Vet360 Vet360 Vol 05 Issue 04 - Page 13

Article reprinted with permission of DVM360 – August 07, 2018. DVM360 MAGAZINE is a copyrighted publication of Advanstar Communications inc. All rights reserved 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