TheGallbladderHaloSign:MorethanCanineAnaphylaxis&Hemoabdomen-aCanineComplicationYouMUSTKnow

GregoryR.Lisciandro,DVM,Dipl.ABVP,Dipl.ACVECCHillCountryVeterinarySpecialists&FASTVet.com,Spicewood,TexasUSA

EmailLearnGlobalFAST@gmail.comCell210.260.5576

Websitewww.FASTVet.com

TextFocusedUltrasoundTechniquesfortheSmallAnimalPractitioner,Wiley©2014availableinSpanish,www.intermedica.com.ar,Greek,Chinese,JapaneseandPolish

IntroductionThelecturewillnotcoverdetailregardingthepathophysiologyofanaphylaxisofwhichthereexistmanyexcellentpublisheddescriptions.Rather,thelecturewillfocusonhowtorapidlygainsupportiveevidenceforthediagnosisofcanineanaphylaxiscausedbyawitnessedorunwitnessedsinglebeesting(orsimilarincitingenvenomation),includingthesonographicmarkerofgallbladderwalledema;andimportantruleoutsforsonographically-detectedgallbladderwalledemathatcanconfoundthediagnosisattheexpenseofthepatient;andanewlydescribedfascinatingcomplicationreferredtobytheauthorascanine"anaphylaxis-related,heparin-inducedhemoabdomen"thatismedically-treated.Themajorreasonforthislectureisthatmanyveterinariansarenowusingpoint-of-careultrasound,specificallyFASTexams,asalife-savingfirstline,screeningtest.Asaresult,ultrasounddetectsfree-fluidandothersofttissuechangesthatarenotrecognizedwithoutultrasound;andmanytriagedcollapseddogswithanaphylaxishavenocutaneoussignsnorwitnessedincitingenvenomation.Thefocusofthesourceofanaphylaxisinthislecturedisregardstheobviouscaninewithclassiccutaneoussignsofangioedema,pruritusandurticaria,butfocusesonthesingleHymenopteraenvenomationthatisoftenunwitnessed.Allveterinariansneedtorecognizethestrengthsandlimitationsofsonographically-detectedgallbladderwalledema,theso-called"halosign"or"haloeffect"or"doublerimeffect"sinceitspresenceisnotpathognomonic;andthatAX-related,heparin-inducedhemoabdomenisamedically-treatedcaninecomplication.Withoutthisknowledge,gallbladderwalledemawillpotentiallybemisinterpretedandsurgicalinterventionwilllikelyleadtoafatalexploratorysurgerywiththefindingsofhepaticswelling,intra-abdominalblood,andnon-specifichistopathology(LisciandroJVECC2016[Abstract]).TheFASTDiaphragmatico-Hepatic(DH)ViewImagingtheGallbladderandDetectingIntramuralEdemaInnormalcy,thegallbladdersonographicallyisgenerallyovalinlongitudinal(sagittal)orientationwithalumenthatishomogeneouslyanechoic(black).Thegallbladderwallisquitereliablyandseensonographicallyasathinhyperechoic(white)lineinbothcaninesandfelinesdespitenormalthicknessreportedtobeupto2-3mm.Insummary,thesonographicfeaturesofthecanineandfelinegallbladder,whenintramuraledemaispresent,areeasytoappreciatebynon-radiologistsonographerswhenimagingtheFASTdiaphragmatico-hepatic(DH)view(subxiphoid).Ina2009study,Quantzetal.publishedinJVECCabrilliantstudythatcorrelatedthepresenceofathickened,edematous,sonographicallystriatedgallbladderwall,referredtoasthe"gallbladderhalosign"or"haloeffect"or"doublerimeffect",withcanineanaphylaxis(AX).TheirstudydesignwasaresultofrecognizingthatinacanineAXresearchmodel,gallbladderwalledema,sonographicstriation,wascommonlyandreliablypresent.Theiroversightinhindsight,wasbyperformingonlyafocusedgallbladderexamination(andnotAFASTandanabdominalfluidscore[betteraGlobalFASTApproach]),thustheylikelymissedaseriouscomplication.

Figure.Normalexpectedsonographicappearanceofthegallbladderwallincanines(andfelines)asathinwhite(hyperechoic)line.UnlabeledmiddlefigurelabeledwithAandB.Ashowsmoresubtlegallbladderwallsonographicstriation/intramuraledemaaswhite(outerwall)-black(intramural)-white(innerwall)orinultrasoundtermsashyperechoic(outerwall)-anechoic(intramural)-hyperechoic(innerwall);andinBshowsmoreobvious/severegallbladderwallsonographicstriation/intramuraledemafollowingthesamedescribedpatternasinA(white-black-white).FarrightimagelabeledAandBisthesameimagebutnowoutlinedtobettershowthesonographicstriation.ThismaterialisreproducedandmodifiedwithpermissionofJohnWiley&Sons,Inc,FocusedUltrasoundTechniquesfortheSmallAnimalPractitioner,Wiley©2014GallbladderWallEdemaasaSonographicMarkerforCanineAnaphylaxis(AX)Anaphylactic(AX)-relatedgallbladderedemaisspecifictocaninesbecausetheirshockorgan,wherethehighestconcentrationofmastcellsarelocated,istheirliverandgastrointestinaltract.Incontrast,theshockorganofcatsandpeopleisthelung,thusgallbladderwalledemaisnotahallmarkofAXinthesespecies.Thecauseofgallbladderwalledemaistheresultofmassivehistaminereleasecausinghepaticvenoussphincterconstrictionandmassivegeneralizedhepaticvenouscongestion.Simplyput,whentheliverswells,sodoesthegallbladderwall.Thisisimportanttorememberwhenconsideringotherruleoutsforcaninegallbladderwalledemaincludinggallbladderwalledemaassociatedwithhepaticvenouscongestionfromright-sidedcongestiveheartfailure.TheAX-relatedintramuralgallbladderedemaisrecognizedsonographicallyassonographicstriation.Thissonographicstriationappearasahyperechoic(white)linesrepresentingtheinnerandouteraspectsofthegallbladderwall,andasonolucentanechoic(black)linestriationrepresentingtheintramuralgallbladderedema.Inotherwords,thegallbladderwallbecomeslayeredaswhite,black,andwhite,(sometimesitiswhite,gray,white),andthushasbeendubbedthe“gallbladderhalosign”andalsolesscommonlythe"haloeffect"and"doublerimeffect."TheQuantzetal.studydocumentedthatAX-inducedgallbladderedemaisanimmediateoccurrencewithinseconds/minutesthatgenerallylastsupto24-48hourspost-insult.Conversely,dogswithmildreactionsintheQuantzetal.studywereunlikelytohaveintramuralgallbladderwalledema.SerumAlanineTransaminase(ALT)asaSerumMarkerforCanineAnaphylaxis(AX)Becausetheliverandgastrointestinaltractaretheshockorgansforthecaninespecies,traditionallyserumalaninetransaminase(ALT)hasbeenusedassupportiveevidenceforcanineAX.However,intheQuantzetal.study,itwasstatedthatserumALTmarkerwasnotasimmediateastheoccurrenceofgallbladderwalledema;andthattheALTmaynotspikeinvalueforupto2-4hourspost-insult.Quantzetal.documentedameanALTof~400IU/Linanaphylacticdogsintheircasestudypopulation.TheClassicConstellationsofSignsforCanineAnaphylaxisKeepinginmindthecanineshockorgan,traditionalmeansofdiagnosingcanineAXhavereliedonahistoryofacutecollapseinapreviouslyhealthydog.Theacutecollapseintheotherwisehealthydogiscommonlyassociatedwithgastrointestinalsigns,i.e.vomitinganddefecation.Thegreatmajorityofthesedogshavenoobviouscutaneoussigns(Quantzetal.stated~40%nocutaneoussignsvs.theauthor'sexperienceis~95%).Uponpresentationduetomassivefluidshifts(upto35%ofintravascularvolumemovedtointerstitialcompartmentinacanineAXresearchmodel)causedbyhistaminereleaseandlikelyotherfactorsthatincreasevascularpermeability(heparin,bradykinin,histamine-2,plateletactivatingfactor,tryptase),dogswithAXarecommonlyhemoconcentratedwithpackedcellvolumes(PCV)>55%rangeandevenhigher(incontrastdogswithahemoabdomenfromableedingtumoraregenerallynothemoconcentratedandoftenlownormalPCVoranemic).Aspreviouslymentioned,theserumALTislikewiseamarkerbecauseofthehepaticinsultduetotheliverandgastrointestinaltractbeingtheshockorgan.TheweathershouldalsobeconsideredbecausemanywarmdaysandcoolnightsmakeHymenopteraspecieslethargicandlesslikelytomoveawayfromthedogwalkingandsniffinginthegrassduringthesecooleveningsandmornings(author'sexperience)inspringandfallinSanAntonio,Texas.GallbladderWallEdemaisNotPathognomonicforCanineAnaphylaxis-It’salsoa"CardiacGallbladder"Inthecollapsedoracutelyweakhypotensivecaninetriagedwiththefindingofgallbladderwallsonographicstriation/edema,otherimportantruleoutsrelatetotheheartandincludepericardialeffusion,right-sidedheartandgeneralizedsystolicdysfunction(DCM)(Lisciandrounpublisheddata2014).Thepathophysiologyofgallbladderwalledemainthesecasesismechanicalobstructionofbloodflowtotherightatrium,inwhichbackflowofbloodleadstoadistendedcaudalvenacava(CVC),andsubsequenthepaticvenouscongestion.Simplyput,whentheliverswells,sodoesthegallbladder.TheseruleoutsareaddressedbylookingpastthediaphragmattheFASTDHviewforpericardialeffusion,the

classic"racetracksign"ofpericardialeffusionroundingthemuscularapexoftheheart;andaddingtherightTFASTPeriCardial(PCS)viewtoassesscontractilityattheleftventricularshort-axisview.Moreover,thereallysavvysonographeralways,alwayslooksatthecaudalvenacava(CVC)whereittraversesthediaphragmwhileattheFASTDHview.TheCVCisamarkerforcentralvenouspressure(CVP)anditshumancounterpart,theinferiorvenacavaattheanalogouslocation,isubiquitouslybeingtaughttomedicaldoctors.TheCVCinAXisflat(novolume,lowCVP)withnovariation(<10%)initsdiameter(<5mm)vs.theCVCcharacterizationinpericardialeffusionandcardiaccasesisdiametricallyopposedasFAT(toomuchvolume,highCVP),ordistendedwithminimalvariation(<10%)initdiameter(>1cm).WhentheCVCisFATfromahighCVP,hepaticveins,notnormallyobviousinlateralorstanding/sternalrecumbency,areobviousbranchingstructuresfromvenousdownstreamobstruction.TheupshotisthatgallbladderwalledemaisnotpathognomonicforcanineAXinthecollapsedorweakcanine;thatveterinariansmustresistsatisfactionofsearcherrorandminimallylookpastthediaphragmattheFASTDHforpericardialeffusion;andtheTFASTrightPeriCardialViewtoevaluatecontractilitybeforeadministeringlargevolumesofcrystalloids.TheauthoradvocatesfortheperformanceofGlobalFAST,thecombineduseofAFASTanditsfluidscoringsystem,TFASTandVetBLUE(lung)aspartofthephysicalexaminationtogetarapid,globalfreefluidandsofttissuescanofthesmallanimalpatientthatexceedsthesensitivity(andspecificity)ofradiography.SeeGlobalFASTProceedingsformoredetailregardingcaudalvenacavalcharacterization.

Figure.ThegallbladderhalosignandFAT(distended)CVCinadogwithpericardialeffusion(PCE)inAandB.PCEshouldberuledoutincollapsed,weakdogssuspectedofhavingAX.ThesinglefigureontherightshowingtheFAT(distended)caudalvenacava(CVC)asittraversesthediaphragm(DIA);andtheassociateddistendedbranchinghepaticveinsappearingastreetrunks(referredtoastheTreetrunkSign).ThecharacteroftheCVCiscompletelydifferentbetweencanineswithAX(flatCVC)andcanineswithpericardialeffusionorright-sidedheartfailure/DCM(FATCVC).LV:leftventricle;RV:rightventricle;PCE:pericardialeffusion;DIA:diaphragm;GB:gallbladder;CVC:caudalvenacava;FF:freeabdominalfluid.ThismaterialisreproducedwithpermissionofJohnWiley&Sons,Inc,FocusedUltrasoundTechniquesfortheSmallAnimalPractitioner,Wiley©2014

CausesofGallbladderWallEdema(theGallbladderHaloSign)*Anaphylaxis(acutecollapse,flatcaudalvenacava)–massivehistaminereleaseresultsinhepaticvenous

congestion*Right-sidedheartfailure/dysfunction(collapse,weakness,FATcaudalvenacava)–backflowofbloodtotheright

heartresultsinhepaticvenouscongestion*Pericardialeffusion(acutecollapse,weakness,FATcaudalvenacava)–obstructionofbloodflowtotheright

heartresultsinhepaticvenouscongestionCholecystitisPancreatitis

Hypoalbuminemia,3rdSpacingRight-sidedVolumeOverload(iatrogenic),fromintravenousfluidtherapy

Immune-mediatedHemolyticAnemia(IMHA),unknowncause,speculateimmune-mediatedPost-BloodTransfusion,unknownpathogenesis,speculateimmune-mediated,volumeoverload

*CausesofGallbladderWallEdema(HaloSign)thatOftenPresentwithAcuteCollapseorWeaknessGregLisciandro,DVM,Dipl.ABVP,Dipl.ACVECC,FASTVet.comCopyright2015,2016,2017,2018

Otherpotentialcausesforgallbladderwalledemathataregenerallypresentinnon-collapseddogsinclude3rdspacingfromhypoalbuminemiaandvasculitis,primarygallbladderdiseaseincludingcholecystitis,pancreatitis,andiatrogenicright-sidedvolumeoverload.Gallbladderwalledemaisoftenobservedindogswithimmune-mediatedhemolyticanemiaandpost-

bloodtransfusion.ItspresenceinthesesubsetsofpatientsdoesnotnecessarilyindicatecanineAX,soitisimportanttolookatthecompleteclinicalprofileofthesecaninepatientsbydoingagoodphysicalexamandperformingGlobalFAST®(AFAST®anditsfluidscoringsystem,TFAST®andVetBLUE®[lung]asasingleexamination).CanineAnaphylaxis-related,Heparin-induced,Medically-treatedHemoabdomenDogswithanaphylaxiscommonlydevelopabdominaleffusionoftenscoredasanabdominalfluidscore(AFS)of1or2usingtheAFAST-appliedfluidscoringsystem(seeAFAST®andGlobalFAST®Proceedings);andaremostcommonlypositiveattheFASTDHview(makessenseduetoacutehepaticvenouscongestionandhepaticswelling).Theselow-scoringeffusions(AFS1and2)areoftenself-resolving,thecaninepatientisnon-coagulopathic(PT,aPTT<25%overupperreferencerange),andthevolumetoosmallforsafelyperformingabdominocentesis.SerialAFASTwithAFS,minimallyonerepeatAFAST4-hourspost-admission,isjustifiedtodetectworsening(increasingscore[AFS])orresolution(decreasingscore[AFS])orstatic(nochangeinscore[AFS])oftheAX-relatedeffusion;anddependingonclinicalcourse,arepeatPCV/TSandCoagulationProfile;andAFASTwithAFSagainrepeatedafterdailypatientroundsuntiltheattendingveterinarianiscertainthatAX-relatedabdominaleffusion/presumedlowgradehemoabdomenhasresolved.Expectthatoncethepatient'scoagulopathytohaveresolved,dramaticresolutionofAFStominimalorabsentfreefluid(AFS0)within24-hours.Infact,GlobalFAST®-AFAST®withAFS,TFAST®andVetBLUE®-isanevenbetterformatoverAFAST®alonebecauseGlobalFAST®providesinformationonvolumestatus,lungstatus,andotherpotentialcomplicationsoccultbyphysicalexam,bloodandurinetesting,radiography,andvitalsigns.OthercasesofcanineAXhavelargevolumeeffusionsofAFS3and4.Evenintheselargevolumeeffusions,thecoagulationprofilemaybeclosetonormalandstayclosetonormal(lessthan<25%overupperreferencerange)onrepeatPCV/TSandCoagulationProfile4-hourspost-admissionalongwithAFASTwithAFS.Theselargevolumeeffusionswilllikewisegenerallyself-resolvewithin24-hoursifthepatientrespondsfavorablytoinitialresuscitationandtherapyforAXincludingfluidresuscitation+/-epinephrine,histamine-1receptorblocker(diphenhydramine),histamine-2receptorblocker(famotidine),andglucocorticoids(dexamethasonesodiumphosphateorprednisone).Abdominocentesisshouldbeperformedifthefreefluidissafelyaccessible,generallyatthemostgravity-dependentregionsoftheabdominalcavity,theAFASTumbilicalview(HRUinrightlateralrecumbencyorSRUinleftlateralrecumbency),whenyourpatientisinlateralrecumbency.Inourexperience,theseeffusionsarehemorrhagicwithacomparativeabdominalPCVofminimally≥50%oftheperipheralPCV.IncanineAXcaseswithabnormalcoagulationprofiles(greaterthan>25%overupperreferencerange),clottingfactorsshouldbereplacedassoonaspossible,e.g.,freshfrozenplasma(FFP).Asacrudeguideline,1in5-7canineAXcasesrequireFFP,and1in20canineAXcasesrequirepRBCs.SomeofthecoagulopathiccaninesrequirerepeatedFFPoverseveraldaysbutmorethan1roundofFFPisuncommonifantihistaminesandglucocorticoidsareusedinitiallytoblockthesecondepisodeofanaphylaxiswhichleadstopersistentcontinuedcoagulopathy(WOAGuidelines).TheauthortreatsallcanineAXcaseswithdiphenhydramine(H1receptorblocker)once,famotidine(H2receptorblocker,mitigatesvascularpermeability)forseveraldays,andimportantlya5-7daytaperingregimenofanti-inflammatorydosingofprednisonetoattenuatethesecondepisode(wave)ofAX-relatedinflammationthatpropagatesandperpetuatescoagulopathy.Glucocorticoidsmustbeadministeredatthetimeofpresentation(initiallyimmediatelyafterfluidresuscitation)andthencontinuedinanti-inflammatorydosagesoverthenext5-7days.Intheauthor'sexperienceoverthepast9-yearsofrecognizingandfirstdescribingAX-relatedheparin-inducedhemoabdomen,dogswithAXthataretreatedwithaninitialimmunosuppressivedoseofdexamethasonesodiumphosphate(0.3mg/kg)IVthenfollowedbyanti-inflammatoryprednisone(0.25mg/kgq12hrsPOfor3daysthen0.25mg/kgq24hrsfor3days)havefarlesstransfusions,muchlowercostofcareandco-morbiditiesthanthosenottreatedinthismanner.Theauthorhasseeninvoicesashigha10-12Kindogsnottreatedthiswaybecauseofthepersistentcoagulopathyandrepeatedneedfortransfusionproductsovermanydays.Glucocorticoidshavelowriskatthesedosages,areinexpensive,andveryimportantlydothefollowing:1)potentlyinhibitphospholipaseA2blockingthearachidonicacidpathwaymitigatingtheproductionofthesecondepisode(wave)ofinflammatoryproductsthatcontributetobradykininreleaseandamplification,2)potentlyblockmastcelldegranulationmitigatingheparinrelease,whichindirectlylimitsbradykininrelease,and3)andpotentlymitigatehistamineproduction.Bradykininandheparinarelikelythemostimportantplayersinthiscoagulopathy.Importantly,maropitantandpantoprazoledoNOTtreatAX.PathophysiologyofCanineAX-relatedHeparin-inducedMedically-treatedHemoabdomen

Intheory,theaPPTismoreaffectedbyheparin,anaturalcomponentofthemastcellgranule;thus,PTandaPTTtimesshouldbediscordantwiththeaPTTfarmoreprolongedthanthePT(oppositeofthewarfarinorcoumadineffect).SowhenthePTisnearnormalormildlyelevatedwithanoutofrangeaPTT,aflagshouldberaisedthatthecoagulopathymaybearesultofAXandheparinreleasebymastcells.However,thediscordanceseemsunreliable(becauseofthecomplexityofthecoagulopathy)andtheentireclinicalpatientprofilemustbeconsidered.Thecoagulopathyislikelyverycomplexwithfactorscontributingtoprolongedclottingtimes(heparinandtryptaseandothers)andvascularpermeability(bradykinin,productsoftheArachidonicAcidPathway,histamine-2,plateletactivatingfactor,andothers)alllikelyplayingroles.Inourcaseseriesof11dogsfromnearly4-yearsago,allsurvivedwithoutsurgerywithcompleteresolutionoftheirhemorrhagiceffusiontrackedusingGlobalFAST.Moreover,oftheclientsthatrespondedtolong-termfollow-up,AXhadnotrecurredintheirdog.ThedatafromthiscaseseriesisavailableoffourFASTVetFacebookpageormayberequestedbyemailingtheauthoratLearnGlobalFAST@gmail.comorgoingtoourwebsiteFASTVet.comConclusionItisimportanttorecognizethelimitationsandadditionalruleoutsforthesonographicfindingofastriatedgallbladderwall,theso-calledgallbladder"halosign"or"haloeffect"or"doublerimeffect";andthatdogshaveauniqueAX-related,heparin-induced,medically-treatedhemoabdomencomplication,andnotover-reacttostablepatientswithnormaltorelativelynormalclottingtimes(lessthan<25%overupperreferencerange)sincemanywillself-resolvewithstandardAXtherapy(fluidresuscitation,lowdoseepinephrine,HR1-blocker,HR2-blocker(famotidine)continuedforseveraldays,andglucocorticoidscontinuedforseveraldays).Inotherwords,manydogswithmildlyabnormalcoagulationprofileswillresolvewithouttransfusionproducts.EquallyimportantistoknownottotakeanAX-relatedcoagulopathiccaninehemoabdomentosurgery,whichcouldbecatastrophicforthedoglikelyresultingindeath.LargercasestudiesandmoresophisticatedcoagulationassessmentareneededtofullyunderstandthisperplexingcanineAX-relatedphenomenon;however,authorexperiencehasshownthattraditionalAXtherapyiseffectiveinmitigatingandcorrectingAX-related,Heparin-induced,Medically-treated,CanineHemoabdomen.Lastly,theGlobalFAST®

Approachisaglobalpatientsurveythatisimperativetoavoid"satisfactionofsearcherror"andmistakingadogwithpericardialeffusionandright-sidedcongestiveheartfailureforcanineAX.

Treatment&MonitoringforCanineAnaphylaxis

FirstLine Intervention Comments DurationofActivity

IntravenousFluids

30-50ml/kgI.V.repeatedasneeded

Short

Epinephrine

Lowdose0.01mg/kg-I.M.orI.V.repeatedasneededasoftenasevery5-10minutes;iffailsthenstarttransientCRI

CanuseasaCRIstartingat

0.05mcg/kg/minthenincreasingasneededbasedonbloodpressure;taperassoonas

possible

Short

SecondLine

*DexamethasoneSodiumPhosphate

(glucocorticoids)

0.3mg/kgI.V.

Repeat12-hoursPost-admissionat0.15mg/kgifnotabletotake

POPrednisone

*PotentArachidonicAcidInflammatoryPathwayBlockerbyinhibitingPhospholipaseA2and

Histamineblocker

Long

Diphenhydramine

(histamine-1receptorblocker)

2mg/kgI.M.ONCEwith

maximumdoseof50mg/dog

AvoidI.V.duetopotentialto

initiatehypotension

Short

Famotidine

0.5mg/kgI.V.orI.M.q12-

Continuefor5-7dayswhile

Short

(histamine-2receptorblocker) 24hrs(P.O.onceappropriate) PatientonSteroids

*Prednisone

0.25mg/kgq12hrsfor3daysthen0.25mg/kgq24hrsfor3

days

TaperingSteroidRegimentoPrevent2ndEpisode(Wave)of

InflammationthatCausesPersistentCoagulopathy

Long

FreshFrozenPlasma

GiveifPT,aPTT>25%overupperreferencerangeand

repeatasneeded

DelayifPT,aPTT<25%overupperreferencerangeandrecheckagainin4-hoursand

thereafterasneededdependingonAFSandclinical

course

FollowthesecaseswithfrequentPCVq2-4hoursplusSerialAFASTandAFS-scoringuntilyouare

ConfidentthattheCoagulopathyandHemoabdomenareResolving

Short

Monitoring AFAST® TFAST® VetBLUE®

GlobalFAST® -combiningAFAST® andAFS,TFAST® andVet

BLUE®

AFASTandfluidscoring-onadmissionandthen4-hourspostadmissionifstableand

soonerifunstable

AFASTandAFSaspartofdailypatientrounds

EXPECTresolutionoffreefluidtosmallvolumeAFS1and2ortotalresolutionwithin24-hourswhen

coagulopathyhasresolved

TFASTforvolumestatusand

contractility

Left-heartLA:AoRatioonshort-axisviewfallbacknon-echoviewVetBLUEforleft-sidedvolume

overload

Right-heartRV:LVonlong-axis4-chamberviewfallbacknon-echoviewtheCVCandhepaticveinsFASTDHviewforright-sided

volumeoverload

VetBLUEforlungedemaandother

respiratorycomplications

*ExpectlungtobedryinCanineAXunlesscomplications!

Copyright©2015,2016,2017GregLisciandro,DVM,Dipl.ABVP,Dipl.ACVECCandCEOofFASTVet.com

References&FurtherReading

1. QuantzJE,MilesMS,ReedAL,etal.2009.Elevationofalaninetransaminaseandgallbladderwallabnormalitiesasbiomarkersofanaphylaxisincaninehypersensitivitypatients.JVetEmergCritCare2009;19(6):536–544.

2. LisciandroGR.AbdominalFAST(AFAST)-detectedHemorrhagicEffusionin11DogswithAcuteCollapseandGallbladderWallEdema(HaloSign)withPresumedAnaphylaxis.AbstractJVetEmergCritCare2016.

3. LisciandroGR.Chapter55:UltrasoundinAnimals.InCriticalCareUltrasound(humantextbook),EditorsLumbandKarakitsos.Elsevier:St.Louis,MO2014.

4. LisciandroGR.Chapter2:TheAbdominal(AFAST)Exam.InFocusedUltrasoundfortheSmallAnimalPractitioner,Editor,LisciandroGR.WileyBlackwell:AmesIA2014.

5. LisciandroGR.Chapter9:TheThoracic(TFAST)Exam.InFocusedUltrasoundfortheSmallAnimalPractitioner,Editor,LisciandroGR.WileyBlackwell:AmesIA2014.

6. LisciandroGR.Chapter10:TheVetBLUELungScan.InFocusedUltrasoundfortheSmallAnimalPractitioner,Editor,LisciandroGR.WileyBlackwell:AmesIA2014.

7. LisciandroGRandArmeniseA.Chapter16:FocusedorCOAST3-CPR,GlobalFASTandFASTABCDE.InFocusedUltrasoundfortheSmallAnimalPractitioner,Editor,LisciandroGR.WileyBlackwell:AmesIA2014.

8. LisciandroGR.Focusedabdominal(AFAST)andthoracic(TFAST)focusedassessmentwithsonographyfortrauma,triageandmonitoringinsmallanimals.JVetEmergCritCare2011;20(2):104-122.

9. LisciandroGR.Caseseriesofdogswiththegallbladderhalosignassociatedwithpericardialeffusionandright-sidedheartfailureduringFASTexams.Unpublished,2014.

10. WorldAllergyOrganizationGuidelinesfortheAssessmentandManagementofAnaphylaxis.WorldAllergyOrganizationJournal2010;4(2):13-37.