EMERGENCY MEDICINE
animal is in shock, it’s vasoconstricting to shunt blood
to its most important organs—the heart and lungs. If
the gut and kidneys aren’t getting appropriate blood
flow during a shocky state, we ideally want to avoid
NSAIDs or steroids until the patient is more stable.
When in doubt, perfuse the patient first.
Again, it’s not corticosteroids or NSAIDs that save
these patients. It’s perfusion, perfusion, perfusion.
4. Giving corticosteroids to head trauma patients
In the patient with head trauma, we ideally want
to avoid the use of corticosteroids due to the
potential for hyperglycaemia. Recent studies have
shown that human patients with head trauma and
hyperglycaemia have a poorer return to cognitive
function than do euglycaemic patients. Why is
hyperglycaemia dangerous in these cases? Because
elevated glucose concentrations provide a substrate
for anaerobic metabolism and glycolysis in the brain.
Hyperglycaemia is also associated with proconvulsant
effects due to increased neuronal excitability.
Instead of reaching for corticosteroids in the head
trauma patient, consider these treatments instead:
•
•
•
•
•
•
Osmotic agents such as mannitol, which have
been found helpful in decreasing intracranial
pressure (ICP)
IV fluid resuscitation to help normalize or maintain
blood pressure and maximize perfusion
Oxygen therapy
Elevation of the head 15 to 30 degrees (to lower
ICP) (Elevate without kinking the neck as kinking
will actually increase ICP. Ed)
Minimal jugular restraint or pressure (to prevent
increased ICP) (Preferably use cephalic veins for
IV access and blood collection - Ed)
Tight glycemic control
5. Not doing FAST ultrasounds
The focused assessment with sonography for trauma
(FAST) ultrasound is a two-minute procedure that
detects the presence of fluid in the abdominal cavity
to allow for rapid therapeutic intervention, such as
fluid resuscitation, abdominocentesis, cytology or
clinicopathologic testing. 1 This quick ultrasound
method to determine “yes fluid/no fluid” is designed
to be used by healthcare professionals with limited
ultrasonographic training and is not designed for
extensive examination of the abdomen.
One of the benefits of the FAST examination is its
ability to detect very small amounts of fluid. Typically,
5 to 25 ml/kg of fluid needs to be present to be
removed by blind abdominocentesis; 10 to 20 ml/kg
of fluid has to be present before it can be detected
by fluid-wave assessment on physical examination;
and approximately 9 ml/kg of fluid needs to be
vet360
Issue 04 | SEPTEMBER 2018 | 14
FELINE MEDICINE
present before it can be detected radiographically.
But as little as 2 ml/kg of fluid can be detected on
a FAST examination, allowing for rapid diagnosis and
identification of underlying pathology.
The FAST examination typically involves assessment
of four sites of the abdomen: caudal to the xiphoid,
cranial to the bladder, and the right- and left-
dependent flank. 1 The presence of fluid at any of
these sites is considered positive. Evaluation of the
xiphoid region allows you to check for fluid between
the liver and diaphragm and the liver lobes, as well
as for pericardial or pleural effusion. 1 The bladder
view evaluates for fluid cranial to the bladder and
for the presence of a bladder. 1 The right-dependent
flank allows for fluid detection between the intestines
and the body wall, whereas the left-dependent flank
view allows for identification of the spleen and any
abdominal effusion near the spleen and body wall, the
kidney and spleen, and the liver and spleen. 1
6. Reluctance to penetrate body cavities
I believe every veterinarian should be comfortable
doing an abdominocentesis and a thoracocentesis.
These benign procedures are both diagnostic and
therapeutic.
Moving quickly but maintaining aseptic protocol, shave
and surgically prep a wide area near the umbilicus (for
abdominocentesis) or thorax (for thoracocentesis).
Thoracocentesis should be performed either dorsally
(for air) or ventrally (for effusion) at the seventh to ninth
intercostal space (ICS). An imaginary line can be drawn
from the end of the xiphoid to the lateral body wall,
which is approximately the eighth ICS. This allows for
rapid identification of where to perform an emergency
thoracocentesis. For an abdominocentesis, a four-
quadrant tap should be aseptically performed at the
periumbilical region.
ABDOMINOCENTESIS TECHNIQUE
An abdominocentesis should be performed using
sterile technique. The abdomen should be clipped,
shaved and prepared aseptically. A four quadrant tap
around the umbilicus should be performed. If you
obtain fluid from one location, there is no reason to
tap the other remaining 3 regions. Gently, but briskly,
insert a sterile 22-ga. needle into these locations.
One can use either a closed technique (e.g., needle
attached to 3 ml syringe) or open technique (e.g.,
needle alone).
If no fluid is obtained, a “2-tap technique” can be used;
a second needle can be inserted several millimeters
away from the first sterile needle insertion - this will
often allow fluid to gently flow out. Once fluid is seen,
gentle suction can be used with an attached 1-, 3- or
6-ml syringe to aspirate the ascites. Editor
References available online: www.vet360.vetlink.co.za