examination, page 33. See Skill Box 12.10 Urinary Catheterization, page 435.

Vagus Sciatic

Diaphragm

Femoral Radial

Esophagus

Adrenal gland

Tibial

Median Kidney Ulnar

Uterine tube

Figure 1.14 Nervous system: lateral view.

Ovarian ligament

Ovary Colon

Ureter Round ligament

Broad ligament

Uterus: Horn Body

Urinary bladder

Urethra Rectum Vagina

Anal gland

Figure 1.15 Urogenital: ventral view, female.

CHAPTER 1 / ANATOMY

11

Kidneys

1

Colon Diaphragm

Esophagus

Prostate gland

Adrenal gland

Kidney

Urethra Ureter Urinary bladder Spermatic cord Prepuce Ureter

Colon

Ductus deferens Epididymis

Urinary bladder

Testis Prostate gland

Spermatic cord Urethra Rectum

Bulbourethral gland Ductus deferens

Penis Prepuce Glans penis

Epididymis Anal gland

Testis

Figure 1.16 Urogenital: ventral view, male.

12

SECTION ONE: ANATOMY

Os penis

Glans penis

Figure 1.17 Urogenital: lateral view, male.

Eye

Ear Bulbar conjunctiva

Sclera

1

See Skill Box 2.5 Otoscopic Examination, page 33. See Skill Box 2.13 Ear Cleaning and Flushing, page 55.

Posterior chamber Choroid Retina

Pinna Iris Cornea

Vitreous humor Lens Optic disc

Anterior chamber

Third eyelid

Suspensory ligament

Optic nerve

Palpebral conjunctiva Vertical auditory canal

Figure 1.18 Eye.

Semicircular canals Vestibule Cochlea

Oval window

Horizontal auditory canal

Auditory nerve

Round window Tympanic membrane Middle ear cavity Eustachian tube (auditory)

Figure 1.19 Ear.

CHAPTER 1 / ANATOMY

13

Section

Two

Preventative Care Chapter 2: Preventative Care and Vaccinations Chapter 3: Nutrition 57

17

Chapter

2

2

Preventative Care and Vaccinations Physical Examinations 18 Preliminary Examination 19 Physical Examination 20 Pediatric Physical Examination 23 Normal Parturition 26 Care and Feeding of Orphaned Puppies and Kittens 27 Geriatric Physical Examination 28 Cardiac Examination 30 Pulmonary Examination 32 Abdominal Examination 33 Otoscopic Examination 33 Regional Lymph Node Examination 34 Neurologic Examination 34 Orthopedic Examination 36 Vaccinations 37 Guidelines to Follow When Vaccinating an Animal 37 Canine Transmissible Diseases 38 Coronavirus, Distemper 38

Hepatitis, Infectious Tracheobronchitis 39 Leptospirosis, Lyme Disease 41 Parvovirus, Rabies 42 Canine Vaccination Protocol 44 Feline Transmissible Diseases 44 Feline Calicivirus 44 Feline Infectious Peritonitis 46 Feline Panleukopenia Virus, Feline Immunodeficiency Virus 47 Feline Leukemia Virus, Feline Rhinotracheitis Virus 49 Feline Vaccination Protocol 51 Animal Care 51 Client Education: Home Dental Care 52 Grooming 53 Bathing 53 Nail Trimming 54 Anal Sac Expression 54 Ear Cleaning and Flushing 55

17

Key Words and Phrasesa Alopecia Amyloid Axillary Canarypox vector Core Cryptorchidism Desquamative Diathesis ELISA Encephalopathy Epistaxis Fistula Fontanelle Granulomatous Halitosis Hemoagglutination Hyaluronic acid Hyperpathia Intussusception Lymphadenopathy

2

a

Lyophilized Melena Noncore Nystagmus Panniculus Papilloma PCR Petechia Prodromal Proprioception Proteoglycan Rales Rhonchi Stenosis Strabismus T-lymphocytes Tortuous, redundant aorta Vascularity Western blot Whelping

Abbreviations

Additional Resources, page

APTT, activated thromboplastin time BCS, body condition score BUN, blood urea nitrogen CBC, complete blood count CNS, central nervous system CPV, canine parvovirus CSF, cerebrospinal fluid DIC, disseminated intravascular coagulation ELISA, enzyme-linked immunosorbent assay F, Fahrenheit FCV, feline calicivirus FECV, feline enteric coronavirus FeLV, feline leukemia FHV-1, feline viral rhinotracheitis FIP, feline infectious peritonitis FIV, feline immunodeficiency virus FPV, feline panleukopenia GIT, gastrointestinal tract IFA, immunofluorescent assay IgG, immunoglobulin gamma G IgM, immunoglobulin gamma M IN, intranasal O2, oxygen OVH, ovariohysterectomy PCR, polymerase chain reaction PT, prothrombin time RBC, red blood cell RV, rabies vaccine SQ, subcutaneously v, variable

Abdominocentesis, 429 Anesthesia, 439 Blood transfusions, 367 CBC, 105 Cesarean section, 542 Chemistry panel, 74 Coagulation tests, 115 Coupage, 432 Dentistry, 497 Ear cytology, 88 Figure: Ear, 13 Figure: Heart, 9 Figure: Internal organs, 8 Figure: Heart valves, 10 Figure: Lymph nodes, 6 Fluid therapy, 359 General medicine, 201 Heat administration, 346 Injections, 348 Laboratory, 71 Microbiology, 122 Nebulization, 432 Nutritional support, 414 Oxygen therapy, 375 Pharmacology, 567 Physical examination, 18 Physical therapy, 558 Radiology, 159 Surgery, 521 Thoracocentesis, 431 Urinalysis, 147

Key words and terms are defined in the glossary on page 631.

PHYSICAL EXAMINATIONS A well-done physical examination gives the clinician invaluable information in the assessment of an animal’s health. Technicians can assist the veterinarian by understanding the pertinence of each part of the examination and by

18

SECTION TWO: PREVENTATIVE CARE

being able to conduct an examination in an orderly, precise, and timely fashion. Physical examinations are conducted prior to immunizing, before an anesthetic procedure, and in conjunction with any visit to the veterinarian for a specific problem. The following charts will cover methods and specific areas of the physical examination in both pediatric and adult patients.

Vital Signs

History

Table 2.1 / Preliminary Examination Definition/Normal/Abnormal

Equipment and Technique

Chief Complaint

• The current issue for which the owner is bringing the animal to the clinic

• Current history • Current appetite, water intake, urination and defecation behavior, recent temperament, and current medications are noted. Recent activities to which the animal may have been exposed or changes in the home environment are also noted.

Past History

• Previous medical conditions that may exacerbate the current complaint

• Past history • Immunization dates as well as current medical therapies are noted.

Signalment

• Age, breed, sex, and reproductive status

• N/A

General Appearance

• The patient’s overall health

• Visual evaluation of the condition of animal’s coat, skin, and temperament

Heart Rate • Cardiac function

Normal • Canine: 70–180 beats/min • Feline: 110–220 beats/min Abnormal • Canine: 160 beats/min • Feline: 200 beats/min

• Direct palpation of chest wall or pulse • Auscultation of the thoracic cavity • See Skill Box 2.2, Cardiac Examination, page 30. • Electrocardiograph • See Chapter 8, Patient Care, page 338. • Doppler pulse monitor

Respiration • Reflects proper oxygenation of the body’s tissues • Ability to eliminate carbon dioxide from the blood

Normal • Canine: 10–30 breaths/min • Feline: 25–40 breaths/min Abnormal • 700 g Birth weight should double in days 10–12

Kitten Normal

• 100 g • Birth weight should double in 14 days.

Evaluation • Constant crying, extreme inactivity, and/or failure to gain weight can be signs of inadequate milk consumption. • Separation from mother and littermates before 6 weeks of age can lead to numerous behavioral problems later in life. • Failure to gain weight is often the first sign of illness. • Body weight should be checked initially, 12 hours after birth, and daily for 2 weeks; then checked weekly.

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

23

2

Table 2.3 / Pediatric Physical Examination (Continued)

Head

2

24

Specific Region/Examination Method

Age

Puppy Normal

Eyes • Visual examination • Penlight • Ophthalmic examination

Birth–6 months

• Eyes open around 5–14 days • Iris is blue gray. • Changes to adult color at approximately 4–6 weeks of age • Adult vision at 5–10 weeks of age • Pupillary light responses may not be evident until 21 days of age. • Strabismus or deviation of eyes at 3–5 months of age

• Discharge, squinting or holding eye(s) closed, rubbing or pawing at eye(s)

Ears • Visual examination • Otoscopic examination

Birth–6 months

• Complete hearing at 4–6 weeks of age • External ear canals open at 6–14 days and are completely open by 17 days. • Canals may be full of desquamative cells and some oil droplets.

• Size and position • Exudate and odor for possible bacterial or yeast infection or mites

Mouth • Penlight • Tongue depressor or cotton swab

Birth–3 months

• Sucking reflex is present at birth and disappears at 3 weeks of age. Deciduous tooth eruption • Incisors: 2–4 weeks • Canines: 3–5 weeks • Premolars: 4–12 weeks

• Hairlip, cleft palate, sucking reflex, occlusion or malfunction of jaw bones (malocclusion)

4–6 months

Permanent tooth eruption • Incisors: 3–5 months • Canines: 4–7 months • Premolars: 4–6 months • Molars: 4–5 months

• Occlusion or malfunction of jaw bones (malocclusion)

Nose • Visual examination

Birth–6 months

• Normal adult appearance

• Obstruction, stenosis, discharge, or abnormal shape, swelling

Skull • Visual examination

Birth–4 weeks

• Normal adult appearance

• Open fontanelle (soft spot on the forehead)

SECTION TWO: PREVENTATIVE CARE

Kitten Normal

Evaluation

Table 2.3 / Pediatric Physical Examination (Continued) Age

Puppy Normal

General Appearance • Visual examination

Birth–6 months

• Symmetrical chest wall

• Wounds and rib fractures • Congenital sternal or spinal abnormalities

Limbs Perineum Genitals

Kitten Normal

Evaluation

Heart • Visual examination • Stethoscope with 2 cm bell and 3 cm diaphragm

Birth–4 weeks

• Heart rate: 220 beats/min • Heart rhythm is a regular sinus rhythm

• Heart rate and pattern • Murmurs (should be noted and veterinarian consulted, as some can be normal/physiologic)

5 weeks–6 months

• Heart rate: 70–180 beats/min

• Heart rate: 110–200 beats/min

Lungs

Birth–4 weeks

• Respiratory rate: 15–35 breaths/min

• Respiratory rate: 25– 35 breaths/min

5 weeks–6 months

• Respiratory rate:10–30 breaths/min

• Respiratory rate: 25– 40 breaths/min

General Appearance • Visual examination

Birth–4 weeks

• Umbilical cord falls off in 2–3 days.

• Umbilical hernia, inflammation, or infection/ulceration

Internal Organs • Palpation

Birth–4 weeks

• Kidneys are palpable in kittens and some puppies. • Normal spleen will sometimes be palpable in an older puppy if foreleg is extended, allowing organs to fall caudally; spleen only palpable if enlarged in kittens. • Liver margins should not extend past the ribs. • Stomach will feel like a large fluid-filled sac if full. • Intestines are soft and freely movable without pain and may be fluid or gas filled. Thickened/ ”ropy” feel may indicate endoparasitism. • Urinary bladder should have resistance to urine outflow.

• Enlarged or abnormally small organs, pain on palpation, masses • Intussusception—a sausage-like mass and very painful

Forelimbs/Hindlimbs • Visual examination • Palpation

Birth–6 months

• Normal adult appearance (breed-influenced)

• Wounds, bruises, or swelling • Deformities or ↑ or ↓ range of motion in joints

Genitalia • Visual • Palpation

Birth–6 months

• Normal adult appearance • Descended testicles by 4–6 weeks of age (diagnose cryptorchid after 16 weeks)

• Cryptorchidism, vaginitis, congenital abnormalities

Anus • Visual • Palpation

Birth–6 months

• Normal adult appearance

• Rectal prolapse, inflammation, or irritation • Defecation/urination on their own usually occurs at 2–3 weeks.

2

Abdomen

Thorax

Specific Region/Examination Method

• Breathing rate and pattern • Asymmetrical or absent lung sounds

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

25

Table 2.4 / Normal Parturition

2

In late term pregnancy (58–63 days), the bitch or queen should be observed for signs of labor. These may include a rectal temperature drop to 2 hours between pups (>1 hour between kittens) is an emergency • Mother may not release the neonate and sever the umbilical cord. • Eating multiple placentas may lead to indigestion and diarrhea. • Queen: if stressed may stop and restart labor the next day

Postpartum

• 1–2 months

• Bitch: 8–10 weeks of bloody discharge • Queen: 3 weeks of black or red discharge

• Mastitis (e.g., fever, lethargy, swollen glands), metritis (e.g., foul smelling discharge), retained placenta (e.g., green discharge) • Eclampsia (e.g., tremors, excitation)

26

• 20–60 minutes per neonate

SECTION TWO: PREVENTATIVE CARE

Skill Box 2.1 / Care and Feeding of Orphaned Puppies and Kittens Housing • Use a box with tall sides to avoid escape, such as a cardboard pet carrier. • Line the bottom of the box with towels and place a diaper or pee pad on top for easy cleaning. • The box will need to be cleaned frequently to keep the neonates clean and dry. Temperature • Neonates are unable to maintain their own body heat; they rely on the ambient temperature and littermates. • The environment should be draft free with a ambient temperature gradient measured by a thermometer. • Electric heating pads and heat lamps should not be used due to the risk of overheating and burns. • The ambient temperature should be 85–90° F for the first week, 80° F for weeks 2–4, and 70° F for week 5.

• Warm the formula to a comfortable temperature, place the neonate in a comfortable dorsal position, and hold the bottle up in a position to closely mimic that of the mother. Ensure that the nipple does not contain air and the bottle is tipped up to avoid air ingestion. Neonates have a vigorous suckling response and can overfeed if not monitored. Milk bubbling out of the neonate’s nose may indicate overzealous feeding or a hole in the nipple that is too large. A satisfied neonate is quiet with a slightly enlarged abdomen. Following each feeding, burping may be necessary to expel excess air ingested. • A nipple bottle is most commonly used, but a feeding tube can be ideal in skilled hands for weak or premature neonates See Skill Box 11.3 Nasoesophageal/Nasogastric Tube, page 415. • With all methods of feeding, care should be taken to avoid aspiration pneumonia, a complication seen with forced nursing, squeezing the bottle, improper feeding tube use, and volume overload. Health • Hydration should be monitored in the neonate by mucus membranes, eyes, urine specific gravity, and urine color.

Diet

• A neonate should gain 10% of its birth weight daily.

• Commercial replacement diets (e.g., Esbilac, KMR) are the best choice for diet replacement.

• Crying for >15 minutes is a sign of distress (e.g., hunger, cold, neglected, pain).

• When commercial diets are not available, the following recipe can be used in the interim.

Urination and Defecation

• 1/2 cup whole milk, 1/2 cup water, 1 tsp. salad oil, 1 drop multivitamins, 2 egg yolks, 2 Tums (antacid) crushed

• For the first 3 weeks, the neonate must be stimulated to urinate and defecate after each feeding.

• Blend all ingredients in a blender, keep refrigerated, and use within 48 hours.

• With the neonate held securely in 1 hand (possibly with a towel) over a sink, gently massaging the lower abdomen in a circular motion. The genitals may also be rubbed with a warm, moist cotton ball.

• The above diet provides 1.2 kcal/mL, which is the same as commercial diets. • Neonates are fed 22–26 kcal/100 g body weight for the first 12 weeks of life. The diet should be gradually increased over 2–3 days to the recommended daily amount to avoid overfeeding and diarrhea.

• The genitals should be cleaned and dried to avoid skin irritation. • Urine and feces should be seen at almost every feeding and in the box. • Feces should be soft, but not green or yellow watery. Overfeeding is the most common cause of diarrhea; further dilute the formula by 1/3 for 2 days.

Feeding • The neonate will cry when hungry, but feeding should initially be expected every 2–3 hours.

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

27

2

Table 2.5 / Geriatric Physical Examination

This chart is designed to show the specific areas to note on geriatric animals. A full examination should be conducted, following Skill Box 2.2, General Physical Examination. However, geriatric animals go through additional changes as a result of the natural aging process and a physical is recommended every 6 months. Many of these changes cannot be visualized on a physical examination, but they may be inferred through the general examination and from discussion with the owner. These symptoms may contribute to or initiate more serious medical conditions, thereby making their determination valuable to the clinician.

General Appearance

Specific Region

Head

2

28

Effects

Associated With

Skin

• ↓ Elastin and collagen • ↓ Blood flow to skin • Thinning of skin and coat

• Ineffective barrier to pathogens • May require more maintenance by owner

Toenails

• ↑ Length because of ↓ activity • More fragile, crumble when trimmed

• Difficulty walking • Wounds in foot pads

Musculature

• ↓ Strength • ↓ Tone

• Muscle atrophy and coordination

Eyes

• • • •

• Atrophy of the iris and ciliary muscles • Nuclear sclerosis

Ears

• Hearing loss

• Loss of cochlear hair cells

Nose

• ↓ Sense of smell

• ↓ Function of olfactory nerve endings, which can affect their eating habits

Neck

• Thyroid nodules

• Hyperthyroidism (feline), tumor

SECTION TWO: PREVENTATIVE CARE

Vision loss ↓ Pupillary light response Change in lens opacity Optic lens hardening

Associated With

Brain

• Amyloid deposition • Memory loss • Personality changes

• Cognitive dysfunction disorder • ↓ Glucose tolerance • Cognitive dysfunction disorder

Lungs

• • • • •

• Rarely a cause of concern unless patient needs to undergo an anesthetic procedure

Heart

• ↑ Sternal contact • Tortuous, redundant aorta (feline) • Radiographic changes

Kidney

• • • • •

Liver

• ↓ Protein synthesis • ↓ Metabolic function

• Liver disease

Limbs

Specific Region

Joints/Cartilage

• ↓ Production of chondroitin sulfate, keratin sulfate, and hyaluronic acid • ↓ Proteoglycan content

• Degenerative joint disease

Urethral Sphincter

• ↓ Tone

• Primary urethral sphincter incontinence

Immune System

• ↓ Function

• Chronic disease • ↑ Susceptibility to infections

Blood

• ↓ Ability to respond to RBC demand • Hypertension

• Anemia • Renal or endocrine disease

Internal Organs

Effects

Genitals

Table 2.5 / Geriatric Physical Examination (Continued)

Loss of lung elasticity ↓ Tidal volume ↓ Expiratory reserve Diminished cough reflex ↑ Density on lung radiographs

↓ ↓ ↓ ↓ ↑

Size Glomerular filtration rate Renal blood flow Ability to handle potassium Mineralization of renal pelvis

2

• Rarely a cause of concern

• Kidney disease • PU/PD • No concern known

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

29

Skill Box 2.2 / Cardiac Examination 2

Cardiac Examination Technique Perform auscultation in a quiet room with a calm patient. Place the patient in a standing or sitting position. Avoid listening to recumbent animals, as the change in heart position and configuration leads to errors. The flat diaphragm is used to detect high-frequency sounds (e.g., normal heart and breath sounds, most murmurs), while the bell is used to detect lower-frequency sounds (e.g., 3rd and 4th heart sounds, diastolic murmurs). The entire heart is examined, paying particular attention to the cardiac valves. Begin by placing the diaphragm gently but firmly at the left apex, where the first heart sound is best heard and also the location of the mitral valve. From here, inch the stethoscope to the left base of the heart, which is approximately 2 rib spaces cranial and slightly dorsal. Note the second heart sound and possible aortic and pulmonic stenosis murmurs. Next, palpate the right apex of the heart and move the stethoscope to this region. This is the tricuspid region and possible location of tricuspid regurgitation. Then move to the right base of the heart and observe for subaortic stenosis. Once an abnormality is noted, the surrounding region should be evaluated to find the point of loudest sound. In this process, the entire heart region should be evaluated and a complete examination given. Rate • Canine: 70–180 beats/min • Feline: 110–220 beats/min

Heart Sounds

Heart Valves

Normal

Normal

• First heart sound (S1) • Location: left apex of the heart • Sound: low-frequency sound longer than S2

• Pulmonic • Location: left 2nd–4th intercostal space above the sternal border

• Second heart sound (S2) • Location: base of the heart • Sound: high-frequency sound shorter than S1 • Third heart sound (S3) • Location: apex • Sound: low-intensity sound shortly after S2 • Fourth heart sound (S4) • Location: apex • Sound: low-intensity sound slightly before S1

30

SECTION TWO: PREVENTATIVE CARE

• Aortic • Location: left 3rd–5th intercostal space at mid-thorax • Mitral • Location: left 4th–6th intercostal space just above the sternal border, the apex of the heart • Tricuspid • Location: right 6th–7th intercostal space at mid-thorax, the apex of the heart

Abnormal • Murmurs Characterized by their location (over which valve they are the loudest), intensity (grade 1/6), frequency (harsh, blowing, musical, honking, or grunting), timing (point in the cardiac cycle the murmur is best heard), and quality (character/behavior).

Rhythms

Description of intensity

• Ventricular premature contractions (VPCs)

• • • • •

Grade 1: barely audible and localized Grade 2: soft and localized, but easily auscultated Grade 3: moderate loudness and evident in more than 1 location Grade 4: loud with palpable thrill and radiates Grade 5: very loud with palpable thrill, audible with stethoscope barely touching thorax • Grade 6: very loud with palpable thrill, audible when the stethoscope is removed from the thorax

• Gallop • Often seen during tachycardia when all four heart sounds are clearly heard. The combination of sounds is similar to the sound of a horse galloping. The rhythm is often heard with congenital heart disease, more specifically with hypertrophic cardiomyopathy in cats. • VPCs interrupt the normal sinus rhythm with a beat that is closer to the previous beat than normal followed by a compensatory pause. Patients often also have pulse deficits. • Atrial fibrillation • Rapid, but totally erratic rhythm with a clunking sound and varying intensity of the first and second heart sounds. Patients often have pulse deficits and variable pulse quality. Artifacts • Panting and excessive thoracic pressure in small patients similar to murmurs • Skin twitching similar to extra heart sounds • Friction from chest piece rubbing across fur similar to crackles

Tip: Ventilation artifacts can be discouraged by holding the mouth shut, whistling, or briefly obstructing a nare. Purring may be controlled with a visual distraction (e.g., visualization of water, another animal), blowing short bursts in air in their face, picking up the cat, or gently pressing over the larynx. Tip: When locating heart valves, count the ribs from caudal to cranial. Tip: The pulse and heart beat should be auscultated together and be synchronous. A heart beat without a pulse is a pulse deficit and may indicate an arrhythmia. Note: See Figures 1.9–1.12, Circulation, pages 9–10, and color plates 1.9, 1.10, and 1.12, pages CP-1, 2.

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2

Skill Box 2.3 / Pulmonary Examination 2

Pulmonary Examination Technique • Begin the examination by observing the respiratory effort (quality) and pattern and any signs of respiratory distress (e.g., nostril flare, intercostal rib retraction). After the initial assessment, perform auscultation in a quiet room with a calm patient. Place the patient in a standing or sitting position. Avoid listening to recumbent patients as it leads to errors due to changes in thoracic conformation. Divide the thoracic cavity into quadrants to follow a sequential pattern. As each quadrant is auscultated, it is observed for respiratory rate and breath sounds. Rate • Canine: 10–30 breaths/min • Feline: 25–40 breaths/min Breath Sounds • Should be heard equally on both sides of the thorax. Breath sounds heard outside the location defined below can be indicative of a medical problem. The normal respirations of canines can be heard throughout inspiration and during the first 1/3 of expiration. Only during inspiration can normal lung sounds be heard in a cat. Normal • Bronchial: • Location: center of the chest cavity over caudal trachea and larger bronchi • Sound: intense and harsh sounds, full inspiratory and expiratory phase with a louder inspiratory phase • Bronchovesicular: • Location: surrounding the bronchial region • Sound: intermediate sounds representing a combination of bronchial and vesicular sounds, full inspiratory phase with a short and quieter expiratory phase. • Vesicular: • Location: periphery of thoracic cavity • Sound: softer sound (e.g., wispy, rustling of leaves), inspiratory phase is slightly longer and louder than expiratory phase.

Abnormal • Stertor: • Location: larynx or trachea • Sound: discontinuous low-pitched snoring sound heard mainly on inspiration • Cause: tissue or secretions transiently obstruct airflow (e.g., elongated soft palate) • Stridor: • Location: larynx or thoracic inlet, referred sounds maybe heard throughout the thorax • Sound: intense continuous high pitched wheezes heard on inspiration • Cause: upper airway obstruction • Crackles (rales): • Location: over chest • Sound: discontinuous popping sound heard mainly on inspiration; defined as fine, medium, or coarse • Cause: fluid or exudate accumulation within airways or inflammation and edema in pulmonary tissue • Rhonchi or wheezes: • Location: isolated or variable • Sound: continuous musical sounds, low or high pitched heard at the end of inspiration or beginning of expiration; defined as high pitched or low pitched • Cause: ↓ airway lumen diameter

Tip: Listen to the lung sounds before listening to heart tones because the ear is much less sensitive to softer sounds once it has adjusted to louder sounds.

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SECTION TWO: PREVENTATIVE CARE

Skill Box 2.4 / Abdominal Examination

Abdominal Examination Technique • Gentleness when palpating an animal is essential as internal structures may be damaged if handled roughly. Structure descriptions can be: doughy (soft tissue that can be impressed with fingertips), firm (normal organ), hard (bones), fluctuant (soft, elastic, and undulates under pressure). Abnormalities noted on palpation are the following: pain, abnormal structures and their size, consistency, and shape, and location. • Large canine • Place the patient in a standing position. Stand on either side or to the rear. Place 1 hand on either side of the abdomen in a flat and relaxed position. Begin at the spine and gently and slowly move ventrally, allowing the abdominal viscera to slip through the fingers. Repeat this process throughout the abdomen moving caudal. • Small canine or feline • Place the patient in a standing position. Stand next to the patient. Cup 1 hand around the abdomen with the thumb on 1 side and the fingers on the other side in a flat and relaxed position. Begin at the spine and gently and slowly move ventrally, allowing the abdominal viscera to slip through the fingers. Repeat this process throughout the abdomen moving caudal.

• Internal structure location • Cranial abdomen • Palpation of the liver, spleen, and the small intestines • Liver is difficult to palpate and extension past the costal arch may indicate hepatomegaly. • Spleen is difficult to palpate and recognition may indicate splenomegaly. • Normal stomach is rarely palpable, but with overeating (doughy or fluid-filled) or gastric distention it may be felt. • Mid-abdomen • Palpation of the small intestines, kidneys, and spleen • Right kidney is more cranial than the left kidney in cats and may be obscured by the ribs. • Mesenteric lymph nodes are difficult to palpate unless enlarged. • Caudal abdomen • Palpation of the colon, uterus, bladder, prostate, and small intestine • Feces can be discerned from a mass by its deformability with fingertip imprints. • Prostate can occasionally be palpated central to the colon and caudal to the bladder.

Note: See Figures 1.6–1.8, Internal Organs, page 8, and Color Plates 1.6–1.8, pages CP-1.

Skill Box 2.5 / Otoscopic Examination

Otoscopic Examination Technique • Examine the good ear first to avoid spread of infection and to decrease resistance to examination of the possibly more painful ear. Begin with an otoscope with the appropriate sized cone for the patient. For ease of examination, the patient should be placed on a table or large canines should be placed in a sitting position. The head should be held in such a manner to avoid crushing the ear canal while directing the

muzzle toward the thoracic inlet. Holding the pinna up and out from the base of the skull will allow straightening of the ear canal. Gently insert the otoscope into the external ear canal and slowly advance while observing the canal. As the cone enters the vertical canal, the pinna is pulled up and over the otoscope while the otoscope handle is rotated to a horizontal position. The tympanic membrane will then be visualized in a normal ear as a white translucent membrane. Any abnormalities such as: inflammation, redness, exudate, foreign objects, mites, or tumors should be noted.

Note: See Figure 1.19, Ear, page 13.

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2

Skill Box 2.6 / Regional Lymph Node Examination 2

Regional Lymph Node Examination Technique • Three pairs of lymph nodes are routinely palpated in a normal animal; submandibular, prescapular, and popliteal. Axillary and inguinal nodes can often only be palpated with enlargement. Peripheral lymph nodes should be palpated simultaneously to evaluate symmetry. Enlarged nodes may be an initial indicator of a problem. Lymph nodes are generally smooth and oval in shape and can be most easily felt by grabbing the skin and allowing it to slip through the fingertips while pulling the hands away. • Submandibular • Location: ventral to the angle of the mandible, cranial to the parotid and submaxillary salivary glands • Size: group of 2 or 3 nodes pea to grape size

• Prescapular (superficial cervical) • Location: in front of the cranial border of the scapula • Size: group of 2 or 3 nodes slightly larger than submandibular nodes • Popliteal • Location: caudal to the stifle • Size: 1 node about the size of a pea; not always palpable in smaller animals • Axillary • Location: caudal and medial to the shoulder joint • Size: 1 or 2 nodes; not palpable in normal animals (0.5–10 mm) • Inguinal • Location: furrow between the abdominal wall and the medial thigh • Size: 2 nodes, not palpable in normal animals (0.5–10 mm)

Note: See Figure 1.2, Regional Lymph Nodes, page 6.

Skill Box 2.7 / Neurologic Examination

Neurologic Examination Technique • The neurologic examination begins as the patient walks into the examination room. Notice should be paid to the patient’s body posture (e.g., head tilt), attitude (e.g., demented, semicomatose, disoriented) and gait (e.g., inability or abnormal walk, dragging limbs, circling), purposeful movement (e.g., attempt to move down limbs), and palpation (e.g., symmetry, worn toenails, ↑ or ↓ muscle tone, masses).

Postural Reactions

Spinal Reflexes

• The patient’s ability to recognize an abnormal position and change its position to bear weight and be able to walk. All levels of the nervous system are evaluated, but lesion localization is not possible.

• Deficits in spinal reflexes alert to a problem along the nerve pathway; receptor, sensory nerve, efferent nerve, and skeletal muscles. Responses seen may be normal, absent, depressed or exaggerated.

• Extensor postural thrust

• Anal sphincter reflex

• While supporting the patient under the thorax, as the hindlimbs touch the floor, monitor for symmetric caudal walking motions. • Hemistanding/hemiwalking • A hindlimb and front limb of the same side are lifted, monitor for lateral walking movements. 34

SECTION TWO: PREVENTATIVE CARE

• Perineal stimulation with a needle or forceps; monitor for contraction of the anal sphincter muscle. • Panniculus reflex • Pin prick stimulus to skin over the back; monitor for twitching of cutaneous trunci muscles on both sides.

Skill Box 2.7 / Neurologic Examination (Continued) • Hopping • While supporting the patient, 3 limbs are lifted and the patient is moved medially and laterally, monitor for initiation and movement of hopping. • Placing • While supporting the patient under the thorax, the thoracic limbs are brought in contact with the edge of a table; immediate placement of the limbs on top of the table is expected. • This is done twice, once with the eyes covered and once with the eyes opened. • Proprioceptive positioning • While supporting the patient, turn the hind foot over onto the dorsal surface and monitor the length of time to turn it back to a normal position, if even able. • Wheelbarrowing • While supporting the patient under the abdomen with the hindlimbs lifted, monitor the length of time to start walking forward and the walking coordination.

Hindlimb Reflexes • Cranial tibial response • Percuss muscle belly; monitor for flexion of the hock. • Crossed extensor reflex • Pinch digits of down limb; monitor for involuntary movement of upper limb. • Gastrocnemius reflex • Percuss Achilles tendon; monitor for extension of the hock. • Patellar reflex • Patient in lateral recumbency and stifle gently supported in a flexed position, percuss patellar tendon; monitor for extension of the stifle. • Sciatic response • Percuss thumb in the sciatic notch; monitor for jerk of the entire limb. • Withdrawal • Patient in lateral recumbency. pinch digits; monitor for flexion of the limb and pain recognition.

Front Limb Reflexes • Extensor carpi radialis response • Percuss the extensor carpi radialis muscle; monitor for extension of the carpus. • Triceps reflex • Patient in lateral recumbency with limb supported, elbow fully extended and leg caudal, percuss the triceps tendon: monitor for slight extension of the elbow. • Withdrawal • Patient in lateral recumbency, pinch digits; monitor for flexion of the limb and pain recognition.

Sensory Evaluation

Cranial Nerves

• Evaluation of deep pain perception • Hyperpathia • Pressure is applied along the thoracic and lumbar regions to the spine and muscles at each vertebra; monitor for a behavioral response to pain • Sensory level • Pin prick stimulus to skin over the back, monitor for behavioral response

• The following cranial nerves (CN) are evaluated with a suspected brain lesion • Optic nerve (CN II): vision, menace response • Oculomotor nerve (CN III): pupillary light response, size and symmetry • Trochlear nerve (CN III, IV, VI): eye movements • Trigeminal nerve (CN V, VII): muscle mass, jaw tone, facial movements, blinking, lip retraction • Vestibulocochlear nerve (CN VIII): hearing • Glossopharyngeal and vagus nerves (CN IX, X, XI): pharyngeal sensation, gag response • Hypoglossal nerve (CN XII): tongue movement and strength CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

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2

Skill Box 2.8 / Orthopedic Examination 2

Orthopedic Examination Technique • Similar to the neurologic examination, the orthopedic examination begins as the patient enters the examination room. Notice should be paid to the patient’s conformation, stance, sitting, standing, rising and gait. The examination should continue with a hands-on evaluation of the area of concern, including the alternate side. A systematic approach should be used to cover the entire limb, often beginning distally and moving proximal. Alterations in range of motion and rotation should be noted along with any crepitus, clicking, clunking, instability, swelling, muscle atrophy or overdevelopment, and pain. Begin the examination by evaluating the nonaffected joint to assess the patient’s normal response to manipulation and pressure.

Stifle

Pelvis

• Cranial drawer motion

• Barden’s procedure

• Patient in lateral recumbency, 1 hand stabilizes the femur proximal to the stifle. The second hand is placed with the thumb behind the fibular head and the index finger over the tibial crest. With the femur stabilized, the second hand moves the tibia cranial and distal in a plane parallel to the tibial plateau. Monitor for the tibia sliding cranially or caudally in relationship to the femur indicating cruciate ligament rupture or partial tear. • Test should be performed with the stifle joint in extension, 90º flexion, and normal standing position. • Tibial compression test • Limb is held in a standing position, the hock is flexed to tense the gastrocnemius muscle which compresses the femur and tibia together; monitor for forward motion of the tibia in a ruptured cranial cruciate ligament. • Patellar luxation, medial • Limb is held extended with the foot rotated internally, digital pressure is applied medially; monitor for medial displacement indicating luxation. • Patellar luxation, lateral • Limb is held slightly flexed with the foot rotated externally, digital pressure is applied laterally; monitor for lateral displacement indicating luxation.

• Patient in lateral recumbency, grasp the femur with 1 hand. Place the thumb of second hand on the greater trochanter of the femur, while resting the rest of your palm on the pelvis. With gentle pressure, attempt to lift the femur, keeping it parallel to the table. Monitor for subluxation of the femur through the thumb on the greater trochanter indicating hip laxity. • Barlow’s sign • Patient in dorsal recumbency with stifle flexed, the left hand is placed on the right stifle and slowly adducted, monitor for luxation of the femoral head from the acetabulum indicating joint capsule stretching. • Hip luxation • Patient in a standing position, place the thumb in the space caudal to the greater trochanter, externally rotate the femur; monitor for the trochanter to roll over the thumb indicating luxation. • Ortolani maneuver, lateral recumbency • Limb is held in a standing position parallel to the table surface. One hand is placed over the hip joint, the other hand cups the stifle joint to apply pressure pushing the femoral head in a dorsal direction in relation to the acetabulum. Monitor for hip subluxation indicating hip laxity. • Ortolani maneuver, dorsal recumbency • Stifles are positioned parallel to each other and perpendicular to the table. Downward pressure is applied on the stifles to subluxate the hip. Maintain pressure and abduct the stifle. Monitor for hip subluxation indicating hip laxity.

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SECTION TWO: PREVENTATIVE CARE

VACCINATIONS Young animals receive a small amount of natural immunity from their mother’s milk, exchanged in the form of colostrum, during the first few days of nursing. However, this temporary maternal protection wanes by 6–9 weeks. To continue and enhance this protection, vaccinations are available to protect the animal from contracting various highly contagious diseases. These diseases and their corresponding vaccinations are charted on the following pages. Vaccines in general are meant to be stored in the refrigerator, and need to be shaken well before dispensing. Lyophilized vaccines should be used within 30 minutes of reconstitution. Heat, excessive cold, and light exposure can inactivate the vaccine and make them ineffective.

Guidelines to Follow When Vaccinating an Animal • A complete physical examination and health evaluation are given by a veterinarian before any vaccination.

Adverse reactions: As with the administration of any drug, vaccines can result in adverse reactions. Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, lethargy, and anaphylactic shock (vomiting, salivation, dyspnea, and incoordination). Precautions should be taken in animals with a history of vaccine reactions. Vaccines should be avoided if possible, but if they must be given the following guidelines should be observed: • A vaccine from a different manufacturer • Premedication with diphenhydramine and prednisolone sodium succinate 30 minutes prior to the vaccination • Hospital observation for the day Clients should be educated to monitor vaccination sites for lump formation and contact their veterinarian if found. Biopsies should be taken following the AAFP guidelines: • Present for 3 months

• Do not vaccinate pregnant animals with a modified live vaccine.

• ≥2 cm in diameter

• Animals with a fever or in debilitated health should not be vaccinated until healthy.

• ↑ Size after 1 month

As a constant effort to increase patient bonding and improve client satisfaction, special steps can be taken to ensure patient and owner comfort. Taking the extra steps to make this a more enjoyable experience will benefit both the patient and staff in future visits. A few tips for making injections a more comfortable procedure include: • Allowing the vaccine to warm to room temperature • Changing needles before injection; use of a 25-gauge needle • Gently squeezing or flicking the injection site to dull the area • Distracting the patient (e.g., treats, sliding the patient across the table or lifting their front legs, twitching a ear or tapping the nose, talking to the patient).

Titers: The discussion of vaccine titers has become very popular in veterinary medicine, and continues to remain controversial. Titers are available from various laboratories for distemper, parvovirus, rabies, and panleukopenia. If a titer is high, it is accepted as providing protection; however a low titer result does not reflect the immunization of an animal. Titers are best used following the puppy vaccine series to ensure proper levels of immunity have been reached. As each animal and its environment are unique, vaccine recommendations will vary accordingly at the discretion of the veterinarian and in accordance with state laws.

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2

Table 2.6 / Canine Transmissible Diseases: Coronavirus, Distemper Distemper

Definition

Contagious viral disease affecting the GIT, resulting in sporadic outbreaks of vomiting and diarrhea. Diarrhea is caused by the virus invading the enterocytes of the villous tips.

An acute to subacute febrile and often fatal, highly contagious viral disease with respiratory, GIT, and central nervous system (CNS) manifestations.

Presenting Clinical Signs

• Most infected dogs are asymptomatic and less signs are exhibited in adult dogs • Anorexia, depression, diarrhea (yellow-green to orange, malodorous) and vomiting

• Mucosal phase: malaise, nasal discharge followed by pneumonia, vomiting, diarrhea and fever • CNS phase: seizures, circling, pacing, ataxia and paresis

Examination Findings

• Dehydration, mild respiratory effects

• Abdominal pustules, anterior uveitis, conjunctivitis, dental enamel hypoplasia, hyperkeratosis of foot pads, KCS, myoclonus, optic neuritis, retinal degeneration and rhinitis

General

• History/clinical signs

• History/clinical signs

Laboratory

• Electron microscope • Fluorescent antibody tests

• CBC: lymphopenia, leukopenia, thrombocytopenia in early disease • Fluorescent antibody test: detection of virus in intact cells (e.g., conjunctival scrapings, buffy coat, urine sediment, CSF, transtracheal wash) • IgM: serum antibodies measured by ELISA • IgG: serial titers on 2 serum samples 2 weeks apart to detect ↑ titers • PCR: virus detection in respiratory secretions, CSF, feces and urine

Imaging

• N/A

• Thoracic: interstitial or alveolar pneumonia

Procedures

• N/A

• N/A

General

• Symptomatic • Supportive • Fluid therapy

• Supportive • Fluid therapy

Medication

• Imodium

• • • •

Antibiotics B vitamin supplementation Anticonvulsant therapy Antiemetics

Nursing Care

• N/A

• • • • •

Humidification of airways; nebulization and coupage Clean discharge from eyes and nose Nutritional support Adequate fluid intake or therapy Isolation to avoid infecting other patients

Diagnosis

Presentation

Coronavirus

Treatment

2

Disease

38

SECTION TWO: PREVENTATIVE CARE

Table 2.6 / Canine Transmissible Diseases: Coronavirus, Distemper (Continued)

Follow-Up

Disease

Coronavirus

Distemper

Patient Care

• N/A

• Monitor dehydration and electrolytes. • Recheck thoracic radiographs if persistent cough.

Prevention/Avoidance

• Vaccinate • Clean up feces: Will be shed in the feces for typically 6–9 days; but can be for many months

• Vaccinate • Avoid infected dogs or wildlife. • Clean up feces: shedding time typically < 2–3 months

Complications

• Persistent diarrhea for 10–12 days • Dehydration and electrolyte imbalances

• Occurrence of CNS signs may appear for up to 2–3 months after clinical signs • Seizures or CNS signs

Prognosis

• Complete recovery expected

• Ranges from subacute to mortality • Mortality rate of 50%

• Optional part of vaccine series • Consider vaccinating high-risk dogs: field trial dogs and kenneled dogs • Transmitted by fecal-oral route

• Unvaccinated puppies 6–12 weeks of age are most at risk. • Transmitted through body secretions, body excretions, and airborne • Easily destroyed by heat and most disinfectants; survives no more than a few days outside the host • Recovered dogs are not carriers. • Incubation period: 1–5 weeks

Notes

2

Table 2.7 / Canine Transmissible Diseases: Hepatitis, Infectious Tracheobronchitis Hepatitis

Infectious Tracheobronchitis

Definition

Viral disease caused by adenovirus type 1. Affects the liver, eyes, and endothelium

Contagious respiratory disease often caused by the bacteria Bordetella bronchiseptica resulting in the harsh, hacking coughing. It can also be caused by the viruses parainfluenza and canine adenovirus 2.

Presenting Clinical Signs

• Coma, depression, diarrhea, disorientation, lethargy, seizures, stupor, vomiting

• Mild form: repetitive dry-sounding hacking cough (referred to as “seal-like”) often followed by gagging and mild serous naso-ocular discharge • Severe form: anorexia, depression, naso-ocular discharge and productive cough

Examination Findings

• Abdominal pain, anterior uveitis, corneal edema, fever, hemorrhagic diathesis, hepatic encephalopathy, hypoglycemia, pale mucous membranes, nonsuppurative encephalitis, tonsillitis-pharyngitis

• Fever

Presentation

Disease

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

39

Table 2.7 / Canine Transmissible Diseases: Hepatitis, Infectious Tracheobronchitis (Continued) Disease

Diagnosis

2

Hepatitis

Infectious Tracheobronchitis

General

• Clinical signs

• Cough easily elicited on palpation of trachea • History of frequenting boarding facilities or off-leash parks

Laboratory

• • • •

• CBC: mild leukopenia, neutrophilic leukocytosis with a left shift • Cultures of nasal swabs, transtracheal or bronchial washings: Bordetella and Mycoplasma • PCR: virus detection

Imaging

• Radiographs, abdominal: hepatomegaly • Ultrasound: hepatomegaly and abdominal effusion

• Abdominal, thoracic: severe form, interstitial density, and alveolar pattern

General

• Symptomatic • Supportive • Fluid therapy +/− potassium and dextrose supplementation

• Supportive

Medication

• Antibiotics for secondary pneumonia or pyelonephritis

• Antibiotics • Bronchodilators • Antitussives

Nursing Care

• Frequent feedings to avoid hypoglycemia • Restricted activity/cage rest

• • • • • •

Patient Care

• Monitor blood chemistries • Monitor dehydration, acid-base balances, body weight, physical assessment, and electrolytes

• Adequate fluid intake • Airway humidification • Strict rest for 14–21 days

Prevention/Avoidance

• Vaccinate • Avoid urine contact: shedding time, 6 months or more

• • • •

Complications

• • • •

• N/A

Prognosis

• Guarded to good • Some with a complete recovery

• Complete recovery expected unless severe disease develops

• Transmitted through oronasal exposure and shed in all secretions during acute infection • Shed for 6–9 months following recovery • Highly resistant to inactivation and disinfection, thus enabling spread by fomites and ectoparasites

• Highly contagious via aerosol spread and fomites • Disinfect with bleach, Nolvasan, or Roccal. • Incubation period: 3–10 days

CBC: neutropenia, lymphopenia and thrombocytopenia Chemistry panel: ↑ AST, ALT and ↓ glucose Bile acids: mild to moderately high Coagulation tests: prolonged PT, APTT, hypofibrinogenemia

Follow-Up

Treatment

Procedures

Notes

40

Hepatic failure or chronic active hepatitis Acute renal failure DIC Glaucoma

SECTION TWO: PREVENTATIVE CARE

Encourage outpatient care for uncomplicated disease. Airway humidification Strict confinement with low stress, and few dogs Nutritional support ↑ Fluid intake Fresh air flow

Vaccinate Prevent fomite spread with bleach diluted 1:32. Isolate infected animals. Shed for up to 3 months, infectious risk is greatly ↓ after recovery of discharge and cough.

Table 2.8 / Canine Transmissible Diseases: Leptospirosis, Lyme Disease Leptospirosis ZOONOTIC

Lyme Disease ZOONOTIC

Definition

Acute and chronic bacterial disease affecting lungs, kidneys, and liver

A multiorgan disease caused by the spirochete Borrelia burgdorferi

Presenting Clinical Signs

• Anorexia, dehydration, depression, myalgia, reluctance to move and vomiting

• Anorexia and lethargy

Examination Findings

• Acute renal or hepatic failure, conjunctivitis, DIC, epistaxis, fever, melena, petechia, poor capillary perfusion, rapid irregular pulse, tachypnea

• Fever, lymphadenopathy, and polyarthritis

General

• Clinical signs

• Joint palpation: lameness, swelling, and pain • History of travel in known tick infested areas

Laboratory

• CBC: leukopenia, thrombocytopenia, and neutrophilia with left shift • Chemistry panel: ↑ BUN, creatinine, AST, ALT, ALP, bilirubin, phosphorus, ↓ chloride, sodium, and potassium • Urinalysis: proteinuria, pyuria, bilirubinuria, and isothenuria • Microscopic agglutination test: + after 1 week, peaking at 3–4 weeks, fourfold rise in titer • Combined IgM-IgG ELISA titers: IgM is + in first week and persists to 2 weeks; IgG is + 2–3 weeks after infection and persists for months

• • • •

Imaging

• N/A

• Radiographs, joints: +/− effusion

Procedures

• N/A

• N/A

General

• Supportive • Fluid therapy • Transfusion therapy

• Supportive

Medication

• Antibiotic: doxycycline, penicillin (leptospiremia)

• Antibiotics: tetracycline, ampicillin, doxycycline, and cephalexin • NSAIDs

Nursing Care

• Restrict activity/cage rest. • Nutritional support

• Encourage outpatient care. • Pain management

Treatment

Diagnosis

Presentation

Disease

IDEXX SNAP 3Dx test IDEXX SNAP 4Dx test IFA and ELISA: ≥1:152 = highly + Synovial fluid analysis: suppurative and +/− Borrelia organisms within WBC

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

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2

Table 2.8 / Canine Transmissible Diseases: Leptospirosis, Lyme Disease (Continued) Disease

Follow-Up

2

Leptospirosis ZOONOTIC

Lyme Disease ZOONOTIC

Patient Care

• Monitor blood chemistries and urinalysis.

• Restricted activity

Prevention/Avoidance

• Vaccinate in high-risk areas. • • Avoid water sources where animals may have urinated; shedding time, months • to years. • •

Complications

• DIC • Permanent renal and hepatic dysfunction

• CNS disorders • Fatal renal failure • Heart block (rare)

Prognosis

• Most infections are subclinical; those that are acutely severe have a guarded prognosis.

• Recovery expected, but recurrence possible within weeks to months

• Spread in the urine of recovered animals for months to years following infection • Transmitted by food, water, bedding, soil, vegetation, or fomites • Disinfect with povidine-iodine; bleach 1:10 dilution. • Enters through skin or mucous membranes or by ingestion of contaminated water • Onset is a few days to 30 days; typically 3–14 days.

• Transmitted most commonly by the deer tick Ixodes dammini through a tick bite. • Infected animals pose little risk to humans; they are more of a risk in passing ticks to humans.

Notes

Limit access to tick-infested areas. Use tick repellants/insecticides. Periodically check dogs for ticks. Vaccinate in high-risk areas.

Table 2.9 / Canine Transmissible Diseases: Parvovirus, Rabies Parvovirus (CPV)

Rabies ZOONOTIC

Definition

Highly contagious disease causing severe enteritis and affecting the lymphatic system. Typically affects puppies between weaning and 6 months of age.

A virus that can infect almost all warm-blooded animals and is considered untreatable. It infects the nervous system, causing death from paralysis.

Presenting Clinical Signs

• Anorexia, depression, and vomiting • Diarrhea: profuse, liquid, hemorrhagic, and distinct metallic odor • Symptoms may vary in older dogs.

Three phases • Prodromal phase (2–3 days): fever, subtle behavior changes • Furious phase (2–4 days): irritability, restlessness, barking, ataxia, and seizures • Paralytic phase (2–4 days): paralysis, depression, coma, and death from respiratory paralysis

Examination Findings

• Extreme dehydration, fever

• Prodromal phase: slow corneal and palpebral reflexes

Presentation

Disease

42

SECTION TWO: PREVENTATIVE CARE

Table 2.9 / Canine Transmissible Diseases: Parvovirus, Rabies (Continued) Parvovirus (CPV)

Rabies ZOONOTIC

General

• History/clinical signs

• History/clinical signs

Laboratory

• CBC: severe leukopenia and lymphopenia, PCV variable • Chemistry panel: ↑ bilirubin, ALT, AST and ↓ potassium, sodium and chloride • ELISA assay • IDEXX Parvo Antigen SNAP test • Fecal hemagglutination test

• CSF: minimal ↑ protein and leukocytes • Postmortem virus isolation from fresh brain tissue

Imaging

• Radiographs, abdominal: gas and fluid distention in GIT • Often causing a misdiagnosis of GIT obstruction

• N/A

Procedures

• N/A

• N/A

General

• Symptomatic • Supportive • Fluid therapy: aggressive

• Supportive

Medication

• Antibiotics: ampicillin and gentamicin • Antiemetics: metoclopramide or H2 blocker

• N/A

Nursing Care

• Nothing by mouth for 24 hours after vomiting and severe diarrhea • Quarantine protocol

• Strictly inpatient/quarantine • Runs and cages should be locked.

Patient Care

• Dogs should remain isolated for 1 week after complete recovery.

• None

Prevention/Avoidance

• Vaccinate out to 16–18 weeks • Isolate puppies as much as possible until vaccine series has been completed.

• Vaccinate • Strict quarantine for those suspected of having rabies • Euthanize all animals known to have rabies

Complications

• Septicemia • Secondary bacterial pneumonia • Intussusception

• N/A

Prognosis

• Survival of 3–4 days is usually followed by rapid recovery. • Immunity by natural infection is lifelong if the dog survives.

• Almost 100% fatal

• Transmitted by the fecal-oral route, saliva, vomitus, or direct contact • Stable in the environment for months to years • Rottweilers, Doberman Pinschers, Pit Bull Terriers, and Labrador Retrievers seem to be at higher risk. • Disinfect with 1:32 dilution of bleach and water or Parvocide®. • Incubation period 5–10 days

• Transmitted in the saliva • Inactivated by disinfectants • Head should be chilled on wet ice (do not freeze) and sent to a lab for analysis.

Follow-Up

Treatment

Diagnosis

Disease

Notes

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

2

43

Table 2.10 / Canine Vaccination Protocol

The site of vaccine injection varies between clinics, but it is important to have a designated location for each vaccine and to note these locations in each patient’s chart. Vaccines are routinely given subcutaneously, except for the intranasal version of Bordetella. Vaccine

≤16 Weeks of Age

>16 Weeks of Age

Vaccine Classificationa

DHPP • Canine distemper (D) • Canine hepatitis/adenovirus (H) (CAV-2) • Canine parainfluenza (P) • Canine parvovirus (P)

• 1 dose at 6–9 weeks, then repeat every 3–4 weeks until 16 weeks (e.g., 1 dose at 8, 12 and 16 weeks) • 1 dose at 12 months, then every 3 years

• 1 dose initially • 1 dose 12 months after initial, then 1 dose every 3 years

Core Core

Leptospirosis • Canine leptospirosis

• 1 dose: 12 and 16 weeks • Annually dependent on patient’s risks

• 2 doses, 2–4 weeks apart • Annually dependent on patient’s risks

Noncore

Bordetella • Infectious tracheobronchitis

• IN: 1 dose at 3–12 weeks, then 1 dose 2–4 weeks later, then biannually or annually dependent on patient’s risks • SQ: 1 dose at 6–8 weeks, repeat 1 dose 2–4 weeks later, then annually dependent on patient’s risks

• IN: 2 doses, 2–4 weeks apart, then biannually or annually dependent on patient’s risks • SQ: 1 dose, then biannually or annually dependent on patient’s risks

Noncore

Rabies • Rabies virus

• 1 dose at 12–16 weeks • 1 dose every 1–3 years dependent on vaccine type and state requirements

• 1 dose initially • 1 dose every 1–3 years dependent on vaccine and state requirements

Core

Lyme • Lyme borreliosis

• 1 dose at 9–12 weeks, then repeat 2–4 weeks later • Annually, dependent on patient’s risk

• 2 doses, 2–4 weeks apart • Annually, dependent on patient’s risk

Noncore

Noncore Core

Note: Injection site, age at administration, and booster protocol may vary depending on the manufacturer of the vaccination and veterinarian’s discretion. Recommendations by the individual manufacturer should be followed. The frequency may vary depending on the state’s requirements and the veterinarian’s protocol. Note: Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, and lethargy to anaphylactic shock (vomiting, salivation, dyspnea, and incoordination). a Core vaccines are those recommended to every dog. Noncore vaccines are recommended based on potential risk factors.

Table 2.11 / Feline Transmissible Diseases: Feline Calcivirus Disease

Feline Calicivirus (FCV)

Definition

One of the major causes of feline upper respiratory disease. An acute, highly contagious viral disease causing oral ulceration, pneumonia, and occasionally arthritis.

Presentation

2

44

Presenting Clinical Signs

Anorexia, depression, dyspnea, mild conjunctivitis, mild sneezing, nasal discharge, ulcerated tip of nose

Examination Findings

• +/− Arthralgia, enteritis, facial and limb edema, fever, gingivitis, limping syndrome, interdigital paw ulcers, oral ulcers

SECTION TWO: PREVENTATIVE CARE

Table 2.11 / Feline Transmissible Diseases: Feline Calcivirus (Continued)

Follow-Up

Treatment

Diagnosis

Disease

Feline Calicivirus (FCV)

2

General

• History/clinical signs

Laboratory

• CBC: neutrophilia and lymphopenia • Chemistry panel: ↑ bilirubin, CK • Virus isolation: cell cultures of swabs from oropharynx, lung tissue, nasal cavity, conjunctiva, feces, and blood

Imaging

• Radiographs, thoracic: generalized ↑ density of the lungs

Procedures

• N/A

General

• Self-limiting in 5–7 days • Supportive

Medication

• • • • •

Nursing Care

• Oxygen supplementation if complicated pneumonia • Nutritional support

Patient Care

• • • • •

Prevention/Avoidance

• Vaccinate • Prevent contact with FCV-infected cats. • Virus is shed continuously.

Complications

• Interstitial pneumonia • Secondary bacterial infections

Prognosis

• Excellent unless pneumonia develops • Recovered cats may shed the virus in their saliva for long periods.

Notes

Antibiotics: amoxicillin Antibiotic (ophthalmic) Pain medication Immunostimulants: interferon Corticosteroids

Keep eyes and nose clear of discharge. Support nutrition and fluid intake Airway humidification Provide soft foods if oral ulcers. Irrigate oral lesions with 0.2% chlorhexidine solution.

• Transmission is through direct contact and fomites; virus is shed in oropharyngeal, conjunctival, and nasal secretions, feces, sloughed hair and skin. • Very resistant virus; disinfect with 1:32 dilution of bleach water. • Cats that recover may remain subclinical carriers for months to years. • Cats should be tested for FIV or FeLV to rule out underlying immunodeficiency syndromes. • Occurs with FHV-1 in most cases. • Incubation period is 1–5 days. • Intermittent shedding may take place for 4 months postinfection.

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

45

Table 2.12 / Feline Transmissible Diseases: Feline Infectious Peritonitis

Definition

A systemic viral disease with high mortality. This disease arises from a mutation of a benign virus, feline enteric coronavirus (FEVC) commonly found in the GIT of cats. There are 2 different forms: wet/effusive form and the dry/noneffusive, granulomatous form.

Presenting Clinical Signs

• Ataxia, behavioral changes, depression, diarrhea, failure to grow, inactivity, paresis, poor condition, seizures, urinary incontinence, vomiting, weight loss • Dry Form: dyspnea, exercise intolerance • Wet Form: abdominal distention

Examination Findings

• Fever, icterus, pallor • Dry form: anterior uveitis, chorioretinitis, iritis, irregular pupils, tumors • Wet Form: abdominal or pleural effusion

General

• Clinical signs after other conditions have been ruled out

Laboratory

• • • • • • •

Imaging

• Radiographs, thoracic: effusion • Radiographs, abdominal: effusion, organomegaly, lymphadenopathy, and ileocolic mass

Procedures

• Abdominocentesis or thoracocentesis; straw-colored fluid, viscous, clots, fibrinous, and ↑ protein • Tumor biopsy: granulomatous inflammation

General

• Therapeutic paracentesis • Fluid therapy • Supportive

Medication

• Corticosteroids: prednisone • Immunosuppressive drugs: cyclophosphamide • Immunostimulants: immunoregulin, interferon, acemannan

Nursing Care

• Nutritional support

Diagnosis

Presentation

Feline Infectious Peritonitis (FIP, Feline Coronavirus)

Treatment

2

Disease

46

SECTION TWO: PREVENTATIVE CARE

CBC: leukopenia (early in disease), leukocytosis with neutrophilia, lymphopenia (late in disease), nonregenerative anemia Chemistry panel: ↑ bilirubin, ALP, ALT, globulins and bile acids, BUN, creatinine Urinalysis: ↓ bilirubin and protein Histopathologic examination: biopsy is the only definitive method for FIP diagnosis Immunohistochemistry: most accurate FIP virus detection on biopsied tissue Titers: limited value, highest titers have ↑ likelihood of disease PCR: virus detection

Table 2.12 / Feline Transmissible Diseases: Feline Infectious Peritonitis (Continued)

Follow-Up

Disease

Feline Infectious Peritonitis (FIP, Feline Coronavirus)

Patient Care

• Confine to prevent exposure to other cats

Prevention/Avoidance

• • • •

Complications

• GIT obstruction • Neurologic disease • Pleural effusion

Prognosis

• Almost 100% mortality • Length of disease is a few days to months.

Notes

2

Prevent contact with FIP-positive cats; transmission is rare between cats. Intranasal vaccine; very low efficacy Routine disinfection Control and prevent feline leukemia virus (FeLV) infection.

• Transmitted through oral and respiratory secretions, feces, urine, and fomites, but most commonly through the mutation of FECV to FIP • Survives in the environment for several weeks • Readily inactivated by commonly used disinfectants

Table 2.13 / Feline Transmissible Diseases: Feline Panleukopenia Virus, Feline Immunodeficiency Virus Feline Panleukopenia Virus (FPV, Feline Parvovirus)

Feline Immunodeficiency Virus (FIV)

Definition

An acute, systemic, and enteric viral disease. It has a sudden onset, is highly contagious, and has a high mortality rate.

An immunodeficiency syndrome characterized by chronic and recurrent infection. Gradually selecting and destroying T-lymphocytes. This process makes cats more prone to secondary syndromes. Affected cats can be asymptomatic for >5years.

Presenting Clinical Signs

• Abdominal pain (crouching position and head between front paws), anorexia, depression, diarrhea, persistent vomiting, rough and dull hair coat

Stage 1 • Usually subclinical: fever, neutropenia, and lymphadenopathy Stage 2 • Latent phase: could last for years Stage 3 • Terminal phase: abscesses, anorexia, cachexia, dementia

Examination Findings

• Fever progressing to hypothermia and progressive dehydration

• Conjunctivitis, gingivitis, otitis, periodontitis, pneumonia, rhinitis, skin infections, stomatitis, tachycardia, urinary tract infections

Presentation

Disease

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

47

Table 2.13 / Feline Transmissible Diseases: Feline Panleukopenia Virus, Feline Immunodeficiency Virus (Continued) Disease

Feline Immunodeficiency Virus (FIV)

General

• History/clinical signs

• History/clinical signs of exposure

Laboratory

• CBC: leukopenia • Chemistry panel: ↑ BUN, creatinine, and electrolyte imbalances • Virus isolation: feces • CITE test for canine parvovirus: detects FPV antigen in the acute stage • Serologic testing: rising titers • Chromatographic test strip, feces: + for FPV and CPV

• • • • • •

Imaging

• N/A

• N/A

Procedures

• N/A

• N/A

General

• Supportive • Fluid therapy • Blood transfusions

• Symptomatic • Fluid therapy • Dental care

Medication

• Antibiotics • Antiemetics: metoclopramide

• • • •

Nursing Care

• Nothing by mouth until vomiting and diarrhea subside • Heat support if hypothermic • Monitor hydration, electrolytes, and CBC

• Nutritional support

Patient Care

• Heat support • Nutritional support once eating

• Maintain current vaccines to prevent infection of respiratory disease

Prevention/Avoidance

• Vaccinate. • Prevent contact with infected cats. • Clean up feces: shedding time up to 6 weeks

• • • •

Complications

• • • •

• N/A

Prognosis

• Poor prognosis in terminal phase: ≤1 year survival

• >50% remain asymptomatic within 2 years after diagnosis • Poor prognosis in terminal phase: ≤1 year survival

• Transmitted by fomites and through all body secretions for up to 6 weeks. • Disinfect with 1:32 dilution of bleach water. • Survives months to years in the environment • In utero transmission from infected queen leads to cerebellar hypoplasia in kittens. • Incubation period: 16 Weeks of Age

Injection Sitea

Vaccine Classificationb

FPV • Feline panleukopenia FCV • Feline calicivirus FHV-1 • Feline viral rhinotracheitis

• 1 dose at 6–9 weeks, then repeat every 3– 4 weeks until 16 weeks (e.g., 1 dose at 8, 12, 16 weeks) • 1 dose 12 months after initial, then 1 dose every 1–3 years dependent on manufacturer and hospital policy

• 2 doses, 3–4 weeks apart • 1 dose 12 months after initial, then 1 dose every 1–3 years dependent on manufacturer and hospital policy

• SQ on right lower shoulder • IN/conjunctival sacs, depending on manufacturer

Core

FeLV • Feline leukemia

• ELISA FeLV test for virus detection prior to vaccination • 1 dose at 8 weeks, then 1 dose 3–4 weeks later • Annually dependent on patient’s risk

• Elisa FeLV test for virus detection prior to vaccination • 2 doses; 3–4 weeks apart • Annually dependent on patient’s risk

• Transdermal on the left hind lower thigh area • SQ on the left lower thigh area

Noncore

Rabies • Rabies virus (RV)

• 1 dose at 8–12 weeks dependent on vaccine type • 1 dose every 1–3 years dependent on vaccine type and state requirements • Annually using canary-pox vector rabies vaccine

• 1 dose initially • 1 dose every 1–3 years dependent on vaccine type and state requirements • Annually using canary-pox vector rabies vaccine

• SQ on right hind lower thigh area

Core

FIV • Feline immunodeficiency virus

• 1 dose at 8 weeks, then 2 doses every 2–3 weeks • Annually dependent on patient’s risk

• 3 doses every 2–3 weeks • Annually dependent on patient’s risk

• SQ

Noncore

Core Core

a

Injection site, age of administration, and booster protocol may vary depending on the manufacturer of the vaccination. Recommendations by the individual manufacturer should be followed. The frequency may vary depending on the state’s requirements and the veterinarian’s protocol. Note: Possible reactions range from sensitivity at the injection site, a small bump or knot at the injection site, slight fever, hives, lethargy, to anaphylactic shock (vomiting, salivation, dyspnea, and incoordination) and injection site sarcomas. Any bump found at the injection site should be assessed by a veterinarian. b Core vaccines are those recommended to every dog. Noncore vaccines are recommended based on potential risk factors.

ANIMAL CARE Along with medical care provided by the veterinarian, owners must take an active role in the day-to-day health of their animals. Dental care, grooming, and basic medical procedures can help provide the animal with increased

health and longevity. Besides providing the basic care, it also allows the owners to be more aware of other health problems that might otherwise be missed (e.g., gum inflammation, tumors, pruritus, otitis externa).

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

51

Skill Box 2.9 / Client Education: Home Dental Care 2

Home dental care should be a daily part of each animal’s life. The commitment to time, energy, and resources from the owner will impact the quantity and quality of their animal’s life.

• Brush the visible teeth (opposite side) and then repeat on the other side. Maintenance:

Supplies:

• Brush daily, at a minimum of 3 times a week.

• Toothbrush (e.g., fingerbrush, pet toothbrush, human toothbrush), gauze, washcloth, pantyhose

• Oral examination

• Veterinary toothpaste, beef bouillon, garlic or tuna water Age: • Home dental care should begin at 8–12 weeks of age. Brushing is not critical until the adult teeth erupt, but starting early allows the animal to become accustomed to the procedure during an impressionable period of development. Introduction: • Regardless of age, introduce brushing slowly and gradually, allowing the animal to determine the amount of time at each stage. • As each step is begun, observe for the animal’s reaction and only advance to the next step once the animal is comfortable. • Massage the animal’s muzzle and lips gently. • Introduce your finger dipped in beef bouillon or garlic water (canine) or tuna water (feline) into the buccal pouch under the upper lip and rub the gum line. • Introduce your finger covered with a gauze, washcloth, or pantyhose and rub the gum line and teeth in a circular motion. • Introduce a pet toothbrush or a very soft human toothbrush held at a 45° angle to the tooth surface, brushing in a oval motion. • Introduce the toothbrush with veterinary toothpaste. • As the animal accepts the procedure, brushing of the lingual surfaces can begin. • Place the nonbrushing hand over the muzzle and tilt head backward to open the animal’s mouth.

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SECTION TWO: PREVENTATIVE CARE

• Gums: redness, swelling, bleeding, pus • Teeth: loss, instability, broken, change in color • Mouth: halitosis, growth Adjuncts to brushing: • Dental diets or treats • Rawhide bones (e.g., Nylabone) • Yearly dental examinations and cleanings, if needed Tips for successful brushing: • Select the same time each day to brush so the animal expects it (routine and repetition). • Brushing in the evening is often preferred as everyone is in a more quiet mood. • Sessions should be short, roughly 2–3 minutes. • Offer praise and reassurance during and following the brushing. Avoid: • Human toothpaste, baking soda, or hydrogen peroxide • Heavy restraint • Brushing aggressively • Brushing if the procedure may cause pain (e.g., recent thorough oral examination, existing CLL, exposed pulp cavities, gingivitis, ulcerations, tooth mobility) • Natural bones, cow hooves, hard nylon toys as they may fracture teeth

Skill Box 2.10 / Grooming

Skill Box 2.11 / Bathing

Grooming is a segment of veterinary care that is limited and typically presents itself as client education. Even though staff may not routinely provide grooming services, clients often have questions regarding the general care of their pets. Brushing, bathing, and toenail trims are the most basic of grooming procedures. There are also certain procedures that may be performed during periods of medical conditions that must be continued routinely to avoid reoccurrence of the problem, such as anal gland expression and ear cleaning and flushing. Brushing should be a routine part of pet care to remove dead fur and dirt and to prevent matting. Besides providing the animal with a shinier and healthier coat and a chance to look and feel for abnormalities, it also allows bonding between the animal and the owner. There are many types of brushes and combs available for specific types of coats; a variety of options can be helpful. Applying a detangler spray before beginning may help with tangled or slightly matted fur. Using a systematic approach, begin at the head and work toward the tail. Use a gentle stroke, as ripping or pulling at the fur is painful and will make brushing a negative experience. For animals with long, thick coats, brush the fur against the natural lay of the fur and then finish with brushing fur down. Following up with a comb may help remove the extra loose fur.

1. Location: a safe place for both owner and animal to stand, a mixture of hot and cold water available, and an area able to withstand water (e.g., shaking wet dog) • Place a towel or mat in the bottom of the tub to supply traction for the animal. • Have a leash hook fastened to the wall so the animal can be secured without having to always have a hand on the animal. 2. Supplies: multiple towels, appropriate shampoo, plastic apron, gloves (depending on type of shampoo) and protective eyewear. 3. Comb, brush, and demat to remove excess fur, which allows better penetration of shampoo as detailed above. 4. Wet down the animal completely, making sure to get water down to the skin. 5. Apply the shampoo and lather the entire animal, including face. 6. Leave shampoo on for the amount of time indicated on the bottle or by the veterinarian. • Use a timer to ensure that the shampoo is on for the correct time: do not guess. 7. Rinse the animal completely, making sure to remove all soapy residue. 8. Dry the animal’s haircoat and ear canals with a combination of shaking (removes 95% of the water) and towels. • Blow in the animal’s ear to get them to shake. • Dry the ear canals, using either cotton balls or a vinegar rinse. Note: Keep the animal in a warm place until completely dry to avoid the animal becoming chilled. 9. Comb and brush out the animal after the bath to remove all the hair that was loosened. Note: Do not use lubricants in the eyes; it may trap the shampoo in the eye instead of protecting the eye. • Do not place an animal in a heater/dryer cage without direct supervision and access to water to prevent overheating and death of the animal. • If drying an animal with a blow dryer, be sure to keep the dryer on the lowest setting and continuously moving to prevent burns to the animals. CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

53

2

2

Skill Box 2.12 / Nail Trimming

Skill Box 2.13 / Anal Sac Expression

Nail trimming is another routine part of pet care. Failing to trim the nails may lead to the nails growing into the pad of the paw, difficulty or inability of the pet to walk, and pain and pad injuries. Most animals are adverse to nail trimming and may need some coaxing. Choosing a time when the pet is tired and comfortable may make the experience more tolerable. When trimming, it is best to hold the trimmer perpendicular (cutting top to bottom) to the nail; when held parallel (cutting side to side), crushing and splintering of the nail may take place. When trimming nails, it is important to avoid cutting the quick, which consists of the blood vessels and nerves that supply the toenail. In dogs, light-colored nails are easy to trim as the blood supply is easily seen and avoided. Dark-colored nails can be difficult to trim and should be done in small cuts. As small cuts are made, the white to pink crescent shape will begin to appear in the middle of the nail. This represents the quick, and continuing to cut will eventually lead to bleeding. Remember to cut all nails including the dewclaws on both front and rear feet. The rear feet nails are typically shorter and require less trimming. In cats, the paw is gently squeezed to expose the nails and then they are trimmed to within 2 mm of the quick.

1. Supplies: gloves, lubricant (e.g., K-Y Jelly), alcohol, absorbent material (e.g., rolled cotton, paper towels, baby wipes), and deodorizer

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SECTION TWO: PREVENTATIVE CARE

2. Put alcohol-soaked absorbent material into the gloved hand during the expression to catch the expressed material, insert the forefinger into the rectum, and immobilize the sac between the forefinger and the thumb on the outside of the rectum. 3. Gently apply pressure to the sac with thumb and forefinger (located at the 4 and 8 o’clock positions when looking at the anus), milking from the bottom of the sac upward toward the duct opening. 4. Note the amount and character of the material expressed. Normal secretions are a clear to slightly greenish, foul-smelling (similar to dead fish) substance that is a liquid to a paste in consistency. Material that is very thick or purulent or very dark should be brought to the attention of the veterinarian. 5. Clean the perianal area of the animal with alcohol-soaked material or baby wipe and then spray with a deodorizer. • If using powdered gloves, put 2 gloves on the hand doing the expression, then remove 1 glove after each sac is expressed. • If having difficulty expressing a gland, try rolling the skin outward with the finger outside the rectum to better expose the duct. • If having trouble with positioning, switch and use the thumb on the inside and the forefinger on the outside or teach yourself to be ambidextrous and express the right gland with the left hand and vice versa.

Skill Box 2.14 / Ear Cleaning and Flushing Method

Ear Cleaning

Ear Flushing

Equipment

• Cotton ball • Cleaning solution (chlorhexidine, povidone iodine, Oti-clens, Epi-Otic) • Bulb syringe/syringe without the needle • towel

• • • • • •

Cotton ball Cleaning solution (Ceremune) Ear irrigator (filled with warm water) Video scope or endoscope Anesthetized patient 5 Fr red rubber feeding tube (cut to about ½ its length)

Technique

• Verify the patient has an intact tympanic membrane. • Using either a bulb syringe or syringe without the needle, fill the ear canal with cleaning solution. Be careful not to form a seal between the instrument and the ear canal, and do not use a direct stream on the tympanic membrane. • Put a towel or piece of roll cotton at the entrance of the ear canal and begin gently massaging the ear canal from the bottom up. This will work the solution from the bottom of the ear canal to the opening. With a cotton ball, gently wipe out any debris. Do not push cotton ball in the ear any farther than your finger will go easily. • Repeat steps 1 and 2 until the ear canal and solution on the cotton ball come out clean (5–10 times). • To dry the ear canal, use either a flushing solution or suction via an infant feeding tube attached to a syringe.

• • • • •

Take a picture of the ear canal. If cytology has not been done, take a sample of the ear debris. Insert the Ceremune or other ear cleaner, and massage gently for 3–4 minutes. Wipe out any excess at the entry of the ear. Insert the feeding tube onto the ear irrigator nozzle and turn on the machine, verifying that the pressure gauges are registering as prescribed in the manual. Position the video scope or endoscope into the ear, and then insert the feeding tube into the port and watch on the monitor screen to see the tip protrude from the scope. Depress the water button on the trumpet, release, and then depress the suction button and suction out debris and liquid. Repeat several times. Remove the feeding tube if debris is clogging the tip and clean. A reapplication of the ear cleaning solution may be necessary in ears with a lot of debris. Be sure to remove all of the Ceremune. Take a second picture of the clean canal. Insert any medications if needed.

• • • • • •

2

Note: See Figure 1.19, Ear, page 13.

CHAPTER 2 / PREVENTATIVE CARE AND VACCINATIONS

55

Chapter

3

3

Nutrition General Nutrition 58 Daily Caloric Requirement Worksheet for a Healthy Animal 59 General Life Stage Feeding Guidelines

Body Condition Scoring System 62 Disease Nutritional Requirements 64 Obesity Management 68 60

Key Words and Termsa Aerophagia Alkali Amino acid Antigenic Bioactive amines Bioavailability Cachexia Carbohydrate Daily energy requirement Digestibility Energy Fat Fatty acid Fiber Hydrolyzed protein Kilocalorie a

Life stage Malnutrition Meat byproducts Meat meal Metabolism Micronutrient Mineral Neonate Nitrogenous waste Nutrient Obesity Protein Resting energy requirement Vasoactive amines Vitamin

Abbreviations

Additional References, page

AAFCO, Association of American Feed Control Officials BCS, body condition score BW, body weight CHF, chronic heart failure DER, daily energy requirement EPI, exocrine pancreatic insufficiency FLUTD, feline lower urinary tract disease GIT, gastrointestinal tract kcal, kilocalorie ME, metabolizable energy NPO, nothing by mouth PLE, protein losing enteropathy RBC, red blood cell RER, resting energy requirement

Laboratory, 71 Parenteral nutrition, 422 Pharmacology, 567 Physical examination, 18 Urinalysis, 147

Key words and terms are defined in the glossary on page 631.

57

GENERAL NUTRITION

3

Proper nutrition is as important as physical examinations, vaccinations, and dental care in maintaining a healthy pet. Unfortunately, not much time is usually given to the subject during client education. Obesity remains the biggest nutritional challenge; it is estimated that 24–44% of dogs and cats in the United States are overweight. Understanding how to feed a pet according to its life stage, how to determine their current condition, how to alter their nutrition based on disease changes, and how to get a pet back to its ideal condition are the keys to proper clinical nutrition. The most important component of proper nutrition begins with a high-quality diet formulated to the appropriate life stage of the animal. Poor-quality, unbalanced, commercial diets; homemade diets of single-food items; indiscriminate mixtures of singlefood items; and variable supplements will lead to dietary imbalances. Along with proper nutrition, fresh, clean water must be provided at all times. Owners often look to the veterinary staff for a better understanding of the “right” diet to feed their pet. Many would like a concrete comparison

58

SECTION TWO: PREVENTATIVE CARE

between different foods, but unfortunately this is virtually impossible to do. The information provided in the ingredient list and on the information panel appears at first glance to be consistent between products, but the variables that exist render a comparison unattainable. The most reliable way to evaluate a food is to evaluate the health and appearance of the animal that is eating it. Each animal is an individual and will handle each diet differently. Some basic guidelines to providing a quality diet include feeding diets that have passed the Association of American Feed Control Officials (AAFCO) feeding trials, feeding diets appropriate for the animal’s life stage, and feeding diets containing meat (not including meat byproducts and meat meal). Some indications that a diet change may be indicated for a particular pet are poor body condition, flatulence, borborygmus, ↑ fecal volume and frequency, changes in the expected appearance of the haircoat. Home-prepared diets can be a very valuable option when an approved recipe is followed to guarantee the proper nutrients have been included. Only those recipes formulated by a credentialed veterinary nutritionist should be considered and then not altered.

Skill Box 3.1 / Daily Caloric Requirement Worksheet for a Healthy Animal Many factors affect the energy requirements of animals. Understanding these factors may prevent an animal from becoming obese. Daily caloric requirements are altered by the physiologic state (e.g., adult maintenance, pregnancy, lactation, and growth), activity level, temperament, environmental temperature, and the diet’s digestibility. The calculations below provide a starting point; adjustments will need to be made based on each individual animal. Step 1: Calculate Daily Resting Energy Requirement (RER) RER = 70 × (current body weight in kg)0.75 or, for animals weighing between 2 and 30 kg: RER = (30 × current body weight in kg) + 70 = ______ kcal/day Adjust kcal based on visual and manual examination and the BCS of animal. Tip: To calculate (BW kg)0.75 without a scientific calculator: multiply the weight by itself 3 times, then take the square root twice Step 2: Calculate daily energy requirement (DER) by multiplying the RER by the activity factor. Life Stage

Activity Factor (RER × ______ = DER) Canine

Feline

2.0

1.6–2.0

Gestation Weeks 5–9 Lactation Week 1–2

1.5a

Week 3–5

a

2.0

1.5 1.5–5.0

Growth Weaning to 50% of adult BW

3.0

3.0

51% of adult BW to adult

2.0

2.0

Inactive, neutered

1.6

1.2

Inactive, intact

1.8

1.4

Active/working

2.0–6.0

1.6

Adult

a 25% of the RER should be provided for each pup in addition to the dam’s DER. These calculations do not take into consideration the type of breed and their differences in growth requirements. Adjust kcal based on visual and manual examination of animal.

Step 3: Calculate volume of food required ______ kcal/day/ ______ kcal/cup or can of food = ______ cup/can(s) of food/day Step 4: Calculate amount of each feeding ______ cup/can(s) of food/day/2–3 feedings per day = ______ cup/can(s) of food/feeding

CHAPTER 3 / NUTRITION

59

3

Table 3.1 / General Life Stage Feeding Guidelines

Each stage of an animal’s life presents changes in nutritional needs. The overall goal of nutrition is to obtain an optimum body condition score (see Table 3.2 Body Condition Scoring System, page 61) while providing the correct balance of nutrients, vitamins, and minerals. Age

Diet

Feeding Method

Comments

Birth to Weaning

• Dam/queen’s milk • Commercial replacement diets • Home prepared replacement diets • See Skill Box 2.1 Care and Feeding of Orphaned Puppies and Kittens, page 27. • Energy requirement is 22–26 kcal/100 g • Begin introducing puppy or kitten diet at 3–4 weeks of age as milk will no longer provide adequate calories or nutrients • Weaning begins at 6–8 weeks of age

• Nursing neonates will feed ad lib • See Skill Box 2.1 Care and Feeding of Orphaned Puppies and Kittens, page 27. • Starting solid food • Mix growth food with warm water to moisten and make into a slurry; place food in a shallow dish. • Allow free access 3–4 times a day. • Remove after 20–30 minutes to prevent bacterial overgrowth. • Neonates can be encouraged to eat by placing their feet in the food, smearing food on their lips, or introducing food into their mouths. • Weaning • Complete weaning should not start before 6 weeks of age (preferably 7–8 weeks of age) and not until close human contact has occurred, and typically does not need assistance after solid foods have been started. • The dam/queen should be separated from the neonates the day before weaning. The neonates should be fed, and food should be withheld from the dam/queen. Water is not removed. • The neonates should be reunited with the dam/queen overnight and be allowed to nurse to drain the mammary glands. Food only should be withheld from both the dam/queen and the neonates overnight. • The neonates are removed from the dam/queen the next day

• Body fat stores are only 1–2% at birth, presenting the risk of hypoglycemia, starvation, and hypothermia. • Adequate glycogen reserves do not develop until after first few days of nursing. • All neonates need to receive colostrum in the first 24 hours of life to ensure transfer of passive immunity. • Hypothermia can lead to poor nursing.

Weaning to 12 Months

• Puppy • Highly digestible, high-quality protein • 25–29% protein of ME • Large- and giant-breed dogs • Overfeeding and extra micronutrients (e.g., calcium) during rapid growth phase contribute to obesity and developmental orthopedic disease. • Maintain feeding puppy diet until an adult to avoid ↑ calcium consumption. • Adjust food intake to maintain a BCS of 2/5. • Kitten • 30% protein of ME • Maintain feeding kitten diet until maturity (10–12 months) if obesity is present, then ↓ amount of food fed.

• Puppy • 2–4 measured feedings per day • Large- and giant-breed dogs • Measured feedings 3–4 meals daily • Remaining food after a meal should be discarded and subsequent meals should be reduced in quantity. • Kitten • Free-feed or measured feedings 2–3 times a day • Neutering ↓ energy requirements by 24–33%

• Obesity: developmental orthopedic disease (large breed) • Thin: hypoglycemia (small breed)

Puppy and Kittens

3

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SECTION TWO: PREVENTATIVE CARE

Adult

Table 3.1 / General Life Stage Feeding Guidelines (Continued) Age

Diet

Feeding Method

Comments

Maintenance

• High-quality adult food • Homemade diets made from approved published recipes

• 2–3 measured feedings per day • See Skill Box 3.1 Daily Caloric requirement Worksheet, page 58.

• Obesity: diabetes, osteoarthritis, skin problems, surgical risk • Thin: hypoglycemia, hypothermia, muscle disorders

3

Pregnancy Canine

• Diet should gradually be changed during the last 3 weeks to a puppy growth diet to provide additional nutrients. • Avoid • Carbohydrate-free meat-type diets should be avoided during gestation and whelping to prevent hypoglycemia and ↑ neonate death.

• During the first 5 weeks, the feeding schedule should not change, and the dam should maintain her normal weight. • Weeks 6–9 • Frequency • Feed smaller, more frequent meals to accommodate the shrinking stomach size • Amount • ↑ 15% each week • By gestation, the dam’s weight should ↑ 15–25%.

• Obesity: ↓ ovulation, ↓ litter size, large neonates, dystocia • Thin: trouble conceiving, ↓ birth weights, ↑ neonate death

Feline

• High-quality diet intended for reproduction/lactation or growth

• Weeks 2–9 • Amount • ↑ Gradually to a total ↑ of 25–50% • By gestation, the queen’s weight should ↑ by about 40%.

• Obesity: large neonates, dystocia • Thin: trouble conceiving, abortion, ↓ birth weights, ↑ neonate death

Lactation Canine

• High-quality puppy growth food • Avoid • Low-calorie diets (e.g., weight-reducing diets)

• Feed free-choice • Daily energy requirements are approximately 3 times that of nonlactating adults. • Lactation peaks at 3–5 weeks postpartum and is maintained until 8 weeks postpartum. • The dam requires approximately 25% of her DER additional for each neonate.

• Obesity/thin: insufficient milk production

Feline

• High-quality diet intended for reproduction/lactation or growth

• Lactation peaks at 3–4 weeks postpartum • The queen requires 2–3 times her DER during lactation. See Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58.

• Obesity/thin: insufficient milk production

Geriatric

• High-quality adult food for healthy animals • Homemade diets made from approved published recipes • Changes in diet (e.g., protein, fat, phosphorous, sodium, fiber, vitamins, minerals) can be made based upon medical conditions.

• 2–3 measured feedings per day • See Skill Box 3.1 Daily Caloric Requirement Worksheet, page 58, on calculating the appropriate amount of food. • The caloric intake may need to be reduced to obtain the desired BCS. • Avoid placing feeding dishes in hard-to-reach places.

• Obesity: diabetes, osteoarthritis, skin problems, surgical risk • Thin: hypoglycemia, hypothermia, muscle disorders

CHAPTER 3 / NUTRITION

61

Table 3.2 / Body Condition Scoring System

The Body Condition Scoring System standardizes the interpretation of the overall physical appearance of the animal. It should be a basic part of every examination and should be noted in the record for future comparison. This technique can be easily and quickly taught to clients as part of weight management at home. The BCS can change by 1 value with a 10% change in body weight. 3

Canine

Body Condition Score 1: Very Thin Ribs: easily visible and felt with no cover Waist: severe waist Tail Base: lumbar vertebrae and pelvic bones are raised with no fat between the skin and bone Side View: severe abdominal tuck Overhead View: accentuated hourglass shape

2: Underweight Ribs: easily felt with minimal fat cover Waist: easily noted Tail Base: bones are raised with minimal fat between the skin and bone Side View: prominent abdominal tuck Overhead View: marked hourglass shape

3: Ideal Ribs: easily felt with slight fat cover Waist: observed behind ribs Tail Base: smooth contour but bones can be felt under a thin layer of fat Side View: abdominal tuck Overhead View: well-proportioned waist

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SECTION TWO: PREVENTATIVE CARE

Feline

Table 3.2 / Body Condition Scoring System (Continued) Canine

Body Condition Score

Feline

4: Overweight Ribs: difficult to feel with moderate fat cover Waist: poorly discernible Tail Base: some thickening but bones can be felt under a moderate layer of fat Side View: no abdominal tuck Overhead View: back is slightly broadened

3

5: Obese Ribs: difficult to feel under thick fat cover Waist: absent Tail Base: thickened and difficult to feel bones beneath prominent layer of fat Side View: fat hangs from the abdomen Overhead View: markedly broadened and prominent paralumbar fat deposits

CHAPTER 3 / NUTRITION

63

Table 3.3 / Disease Nutritional Requirements

3

Each disease or combination of diseases alters the nutritional requirements of a patient. Each patient should have a complete nutritional evaluation to ensure the type of diet and the feeding method are appropriate. The overall consideration regarding nutrition is to optimize BCS. Often it is more important to maintain a patient eating versus providing the exact nutritional requirements. For example, it is more important for a patient with CHF to consume enough food to prevent cachexia than it is to restrict sodium. It often requires a dedicated owner to cater to the changing desires of the patient along with providing the necessary nutritional requirements. It is beyond the scope of this book to provide specific alterations; please consult dedicated nutritional references and seek the advice of a credentialed veterinary nutritionist for specific nutritional alterations. Disease

Objective

Comments

Anemia

• Support RBC production.

• Nutritional evaluation: minerals (e.g., iron), protein, vitamins (e.g., B) • Iron deficiency is usually due to excessive loss (e.g., hemorrhage, GIT ulcers, and ectoparasitism) versus inadequate intake.

Bone Loss and Fracture Repair

• Ensure diet is properly balanced. • Ensure adequate energy and protein intake.

• Nutritional evaluation: energy, minerals (e.g., calcium, phosphorus), protein • Supplemental calcium must be absorbable and balanced with phosphorous intake.

Cardiac Disease

• • • •

Control or correct cachexia. Maintain BCS. Control sodium retention. Encourage eating.

• Nutritional evaluation: amino acids (e.g., taurine), carnitine, energy, minerals (e.g., chloride, magnesium, phosphorus, potassium, sodium), water • Sodium and chloride restriction is based on the degree of cardiac disease • Additional sources of sodium should be considered (e.g., softened water, treats, table scraps) when determining total sodium intake.

Constipation

• • • •

Normalize GIT motility. ↑ Water consumption ↑ Bulk or ↓ quantity Optimize BCS.

• • • • • • • •

Nutritional evaluation: fiber, water Feed a highly digestible diet. ↑ Fiber ≤5% per week until clinical signs resolve Additional fiber may be achieved through therapeutic veterinary diets or adding ≤10% fiber to regular diet (e.g., pumpkin, high-fiber cereal). Provide small, frequent meals. ↑ Exercise and prevent obesity. Encourage defecation (e.g., frequent walks, clean litter box). Check anus/rectum for causes of poor defecation habits, tenesmus, or dyschezia.

Degenerative Joint Disease

• ↓ Degenerative joint changes • Optimize BCS.

• Nutritional evaluation: fatty acids, vitamins (e.g., E) • ± Chondroprotectives

Dental Disease

• Prevent or correct periodontal disease. • Optimize oral health.

• Nutritional evaluation: carbohydrates, minerals (e.g., calcium, phosphorus), protein, vitamins (e.g., A, B, C, D), water • Food texture and composition may contribute to ↓ plaque accumulation.

Diabetes Mellitus

• Optimize BCS. • Minimize postprandial fluctuations in blood glucose. • Consistent feeding times and caloric intake

• Nutritional evaluation: energy, fat, fatty acids, fiber, minerals, protein, soluble carbohydrates, water • Avoid semimoist foods as they contain simple carbohydrates and may have a hyperglycemic effect. • Provide small, frequent meals and weigh animal frequently. • Changes in exercise and weight may necessitate altering the insulin dose.

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SECTION TWO: PREVENTATIVE CARE

Table 3.3 / Disease Nutritional Requirements (Continued) Disease

Objective

Comments

Exocrine Pancreatic Insufficiency (EPI)

• Correct malnutrition. • Reduce requirements for digestive enzymes. • ↑ Caloric intake/density • Optimize BCS.

• Nutritional evaluation: fat, fiber, vitamins (e.g., A, D, K, cobalamin, folate) • Avoid high-fiber diets. • Provide small, frequent meals.

Flatulence

• ↓ Intestinal gas production and bacterial fermentation of undigested food • ↓ Aerophagia

• • • •

Food Allergy

• Identification and avoidance of offending foods (protein) and/or food additives • Relieve clinical signs (e.g., otitis, pruritus, dermatitis, erythema, peripheral lymphadenopathy).

• Nutritional evaluation: food additives, protein, vasoactive or biogenic amines • An elimination diet is feed exclusively for 8–12 weeks consisting of 1–2 protein sources the patient has not be exposed to and void of food additives, vasoactive and biogenic amines, and excess protein. • Regardless of diet fed (e.g., commercial or home prepared), it must be nutritionally adequate for the patient’s life stage and condition. • Diet should be continued 2–3 weeks past glucocorticoid administration. • Canned food contains the least amount of additives. • Feeding dishes should be glass, ceramic, or stainless steel. • Outdoor pets should be confined to avoid dietary indiscretions. • Avoid all flavored medications, treats, table scraps, and vitamin supplements. • With the disappearance of clinical signs, begin feeding 1 eliminated food item back daily for 7 days, discontinue if relapse is noted or assume no allergy if no reactions are seen after 7 days.

Hepatic Disease

• Maintain body weight and BCS. • Promote hepatic regeneration. • ↑ Caloric intake/density

• Nutritional evaluation: amino acids (e.g., taurine), energy, fat, fiber, minerals (e.g., iron, potassium, zinc), protein, vitamins (e.g., C, E, K) • Feed a highly digestible diet. • Provide small, frequent meals while slowly ↑ amount fed over a few days.

Hepatic Lipidosis

• Correct anorexia and malnutrition. • ↑ Caloric intake/density

• Nutritional evaluation: carnitine, energy, fat, minerals (e.g., iron, potassium, zinc), protein, vitamins (e.g., C, E, K) • Recovery is directly related to early diagnosis and treatment via enteral or parenteral nutrition.

Hyperadrenocorticism

• Prevent or correct cachexia. • Optimize BCS.

• Nutritional evaluation: fat, fiber, minerals (e.g., chloride, sodium), protein, water • Feed a highly digestible diet.

Hyperthyroidism

• Correct cachexia. • Optimize BCS.

• Nutritional evaluation: energy, fat, minerals (e.g., calcium, chloride, iodine, iron, phosphorus, potassium, selenium, sodium), protein, water • Feed a highly digestible diet. • Poor absorption of many nutrients and ↑ metabolism

Hypoadrenocorticism

• Optimize BCS.

• Nutritional factors to evaluate: energy, minerals (e.g., chloride, potassium, sodium), protein, water • Feed a highly digestible diet.

3 Nutritional evaluation: carbohydrate, fiber, protein, variable per patient Feed a highly digestible diet. Provide small, frequent meals. Discourage gluttony; provide a noncompetitive environment or slow consumption via novel methods. • ↑ Exercise and ↓ stress

CHAPTER 3 / NUTRITION

65

Table 3.3 / Disease Nutritional Requirements (Continued) Disease

Objective

Comments

Hypothyroidism

• Optimize BCS.

• Nutritional evaluation: fat, energy, fiber, trace minerals

Inflammatory Bowel Disease

• ↓ Antigenic stimulation of the GIT • Provide GIT rest and normalize motility. • ↑ Water consumption

• Nutritional evaluation: energy, fat, fatty acids, fiber, minerals (e.g., potassium, zinc), protein, vitamins (e.g., thiamin, vitamin K) • Diets may consist of a highly digestible low-residue GIT diet, ↑ fiber, or an elimination diet (a “sacrificial” novel protein is fed initially while the GIT is healing and then replaced by a second novel protein or hydrolyzed protein diet long term).

Obesity

• ↓ Body weight and optimize BCS • Control caloric intake. • Prevent obesity-related diseases.

• Nutritional evaluation: carbohydrates, energy, fat, fiber, protein • Prevention is easier than treatment of obesity. • See Skill Box 3.2 Obesity Management, page 67.

Oncology

• Prevent or correct cancer cachexia. • ↑ Nutrient intake • Encourage eating.

• Nutritional evaluation: amino acids (e.g., arginine, glutamine, glycine, tyrosine, phenylalanine, methionine, asparagine), fat, fatty acids, carbohydrates, protein, vitamins (e.g., retinoids, vitamins C and E, beta-carotene) • Feed a highly digestible diet. • Nutritional intervention must begin early in disease to prevent cachexia.

Orthopedic Disease, Developmental

• ↓ Nutrition-related disease • Optimize BCS.

• Nutritional evaluation: energy, fat, minerals (e.g., calcium, copper, phosphorus, zinc), vitamins (e.g., A, C, D) • Overfeeding and extra vitamins (e.g., calcium) during rapid growth phase in large- and giant-breed dogs lead to skeletal disease. • Switching growing animals to an adult food should be avoided as nutritional factors may be inappropriately altered (e.g., calcium). • See Table 3.1 General Life Stage Feeding Guidelines, page 58.

Pancreatitis

• ↓ Pancreatic secretions • Provide pancreatic rest. • Optimize BCS.

• • • • •

Nutritional evaluation: fat, protein, water Feed a highly digestible diet. Enteral and/or parenteral feeding may be part of the initial treatment. Traditional low-fat, weight-reducing diets may be too calorie restrictive. Canine: NPO for 3–7 days, begin with small amounts of water, gradually add in a carbohydrate (e.g., rice) and then a protein source of ↑ bioavailability (e.g., cottage cheese, lean meat)

Protein Losing Enteropathy (PLE)

• Correct cachexia. • ↓ Enteric loss of plasma protein

• • • • •

Nutritional evaluation: carbohydrates, fat, fiber, protein Feed a highly digestible diet. Determining the underlying cause of PLE may alter nutrition. Monitor for protein malnutrition. Provide small, frequent meals.

Renal Disease

• Delay progression of renal failure. • ↓ Amount of nitrogenous waste (↓ azotemia) • Prevent malnutrition and optimize BCS. • ↑ Water consumption • Encourage eating.

• Nutritional evaluation: acid load, amino acids (e.g., arginine), energy, fat, fiber, minerals (e.g., chloride, phosphorus, potassium, sodium, protein, vitamins (e.g., A, B, D), water • Feed a highly digestible diet. • Avoid excess dietary protein in moderate to severe renal failure. • Protein recommendations: • Dogs: 2.0–2.2 g/kg/day • Cats: 3.3–3.5 g/kg/day • Monitor and control mineral imbalances (e.g., phosphorus, calcium). • Optimizing BCS is more important than restricting protein. • Sodium restriction should take place gradually over 2–4 weeks.

3

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SECTION TWO: PREVENTATIVE CARE

Table 3.3 / Disease Nutritional Requirements (Continued) Disease

Objective

Comments

Urolithiasis, Canine– Ammonium Urate

• Maintain alkaline urine (pH of 7.0–7.5). • Dissolution and prevention of uroliths • ↑ Water consumption and subsequent ↓ urine concentration

• Nutritional evaluation: protein, water • Dissolution on average take 4 weeks. • Meat-based diets tend to have ↑ purine; vegetable-based diets may be more suitable.

Calcium Oxalate

• Maintain alkaline urine (pH of 7.1–7.7). • Prevent uroliths. • ↑ Water consumption and subsequent ↓ urine concentration

• Nutritional evaluation: minerals (e.g., calcium, magnesium, sodium), oxalates, protein, vitamins (e.g., B6, C, D), water • Medical regimen dissolution is not possible for calcium oxalate stones, once formed.

Cystine

• Maintain alkaline urine (pH of 7.5). • Dissolution and prevention of uroliths • ↑ Water consumption and subsequent ↓ urine concentration

• Nutritional evaluation: protein, water • Dissolution can be possible with the addition of 2-MPG.

Struvite

• Maintain acidic urine (pH of 6.2–6.4). • Resolve underlying infection. • ↑ Water consumption and subsequent ↓ urine concentration

• Nutritional evaluation: minerals (e.g., magnesium, phosphorus), protein, water • Dissolution on average takes 3.5 months. • Avoid long-term feeding of dissolution diet due to ↓ protein and sodium.

• Maintain alkaline urine (pH of 6.6–6.8). • Prevent uroliths. • ↑ Water consumption and subsequent ↓ urine concentration

• Nutritional evaluation: fat, fiber, minerals (e.g., calcium, magnesium, sodium), oxalates, protein, vitamins (e.g., B6, C, D), water • Medical regimen dissolution is not possible for calcium oxalate stones, once formed.

• Maintain acidic urine (pH of 2% a week is thought to be detrimental to the patient’s health. • Treats should be 1,000 (canine)

↑ Cholangitis/cholangiohepatitis, hepatic disease/failure, hepatic lipidosis

Handling • Heparinized sample preferred • Centrifuge and pour off plasma immediately. Storage • Store on ice and assay within 1 hour. • Freeze immediately and assay within 2 days. Notes • Vein occlusion for an extended period or strenuous exercise; ↑ values • Antibiotics, enemas, lactulose, diphenhydramine, parenteral amino acids, narcotics, diuretics, or blood transfusions may alter laboratory results.

Amylase

Source • Major: pancreas • Minor: liver and small intestines Role • Breakdown of starches and glycogen in sugars Notes • ↑ values are not always indicative of severity of disease nor specific for pancreas

Canine • 300–1,500 units Feline • 500–1,500 units

↑ Pancreatitis, peritonitis, chronic renal failure, toxoplasmosis

Handling • Hemolysis; ↑ values • Lipemia; ↓ values • Do not use EDTA Storage • 7 days at 68° F • 1 month at 32°–39° F Notes • Corticosteroids; ± ↓ values • Saccharogenic method; ± false ↑ values (canine)

CHAPTER 4 / LABORATORY

77

4

Table 4.2 / Blood Chemistries (Continued) Chemistry

Definition

Normal Range

Anion Gap (AG)

Source • N/A Role • To differentiate causes of metabolic acidosis Notes • To calculate: (Na+ − K+) − (Cl− + HCO3−) = AG

Canine • 12–25 Feline • 13–25

Aspartate Aminotransferase (AST, SGOT)

Source • Major: hepatocytes • Minor: cardiac and skeletal muscles, kidneys, pancreas and erythrocytes Role • Amino acid metabolism Notes • Not liver-specific; ↑ values may indicate liver damage, strenuous exercise, IM injections • Tends to parallel ALT values when caused by hepatic disease

Canine • 16–60 U/L Feline • 26–43 U/L

↑ Cholangitis/cholangiohepatitis, congestive heart failure, diabetes mellitus, endocardiosis, feline dilated cardiomyopathy, feline hypertrophic cardiomyopathy, hepatic disease/ failure, hepatic lipidosis, hyperthyroidism, hypoadrenocorticism, peritonitis, toxoplasmosis

Handling • Hemolysis and lipemia; ↑ values Storage • 2 days at 68° F • 2 weeks at 32–39° F Notes • N/A

Bicarbonate (Venous TCO2)

Source • All cells Role • Aids in transport of CO2 from tissues to the lungs • Bicarbonate/carbonic acid buffer system Notes • 95% of total CO2 measured

Canine/Feline • 21–31 mEq/L

↓ Metabolic acidosis, acute renal failure

Handling • Chill in ice water to prevent alteration of acid–base composition. Storage • Do not freeze, as it results in hemolysis. Notes • N/A

Bilirubin

Source • Hemoglobin via liver processing Role • N/A Notes • Byproduct of erythrocyte degradation • Total bilirubin is composed of conjugated and unconjugated bilirubin. • Not liver specific

Canine/Feline • 0.0–0.5 mg/dL

↑ Cholangitis/cholangiohepatitis, hepatic disease/failure, hemobartonellosis, hemolytic anemia, hepatic lipidosis, hyperthyroidism, pancreatitis, peritonitis, toxoplasmosis

Handling • Lipemia; ↑ values Storage • Not stable when stored in the light or at 68° F • 2 weeks at 32–39° F in the dark Notes • Total bilirubin may ↓ by 50%/hr with direct exposure to sunlight or artificial light.

4

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SECTION THREE: DIAGNOSTIC SKILLS

Associated Conditions

Handling and Special Considerations Handling • Refer to N.a, K., Cl−, and HCO3− Storage • Refer to N.a, K., Cl−, and HCO3− Notes • Drugs used in combination may blunt the gap ↑.

Table 4.2 / Blood Chemistries (Continued) Chemistry

Definition

Normal Range

Associated Conditions

Handling and Special Considerations

Blood Urea Nitrogen (BUN, SUN)

Source • Amino acids via liver processing Role • N/A Notes • Byproduct of amino acid breakdown • 75% of the kidney must be nonfunctional before ↑ values are seen

Canine • 6–29 mg/dL Feline • 10–35 mg/dL

↑ Canine/feline dilated cardiomyopathy, congestive heart failure, cystic calculi, ehrlichiosis, endocardiosis, hepatic disease/failure, hypertension, hyperthyroidism, hypoadrenocorticism, mastitis, pancreatitis, pyelonephritis, renal failure, Rocky Mountain spotted fever ↓ Cholangitis/cholangiohepatitis, hepatic disease/failure, hepatic lipidosis, overhydration, dietary protein restriction

Handling • N/A Storage • 8 hours at 68° F • 10 days at 32–39° F Notes • 18-hour fast is recommended, because high-protein diets can cause ↑ values

Calcium

Source • Bones Role • Maintenance of neuromuscular excitability and tone • Inorganic ion transfer across cell membranes • Blood coagulation Notes • Hemoglobin and bilirubin; ↑ values with colorimetric test methods • Hypoalbuminemia; ↓ values

Canine/Feline • 8.0–12.0 mg/dL Danger level • ≤7.0 mg/dL or ≥16.0 mg/dL

↑ Hyperparathyroidism, hypoadrenocorticism, neoplasia, renal failure ↓ Dystocia, eclampsia, hypoparathyroidism, pancreatitis, protein losing enteropathy, renal failure

Handling • Hemolysis and contact with cork stoppers; ↓ values • Lipema; ↑ values • Citrate, oxalate, or EDTA anticoagulants; ↓ values Storage • 10 days at 68° F or 32–39° F Notes • N/A

Chloride

Source • Extracellular fluid Role • Acid-base balance • Maintenance of water distribution • Osmotic pressure in blood Notes • Hemoglobin and bilirubin; ↑ values with colorimetric test methods • Tends to parallel serum sodium

Canine • 100–115 mEq/L Feline • 117–128 mEq/L

↑ Metabolic acidosis ↓ Canine dilated cardiomyopathy, constipation, aggressive diuretics, severe emesis, Rocky Mountain spotted fever

Handling • Hemolysis and lipemia; ↓ values Storage • Stable if separated from blood cells Notes • Potassium bromide, acetazolamide, ammonium chloride, androgens, cholestyramine, lithium, demeclocycline and amphotericin; ↑ values

CHAPTER 4 / LABORATORY

4

79

Table 4.2 / Blood Chemistries (Continued) Chemistry

Definition

Normal Range

Associated Conditions

Handling and Special Considerations

Cholesterol

Source • Major: hepatocytes • Minor: adrenal cortex, ovaries, testes and intestinal epithelium Role • Steroid hormone production Notes • Helpful in screening for hypothyroidism and Cushing’s disease

Canine 150–275 mg/dL Feline 75–175 mg/dL

↑ Diabetes mellitus, hepatic disease, failure, hyperadrenocorticism, hypertension, hypoadrenocorticism, hypothyroidism, pancreatitis, Rocky Mountain spotted fever ↓ Drugs, exocrine pancreatic insufficiency, hepatic disease/failure, protein losing enteropathy

Handling • Hemolysis, fluoride, and oxalate; ± ↑ values, depending on testing method Storage • Very stable at 68° F if separated from blood cells Notes • Corticosteroids; ± ↑ values

Creatine Kinase (CK)

Source • Cardiac and skeletal muscle and brain tissue Role • Enzyme that cleaves creatine in muscle for energy utilization Notes • Peaks 6–12 hours after muscle injury and returns to normal in 24–48 hours unless damage is ongoing • Very specific, but almost too sensitive • Only large ↑ are clinically significant (≥10,000 U/L) or chronic elevations (≥2,000 U/L) indicating ongoing muscle damage

Canine/Feline • 50–300 U/L

↑ Encephalitis, feline dilated cardiomyopathy, feline hypertrophic cardiomyopathy, hypothyroidism, myasthenia gravis, polymyositis

Handling • Severe hemolysis, icterus, IM injections; ↑ values • EDTA, citrate, fluoride, exposure to sunlight, and delayed analysis; ↓ values Storage • Not stable, do not freeze; analyze as soon as possible Notes • Exercise, recumbency, IM injections; ± ↑ values

Creatinine

Source • Skeletal muscle Role • N/A Notes • Byproduct of creatine degradation • 75% of the kidney must be nonfunctional before ↑ values are seen

Canine • 0.6–1.6 mg/dL Feline • 1.0–2.0 mg/dL

↑ Canine/feline dilated cardiomyopathy, congestive heart failure, drugs, ehrlichiosis, endocardiosis, hypertension, hyperthyroidism, hypoadrenocorticism, severe muscle damage, pancreatitis, pyelonephritis, renal failure, Rocky Mountain spotted fever, toxoplasmosis

Handling • N/A Storage • 1 week at 86–98.6° F Notes • Exercise, active muscle wasting, and meal containing meat; mild ↑ values

Fibrinogen

Source • Hepatocytes Role • Clot formation Notes • No fibrinogen found in serum, because it is removed from the plasma by the clotting process • Used mostly in cattle and horses

Canine • 100–245 mg/dL Feline • 110–370 mg/dL

↑ Cholangitis/cholangiohepatitis, hepatic failure, severe inflammation ↓ DIC, liver failure/end stage

Handling • Heparin; ↓ values Storage • Several days at 68° F • Several weeks at 32–39° F Notes • N/A

4

80

SECTION THREE: DIAGNOSTIC SKILLS

Table 4.2 / Blood Chemistries (Continued) Chemistry

Definition

Normal Range

Associated Conditions

Handling and Special Considerations

Gamma Glutamyltranspeptidase (GGT)

Source • Major: hepatocytes • Minor: kidneys, pancreas, intestines, and muscle cells Role • Enzyme: function unknown Notes • Values typically parallel ↑ in ALP; can be less influenced by secondary nonhepatic conditions or enzymeinducing drugs • Slightly more sensitive and specific for feline hepatic disease than canine

Canine • 2–10 U/L Feline • 1–8 U/L

↑ Anterior uveitis, brucellosis, deep pyoderma, ehrlichiosis, feline immunodeficiency virus, hepatic disease/failure, meningitis, pleural effusion, pyometra

Handling • N/A Storage • 2 days at 68° F • 1 week at 32–39° F Notes • Corticosteroids or anticonvulsant therapy; ± ↑ values

Globulins

Source • α-Globulins: hepatocytes • β-Globulins: hepatocytes • γ-Globulins: plasma cells Role • α- and β-globulins: transport and bind proteins • γ-Globulins: antibody Notes • Total serum globulin concentration = total serum protein concentration − albumin concentration

Canine • 2.7–4.4 g/dL Feline • 2.6–5.1 g/dL

↑ Diabetes mellitus, hepatic failure, hyperadrenocorticism, hypertension, hyperthyroidism, immune mediated disease, neoplasia, pancreatitis, polyconal gammopathies, renal failure, acute ↓ Acute blood loss, heartworm disease, protein losing enteropathy/ nephropathy

Handling • Hemolysis and lipemia; ↑ values Storage • See Albumin and Total Protein Notes • Dehydration; ↑ values • Neonatal animals are 60–80% of adult values; ↓ values

Glucose

Source • Dietary intake and gluconeogenesis or glycogenolysis by the liver Role • Cellular energy Notes • Indicator of carbohydrate metabolism or endocrine function of the pancreas

Canine • 65–130 mg/dL Feline • 70–125 mg/dL Danger level • ≤60 mg/dL

↑ Diabetes mellitus, hypertension, hyperthyroidism, hyperadrenal, hypoparathyroidism, pyelonephritis, renal failure ↓ Dystocia, hepatic failure, failure, hypoadrenocorticism, insulinoma, neoplasia, peritonitis, sepsis

Handling • GTT at 6–10mg/mL of blood as a glucose preservative Storage • Separate from blood cells immediately (1,000 mg/dL

↑ Diabetes mellitus, hyperlipidemia, hypothyroidism, pancreatitis, postprandial ↓ Lymphangectasia, protein-losing enteropathy

Handling ↑ Lipemia; ↑ values Storage • N/A Notes • 12-hour fast recommended

Magnesium

Source • Bones Role • Activator of enzyme systems and involved in production and decomposition of acetylcholine Notes • ↑ Bilirubin can cause ↑ values of magnesium

Canine • 1.8–2.4 mg/dL Feline • 2.0–2.5 mg/dL Danger Level • 10.0 mg/dL

↑ Hypoadrenocorticism, renal failure ↓ Metabolic conditions

Handling • Hemolysis and metal containers; ↑ values • Only heparin anticoagulants should be used. Storage • Samples are very stable. Notes • N/A

4

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SECTION THREE: DIAGNOSTIC SKILLS

Table 4.2 / Blood Chemistries (Continued) Chemistry

Definition

Normal Range

Associated Conditions

Handling and Special Considerations

Potassium

Source • Intracellular fluid Role • Muscular function, respiration, cardiac function, nerve impulse transmission, and carbohydrate metabolism Notes • N/A

Canine • 4.0–5.7 mEq/L Feline • 4.0–5.8 mEq/L Danger level • ≤2.5 or ≥7.5 mEq/L

↑ Diabetes mellitus, hypoadrenocorticism, massive tissue trauma, acute renal failure, urethral obstruction ↓ Canine/feline dilated cardiomyopathy, congestive heart failure, constipation, diabetes mellitus, gastrointestinal losses, hepatic lipidosis, peritonitis, renal failure

Handling • Hemolysis (esp. Akitas) and refrigeration of an nonseparated sample; ↑ value Storage • Do not freeze nonseparated samples. • Stability is not known. Notes • Plasma is the preferred sample.

Sodium

Source • Extracellular fluid Role • Water distribution, body fluid osmotic pressure maintenance, and pH balance Notes • “Pseudohyponatremia” seen in cases of hyperlipidemia or severe hyperproteinemia

Canine • 140–158 mEq/L Feline • 145–160 mEq/L

↑ Dehydration, heat stroke ↓ Canine dilated cardiomyopathy, congestive heart failure, gastrointestinal losses, hypoadrenocorticism, chronic renal failure, Rocky Mountain spotted fever

Handling • Heparin; ↑ value • Hemolysis; ↓ value Storage • Stability is not known. Notes • Diuretic drugs; ↓ value

Total Protein (TP)

Source • See Albumin and Globulins Role • Oncotic blood pressure, transport mechanism, and immunity Notes • Composed of albumin and globulins

Canine • 5.4–7.6 g/dL Feline • 6.0–8.1 g/dL

↑ Dehydration, gammopathy ↓ Acute blood loss, overhydrated

Handling • Severe hemolysis and sample dehydration; ↑ value Storage • Keep sample covered to prevent dehydration. • Stability is not known. Notes • See Albumin and Globulins

BONE MARROW EVALUATION Bone marrow evaluations can be used to diagnose, to stage certain neoplasias, or to monitor conditions and the body’s response to treatments. The collection and preservation of bone marrow samples are critical to producing diagnostic slides. Properly collected and prepared slides are often evaluated in-house for a preliminary diagnosis before receiving a confirmation from a cytopathologist.

Bone Marrow Collection, Handling, Storage, and Transport Tips Collection • Bone marrow samples degenerate rapidly after collection: neutrophils are the first to take on morphologic changes resembling neoplasia. • Samples should be obtained and prepared within 30 minutes of an animal’s death. CHAPTER 4 / LABORATORY

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4

Skill Box 4.1 / Supplies for Bone Marrow Collection • Surgical preparation materials

• Place bone marrow aspirate immediately into an EDTA lavender top tube if slides cannot be made immediately.

• Sterile surgical supplies (e.g., gloves, drapes)

• Smears must be made within 30 seconds if an EDTA/isotonic solution is not used, to avoid clotting and cell morphology distortion.

• Analgesic/anesthetic drugs

• Allow the slides to air dry. • Samples must be stained as soon as possible to retain accurate morphology.

3

• 16–18 gauge, 1–1 /4-inch bone marrow biopsy needle

4

Handling

• Scalpel blade

• Staining typically requires 2 times the usual stain contact time to reach adequate staining.

• 12 or 20 mL syringe • Clean microscope slides • 10–20 mL syringe with 2–3% EDTA/isotonic fluid solution Tip: Injecting 0.35 mL isotonic solution into a 7-mL EDTA blood collection tube produces 0.42 mL of 2.5% EDTA/isotonic fluid solution.

Skill Box 4.2 / Smear Techniques Technique

Definition/Uses

Procedure

General Information

Smear Without EDTA

• Samples collected using a clean, dry syringe

1. Hold a slide at a 45–70° angle. 2. Drip the marrow sample down the tilted slide, allowing the marrow flecks to adhere to the slide. 3. With the first slide laying flat, place a second slide on top, allow the drop to spread, and gently pull each slide horizontally in opposite directions. 4. Slides are air-dried and then stained.

• Sample must be smeared within 30 seconds of collection.

Smear With EDTA

• Samples collected using an EDTA/ isotonic solution–filled syringe

1. Sample collected into an EDTA/isotonic solution syringe is expelled onto a Petri dish. 2. Tilt the Petri dish to allow the fluid to drain to the bottom and the marrow flecks to remain adhered to the dish. 3. Using a PCV tube, collect a marrow fleck/spicule and gently place it on a glass slide. 4. Place a coverslip at a 45° angle on the slide so that the corner of the coverslip hangs off the slide. 5. Pull the corner of the coverslip to make a smear of the marrow fleck. 6. Slides are air-dried and then stained.

• Sample must be smeared within a few minutes of collection.

Note: Make some slides using no pressure and some using gentle digital pressure placed on the coverslip.

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SECTION THREE: DIAGNOSTIC SKILLS

1. Prepare a slide with stain.

Storage

2. Scan the slide, using ×4 magnification.

• Slides need to be completely dry before placing in a slide holder.

a. b. c. d.

Transport • Padding should be placed around both sides of the slide holder to prevent breakage (e.g., bubble wrap, padded envelopes). • Do not mail slides with bottles containing formalin, because the fumes may alter the staining capabilities of the slides.

Verify adequate staining. Verify proper slide preparation. Determine the cellularity. Determine the quantity and maturation of megakaryocytes.

3. Examine the slide, using ×10 magnification. a. Cell size b. Cell type

Evaluation

4

4. Examine the slide, using ×40 magnification.

An air-dried slide should quickly be evaluated with new methylene blue to verify the presence of marrow elements (e.g., megakaryocytes) and its diagnostic quality. If the slide is not adequate, further samples should be taken. Once quality slides are available, a stepwise approach should be taken to ensure a thorough evaluation is completed.

a. Chromatin pattern b. Nucleoli 5. Examine the slide, using oil immersion magnification. a. Myeloid:erythroid ratio

Table 4.3 / Bone Marrow Evaluation Definition

Examination

Classification

Cellularity

Proportion of cells compared to fat cells

Low power (×4–10)

Proportion • Normocellular: 30–70% • Hypercellular: >50–70% • Hypocellular: 50%

Erythrocytes

Quantity, proportions, and morphology

Low and high power (×10–100)

Quantity • Rubricyte: 60–70% • Metarubricyte: 30–35% • Prorubricyte: 2% • Rubriblast: 1 : 1

Organisms

Identification

High power (×100)

• Microorganisms: Histoplasma capsulatum, Toxoplasma gondii, Cytauxzoon felis, Erlichia sp. • Parasites: Mycoplasma sp., Babesia sp.

Note: Lymphocytes, plasma cells, monocytes, macrophage, and iron storage can also be evaluated.

Table 4.4 / Cell Type Identification (See Figure 4.1, 4.2, and 4.3, CP-3) Cell Type

Erthyrocytes

4

Definition

86

Appearance

Rubriblast

• • • •

1–2 Blue nucleoli Large, round, dark purple nucleus with smooth edges Fine granular, linear chromatin Distinct blue tint

Prorubricyte

• • • •

Smaller than rubriblasts Round nucleus with smooth edges Coarse and thickened chromatin Reddish tinge

Rubricyte

• • • •

Smaller than prorubricyte Dark clumps of coarse chromatin that begin to disappear Disappearing nucleoli Redder

Metarubricyte

• Larger than a mature RBC • Very dark, pyknotic nucleus • Chromatin and nucleoli are gone

Reticulocyte

• • • •

SECTION THREE: DIAGNOSTIC SKILLS

Large Nonnucleated Basophilic stippling when stained Residual, nonfunctional RNA

Table 4.4 / Cell Type Identification (See Color Plates 4.1, 4.2, and 4.3) (Continued) Cell Type Myeloblast

• • • • •

Large Nongranular, blue–pink cytoplasm Round to oval, red nucleus Chromatin with stippled pattern 1–2 pale blue nucleoli

Progranulocyte/Promyelocyte

• • • •

↑ Cytoplasm with small, pink granules Dark nucleus Chromatin is dark and lacy in pattern ± Nucleoli

Myelocyte

• • • •

Metamyelocyte

• Indented or U-shaped nucleus • Cytoplasm stains light blue • Can be confused with monocytes of peripheral blood

Band

• U-shaped nucleus with smooth edges • ± Chromatin clumps present • Cytoplasm stains light blue

Megakaryoblast

• Not commonly distinguished in bone marrow samples because of size and number present • 2 reddish nuclei • Small amount of basophilic cytoplasm

Promegakaryoblast

• Dividing nuclei • Deep blue cytoplasm • 2–4 Nucleoli

Megakaryocyte

• Extremely large • Abundant, deep blue to pale blue granular cytoplasm • >4 Nucleoli

Granulocyte Platelet

Appearance

4

Oval nucleus Chromatin is dense with a coarse pattern Cytoplasm stains gray–blue Granules take on stain • Eosinophil—red granules • Canine: pleomorphic • Feline: rod-shaped • Basophil—blue granules • Canine: round, red–purple, and few to many • Feline: oval, lavender, and fill cytoplasm • Can be confused with monocytes of peripheral blood

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Interpretation

4

Once a slide has been evaluated, the results are interpreted in conjunction with the results of the complete blood count (CBC). Interpretation may lead to a definitive diagnosis or be just 1 more step in the diagnostic path. Depending on the findings, additional tests may be indicated or an initial treatment plan may be established. Even though the preliminary diagnosis can be made by the veterinarian, it is recommended that these slides be sent to a cytology laboratory for confirmation and staging by a board-certified clinical pathologist/hematologist.

cinoma), the stage of disease, and its prognosis. Although the final diagnosis must lie in the hands of the veterinarian, the technician may make crucial evaluations and interpretations of the slide material, aiding the veterinarian in the diagnosis.

Cytology Collection, Handling, Storage, and Transport Tips Collection • Multiple collection attempts at multiple sites from the lesion should be made to ensure a representative sample. • Adequate pressure must be used with fine-needle aspiration (FNA) to ensure retrieval of cells.

CYTOLOGY Cytology is performed in a clinical setting on a day-to-day basis. A technician well trained in cytology can quickly and easily make preliminary findings. These findings may aid in the distinction in the type of cell (e.g., adenocar-

• Excessive negative syringe pressure or prolonged aspiration often leads to blood contamination and nondiagnostic slides. • Several slides should be made to allow different staining techniques.

Skill Box 4.3 / Collection Techniques Technique

Uses

Procedure

Comments

Imprints

• External lesions or fresh tissue samples from a surgical biopsy or necropsy

1. Blot the lesion or area to be imprinted with a clean, dry gauze. 2. Touch the lesion against a clean glass slide to make an imprint. • Can repeat several times on 1 slide. • Imprint ulcers before and after cleaning.

• Typically collects the fewest number of cells with the greatest amount of contamination

Scrapings

• External lesions or tissues from surgical biopsy or necropsy

1. Clean lesion and blot dry. 2. Hold scalpel perpendicular to lesion. 3. Pull the blade toward oneself several times in a scraping motion. 4. Transfer the material to the middle of a glass slide with the scalpel blade and smear.

• Collects a large number of cells and possibly a large amount of bacterial contamination and inflammation

Swabs

• Fistulous tracts and vaginal collections

1. Moisten a sterile swab with saline. 2. Gently roll the swab against the inside wall of the tract or vagina. 3. Gently roll the swab across a slide to transfer material in a thin smear.

• Only alternative for tract-like lesions • ↑ Cell damage with rough or improper handling

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Skill Box 4.3 / Collection Techniques (Continued) Technique

Fine Needle Biopsya

Aspirate

a

Nonaspirate

Uses

Procedure

Comments

• Lesions

1. Isolate and firmly hold the tumor. 2. Insert the needle into the tumor and apply strong negative pressure by pulling the plunger 3/4 of the way back and release pressure. 3. Redirect the needle to a different part of the tumor and again apply pressure; continue this several times in different locations. 4. Quickly smear the contents, using 1 of the smear techniques. (See Skill Box 4.5 Smear Techniques, page 90.) • If the tumor is large enough, negative pressure may be maintained while the needle is being redirected.

• Avoids superficial contamination, but with ↑ contamination of tissues surrounding the tumor during aspiration • ↑ Blood contamination with certain types of tumors • Allows for collection from multiple locations within the lesion

1. Isolate and firmly hold the tumor. 2. Insert the needle only into the tumor and rapidly move the needle up and down while maintaining the same track. 3. Remove the needle and attach an air-filled syringe and quickly expel the contents onto a clean glass slide. 4. Smear the contents, using 1 of the smear techniques. (See Skill Box 4.5 Smear Techniques, page 90.)

• Avoids superficial contamination, but with ↑ contamination of tissues surrounding the tumor during aspiration • Enough material collected for only 1 smear, which may reduce diagnostic yield

• Any mass or solid lesion that is of large enough size to isolate • Ultrasound-guided biopsy of deep tissues • Highly vascular lesions

Fine needle biopsy to the center of a mass typically yields necrotic debris and inflammatory cells, peripheral locations may produce the best results. Difficult in small masses ≤10 mm.

Skill Box 4.4 / FNB Needle and Syringe Selection • The softer the tissue being aspirated, the smaller are the gauge of needle and syringe. • Do not use needles larger than 21 gauge, because they produce core biopsies and have a greater likelihood of blood contamination. • 12-mL syringes are a safe bet for all tumors.

Handling • The material obtained must be prepared and smeared on a slide immediately to avoid drying, clumping, and clotting. • Do not allow the smear to reach the edges of the slide if possible. • Rapidly dry the slide after smearing by waving in the air or using a blow dryer. • Slides should be marked as to which side is the top by using the patient’s information. • 2–3 air-dried unstained slides and 2–3 air-dried stained slides should be prepared when sending to the laboratory. The stained slides are a precaution for those cells that do not hold up well unstained for extended periods. • Fluid samples should be sent with prepared slides if possible. CHAPTER 4 / LABORATORY

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4

Skill Box 4.5 / Smear Techniques The most common error in cytology is sample handling by the laboratory technician. An improperly prepared slide may contain ruptured cells or areas too thick to read, or the sample may dry before it is smeared. All of these errors may lead to improper evaluation, but they can be remedied by proper technique and care on the part of the laboratory technician.

4

Technique

Definition/Uses

Procedure

Blood Smear Technique

• Produces a thin layer of fluid material across the slide • Fluid samples

1. Expel the aspirate material onto a glass slide. 2. Place the second glass slide at a 30–40° angle to the first slide in front of the material. 3. Pull the second slide back into the material and then gently, but swiftly, push across to the end of the first slide. • Rest the “smearing” slide against a fingertip to push across allows a gentle and smooth movement. • The end of the smear should have a feathered edge and not run off the edge of the slide.

Squash Preparation

• Produces well-smeared slides • Thicker samples (e.g., bone marrow aspirates)

1. Expel the aspirate material onto a glass slide. 2. Place a second glass slide on top of the material at a right angle. 3. Without applying any downward pressure, quickly and smoothly slide the top slide across the bottom slide to smear the material.

Squash-Modified Preparation

• Produces well-smeared slides with a ↓ tendency for cell rupture • Thicker samples (e.g., bone marrow aspirates)

1. Follow steps 1 and 2 above. 2. Rotate the top slide 45° and then lift up.

Combination Technique

• A combination using the squash preparation and the blood smear technique • Any sample

1. Expel the aspirate material onto a glass slide. 2. Mentally divide the material into 3 sections and do a blood smear technique on one third of the slide and a squash preparation on the opposite third.

Starfish Preparation

• Prevents destruction of fragile cells • Any sample

1. Expel the aspirate material onto a glass slide. 2. Using the tip of the needle, spread the material out into the shape of a starfish.

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SECTION THREE: DIAGNOSTIC SKILLS

Storage • Slides need to be completely dry before placing in a slide holder. Transport • Padding should be placed around both sides of the slide holder to prevent breakage (e.g., bubble wrap, padded envelopes). • Do not mail slides with bottles containing formalin, because the fumes may alter the staining capabilities of the slides. • Protect the slides from moisture as the sample may become distorted.

Evaluation Once each slide has been properly collected and prepared, it is often evaluated in the clinic for a preliminary diagnosis. The technician is an integral part of this procedure by evaluating the slide and noting any alterations. The DVM then confirms the slide contents and makes a preliminary diagnosis. The slide is sent to a reference laboratory for official diagnosis. 1. Prepare a slide with stain. 2. Scan the entire slide using ×4 magnification. a. Verify adequate staining. b. Check for staining features and artifacts.

c. Check for overall cellularity and localized areas of cellularity. d. Check for crystals, foreign bodies, parasites, and fungal hyphae. 3. Examine the slide, using ×10 magnification. a. Cell size b. Cell type c. Cellularity 4. Examine the slide, using ×40 magnification. a. Chromatin pattern b. Nucleoli

4

5. Examine the slide, using oil immersion magnification. a. Cell inclusions b. Cell organisms c. Mitotic figures Tip: Placing a drop of immersion oil on a prepared slide (excluding a wet mount) covered by a coverslip enhances the clarity of the slide contents. To increase magnification to ×100, another drop of immersion oil can be placed on top of the coverslip and examined. To save the slide for later evaluation, the coverslip can be gently slid off horizontally to avoid damaging the slide’s contents.

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Table 4.5 / Cytologic Criteria of Malignancy

Any slide showing 1 or a combination of the following cellular changes should be carefully reviewed for potential malignancy. A cytology laboratory should be consulted for clarification if needed. Nuclear characteristics have proven to be the most reliable source of determining malignancy. However, all aspects of the cells should be evaluated. Some types of malignant cells do not routinely show any of the following characteristics; therefore, all other aspects of the complete workup should be viewed simultaneously.

4

Cytologic Characteristics

Appearance

Tumor Cell Types

Nuclear

• • • • • •

Anisokaryosis Macrokaryosis Variation in nuclear : cytoplasmic ratio Coarse chromatin pattern that clumps Irregular nuclear pattern Abnormal size, shape, and appearance of nucleoli • Irregular nuclear membrane

Epithelial • Round nucleus with a smooth to slightly coarse chromatin pattern and usually centrally located • 1 or more nucleoli Mesenchymal • Oval nucleus and centrally located Round cell • Centrally or eccentrically located

Cytoplasmic

• Vascuolization • Variable amount of cytoplasm from cell to cell • Basophilia with Wright’s stain • Abnormal cytoplasmic boundaries

Epithelial • ↑ Cytoplasm with secretory products or vacuolated Mesenchymal • Abnormal cytoplasmic boundaries and extensions • Moderate amount Round cell • Well-defined cytoplasmic boundaries • Variable amount, granularity, and vacuolization

Structural

• Anisocytosis • Macrocytosis • Pleomorphism

Epithelial • Large to very large cells • Round to oval to caudate cells, easily exfoliating into sheets, clusters, or clumps Mesenchymal • Small to medium cells • Spindle-shaped cells hard to exfoliate • Individual cells or in disorganized clusters Round cell • Small to medium cells • Round to oval cells; easy to exfoliate individual cells

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SECTION THREE: DIAGNOSTIC SKILLS

Table 4.5 / Cytologic Criteria of Malignancy (Continued)

4

Figure 4.4 Cytologic criteria of malignancy. Note: Courtesy of Dina A. Andrews, DVM, Ph.D, DipACVP.

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Table 4.6 / Specific Tumor Cells

The following chart gives a general description of common tumor types. Multiple variations can be seen because of location, duration, and malignancy. Each cell should be evaluated in lieu of the rest of the slide and the general findings of the animal. The diagnosis of a particular condition must be made by the veterinarian. Tumor Type

Epithelial Mesenchymal

Basophilic cytoplasm with ± vacuoles with secretory products Variable nuclear size and nuclear : cytoplasm ratio Nuclei often eccentrically displaced to the periphery of the cells Round to oval cells appearing in clusters Variable nucleolar shape and number

Mammary Adenocarcinoma

• • • • •

Perianal Adenoma

• Hepatoid appearing in clumps • Round to oval nuclei with 1–2 nucleoli • Abundant, foamy, and gray to tan cytoplasm with ± granules

Sebaceous Gland Tumor

• • • •

Squamous Cell Carcinoma

• Basophilic cytoplasm to abundant, pale cytoplasm • Large nuclei with clumped chromatin • Variable nuclear : cytoplasm ratio

Lipoma

• Large cells distended with fat or lacy, collapsed cells

Osteosarcoma

• Variably sized nucleus with clumped chromatin • Spindle-shaped • Abundant, foamy basophilic cytoplasm

Soft Tissue Sarcoma

• Anisocytosis or spindle shaped • Dark blue cytoplasm with ± vacuoles and pink granules • Variable number and size of nucleoli

4

94

Appearance

SECTION THREE: DIAGNOSTIC SKILLS

Large cell Nucleus with a slightly coarse chromatin pattern ↑ Nuclear : cytoplasm ratio ± Basophilic and foamy cytoplasm

Table 4.6 / Specific Tumor Cells (continued)

Round Cell Tumor

Tumor Type

Appearance

Histiocytoma • Color Plate 4.5, CP-4

• • • • •

Anisocytosis Poikilocytosis Variable amount of pale blue cytoplasm ↑ Nuclear:cytoplasm ratio Round, oval, or irregularly shaped nuclei with lacy or finely stippled chromatin pattern

Lymphoma • Color Plate 4.6, CP-4

• • • •

Dense nuclear margins with basophilic cytoplasm ↑ Nuclear:cytoplasm ratio Granular chromatin ≥1 Nucleolus

Mast Cell Tumors • Color Plate 4.7, CP-4

• • • •

Anisocytosis Round to oval nuclei, stain palely Fine to coarse, blue-black to reddish-purple granules within cytoplasm Variable nuclear:cytoplasm ratio depending on differentiation and grade

Melanoma

• Green-black to brown granules that are irregular in shape and size in cytoplasm • Poikilocytosis

Plasma Cell Tumor

• • • •

Interpretation Once a slide has been evaluated, the results should confirm an inflammatory and/or neoplastic process. The distinction of inflammation alone often will enable the veterinarian to determine an initial protocol and treatment plan.

4

Oval to round cells with coarse, clumped chromatin 1 small nucleolus ± Basophilic cytoplasm Nonstaining Golgi apparatus eccentrically placed

If the slide is found to have neoplastic cells, they are then reviewed against the criteria of malignancy. A preliminary diagnosis on cell type, associated disease, and malignancy can be made by the veterinarian. Often, the results are sent to a cytology laboratory for confirmation and staging.

CHAPTER 4 / LABORATORY

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Table 4.7 / Fecal Cytology

Appearance

Clostridium sp. • Color Plate 4.8, CP-4

• • • •

Giardia • Color Plate 4.9, CP-5

Trophozoites • Pear-shaped with a concave ventral surface • Two outlined nuclei resembling eyes along with a nose and mouth, which are axonemes and median bodies • Forward or “falling leaf” motility • Size: 6–10 μm Cysts • Crescent-shaped indentation when collapsing in fecal float solution • Nuclei, cyst wall, and axonemes seen • Size: 11–13 μm

Curved or Spiral Bacteria

Organism

Yeast

4

Fecal cytology is an important diagnostic tool for identifying inflammatory cells and potentially pathogenic organisms of the GIT. It is indicated in diarrheic animals, either acute or chronic. The first step is to assess the presence and quantity of bacteria. One predominant bacteria may indicate it as an pathogenic organism and a bacterial culture should be pursued. Some conditions may have more than 1 predominant bacteria (e.g., malabsorption, maldigestion). The presence of small numbers of epithelial cells may be found in normal animals. However, the presence of neutrophils or eosinophils may be indicative of inflammatory disease (e.g., Salmonella, Campylobacter sp., eosinophilic colitis). Fecal cytology may also reveal protozoal (e.g., Giardia) or fungal (e.g., Histoplasma sp.) organisms. Fecal cytology is set up in 1 of 2 ways: wet prep or dry prep. See Skill Box 4.16 Endoparasite Examination Methods page 134, for further information.

96

Large, gram-positive rods More easily recognized in the sporulated form “Safety pin” appearance, which represents a nonstaining spore within the sporangium (the body of the cell) >5 per ×100 field may indicate overgrowth

Campylobacter • Color Plate 4.10, CP-5

• • • • •

Treponeme and Spirillum Type (true spirochetes) • Color Plate 4.11, CP-5

• Gram-negative • Stiff corkscrew helical rods with tight spirals • Corkscrewing motility

Brachyspira

• Looser, sinusoid, thin spirals • Rapid, nematode-like movement; when attached to shed epithelial cells in large numbers resemble flagella

Trichomonas sp.

• Single nucleus and undulating membrane • Rolling and erratic motility, flexing axostyle visible, jerky movement • Can be confused with Giardia (feline; diarrheic)

Candida-like • Color Plate 4.12, CP-5

• Rarely internal structures; smaller than Giarda cysts

Cyniclomyes (Sarrharomycopsis)

• Large elongated yeast with bipolar inclusions; sometimes see branching

SECTION THREE: DIAGNOSTIC SKILLS

Gram-negative Tiny, curved, gram-negative rods (not tightly spiraled) Two attached together as a “seagull” or “W” shape “Swarm of bees”: rapid and darting motility Size: 1.5–5 μm

Vaginal Cytology Vaginal cytology is used in evaluating an animal’s stage of estrus cycle. Because of the constant changing of cellular structures during the estrus

cycle, the evaluation of vaginal cells should be done every few days and in conjunction with a thorough medical history and examination (e.g., multiple, sequential samples increase accuracy of estrus stage estimation).

Table 4.8 / Classifying Vaginal Cells

Noncornified Squamous Epithelial Cells

Appearance

Parabasal cells

• Small round cells with a small amount of cytoplasm • Round, distinct nuclei • Uniform in size and shape

Intermediate cells

• Large round cells with a large amount of cytoplasm • Round nuclei

Superficial Intermediate cells

• ↑ Cytoplasm that is irregular, folded, and angular • Smaller nuclei, pyknotic

Cornified Squamous Epithelial Cells

Vaginal Cells

4

Superficial cells

• Large cells • ↑ Cytoplasm, folded and angular • Distinct edges As the cell ages • ± Nucleus (nucleated with young cells and anuclear with older/advanced cells) and vacuoles

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Table 4.9 / Staging the Estrus Cycle Estrus Stage

Definition

Cell Appearance

Anestrus

• No physical changes • Does not attract or accept males • Duration: 1,000 μg/dL

• Fast for 12 hours and give enemas to clear lower bowel • Obtain baseline sample • Give ammonium chloride at 0.1 g/kg (max of 3 g) • Orally dissolved in 20– 50 mL water and given by stomach tube • Rectally as a 5% solution • Orally as a powder in gelatin capsules • Draw heparinized blood samples at 30 to 45 (gelatin capsules) minutes post

Handling/Storage • Centrifuged immediately, pour plasma off and analyze within 1–3 hours or freeze at −68° F Notes • Not recommended for felines • Do not perform if resting ammonia levels are already ↑, because it may cause hepatic encephalopathy. • Oral administration may cause regurgitation. • Vomiting may occur but does not invalidate test. • Venous occlusion, vigorous activity before, and muscle exertion during restraint; ↑ values • 3–10-fold ↑ indicates portosystemic shunts

A dysfunctional hepatobiliary system allows ↑ levels of bile acids to be found systemically. This test is a very sensitive function test of hepatic and biliary abnormalities.

Canine/Feline Fasted: • 35), and ↓ specific gravity: 20 μg/dL with endogenous HAC, blunted or no response iatrogenic HAC • Low dose dexamethasone suppression test: to confirm diagnosis, >1 μg/dL during 8 hour test • High dose dexamethasone suppression test: to differentiate type, 1.5 μg/dL with adrenocortical neoplasia • Endogenous plasma ACTH concentration: to differentiate type, >40 pg/mL with pituitary dependent HAC and 4 μg/dL • Free T4 by equilibrium analysis: ↑ value • T3 suppression test: >1.5 μg/dL • TRH response test: little to no ↑ in serum T4 • TLI: ↓ TSH

• CBC: normocytic, normochromic nonregenerative anemia • Chemistry panel: ↑ ALT, AST, calcium, potassium, creatinine, BUN and ↓ phosphorus, sodium, chloride, cholesterol, glucose • Urinalysis: ↑ ketones, glucose, ↓ specific gravity: 1 : 256 or >1 : 64 and negative IgG indicates active infection • IgG: elevated 2–4 weeks postinfection, >1 : 512 active infection or 2–4 fold rising titer 2 weeks apart • Antigen serum titers: + 1–4 weeks postinfection

Imaging

• N/A

• Radiographs, abdominal: hepatomegaly, effusion • Radiographs, thoracic: effusion, patchy alveolar and interstitial pulmonary infiltrates

Procedures

• N/A

• ECG: arrhythmia, cardiac irregularity

General

• Supportive • Fluid therapy • Wound management: debridement, H2O2 flushing, cleaning

• Supportive • Fluid therapy

Medication

• Antibiotics: penicillin G or metronidazole • Anticonvulsants/muscle relaxants: diazepam, chlorpromazine, acetylpromazine, phenobarbital, pentobarbital, methocarbamol • Tetanus antitoxin

• Antibiotics: clindamycin, pyrimethamine, trimethoprimsulfonamide • Folic acid, yeast • Ophthalmic drops: 1% prednisone

Nursing Care

• Keep patient in a dark quiet area and do not disturb. • Provide soft bedding and rotate every 4 hours to prevent decubital sores and lung congestion. • Prevent urinary and fecal retention with urinary catheterization and enemas. • Nutritional support: force feeding is not advised because it may cause tetanic state. • Monitor blood pressure and ECG.

• Typically treat as outpatients. • Confine patients with neurologic signs.

Patient Care

• N/A

• Examine 2 and 14 days post initiation of treatment for improvement. • Provide a high-quality diet, biannual physical examinations, annual blood work, vaccines, and prompt attention to illness.

Diagnosis

General

Follow-Up

Treatment

6

260

Toxoplasmosis ZOONOTIC

SECTION THREE: DIAGNOSTIC SKILLS

Table 6.34 / Infectious Diseases: Tetanus and Toxoplasmosis (Continued)

Follow-Up

Disease

Tetanus

Toxoplasmosis ZOONOTIC

Prevention/ Avoidance

• Prevent skin wounds: maintain clean and safe runs and yards. • Give proper wound care management. • Aseptic surgical technique

• Prevent ingestion of raw meat, bones, viscera, or unpasteurized milk. • Prevent free roaming to hunt prey or access to the housing of food-producing animals.

Complications

• N/A

• N/A

Prognosis

• Extremely guarded when severely affected

• Guarded: can be become carriers and relapse clinically if immunocompromised

• Clinical signs show up 5 days to 3 weeks later. • Death is from respiratory dysfunction. • Animals can be pretested for anaphylactic reaction to the antitoxin by giving an intradermal injection first and monitoring for 30 minutes.

• Caution: Disease can be transmitted to an unborn fetus by an infected human mother. • Transmitted by ingesting infected animal tissues, cat feces, and transplacental infection • Excrete eggs 3–10 days after infection for 1–2 weeks: can shed again if stressed. • Oocysts must first sporulate to become infectious. • Oocysts can last in the soil for >1 year.

Notes

6

MUSCULOSKELETAL Table 6.35 / Musculoskeletal: Arthritis Disease

Arthritis Acute

Diagnosis

Presentation

Definition

Degenerative Joint Disease (DJD, Osteoarthritis)

There are two types of clinically diagnosed arthritis: degenerative and acute inflammatory. Acute arthritis is a pathogenic organism within the closed space of a joint and is broken down into 3 types: septic, traumatic, and immune-mediated. DJD is a progressive deterioration, characterized by a loss of hyaline cartilage matrix and death of chondrocytes. There is no cure for DJD; treatment is based on alleviating clinical signs and slowing progression.

Clinical Signs

• Joint swelling, lameness, pain, reluctance to jump or climb stairs, stiff gait

• Abnormal gait, ataxia, exercise intolerance, ↑ lameness following moderate to heavy exercise, stiff upon rising after recumbency, swelling, walking difficulty

Examination Findings

• Crepitus, laxity, pain, ↓ ROM

• Crepitus, edema, laxity, muscle atropy, pain

General

• History/clinical signs • Joint palpation and manipulation

• History/clinical signs • Joint palpation

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Table 6.35 / Musculoskeletal: Arthritis (Continued) Disease

Degenerative Joint Disease (DJD, Osteoarthritis)

Laboratory

• • • • • • • • •

• Synovial fluid analysis: ↑ mononuclear cells (e.g., lymphocytes), protein, ↓ viscosity, cell count (compared to septic or inflammatory arthritides) • Mucin clot test: clot poor

Imaging

• Radiograph, affected joint: joint capsular distension, soft tissue thickening, joint effusion and bone lysis

• Radiograph, affected joint: osteophytes, subchondral sclerosis, narrowed joint space, and remodeling of subchondral bone/ epiphyses

Procedures

• Arthrocentesis

• Arthrocentesis

General

• Supportive • Surgery: arthrotomy, reconstructive procedures, arthrodesis

• Supportive • Surgery: resection arthroplasty, joint replacement, arthrodesis

Medication

• Antibiotics: variable • Chondroprotective agents: Adequan, glucosamine with chondroitin sulfate • Corticosteroids: prednisone or triamcinolone • Methyl sulfonyl methane • Misoprostol • NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin

• • • •

Nursing Care

• Standard postoperative • Treated as outpatient

• Standard postoperative • Treated as outpatient

Patient Care

• Moderate activity, but restricted to a level that minimizes discomfort • Strict confinement with acutely painful episodes • Obesity control • Physical therapy: hot/cold treatment, swimming, ROM exercises and massage

• Weight control • Encourage moderate and consistent exercise (e.g., swimming—low impact)

Prevention/ Avoidance

• Maintain appropriate weight control. • Early recognition to prevent proceeding to secondary condition

• Maintain proper weight control. • Early use of glucosamine with chondroitin sulfate to slow progression

Complications

• Nonambulatory • DJD • Osteomyelitis

• Nonambulatory

Prognosis

• Good with septic form • Fair to guarded with immune-mediated form

• Progressive

Diagnosis

Acute

Follow-Up

Treatment

6

262

Arthritis

CBC: leukocytosis, neutrophilia Urinalysis: ↑ protein ANA test: + results Tick-borne agent serology: + results Synovial fluid analysis: ↑ WBCs and bacteria Biopsy, synovial: neoplasia Cytology, synovial: ↑ WBCs, turbidity, bacteria Culture, synovial: bacteria, yeast, fungi, additional organisms Mucin clot test: clot poor

SECTION THREE: DIAGNOSTIC SKILLS

Chondroprotective agents: glucosamine with chondroitin sulfate Corticosteroids: prednisone or triamcinolone Misoprostol NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin

Table 6.36 / Musculoskeletal: Cruciate Disease and Hip Dysplasia Cruciate Disease (Cranial Cruciate Rupture)

Hip Dysplasia

Definition

Cruciate disease results in a partial or complete instability of the stifle joint. The tearing of the anterior cruciate ligament can be done acutely or as a degenerative process.

Hip dysplasia is the most common condition of the hip joint and cause of osteoarthritis. Hip dysplasia is a faulty development of the hip joint contributing to joint laxity and subluxation early in life. Joint instability occurs as muscle development and maturation lag behind the rate of skeletal growth.

Clinical Signs

• Abnormal gait, acute or intermittent lameness, ataxia, walking difficulty

• Abnormal gait, ataxia, exercise intolerance, hindlimb lameness

Examination Findings

• Deformed stifle joint, edema, joint effusion, muscle atrophy of hindlimb musculature, swelling

• Barden’s sign, Barlow’s sign, crepitus, joint laxity, muscle atrophy, Ortolani + test, pain, ↓ ROM

General

• History/clinical signs • Joint palpation: + anterior drawer sign

• History/clinical signs • Joint palpation

Laboratory

• Synovial fluid analysis: rule out sepsis and immune-mediated disease

• N/A

Imaging

• Radiograph, stifle joint: joint effusion with capsular distention, periarticular osteophytes, compression of infrapatellar fat pad and calcification of cruciate ligament • MRI: confirmation and severity of disease

• Radiographs, skeletal: joint subluxation of femoral head, flattening of femoral head, shallow acetabulum, periarticular osteophytes, or widening of joint space between femoral head and cranial acetabulum

Procedures

• Arthrocentesis • Arthroscopy: confirmation and severity of disease

• N/A

General

• Symptomatic • Cage rest • Surgery: tibial plateau leveling osteotomy (TPLO), “over-the-top” fascia lata graft, fibular head transposition imbrication procedure, extracapsular reinforcing procedures

• Surgery: triple pelvic osteotomy (TPO), femoral head and neck excision arthroplasty, pectineal myectomy, intertrochanteric osteotomy, or total hip replacement

Medication

• Chondroprotective drugs: Adequan, glucosamine with chondroitin sulfate • Misoprostol • NSAIDs: aspirin, carprofen, deracoxib, etodolac, firocoxib, meloxicam, tepoxalin

• Analgesics: variable • Chondroprotective agents: Adequan or glucosamine with chondroitin sulfate • Corticosteroids: prednisone, triamcinolone (short-term use) • Misoprostol • NSAIDs: aspirin, piroxicam, carprofen, etodolac, phenylbutazone, meclofenamic acid

Nursing Care

• Placement of Robert Jones bandage

• Postoperative radiographs to evaluate surgery • Physical therapy • Restrict activity.

Treatment

Diagnosis

Presentation

Disease

6

CHAPTER 6 / GENERAL MEDICINE

263

Table 6.36 / Musculoskeletal: Cruciate Disease and Hip Dysplasia (Continued)

Follow-Up

Disease

6

Cruciate Disease (Cranial Cruciate Rupture)

Hip Dysplasia

Patient Care

• Cryotherapy • Physical therapy: ROM exercises and massage • Restricted activity: leash only exercise and no use of stairs for 3 months postoperative • Reradiograph at 8 weeks • Full exercise by 6–9 months postoperative • Control obesity

• Restrict activity. • Monitor radiographs to assess degeneration.

Prevention/ Avoidance

• Selective breeding • Maintain proper weight control.

• Selective breeding • Nutritional manipulation for large breed dogs during growth and development • Avoid excessive exercise.

Complications

• Osteoarthritis

• Osteoarthritis • Nonambulatory

Prognosis

• Excellent with surgery

• Good depending on severity of disease

Notes

• Joint is palpated for drawer motion, movement of tibia relative to femur during the tibial compression test, and thickening of joint capsule. • In 30–40% of canines, the opposite cranial cruciate ligament ruptures within 17 months. • Rottweiler and Labrador Retriever

Table 6.37 / Musculoskeletal: Osteochondrosis and Osteomyelitis Osteochondrosis or Osteochondritis Dessicans (OCD)

Osteomyelitis

Definition

Osteochondrosis is a defect in endochondral ossification leading to an excessive retention of cartilage. This defect may occur in any limb joint. Ununited anconeal process and fragmented coronoid process may also be seen along with osteochondrosis or separately. It is often seen in animals between 5–10 months of age.

Osteomyelitis is an infection of the bone and its soft tissue elements and membranes. Infectious organisms often complicate an existing condition leading to an infection that is very difficult, and sometimes impossible, to treat.

Clinical Signs

• Abnormal gait, anorexia, cachexia, forelimb or hindlimb lameness, reluctance to exercise, walking difficulty

• Anorexia, cachexia, depression, exercise intolerance, lameness, lethargy, rising difficulty, weakness

Examination Findings

• Arthritis, crepitus, hyperextension pain, joint effusion, joint pain, muscle atrophy, swelling

• Edema, inflammation, intermittent draining tracts, pain, paralysis, paresis, pyrexia, swelling, tachycardia

General

• History/clinical signs • Joint palpation

• History/clinical signs • Skeletal palpation • Neurologic examination

Diagnosis

Presentation

Disease

264

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Table 6.37 / Musculoskeletal: Osteochondrosis and Osteomyelitis (Continued)

Follow-Up

Treatment

Diagnosis

Disease

Osteochondrosis or Osteochondritis Dessicans (OCD)

Osteomyelitis

Laboratory

• Joint tap and fluid analysis: confirms involvement and mononucleated cells

• CBC: neutrophilic leukocytosis • Cytology: toxic neutrophils, phagocytized bacteria or fungal organisms • Culture: bacteria isolation and identification and sensitivity

Imaging

• Radiographs, skeletal: joint abnormalities, bone lengths, arthritis, sclerosis of underlying bone or bone flap/fragments (joint “mice”) • CT/MRI: location and severity of lesion • Arthrogram: identifies cartilage flap or loose cartilage via contrast enhanced joint radiographs after intraarticular injections

• Radiographs, skeletal: soft tissue swelling, bone resorption, sclerosis, bone sequestra, fracture nonunion, cortical thinning, widening of fracture gap, reactive periosteal new bone, foreign bodies, or fungal lesions • Contrast: sinus location and severity, foreign bodies • Radionuclide imaging: detecting osteomyelitis

Procedures

• Arthroscopy: confirming cartilage lesion

• N/A

General

• Symptomatic • Surgery: arthrotomy or arthroscopy

• Symptomatic • Wound management: debridement, drainage and irrigation • Surgery: sequestrectomy, amputation, bone grafts, or biopsy

Medication

• Analgesics • NSAIDs

• Antibiotics: variable

Nursing Care

• Cryotherapy postoperative • Place modified Robert Jones bandage.

• Sterile dressing applied to surgical wounds left to close by 2º intention. • Irrigate daily with sterile saline.

Patient Care

• Cryotherapy for 15–20 minutes 3 times daily for 3–5 days if no bandage placed • Physical therapy: ROM exercises • Restrict activity for 4 weeks, then gradually increase to normal activity over the next 4 weeks. • Reradiograph 4–6 weeks postoperative • Obesity management

• Monitor radiographs for fracture healing.

Prevention/ Avoidance

• Selective breeding • Maintain proper weight control. • Nutritional manipulation for large-breed dogs during growth and development

• Proper wound and fracture management

Complications

• Osteoarthritis • Disuse atrophy

• Recurrence and relapse • Limb deformity or impaired function • Neurologic disease

Prognosis

• Good with early surgical repair (forelimb) • Guarded with stifle or tarsal OC

• Good with acute disease • Poor with chronic disease

• Great Dane, Labrador Retriever, Newfoundland, Rottweiler, Bernese Mountain Dog, English Setter, and Old English Sheepdog

• Saint Bernard, German Shepard, Labrador Retriever, Golden Retriever, and Rottweiler

Notes

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265

Table 6.38 / Musculoskeletal: Patella Luxation and Panosteitis Patellar Luxation, Medial

Panosteitis (Enostosis)

Definition

Medial patellar luxation is generally a concern of small breed dogs. It is typically a congenital or developmental malformation of the stifle joint causing the patellar to displace from the femoral trochlea. Luxations are graded on a scale of I–IV, which allows guidance of treatment options.

Panosteitis is a disease of young large-breed dogs that begins in the medullary bone marrow in the region of the nutrient foramen. Its cause is unknown. It gives intermittent lameness of one or multiple limbs. The disease is self-limiting, but its clinical signs will remain for months.

Clinical Signs

• Abnormal gait, ataxia, intermittent lameness of hindlimb, skipping, walking difficulty

• Anorexia, ataxia, cachexia, depression, forelimb and hindlimb lameness, lethargy, shifting leg lameness, walking difficulty

Examination Findings

• Arthritis, pain, stifle joint deformity

• Pain on palpation of diaphysis, pyrexia

General

• History/clinical signs • Patella palpation: laxity

• History/clinical signs • Bone palpation

Laboratory

• N/A

• CBC: eosinophilia (v)

Imaging

• Radiographs, hindlimb: bowing and/or torsion of tibia or femur and shape of femoral trochlea

• Radiograph, skeletal: ↑ density, progressive mottling and radiopacity within the medullary cavity, new bone formation and thickened bone cortices • Scintigrams, bone: bone lesions

Procedures

• N/A

• N/A

General

• Supportive • Symptomatic • Surgical: trochleoplasty, trochlear sulcoplasty, recession sulcoplasty, trochlear chondroplasty, chondroplasty, wedge recession, patelloplasty or tibial tuberosity translocation

• Supportive

Medication

• Analgesics • Chondroprotective agents: Adequan or glucosamine with chondroitin sulfate • Corticosteroids: prednisone (short-term use) • Misoprostol • NSAIDs: aspirin, carprofen, etodolac, piroxicam

• • • •

Nursing Care

• Cryotherapy immediately postoperative then 15–20 minutes daily for 3–5 days if no bandage • Placement of Robert Jones bandage • Physical therapy: ROM exercises and swimming

• Treated as outpatient

Patient Care

• Restricted activity: leash only exercise and no use of stairs for 3 months postoperative • Full exercise by 6–9 months postoperative • Correct obesity

• Restrict activity • Recheck lameness every 2–4 weeks for more serious orthopedic problems

Presentation

Disease

Follow-Up

Treatment

Diagnosis

6

266

SECTION THREE: DIAGNOSTIC SKILLS

Analgesics Corticosteroids: prednisone Misoprostol NSAIDs: aspirin, piroxicam, carprofen, etodolac

Table 6.38 / Musculoskeletal: Patella Luxation and Panosteitis (Continued)

Follow-Up

Disease

Patellar Luxation, Medial

Panosteitis (Enostosis)

Prevention/ Avoidance

• Selective breeding • Maintain proper weight control

• N/A

Complications

• Recurrence following surgery • DJD

• N/A

Prognosis

• Excellent with surgery

• Excellent

• Miniature and Toy Poodle, Yorkshire Terrier, Pomeranian, Pekingese, Chihuahua, and Boston Terrier

• German Shepard, Irish Setter, Saint Bernard, Doberman Pinscher, Airedale, Basset Hound, and Miniature Schnauzer

Notes

6

NEUROLOGY Table 6.39 / Neurology: Encephalitis and Epilepsy Encephalitis

Epilepsy

Definition

Encephalitis is an inflammatory disease of the brain with random progression. The causes of this condition are wide ranging from breed predilections to infectious diseases to viral, protozoan, fungal, and bacterial infections. The clinical signs, diagnosis, and treatment are all dependent on determining the underlying disease.

Epilepsy is a condition of recurring seizures regardless of their cause. Primary epilepsy has no known cause and may be genetic/ hereditary. Secondary epilepsy is acquired through brain injury and/or inflammation.

Clinical Signs

• Dependent on underlying disease • Aggression, ataxia, behavioral changes, circling, depression, head tilt, pacing, paralysis, photophobia, seizures, tremors, vomiting

3 Stages of Seizures • Aura: immediately preceding seizure, restlessness, crying and hiding • Ictus: actual seizure, lasting 25–30 mm Hg (canine) and >31 mm Hg (feline) • Electroretinography: vision loss

General

• Surgery: cryoepilation, electroepilation, tarsoconjunctival resection, facial fold resection, or medial canthal closure

• Supportive • Symptomatic • Surgery: cyclophotocoagulation, gonioimplatation, intraocular prosthesis or enucleation

Medication

• Antibiotics (topical): triple antibiotic

• Adrenergic agents: 0.1% dipivefrin, 0.25–0.5% timolol • Miotics: pilocarpine 2%, demecarium bromide, epinephrine 1%, dipivefrin HCl 0.1%, or timolol maleate 0.5% • Carbonic anhydrase inhibitors: methazolamide, dorzolamide, brinzolamide • Corticosteroids: dexamethasone • Diuretics: 20% mannitol or glycerin • Prostaglandins: latanoprost

Nursing Care

• Treated as outpatient

• Treated as outpatient

Patient Care

• Treat swelling with topical antibiotics, corticosteroids, and/or hypertonic saline.

• Warm, moist compresses twice daily for 5–7 days postoperative • Monitor every 1–2 days for 1 week for improvement. • Treat the other eye prophylactically daily with an autonomic agent.

Definition

Follow-Up

Cilia Disorders (Distichiasis, Trichiasis and Ectopic Cilia)

6

Laboratory

CHAPTER 6 / GENERAL MEDICINE

287

Table 6.48 / Ophthalmology: Cilia Disorders and Glaucoma (Continued)

Follow-Up

Disease

Cilia Disorders (Distichiasis, Trichiasis and Ectopic Cilia)

Glaucoma

Prevention/ Avoidance

• Clip hair on facial folds and around the eyes.

• Yearly ophthalmic examination in predisposed breeds • Examinations 2–3 times a year on unaffected eye when 1 eye already has glaucoma

Complications

• Recurrence • Conjunctivitis • Keratitis

• Blindness • Chronic ocular pain

Prognosis

• Excellent with facial fold resection • Fair to good with hair removal

• Fair with surgery • Poor with medical treatment alone

• Felines do not have cilia, and canines normally only have them on the upper eyelid.

• Normal intraocular pressure is 15–25 mm Hg. • 50% of animals develop glaucoma in the second eye within 8 months of the initial diagnosis. • 40% of dogs will be blind in affected eye within 1 year regardless of treatment. • May take up to 6 weeks for vision to return

Notes

6

Table 6.49 / Ophthalmology: Keratitis and Keratoconjunctivitis Sicca Disease

Presentation

Keratoconjunctivitis Sicca (KCS, Dry Eye Syndrome)

Nonulcerative (Chronic Superficial Keratitis)

Ulcerative (Corneal Ulceration/Erosion)

Keratitis is inflammation of the cornea with possible corneal erosion. It can be caused by trauma, foreign bodies, bacterial infection, irritant, cilia disorders, KCS, feline herpesvirus, or corneal exposure.

Ulceration is the loss of a full-thickness of epithelium with at least some stromal loss. This can be caused by trauma, bacterial infection, pseudomonas, feline herpesvirus, epithelial dystrophy, corneal dryness, neurotrophic keratitis, or complications from other diseases.

KCS is a lack of normal tear production causing drying and inflammation of the cornea and conjunctiva. It is thought to be an immune-mediated disease against the lacrimal gland. It can also be caused by long-term use of sulfonamides.

Clinical Signs

• Blepharospasm, photophobia, prolapsed third eyelid, squinting, rubbing at eyes, serous to mucopurulent discharge, tearing

• Blepharospasm, epiphora, photophobia, rubbing at eyes, serous to mucopurulent discharge

• Blepharospasms, blindness, eye rubbing, mucoid to mucopurulent discharge, periocular crust, photophobia, pruritus

Examination Findings

• Corneal edema, hyperemia, neovascularization, pigmentation

• Aqueous flare, corneal edema, corneal opacity, conjunctival hyperemia, hypotony, miosis, neovascularization, surface depression

• Chemosis, dull, opaque or pigmentation of cornea, hyperemia, superficial vascularization, thickened conjunctiva, ulceration

Definition

288

Keratitis

SECTION THREE: DIAGNOSTIC SKILLS

Table 6.49 / Ophthalmology: Keratitis and Keratoconjunctivitis Sicca (Continued)

Follow-Up

Treatment

Diagnosis

Disease

Keratitis

Keratoconjunctivitis Sicca (KCS, Dry Eye Syndrome)

Nonulcerative (Chronic Superficial Keratitis)

Ulcerative (Corneal Ulceration/Erosion)

General

• History/clinical signs • Ophthalmic examination

• History/clinical signs • Ophthalmic examination

• History/clinical signs • Ophthalmic examination

Laboratory

• Virus isolation: feline herpesvirus

• Virus isolation: feline herpesvirus • Culture: bacteria or fungi isolation and identification

• Cytology: severity of bacterial overgrowth

Imaging

• N/A

• N/A

• N/A

Procedures

• Schirmer tear test: ↓ production • Cytology: recognition and identification of bacteria

• Fluorescein stain: retention of stain • Schirmer tear test: >15 mm/min

• Schirmer tear test: ↓ production, 1 (3–5 severe) • Urine culture: bacteria isolation and identification • Blood gasses: metabolic acidosis • Serology: leptospirosis or ehrlichiosis • Eythlene glycol concentration: + results • Biopsy: confirmation, cause and severity of disease

• CBC: nonregenerative anemia • Chemistry panel: ↑ protein, BUN, creatinine, amylase, lipase, phosphate, ↓ potassium, ± calcium and metabolic acidosis • Urinalysis: ↑ protein (v), ↓ specific gravity • Protein:creatinine ratio: to determine severity of proteinuria and glomerular disease • Culture, urine: bacteria isolation and identification • Biopsy, renal: confirmation, cause and severity of disease

Definition

Diagnosis

6

Disease

SECTION THREE: DIAGNOSTIC SKILLS

Table 6.52 / Urology: Renal Failure (Continued) Disease

Chronic (CRF)

Imaging

• Radiographs, abdominal: renal size and shape, renal uroliths, peritonitis • Contrast: obstruction or structural rupture • Ultrasound, abdominal: renal uroliths and parenchymal and anatomical abnormalities

• Radiographs, abdominal: renal size and shape and renal uroliths • Contrast: obstruction or structural rupture

Procedures

• Endoscopy: gastric ulcers • Blood pressure: hypertension

• Blood pressure: hypertension

General

• • • • • • • •

• • • • • • •

Diagnosis

Acute (ARF)

Symptomatic Supportive Fluid therapy, ± potassium Hemodialysis Peritoneal dialysis Blood transfusions Poison antidotes (e.g., ethylene glycol) Renal transplantation

Medication

• • • • • • • •

Nursing Care

• • • •

Patient Care

• Monitor blood values until normal. • Nutritional support • Renal diet: ↑ omega-3, omega-6, caloric density, fiber, ↓ highquality protein, phosphorus, sodium • Fresh water at all times to increase water consumption • Subcutaneous fluids for diuresis and hydration

Treatment Follow-Up

Renal Failure

Alkalinizer: sodium bicarbonate Anabolics: testosterone, nandrolone, oxymethalone, stanozolol Antibiotics: variable Antiemetics: trimethobenzamide or chlorpromazine Calcium gluconate Diuretics: 20% mannitol, 20% dextrose, furosemide H2-receptor antagonist: cimetidine or rantidine Phosphate binders: aluminum hydroxide, calcium carbonate, calcium acetate, epakitin • Potassium supplement: potassium chloride, potassium gluconate • Vasodilators: dopamine

Symptomatic Supportive Fluid therapy Hemodialysis Peritoneal dialysis Blood transfusions Renal transplantation

6

• • • • • •

ACE inhibitors: enalapril, benazepril, amlodipine Alkalinizer: sodium bicarbonate Androgens: stanozolol, nandrolone decanoate Erythropoietin: rHuEPO H2-receptor antagonist: cimetidine, famotidine, rantidine Phosphate binders: aluminum hydroxide, calcium carbonate, calcium acetate, epakitin • Potassium supplement: potassium chloride, potassium gluconate • Vitamin D: calcitriol

Nutritional support Monitor urine output, 1–3 mL/min initially. Monitor hydration, temperature, and body weight. Monitor PCV and blood values. • Nutritional support • Renal diet: ↑ omega-3, omega-6, caloric density, fiber, ↓ high quality protein, phosphorus, sodium • Fresh water at all times to increase water consumption • Subcutaneous fluids for diuresis and hydration • Monitor weekly initially, then monitor hydration; weight and blood values every 1–4 months depending on severity of CRF

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295

Table 6.52 / Urology: Renal Failure (Continued)

Follow-Up

Disease

Renal Failure Acute (ARF)

Chronic (CRF)

Prevention/ Avoidance

• Anticipate ARF in susceptible animals and conduct preventative fluids and medication. • Avoid use of nephrotoxic drugs. • Restrict exposure to antifreeze. • Maintain adequate blood pressure during anesthesia, especially in prolonged procedures and older animals.

• Anticipate ARF in susceptible animals and conduct preventative fluids and medication. • Avoid use of nephrotoxic drugs. • Maintain adequate blood pressure during anesthesia. • Selective breeding

Complications

• Cardiac arrhythmias, congestive heart failure, pulmonary edema, uremic pneumonitis, or cardiopulmonary arrest • Gastrointestinal bleed • Hypovolemia, sepsis, and death • Seizures or coma

• • • • • • •

Prognosis

• Guarded to poor, but depends on severity and cause of disease

• Guarded to poor long term due to progression of disease

Urine Output • Anuria: ≤0.1 mL/kg/hr • Oliguria: ≤0.25 mL/kg/hr • Nonoliguria: ≥2 mL/kg/hr

• Approximately 75% of the kidney must be nonfunctional before an elevation in serum BUN and creatinine is seen.

6

Notes

Anemia Dehydration and constipation Gastroenteritis Hypertension Uremic stomatitis Urinary tract infection Weight loss

Table 6.53 / Urology: Urinary Tract Obstruction and Urinary Tract Infection Disease

Presentation

Definition

296

Urinary Tract Obstruction

Urinary Tract Infection (Cystitis, Urethrocystitis)

An obstruction restricting the flow of urine along the pathway from the kidneys to the external urethral orifice. The obstruction can be from blood clots, urethral plugs, uroliths, and sloughed tissue fragments.

Urinary tract infection is usually bacteria-induced inflammation of the lower urinary tract including the bladder and urethra. The cause is due to an ascending bacterial infection from the urethral orifice or hematogenous.

Clinical Signs

• Anorexia, crouching, depression, dysuria, hematuria, lethargy, pollakiuria, ↑ size and velocity of urine stream, stranguria, vomiting

• Dysuria, hematuria, malodorous, periuria, pollakiuria, stranguria, urinary incontinence

Examination Findings

• Abdominal pain, bradycardia, dehydration, distended urinary bladder, hypothermia, renomegaly

• Thickened, firm contracted bladder wall

SECTION THREE: DIAGNOSTIC SKILLS

Table 6.53 / Urology: Urinary Tract Obstructin and Urinary Tract Infection (Continued)

Follow-Up

Treatment

Diagnosis

Disease

Urinary Tract Obstruction

Urinary Tract Infection (Cystitis, Urethrocystitis)

General

• History/clinical signs • Abdominal palpation: kidneys and bladder

• History/clinical signs: recent catheterization or urinary tract surgery • Abdominal palpation: kidneys and bladder • Digital rectal examination: prostate in males

Laboratory

• • • •

Imaging

• Radiographs, abdominal: anatomic abnormalities, extended bladder, calculi, urethral plugs, tumors or urachal diverticula • Contrast: urethral strictures, tumors, radiolucent uroliths or vesicourachal diverticula • Ultrasound, abdominal: anatomic abnormalities, extended bladder, calculi, tumors, or urachal diverticula

• Radiographs, abdominal: anatomic abnormalities, calculi, tumors or urachal diverticula • Contrast: radiolucent calculi • Ultrasound, abdominal: anatomic abnormalities, calculi, tumors, or urachal diverticula

Procedures

• Cystoscopy • ECG: bradycardia, atrial standstill

• N/A

General

• • • •

• Symptomatic

Medication

• Antibiotics: variable • Calcium gluconate • Sodium bicarbonate

• Antibiotics: variable

Nursing Care

• Monitor bladder size and urine output.

• Treated as outpatient

Patient Care

• Monitor urine output and hydration status.

• Culture urine 1 week and 1 month after beginning treatment. • Allow frequent access to litter box or outdoors.

Prevention/ Avoidance

• Dependent on cause of obstruction

• Avoid glucocorticoid use or urethral catheterization.

Complications

• • • •

• Pyelonephritis • Cystic calculi • Recurrence

Prognosis

• Good with early detection and correction

CBC: ± stress leukogram Chemistry panel: ↑ phosphorus, potassium, ↓ calcium and azotemia Urinalysis: ↑ blood, protein, crystals Blood gases: metabolic acidosis

Fluid therapy Urohydropulsion Surgery: urethrotomy, urethrostomy Lithotripsy

Reobstruction UTI Urinary bladder rupture Urethral trauma during catheterization

• • • •

Chemistry panel: ↑ BUN, creatinine and azotemia Urinalysis: pyuria, ↑ blood, protein, bacteria, specific gravity Urine culture: bacteria isolation and identification Prostatic fluid analysis: bacteria and neutrophils

• Excellent

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6

Table 6.53 / Urology: Urinary Tract Obstructin and Urinary Tract Infection (Continued) Disease

Urinary Tract Obstruction

Urinary Tract Infection (Cystitis, Urethrocystitis)

Notes

• Caution: Due to the patient’s compromised state, chose anesthetics carefully. • Fluid therapy should not be started until obstruction is relieved.

Significant Bacteria Count Canine Cystocentesis: ≥1000 Catheter: ≥10,000 Voided: ≥100,000 Expressed: ≥100,000

6

298

SECTION THREE: DIAGNOSTIC SKILLS

Feline ≥1000 ≥1000 ≥10,000 ≥10,000

Chapter

7

Emergency Medicine Emergency Medicine 301 Emergency Supplies 301 Telephone Assessment and Emergency Transportation Recommendations 304 Inducing Vomiting At-Home 305 Triage 306 Primary Survey 306 Hemostasis 307 Cardiopulmonary Cerebrovascular Resuscitation (CPCR) 308 Secondary Survey 309 Shock 310 Cardiac Emergencies 312 Environmental Emergencies 313

Gastrointestinal Emergencies 314 Hematologic Emergencies 315 Metabolic and Endocrine Emergencies 316 Neonatal Emergencies 317 Neonatal Resuscitation Post-Cesarean 317 Neurologic Emergencies 318 Ophthalmic Emergencies 319 Renal and Urinary Emergencies 320 Reproductive and Genital Emergencies 321 Respiratory Emergencies 322 Toxicologic Emergencies 323 Toxins 324 Trauma Emergencies 326

7

299

Key Words and Termsa Abducted Ambulation Anisocoria Ataxia Azotemia Cathartics Cyanosis Decerebellate posture Decerebrate resposne Dyschezia Dystocia Ecchymoses Edema Epistaxis Flail chest Hematemesis Hematochezia Hemoptysis Hyperemic Hyperesthesia Hyperreflexia Hyperthermia Hypertonia Icterus Incontinence Intraosseus Intussusception

7

a

Isoerythrolysis Lacrimation Lymphadenopathy Melena Mentation Micturition Mydriasis Nystagmus Oliguria Pallor Paradoxical respiration Paraphimosis Philtrum Pollakiuria Polydipsia Polyuria Ptyalism Pulse deficits Purulent Schiff-Sherrington’s posture Scleral injection Septicemia Strabismus Stranguria Triage

Key words and terms are defined in the glossary on page 631.

300

SECTION THREE: DIAGNOSTIC SKILLS

Abbreviations

Additional Resources, page

ACT, activated clotting time ACTH, adrenocorticotropic hormone ANA, antinuclear antibody ASPCA, American Society for the Prevention of Cruelty to Animals BP, blood pressure BUN, blood urea nitrogen Ca2+, Calcium cm H2O, centimeters of water CNS, central nervous system CPCR, cardiopulmonary cerebrovascular resuscitation CRT, capillary refill time CT, computed tomography CVP, central venous pressure DOCP, desoxycorticosterone acetate ECG, electrocardiogram ET, endotracheal tube Fr, French GDV, gastric dilatation volvulus GIT, gastrointestinal tract GV, governing vessel H2O2, hydrogen peroxide HR, heart rate IV, intravenous kg, kilogram mg, milligram mm Hg, milliliters of mercury MM, mucous membranes MRI, magnetic resonance imaging NPO, nothing by mouth NSAIDs, nonsteroidal anti-inflammatory drugs PCV, packed cell volume pH, potential of hydrogen RR, respiratory rate Tb, tablespoon TP, total protein URI, upper respiratory infection UTI, urinary tract infection

Abdominocentesis, 429 Blood culture, 122 Blood gas analysis, 335 Blood pressure, 332 Blood transfusions, 367 Bone marrow evaluation, 83 Cardiopulmonary, 30 Central venous pressure, 334 Cesarean section, 542 Chest drain, 431 Coagulation tests, 115 Coupage, 432 CPCR, 308 Diagnostic peritoneal lavage, 429 Disinfectants, 627 Electrocardiogram, 338 Endoscopy, 551 Enema, 430 Fecal analysis, 134 Fine needle biopsy, 89 Fluid therapy, 359 Fluorescein sodium stain, 430 Gastric lavage, 428 Heat administration, 346 Laboratory, 71 Nebulization, 432

Neurologic examination, 34 Nutritional support, 413 Orthopedic examination, 36 Otoscopic examination, 33 Oxygen therapy, 375 Pain management, 379 Patient monitoring, 332 Pericardiocentesis, 431 Pharmacology, 567 Physical examination, 18 Pulse oximetry, 463 Radiology, 157 Recumbent patient care, 347 Shirmer tear test, 430 Stomach tube, 428 Surgery, 521 Thoracocentesis, 431 Tonometry, 430 Tracheostomy, 377 Ultrasound, 197 Urinalysis, 147 Urinary catheter maintenance, 436 Urinary catheter placement, 435 Urine collection, 434 Ventilator, 474 Vital signs, 19

Emergency Medicine Emergencies typically happen at the most inconvenient times. A well-stocked clinic and a staff trained in handling emergencies will make your team more efficient and each emergency therefore less stressful. Each member of the clinic should have a specific job during emergencies. Understanding the basics of what constitutes an emergency as well as being able to perform stabilizing and monitoring techniques is essential to assisting the veterinarian. This chapter covers the basic supplies, support, and monitoring techniques

necessary to handle an emergency. It also gives a very general coverage of emergencies by body system. All diagnoses and treatment prescriptions can be done only by the veterinarian. These tables are to assist the technician in monitoring the patient. The technician then will be able to alert the veterinarian of abnormalities and to carry out the veterinarian’s treatment therapy where applicable. Please note that this chapter is not meant to be “all inclusive,” and we urge each clinic to have a thorough emergency resource library in the clinic.

Table 7.1 / Emergency Supplies

Before any emergency patient arrives at the hospital, a crash cart should be assembled and diligently maintained to be available to assist the veterinarian and staff. Each clinic will have preferences regarding supplies and should set up their supplies to suit their needs. The items listed are examples of what may be needed and are not meant to be all inclusive. The most important part of the selected emergency supplies is familiarity. Each staff member must know his or her location and understand their use and operation. This knowledge will lead to a smooth recovery attempt.

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Crash Cart • The items contained in the crash cart are the first items utilized in an emergency. These items should be dedicated to emergencies and are not used for daily purposes. One person should be designated to maintain the crash cart on a regular basis and to alert staff to any changes. Supplies • Stethoscope • IV catheters of various sizes, caps, T-ports, and tape • Syringes and needles (regular, spinal, intraosseus) of various sizes • Blood collection tubes

• Fluid delivery system (IV fluid bags and IV administration tubing) • Clippers and surgical scrub • Masks and gloves • Minor surgical instrument pack (scalpel handle, thumb forceps, needle holders, and 3 hemostats of various sizes)

• Scalpel blades • Suture material of various types • Endotracheal tubes of various sizes, laryngoscope, local anesthetic, ties, cuff syringe, and mouth gags • Urinary catheters for intratracheal injection

Equipment • Defibrillator

• Electrocardiograph

Drugs • • • •

Drug dose chart Atropine Ca2+ chloride or gluconate Dexamethasone sodium phosphate

• • • •

Dextrose Diazepam (if lock box available) Epinephrine Lidocaine 2%

• IV fluids (LRS, dextran 70, hypertonic saline, hetastarch) • Sodium bicarbonate • ± Phenobarbital (if lock box available)

Basic Equipment • These items provide basic support to the patient. These supplies may not necessarily be in the crash cart due to size and multiple hospital uses, but their location is known and easily accessible.

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Table 7.1 / Emergency Supplies (Continued) Supplies • • • •

Bandaging material Lubricating jelly Thermometer Heat support

• • • •

Blood pressure equipment Blood gas analyzer Pressurized fluid infusion cuff IV fluid warmer

• Oxygen delivery system (ambu bag, line to oxygen source, humidifier) • Pulse oximetry • Nebulizer

Specialized Equipment • These items are advanced equipment used in specific, critical situations. These items may not necessarily be in the crash cart due to size and multiple uses, but their location is known and easily accessible. • Respirator • Suction supplies (suction tubing, jar, pump)

• Tracheostomy pack • Thoracotomy pack

• Pericardiocentesis pack • Abdominocentesis pack

Drugs • This listing of drugs includes most of those used to treat critical patients. These drugs are typically kept in their regular location, the exception to the drugs listed in the crash cart. These drugs are used for treatment and not for immediate life-threatening situations.

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Cardiac Drugs • Antiarrhythmics • Diltiazem, dexamethasone sodium phosphate, esmolol, lidocaine, procainamide, propranolol, verapamil • Diuretics • Furosemide • Inotropes • Digoxin, dobutamine, dopamine, isoprenaline, isoproterenol

• Vasodilators • Acepromazine, hydralazine, nitroglycerin ointment, nitroglycerin patch, captopril, diltiazem, sodium nitroprusside, amlodipine besylate, enalapril • Sedatives • Morphine, butorphanol, buprenorphine

• Other • Aspirin (antithrombotic therapy) • Ca2+ chloride (ventricular asystole) • Glycopyrrolate • Heparin (antithrombotic therapy) • Potassium chloride (chemical defibrillator)

• Bronchodilators • Cholinergic blockers, antihistamines, beta-2-adrenergic agonists (epinephrine, isoproterenol, albuterol), Methylxanthines (aminophylline)

• Stimulants • Doxapram hydrochloride, naloxone, yohimbine

• Antiulcer • H2-receptor antagonists (cimetidine, famotidine, ranitidine), antacids (magnesium hydroxide), gastromucosal protectants (sucralfate) • Misoprostol • Proton pump inhibitors (omeprazole) • Laxatives • Enemas, milk of magnesias, and glycerin

• Emetics • apomorphine, xylazine, ipecac syrup, hydrogen peroxide • Protectants/adsorbents • Bismuth subsalicylate, kaolin/pectin, activated charcoal

Respiratory Drugs • Antitussives • Butorphanol tartrate, hydrocodone bitartrate, codeine, dextromethorphan, Temaril-P Gastrointestinal Drugs • Antidiarrheals • Narcotic analgesics • Antiemetics • Chlorpromazine, prochlorperazine, anticholinergics, metoclopramide

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SECTION THREE: DIAGNOSTIC SKILLS

Table 7.1 / Emergency Supplies (Continued) Neurologic Drugs • Antiseizuring • Diazepam, phenobarbital

• Muscle relaxant • Methocarbamol

• Rapid-acting corticosteroids • Methylprednisolone sodium succinate

• Topical anesthetics • Proparacaine hydrochloride, tetracaine

• Stains • Fluorescein strips

• Ca2+ channel blockers • Diltiazem, verapamil • Diuretics • Furosemide, mannitol 20%, glucose

• Urinary alkalizers • Potassium citrate, sodium bicarbonate (oral) • Vasodilators • Hydralazine, dopamine, dobutamine

• R-insulin

• Percorten (DOCP)

• Pralidoxime (against organophosphates) • Fomepizole/Antizol-Vet (against ethylene glycol—dogs only)

• Hemostatic agent • Vitamin K1 • Antihistamine • Diphenhydramine

Ophthalmic Drugs • Reduces Intraocular pressure (IOP) • Carbonic anhydrase inhibitors, timolol maleate, mannitol, glycerol Renal/Urinary Drugs • ACE inhibitors • Captopril, enalapril • Antidiuretics • Vasopressin

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Reproductive Drugs/Hormones • Oxytocin Toxicologic Drugs—Antidotes • Antidotes • Acetylcysteine (against acetaminophen) • Dimercaprol (against arsenical compounds) • Ethanol (against ethylene glycol)

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Table 7.2 / Telephone Assessment and Emergency Transportation Recommendations

When a client calls with an emergency situation, asking very specific questions and advising the owner on how to assess the situation, provide initial treatment, and move the animal are very important. Before beginning the assessment, inquire as to whether the owner and the animal are in a safe place. In any traumatic emergent situation, it is advisable to place a muzzle on the animal if no respiratory distress is noted and mucous membranes are pink. Recommendations listed below should be altered if the animal becomes aggressive or the procedure produces additional stress. Always ask the owner what is their expected arrival time. This will allow the staff to make any preparations necessary prior to their arrival. The goal of dealing with an emergency situation is to minimize stress of both the owner and the patient. Questions may need to be asked multiple times to maintain the attention of the upset and distracted owner. Regardless of the nature of the injury, if the owner perceives it as an emergency, it must be handled in that manner. On-Site Questions to the Client

Recommendations

What is the nature of the injury?

Have the owner give a quick assessment of the situation and the extent of the injuries. Based on this information, further questions can be asked.

Traumatic

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• Hit by car, poisoning, seizures, drowning, fall, lacerations, fractures, and eye injuries • Is your animal awake or unconscious? • Does your animal respond to your commands?

• If the animal is unconscious, it needs to be rapidly assessed for breathing and circulation.

• Is your animal breathing? • Is your animal having trouble breathing?

• Animals in respiratory distress should have limited activity during transport and be allowed to maintain a position of comfort. • Animals not breathing should be given mouth-to-nose resuscitation and chest compressions during transport. Frequently, this will stimulate spontaneous breathing if initially caused by a vasovagal reflex. • See Skill Box 7.3 Cardiopulmonary Cerebrovascular Resuscitation (CPCR), page 308.

• What is the color of your animal’s mucous membranes?

• Compare the mucous membranes to your own—Are they more white, blue, or red? • If white or blue, assess for breathing and circulation. • Palpate the chest for a heartbeat or feel for a jugular pulse.

• Does your animal have external bleeding? • Is it pulsating?

• Apply direct pressure to the site of bleeding and elevate above the heart. • Leashes or ropes can be used as tourniquets placed proximal to the injury with arterial pulsating bleeding.

• Does your animal have a limb in an abnormal position? • Is he limping or not bearing any weight on the limb?

• Support fractures believed to be below the elbow or hock. • Secure the fractured limb with a roll of newspaper, magazine, board, or piece of cardboard with pieces of fabric or duct tape. • If this causes additional stress, gently transport the animal on thick fabric or a board (thin wood or cardboard).

Acute • GDV, poisoning, GIT obstruction, hives, vaccine reaction, respiratory complications • Is your animal having a seizure?

• If diabetic, administer Karo syrup orally. • Transport in a large towel for protection of the owner and animal; only loosely cover the animal during transport to avoid hyperthermia.

• Does your animal have a distended abdomen?

• Avoid pressure on the abdomen. • Do not allow the animal to eat or drink in transport. • If nonambulatory, transport on thick fabric or a board (thin wood or cardboard).

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SECTION THREE: DIAGNOSTIC SKILLS

Table 7.2 / Telephone Assessment and Emergency Transportation Recommendations (Continued) • Has your animal eaten something poisonous? If so, when?

• Remove the animal from the toxin. • Bring any remaining substance and/or packaging, vomit, or feces. • If no other symptoms are present, call Poison Control Center and possibly induce vomiting (e.g., hydrogen peroxide). • See Skill Box 7.1, page 305 and Chapter 17 Pharmacology, page 593.

• Is your animal vomiting or have diarrhea?

• Bring in samples.

• Is your animal gagging/retching?

• Try to comfort the animal to decrease these symptoms.

• Is your animal choking?

• If possible, observe the inside of the mouth for an obstruction to be removed. • Administer a sharp blow with the palm of your hand between the shoulder blades. • Perform a modified Heimlich procedure—With the animal beside you and head forward, place arms around abdomen with fist just behind the ribs, compress the abdomen 3–5 times with quick inward-up pushes, check the mouth for the foreign body, and repeat 1–2 more times if necessary.

Chronic • UTI, kennel cough, URI

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• What is your animal’s ability to urinate?

• Avoid pressure on the abdomen.

• Is your animal coughing?

• Once arriving at the clinic, leave your animal in the car while checking in.

• Is your animal in labor?

• Place the delivered neonates in a box with heat support (warm water bottles or heating pad wrapped in a towel). • Gently transport the female as she may be quite uncomfortable.

Skill Box 7.1 / Inducing Vomiting At-Home Inducing vomiting is a very common treatment for a foreign body or toxic ingestions. However, care must be taken before giving this advice or performing the procedure as it can be more dangerous to bring the item back up versus letting the animal digest or pass the item. For example, alkalis, acids, corrosive agents, petroleum products, or hydrocarbons should not be expelled, and animals with preexisting conditions such as epilepsy, cardiovascular disease, debilitated, or recent abdominal surgery or those with a potential for gastric torsion should avoid induced vomiting. One of the best resources for accurate information is the Poison Control Center (800-222-1222) or the ASPCA Poison Control Center (888-426-4435 with a possible consultation fee). Vomiting at-home is best performed using hydrogen peroxide (H2O2) within 2–3 hours postingestion with expectation of getting 40–60% of the stomach contents expelled. Three percent H2O2 produces mild gastric irritation leading to vomiting. Higher strengths or overdosing will lead to severe gastritis, especially in cats. If no vomiting occurs after the second

dose, the animal should be brought in for administration of apomorphine and/or other treatments. H2O2 Dose 1 mL (1 tsp) per lb. to a maximum dose of 45 mL (3 Tb) This dose may be repeated 1 time in 10 minutes. Tips for a Successful At-Home Procedure 1. Verify the H2O2 is a 3% strength. 2. Verify the H2O2 has not expired. 3. Feed a small meal, e.g., 1–2 pieces of bread. 4. Administer the H2O2. a. Mix with equal parts of milk or ice cream (1 Tb. H2O2 + 1 Tb. milk). b. Use a liquid medicine syringe, sports squirt bottle, or turkey baster. 5. Exercise the animal (e.g., playing fetch, quick walk). CHAPTER 7 / EMERGENCY MEDICINE

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Triage When presented with an animal suffering a life-threatening problem, a successful outcome requires hospital readiness, effective teamwork, practiced triage skills, and a rapid response to primary survey abnormalities. “Triage” is the process of giving priority to those patients with the most critical problems. This begins with the assessment of the 3 major body systems: respiratory, cardiovascular, and neurologic. This quick primary survey will allow the best approach to treatment to be continued during the secondary survey. The primary survey is a brief physical examination. Many details are ascertained simultaneously to obtain the information quicker. Even though obvious injuries can be alarming, the patient must have a stable cardiovas-

cular and respiratory system before other injuries are addressed. Begin the assessment as you approach the animal, evaluating the presenting clinical signs. Next, address any arterial vessel injury. Respirations can then be appreciated with auscultation while also evaluating the heart. If no respirations are heard, oxygen supplementation via ET tube or tracheostomy should be done. The heart should have clear decisive sounds heard from either side and should be evaluated in conjunction with the peripheral pulse. The patient’s capillary refill time, mucous membrane color, and body temperature should also be evaluated. Any alterations should be addressed (e.g., CPCR, drug administration, debrillator, etc.) to stabilize the patient. The central nervous system should also be evaluated through pupillary response and position, reflexes, and presenting clinical signs.

Table 7.3 / Primary Survey

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Presenting Clinical Signs

Physical Examination

Causes

Immediate Action

• No passage of air • Loud inspiratory or expiratory sounds • Altered breathing patterns • ↑ Respiratory effort, dyspnea • Change in mucous membrane color

• • • • • • • •

Respiratory distress Complete or partial obstruction Upper airway trauma or rupture Pneumothorax Hemothorax Pulmonary contusions Diaphragmatic hernia Flail chest

• Oxygen therapy • Intubate orally or by slash tracheostomy • Remove foreign object manually or by a modified-Heimlich maneuver • CPCR

• Change in mucous membrane color and moisture • Delayed capillary refill time • Pulse presence and intensity • Heart rate and rhythm • Hyper- or hypothermia • Cold extremities • Crackles in lung fields on auscultation

• • • • •

Arterial or venous injury Heart failure Thromboembolism Pleural effusion Pulmonary edema

• • • • •

Respiratory • • • • • •

Panting (feline) Paradoxical respiration Open mouth breathing Coughing ↑ or ↓ Respiratory rates Extended head or neck with abducted elbows • Nasal flare Cardiovascular • • • • •

External hemorrhage Panting Weakness, collapse Abdominal distention Cough, exacerbated with activity or exercise

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SECTION THREE: DIAGNOSTIC SKILLS

Hemostasis Oxygen therapy CPCR Thoracocentesis/pericardiocentesis ECG monitoring

Table 7.3 / Primary Survey (Continued) Presenting Clinical Signs

Physical Examination

Causes

Immediate Action

• Pupillary response, size, and position • Eye position: strabismus, nystagmus • Motor reflexes • Pain response • Hyperthermia • Hypertonia • Hyperflexia

• • • • • •

• Oxygen therapy • Anticonvulsants

• Changes in conformation, limb angles • Pain response • Bleeding soft tissue wounds

• Trauma

Central Nervous System • • • •

Level of consciousness Head position Seizuring Ambulation • Severe front end rigidity and hindend weakness: Shiff-Sherrington Syndrome • Generalized weakness/paresis

Heat trauma Intoxication Spinal cord injury Seizures Infections; bacterial, parasitic Vestibular syndrome

Body Condition • • • • •

Lacerations Fractures/malalignments Eye injuries Abdominal distention Burns

• Oxygen therapy • Analgesics • Wound care: keep moist with a sterile water soluble lubricant and sterile dressing • Fractures: clip, examined, stabilize

Skill Box 7.2 / Hemostasis Controlling hemorrhage can be a first-line defense against shock, allowing the patient to maintain an adequate volume of blood. Initially, direct digital pressure can be placed to provide hemostasis. This can be direct pressure over the injury (or if an extremity or tail) by encircling the area proximal to the injury and applying pressure. Sterile dressings should always be used to avoid contamination of the wound. Pressure wraps can be placed for hemostasis. If the wrap becomes soaked, another wrap

should be placed on top of the first. Tourniquets should be avoided as they can cause tissue and nerve damage within minutes. With arterial hemorrhage, the artery should be clamped and ligated when possible. If that is not possible, direct pressure should be placed on a pressure point following one of the techniques below dependent on which artery is compromised.

Area of Hemorrhage

Pressure Point

Area of Hemorrhage

Pressure Point

• Maxillary artery

• Deep area adjacent and ventral to the mandible

• Inguinal artery

• Caudal abdomen

• Brachial artery

• Axillary area

• Distal extremity artery

• BP cuff placed proximal to the injury with a pressure of 200 mm Hg

• Femoral artery

• Inguinal and femoral canal region

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Skill Box 7.3 / Cardiopulmonary Cerebrovascular Resuscitation (CPCR) CPCR should ideally be conducted on an adjustable height solid table. Depending on the size of the animal and staff, it may be necessary to provide a stool or perform the procedure on the floor. A surgical grated prep table should not be used for CPCR as it does not provide the counterpressure needed for chest and abdominal compressions. The steps below should be assigned to various team members so that the animal’s resuscitation is conducted as smoothly and thoroughly as possible.

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A. Airway Alert the emergency team of upcoming arrival of patient. Assess the airway. • Extend the patient’s head and neck and pull tongue forward; remove any debris manually or with suction. • Establish a patent airway with endotracheal intubation or a slash tracheostomy. B. Breathing Assess breathing. • Confirm apnea. • Provide mechanical ventilation via an Ambu bag or anesthetic machine with 100% oxygen at a rate of 150 mL/kg/min. • Initiate with 2 breaths for 2 seconds each. • Reassess for spontaneous respiration. • If none, continue at 12–20 breaths/min (1 breath/3–5 seconds) and attempt acupuncture to stimulate respiration. (Place a 25-gauge needle into the midline just below the nose [philtrum] at acupuncture point governing vessel [GV] 26. Penetrate the skin and subcutaneous tissue from 2 to 4 mm. Rotate the needle up and down at this point to stimulate the site.) • Each breath should have an expiration slightly longer than inspiration and a manometer pressure reading of: • Canine pressure: ≤20 cm H2O • Feline pressure: ≤15 cm H2O C. Circulation Assess circulatory function. • Confirm absence of heart beat and peripheral pulses. • External cardiac compression • Provides ∼30% of normal cardiac output • Check for femoral or carotid artery pulse repeatedly throughout this process. • Animal weighing 7 kg: lay in right lateral or dorsal recumbency and start compressions with the palm of the hands over the distal 1/3 of the rib cage. • Use enough force to displace the thorax 30%. • Respirations are given with every or every other compression. • Abdominal compressions are given between chest compressions. • One person: 5 compressions, then 1 ventilation. • Two people: 1 compression, then 1 ventilation. • Three people: 1 compression, 1 ventilation, then 1 abdominal compression. • Internal cardiac compression • Provides 60–90% more effective cerebral and coronary perfusion • Preferred method with rib fractures, pleural effusion, pneumothorax, cardiac tamponade, diaphragmatic hernia, flail chest • Initiated after 5 minutes if effective tissue perfusion is not seen 308

SECTION THREE: DIAGNOSTIC SKILLS

Skill Box 7.3 / Cardiopulmonary Cerebrovascular Resuscitation (CPCR) (Continued) • Initiated after 10 minutes is spontaneous rhythm has not returned • Place in left lateral recumbency and a thoracotomy is performed at the 5th–6th intercostal space. • The palm and fingers are used to pump the heart in a rhythmic fashion. D. Drugs (atropine, epinephrine, lidocaine, naloxone, magnesium chloride) E. Evaluation of the patient with a thorough examination ECG F. Fibrillation Control Fluids

Table 7.4 / Secondary Survey

After the primary survey, the patient is classified as stable, potentially unstable, or unstable. Following this determination, resuscitation of vital functions and stabilization of life-threatening problems takes place. Once stable, a thorough past and current medical history, physical examination, and laboratory database are obtained. This is followed by reassessment of the original treatments. Secondary Survey

History and Procedures

Past Medical History

• • • • •

Medical conditions Drug therapies Allergies Vaccination history Previous transfusions

Current Medical History

• • • • • • • • • •

Presenting complaint When animal was last normal Chronology and progression of signs Potential toxin ingestion Physical trauma Signs of collapse, weakness or ↓ ability to exercise Signs of abnormal neurologic behavior Travel history Access to other animals Affinity to eat abnormal things

Physical Examination

• Vital signs • Evaluation of organ systems not involved • See Chapter 2 Physical Examination, page 18.

Stat Lab Database

• • • •

PCV, TP Chemistry panel and electrolytes Complete blood count Urinalysis

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Table 7.5 / Shock

Shock is typically the result of poor oxygen delivery. The goal, regardless of form, is to optimize oxygen delivery. The most effective way to improve oxygen delivery is to ↑ cardiac output by optimizing preload with fluid administration. Cardiogenic Shock

Septic Shock

Definition

Diminished blood volume leading to tissue perfusion failure.

Tissue perfusion failure due to inadequate cardiac output

Circulatory disorder due to bacteria or bacterial endotoxin release

Cause

Hemorrhage, fluid loss (e.g., burns, vomiting, diarrhea, ↑ urine production), poor venous return (e.g., GDV), severe GIT bleed, severe epistaxis, addisonian crisis (e.g., hypotension)

Cardiomyopathy, cardiac tamponade, cardiac arrhythmias, heartworm disease, pulmonary hypertension, pulmonary thromboembolism, pericardial disease, heart failure, valvular disease with decompensation

GIT compromise/rupture, urinary tract infection (UTI), septic peritonitis, pneumonia, bacterial endocarditis, bite wounds, myelosuppression, prostatitis

Presenting Clinical Signs

• Muscle weakness, mental depression

• Muscle weakness or collapse, mental depression, cough, labored breathing

• Extreme weakness, mental depression

Primary Survey Findings

Compensatory stage: bounding pulses, cool extremities, pale or hyperemic mucous membranes, hypertension, delayed CRT, tachycardia, tachypnea Decompensatory stage: hypotension, hypothermia, ↓ mental status, oliguria, pale or muddy mucous membranes, delayed CRT, poor peripheral pulses, tachycardia or bradycardia

Abnormal heart sounds (e.g., gallop, murmur), arrhythymias, cardiac tamponade (tachycardia, weak pulses, hepatomegaly, jugular distention), cool extremities or hypothermia, dyspnea or tachypnea, harsh lung sounds or crackles, pale or cyanotic mucous membranes, prolonged CRT, variable HR and RR, weak femoral pulses and pulse deficits

Compensatory stage: bounding pulses, dyspnea or tachypnea, hyperemic mucous membranes, hypertension, mental depression, pyrexia, rapid CRT (60 minutes without delivery of a fetus, anorexia, fever, foul-smelling or purulent vulvar discharge, hot/swollen/painful mammary glands, muscle weakness, time delay between pups/kittens >4–5 hours

Equipment

• • • •

Basic crash cart equipment Specialized crash cart equipment Radiology Ultrasonography

Medication

• • • • •

Antibiotics Analgesics Ecbolic agents Metabolic imbalances (e.g., Ca2+, potassium, insulin, dextrose) NSAIDs

Procedures

• Imaging: • Abdominal radiographs • Ultrasonography • Lab tests: • Stat lab database • Vaginal cytology • Blood gas analysis • Manual manipulation, hyperosmotic topical therapy to shrink tissues • Surgery

Monitoring

• • • •

Treatment

Preparation

Presentation

Emergent Condition

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General: Mentation, body temperature, Elizabethan collar, pain management Cardiovascular: HR and rhythm Renal: Urine output Lab tests: PCV, TP, electrolytes, BUN, creatinine, liver enzymes

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Table 7.16 / Respiratory Emergencies • Aspiration pneumonia, brachycephalic occlusive syndrome, bronchitis, cancer, collapsing trachea, diaphragmatic hernia, feline asthma, flail chest, tracheal and bronchial foreign bodies, hemothorax, laryngeal paralysis, lung contusions, lung parenchymal issues, pleural effusion, pneumomediastinum, pneumonia, pneumothorax, pulmonary edema, smoke inhalation, soft tissue swellings, tracheal stenosis

Presenting Clinical Signs

• Abduction of elbows, cough, flared nostrils, head straightened, hemoptysis, lips drawn back, neck extended, preference to stand or lie in sternal recumbency, reluctance to hold mouth closed, subcutaneous emphysema, wheezing, apnea, dyspnea, open mouth breathing

Primary Survey Findings

• Hyperthermia, ↑ respiratory rate and effort, abnormal respiratory sounds (e.g., laryngeal stridor), irregular respiratory pattern, change in mucous membranes color, tachycardia

Equipment

• Basic crash cart equipment • Specialized crash cart equipment

Medication

• • • • • •

Antibiotics Bronchodilators Cough suppressants Diuretics Steroids Tranquilizers

Procedures

• • • •

Airway suctioning Bronchioalveolar lavage Chest tube placement Imaging: • Thoracic radiographs • Tracheoscopy, bronchoscopy for foreign body retrieval Lab tests: • Stat lab database • Blood gas analysis • Heartworm tests • Fecal analysis • Fluid analysis Oxygen and/or ventilator therapy Surgery Thoracocentesis Tracheostomy, nasal catheter, transtracheal catheter Transtracheal wash

Treatment

•

• • • • • Patient Care

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Preparation

Presentation

Emergent Condition

322

Monitoring

SECTION THREE: DIAGNOSTIC SKILLS

• General: Pain management, minimal patient handling, calm and quiet environment, turn recumbent patients every 2–4 hours, use harnesses instead of collars • Respiratory: RR and effort, lung sounds, nebulization/coupage • Cardiovascular: HR and rhythm, pulse quality and rate, BP, mucous membranes, SpO2 • Renal: Urine output • Lab tests: Blood gas analysis

Table 7.17 / Toxicologic Emergencies

Patient Care

• Bacterial/fungal toxins, food ingredient (e.g., grapes, onions), household compounds/chemicals, household plants, insecticides, herbicides, medication ingestions/overdoses, pesticides, rodenticides, zinc ingestion

Presenting Clinical Signs

• Ataxia, coma, diarrhea, hyperexcitability, hypersalivation, muscle tremors, progressive depression, stupor, vomiting, weakness, dyspnea, seizures, anuria

Primary Survey Findings

• Abdominal pain, facial edema, hyperthermia, mouth odor, cardiac arrhythmias, cyanosis, pallor mucous membranes, urinary incontinence, vomiting

Equipment

• Basic crash cart equipment • Specialized crash cart equipment

Medication

• • • • • • •

Procedures

• • • • • •

Monitoring

• • • • • •

Treatment

Preparation

Presentation

Emergent Condition

Anticonvulsants Antidote (if available and specific toxin identified) Antiemetics Diuretics Emetics Gastrointestinal protectants Muscle relaxants

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Bathing, rinsing ECG Enemas Emesis Gastric lavage and charcoal administration Imaging: • Radiographs • Lab tests: • Stat lab database • Ethylene glycol testing • Coagulation testing General: Mentation, body temperature Respiratory: RR and effort Cardiovascular: HR and rhythm, pulse rate and quality, CVP Neurologic: Tremors, seizures Renal: Urine output Lab tests: Electrolytes, BUN, creatinine, urinalysis

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Table 7.18 / Toxins

The goals with poisoning are always the same—prevent further exposure, ↓ absorption, hasten elimination, and provide supportive care. The prognosis for each situation depends on the toxin, quantity, and time delay from initial exposure to toxin.

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Toxin

Toxic Doses

Clinical Signs

Treatment

Acetaminophen

Canine: 150 mg/kg Feline: 50–60 mg/kg Onset: hours to days

• Brown mucous membranes and blood, depression, facial or paw edema, hepatic necrosis, hypothermia, icterus, vomiting, weakness, cyanosis, dyspnea, tachypnea, keratoconjunctivitis sicca (canine)

• Emesis, gastric lavage, cathartics, oxygen therapy, blood transfusions, diuresis, cimetidine, ascorbic acid • Antidote: 5% N-acetylcysteine (NAC) solution

Amphetamines

1.3 mg/kg Onset: variable

• Agitation, circulatory collapse, coma, hyper- or hypotension, hyperactivity, hypertension, hyperthermia, mydriasis, pallor or hyperemic mucous membranes, ptyalism, restlessness, tremors, tachypnea, cardiac arrhythmias, tachycardia, seizures

• Emesis, gastric lavage, activated charcoal, cathartics, oxygen therapy • Antidote: chlorpromazine

Ethylene glycol

Canine: 4–6 mL/kg Feline: 1.5 mL/kg Onset: 30 minutes–12 hours

• Ataxia, coma, depression, knuckling, lethargy, nystagmus, vomiting, tachypnea, tachycardia, polydipsia, polyuria, seizures

• Blacklight detection, emesis, gastric lavage, supportive care • Antidote: 20% ethanol (feline), 4-methylpyrazole (canine)

Ibuprofen

Canine: 100 mg/kg Feline: 50 mg/kg Onset: 1–4 hours

• Abdominal pain, anorexia, coma, depression, diarrhea, hematemesis, melena, polyuria, stupor, vomiting, seizures

Emesis, gastric lavage, activated charcoal, GIT protectants, diuresis

Metaldehydes • Snail and slug bait

100 mg/kg Onset: 1–4 hours

• Anxiety, ataxia, hyperesthesia, hypersalivation, hyperthermia, incoordination, nystagmus, pulse irregularities, tremors, bradypnea, tachy- or bradycardia, seizures

• Milk, emesis, gastric lavage, activated charcoal • Antidote: none

Organophosphates • Sprays, dusts, dips

Variable Onset: variable

• Colic, diarrhea, hypersalivation, lacrimation, miosis, tremors, vomiting, bronchoconstriction, excessive bronchial secretions, bradycardia, seizures, frequent urination

• Bathing, activated charcoal, cathartics, anticholinergics • Antidote: pralidoxime chloride

Pyrethrins/pyrethroids • Sprays, dips, foggers

Variable Onset: variable

• Anorexia, ataxia, depression, diarrhea, disorientation, hyperactivity, hyperexcitability, hypersalivation, muscle twitching, tremors, vocalization, vomiting, bradycardia, dyspnea, seizures

• Bathing, emesis, gastric lavage, activated charcoal, cathartics, anticholinergics

• Permethrin

Onset: 3–72 hours

• Tremors, seizures

• Bathing (liquid hand soap), methocarbamol, barbiturates, and/or propofol

Insecticides

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Table 7.18 / Toxins (Continued) Toxin

Toxic Doses

Clinical Signs

Treatment

Lily

Onset: 2 hours

• Anorexia, depression, vomiting, polyuria

• Emesis, activated charcoal, cathartics

Mushrooms

Variable Onset: 6–8 hours

• Abdominal pain, ataxia, coma, defecation, depression, diarrhea, DIC, hallucinations, hyperthermia, lacrimation, nausea, salivation, vomiting, seizures, urination

• Emesis, gastric lavage, activated charcoal, cathartics, bowel irrigation, oxygen therapy, supportive care

Pseudoephedrines

5–6 mg/kg Onset: 15–30 minutes

• Agitation, head bobbing, hyperactivity, hypertension, hyperthermia, mydriasis, panting, tremors, cardiac arrhythmias, tachycardia, seizures

• Emesis, gastric lavage, activated charcoal, GIT protectants, diuresis

Anticoagulant • Warfarin, pindone, bromadiolone, brodifacoum, chlorphacinone, difethialone, diphacinone, coumafuryl, dicoumarol, difenamrol

Variable Onset: 6 hours–2 days

• Anorexia, blindness, depression, ecchymoses, epistaxis, exercise intolerance, frank and petechial hemorrhage, hematemesis, hematochezia, lameness, lethargy, melena, pale mucous membranes, paralysis swollen joints, weakness, cough, dyspnea, hematuria

• Emesis, activated charcoal, cathartics, blood transfusions, oxygen therapy • Vitamin K therapy

Bromethalin

Canine: 4.7 mg/kg Feline: 1.8 mg/kg Onset: immediate–2 weeks

• Anisocoria, CNS depression, excitement, forelimb extensor rigidity, head pressing, hyperesthesia, hyperexcitability, hyperthermia, loss of vocalization, paralysis, paresis, Schiff-Sherrington posture, tremors, weakness, seizures

• Emesis, gastric lavage, activated charcoal, cathartics, bowel irrigation, supportive care, diuretics, steroids, Ginkgo biloba • Antidote: none

Cholecalciferol • Vitamin D3

0.1 mg/kg Onset: 12–36 hours

• Anorexia, constipation, depression, hematemesis, hypertension, lethargy, muscle weakness, petechiation, vomiting, ventricular fibrillation, polydipsia, polyuria, seizures

• Emesis, gastric lavage, activated charcoal, cathartics, diuretics, steroids • Antidote: calcitonin, pamidronate

Snakebite envenomation

Variable Onset: immediate

• Dilated pupils, edema, fang marks, hemorrhages, pain, salivation, swelling, tachycardia

• Supportive care • Antidote: antivenin, trivalent crotalidae, atropine

Spider bite envenomation

Variable Onset: immediate-weeks

• Abdominal rigidity, hypersalivation, hypertension, muscle spasms and rigidity, pain, restlessness, salivation, respiratory distress, bronchorrhea

• Supportive care • Antidote: antivenin, dantrolene sodium, Dapsone

Theobromine • Chocolate

10–15 mg/kg Milk chocolate: 44 mg/oz theobromine Baking chocolate: 390 mg/ oz theobromine Onset: 2–4 hours

• Abdominal pain, agitation, ataxia, bloating, coma, cyanosis, diarrhea, hyper- or hypotension, muscle tremors, vomiting, cardiac arrhythmias, tachycardia, seizures, hematuria, polydipsia, polyuria, urinary incontinence

• Emesis, gastric lavage, activated charcoal, cathartics, supportive care, ECG, urinary catheter • Anticonvulsants and antiarrhythmics

Plants

Rodenticides

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Table 7.19 / Trauma Emergencies

Preparation

Presentation

Emergent Condition Presenting Clinical Signs

• Depression, fractures, lacerations, limping, loss of consciousness, pain, panting, shivering, shock, seizures

Primary Survey Findings

• Burns, hemoptysis, hemorrhage, hyper- or hypothermia, necrosis of lips/tongue, pain, petechiation, dyspnea, irregular lung sounds, patterns and rates, maligned or deformed limbs, pneumomediastinum, pneumothorax, pulmonary edema, subcutaneous emphysema, thoracic or abdominal effusion, tachy- or bradycardia

Equipment

• Basic crash cart equipment • Specialized crash cart equipment

Medication

• • • •

Procedures

• • • • •

Monitoring

• • • • •

Patient Care

Treatment

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326

• Animal attack, burns, fractures, hit by car, lacerations

SECTION THREE: DIAGNOSTIC SKILLS

Analgesics Antibiotics Blood transfusions Corticosteroids

Abdominal tap/abdominal pressure wrap Bandaging, splinting, and basic wound care ECG Heat support Imaging: • Thoracic and abdominal radiographs • Spinal and skull radiographs • Ultrasonography • Lab tests: • Stat lab database • Blood gas analysis • Oxygen therapy • Surgery General: Mentation, body temperature, pain management, immobilize as needed Respiratory: RR and effort, lung sounds Cardiovascular: HR and rhythm, pulse rate and quality, BP, ECG, CVP, SpO2 Renal: Micturition reflex, urine output Lab tests: PCV, TP, electrolytes, BUN, blood glucose, blood gas analysis, platelet count

Section

Four

Patient Care Skills Chapter 8: Patient Care 329 Chapter 9: Pain Management 379 Chapter 10: Wound Care 395

Chapter 11: Parenteral Nutrition 413 Chapter 12: Medical Procedures 427

Chapter

8

Patient Care Patient Monitoring 332 Blood Pressure 332 Blood Pressure Procedure 332 Blood Pressure Results 333 Central Venous Pressure 334 Blood Gas Analysis 335 Blood Gas Analysis 335 Arterial Blood Gas Interpretation 337 Acid-Base Disturbances 337 Electrocardiogram 338 ECG Procedure 338 ECG Leads 339 ECG Interpretation 340 Figure 8.1 Normal Canine Electrocardiogram 341 Heart Rate Calculation 342 Common Rhythm Abnormalities 343 Figure 8.2 Atrial Premature Contraction/Complex 344 Figure 8.3 ST-Segment Elevation 344 Figure 8.4 Ventricular Premature Contraction/ Complex 344

ECG Problems and Artifacts 345 Heat Administration 346 Recumbent Patient Care 347 Drug Administration 348 Injections 348 Intravenous Catheter Placement 349 Peripheral and Jugular 349 Arterial and Intraosseous 350 Monitoring and Maintenance 351 Chemotherapy 352 Administration 352 Toxicity 353 Client Education: Monitoring Chemotherapy Response 356 Insulin Therapy 357 Client Education: Insulin Administration 357 Client Education: Monitoring Insulin Response 358 Client Education: Monitoring for Hypoglycemia 359 Fluid Therapy 359 Hydration Assessment 360

8

329

Calculating Fluid Requirements 361 Routes of Fluid Administration 362 Commonly Used Fluids 363 Fluid Additives 365 Calculating Drip Rates 365 Monitoring Fluid Therapy 366 Blood Transfusions 367 Blood Types 368 Blood Collection 369

8

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SECTION FOUR: PATIENT CARE SKILLS

Blood Products 371 Blood Administration 373 Blood Transfusion Reactions 374 Oxygen Therapy 375 Oxygen Administration 375 Routes of Oxygen Administration 376 Oxygen Hood and Nasal Catheter 376 Transtracheal Catheter and Tracheostomy

377

Key Words and Phrasesa Acidotic Alkalosis Alloantibody Amplitude Antiemetics Antipyretics Apex Ataxia Bipolar Cachexia Carbohydrate Chemo-pin Crystalloids Cyanosis Decubital Diastolic Electromechanical dissociation Epistaxis Erythema Extracellular Extravasation F wave Fructosamine Glycosylated Hemolyzed Holter apparatus Humidification Hypercalcemia Hyperglycemia Hyperkalemia Hypernatremia Hyperoncotic Hypochloremia Hypoglycemia Hyponatremia Hyporeflexia Immunogenic Infarction a

Intracellular Ischemia Isoantibody Manometer Metabolic acidosis Metabolic alkalosis Microaggregates Myelosuppressive Myocardium Nadir Neuropathy Neutropenia Normovolemic Oscillometric Osmotic Osteopenia Papilledema Perfusion Perioperative Petechiae Pollakiuria Polydipsia Polyuria Precordial Prophylaxis Pruritis Repolarization Respiratory acidosis Respiratory alkalosis Serous Stranguria Supraventricular Systolic Tetany Thrombocytopenia Turgor Unipolar Urticaria Vagal

Abbreviations APC, atrial premature contraction/complex APTT, activated partial thromboplastin time aVF, augmented voltage foot aVL, augmented voltage left arm aVR, augmented voltage right arm BG, blood glucose BGC, blood glucose curve bpm, beats per minutes BW, body weight C, Celsius CBC, complete blood count CHF, chronic heart failure CO2, carbon dioxide CPCR, cardiopulmonary cerebrovascular resuscitation CPD, citrate phosphate dextrose CPDA-1, citrate phosphate dextrose adenine CRT, capillary refill time CVP, central venous pressure D5W, 5% dextrose in water DEA, dog erythrocyte antigen DIC, disseminated intravascular coagulation DMSO, dimethylsulfoxide ECG, electrocardiogram E-collar, Elizabethan collar ET, endotracheal tube FeLV, feline leukemia virus FFP, fresh frozen plasma FIV, feline immunodeficiency virus FP, frozen plasma Fr, French FUO, fever of unknown origin GFR, glomerular filtration rate H2O, water IM, intramuscular IO, intraosseous IV, intravenous

Additional Resources, page KCl, potassium chloride kg, kilogram L, liter LA, left arm lb, pound LL, left leg LRS, lactated Ringer’s solution mg, milligram dL, deciliter min, minute mL, milliliter NaCl, sodium chloride NSAIDs, nonsteroidal antiinflammatory drugs O2, oxygen PCV, packed cell volume PPV, positive pressure ventilation pRBCs, packed red blood cells PT, prothrombin time PZI, protamine zinc insulin R, right RA, right arm RBC, red blood cell RL, right leg SA, sinoatrial SIRS, systemic inflammatory response syndrome SQ, subcutaneous STD, standard SWB, stored whole blood TP, total protein V, voltage VPC, ventricular premature contraction/complex WBC, white blood cell

Anatomy, 3 Anesthesia, 439 Blood chemistries, 74 Canine transmissible diseases, 38 Cardiology, 204 Feline transmissible diseases, 44 General medicine, 201 Injections, 348 Laboratory, 71 Nebulization, 432 Nutrition, 57 Radiographs, 159 Surgery, 521 Urinalysis, 147

8

Key words and terms are defined in the glossary on page 631.

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331

PATIENT MONITORING Monitoring of a hospitalized patient is one of the crucial responsibilities of a veterinary technician. This section includes some basic monitoring skills;

blood pressure, central venous pressure (CVP), cardiac values (ECG readings), and heat administration. See Skill Box 13.8, page 467, and Chapter 9 Pain Management, page 379, for further monitoring information.

Blood Pressure Skill Box 8.1 / Blood Pressure Procedure Measuring accurate blood pressures on animals is not trivial, and lots of experience and attention to every detail is important:—limb selection, proper cuff size, snug fit of the cuff, position of the animal—is important so that no weight or pressure is on the measurement limb or cuff, the animal is a relaxed and still. Research has shown that if an animal is upset or agitated due to handling or due to the measurement procedure itself, it will take 8–10 minutes after the animal is calmed and relaxed for the animal’s blood pressure to return to normal. Measurements on an agitated animal are not an indication of their normal blood pressure and are usually worthless clinically when diagnosing a hypertensive animal. 8

Method:

Direct Arterial Pressure

Doppler Ultrasound Flow Detectors

Oscillometric

Indications

• Monitoring during anesthesia, CPCR, shock, fluid administration, and any other condition leading to secondary hyper- or hypotension

• Monitoring during anesthesia, CPCR, shock, and any other condition leading to secondary hyper- or hypotension • Detection of flow in distal limbs (e.g., traumatic wounds, saddle thrombi), corneal flow during CPCR • Irregular pulse signals or rates can indicate cardiac arrhythmias.

• Monitoring during anesthesia, CPCR, shock, fluid administration, and any other condition leading to secondary hyper- or hypotension

Contraindications

• Using large vessels in patients with coagulopathies • Upset or agitated patients

• Upset or agitated patients

• Upset or agitated patients

Setup

• Catheter (e.g., arterial, over-the-needle, through-the-needle) • Heparinized saline • Pressure transducer and monitor

• Equipment • Ultrasonic gel

• Equipment (e.g., petMAP)

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Skill Box 8.1 / Blood Pressure Procedure (Continued) Method:

Direct Arterial Pressure

Doppler Ultrasound Flow Detectors

Oscillometric

Procedure

The catheter is placed in an artery (e.g., dorsal pedal, femoral, or auricular) and flushed with 1–1.5 mL of heparinized saline. The catheter is thoroughly secured with tape to avoid dislodging or kinking. The catheter is then labeled to prevent inadvertent intra-arterial injections. The catheter is then connected to the pressure transducer by rigid tubing filled with heparinized saline. Refer to the manufacturer’s guidelines for further setup and monitoring instructions. The method for measuring CVP can also be used if a transducer system is not available.

Place the patient in a comfortable position. Select a cuff that has a width that is approximately 40% of the circumference of the patient’s distal limb or tail. Snugly place the cuff on any place an artery is accessible, typically a limb distal to the elbow or hock or the base of the tail. Place the probe over the artery but distal to the cuff, turn on Doppler, and listen for blood flow. Position probe until a clear flow is heard and tape into place. Inflate the cuff and slowly release the trigger until the first flow sound is heard, this is the systolic pressure. The second sound heard is the diastolic, which often cannot be heard.

Place the patient in a comfortable position. Select a cuff that has a wdith that is approximately 40% of the circumference of the patient’s distal limb or tail. Snugly place the cuff on any place an artery is accessible, typically a limb distal to the elbow or hock or the base of the tail. Connect the cuff to the monitor and turn on. The cuff is inflated until the artery is occluded and then slowly released until the pulse returns. The systolic, diastolic, and mean arterial pressures and heart rate will be displayed.

Complications

• Hemorrhage, thrombosis, infection, and necrosis

• Poor contact between probe and artery

• Poor blood flow, small arteries, movement, shaking, or shivering can lead to inaccurate results.

Tip: Doppler: if the skin is dry, rub in ultrasonic gel first and then apply more when placing the probe over the artery.

Table 8.1 / Blood Pressure Results

The normal and abnormal values for blood pressure measurements are clearly defined in human medicine but have not yet been solidly established in veterinary medicine. The following table shows the ranges currently accepted.

a

Blood Pressure

Normal

Abnormala

Canine

• Systolic: 110–160 mm Hg • Diastolic: 60–100 mm Hg • Mean: 80–120 mm Hg

• Systolic: 160 mm Hg • Diastolic: >100 mm Hg • Mean: 120 mm Hg

Feline

• Systolic: 120–170 mm Hg • Diastolic: 70–120 mm Hg • Mean: 80–120 mm Hg

• Systolic: 160 mm Hg • Diastolic: >120 mm Hg • Mean: 120 mm Hg

Abnormal results do not necessarily warrant therapy.

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8

Skill Box 8.2 / Central Venous Pressure The CVP measures the heart’s ability to pump fluids returned to it and also evaluates blood volume compared to blood volume capacity. The pressure within the intrathoracic anterior vena cava is compared to a column of water in a manometer or pressure transducer and oscilloscope. Fluctuations are seen with changes in pressure. An ↑ CVP can indicate a backup of blood due to excessive volume (e.g., fluid overload) leading to ascites, pulmonary edema, pneumothorax, or pneumomediastinum. A ↓ CVP can indicate a ↓ blood volume (e.g., dehydration) leading to hypovolemia. An initial crude estimate of CVP can also be done by evaluating resting jugular distention, then filling and relaxation time with digital occlusion. The jugular vein is clipped and observed: Passive • Observed for tension • Mildly distended: often seen with patients in lateral recumbency • Highly distended: patient standing or in sternal recumbency indicates a ↑ CVP • Flat: indicates ↓ CVP and hypovolemia Active Test • Occluded with digital pressure and observed for filling time and then released and observed for relaxation time • ↓ Filling time: >4 seconds indicates ↓ CVP and hypovolemia • ↓ Relaxation time: >2 seconds indicates right side of the heart may be overloaded as with chronic right-sided heart failure, chronic liver disease, acute heart failure 8

Method

Central Venous Pressure

Indications

• Patients prone to hypertension (e.g., renal or liver failure)

Contraindications

• Burn, abrasion, or pyoderma over site, severe coagulopathy, hypercoagulable, or thrombosis of chosen vein inhibiting jugular catheter placement

Setup

• Surgical site preparation materials • IV jugular catheter • Heparinized saline

Procedure

A jugular catheter is placed and advanced to the cranial vena cava. (See Skill Box 8.9 Intravenous Catheter Placement, Peripheral and Jugular, page 349.) Attach an extension set to the catheter, followed by a 3-way stopcock. Attach the IV fluids to the open line of the stopcock. Attach the manometer to the upright opening of the stopcock. Place the patient in sternal recumbency, and position the manometer at the level of the sternum. Turn off the fluids to the patient and fill the manometer with fluids. Open the extension set and the fluid level will equalize. The level at which the fluids stabilizes is the CVP reading. Repeat twice more for accurate results.

Complications

• Blood clots or occlusions can ↑ values. • If fluids are not running through the catheter, flush with heparinized saline every hour.

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SECTION FOUR: PATIENT CARE SKILLS

• 3-way stopcock • Bandaging materials • IV fluid set up

Skill Box 8.2 / Central Venous Pressure (Continued) Method

Central Venous Pressure

Results

Normal: 12–15 cm H2O • Monitor trends over time, not a single reading. Following a Fluid Bolus • Normovolemic: ↑ of 2–4 cm H2O with a return to baseline in 15 minutes • Hypovolemic: ↑ with a rapid return to baseline • Hypovolemic (severe): small or no ↑

Tip: Jugular catheter placement can be verified by the 2–5 mm fluctuations seen on the manometer with each respiration.

Blood Gas Analysis 8 Skill Box 8.3 / Blood Gas Analysis Blood gas analysis is used to monitor pulmonary function and the metabolic state of the patient through the delicate balance between carbon dioxide (CO2), bicarbonate (HCO3−), hydrogen (H+), and oxygen (O2). With a change in CO2 or HCO3−, alterations are seen in the body’s pH, ultimately affecting its ability to carry out various enzyme activities. The acid-base equation (CO2 + HCO3 ↔ CO2 + H2O) shows how a change in CO2 or HCO3− can alter the pH. The lungs are primarily responsible for regulating CO2 through respiration, while the kidneys regulate HCO3− through resorption and excretion in the proximal tubule. Because CO2 and HCO3− are the main determinates to the acid-base status (pH) of a patient, a change in one factor can affect the other. For example, it is common to see respiratory changes with metabolic disturbances. The body’s ability to compensate for abnormalities can often mask underlying disturbances, making diagnosis and treatment more difficult. Method

Blood Gas Analysis

Indications

• Patients with respiratory disease and/or metabolic disturbances (e.g., toxins, hypoadrenocorticism, diabetes mellitus, chronic renal failure)

Contraindications

• Patients taking potassium bromide

Setup

• • • • •

25-gauge needle with 1 mL syringe Heparin Cork to cap needle or sterile red top tube Ice bath (for temporary storage) Blood gas analyzer

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Skill Box 8.3 / Blood Gas Analysis (Continued) Method

Blood Gas Analysis

Procedure

A syringe coated with heparin (1,000 U/mL) is used to obtain a blood sample. A full 1 mL of blood should be obtained to avoid any dilution with heparin. All excess air is expelled from the syringe and the sample is analyzed immediately. If temporary storage is required, the sample can be stored at room temperature for