Emergency treatment with intravenous infusion of methylene blue followed by oral administration in a cat presented with severe recurrent methemoglobinemia.

OBJECTIVE: To describe the use of IV infusion followed by oral administration of methylene blue (MB) to successfully treat recurrent methemoglobinemia (MetHb) in a young cat. CASE SUMMARY: A 6-month-old male Ragdoll cat presented with recurrent episodes of severe MetHb and was successfully managed with IV infusion of MB followed by a course of oral MB. Although the definitive cause of the patient's MetHb remains unknown, the cat made a full recovery following treatment without developing any significant side effects secondary to therapy and at the time of writing not had any further recurrences. Follow-up at 6 months found the patient in good health and without any long-term consequences. NEW INFORMATION PROVIDED: To the authors' knowledge, this is the first report of a cat presented with severe MetHb quantitatively assessed via co-oximetry and successfully treated with both IV and oral administration of MB.

Hemodialysis as emergency treatment of a severe baclofen intoxication in a 3 kg dog.

OBJECTIVE: To describe the clinical efficacy and drug removal kinetics of hemodialysis (HD) as emergency treatment in a small size dog with severe baclofen intoxication. CASE DESCRIPTION: A 2-year-old dog was presented in stupor to the emergency service a few hours after ingestion of up to 25 mg of baclofen. Medical stabilisation was attempted but was unsuccessful in improving the neurological condition and the patient rapidly progressed to coma. A 4-h session of HD was performed in emergency with near complete resolution of neurological signs and only mild disorientation by the end of the treatment. No adverse side effects occurred during HD. Baclofen concentration was measured serially during the session. Drug extraction ratio, clearance and mass removal by the dialyser were calculated. Dialytic elimination rate constant (Kd ) was seven times higher than the intrinsic elimination rate constant (Kintr ) and the half-life (t½) during HD was nearly nine times shorter than the endogenous one. NEW OR UNIQUE INFORMATION PROVIDED: This is the first case report providing pharmacokinetic data associated with HD treatment of severe baclofen intoxication in a dog.

An internet survey of the perceived prevalence of zoological companion animal (ZCA) species being evaluated by ACVECC diplomates and emergency and critical care residents and to gauge potential interest in advanced training opportunities in the emergency treatment of these patients.

OBJECTIVES: To describe the perceived prevalence of zoological companion animal (ZCA) species being evaluated and treated by American College of Veterinary Emergency and Critical Care (ACVECC) diplomates and Emergency and Critical Care (ECC) residents in an emergency room (ER) setting and to assess potential interest in further training for the ACVECC community in the emergency treatment and stabilization of these species. DESIGN: Internet-based survey. SUBJECTS: One hundred and thirty-nine ACVECC diplomates and ECC residents. PROCEDURE: An online survey was designed and administered to assess the perceived prevalence of ZCA species that were evaluated and treated in the veterinary ER and to gauge potential interest in advanced training opportunities in the emergency treatment of these patients. RESULTS: One hundred and fifteen (83%) respondents reported that their hospital offered veterinary services to ZCA species during business hours and 120 (86%) reported that they offered veterinary services to ZCA species during off-hours. Ninety-one (65%) respondents reported that ZCA patients were evaluated and treated through their ER with small mammals (n = 60/91 [66%]) and small birds (n = 48/91 [53%]) being the most common species presented. In hospitals with an available ZCA specialist (80/139 [56%]), primary case responsibility was maintained by the ZCA specialist 24-7 in 11 of 91 (14%) hospitals. Seventy-three (53%) ACVECC diplomate and ECC resident survey respondents reported clinical training specific to ZCA species during veterinary school. A total of 84 of 139 (60%) survey respondents expressed interest in further training regarding ZCA species, with 73 of 84 (87%) those individuals specifying interest or potential interest in a formal ACVECC certificate or other type of advanced training.

Emergency treatment with intermittent hemodialysis for amikacin overdose in a cat.

OBJECTIVE: To describe the safety and use of intermittent hemodialysis (IHD) for the emergency treatment of a cat with an amikacin overdose. CASE SUMMARY: A cat was accidentally administered 400 mg (97.5 mg/kg, IV) of amikacin. Four hours after the time of the overdose, a single emergency IHD session to remove amikacin was performed. The 4-hour IHD treatment allowed for the active removal of approximately 110 mg of amikacin. The plasma concentration of amikacin from the beginning to the end of the session decreased from approximately 160 µg/mL to a nontoxic concentration of 10 µg/mL. Following IHD treatment, the cat developed an International Renal Interest Society (IRIS) grade IV acute kidney injury (AKI) with a peak creatinine of 486 µmol/L (5.5 mg/dL) and was hospitalized for 4 days for supportive management of AKI. At the time of discharge, 4 days following the overdose, the AKI had resolved. NEW OR UNIQUE INFORMATION PROVIDED: This is the first report describing the use and safety of using IHD for emergency removal of amikacin overdose in a cat.

Evaluation of cardiac troponin I in dogs presenting to the emergency room using a point-of-care assay.

We used a point-of-care assay to evaluate cardiac troponin I (cTnI) in clinically normal dogs and a heterogeneous population of dogs presenting to the emergency room (ER) and to determine whether cTnI has prognostic capabilities in an ER population. Fourteen clinically normal dogs and 129 dogs presented to the ER were evaluated. Of the study group, 88 dogs had normal cTnI (< 0.1 ng/mL), 29 had elevated cTnI (0.1 to 1.0 ng/mL), and 12 had high cTnI (> 1.0 ng/mL). Dogs with elevated cTnI had 8 times the odds of mortality compared to dogs with normal cTnI [odds ratio (OR): 8.2, 95% confidence interval (CI): 3.0, 22.3]. Dogs with high cTnI had 17 times higher odds of mortality compared to dogs with normal cTnI (OR: 17.6, 95% CI: 4.4, 70.1). We conclude that cTnI shows promise as a prognostic indicator for dogs presenting to the ER and can be easily evaluated using a point-of-care assay.

Évaluation de la troponine I chez les chiens présentés à la salle d'urgence à l'aide d'un test au point de service. Nous avons utilisé un test au point de service pour évaluer la troponine I (cTnI) cardiaque chez des chiens cliniquement normaux et une population présentée à la salle d'urgence (SU) pour déterminer si la cTnI comportait des capacités de pronostic dans une population de SU. Quatorze chiens cliniquement normaux et 129 chiens présentés à la SU ont été évalués. Dans le groupe à l'étude, 88 chiens présentaient une cTnI normale (< 0,1 ng/mL), 29 avaient une cTnI élevée (0,1 à 1,0 ng/mL) et 12 avaient une cTnI haute (> 1,0 ng/mL). Les chiens avec une cTnI élevée présentaient des risques 8 fois supérieurs de mortalité par rapport aux chiens avec une cTnI normale [rapport de cotes (RC): 8,2, intervalle de confiance (IC) de 95 % de 3,0, 22,3]. Les chiens avec une cTnI haute présentaient des risques 17 fois supérieurs de mortalité par rapport aux chiens ayant une cTnI normale (RV: 17,6, IC de 95 % : 4,4, 70,1). Nous concluons donc que la cTnI s'avère prometteuse comme indicateur de pronostic pour les chiens présentés à la SU et qu'elle peut être facilement évaluée à l'aide d'un test au point de service.(Traduit par Isabelle Vallières).

Hypoglycemia associated with oleander toxicity in a dog.

Oleander poisoning typically results in cardiac arrhythmias, hyperkalemia, and gastrointestinal irritation, and can be fatal. Oleander extracts have also been studied experimentally as hypoglycemic agents. Here, we describe a dog with confirmed oleander toxicosis presenting with classical symptoms and also hypoglycemia. After excluding other likely causes of hypoglycemia, the finding was attributed to oleander toxicosis, which has not been previously reported in dogs. A 7-year-old female spayed Maltese was presented to the emergency service after ingesting oleander leaves. Toxicosis was confirmed by measurement of digoxin using a competitive binding immunoassay, patient level 0.7 ng/mL (0.9 nmol/L) 24-h post-ingestion. Clinical symptoms included vomiting, cardiac arrhythmia, mild hyperkalemia, and hypoglycemia. Treatment was successful with aggressive supportive care, and the dog was discharged from the hospital after 48 h and made a full recovery. This case reviews the presentation and treatment of oleander toxicity but also highlights possible effects of oleander on blood sugar in dogs. Hypoglycemia in this dog, attributed to oleander poisoning, is interesting as it supports experimental research into hypoglycemic properties of oleander extracts.

Identification, management and outcome of postoperative hemoperitoneum in 23 horses after emergency exploratory celiotomy for gastrointestinal disease.

OBJECTIVE: To investigate postoperative hemoperitoneum in a population of horses that had surgery for colic. STUDY DESIGN: Retrospective case series. ANIMALS: Horses (n = 23). METHODS: Preoperative, intraoperative, and postoperative information was obtained from medical records (1985-2012) of horses with postoperative hemoperitoneum after emergency exploratory celiotomy. Pre-existing hemoperitoneum during surgery and nonsurgical hemoperitoneum were excluded. RESULTS: Of 4520 horses that had emergency exploratory celiotomy for gastrointestinal disease, 23 horses met inclusion criteria; an incidence of 0.5%. Horse signalment approximated the colic population, although Thoroughbreds were significantly overrepresented. Hemoperitoneum was significantly associated with intestinal resection. Postoperative hemoperitoneum was recognized a mean (± SD) of 1.0 ± 0.7 days after surgery and associated with tachycardia, decreasing hematocrit, incisional drainage, or ultrasonographic identification of swirling, echogenic abdominal fluid. Primary treatments included intravenous fluid therapy (n = 23), colloid support (20), blood transfusion (13), and antifibrinolytic agents (11). Fifteen horses (65%) survived to discharge, which was associated with admission lactate and days of hospitalization. CONCLUSIONS: Postoperative hemoperitoneum is a rare complication of exploratory celiotomy in horses that should be considered when there are signs of abdominal discomfort and declining hematocrit in the early postoperative period. Prognosis is guarded because of potential sequelae of septic peritonitis and adhesion formation.

Traumatic Dentoalveolar and Maxillofacial Injuries in Cats: Overview of diagnosis and management.

PRACTICAL RELEVANCE: Maxillofacial and traumatic dentoalveolar injuries can cause pain and inflammation, and reduce function of the mouth, impacting a cat's quality of life. Many traumatically induced feline fractures have been reported to involve the mandible or skull and, in cats with maxillofacial trauma, traumatic dentoalveolar injuries are particularly prevalent. Traumatic dentoalveolar injuries can also often be found in otherwise healthy cats. CLINICAL CHALLENGES: Some traumatic dentoalveolar injuries require emergency treatment; timely recognition and managment is therefore important for achieving the optimal outcome. Multiple approaches exist for the management and repair of maxillofacial traumatic injuries. However, those for traumatic dentoalveolar injuries may be more limited. AUDIENCE: This review is aimed at feline and general practitioners, as well as veterinarians with expertise in dentistry. EVIDENCE BASE: The authors draw on their clinical experience and evidence from the literature, where appropriate, to produce an overview of foundation guidelines. It is hoped that this will serve as a stimulus for deeper consideration as to what constitutes 'best practice' principles for cats with traumatic dentoalveolar and maxillofacial injuries.

Does intraoperative low arterial partial pressure of oxygen increase the risk of surgical site infection following emergency exploratory laparotomy in horses?

Decreased tissue oxygenation is a critical factor in the development of wound infection as neutrophil mediated oxidative killing is an essential mechanism against surgical pathogens. The objective of this prospective case series was to assess the impact of intraoperative arterial partial pressure of oxygen (PaO2) on surgical site infection (SSI) in horses undergoing emergency exploratory laparotomy for acute gastrointestinal disease. The anaesthetic and antibiotic protocol was standardised. Demographic data, surgical potential risk factors and PaO2, obtained 1h after induction of anaesthesia were recorded. Surgical wounds were assessed daily for infection during hospitalisation and follow up information was obtained after discharge. A total of 84 adult horses were included. SSI developed in 34 (40.4%) horses. Multivariate logistic regression showed that PaO2, anaesthetic time and subcutaneous suture material were predictors of SSI (AUC=0.76, sensitivity=71%, specificity=65%). The use of polyglycolic acid sutures increased the risk and horses with a PaO2 value < 80 mm Hg [10.6 kPa] and anaesthetic time >2h had the highest risk of developing SSI (OR=9.01; 95% CI 2.28-35.64). The results of this study confirm the hypothesis that low intraoperative PaO2 contributes to the development of SSI following colic surgery.

Monitoring equine visceral pain with a composite pain scale score and correlation with survival after emergency gastrointestinal surgery.

Recognition and management of equine pain have been studied extensively in recent decades and this has led to significant advances. However, there is still room for improvement in the ability to identify and treat pain in horses that have undergone emergency gastrointestinal surgery. This study assessed the validity and clinical application of the composite pain scale (CPS) in horses after emergency gastrointestinal surgery. Composite pain scores were determined every 4h over 3 days following emergency gastrointestinal surgery in 48 horses. Inter-observer reliability was determined and another composite visceral pain score (numerical rating scale, NRS) was determined simultaneously with CPS scores. CPS scores had higher inter-observer reliability (r=0.87, K=0.84, P<0.001), compared to NRS scores (r=0.68, K=0.72, P<0.001). Horses that survived without complications had significantly lower CPS and NRS scores compared to horses that were euthanased or had to undergo re-laparotomy (P<0.001). Breed and the location in the intestinal tract (small or large intestine) did not influence pain scores. In conclusion, the use of the CPS improved objectivity of pain scoring in horses following emergency gastrointestinal surgery. High inter-observer reliability allows for comparisons between different observers. This will be of great benefit in larger veterinary hospitals where several attending clinicians are often involved in the care of each case.

Guide to emergency interception during parturition in the dog and cat.

Clinicians in private practice, specialty practice, and emergency clinic settings are likely to be presented with bitches and queens with parturition emergencies. Parameters for the identification of dystocia include prolonged parturition, collapse of the dam, abnormal vaginal discharge, prolonged labor, prolonged interval between delivery of neonates, uterine inertia, malpresentation of the fetus, and large litter sizes. Methods for the diagnosis of dystocia are discussed. Resolution of parturition emergencies may be achieved through manipulative, medical, or surgical methods, although the great percentage of dystocia will require surgical intervention. Techniques for medical and surgical interception are discussed.

Surgical decompression of a caudal vertebral disc extrusion by dorsal laminectomy.

A 3.5-year-old female spayed Beagle cross was presented to our emergency and referral facility for the complaint of acute onset paralysis of the tail. A full physical and neurological examination was performed which confirmed the absence of motor function in the tail. Signs of superficial and deep pain sensation to the tail remained intact. Orthogonal view survey radiographs identified mineralization superimposed over the intervertebral foramen of the first and second caudal vertebrae. A dorsal laminectomy was performed for surgical decompression of the caudal nerve roots. On the fourth postoperative day, the patient exhibited good motor function of the tail. Neurological improvement continued and 11 days postoperatively the patient demonstrated normal neurological function, free range-of-motion of the tail, and it did not exhibit any signs of pain. Follow-up examination was performed 76 days after surgery, at which time the patient exhibited normal neurological function and signs of a pain-free range-of-motion on manipulation of its tail.

Head trauma in the cat: 1. assessment and management of craniofacial injury.

PRACTICAL RELEVANCE: Feline trauma is commonly seen in general practice and frequently involves damage to the head. CLINICAL CHALLENGES: While craniofacial injuries following trauma vary widely in severity, affected cats can often be severely compromised in terms of their neurological, respiratory and cardiovascular status, and their management can be challenging in both the short and long term. They need prompt stabilisation and careful monitoring in the initial period to maximise prospects of a successful outcome. Many cats with severe facial trauma will require surgery to stabilise skull fractures or address injuries to the eyes, with its inherent issues surrounding pain management, ensuring adequate nutrition and the necessity for ongoing hospitalisation. DIAGNOSTICS: Cats with head trauma benefit from imaging of the injured areas as well as thoracic radiography. Imaging the skull can be challenging and is best performed under general anaesthesia. In unstable patients this can be delayed to prevent any associated morbidity. EVIDENCE BASE: The clinical evidence base relating to injury to the feline head is limited, despite its relative frequency in general practice. This review focuses on the initial approach to craniofacial (in particular, ocular and jaw) trauma, and outlines simple techniques for management of soft tissue and bone injuries. Much of the information is based on the authors' clinical experience, as there is a paucity of well-described clinical case material.

Head trauma in the cat: 2. assessment and management of traumatic brain injury.

PRACTICAL RELEVANCE: Feline trauma patients are commonly seen in general practice and frequently have sustained some degree of brain injury. CLINICAL CHALLENGES: Cats with traumatic brain injuries may have a variety of clinical signs, ranging from minor neurological deficits to life-threatening neurological impairment. Appropriate management depends on prompt and accurate patient assessment, and an understanding of the pathophysiology of brain injury. The most important consideration in managing these patients is maintenance of cerebral perfusion and oxygenation. For cats with severe head injury requiring decompressive surgery, early intervention is critical. EVIDENCE BASE: There is a limited clinical evidence base to support the treatment of traumatic brain injury in cats, despite its relative frequency in general practice. Appropriate therapy is, therefore, controversial in veterinary medicine and mostly based on experimental studies or human head trauma studies. This review, which sets out to describe the specific approach to diagnosis and management of traumatic brain injury in cats, draws on the current evidence, as far as it exists, as well as the authors' clinical experience.