Assessing Acute Collapse for Presentation Powerpoint and Handouts

“I’ve Fallen and [email protected] I Can’t Get Up” Assessing Acute Collapse For Presentation PowerPoint and Handouts: http://wendyblount.com

Wendy Blount, DVM

Kinds of Shock [email protected] Anaphylactic Shock •Obstructed airway •Acute allergic reaction •Lung Disease •Mast Cell Tumor Degranulation •Pleural air or effusion Cardiovascular Shock Neurogenic shock •Arrhythmia •Forebrain and brainstem - For Presentation PowerPoint •Left Heart Failure decreased consciousness •Right Heart Failure •Spinal cord – flaccid paralysis and Handouts: •Pericardial Disease Septic Shock http://wendyblount.com Hypovolemic Shock •Overwhelming infection •Dehydration Traumatic Shock •Hemorrhage •Due to pain •Hypoproteinemia Toxic Shock Hypoxic Shock •Due to inflammatory mediators, •Anemia endogenous and exogenous •Hemoglobin Pathology toxins

Collapse Other Than Shock Assessment of Inability or Unwillingness to get up Collapse Profound Weakness Ataxia – lack of coordination •Metabolic weakness •Vestibular ataxia Quick Assessment •Hypercalcemia •Cerebellar ataxia Life Saving Treatment •Hypokalemia •Sensory ataxia •Hypoglycemia Paresis - loss of voluntary Physical Exam •Neurotoxins motor Emergency Diagnostics •Polyneuropathy •Lower Motor Neuron •Junctionopathy •CNS Lesion at level of History •Myopathy paresis Pain •Flaccid paresis In House Diagnostics •Spinal Cord/Nerve Pain •Upper Motor Neuron •Orthopedic Pain •CNS Lesion above paresis •Muscular Pain •Spastic paresis

1 Assessment of Assessment of Collapse Collapse

Quick Assessment Life Saving Treatment Airway Oxygen Breathing IV fluids and colloids Circulation Therapeutic centesis Vital Signs – TPR & BP Thorax, abdomen, pericardium Diagnostic Centesis Normalize temperature thorax, abdomen Emergency Surgery

Assessment of Assessment of Collapse Collapse

Physical Exam Emergency Diagnostics General Exam PCV, TP, glucose, BUN creat Cardiovascular Exam Blood gases/lytes Neurologic Exam ECG Radiographs Lateral thorax Lateral abdomen

Assessment of Assessment of Collapse Collapse

Quick Assessment In House Diagnostics

Life Saving Treatment CBC, profile, UA - Get urine prior to fluid therapy Physical Exam Heartworm test in dogs Emergency Diagnostics FeLV/FIV in cats History Coags - PT, PTT/ACT, In House Diagnostics BMBT If all else fails, US abdomen

2 Quick Assessment Quick Assessment

Check Airway and Breathing If dyspnea and muffled heart/lung sounds, •Clear airway perform diagnostic/therapeutic chest tap •Intubate and begin IPPV if not breathing •If in sternal Check Pulses, Heart Sounds and Pulse deficits •Hook up ECG if pulse deficits or auscultable arrhythmia recumbency, tap •Begin CPR if no pulses or heartbeats right & left •Plan for chest x-rays if abnormal heart/lung sounds or pleural caudodorsal rubs lung fields Place IV catheter Supplement oxygen by mask, nasal or flow-by

Quick Assessment Quick Assessment

If dyspnea and muffled heart/lung sounds, If abdominal fluid wave, do a diagnostic perform diagnostic/therapeutic chest tap abdominal tap – 4 quadrants •If in lateral recumbency, tap the highest point on •R cranial, L cranial, R caudal, L caudal each side •Syringe and 18-20g needle are fine •Butterfly catheter with 6-12 cc syringe first •Put fluid in EDTA and red top tubes for analysis •Attach larger syringe & 3-way stopcock if •Spin down for cytology evacuation is needed •Save red top tube for culture if needed •Save fluid for analysis and possibly culture •Run EDTA through CBC machine for cell counts •EDTA tube for fluid analysis •Red top tube for culture Fluid Analysis Handout

DDx By Fluid Analysis DDx By Fluid Analysis Pure Transudate •Coagulopathy •Hypoalbuminemia (<1.5 g/dl) •Vasculitis Septic Exudate Bilious Effusion •Rupture of a cyst – Hepatobiliary. •Idiopathic pericardial effusion •GI perforation •Ruptured gall bladder Pancreatic, perirenal, prostatic •Trauma •Neoplasia •Ruptured biliary vessel Non-Septic Exudate •Thrombosis Uroabdomen Modified Transudate •Volvulus •Ruptured urinary bladder •Early hepatic cirrhosis •Neutrophilic •Intussusception •Caval occlusion, HW Disease •Pancreatitis, steatitis •Penetrating Wound Chylous Effusion •Right CHF •Tissue necrosis •Surgical Dehiscense •Heartworm disease •Neoplasia •Idiopathic pericardial effusion •Ruptured abscess •RHF •uroabdomen, bile peritonitis •Pulmonary hypertension •FIP •Septicemia •Idiopathic •lymphangitis •Eosinophilic •Bile peritonitis •Trauma •Neoplastic effusion •Heartworm disease FIP •Lymphangitis •Eosinophilic effusions •Systemic mastocytosis •Lymphoma •Rarely FIP •Hypereosinophilic syndrome Hemorrhage •Eosinophilic lung disease •Bleeding neoplasia •neoplasia Interpret dysplastic epithelial/mesothelial cells with care Culture exudative, bilious and hemorrhagic effusions

3 Fluid Therapy Fluid Therapy

“Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •NO shock fluids if there is anuria or CHF (Angel) •YES if evidence of dehydration, anaphylaxis, hemorrhage, •Anuria - you can probably get way with one shock dose if or sepsis the dog hasn’t had prior fluid therapy •Anaphylaxis •MONITOR URINE OUTPUT AFTER THE SHOCK •pale mucous membranes and weakness despite no DOSE dehydration, no CHF and no apparent external/internal fluid •YES shock fluids if there is evidence of hypovolemia loss •Pale mucous membranes, slow CRT •Cats often have pulmonary edema (tachypnea/dyspnea) •Dogs often have abdominal pain •Weak peripheral pulses

Fluid Therapy Fluid Therapy

“Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •YES if confirmed pericardial effusion (PE) without CHF •YES if confirmed pericardial effusion (PE) without CHF •Muffled heart and lung sounds, dyspnea •If modified transudate, RHF is possible •Negative diagnostic thoracocentesis •Signs of RHF on exam – •Lateral chest x-ray raises suspicion of PE •peripheral edema •Huge heart (DDx cardiomegaly, Pericardial Dz) •Diarrhea •Quick ultrasound of the heart confirms PE or PPDH •distended jugular veins or abnormal jugular pulses •If hemorrhagic PE (PCV PE = PCV blood), then bolus •positive hepatojugular reflux fluids

Fluid Therapy Fluid Therapy

“Shock/Replacement Fluids” “Shock/Replacement Fluids” •Bolus of 10 ml/lb over 10-15 minutes, then reassess •Bolus of 10 ml/lb over 10-15 minutes, then reassess •YES if confirmed pericardial effusion (PE) without CHF •CAREFUL if hypoalbuminemia •If modified transudate, RHF is possible •If TP low, get albumin ASAP •RHF can be a cause of or a result of pericardial effusion Aggressive fluid therapy + hypoalbuminemia = •Tricuspid murmur (right apex) suggests primary pulmonary edema RHF •Re-listen AFTER pericardial tap •Replace colloids first – hetastarch •Resolution of RHF after pericardial tap suggests no •shock fluids may not be necessary, and could even primary RHF (by the next day) lead to volume overload

4 Fluid Therapy Pneumothorax

Maintenance Fluids •1-2 ml/lb/hr – fine tune later 1. Use butterfly catheter and 3-way stop cock to •To keep the IV line open while the patient is assessed evacuate the air from the left and right sides •Most patients fall under this category • Continue until you get negative pressure • Take chest x-rays to confirm lungs expanded No Fluids – if CHF is possible • Some cases of spontaneous pneumothorax will resolve with •Heart murmur this treatment •Auscultable arrhythmia or pulse deficits • If the patient is getting worse, or you can not get negative pressure after several minutes, continue to step 2 •Undiagnosed thoracic effusion or ascites – modified transudate •Dyspneic animal who has not had chest x-rays yet •Be especially careful with cats •Fluids, corticosteroids or x-rays can KILL a cat in CHF

Pneumothorax Pneumothorax

3. Keep pneumothorax evacuated. 2. Place chest tube and evacuate air. • Evacuate hourly at first, then less often as needed to get • You may need to place a chest tube on each side negative pleural pressure. • If air constantly re-enters the chest, place continuous • Apply continuous negative pressure if necessary. suction on the chest tubes. • Offer referral to a 24-hour ICU if your clinic does not offer 24- • Slow leaks will sometimes eventually seal without surgery hour care • Take chest x-rays to confirm tubes placed well and lungs • An uncapped chest tube can cause death by expanded pneumothorax within minutes. • If the patient is getting worse, and you can not get negative • Remove chest tube when no air is aspirated for 24 hours, pressure, you must induce anesthesia and open the chest to and chest x-rays confirm resolution of pneumothorax. get immediate control of lung expansion, and find and • It is normal for a chest tube to produce a small amount of correct the source of the leak. serosanguinous pleural fluid as long is it is present.

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Pleural Effusion Pleural Effusion

1. Use butterfly catheter and 3-way stop cock to 2. Indications for a chest tube. • Pyothorax evacuate the fluid from the left and right sides • Managed by treating with antibiotics, and lavaging the • Continue until you get negative pressure chest with small amounts of sterile isotonic fluid • Take chest x-rays to confirm lungs expanded • 5-10 ml/lb, sit for 5 minutes, drain • Some scalloping of the lungs may remain if effusion is • Lavage BID chronic • Chest tube can be removed when: • Perform fluid analysis to characterize the fluid, then the • bacteria are no longer present in the retrieved fluid indicated diagnostics to determine the specific cause. (check for phagocytosed bacteria) • If the effusion is hemorrhagic, remove only enough blood to • Fluid production is down to 1-1.5 ml/lb/day alleviate dyspnea • Recheck chest x-rays one week after tubes pulled. • the remaining will autotransfuse if the source of hemorrhage • Occasionally lung lobectomy will be needed to resolve can be treated or is likely to resolve. the problem.

5 Pericardial Pleural Effusion Effusion

2. Indications for a chest tube. Pericardial tap is life saving, and not as scary as it seems • Chylothorax • Clip and prep the are over the heart on the right side • Until source of effusion can be treated or • Place the animal in right lateral recumbency • Use an echo table for easy access resolved. • Or just roll them up a little to lift the sternum off the table • Bring their sternum to the edge of the table • Management of pleural effusion pending surgical • Wear sterile gloves therapy. • Feel for the apical beat on the right chest wall. • Introduce a long IV catheter until you get free flow of fluid (runs or drips)

Pericardial Ascites Effusion

Pericardial tap is life saving, and not as scary as it Transudate or Modified Transudate seems • Remove enough fluid to alleviate dyspnea, and allow comfortable chest x-rays & abdominal ultrasound • Thread catheter in and evacuate the fluid • Bloodwork and abdominal ultrasound to determine the • Use a three-way stop cock & extension set if desired cause, and treat accordingly • As flow stops, thread the catheter in or out a little to • If cause is congestive heart failure, remove all fluid reposition the tip • I am not a big fan of cutting additional side holes in the Hemorrhage - usually a surgical problem, unless catheter to improve flow • Coagulopathy is identified and treated • Can cause the catheter to break off when removed • Traumatic hemorrhage resolves spontaneously • Save samples for cytology and culture • Give pain meds Non-septic exudate • Imaging determines whether the problem is surgical

Dyspnea Dyspnea

Pleural effusions & Pneumothorax discussed previously Pleural effusions & Pneumothorax discussed previously That leaves: That leaves: • Airway problems • Pericardial effusion • Collapsing trachea and bronchi • Hemorrhagic – neoplasia, idiopathic • Feline Asthma • Modified transudate – idiopathic, neoplasia • COPD/Allergic Bronchitis (Joshua) • Exudative - infectious • External ligature or foreign body • Peritoneopericardial Diaphragmatic hernia • Lung Parenchyma Problems • Pectus excavatum is a clue • Infectious Pneumonia – bacterial, viral, fungal, • Confirmed by ultrasound or barium series protozoan, parasitic • Treated surgically • Noncardiogenic pulmonary edema • Adhesions can be vexing • Pulmonary trauma • Re-expansion pulmonary edema can complicate • Eosinophilic Pneumonitis recovery • Primary and metastatic neoplasia • Lung lobe torsion

6 Dyspnea Dyspnea

Pleural effusions & Pneumothorax discussed previously Emergency Drugs for Dyspnea That leaves: When you think you just might kill your patient with x-rays • Furosemide – 2 mg/lb IM • Diaphragmatic hernia • If dyspnea with mitral murmur, give lasix and put in oxygen • Confirmed by ultrasound • If coughing up pink frothy fluid, CHF is a good bet • Loops of gut in the chest on rads are the giveaway • Furosemide will not help the other causes of dyspnea, but • Giving a little barium helps see these there aren’t many made worse when used <24 hours • Treated surgically • Big translucent Rubbermaid containers make workable • If liver is entrapped or gut strangulated, can be an temporary oxygen chambers in clinics with no oxygen cage emergency • Check frequently – they can get warm • If clinical response, continue furosemide 1-2 mg/lb every 2 hours until respiratory rate is <40 per minute • When stable, place IV catheter, and take chest x-rays • Then take blood and get ECG • Echo can happen on another day

Dyspnea Dyspnea

Emergency Drugs for Dyspnea Emergency Drugs for Dyspnea When you think you just might kill your patient with x-rays When you think you just might kill your patient with x-rays • Bronchodilators • Bronchodilators • If cat has dyspnea with no murmur and harsh lung sounds, • If marked improvement, proceed to corticosteroid consider asthma administration, and repeat inhaled bronchodilators as • Cat can have CHF without murmur, though dogs almost needed never do • If still no improvement, consider more furosemide prior to • If cat is stable enough, give lasix IM and place in oxygen for rads 15-30 minutes. • Or “Man Up” and try furosemide with corticosteroids • If not, skip to next step • Draw blood and take chest x-rays when cat stable • If no improvement, give 2-3 puffs of albuterol and wait 5-10 • Echo and ECG can happen on another day minutes • Can use AeroKat spacer for $100 • Or a 60cc syringe case for a few bucks

Dyspnea Dyspnea

Emergency Drugs for Dyspnea When you think you just might kill your patient with x-rays If emergency drugs for dyspnea do not make Sedation – mixed in same syringe and given IM your dyspneic patient better within an 1. Acepromazine – 0.025 mg/lb, 1 mg maximum hour, you might have to try one quick Buprenorphine – 0.01 mg/kg 2. Morphine – 0.5 mg/kg IM lateral thoracic radiograph, and hope for • If collapsing trachea, laryngeal paralysis or COPD are the best. suspected, sedating can be life saving • Milkshake-straw analogy You have to understand the problem in order • Most animals in CHF can be sedated safely with the above to be able to treat it well. protocols • Most cats with asthma won’t be harmed • Morphine has bronchodilator activity

7 Noncardiogenic Pulmonary Edema Noncardiogenic Pulmonary Edema

Bulldog Conformation The Vicious Cycle •Redundant esophagus predisposes to chronic aspiration 1. Obstructive hypoventilation and respiratory stridor pneumonia 2. Leads to respiratory acidosis •This can lead to chronic COPD and hypoxia •Upper airway compromise/obstruction 3. Damages pulmonary endothelium •Stenotic nares 4. Pulmonary edema results •Elongated soft palate 5. Hypoxia ensues •Hypoplastic trachea 6. More pulmonary edema, then worsening hypoxia •Everted saccules 7. ARDS (Acute Respiratory Distress) results The bottom line is there is no “respiratory reserve” to Emergency treatment call on in case of increased oxygen demand • Establishing a patent airway early in the process is the most •Overheating effective treatment •Excitement or exercise • Sedate and intubate •Pulling on a collar while walking • Tracheostomy if necessary •Restraint at the veterinary office • Later intervention may require putting the dog on a ventilator •Respiratory disease • Talk to bulldog owners BEFORE this happens (handout) •Cardiovascular Disease

History History

Change in Voice, Noisy Breathing •Laryngeal paralysis •Isolated, or associated with LMN Disease Regurgitation •Megaesophagus may be isolated, or may be associated with LMN disease •History of “vomiting” and “coughing” - think megaesophagus with aspiration pneumonia

History History

Acute collapse over seconds Acute collapse over minutes •Seizures - stiff •Anaphylaxis •Pre-ictal signs, abnormal behavior •after insect bite, snake bite •Preceded by twitching or other partial seizure activity •after heartworm prevention in untested dog •Post-ictal signs, abnormal behavior •after going outside •Syncope - flaccid or stiff if hypoxia is severe enough •Acute spinal cord injury •Recovery is usually quick •Immediately after crying out •No loss of consciousness

8 History History

Acute ascending paralysis over a few hours Collapse With Exercise •Coral snake bite •Myasthenia gravis •Exercise induced collapse of Labrador Retrievers Acute ascending paralysis over 12-24 hours •Paralysis is often ascending, with recovery •Botulism within 15-20 minutes •Coonhound paralysis (bite wounds 7-10 days ago) Eating carrion or garbage •Tick paralysis (female Dermacentor ) •Botulism – flaccid paralysis •Improvement begins after the tick is removed •Roquefortine toxin – seizures and twitching •HGE – hemorrhagic gastroenteritis

Physical Exam Physical Exam

Temperature Heart Rate •Hyperthermia •Sinus Bradycardia •Fever – save urine for possible culture •Impending death •Heat stroke •Hypothyroidism – myxedema coma •Increased vagal tone – •Seizures • increased CSF pressure •Exercise induced collapse of Retrievers • abdominal disease •Hypothermia • tracheal trauma •Shock • increased IOP •Exposure • retching •Give atropine or glycopyrrolate and recheck

Physical Exam Physical Exam

Heart Rate Heart Sounds •Sinus Tachycardia •Muffled heart sounds – take chest x-rays •Pain or anxiety •pneumothorax •give pain meds •Pleural effusion, pericardial effusion •Hypovolemic shock •obesity • increase the fluid rate •Chaotic heart sounds (audio ) •Heart failure •Like tennis shoes in a dryer •Pericardial tamponade •Many VPCs •Tap and give IV fluid bolus •Atrial fibrillation •Get an ECG ASAP

9 Physical Exam Physical Exam

Heart Murmurs Mucous Membrane Color •Holosystolic murmur loudest at the cardiac apex (audio ) •Cyanosis •Anemia •Respiratory failure – airway obstruction, alveolar disease or pleural/pericardial disease (air/fluid/organs) •Hypoproteinemia •Congestive heart failure •Physiologic in puppies (often musical) •Pulmonary hypertension •Mitral regurgitation (left), Tricuspid regurgitation (right) •Differential cyanosis •To and Fro murmur (audio ) •Pink in front, blue in back (Reverse PDA or FATE) •Hx - Chronic weight loss and fever, then left heart failure •Muddy Brown mucous membranes in a cat •Aortic endocarditis •Acetaminophen toxicity •Gallop rhythm •Brick red mucous membranes •Check chest x-rays for enlarge heart and heart failure •Sepsis – do CBC, and albumin •HGE (hemorrhagic gastroenteritis in dogs)

Physical Exam Physical Exam

Mucous Membrane Color Mucous Membrane Color •Icterus •Check CBC first to rule out hemolysis •Pallor •If anemic, check for autoagglutination •Pain •Very small drop of blood + large amt of saline on a slide •Cardiovascular shock •Coverslip and look at 40x-100x •Anaphylactic shock •Should be dilute enough to see space between RBC •Anemia •“Poker Chip Stacks” is OK – rouleaux •Hypovolemia – hemorrhage, hypoproteinemia •“Poker Chip Winnings Pile” – autoagglutination •Don’t rely on observation with naked eye CRT >2 sec means poor peripheral perfusion •If not anemic, you are left with hepatic or bile obstruction •No point doing bile acids if bilirubin is high •Abdominal US more helpful

Physical Exam Physical Exam

Respirations Lung Auscultation •Minimal chest excursions can indicate LMN •Respiratory crackles (audio ) paralysis •Moisture in the small airways •Pulmonary edema •Exaggerated chest excursions already •Chronic airway disease discussed under Emergency Treatment for •Alveolar pneumonia Dyspnea •Harsh lung sounds with no murmur in a cat •Think asthma •But cats can have CHF without a murmur •Pleural rubs – tap the chest (audio )

10 Physical Exam Physical Exam

Pulses Pulses •Jugular pulses •Peripheral Pulses •Hepatojugular reflux •Bounding pulses - Big difference in pressure between systole •apply pressure to the liver for 10-15 seconds and diastole •Filling of the jugular veins indicates right heart failure or •Fever/Sepsis (vasodilation makes diastolic pressure lower) pericardial disease •PDA (back flow during systole) •Peripheral Pulses •Aortic endocarditis (black flow during systole) •Weak pulses •Extreme bradycardia (volume overload) •CHF •Anemia (low blood viscosity) •Pericardial disease •Pulsus paradoxus – absent during peak inspiration •Shock of any kind, especially hypovolemic •Pericardial effusion or hernia •Hypertension •No pulses in only one area •Thromboembolic disease

Physical Exam Physical Exam

Skin Abdominal Palpation •Attached tick – tick paralysis •Distension •Obesity, pendulous abdomen •Coral snake bites cause minimal reaction and can be •Pregnancy, pyometra - ultrasound very hard to find •Balotte fluid wave – tap •Crotalid snake bite - swelling, bite wound •Palpate organomegaly – ultrasound •Hemorrhages might indicate coagulopathy – do coags •Relieve urinary obstruction or express if bladder •Ecchymoses and petechiae •Abdominal mass – ultrasound •Peripheral edema •If cystic masses, may not be safe to aspirate •Right heart failure •Can aspirate solid masses later •Vasculitis, venous or lymphatic obstruction •Aspirate homogeneous enlarged spleen (MCT, Lymphoma) •Hypoalbuminemia •Gut distended with gas – radiograph •Infiltrative tumor such as myxosarcoma can look like edema •Pass stomach tube if gastric

Physical Exam Physical Exam

Abdominal Palpation Musculoskeletal •Abdominal Discomfort •Rule out unwillingness to get up due to •Anaphylaxis in dogs •GI obstruction/perforation – rads and US orthopedic pain •Peritonitis – US and fluid analysis •Bilateral cruciate disease •Enlarged organs – rads and US •Bilateral cranial drawer signs •Referred back pain – spinal rads •Dog often supports weight on the front limbs •Polyarthritis •Joints warm to the touch •Synovial effusion •Joint taps for cytology and culture are warranted for FUO, even if no outward signs of polyarthritis

11 Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Mentation •Mentation •Depressed or abnormal with forebrain and brainstem •Level of consciousness (0-4) – regulated by cerebrum & brain lesions stem, as well as acid-base status •Forebrain = cerebrum and diencephalon •Excited (3-4) •Diencephalon = thalamus and hypothalamus •Alert – Normal (2) •Depressed/obtunded – drowsy but arousable (1) •Depressed with any cause of shock, or severe metabolic •Stuporous – sleeps if left alone, arousable (1) disease •Comatose – no response to pain (0) •Normal with most LMN Disease •Except coral snake – seems mildly sedated •Quality of Consciousness •Normal •Demented – responds inappropriately (cerebral lesion)

Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Sensation •Posture (lateral recumbency) •Muscle pain •Schiff-Sherrington •Polymyositis - check CPK •Extension of thoracic limbs •Immune mediated, Toxoplasma, Hepatozoon •Pelvic limbs drawn under •Hypoglycemic myopathy •T2-L2 lesion (border cells) •If LMN paralysis (all reflexes suppressed) •Decerebrate rigidity •normal sensation – Coonhound, tick paralysis, botulism •Extension of all limbs, sometimes opsithotonus •decreased sensation – coral snake bite •Often stupor or coma •hyperesthesia – Coonhound paralysis •Severe brainstem lesion

Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Posture (lateral recumbency) •Attitude •Decerebellate Rigidity (position of head relative to body) •opsithotonus •Head tilt – vestibular disease or cranial neck pain •Extension of thoracic limbs •Examine the ears •Flexion of the hips •Nystagmus, no CP deficits, falling to one side, •Mentation is not affected head tilt to same side, no other CN deficiencies •Severe cerebellar lesion – often acute cerebellar •Unilateral Peripheral Vestibular disease herniation •Ventroflexion of the neck in cats •Indicates weakness or neck pain •If weakness, think hypokalemia or LMN Disease

12 Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Cranial Nerve Reflexes •Cranial Nerve Reflexes •Vision •PLR – indirect and direct R and L (absent or slow) •If responsive, do they track a falling cotton ball? •unconscious •Menace will be absent with cerebellar disease •Forebrain or cranial brainstem lesion •No menace also in puppies and kittens < 12 weeks •Optic nerve, chiasm, tract lesion •Anisocoria •Retinal blindness •forebrain or brain stem lesion •Iris atrophy •FeLV (hippus) •If PLR negative, Try Dazzle Reflex •Horner’s Syndrome •Shine a bright light into the eye •Miosis (small pupil) •The eye should squint as long as the light is held there •Ptosis (droopy eyelid) •Apparent blindness with intact PLR & Dazzle = •Enophthalmos (sunken eye) •cortical blindness •Prolapsed third eyelid

Physical Exam Physical Exam

Neurologic Exam •Cranial Nerve Reflexes •Palpebral response – medial and lateral L and R •Fatigue can indicate myasthenia gravis •Unilateral deficit can indicate trigeminal nerve deficits and/or facial nerve paralysis

Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Cranial Nerve Reflexes •Cranial Nerve Reflexes •Facial Symmetry •Nystagmus •Paralysis or spasm of the facial muscles? •Normal Siamese nystagmus has equal time left and right •Puckering of the skin indicates spasm •Pathologic nystagmus has fast & slow phases (fast away) •Flaccid muscle tone indicates paralysis •Positional nystagmus (only in dorsal recumbency) indicates vestibular disease •Peripheral nerve or brain stem disease •Combined with other nearby CN deficits, think brain stem •Peripheral disease can be bilateral

13 Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Spinal Nerve Reflexes •Spinal Nerve Reflexes •UMN reflexes – stiff, exaggerated •LMN reflexes – flaccid, suppressed •Lesion in the CNS above where nerves originate from •Lesion in CNS where nerves originate from •Things that can Mimic UMN reflexes •Extreme excitement •Things that can mimic LMN reflexes •Pseudohyperreflexia •Severe muscle or joint rigidity •Patellar reflex is exaggerated •Metabolic disease causing weakness •But reflexes caudal to that are suppressed •Hypokalemia, acidosis, hypercalcemia •Caudal muscle thigh tone normally dampens the patellar •Spinal Shock reflex •Reflex suppression caudal to acute SC injury •Lack of tone to the caudal thigh muscles allows seemingly •Reflexes return within 30-60 minutes exaggerated patellar reflex

Physical Exam Physical Exam

Neurologic Exam Neurologic Exam •Spinal Nerve Reflexes •Spinal Nerve Reflexes •Withdrawal (flexor) reflex •All reflexes decreased – weakness or LMN disease •Remember this is a spinal reflex that can occur below a severed spinal cord •Suppressed (LMN) CN reflexes – brain stem disease •When assessing perception of deep pain which required •Normal mentation and CN connection to the brain: •UMN all 4 limbs – cervical lesion •Look for conscious acknowledgement of pain, not just pulling the foot back •LMN front, UMN back – C4-T2 •Pet may look at you, whine, or snap •Normal front, UMN back – T2-L2 •Pupils may dilate •Pseudohyperreflexia, flaccid bladder, poor anal tone – LS •Flaccid tail, bladder, anal – S-Cd (handout )

LMN Disease Multifocal CNS Disease

Anomalous Metabolic Dogs and Cats Infectious •Congenital Myasthenia gravis •Hypothyroidism Degenerative •Bacterial meningioencephalitis •End stage CNS atrophy of •Fungal meningioencephalitis •Exercise Induced Collapse of •Hypoadrenocorticism advanced age •Toxoplasma gondii Retrievers Toxic Anomalous •Aberrant adult heartworm Immune Mediated •Dandy Walker Syndrome •Visceral Larval Migrans – •Botulism Bayliascaris procyonis •Acquired Myasthenia gravis Neoplastic •Neurotoxic snake bites •Prototheca spp. •Metastatic neoplasia •Coonhound paralysis Vascular •Tick paralysis Nutritional •Ischemic encephalopathy Infectious •Thiamine deficiency •Botulism Immune Mediated •GME – granulomatous meningioencephalitis •Eosinophilc meningioencephalitis

14 Multifocal CNS Disease Emergency Diagnostics Dogs Cats Degenerative Infectious •Leukodystrophy •Feline Infectious Peritonitis •Neuronal Vacuolation of •Borna Disease ECG Rottweilers •Cuterebera spp. •Identify whether the animal has a normal rhythm •Abiotrophy of Cocker Spaniels •Taenia serialis–cystic coenurus •P wave, QRS and T for every beat Infectious •Canine Distemper Virus •No abnormal beats (VPC, fibrillation) •Neospora caninum •Ehrlichia canis •Rocky Mountain Spotted Fever •Lyme Disease

ECG Tips ECG Tips

• Always in right lateral recumbency Which lead goes where? • Patient on a towel or rubber mat • “Snow and Grass are on the ground” • Metal tables are more problematic – White and green leads are on the bottom (R) • Limbs perpendicular to body • “Christmas comes at the end of the year” • Place leads at the elbow and knee – Red and green are on the back legs • No one moves while the ECG is being • “Read the newspaper with your hands” recorded – White and black are on front legs • Enhance lead contact with gel or alcohol • If all else fails, label the leads with stickers – White – RF Green – RR (ground) Alcohol is FLAMMABLE!! – Black – LF Red – LR

In House ECG Tips Diagnostics

At 25 mm/sec, 150mm = 6 sec Emergency Bloodwork • “Bic Pen Times Ten” •CBC with platelets • Accurate within 10 beats per minute •General health profile – include P, Ca ++ , albumin and At 50 mm/sec, 300mm = 6 sec triglycerides • Bic Pen times Twenty •Electrolytes and blood gases • Accurate within 20 beats per minute •Urinalysis – specific gravity prior to fluid is crucial to Normals interpreting azotemia • Giant dogs 60-140 Med-Lg dogs 70-160 •Use a 5F infant feeding tube to catheterize male dog > • Toy dogs 80-180 Puppies 70-220 75 pounds • Cats 100-240 (Arrhythmia handout ) •Use US guidance if needed for cystocentesis of small bladder

15 In House In House Diagnostics Diagnostics

Potassium Coags •Hypokalemia causing profound weakness •Buccal Mucosal Bleeding Time •Renal tubular acidosis •Triplett, Surgicutt, Simplate •Diabetic ketoacidosis •ACT cartridges available for iSTAT •Hyperkalemia •Or get gray top kaolin tubes ( http://www.haemtech.com/ACT.htm ) •Hypoadrenocorticism •Invert once every 30 seconds, until first sign of clot •Urinary obstruction (post-renal azotemia) •PT and PTT •Acute oliguric/anuric renal failure •whipworms •Idexx has in house coags now •SCA2000 is another option (handout )

Pericardial LHF RHF Effusion Tips for Thoracic Radiographs Lateral DV Respiratory Disease Cardiac Both views Enlarged LA Enlarged RA Silhouette Large and round Enlarged LV Enlarged RV Pulmonary Enlarged Enlarged vena + enlarged vena Lung Fields Airways Great Vessels Vessels pulmonary veins cavae cavae Collapsing Normal Normal Narrowed trachea No pleural + pleural Trachea Pleural Space Pleural effusion effusion effusion Chronic Airway Peribronchiolar Enlarged Normal Disease infiltrates pulmonary aa. Pulmonary edema + Interstitial Interstitial or miliary Lung Fields normal Fungal Pneumonia Normal Normal Air bronchograms pattern pattern Bacterial Interstitial to alveolar Normal Normal Tips for Thoracic Radiographs Pneumonia pattern Noncardiogenic Interstitial to alveolar Heart Disease Normal Normal pulmonary edema pattern Masses of various Neoplasia Normal Normal handout sizes

In House Diagnostics

NTproBMP ELISA N-terminal pro-B type Natriuretic Peptide •In clinic test to distinguish cardiac from respiratory dyspnea •Validated in dogs JACVIM January 2008 Emergency Seizure •<210 pmol/L – more likely respiratory disease Protocol Handout •>210 pmol/L – more likely cardiac disease •Falsely elevated by increased creatinine •Helpful in distinguishing cardiac from respiratory dyspnea when creatinine is not elevated