Veterinary Emergency and Critical Care

Objective -To review the pathophysiology, clinical signs, diagnosis, and treatment of pulmonary thromboembolism (PTE) in small animals. Data Sources -Human and veterinary clinical studies, reviews, texts, and recent research in canine and feline PTE diagnosis and thromboembolic therapeutics. Human Data Synthesis -In humans, clinical probability assessment and point-of-care D-dimer-based algorithms are widely used. Computed tomography pulmonary angiography is the gold standard for PTE diagnosis in humans. Echocardiography is increasingly used for bedside assessment of affected patients. In low-risk human patients anticoagulants alone are recommended while patients with cardiogenic shock are treated with thrombolytics followed by anticoagulation. Veterinary Data Synthesis -PTE is associated with numerous predisposing conditions causing hypercoagulability, blood flow stasis, or endothelial injury. Identifying at-risk patients is key to diagnosis in small animals. Thromboelastography provides a method for identifying hypercoagulable patients. Computed tomography pulmonary angiography may replace selective pulmonary angiography as the imaging technique of choice for PTE diagnosis. PTE therapy consists of supportive treatment combined with appropriate, individualized thromboembolic pharmacotherapy for acute treatment and chronic management. Thrombolytic therapy for PTE remains controversial but may be indicated in hemodynamically unstable acute PTE. Thromboprophylaxis in specific conditions is rational although evidence of efficacy is limited. Prognosis depends upon degree of cardiopulmonary compromise and patient response to therapy. Mortality rates in small animals are unknown. Conclusions -New diagnostic techniques and advances in therapy offer significant potential for improvements in the identification and treatment of PTE in small animals. Further study must be directed to validating new diagnostic modalities and evaluating therapeutic regimes.

Summqy VenousMood lactate concentrations were measured on 109 ill dogs and 20 ciinical~normal dogs. 111 dogs were grouped into survivor and nonsurvivor groups, and categorized based on their pn"may problem. Ninep@epercent oJill dogs had iactate concentrations lugher than clinical~normal dogs and published normal values. Seveny-six percent OJill dogs with increased lactate concentrations sum"ved to be discharged. tictate concentrailons were s@@?cant~?ugherin nonsurvivors than in survivors and clinical~normal dogs. Lactate concentrations in dogs with nugor trauma and intoxicaaons, and with cardiopulmonary, gastrointesfihal and neurolo~k problems were s@nficanth gher than in clinica[~normal dogs and dogs with other problems.

Cats are popular pets, but until recently, their peri-operative and traumatic pain had been seriously underestimated and under-treated. The lack of treatment stems from difficulty in recognizing pain, lack of licensed analgesic drugs, fear of toxic side effects, and lack of information specific to cats. Fortunately, in the last decade, many advances have been made in feline analgesia. It is now obvious that because of the cat's unique metabolism, species-specific studies are essential. Opioids are the mainstay of any analgesic protocol for acute pain and can be used with few side effects. Other drugs that can be utilized include the a 2-agonists, local anesthetics, and non-steroidal anti-inflammatory drugs. Pain assessment in cats is challenging and developing, and validating pain scoring systems remains an important goal. The information in this article will help the critical care and emergency clinician formulate a safe and effective analgesic plan for feline patients.

Objectives -This case series describes 5 dogs with small intestinal intussusception and acute kidney injury due to infection with Leptospira interrogans serovar Australis. Case Series Summary -Small intestinal intussusception was observed in 4 dogs diagnosed with acute kidney injury due to leptospirosis presented between 1997 and 2005. Intussusception was diagnosed at initial presentation or later during hospitalization. An additional dog fulfilling our inclusion criteria was presented to a small animal specialty clinic nearby and was included. Upon admission, all dogs were severely azotemic and thrombocytopenic. All 5 dogs showed the strongest microscopic agglutination test serology reaction to L. interrogans serovar Australis. Two dogs survived with no apparent residual renal damage, 1 survived with subsequent mild chronic kidney disease, and 2 dogs were euthanized at the owners' request due to a guarded prognosis. New or Unique Information Provided -Intussusception can occur or may be seen in dogs with leptospirosis due to L. interrogans serovar Australis and patients should be monitored closely for this potential complication. As all 5 dogs described in this case series showed the highest titer for L. interrogans serovar Australis, these precautions may be especially applied in geographic areas where this particular serovar is seen.

he purpose oJthis study is to report the arterial bloodgm~ndings in dogs with batten'al pneumonia. Arterial bloodgas samples were collected~om 62 dogs with cukure-con@ned bacten"al pneumonia. These results were compared with 46 normal dog arterial bioodgas samples. Results demonstrated that respiratory acidosis was not a problem in dogs with pneumonia in this study. S@njt?cant evidence o~hypoxemia was noted with abnormal mean values in Pa02 (P c O.001) and the Alveo2arartenal (A-a) gradient (P c O. 001).

Objective -(1) To determine the ability of a continuous interstitial glucose monitoring system (CGMS) to accurately estimate blood glucose (BG) in dogs and cats with diabetic ketoacidosis. (2) To determine the effect of perfusion, hydration, body condition score, severity of ketosis, and frequency of calibration on the accuracy of the CGMS. Design -Prospective study. Setting -University Teaching Hospital. Animals -Thirteen dogs and 11 cats diagnosed with diabetic ketoacidosis were enrolled in the study within 24 hours of presentation.

Objective -To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. Design -Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. Setting -Academia, referral practice and general practice. Results -A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. Conclusions -Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Objective -To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. Design -Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. Setting -Academia, referral practice and general practice. Results -A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. Conclusions -Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Ek?vationin biooa'lactate concentration, with or without accompanying rnetaboiicacidosis, is a hallrnark@nding in patients with ci?cularo~compromise, and is ako consistently noted in other conditions afecn"ngm"tical~ili or inJ"ured individual. Little is reported in the veten"naryliterature regarding lactate measurement in the emugenqv and critikai care setting, despite impressive reporzs OJthe clinical use~lness OJlactate measurement in people. i'%epurpose OJthis article is to review lactate kinetics and the clinical utilip of lactate measurement. Limitations to lactate evaluation will also be dkussed.

Objective – To review the pathophysiology, clinical signs, diagnosis, and treatment of pulmonary thromboembolism (PTE) in small animals.Data Sources – Human and veterinary clinical studies, reviews, texts, and recent research in canine and feline PTE diagnosis and thromboembolic therapeutics.Human Data Synthesis – In humans, clinical probability assessment and point-of-care D-dimer-based algorithms are widely used. Computed tomography pulmonary angiography is the gold standard for PTE diagnosis in humans. Echocardiography is increasingly used for bedside assessment of affected patients. In low-risk human patients anticoagulants alone are recommended while patients with cardiogenic shock are treated with thrombolytics followed by anticoagulation.Veterinary Data Synthesis – PTE is associated with numerous predisposing conditions causing hypercoagulability, blood flow stasis, or endothelial injury. Identifying at-risk patients is key to diagnosis in small animals. Thromboelastography provides a method for identifying hypercoagulable patients. Computed tomography pulmonary angiography may replace selective pulmonary angiography as the imaging technique of choice for PTE diagnosis. PTE therapy consists of supportive treatment combined with appropriate, individualized thromboembolic pharmacotherapy for acute treatment and chronic management. Thrombolytic therapy for PTE remains controversial but may be indicated in hemodynamically unstable acute PTE. Thromboprophylaxis in specific conditions is rational although evidence of efficacy is limited. Prognosis depends upon degree of cardiopulmonary compromise and patient response to therapy. Mortality rates in small animals are unknown.Conclusions – New diagnostic techniques and advances in therapy offer significant potential for improvements in the identification and treatment of PTE in small animals. Further study must be directed to validating new diagnostic modalities and evaluating therapeutic regimes.

Objective – To characterize the clinical features and population differences among cats sustaining traumatic and nontraumatic rib fractures.Design – Retrospective clinical study.Setting – University small animal hospital.Animals – Thirty-three cats with radiographic evidence of rib fractures.Interventions – None.Measurements and Main Results – Cats with rib fractures were identified by performing a computer search of the radiology database. Thirty-three cats that sustained rib fractures were identified between January 2000 and September 2009. Seventeen cats had fractures due to trauma and 16 were deemed to occur from nontraumatic causes. A Mann-Whitney rank-sum test revealed statistically significant differences in the median ages between the 2 groups. Older cats were more likely to sustain rib fractures as a result of a presumed nontraumatic causes. A Chi-square analysis showed that nontraumatic fractures occurred significantly more often in the midbody region and involved the 9th–13th ribs. The majority of cats with presumed nontraumatic rib fracture had respiratory disease; the remaining cats had chronic renal disease or neoplasia. Cats with traumatic rib fractures had external signs of trauma.Conclusion – Rib fractures in cats may be clearly associated with trauma, or may be an incidental finding in cats with comorbidities. Cats with diseases that cause prolonged respiratory effort or coughing, metabolic diseases, or certain neoplasms, are at increased risk of spontaneous nontraumatic rib fractures.

Objective -To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. Design -Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. Setting -Academia, referral practice and general practice. Results -A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. Conclusions -Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Objective: This case report describes antivenin-associated acute and delayed hypersensitivity reactions in a dog envenomated by an Eastern diamondback rattlesnake (Crotalus adamanteus), specifically reviewing the syndrome of antivenin-associated serum sickness. Clinician awareness of this syndrome is important in order to allow for its recognition and appropriate treatment. Case summary: A Boxer dog was envenomated by an Eastern diamondback rattlesnake. Shock, echinocytosis, and coagulopathy were manifested, and the dog was given antivenin crotalidae polyvalent therapy and supportive care. The early onset of an anaphylactoid reaction was attributed to antivenin therapy and was managed with diphenhydramine and subcutaneous epinephrine therapy. Fever, chemosis, and limb edema occurred during the 3rd through 6th hospital days following antivenin therapy and were consistent with serum sickness syndrome as described in humans. Further immunoassay support reflecting complement activation and response to treatment were characteristic. New information provided: To our knowledge, this describes the first reported case of antivenin-associated serum sickness in a dog. (J Vet Emerg Crit Care 2005; 15(3): 206-212)

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

Objective -To provide a review of clinically relevant observations related to Bartonella species as emerging pathogens in veterinary and human medicine. Data Sources -Literature as cited in PubMed and as generated by each of the authors who have contributed to various aspects of the clinical understanding of bartonellosis. Human Data Synthesis -Important historical and recent publications illustrating the evolving role of animal reservoirs as a source of human infection. Veterinary Data Synthesis -Comprehensive review of the veterinary literature.

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

Metaldehyde and methiocarb are two snail baits (molluscicides) which are commonly ingested by dogs and cause rapid onset of severe neurological symptoms. Rapid and appropriate treatment is essential for patient survival. This paper summarizes the literature on treatment of metaldehyde and methiocarb toxicity, based primarily on actual case reports from the past 35 years.There are important differences between metaldehyde and methiocarb in their mechanisms and treatment. Metaldehyde's mechanism is unknown; methiocarb is a carbamate and parasympathomimetic. Pentobarbitone anesthesia and atropine have been the mainstays of treatment in metal-dehyde and methiocarb toxicity, respectively; their limitations and disadvantages are discussed. Other drugs and aspects of treatment, such as acetylpromazine, diazepam, gastric lavage, and hypetihermia, are also discussed.Clinical signs are similar in both types of toxicity, but treatment may be complicated by the development of hyperthermia and atropine poisoning which also have similar clinical signs.

The scientific journal of the University of veterinary medicine and pharmacy in Košice -The slovak republic issn 0015-5748 3-4 LVI I • 2013 FOLIA VETERINARIA is issued by the University of Veterinary Medicine and Pharmacy in Košice (UVMP); address: Komenského 73, 041 81 K o š i c e, The Slovak Republic (tel.: +421 915 984 669, fax: +421 55 632 52 93, E-mail: [email protected]). IČO: 397 474

Objective: To determine the frequency of the systemic inflammatory response syndrome (SIRS) in canine pyometra and to evaluate the relationship between C-reactive protein (CRP), tumor necrosis factor a (TNFa), interleukin-6 (IL-6), and SIRS. Design: Prospective clinical study. Setting: Veterinary teaching hospital. Animals: Fifty-three clinical cases of canine pyometra and 19 healthy control bitches. Interventions: Upon admission to the veterinary hospital, history and physical examination findings, including previously defined clinical SIRS parameters, were documented. Blood samples were obtained for hematology and biochemical tests and for CRP, TNFa, and IL-6 analysis. The diagnosis of pyometra was confirmed by histopathology of the uterus after ovariohysterectomy. After surgery, clinical SIRS parameters, length of hospitalization, and mortality were recorded. Measurements and main results: Pyometra dogs were grouped as SIRS positive (30/53; 57%) or SIRS negative (23/53; 43%). Logistic regression showed that CRP was the only parameter that significantly related to SIRS apart from the clinical criteria that define this syndrome. The mortality rate was low (2/53; 3.8%), and conclusions regarding association with SIRS could not be drawn. A positive SIRS status, high plasma CRP concentration, and high body temperature were variables that related to increased morbidity reflected by the length of hospitalization. Conclusions: SIRS was seen in 57% of canine pyometra cases and a positive SIRS status showed a positive association with prolonged hospitalization. The mortality rate was low (3.3%) among SIRS positive dogs, indicating that progression to multiple organ dysfunction syndrome (MODS) rarely occurs in surgically treated cases of pyometra. CRP was associated with SIRS and with prolonged hospitalization. Further studies of plasma CRP may be warranted in canine intensive care cases susceptible to development of SIRS and MODS.

Objective -To determine the reference interval for various venous analyte concentrations using a point-ofcare (POC) analyzer in healthy, 4-84-day-old puppies and identify any age-specific variations in the values as compared with adults. Design -A prospective cohort study. Setting -University teaching hospital. Animals -Clinically healthy dogs; 68 puppies and 30 adults. Measurements and Main Results -Samples were collected by jugular venipuncture from 68 clinically healthy puppies at 4, 10, 12, 16, 28, 70, 77, and 84 days of age and once each from 30 clinically healthy adult dogs. Blood samples (n = 287) were analyzed within 5 minutes of collection using an automated POC analyzer. a Reference intervals for puppies at various ages were estimated using a bootstrap sampling approach. The analytes that were closest to the adult values were pH and bicarbonate. On days 4 and 10 the pH for puppies was higher than the adults while the HCO 3 was higher than the adults only on day 4. HCT on day 4 approximated adult values but fell to a nadir on day 28 before rising toward adult levels. At all time points, sodium, chloride, and ionized magnesium concentrations were lower than adult values, and potassium and ionized calcium were higher than adult values. Glucose was similar to adult values on day 4 but was above adult values at all other time points. Blood urea nitrogen (BUN) was higher in puppies until day 28 when it became lower than in adults. BUN levels remained lower than adults through day 84. Conclusions -Variations exist between puppies and adults for venous POC analyzer results. Adult reference intervals should not be used for puppies as this might cause misinterpretation of the results. (J Vet Emerg Crit Care 2014; 00(0): 1-11)

Objective -To evaluate population characteristics, injuries, emergency diagnostic testing, and outcome of dogs with blunt trauma requiring intensive care in an urban hospital. Design -Retrospective study 1997-2003. Setting -All data obtained from the University of Pennsylvania -Matthew J. Ryan Veterinary Hospital. Animals -Dogs admitted to the intensive care unit for treatment following blunt trauma.

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

Objective -To review the current in vivo and in vitro tests of platelet function (PF) currently available and applicable to companion animals. Data Sources -Scientific reviews, case reports, original clinical and laboratory research publications, and recent veterinary research conference proceedings. Human Data Synthesis -Disorders of primary hemostasis are very common in human medicine. These include inborn errors of PF and granule storage contents, primary disease mechanisms that alter PF, disorders secondary to surgical interventions, and the effects of anticoagulant medications. Knowledge of PF disorders and the optimal method for assessment must be known to understand the mechanism and to monitor the process or drug therapy. Veterinary Data Synthesis -Interest in the study and treatment of primary coagulopathies in clinical veterinary patients has resulted in a surge of recent publications and scientific research presentations. A translational approach that uses laboratory and point-of-care tools to uncover the pathophysiologic mechanisms in the patient with defects in primary hemostasis allows the clinician to plan the diagnosis and treatment more effectively. Summary -Primary hemostatic disorders are being more commonly recognized in clinical veterinary practice. The diagnosis of platelet dysfunction may be obtained via point-of-care analyzers that use relatively small blood samples and have a quick turnaround time. Recent investigations may lead to a better understanding of the pathophysiology of PF disorders and potentially the optimization, or discovery, of novel treatments. Conclusions -The assessment of PF can be completed through in vivo and in vitro point-of-care techniques as well as by submission of blood samples to more specialized platelet biology laboratories. The information obtained including the physical examination and clinical manifestations of a hemostatic disorder, as well as the benefits of each testing modality, must be known prior to the diagnostic investigation of a patient with a coagulopathy. (J Vet Emerg Crit Care 2012; 22(1): 81-98)

success>{ resuscitation o~a trauma-induced suspected tension pneumomediastiruim in a dog is presented. me cause was a caudal Cervical penetrahon wound which acted as a one-way valve allowing air to entec but not exit the cranial mediasti"num.Ear~in the course ojhospitalization, respiratory and cardiovascular collapse occurreh an emergent parasternotomy allowed decompression of the mediastirwm, and the cardiovascular system immediate~responded. ??zedog made a complete recove~following surgka[ exploration and removal o~contaminated mediastinal tissue. Nine days OJintensive care included 24-hour monitotihg, o~gen therapy, intravenous crystalloid and colioids, conn"nuous pleural suctioning, nu&ifi"onal suppor~antibiofi"cs, and pain control. my words: tension pneumomediastinum, pneumomediastinum, dog, parasternotomy

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

Objective: Description of a case series of 4 dogs with acute renal failure after ingestion of raisins or grapes. Case summary: Four dogs were presented with acute oliguric or anuric renal failure after a known ingestion of varying quantities of raisins or grapes. Prior to the onset of vomiting, all dogs were healthy, had no previous history of renal insufficiency, and had no exposure to other potentially nephrotoxic agents. This case series describes the clinical course and various treatment modalities used in the 4 dogs. New or unique information provided: This is the first report of clinical signs, treatment, and clinical outcome in dogs that developed renal failure after ingestion of raisins or grapes. The pathogenesis of nephrotoxicity associated with raisins and grapes remains unknown. Outcome was favorable in 2 out of the 4 cases of acute renal failure associated with raisin or grape ingestion in these dogs. (J Vet Emerg Crit Care 2004; 14(3): 203-212)

Objective -To systematically examine the evidence on the effect of prevention and preparedness measures on outcomes in veterinary cardiopulmonary resuscitation and to determine knowledge gaps. Design -Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Relevant questions were answered on a worksheet template and reviewed by the Reassessment Campaign on Veterinary Resuscitation (RECOVER) prevention and preparedness domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 3 months. Setting -Academia, referral practice, and general practice. Results -Nine worksheets were prepared to determine the extent to which preparation of the environment (charts, visual aids, etc) and personnel (training, debriefing, etc) are beneficial in improving return of spontaneous circulation. Conclusions -Of the questions evaluated, only the association between anesthesia-related cardiopulmonary arrest and better outcomes was supported by strong evidence. There is some evidence from the human literature that the use of cognitive aids, standardized didactic, and hands-on training with high-fidelity simulators, team and leadership training, and post-cardiac arrest debriefing improve adherence to cardiopulmonary resuscitation guidelines and, in some cases, patient outcomes. Veterinary studies investigating these issues are lacking, and development of initial guidelines is a crucial first step.

Objective -To present a series of evidence-based, consensus guidelines for veterinary CPR in dogs and cats. Design -Standardized, systematic evaluation of the literature, categorization of relevant articles according to level of evidence and quality, and development of consensus on conclusions for application of the concepts to clinical practice. Questions in five domains were examined: Preparedness and Prevention, Basic Life Support, Advanced Life Support, Monitoring, and Post-Cardiac Arrest Care. Standardized worksheet templates were used for each question, and the results reviewed by the domain members, by the RECOVER committee, and opened for comments by veterinary professionals for 4 weeks. Clinical guidelines were devised from these findings and again reviewed and commented on by the different entities within RECOVER as well as by veterinary professionals. Setting -Academia, referral practice and general practice. Results -A total of 74 worksheets were prepared to evaluate questions across the five domains. A series of 101 individual clinical guidelines were generated. In addition, a CPR algorithm, resuscitation drug-dosing scheme, and postcardiac arrest care algorithm were developed. Conclusions -Although many knowledge gaps were identified, specific clinical guidelines for small animal veterinary CPR were generated from this evidence-based process. Future work is needed to objectively evaluate the effects of these new clinical guidelines on CPR outcome, and to address the knowledge gaps identified through this process.

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

The purpose OJthis study is to report on~ve cases oJcoral snake envenornation in the dog to substanfi"ateearlierJndings in~our dogs reportedprevioudy, and to descn~e any additional c[in-icai~eaturesthat have notyet been noted. The combined results~om both studies ailow~ora more accurateprqection o~the~equenqv o~certain clinical sz@s. Both groups showed sijgnsoJlethar-gE lower motor neuron weakness (80J9 dogs) and varying hematology changes with hemo@is and hemoglobinuria occurringmost common~(7'of 9 dogs), Cardiacdysrhythmias were recorded in>equent~(2 OJ9 dogs). Not reportedpreviously was the presence OJa subtle bite wound located on the upper or lower I@o~three dogs in the present series. An unexpectedJinding in this second series was the occurence OJan anaphylactoid reaction in one dog presumab~attributed to the antivenin. Closeexamination oJthe lip m~ghtreveal the site o~envenomation (asfound in 4 oJ9 dogsfiom both studies). Z7eatmentwith coralsnake antivenin should be given as ear~as possible andJo[Zowedby close observationJor s@ns of anaphykzxis. The results of thti study substanfl"ateearlierjndings and providefor a larger data baseJor&ther reference.

Objective: To establish normal parameters of thromboelastography (TEG) in healthy adult cats. Background: Thromboelastography (TEG) is an in vitro test of coagulation that has been shown to be useful in humans, dogs and select species to identify and quantify alterations of hemostasis (e.g., hypercoagulable and hypocoagulable states). It has also been demonstrated to be useful in monitoring effects of anticoagulant therapies. This test has not been evaluated in cats. Methods: Blood was collected from 25 clinically normal cats by venipuncture using a 21 gauge  3 1/2 inch butterfly catheter and syringe for medial saphenous or jugular venipuncture. A single 1.8 mL sample in 3.8% Sodium Citrate (9:1) was collected from each cat. Recalcified whole blood was analyzed 30 minutes following collection with the TEG s 5000 analyzer (Haemoscope, Niles, IL). Analysis temperature was 37.6 1C. TEG parameters recorded included: R-value (represents initial fibrin formation), K (time from R to standard fixed measure of clot firmness which represents contributions of platelets and fibrinogen), maximum amplitude (MA; represents absolute clot strength), and alpha angle (a; the slope of TEG tracing which represents rate of clot formation). The coagulation index (CI) was derived from the formula generated for humans to provide an overall assessment of whether the sample was hyper-or hypocoagulable. Results: Values for the 25 normal cat samples are reported as mean AE 2 standard deviations. R 5 2.97; 1.23-4.72; K 5 1.54, 0.38-2.71; a 5 70.70, 57.76-83.65; MA 5 58.50, 45.26-71.74 and CI 5 2.27, 0.07-4.46. Compared to historical information obtained on normal dogs, cats have significantly shorter R and K and larger a, MA and CI. Conclusions: TEG does have reproducible performance when used to evaluate coagulation status in normal cats. Compared to dogs, normal cats favor a hypercoagulable state. Species-specific normal values are necessary for interpretation of TEG results. This test bears potential value for use in future experimental and clinical work to investigate hemostasis in cats receiving anticoagulant therapies or in cats suffering from diseases such as cardiomyopathy which are thought to be associated with altered coagulation status.

Emergency rescue operations of equines should optimize both rescuer safety and the victim's prognosis for post-incident recovery. This can be achieved by the selection of appropriate rescue procedures and the implementation of an organized team approach among veterinarians and other emergency responders.

Fluid and electrolyte imbalances are frequent~ encountered in a varieO: of medical and surgical disorders therefore requiring the clinician's astute evaluation of his~her patient's fluid and electrolyte status. Disorders involving the gastrointestinal tract, kidneys, and endocrine organs will frequently cause abnormagties in sodium, potassium, magnesium, and chloride balance. An accurate initial assessment of serum electrolyte concentrations and monitoring during the treatment is essential in order to maintain electrolyte homeostasis. Failure to do so can lead to severe clinical consequences for the patient and change a diagnostic triumph into a therapeutic failure. This presentation provides an overview of the etiologies, clinical signs, and therapeutic approaches to electrolyte disorders in the critically ill animal.

Objective: To review the human and companion animal veterinary literature on nosocomial infections and antimicrobial drug resistance as they pertain to the critically ill patient. Data sources: Data from human and veterinary sources were reviewed using PubMed and CAB. Human data synthesis: There is a large amount of published data on nosocomially-acquired bloodstream infections, pneumonia, urinary tract infections and surgical site infections, and strategies to minimize the frequency of these infections, in human medicine. Nosocomial infections caused by multi-drug-resistant (MDR) pathogens are a leading cause of increased patient morbidity and mortality, medical treatment costs, and prolonged hospital stay. Epidemiology and risk factor analyses have shown that the major risk factor for the development of antimicrobial resistance in critically ill human patients is heavy antibiotic usage. Veterinary data synthesis: There is a paucity of information on the development of antimicrobial drug resistance and nosocomially-acquired infections in critically ill small animal veterinary patients. Mechanisms of antimicrobial drug resistance are universal, although the selection effects created by antibiotic usage may be less significant in veterinary patients. Future studies on the development of antimicrobial drug resistance in critically ill animals may benefit from research that has been conducted in humans. Conclusions: Antimicrobial use in critically ill patients selects for antimicrobial drug resistance and MDR nosocomial pathogens. The choice of antimicrobials should be prudent and based on regular surveillance studies and accurate microbiological diagnostics. Antimicrobial drug resistance is becoming an increasing problem in veterinary medicine, particularly in the critical care setting, and institution-specific strategies should be developed to prevent the emergence of MDR infections. The collation of data from tertiary-care veterinary hospitals may identify trends in antimicrobial drug resistance patterns in nosocomial pathogens and aid in formulating guidelines for antimicrobial use.

BSTRACT A six-year-old, male, castrated domestic shorthair cat was presented for evaluation of an oral mass. Full physical examination revealed a large hard mass arising from the lateral aspect of the caudal part of the left mandible. Abdominal ultrasound and thoracic computed tomography (CT) were performed to rule out metastatic disease. In addition, CT of the skull with intravenous contrast agent was performed. Histopathological examination of extra-oral biopsies confirmed the tentative diagnosis of peripheral osteoma. A three-dimensional printed skull was used in conjunction with the CT images to determine the detailed location and extent of the mass and to identify anatomical spatial relationships with important neurovascular structures. Surgical debulking of the osteoma was performed. The cat recovered uneventfully but the mass regrew nine months after debulking therapy, sooner than expected. Nevertheless, CT scan of the skull was suggestive for regrowth of the peripheral osteoma rather than for malignant transformation. The owners did not elect to pursue caudal mandibulectomy. SAMENVATTING Een zesjarige, mannelijke, gecastreerde kat werd aangeboden voor evaluatie van een orale massa. Op het lichamelijk onderzoek werd een grote harde massa opgemerkt aan de laterale kant van het cau-dale deel van de linkermandibula. Abdominale echografie en computertomografie (CT) van de thorax werden uitgevoerd om metastasen uit te sluiten. Bijkomend werd een CT-scan van de schedel met intraveneuze contrastvloeistof genomen. Histopathologisch onderzoek van extraorale biopsieën be-vestigde de waarschijnlijkheidsdiagnose van perifeer osteoma. Een driedimensionale (3-D), geprinte schedel in combinatie met CT-beelden werd gebruikt om de exacte locatie en omvang van de massa te beoordelen en om alle belangrijke neurovasculaire structuren te kunnen onderscheiden. Chirurgische debulking van het osteoma werd uitgevoerd. De kat herstelde zonder problemen, maar de massa kwam negen maanden na debulking terug. Dat was eerder dan verwacht. Desondanks was de CT-scan van de schedel suggestiever voor terugkeer van het perifere osteoma dan voor een maligne transformatie. De eigenaren kozen ervoor om niet verder te gaan met caudale mandibulectomie.