University of MelbourneEmergency and Critical

CareTier 2 Rotation

Amy Greenhill

Immune-Mediated ThrombocytopeniaSignalment: 11yo, female neutered Shitzu

Presentating Problem: Referral for blood transfusion due to blood results from referring vet CBC: HCT 0.26, WBC increased @ 27.6, Neutrophilia 19.3, increased bands @ 9%, Monocytosis @ 3.0, 4 Nucleated RBCs/100 WBCs, marked severe Thromobocytopaenia @ 4. Evidence of regeneration on smear with ansiocytosis and polychromasia. Toxic changes on smear with basophilic cytoplasm. No platelet clumps on smear.

Clinical Examintion:• HR 132, RR 44- ↑ inspiratory with expiratory push, temp 37.9 °C, MMs

pale pink, CRT <1s, pulses ↓ width and height. • Marked ecchymoses over ventral abdomen, inner thighs, forearms and over jugular venipuncture• Scleral haemorrhage. • Melena.• Petechiation on gums

Investigations and Results: • Venous blood gas- ↑ lactate at 4.6 (0.6-2.5)• Manual PCV- 11• Slide agglutination- Negative• Abdo U/S- Sliding of the pleural line indicates the lack of air between the visceral

and parietal pleural

Diagnosis: Severe Thrombocytopenia. Level consistent with Immune-Mediated Thrombocytopenia.

Treatment Options: • Stabilisation• Blood transfusion• Immunosuppressive dose of prenisolone• Euthanasia

Outcome: Humane euthanasia with IV pentobarbitone.

Snake EnvenomationSignalment: 6yo, male neutered Kelpie x

Presenting Problem: Snake envenomation treated with 1 vile of anti-venom by referring vet, severe respiratory weakness, prolonged activated clotting time, epileptic seizure treated with valium by referring vet.

Clinical Examination: • HR 104, RR 26- paradoxical pattern, reduced chest wall effort, temp

38.9°C, MMs pink, CRT 1s, pulses tall and synchronous. • Mentation paralysed/sedated. • Dilated pupils. • Port wine coloured urine suspect myoglobinuria. • LMN weakness.

Investigations and results: • SpO2- 95-99% on O2 supplementation via face mask• ECG- sinus rhythm• Blood Pressure- systolic = 161, diastolic = 112, MAP = 128

Outcome: Human euthanasia with IV pentobarbitone.

Pharyngeal Foreign BodySignalment: 7yo, male entire, German Shepherd Dog

Presenting Problem: Noted to be repeatedly retching and struggling to breathe at home, owner called the Emergency Service and was advised that he should be seen urgently in case this was a possible GDV/dilatation. He presented in difficulty and in a brief history it emerged that his rubber Kong ball had gone missing.

Clinical Examination: • HR 164, RR 60- increased effort with URT noise, obstructive as

red ball seen in pharynx, temp 39.6°C, MMs injected, CRT <1s, normal pulses.

• Further examination not performed due to finding respiratory obstruction and requiring immediate treatment.

Treatment and Procedures: • IV catheter placed and anaesthesia induced with 2mg/kg

Alfaxalone• Ball removed manually with great difficulty from pharynx- hole

in Kong allowed dog to breathe.• 0.2mg/kg Dexamethasone SC to reduce inflammation

Outcome: Dog observed for 3 hours after removal of FB to ensure no ill effects, including neurogenic pulmonary oedema occurred before being discharged.

Progressive LMN WeaknessSignalment: 6yo, male neutered, Staffordshire Bull Terrier

Presenting problem: Dyspnoeic, progressive LMN muscle weakness resulting in tetraparesis. Tested for Toxoplasma at referring vet, titres were mildly elevated (IgG and IgM), and treatment with Clindamycin was initiated with no improvement. Progressive difficulty swallowing and breathing in last 2 days.

Clinical Examination: • HR 140, RR 112- panting, paradoxical abdominal motion, temp 38.5°C,

MMs pink, CRT 1.5s. • Abdomen mildly tympanic- suspect aerophagia. • Tetraparetic, patellar reflexes absent.

Investigations and Results:• Venous blood gas and electrolyes- no abnormalities

Outcome: Hospitalised overnight to monitor for respiratory deterioration as owner warned may require ventilation. Referred to Neurology Service next day but deteriorated further and so humane euthanasia performed.

Cat Bite AbscessSignalment: 4yo, female neuter, Domestic Short Hair

Presenting Problem: Lethargic and uninterested in food. Owner heard cat fight previous day.

Clinical Examination: • HR 200, RR 20, temp 39.8°C, MMs pink, CRT 1s.• Multiple cat scratches found on hind quarters. • 0.5mm skin flap over right hip• Puncture wound on left hip- ambulatory, no swelling• Painful left hind foot on palpation.

Investigations and Results:• Clipped hair around puncture wound and skin flap, flushed with 0.9%

saline• Investigated left hind foot under buprenorphine- revealed small

scratches but no puncture wounds.

Outcome: Discharged with Amoxicillin and Clavulanic Acid 62.5mg PO BID for 5 days and Buprenorphine 0.06mg PO q8hrs for 1 day.

Chocolate Ingestion

Signalment: 10yo and 13yo, male entire, Staffordshire Bull Terrier X’s

Presenting Problem: Empty 200g bar of milk chocolate but unsure which dog, or if both, ate it. Toxic dose is 40mg/kg. The chocolate was ingested no more than 4 hours before presentation.

Clinical Examination: Neither of the two dogs were showing clinical signs of toxicity. All vital parameters were within normal limits except for the HR of the younger dog which was 124bpm.

Treatment: • Both dogs were given 0.5 tablets of Apomorphine conjunctively to induce emesis. • The younger dog vomited within 5mins of administration and vomited up

7cmx3cm piece of hard plastic. Further vomiting prevented by washing the eye with cool water as risk of possible other FB causing damage.

• Emesis was not induced with 0.5 tabs in older dog so further 0.25 tabs given into conjunctiva. Again, no emesis induced so administer 0.3mg Apomorphine IV. Emesis was induced and the dog vomited up chocolate. 1.25mg of Metaclopramide was administered to resolve nausea. No activated charcoal given due to being slightly sedate.

Outcome: Both dogs were discharged. The owner was advised of risks of chocolate toxicity include vomiting, diarrhoea and seizures. If concerned then to come back immediately.

Diabetic CollapseSignalment: 13yo, female neutered, Spotted Mist

Presenting Problem: Diagnosed as diabetic in July ‘14. Owner returned home to find her collapsed and unreposnsive. Diabetes had never been fully controlled. Been receiving increasing insulin doses starting at 1IU BID up to 4IU BID in the last 2 weeks.

Clinical Examination: • HR 210, RR 12, temp 33.6°C, MMs pale pink, CRT 2s, pulses tall and narrow. • Recumbant gait. Dull, minimally responsive mentation. Marked mydriasis.

Mucoid diarrhoea.

Stabilisation:• IV catheter placed in right cephalic- 2.5ml of 50% dextrose diluted in 50% 0.9%

saline adminstered IV.• Fed 1.5 tins of a/d food.

Investigations and Results:• Venous blood gas- poor sample• Blood glucose on glucometer- 1.1mmol/L

Treatment:• Hospitalise- continuously monitor blood glucose Q2-4h• If blood glucose >15mmol/L administer 2IU Glargine

Outcome: Discharged with instructions to administer 2IU of Glargine in the morning only as blood glucose falls to 7mmol/L at its nadir. Consultation with Medicine Service in one week.

Snake Envenomation

Signalment: 14yo, female neutered, Domestic Short Hair

Presentation: Owner found immobile 1 hour before presentation and immediately brought to emergency department as recognised signs of snake envenomation.

Clinical Examination: • HR 204- greadeII/III systolic heart murmur, intermittent gallop, RR 32- increased

paradoxical motion, temp 36.9°C, MMs pink, CRT 1.5s, pulses short and narrow• Non-ambulatory tetraparesis, alert but minimally responsive due to

neuromuscular weakness• Bilateral mydriasis and absent PLRs• Bladder ½ full- expressed: orange tinged urine

Investigations and Results:• Snake Venom Detection Kit- strongly positive for tiger snake• Venous Blood Gas- metabolic acidosis although lactate has come down. PH 7.24,

pCO2 45.5, SBE -7.3mmol/L, HCO3 18.8, Lactate 2mmol/L

Stabilisation• Given one vial of tiger-brown antivenom (diluted in 40mls saline) IV immediately.

Premedicated with 5mg chlorpheniramine IV.

Treatment:• 0.8mg of Methadone IV Q4h• Lacrilube in both eyes Q2h- developed corneal ulcer on R eye• Premedication with chlorphenamine 5g IV• 2nd vial of tiger-brown antivenom

Outcome: Hospitalised in ICU due to developing cellulitis. An oesophageal tube was placed and feed started on 1/3 of recommended energy requirement. Case still active.

Elbow AbscessSignalment: 7yo, male neutered, Neapolitan Mastiff

Presenting Problem: Lame on left forelimb but is weight bearing. Owners noticed swelling around left elbow and so gave 150mg of Carprofen. Owners did not witness any trauma. Has a history of reduced eyesight and receiving treatment for with Tricin BID.

Clinical Examination: • HR 112, RR 16- grunting and snoring, temp 40.9°C in consult,

39.5°C 1 hour later (probably due to Carprofen), MMs pink, CRT 1.5s, strong pulses.

• Discomfort on L FL but weight bearing. Swelling around L elbow extending down to foot. Swelling is soft and does not seem painful on palpation

• Flakey skin and lots of sores around pressure points on limbs.• Submandibular lymphadenopathy likely secondary to infection• Abscess ruptured from elbow in consult room. Large volume of

bloody purulent fluid leaked from left forelimb following rupture.

Investigations and Results-:• CBC- leukocytosis• PCV/TP- 42/78• Venous Blood Gas- all values within normal limits

Treatment:• IV catheter in L saphenous• Methadone 10mg Iv Q4h• Wound flushed with 1L 0.9% sterile saline • IV antibiotics cephazolin 22mg/kg q8• IVFT with Hartmann’s at 820ml/hr (4x maintenance)• FNA of elbow revealed turbid serosanguinous fluid- multiple RBS and degenerate

WBCs but no bacteria• Culture of fluid from abscess

Outcome: Discharged home with Cephalexin 2000mg PO q12, Tramadol 200mg PO Q8h and advice on how to minimise pressure sores by ensuring that the bed is padded. An appointment was made with the local vet for continuing treatment and monitoring. The owners were informed hat they would be contacted with the pending microbiology results regarding which long term antibiotic they would be administering.

Metaldehyde Toxicity

Signalment: 13yo, female neutered, Staffordshire Bull Terrier

Presenting Problem: Ingested metaldehyde up to 5 hours previous to presentation and showing mild clinical signs of toxicity. Prior to presentation, owner advised by referring vet to give a handful of soda crystals to induce vomiting in dog- owner gave golf ball size of soda crystals and dog vomited large amount of green metaldehyde. The dog was then given a second golf ball size of soda crystals which did not induce vomiting.

Clinical Examination: • HR 180, RR panting, temp 38.7°C, MMs injected, CRT 1s, pulses short and

narrow.• Able to stand but falling into sternal• Comfortable on abdominal palpation, no free fluid• Mild muscle tremors.

Investigations and Results: • PCV/TP- 50/75• Electrolytes- Na+ 148 mmol/L, K+ 3.7 mmol/L, Cl 114 mmol/L, Ca2+(i) 1.32

mmol/L

Treatment: • Apomorphine IV to try and induce faster emesis but no emesis induced so

given 2 SC injections of apomorphine but no vomit produced • 10mg metaclopramide SC and 4mg ondasterone IV to prevent emesis before

surgery• Anaesthetic induction with methadone and alfaxalone- initial apnoea but

then stable throughout• Enema revealed large amount of green thick paste like material consistent

with metaldehyde occasional mucoid discharge with blood fleck.• Gastric lavage reveal small amount of green tinged water with occasional

thick saliva. Repeat enema after gastric lavage due to further thick green paste like material passed.

• IVFT Hartmann’s at 4ml/kg/hr• Pantoprazole 20mg/kg slow IV• Metronidazole 160mg IV• Methocarbamol 400 mg IV - administered once and seemed to resolve

persisting tremors; not needed subsequently

Outcome: Discharged home for further supportive care since eating well and noFurther clinical signs of metaldehyde toxicity. Discharged with omeprazole. Readmit if clinical signs recur or other symptoms occur.

VomitingSignalment: 2yo, female neutered, Pug X

Presenting Problem: 2D history of lethargy, reduced appetite and vomiting. There was no access to toxins and no recent change of diet. Not recently wormed.

Clinical Examination: • HR 128, RR 32- referred URT noise due to restricted nasal airflow, temp

38.2°C, MMs pink and moist, CRT 1s.• On abdominal palpation it was relaxed and no foreign bodies were

palpable. There was no distension of the intestines palpable nor was pain elicited.

Differentials:• Primary gastroenteritis • Foreign body • Bacterial/viral/fungal infection • Pancreatitis

Treatment:• 0.5ml SC Maropitant• Drontal• GI probiotic

Outcome: • Discharged and owner told to monitor for continuation of vomiting or deterioration

clinically. Dog readmitted later that evening as continued to vomit through Maropitant.

• An abdo U/S was performed with no abnormalities found and so she was admitted to the hospital for further monitoring.

• After 2 days in ICU there was no marked improvement and she was neither eating nor drinking and so was put on IVFT 2x maintenance.

• The dog was discharged the next day with advice on feeding a bland diet and administering omeprazole. The owner was also given advice on watching for deterioration once Maropitant wore off.

Cycad IngestionSignalment: 5yo, female neutered, Dachshund X

Presenting Problem: Owner witnessed dog eating cycad root 3 hours prior to arrival. Confirmed picture of cycad fern with onwer. Dog also ate BBQ fat. Dog vomited at least 7 times in 2 hours but only foam was produced. No diarrhoea or other clinical signs.

Clinical Examination:• HR 120, RR 24, temp 38°C, MMs pink, CRT 2s, tall and narrow pulses.• No pain on abdo palpation, nausea evident

Assessment: • Eaten cycad root with current GI signs evident - risk include acute

hepatic failure and poor prognosis.• Pancreatitis risk re: fat ingestion

Stabilisation: • Elected to induce emesis given potentially fatal side effects of Cycad

ingestion. Administered 1 apomorphine tablet sub-conjunctival in right eye. Produced 6-8 vomits which were clear in nature, some bile staining in later vomits. Eye then washed until clear with water

• Reversed with IV ondansetron and Maropitant as reluctant to given metoclopramide in case significant cycad root ingested and risk of FB

• IVFT with Hartmann’s at 5ml/kg/hr with 20mmol/L KCl• Given 1g activated charcoal

Diagnostics:• PCV/TP : 42 / 64 serum clear in nature• VBG: PH 7.444 pco2 30.8 SBE -2.6 Lactate 3.2 >> post vomiting Glucose 5.0, Na

148 K 3.4 Cl 118 Ca 1.34• CBC : WNL• BIOCHEM : All WNL except elevated lipase @ 2427• PT 13 sec APTT 70 sec ( fast)

Treatment:• Hartmann’s at 5ml/kg/hr supplemented with KCl 20mmol/L

Outcome: Discharged home as no concerning clinical signs and no hepatopathy associated with cycad ingestion. Owner told to monitor for deterioration or change in behaviour.

Collapsed RabbitSignalment: 7wk old, male entire, Miniture Lop

Presenting Problem: Acute onset weakness and dull, not been witnessed to eat, drink or defecate. One of six rabbits bred by owners. Live outside in aviary on concrete floor bedded with hay.

Clinical Examination: • HR 280, RR 176, temp 38.8, MMs pink, CRT 1s, strong pulses.• Lying down in sternal with occasional head tilt to right• Able to pull hind legs under him into normal position from stretched out

position. However this reaction was greatly delayed• Faecal pellets felt in abdomen, no gas distension, no GI sounds and no

pellets passed in journey to emergency department nor during examination.

Investigations and Results:• Blood glucose- 9.1mmol/L

Stabilisation:• Panacure 20mg/kg dose PO • 40ml subcut 0.9% NaCl (warmed)• 5kg dose of meloxicam once a day (0.3 mg/kg sid PO)• Critical care mix 5ml Q2h

Outcome: The rabbit was discharged home for supportive care feeding Critical Care mix Q2h and advised to make an appointment with rabbit specialist if not passed any faeces overnight.

Rabbit readmitted due to progressive weakness and being unable to syringe feed at home. The rabbit had critical care mix stuck in his mouth and was very limp.

Clinical Examination:• HR 120, RR 60- short very shallow resps, minimal chest excursion, temp 39.4°C, MMs cyanotic• Recumbent, not moving, obtunded• On abdo palp intestines hard and full, no gaseous distension• Tongue hanging out of mouth unable to swallow food or spit it out

Stabilisation:• Removed food from mouth with damp swab• 24G IV catheter in ear vein• 10ml IV bolus of Hartmann’s• Flow by oxygen

Final Outcome: Owners elected for humane euthanasia by IV pentobarbitone. Declined PM due to wanting body back. Owners advised to monitor other rabbits closely for signs of illness.

GlaucomaSignalment: 17yo, male neutered, Australian Silky Terrier X

Presenting Problem: Twitching left eye, clear serous discharge from it. 3 year history of discolouration in both eyes but has had no other medical problems. No history of trauma and not receiving any medication. Owner reports that the dog has lost depth but is not bumping into objects.

Clinical Examination:• HR 88, RR 24 MMs pink, CRT 1s, pulses strong, grade 3 systolic heart murmur• Both eyes were cloudy and discoloured, previously diagnosed cataracts present in

both eyes. Serous discharge from left eye and repeated blinking. Painful on palpation. Anterior luxation of lens in left eye.

Investigations and Results:• Tonometer- IOP of left eye= 67, IOP of right eye =12

Treatment:• Tropicamide- attempt to dilate pupil (pressure reduced from 65 down to 25),• Dexamethasone 0.1% topical q4• Methadone 0.2mg/kg IV q4-6• Atropine used to try and further dilate the pupil to allow posterior movement of

the lens. This was not successful

Outcome: Hospitalised overnight in order to monitor IOP and administer medication. Within 24 hours the anterior luxated lens resolved and moved back into posterior chamber. Pilocarpine 1% applied to left eye Q8hrs to keep pupil constricted now that lens has moved into posterior chamber.

Jugular TransectionSignalment: 10yo, female entire, Jack Russell Terrier

Presenting Problem: Dog attack, severed right jugular vein that bled profusely.

Clinical Examination: • HR 114, RR 20, temp 36.7°C decreasing rapidly, MMs pale pink, CRT 2s, weak

pulses• Right jugular vein exposed and oozing blood• Obtunded and recumbent• 2cm laceration to right jugular groove, 2cm laceration (full thickness skin, not

extending beyond) and a puncture to dorsal neck and a small puncture lateroventral to L eye

Stabilisation:• IV catheter placed in left saphenous vein, methadone 1mg IV. A 100ml, 200ml

and a final 100ml bolus of LRS were administered over the first hour of treatment - raising blood pressure (MAP) to the mid 50's. This period extended into the surgical period.

• Blood transfusion: 86ml of packed RBC's (Positive, not cross-matched) given with 0.9% NaCl over 2 hours. First 25ml given in 15 minutes, second given over 30 minutes

Investigations and Results:• Blood Pressure- MAP 66 rapidly falling to 30’s• PCV/TS: 14/30• Blood gas: pH 7.022, pCO2 54.6, SBE -15.5, Lactate 9.6, Glucose 7.6• Electrolytes: Na 147, K 3.5, Cl 120, Ca 1.29

Treatment:• Anaesthesia induced with 10mg alfaxalone and a size 6 ET tube placed. Maintained

on isoflurane• Cranial end of R jugular vein identified and isolated and ligated with 4x 2/0 monoplus

ligatures• Caudal end could not be located but no obvious haemorrhage• Loose material debrided away• Penrose drain placed • Surgical site was flushed with 250ml 0.9% saline• Ticarcillin• Pantoprazole• IVFT with Hartmann’s supplemented with KCl 30mmol/L

Outcome: Transferred to General Practice for continued monitoring and supportive care.