What%to%expect%before%entering%clinics…%%

Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl justine@vetgirlontherun.com @VetGirlOnTheRun @drjustinelee

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Come%prepared%

HOW$TO$GET$A$GOOD$HISTORY$

How%to%take%a%good%history%

•  Introduce%yourself%then%take%control%–  18%second%rule%

•  Pet%their%pet!%

•  Quick,%but%thorough%–  15^20%minutes%

•  EMR/UVIS%–  Type%as%you%go%–  Spelling!%–  Professional!%

How%to%take%a%good%history %%

•  Presen7ng%complaint%(PC)%

•  Details%–  Dates,%quan77es,%vomi7ng%vs.%regurg,%dysuria,%hematuria%(stream?),%7me%of%toxin,%7me%of%going%down%

–  Start%from%the%beginning:%PMHX%–  The%three%Ts:%

•  Trauma%•  Toxins%•  Ticks%

•  �Is%there%anything%else%I%can…?�%

Presen7ng%it%to%the%Doc%

•  Totally%different%from%what%the%o%will%tell%us%

•  Quick,%efficient,%organized%

•  Start%with:%–  Signalment%–  PC%–  Physical%exam%findings%–  Problem%list%–  Your%plan%

•  Rule%outs%%•  Diagnos7cs%

#1%Physical%examina7on%

•  Efficient%•  Easily%repeatable%

–  Serial%exams%

•  Inexpensive%•  Fine^tuned%%•  Focused/targeted%•  Subjec7ve%

•  Tips:%%–  Palpate%aler%euthanasia%–  Palpate%under%anesthesia%–  Palpate%abnormal%

%

What%people%forget:%%Importance%of%TPR/weight%

•  Always%weigh%the%pa7ent%daily%

•  Don�t%use%the%carrier%(too%much%variability!)%

•  Note%what%scale%you%weighed%the%pa7ent%on%(on%ICU%sheet)%

Weight%•  Example:%30%kg%dog,%10%%dry%

–  Dehydra7on:%30%kgs%X%0.1%X%1000%mls%=%3000%mls%replacement%

–  I%L%=%1%kg%

–  You%expect&this%dog%to%gain%to%33%kgs%once%hydrated!%

•  Take%home%message:%weight%SID^QID!%

THE$ICU$SHEET$

ICU%sheets%

•  How%to%cross%out%an%error%

•  Document,%document,%document!%– Observa7ons%– To%x^ray,%AUS,%visi7ng%o%

•  Every%other%line%

•  Black%ball%point%pen%%%

You&touch&the&animal?&&You&write&it&down.&

•  mcg%vs.%mg%vs%%μg%"%1000%mcg%to%1%mg%%

•  0.75%mls%vs%75%mls%%•  Honesty,%honesty,%honesty!%

Examples%of%documenta7on%

•  Catheter%placement%

•  Labeling%catheters%

•  Unblocking%a%cat%–%what%was%it%like?%

•  Subjec7ve%–%does%the%pa7ent%look%nauseated?%

•  FAST%ultrasound%exam%%

ICU%sheets%

•  Save%those%lines!%%–  Need%a%CBC%drawn%at%8%am?%%–  Flip%+%lube%eyes%

•  Assess%your%own%pa7ent%frequently%yourself!%

•  Order%your%drugs%efficiently%–  Cost%effec7ve%–  Wasteful%–  Recycle/return%ziploc%bags%to%pharmacy%

Be%efficient%

•  Disconnec7ng%dog%for%AUS%–%take%it%outside%before%or%aler%(unless%they%need%a%cysto)%

•  Minimizes%#%of%hep%flushes/disconnec7ng%"%errors%•  Weight?%

•  Save%a%walk%for%ICU%techs%if%he�s%already%out%

•  Owners%=%walk%dogs%

•  S7cking%dogs/mean%cats%

Don’t%get%biuen…%

FORMULAS$TO$KNOW…$

•  No%longer%“shock%dose”%of%fluids%(60^90%ml/kg):%

–  Instead:%1/3%of%a%shock%bolus%aliquot%(20^30%mls/kg)%

•  Blood%transfusion%dose:%10^20%mls/kg%

•  DPL%dose:%20%ml/kg%

%

•  3^5%days,%5^7%days,%10^14%days%

CLINICOPATHOLOGIC$TESTING$

BIG%4%vs.%CBC/CHEM/UA%

•  ER%=%40%%outpa7ent%

•  Would%you&spend%$300%for%blood%work%each%7me%your%dog%vomited?%

•  BIG%4%+%EG8%vs.%complete%blood%work%

↓ PCV/ N TS (i.e., 25%/7 g/dL) ↑ PCV/N TS

(i.e., 65%/7 g/dL) N PCV/↓ TS (i.e., 40%/5 g/dL)

N PCV/↑ TS (i.e., 40%/9 g/dL)

↑ PCV/↑TS (i.e., 66%/8 g/dL)

↓ PCV/ ↓ TS (i.e., 25%/5 g/dL)

Hemolytic anemia Polycythemia vera Protein-losing enteropathy (PLE)

Multiple myeloma Hemocon- centration Chronic blood

loss (Melena) Aplastic anemia Hyperthyroidism Protein-losing

nephropathy (PLN)

Feline infectious peritonitis (FIP) Blood loss

(subacute)

Pure red blood cell aplasia Cushings Liver failure (lack

of production of albumin)

Chronic globulin stimulation (i.e., dental, skin disease)

Anemia of chronic disease Hemorrhagic

Gastroenteritis (HGE)

Acute blood loss (with splenic contraction)

Severe dehydration + anemia (i.e., CRF)

Is the sample hemolyzed? Icteric? # IMHA

EPO-producing tumor (renal) Third spacing Lipemic serum

BIG%4:%%Don’t%forget%that%blood%smear!%

•  Checking%for%the%presence%of%WBC%

–  Parvovirus%puppies%

•  Checking%for%the%presence%of%platelets%–  Epistaxis,%bruising%from%ITP%

–  1%plt/HPF%=%10,000%–%15,000%plt%

•  Checking%for%the%presence%of%spherocytes%–  DDX:%IMHA%

–  Found%in%80%%of%IMHA%pa7ents%

Coag%Quickies%

•  Prothrombin%(PT):%extrinsic%+%common%–  Elevated%quickly%with%Vitamin%K%roden7cides%–  Vitamin%K%dependent%factors:%II,%VII,%IX,%X%–  Half^life%of%VII:%7%hours%

•  Ac7vated%par7al%thromboplas7n%7me%(PTT):%intrinsic%+%common%

•  Ac7vated%clo{ng%7me%(ACT):%intrinsic%+%common%+%platelets)

•  ACT%=%PTT%

Coag%quickies:%

•  PT/PTT%never&affected%by%thrombocytopenia!%

•  Buccal%mucosal%bleeding%7me%(BMBT)%and%ACT%–  If%thrombocytopenic%(<50,000),%don�t%bother%

•  Clinical%thrombocytopenia%–  <%20^30,000%platelets%%

DRUG$CALCULATIONS$

Basic%calcula7ons%

•  %%=%�0�%+%mg/ml%

•  Lasix%5%%=%50%mg/ml%

•  50%%Dextrose%=%500%mg/ml%

•  25%%Mannitol%=%??%

When%in%doubt…%

•  If%it%doesn�t%feel%right,%it�s%not.%

•  If%it’s%not%clear,%it%doesn’t%go%IV%(for%the%most%part).%–  Sucralfate%IV%–  AlOH%IV%–  Clinicare%IV%

•  Ask%

•  Intern%director%screaming%at%intern%

–  Digoxin%dosing%

Drug%administra7on%

•  Drug%in%mgs%X%concentra7on%of%ml%=%amount%%% % % % % %mgs%

•  Dog:%30%kgs,%%Dose:%Pepcid%0.5%mg/kg%SID%IV%

•  30%kgs%X%0.5%mgs/kg%=%15%mgs%

•  15%mgs%X%1%ml/10%mgs%=%15/10%=%1.5%mls%

Con7nuous%Rate%Infusions%(CRIs)%•  Calculate%fluid%rate%

•  Calculate%how%many%�hours�%are%in%that%whole%bag%of%fluids%

•  Calculate%dose/hour%

•  Mul7ple%the%#%of%hours%in%the%bag%by%the%dose/hour%

•  Convert%to%mls%=%how%many%mls%to%add%into%the%total%bag%of%fluids%

CRI%of%5%mcg/kg/minute%of%Dopamine,%%30%kg%dog%

•  Fluid%rate%of%5%mls/hour%

•  250%ml%bag%of%0.9%%saline/5%mls%per%hour%=%50%hours%in%the%bag%

•  5%mcg%X%30%kgs%X%60%minutes%=%9000%mcg/hour%–  9000%mcg/hour%=%9%mgs/hour%

•  50%hours%in%a%bag%X%9%mgs/hour%=%450%mgs/bag%

•  450%mgs/bag%X%1%ml/40%mgs%=%11.25%mls/bag%

Dextrose%CRIs%% % % %%%%%C1%X%V1%=%C2%X%V2%

%•  Make%a%2.5%%dextrose%mix%to%IVF%%

•  50%%dextrose%=%500%mg/ml%

•  (50%)(X%ml)%=%(2.5%)(1000%ml)%

•  (X%ml)%=%50%ml%

•  Remove%50%mls%from%a%liter%bag%of%fluids%and%replace%it%with%50%ml%of%50%%dextrose%

Seriously,%the%hardest%part%of%EG?%% % % %C1%X%V1%=%C2%X%V2%%

•  Make%a%7%%ethanol%solu7on%with%Everclear%(check%proof&8&190%proof,%95%%alcohol):%%

•  (95%)(X%ml)%=%(7%)(1000%ml)%

•  (X%ml)%=%74%ml%

•  Remove%74%mls%from%a%liter%bag%of%fluids%and%replace%it%with%74%ml%of%190%proof%vodka%

VENOUS$BLOOD$GASES…$JUST$GUESS$METABOLIC$ACIDOSIS$

KISS:%interpre7ng%blood%gas%

1.  pH% % %7.35^7.45%

2.  BE% % %^3%to%+3%

3.  pCO2% % %30^35%mmHg%

4.  HCO3 % %20^24%mmHg%

5.  pO2% % %80^100%mmHg%

Tips%on%acid^base%•  #1%disturbance:%metabolic%acidosis%

•  pCO2%%%=%acid%

•  HCO3%=%buffers%acid!%

•  Venous%pCO2%vs.%arterial%pCO2%%– Difference%of%5^10%mmHg%

%

pH% % %7.35^7.45%BE% % %^3%to%+3%pCO2% %30^35%mmHg%HCO3 %20^24%mmHg%pO2%% %80^100%mmHg%

Steps%of%blood^gas%analysis%

1.  pH%=%acidemic%vs.%alkalemic?%

2.  BE%=%truest%component%of%metabolic%component%

3.  pCO2%=%evalua7on%of%respiratory%component%

4.  Hypoxic?%

5.  A^a%gradient%%A:%[760%mmHg%X%FIO2]%

%%%%%%150%–%[pCO2X%1.2]%

6.  Compensatory?%

pH% % %7.35^7.45%BE% % %^3%to%+3%pCO2% %30^35%mmHg%HCO3 %20^24%mmHg%pO2%% %80^100%mmHg%

Expected%magnitude%of%compensa7on%to%a%primary%event%

Primary Event

Expected compensation

Metabolic Acidosis

Each 1 mEq/L ↓ HCO3- PaCO2 ↓ by 0.7 mmHg

Expected PaCO2 = 35 – [(22-HCO3) X 0.7] mmHg

Metabolic Alkalosis

Each 1 mEq/L ↑ HCO3- PaCO2 ↑ by 0.7 mmHg

Expected PaCO2 = 35 + [(22-HCO3) X 0.7] mmHg

Expected compensation

Respiratory Acidosis Acute Chronic

Each 1 mmHg ↑ pCO2 HCO3

- ↑ by 0.15 mEq/L Expected HC03 = 22 + [(pCO2 – 35) X 0.15] Each 1 mmHg ↑ pCO2 HCO3

- ↑ by 0.35 mEq/L Expected HC03 = 22 + [(pCO2 – 35) X 0.35]

Respiratory Alkalosis Acute Chronic

Each 1 mmHg ↓ pCO2 HCO3

- ↓ by 0.25 mEq/L Expected HC03 = 22 - [(35 - pCO2) X 0.25] Each 1 mmHg ↓ pCO2 HCO3

- ↓ by 0.55 mEq/L Expected HC03 = 22 - [(35 - pCO2) X 0.55]

11%yo%FS%Dachshund%•  Venous%•  pH% % %6.940%

•  PCO2% %26.2%mmHg%

•  PO2% %52.2%mmHg%

•  BE% % %^27%mmol/L%

•  HCO3 %5.9%

•  O2%Sat %71.6%%

•  Severe%metabolic%acidosis%with%compensatory%respiratory%alkalosis%

•  PaCO2:%35–%[(22^HCO3)X0.7]%

%

•  Compensatory%

pH% % %7.35^7.45%BE% % %^3%to%+3%pCO2% %30^35%mmHg%HCO3 %20^24%mmHg%pO2%% %80^100%mmHg%

10%yo%FS%Bichon%•  PC:%Cushings,%PTE%•  Room%air%

•  Arterial%•  pH% % %7.334%

•  PCO2% %23.7%mmHg%

•  PO2% %81.3%mmHg%

•  BE% % %^13.3%mmol/L%

•  HCO3 %12.5%

•  O2%Sat %94.8%%

pH% % %7.35^7.45%BE% % %^3%to%+3%pCO2% %30^35%mmHg%HCO3 %20^24%mmHg%pO2%% %80^100%mmHg%

10%yo%FS%Bichon%•  Arterial%•  pH% % %7.334%•  PCO2% %23.7%mmHg%•  PO2% %81.3%mmHg%•  BE% % %^13.3%mmol/L%•  HCO3 %12.5%•  O2%Sat %94.8%%

•  Mixed%acid%base:%%Metabolic%acidosis%and%respiratory%alkalosis%

•  PaCO2%=%35%–%[(22^HCO3)%X%0.7]%mmHg%=%28%

•  Compensa7on%for%m.%acidosis%should%be%a%pCO2%of%28.%%Dog%is%hyperven7la7ng%(not%overcompensa7ng!)%

•  A^a:%%81^[150^23.7(1.2)]%=%40%

•  Pulmonary%parenchymal%disease!%%

pH% % %7.35^7.45%BE% % %^3%to%+3%pCO2% %30^35%mmHg%HCO3 %20^24%mmHg%pO2%% %80^100%mmHg%

ASSESSING$FLUID$NEEDS$(HYPOVOLEMIA$VS.$DEHYRATION)$BETTER$

For%those%of%you%mathema7cally%impaired%under%cor7sol%s7mula7on…%

•  Shocky%dog?%•  No%calculator?%•  Add%a%“0”%to%the%pound%weight%

•  77%lb%dog%presents%tachycardiac,%shocky,%pale,%poor%pulse%quality%aler%HBC%– 77%+%0%=%770%mls!%

Physical%assessment%of%dehydra7on%

% dehydration Clinical signs

<5% Not detectable

5-6% Subtle loss of skin elasticity

6-8% Definite delay in return of skin to normal position Slight prolongation of CRT Possibly dry mm

10-12% Tented skin stands in place Definite prolongation in CRT Sunken eyes Dry mm Possible signs of shock

12-15% Definite signs of shock Death imminent

Evalua7ng%hydra7on:%%10%%dry%Labrador,%30%kgs%

$PCV/TS $ $Sp$Gr. $ $Weight$%55/9 %% %1.029 %%% %30%kgs%

%40/7 % %1.024 %%% %31%kgs%

%35/5 % %1.015^1.018% %33%kgs%

Not%assessing%hydra7on%beuer!%

•  Sp.%gravity%1.015^1.018%

•  Urine%volume%

•  Drinking%water%in%the%cage%

SQ%fluids:%%How%much%can%you%give?%

•  Dose%=%�maintenance%fluids�%

•  30%kg%dog%X%50%ml/kg/day%=%1500%mls%

•  1%L%SQ%once%

BEING$SCARED$TO$PENETRATE$BODY$CAVITIES$

%[With%a%18%g%needle%and%the%good%thrust%of%the%hand,%there%is%no%body%cavity%you%can’t%penetrate…]%

– House&of&God,%Dr.%Shem%

%

Thoracocentesis%•  Supplies:%

– 20%cc%syringe%– 3%way%stopcock%– 16^22%ga.%needle%or%%%%%buuerfly%catheter%

– Extension%se{ng%

– Empty%bowl%

– +/^%seda7on%•  Butorphanol:%%0.2^0.8%mg/kg%IM%or%IV%

•  Diazepam:%%%%%0.1^0.25%mg/kg%IV%%

Abdominocentesis%

•  Shave%a%large%area%•  Alcohol%spray%%

– 2%minute%contact%7me,%degreaser%

•  Scrub%•  Gloves?%

Loca7on%for%performing%FAST%

•  Caudal%to%the%xyphoid%•  Cranial%to%the%bladder%•  Right%gravity^dependent%%•  Lel%gravity^dependent%

Figure%courtesy%of%Boysen%SR%from%IVECCS%proceedings%2006.%

Your%job%

•  Know%your%pa7ent%–  Take%good%care%of%them!%–  Treat%the%pa7ent%the%same%way%

you%would%if%it%was%your%pet.%

•  Learn%how%to%do%�tedious�%procedures%–  Keeping%pa7ents%clean%and%dry%–  Doppler%–  Strong%work%ethic%

•  Team%work%

•  Communicate%

•  Read%up%at%home%–  5^minute%guide%–  Not%Wikipedia%

•  Stay%hydrated%

Baby%boomer%vs.%X%vs.%Y%•  Strong%work%ethic%

–  Put%in%your%7me%and%hours%

–  Deteriora7on%in%veterinary%medicine%

•  You%don�t%go%home%un7l%the%clinician%goes%home%

•  Play%nicely%

•  Love%up%your%technical%staff%

•  Only%year%to%learn%

•  You%can%do%anything%as%a%veterinarian…%

•  Save%lives%and%experiment%–  CSF%taps%on%cats%

•  Learn%how%to%prac7ce%�street�%medicine%–  Learning%from%people%you%didn�t%think%you%could%learn%from!%

•  Trust%your%physical%exam%

•  Learn%from%your%mistakes…%

•  Complete%your%bucket%list%

%@VetGirlOnTheRun%%%VetGirlOnTheRun%%%garret@vetgirlontherun.com%%jus7ne@vetgirlontherun.com%%%%%%%%

Questions?

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Associa7on,%Dover%Downs,%DE%

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