Article reprinted with permission of DVM360 – August 07,
2018. DVM360 MAGAZINE is a copyrighted publication of
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6
EMERGENCY MEDICINE
Mistakes to Avoid in
the Veterinary ER
And if you can’t remember any of them in the heat of the
moment, focus on this: perfusion, perfusion, perfusion.
By Justine Lee, DVM; DACVECC; DABT; CEO, VETgirl
Take a deep breath, doc. You got this. Does the idea
of a dog presenting with pale mucous membranes, a
weak pulse and a heart rate of 190 beats/min make
your knees weak? Do you get tachypnoeic when you
see a dyspnoeic cat fish-mouth breathing in front of
you?
If you don’t see emergency cases every day, you’re
in the right place—this article discusses how to avoid
common errors in emergency patients and save your
patients’ lives. Having practiced everywhere from a
busy inner-city emergency room to the ivory tower
of academia, I’ve seen these mistakes made and I’ve
made them myself. Now you don’t have to — and
your patients (or at least their owners) will thank you.
Here’s what to avoid.
1. Not doing chest radiographs
I can’t tell you how many times I’ve had a case referred
to the emergency clinic for abdominal ultrasound or
postoperative supportive care, only to find a chest full
of metastatic lesions. Chest radiographs need to be
part of routine geriatric diagnostics.
Dogs older than 6 or 7 years of age and cats older than
12 with, for example, hepatosplenomegaly, icterus,
haemoabdomen, immune-mediated disease or fever
of unknown origin should have chest radiographs
done at the same time as abdominal radiographs.
Typically, a three-view chest set is the method of
choice, but a right- and left-lateral chest radiograph is
also an effective way to screen for metastasis.
While a met check is a “low-yield test” (the likelihood
of identifying chest metastasis is relatively low), it’s an
important screening tool that can help you counsel
pet owners on end-of-life decision-making and
overall prognosis. However, keep in mind that doing
chest radiographs may be too stressful for dyspnoeic
cats—stabilise them first
2. Using the shock dose of fluids
The “shock dose” of fluids is extrapolated from a
patient’s blood volume (60-90 ml/kg for dogs; 60 ml/
kg for cats). But recently, emergency and critical care
specialists have moved away from using the entire
shock dose when trying to stabilise hypovolemic
patients—smaller aliquots (one-quarter to one-third
of a shock dose) of intravenous (IV) crystalloid fluids
are preferred. Better to give small amounts frequently
while monitoring!
3. Using the wrong dose of corticosteroids
Traditionally, emergency books have included
“shock doses” of corticosteroids—for example,
dexamethasone sodium phosphate (DexSP) 4-6 mg/
kg. However, criticalists have moved away from giving
corticosteroids with trauma because of potential
deleterious effects, including gastric ulceration in a
poorly perfused “shock gut” in the dog, exacerbation
of hyperglycemia, and delayed wound healing.
Recently we have moved to administering different
doses of DexSP. An anti-inflammatory dose of
DexSP is generally considered 0.1 mg/kg, whereas
immunosuppressive doses are as low as 0.25 mg/kg
IV every 12 to 24 hours. For that reason, the 4-6 mg/
kg dose for shock is no longer indicated. Remember
that DexSP is approximately eight to 15 times stronger
than prednisone.
Perfusion, perfusion, perfusion
In the first six hours of a critical care case, I focus on
perfusion—and avoid corticosteroids and NSAIDs.
The definition of shock is considered cellular
hypoxia—the patient’s cells are starving for oxygen.
Do corticosteroids increase oxygen to cells? No; IV
fluids do (with the exception of cardiogenic shock!).
The reason I’ve moved away from using NSAIDs
immediately in the shocky patient is that the dog’s
“shock organ” is the gastrointestinal tract. When an
Issue 04 | SEPTEMBER 2018 | 13