Hemoabdomen: Is it always a surgical disease? Introduction. Introduction 9/29/2013. Thanks to today s SPONSOR!
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1 Hemoabdomen: Thanks to today s SPONSOR! Is it always a surgical disease? Garret Pachtinger, VMD, DACVECC COO, VetGirl garret@vetgirlontherun.com Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl justine@vetgirlontherun.com Introduction Introduction Garret Pachtinger, VMD, DACVECC COO, VetGirl Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl 1
2 VetGirl on the RUN! The tech-saavy way to get CE credit! A subscription based-podcast service offering RACE-approved CE Subscription plans VetGirl Standard: podcasts/year $99/year 4 hours of RACE-CE VetGirl ELITE: podcasts/year plus 12 hours of webinars! $199/year 16 hours of RACE-CE Blogs and Social Media BE READY! facebook.com/vetgirlontherun 2
3 9/29/2013 Endotracheal Tubes BE READY! Have a designated emergency area Have it stocked with IV catheters IV fluids Monitoring equipment Oxygen (?) Tubes and Catheters Hemoabdomen Important! Age Breed 3
4 Examination Treatment / Diagnosis Pale MM Prolonged CRT Abnormal pulses Tachycardia Tachypnea Distended abdomen Abnormal mentation MDB / EDB Differentiating? MBD / Big 4 / EDB FANCY TOYS? Sepsis? Cardiogenic? 4
5 your EDB comes back Learning point- 1 Hct: 45% TS: 4.8 g/dl Glucose: 108 mg/dl BUN mg/dl Lactate 5.6 mmol/l FAST Scan Sensitivity Blind vs U/S FAST stands for Focused Assessment with Sonography for Trauma The abdomen including the retroperitoneal space is scanned at four sites 1) Diaphragmatic-hepatic view 2) Cystocolic view 3) Splenorenal view 4) Hepatorenal view Blind: 5-25 ml/kg of effusion * FAST scan 4ml/kg * Crowe,
6 Learning point Quadrant Abdominocentesis Umbilicus is the center point Insert needle Dependent cranial quadrant Nondependent cranial quadrant Dependent caudal quadrant nondependent caudal quadrant. X-Rays Still no luck? Retroperitoneal effusion Peritoneal effusion 6
7 abdominocentesis Effusion confusion? A cytological evaluation is important! Additional diagnostics on the fluid can also be performed: Not a hemoabdomen? Measurement of potassium and creatinine if urinary bladder rupture is suspected AFK+:PBK+ ratio > 1.4 and AFCr:PBCr ratio > 2:1 Not a hemoabdomen? Bilirubin if gall bladder rupture is possible. Anything > in the abdomen is a concerning, but clinically it is often 2X that of the peripheral blood. 7
8 Not a hemoabdomen? Classifications Septic Abdomen Glucose - 20mg/dl < serum Lactate - 2.0mmol/L> serum Coagulopathic Nontraumatic (spontaneous) Traumatic Coagulopathy Rodenticides - MOA Rodenticide vs. other (owners Coumadin for example) 2 year old dog that went missing for 4 days? Anticoagulant rodenticides are among the most common toxins ingested by dogs and are responsible for significant morbidity and mortality in dogs. Induce a profound coagulopathy secondary to the antagonism of hepatic vitamin K epoxide reductase. 8
9 Rodenticides 1 of 2 These patients are often presented in 1 of 2 ways. Learning point- 3 PT vs PTT The actual value Consumptive Vs Coagulopathic (primary) Coagulopathy Cullen s sign Although surface bleeding) may occur Bleeding into body cavities is more common. 9
10 Rodenticides - Treatment Not coagulopathic? Fluids Vit K FFP RBC Spontaneous Diagnostic Imaging? Some dogs may have a slightly more chronic history with intermittent bouts of weakness followed by recovery. 10
11 Ultrasound Ultrasound??? Personal experience with an abdominal ultrasound and interpretation for clients: Does every patient need an ultrasound? 1) Solitary mass (spleen, liver, etc) that can be identified. 2) Multiple masses present (possibly not just on one organ). 3) No masses/lesions have been identified Hemangiosarcoma Hemangiosarcoma Survival times? Surgery? Surgery and Chemotherapy No treatment? Surgical evaluation vs Medical Evaluation 11
12 Hemangiosarcoma Traumatic Hemoabdomen Evidence for cutting or not traumatic hemoabdomens Evidence for cutting or not traumatic hemoabdomens 1) Traumatic hemoperitoneum in 28 cases: a retrospective review J Am Anim Hosp Assoc May-Jun;31(3): Refs C M Mongil, K J Drobatz, J C Hendricks University of Pennsylvania, Philadelphia 2) Evaluation of vehicular trauma in dogs: 239 cases (January-December 2001). J Am Vet Med Assoc. August 2009;235(4): Elizabeth M Streeter, Elizabeth A Rozanski, Armelle de Laforcade-Buress, Lisa M Freeman, John E Rush Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA 12
13 Evidence for cutting or not traumatic hemoabdomens Evidence for cutting or not traumatic hemoabdomens Many traumatic hemoabdomen cases can be managed with non-surgical measures. Evidence for cutting or not traumatic hemoabdomens Evidence for cutting or not traumatic hemoabdomens Some of the variables that I look at in order to help me make management decisions are: Blood pressure Heart rate PCV and TP Lactate Measuring intra-abdominal pressure Urinary catheter Pressures above 25cm H 2 O are associated with decreased organ perfusion. 13
14 Evidence for cutting or not traumatic hemoabdomens Evidence for cutting or not traumatic hemoabdomens - Splenic rupture? - Liver rupture - Avulsed renal artery - Other major artery "There is a marked trend toward nonoperative management of abdominal trauma. World J Surg Nov;25(11): "CONCLUSIONS: Nonoperative management is safe for hemodynamically stable patients with blunt hepatic injury, regardless of injury severity. There are fewer abdominal complications and less transfusions when compared with a matched cohort of operated patients. NON-Traumatic Hemoabdomen Before rushing to surgery Other diagnostics to consider once the patient is stable include: A complete blood count Chemistry screen Coagulation screen Blood type (and cross match if the patient has had a previous transfusion) Urinalysis 14
15 Important Diagnostic Blood typing? Cats? First time? Dea 1.1- on hand? Natural antibodies? Auto-transfusion? Common? Rare? Diagnosis? Prognosis? 15
16 Small vs large Do small breed dogs have a better prognosis? Different differentials? Volume Replacement Initial resuscitation often accompanies diagnosis Once diagnosed, this helps guide continued volume resuscitation. Options: - Whole blood vs. component therapy - Synthetic colloids, crystalloids (isotonic vs. hypertonic) Shock! Crystalloids or colloids - often the initial fluids for volume replacement. Shock" dose of crystalloids in the dog is 90ml/kg and the ml/kg in the cat.. Shock" dose of colloids in the dog is 5-10ml/kg and the 3-5 ml/kg in the cat. Reassessment of perfusion after administering the fluid bolus / volume What to do when the parameters improved? No improvement? Shock! 16
17 Abdominal Wrap Abdominal counter pressure (abdominal wrap) may help with hemostasis and control hemorrhage. Contraindications? Slow and steady Slow removal - craniodorsal aspect to start. This incremental approach can be continued until the wrap is completely removed. Hypotensive Resuscitation Delayed hypotensive resuscitation has been recommended in people with traumatic hemoabdomen. Cage Rest! Strict cage rest for 2 3 days and observed closely Prevent measures that can disrupt a tenuously "clinging" blood clot. 17
18 Summary Overall approach to the emergency patient with clinically significant abdominal hemorrhage includes: Triage assessment Confirming abdominal hemorrhage Initial volume resuscitation Measuring appropriate clinicopathologic parameters (PCV, TS, lactate, complete blood count, chemistry screen, coagulation profile, blood type, crossmatch, etc.). Determining the TYPE / cause of hemoabdomen. Surgery should be performed if medical stabilization is not achieved or surgical biopsy is necessary to confirm the diagnosis. Where is VetGirl going to be? Check out our upcoming 2013 lectures here: September: IVECCS, San Diego, CA (Drs. Lee and Pachtinger) International Veterinary Seminars, Kilimanjaro (Dr. Lee) October: NYSVMA, Ithaca, NY (Dr. Lee) Academy of Veterinary Medicine, Cleveland, OH (Dr. Lee) Northeast Pennsylvania Veterinary Medical Association, Pocono, Pa (Dr. Pachtinger) November: Virginia VMA, Greenbriar, VA (Dr. Lee) Latin America VECCS, Ecuador (Dr. Lee) WSAVA, Bangkok, Thailand (Dr. Pachtinger) December: SE Michigan VMA, Detroit, MI (Dr. Lee) Novotech, Madrid, Spain (Dr. Lee) Exhibiting debut! Thank you January 2014: NAVC, Orlando, FL Stop by and get a free VetGirl sticker and water bottle! 18
19 Questions? @VetGirlOnTheRun VetGirlOnTheRun 19
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