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 Ninth Edition

Richard B. Ford, DVM, MS, DACVIM, DACPM

Professor of Medicine
Department of Clinical Sciences
College of Veterinary Medicine
North Carolina State University
Raleigh, North Carolina
Diplomate, American College of Veterinary Internal Medicine
Diplomate (Honorary), American College of Preventive Medicine

Elisa Mazzaferro, MS, DVM, PhD

Director of Emergency Services
Wheat Ridge Veterinary Specialists
Wheat Ridge, Colorado
Diplomate, American College of Veterinary Emergency and Critical Care
3251 Riverport Lane
St. Louis, Missouri 63043

KIRK AND BISTNER’S HANDBOOK OF VETERINARY

PROCEDURES AND EMERGENCY TREATMENT ISBN: 978-1-4377-0798-4

Copyright © 2012 by Saunders, an imprint of Elsevier Inc.

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Publisher (other than as may be noted herein).

Notices
Knowledge and best practice in this field are constantly changing. As new research and experience
broaden our understanding, changes in research methods, professional practices, or medical
treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating
and using any information, methods, compounds, or experiments described herein. In using such
information or methods they should be mindful of their own safety and the safety of others,
including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or formula, the method and duration
of administration, and contraindications. It is the responsibility of practitioners, relying on their
own experience and knowledge of their patients, to make diagnoses, to determine dosages and the
best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume
any liability for any injury and/or damage to persons or property as a matter of products liability,
negligence or otherwise, or from any use or operation of any methods, products, instructions, or
ideas contained in the material herein.

Previous editions copyrighted 2006, 2000, 1995, 1990, 1985, 1981, 1975, 1969

Library of Congress Cataloging-in-Publication Data or Control Number (in STL)

Vice President and Publisher: Linda Duncan

Editor: Heidi Pohlman
Associate Developmental Editor: Brandi Graham
Publishing Services Manager: Julie Eddy
Senior Project Manager: Richard Barber
Design Manager: Karen Pauls

Printed in the United States

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 Dr. Robert W. Kirk
May 20, 1922 – January 20, 2011

Clinician, educator, dedicated teacher.

A man whose commitment and contributions to
companion animal medicine have been global in reach
and legendary in scope.
Preface

The 9th edition of Kirk & Bistner's Handbook of Veterinary Procedures and Emergency
Treatment exemplifies the pace of change occurring in veterinary medicine today. The
­veterinary profession and the patients we serve continue to benefit from impressive
­technological advances in emergency and critical care medicine, diagnostic testing, and
therapy. As the editors of this edition, we have made significant effort to include current
diagnostic techniques, procedures, and management recommendations consistent with the
standards of care in companion animal medicine.
To facilitate quick and easy access to information, the text is divided into six distinct
­sections with special emphasis placed on Section 1, Emergency Diagnostic and Therapeutic
Treatment. This section is organized to facilitate rapid access to diagnostic and treatment
recommendations for emergency and critical care patients. Included are major ­subsections
on Prehospital Management, Initial Emergency Triage and Management, Emergency
Procedures, Pain Assessment and Management, and Emergency Management of Specific
Conditions.
Sections 2 through 5 focus on diagnostic strategies including patient evaluation,
­problem identification, routine and advanced procedures, and laboratory testing/­
interpretation. Each of these four sections addresses specific aspects of the patient's
­clinical presentation.
Section 2, Patient Evaluation and Organ System Examination, focuses on the initial
patient assessment and includes templates for medical record entries and plans for advanced
diagnostics.
Section 3, Clinical Signs, is a problem-based approach to differential diagnoses and is
redesigned such that the patient's problem is represented from the client's perspective—the
same way problems are presented in clinical practice.
Section 4 addresses both routine and advanced diagnostic, as well as therapeutic,
­procedures. Advanced procedures are now presented in an organ-system format to enhance
access to current diagnostic procedures that may be needed when evaluating complex
cases.
Section 5, Laboratory Diagnosis and Test Protocols, is a succinct, highly structured
­reference for performing routine and advanced diagnostic testing in cats and dogs.
Each test represented includes information on patient preparation, the test protocol,
type of ­sample to collect versus type of sample to submit, interpretation of test results,
and more.
Section 6 is a compilation of clinically pertinent tables and charts that have been
extensively reviewed and updated. Some of the tables included provide information on
Annualized Vaccination Protocol for Cats and Dogs, Common Drug Indications and
Dosages, and Emergency Hotlines.
It was Dr. Robert W. Kirk who, in 1969, published the first edition of this text. It
is Dr. Kirk who can be credited with being among the first academicians to ­recognize
a unique role for emergency care in veterinary medicine. It was his vision that has
­ultimately led to the development and growth of specialty practices in emergency and
critical care ­medicine. We are all indebted to Dr. Kirk for his commitment and dedication
to ­veterinary medicine.

vii
viii Preface

Regretfully, Dr. Kirk passed away earlier this year. His numerous contributions, ­however,
will continue to serve the profession for years to come. We are honored to dedicate this
­edition of the Emergency Handbook to Dr. Kirk.
Richard B. Ford, DVM, MS
Elisa Mazzaferro, MS, DVM, PhD
Foreword

Veterinary technicians and Veterinary Technician Specialists (VTS) serve a vital role in
assisting the veterinarian in diagnosis, prognosis, and prescribing therapy for their patients.
A thorough knowledge of the clinical manifestations of common diseases as well as ­methods
for diagnosing and treating those diseases is essential to understanding the significance of
test results. The technician is involved in monitoring the patient and performing and
recording observations of patients. The rationale used by the veterinarian in choosing
­specific diagnostic tests and treatment protocols improves the veterinary technician's ­ability
to assess and monitor patients.
The expanded and updated 9th edition of this essential reference text is organized into
six sections to provide rapid access to relevant information on clinical signs of disease,
patient evaluation, emergency care, diagnostic and therapeutic procedures, and laboratory
diagnostics, as well as charts of normal values, vaccination protocols, and a drug ­formulary.
The sections on Diagnostic and Therapeutic Procedures and Laboratory Diagnosis and
Test Protocols are particularly applicable to Veterinary Technicians, as these skills are
­primarily performed by the veterinary technician under the direction of the ­veterinarian
in a ­progressive small animal practice. These sections as well as those on Emergency ­Care
­contain practical information related to skills performed on a daily basis by many ­veterinary
technician specialists.
Veterinary technician students will find this text a useful adjunct to their studies. The
book provides a ready reference that allows the student to quickly review clinical applica-
tions of basic concepts while studying foundation courses such as anatomy and physiology,
in addition to more advanced clinical pathology, radiology, and p ­ harmacology courses.
I hope that every veterinary technician, veterinary technician specialist, and veterinary
technician student includes this valuable resource in their personal library.
Margi Sirois, EdD, MS, RVT

ix
 Section I

Emergency Care
Elisa M. Mazzaferro and Richard B. Ford

Prehospital management of the injured animal, 2

Survey of the Scene, 2
Initial Examination, 2
Preparation for Transport, 3
Initial emergency examination, management, and triage, 3
Primary Survey and Emergency Resuscitation Measures, 3
Ancillary Diagnostic Evaluation, 5
Summary of Patient Status, 6
The Rapidly Decompensating Patient, 6
Emergency diagnostic and therapeutic procedures, 7
Abdominal Paracentesis and Diagnostic Peritoneal Lavage, 7
Bandaging and Splinting Techniques, 8
Blood Component Therapy, 19
Central Venous Pressure Measurement, 30
Fluid Therapy, 32
Orogastric Lavage, 45
Oxygen Supplementation, 45
Pulse Oximetry, 48
Capnometry (End-Tidal Carbon Dioxide Monitoring), 49
Thoracocentesis, 50
Tracheostomy, 53
Urohydropulsion, 54
Vascular Access Techniques, 55
Pain: assessment, prevention, and management, 65
Physiologic Impact of Untreated Pain, 66
Recognition and Assessment of Pain, 67
Acute Pain Management for Emergent, Critical or Intensive Care, and Trauma Patients, 68
Pharmacologic Means to Analgesia: Major Analgesics, 69
Analgesia: Minor Analgesics, 73
Adjunctive Analgesic Drugs, 73
Local and Regional Techniques for the Emergent Patient, 74
Emergency management of specific conditions, 77
Acute Condition in the Abdomen, 77
Adjunctive Therapies, 79
Anaphylactic (Anaphylactoid) Shock, 91
Angioneurotic Edema and Urticaria, 92
Anesthetic Complications and Emergencies, 93
Bleeding Disorders, 97
Burns, 105
Cardiac Emergencies, 110
Ear Emergencies, 131
Electrical Injury and Electrical Shock, 133
Emergencies of the Female Reproductive Tract and Genitalia, 134
Emergencies of the Male Genitalia and Reproductive Tract, 139
Environmental and Household Emergencies, 144
Fractures and Musculoskeletal Trauma, 152
Gastrointestinal Emergencies, 157
Hypertension: Systemic, 174
Metabolic Emergencies, 176

1
 2 1 Emergency Care

Neurologic Emergencies, 184

1 Ocular Emergencies, 195
Oncologic Emergencies, 204
Poisons and Toxins, 211
Respiratory Emergencies, 255
Pulmonary Diseases, 268
Superficial Soft Tissue Injuries, 274
Shock, 279
Management of the Shock Patient, 281
Thromboembolism: Systemic, 288
Urinary Tract Emergencies, 290

Prehospital management of the injured animal

Survey of the Scene
1. Call for help! At the accident scene, it usually takes more than one person to assist the
animal and prevent injury to the animal and human bystanders.
2. If an accident has occurred in a traffic zone, alert oncoming traffic regarding the injured
animal in the road. Make sure you have a piece of clothing or other object to alert
­oncoming traffic. Do not become injured yourself because oncoming traffic cannot see
or identify you!
3. If the animal is conscious, prevent yourself from becoming injured while moving the ani-
mal to a safe location. Use a belt, rope, or piece of long cloth to make a muzzle to secure
around the animal's mouth and head. If this is not possible, cover the animal's head with a
towel, blanket, or coat before moving it, to prevent the animal from biting you.
4. If the animal is unconscious or is unconscious and immobile, move it to a safe location
with a back support device that can be made from a box, door, flat board, blanket, or
sheet.

Initial Examination
1. Is there a patent airway? If airway noises are present or the animal is stuporous, gently and
carefully extend the head and neck. If possible, extend the tongue. Wipe mucus, blood, or
vomitus from the mouth. In unconscious animals, maintain head and neck stability.
2. Look for signs of breathing. If there is no evidence of breathing or the gum color is blue,
begin mouth-to-nose breathing. Encircle the muzzle area with your hands to pinch down
on the gums, and blow into the nose 15 to 20 times per minute.
3. Is there evidence of cardiac function? Check for a palpable pulse on the hind legs or for
an apex beat over the sternum. If no signs of cardiac function are found, begin external
cardiac compressions at 80 to 120 times per minute.
4. Is there any hemorrhage? Use a clean cloth, towel, paper towel, or disposable diaper or
feminine hygiene product to cover the wound. Apply firm pressure to slow hemorrhage
and prevent further blood loss. Do not use a tourniquet, because this can cause further
damage. Apply pressure, and as blood seeps through the first layer of bandage material,
place a second layer over the top.
5. Cover any external wounds. Use a clean bandage material soaked in warm water, and
transport the animal to the nearest veterinary emergency facility. Address penetrating
wounds to the abdomen and thorax immediately.
6. Are there any obvious fractures present? Immobilize fractures with homemade splints
made of newspaper, broom handles, or sticks. Muzzle the awake animal before ­attempting
to place any splints. If a splint cannot be attached safely, place the animal on a towel or
blanket and transport the animal to the nearest veterinary emergency facility.
 Initial emergency examination, management, and triage 3

7. Are there any burns? Place wet, cool towels over the burned area and remove as the
­compress warms to body temperature.
8. Wrap the patient to conserve heat. If the animal is shivering or in shock, wrap it in a 1
blanket, towel, or coat and transport it to the nearest veterinary emergency facility.
9. Is the animal experiencing heat-induced illness (heat stroke)? Cool the animal with
room-temperature wet towels (not cold) and transport it to the nearest veterinary
­emergency facility.

Preparation for Transport

1. Call ahead! Let the facility know that you are coming. Be prepared by having emergency
numbers and locations available. The police or sheriff 's department may be able to aid in
locating the nearest veterinary emergency facility.
2. Line upholstery with plastic bags or sheeting to prevent soilage, when possible.
3. Move the injured patient carefully. Use the same approach as moving the animal from
the pavement.
4. Drive safely. Do not turn one accident into two. Ideally, have a bystander or friend or
family member drive while another person stays in the backseat with the animal.

Initial emergency examination, management, and triage

Examination of the acutely injured animal that is unconscious, in shock, or demonstrating
acute hemorrhage or respiratory distress must proceed simultaneously with immediate
aggressive lifesaving treatment. Because there often is no time for detailed history taking,
diagnosis is largely based on the physical examination findings and simple diagnostic tests.
Triage is the art and practice of being able to assess patients rapidly and sort them according
to the urgency of treatment required. Immediate recognition and prompt treatment
­potentially can be lifesaving.

Primary Survey and Emergency Resuscitation Measures

Perform a brief but thorough systematic examination of the animal, noting the most
­important ABCs of any emergent patient.
ABCs
A = Airway
Is the airway patent? Pull the patient's tongue forward and remove any debris obstructing
the airway. Suction and a laryngoscope may be necessary. Intubate, or place a ­transtracheal
oxygen source, if necessary. An emergency tracheostomy may be necessary if upper
­airway obstruction is present and cannot be resolved immediately with the foregoing
measures.

B = Breathing
Is the animal breathing? If the animal is not breathing, immediately intubate the animal and
start artificial ventilations with a supplemental oxygen source (see Cardiac Arrest and
Cardiopulmonary Cerebral Resuscitation).
If the animal is breathing, what are the respiratory rate and pattern? Is the respiratory rate
normal, increased, or decreased? Is the respiratory pattern normal, or is the breathing rapid
and shallow, or slow and deep with inspiratory distress? Are the respiratory noises normal,
or is there a high-pitched stridor on inspiration characteristic of an upper airway obstruc-
tion? Does the animal have its head extended and elbows abducted away from the body with
orthopnea? Do the commissures of the mouth move with inhalation and exhalation? Is there
evidence of expiratory distress with an abdominal push on exhalation? Note the lateral chest
wall. Do the ribs move out and in with inhalation and exhalation, or is there paradoxical chest
 4 1 Emergency Care

wall motion in an area that moves in during inhalation and out during exhalation, ­suggestive
1 of a flail chest? Is there any subcutaneous emphysema that suggests airway injury?
Auscultate the thorax bilaterally. Are the breath sounds normal? Do they sound harsh
with crackles because of pneumonia, pulmonary edema, or pulmonary contusions? Are the
lung sounds muffled because of pleural effusion or pneumothorax? Are there inspiratory
wheezes in a cat with bronchitis (asthma)? What is the mucous membrane color? Are the
mucous membranes pink and normal, or pale or cyanotic? Palpate the neck, lateral thorax,
and dorsal cervical region to check for tracheal displacement, subcutaneous emphysema,
and rib fractures.

C = Circulation
What is the circulatory status? What is the status of the patient's heart rate and rhythm? Can
you hear the heart, or is it muffled because of hypovolemia, pleural or pericardial effusion,
pneumothorax, or diaphragmatic hernia? Palpate the pulses. Is the pulse quality strong and
regular and synchronous with each heartbeat, or are there thready, dropped pulses? What
are the patient's electrocardiogram (ECG) rhythm and blood pressure (BP)?
Is there arterial hemorrhage? Note whether there is any bleeding present. Use caution if
there is any blood on the fur. Wear gloves. The blood may be from the patient, and gloves
will help prevent further contamination of any wounds; or the blood may be from a good
Samaritan bystander. If external wounds are present, note their character and condition.
Place a pressure bandage on any arterial bleeding or external wounds to prevent further
hemorrhage or contamination with nosocomial organisms.
Establish large-bore vascular or intraosseous access (see Vascular Access Techniques). If
hypovolemic or hemorrhagic shock is present, institute immediate fluid resuscitation mea-
sures. Start with one fourth of a calculated shock dose of crystalloid fluids (0.25 × [90 mL/
kg] for dogs; 0.25 × [44 mL/kg] for cats), and reassess perfusion parameters of heart rate,
capillary refill time, and BP. If pulmonary contusions are suspected, use of a colloid such
as hydroxyethyl starch at 5 mL/kg in incremental boluses can improve perfusion with a
smaller volume of fluid. In cases of head trauma, hypertonic (7%) sodium chloride (saline)
can be administered (4 mL/kg intravenous bolus) with hydroxyethyl starch. Acute abdomi-
nal ­hemorrhage caused by trauma can be tamponaded with an abdominal compression
bandage.
After the immediate ABCs, proceed with the rest of the physical examination and
­treatment by using the mnemonic A CRASH PLAN.

A Crash Plan
A = Airway
C and R = Cardiovascular and Respiratory
A = Abdomen
Palpate the patient's abdomen. Is there any pain or are there any penetrating injuries
­present? Look at the patient's umbilicus. Reddening around the umbilicus can suggest
intraabdominal hemorrhage. Is there a fluid wave or mass palpable? Examine the inguinal,
caudal, thoracic, and paralumbar regions. Clip the fur to examine the patient for bruising
or penetrating wounds. Percuss and auscultate the abdomen for borborygmi.

S = Spine
Palpate the animal's spine for symmetry. Is any pain or obvious swelling or fracture present?
Perform a neurologic examination from C1 to the last caudal vertebra.

H = Head
Examine the eyes, ears, mouth, teeth, nose, and all cranial nerves. Stain the eyes with
­fluorescence dye to examine for corneal ulcers in any case of head trauma. Is anisocoria or
Horner syndrome present?
 Initial emergency examination, management, and triage 5

P = Pelvis
Perform a rectal examination. Palpate for fractures or hemorrhage. Examine the perineal
and rectal areas. Examine the external genitalia.
1
L = Limbs
Examine the pectoral and pelvic extremities. Are there any obvious open or closed ­fractures?
Quickly splint the limbs to prevent further damage and help control pain. Examine the skin,
muscles, and tendons.

A = Arteries
Palpate the peripheral arteries for pulses. Use a Doppler piezoelectric crystal to aid in
­finding a pulse if thromboembolic disease is present. Measure the patient's BP.

N = Nerves
From afar, note the level of consciousness, behavior, and posture. Note respiratory rate,
­pattern, and effort. Is the patient conscious, or is the patient obtunded or comatose? Are the
pupils symmetric and responsive to light, or is there anisocoria present? Does the patient
display any abnormal postures such as Schiff-Sherrington posture (extended rigid ­forelimbs,
flaccid paralysis of the hindlimbs) that may signify severe spinal shock or a severed spinal
cord? Examine the peripheral nerves for motor and sensory input and output to the limbs
and tail.

Ancillary Diagnostic Evaluation

Hemodynamic Techniques
Perform electrocardiography, direct or indirect BP monitoring, and pulse oximetry in any
critically ill traumatized patient.

Imaging Techniques
Obtain radiographs of the thorax and abdomen in any animal that has sustained a
­traumatic injury once the patient's condition is more stable and the animal can tolerate
positioning for the procedures. Survey radiographs may reveal pneumothorax, pulmo-
nary contusions, ­diaphragmatic hernia, pleural or abdominal effusion, or pneumo­
peritoneum.

AFAST and TFAST

Focused assessments of the abdomen and thorax after trauma (AFAST and TFAST) have
been described to evaluate the abdomen for fluid and to evaluate the thorax for fluid, free
air, and pericardial effusion. During these examinations, ultrasound is used to evaluate
four quadrants of the abdomen: (1) the diaphragm or hepatic view, on ventral midline just
­caudal to the sternum, (2) the spleno-renal view in the left lateral quadrant, (3) the
­cysto-colic view on ventral midline over the urinary bladder, and (4) the hepato-renal
view on right lateral, the most dependent area of the abdomen with the patient in right
lateral recumbency. For evaluation of the thorax, the patient is positioned in lateral recum-
bency and the ultrasound probe is directed in a horizontal plane at the dorsal aspect of the
ninth intercostal space, in the transverse and longitudinal planes caudal to the point of the
elbow, over the heart to evaluate for pericardial and pleural effusion. The examinations
take only small amounts of time and can reveal whether ongoing fluid loss is occurring. As
with other ultrasonographic techniques, AFAST and TFAST results are sometimes
­operator-dependent.
 6 1 Emergency Care

Laboratory Testing
1 Immediate diagnostic testing should include hematocrit, total solids, glucose, blood urea
nitrogen (BUN) or Azostix, and urine specific gravity. Ancillary diagnostic tests that can be
performed soon thereafter include a complete blood count and peripheral blood smear to
evaluate platelet count and red and white blood cell (WBC) morphology. Also consider
arterial blood gas and electrolytes, coagulation parameters (activated clotting time [ACT],
prothrombin time [PT], activated partial thromboplastin time [APTT]), serum ­biochemistry
profile, serum lactate, and urinalysis.

Invasive Testing
Invasive diagnostic techniques that may need to be performed include thoracocentesis,
abdominal paracentesis, and diagnostic peritoneal lavage (DPL).

Summary of Patient Status

After completing the initial physical examination, answer the following questions: What
supportive care is required at this time? Are additional diagnostic procedures needed? If
so, which procedures, and is the patient stable enough to tolerate those procedures with-
out further stress? Should an additional period of observation be instituted before further
definitive treatment plans are undertaken? Is immediate surgical intervention necessary?
Is additional supportive care required before surgery? What anesthetic risks are evident?

The Rapidly Decompensating Patient

Animals that do not respond to initial resuscitation usually have severe ongoing or preexist-
ing physiologic disturbances that contribute to severe cardiovascular and metabolic
­instability. A patient that does not respond to or responds to and then stops responding to
initial resuscitation efforts should alert the clinician that decompensation is occurring
(Boxes 1-1 and 1-2).

Box 1-1 Clinical Signs of Decompensation

Weak or poor peripheral pulse quality Depression

Cool peripheral extremities Tachycardia or bradycardia
Cyanosis or muddy-colored (gray) mucous Declining hematocrit
membranes Distended, painful abdomen
Pale mucous membranes Cardiac dysrhythmia
Prolonged capillary refill time Abnormal respiratory pattern
Increased or decreased body temperature Respiratory difficulty or distress
Decreased renal output in a euvolemic patient Gastrointestinal blood loss via hematemesis or
Inappropriate mentation or confusion in feces

Box 1-2 Causes of Acute Decompensation

Acute renal failure Internal hemorrhage

Acute respiratory distress syndrome Multiple organ dysfunction syndrome
Bowel and gastric rupture Pneumothorax
Cardiac dysrhythmia Pulmonary contusions
Central nervous system edema and Pulmonary thromboembolism
­hemorrhage, and brainstem herniation Sepsis or septic shock
Coagulopathies including disseminated Systemic inflammatory response syndrome
­intravascular coagulation Urinary bladder rupture
 Emergency diagnostic and therapeutic procedures 7

Additional Reading
Crowe DT: Patient triage. In Silverstein DC, Hopper K, editors: Small animal critical care
­medicine, St Louis, 2009, Elsevier. 1
Ettinger SJ, Feldman EC, editors: Critical care. In Textbook of veterinary internal medicine, ed 7,
St Louis, 2010, Elsevier-Saunders.
Lisciandro GR, Lagutchik MS, Mann KA, et al: Evaluation of an abdominal fluid scoring system
determined using abdominal focused assessment with sonography for trauma in 101 dogs
with motor vehicle trauma, J Vet Emerg Crit Care 19:426–437, 2009.
Lisciandro GR, Lagutchik MS, Mann KA, et al: Evaluation of a thoracic focused assessment with
sonography for trauma (TFAST) protocol to detect pneumothorax and concurrent thoracic
injury in 145 traumatized dogs, J Vet Emerg Crit Care 18:258–269, 2008.
Mathews KA: Veterinary emergency and critical care manual, Guelph, Ontario, Canada, 1996,
Lifelearn.
Wingfield WE: Decision making in veterinary emergency medicine. In Wingfield WE, editor:
Veterinary emergency secrets, ed 2, Philadelphia, 2001, Hanley & Belfus.
Wingfield WE: Treatment priorities in trauma. In Wingfield WE, editor: Veterinary emergency
secrets, ed 2, Philadelphia, 2001, Hanley & Belfus.

Emergency diagnostic and therapeutic procedures

Abdominal Paracentesis and Diagnostic Peritoneal Lavage
Abdominocentesis (abdominal paracentesis) refers to puncture into the peritoneal cavity for
the purpose of fluid collection. Abdominal paracentesis is a somewhat sensitive technique
for fluid collection as long as more than 6 mL/kg of fluid are present within the abdominal
cavity. In the event that you suspect peritonitis and have a negative tap with abdominal
paracentesis, DPL can be performed.
To perform abdominal paracentesis, follow this procedure:
1. Place the patient in left lateral recumbency and clip a 4- to 6-inch square with the
­umbilicus in the center.
2. Aseptically scrub the clipped area with antimicrobial scrub solution.
3. Wearing gloves, insert a 22- or 20-gauge needle or over-the-needle catheter in four quad-
rants: cranial and to the right, cranial and to the left, caudal and to the right, and caudal
and to the left of the umbilicus. As you insert the needle or catheter, gently twist the
­needle to push any abdominal organs away from the tip of the needle. Local anesthesia
typically is not required for this procedure, although a light sedative or analgesic may be
necessary if severe abdominal pain is present. In some cases, fluid will flow freely from
one or more of the needles. If not, gently aspirate with a 3- to 6-mL syringe or aspirate
with the patient in a standing position. Avoid changing positions with needles in place
because iatrogenic puncture of intraabdominal organs may occur.
4. Save any fluid collected in sterile red- and lavender-topped tubes for cytologic and
­biochemical analyses and bacterial culture. Monitor hemorrhagic fluid carefully for the
presence of clots. Normally, hemorrhagic effusions rapidly become defibrinated and do
not clot. Clot formation can occur in the presence of ongoing active hemorrhage or may
be caused by the iatrogenic puncture of organs such as the spleen or liver.
If abdominal paracentesis is negative, DPL can be performed. Although peritoneal
­dialysis kits are commercially available, they are fairly expensive and often impractical for
the general practitioner.
To perform DPL, follow this procedure:
1. Clip and aseptically scrub the ventral abdomen as described previously.
2. Wearing sterile gloves, cut multiple side ports in a 16- or 18-gauge over-the-needle ­catheter.
Use care to not cut more than 50% of the circumference of the catheter, or else the catheter
will become weakened and potentially can break off in the patient's abdomen.
3. Insert the catheter into the peritoneal cavity caudal and to the right of the umbilicus,
directing the catheter dorsally and caudally.
 8 1 Emergency Care

4. Infuse 10 to 20 mL of sterile lactated Ringer's solution or 0.9% saline solution that has
1 been warmed to the patient's body temperature. During the instillation of fluid into
the peritoneal cavity, watch closely for signs of respiratory distress because an increase
in intraabdominal pressure can impair diaphragmatic excursions and respiratory
function.
5. Remove the catheter.
6. In ambulatory patients, walk the patient around while massaging the abdomen to
­distribute the fluid throughout the abdominal cavity. In nonambulatory patients, gently
roll the patient from side to side.
7. Next, aseptically scrub the patient's ventral abdomen again, and perform abdominal
­paracentesis as described previously. Save collected fluid for culture and cytologic analy-
ses; however, biochemical analysis findings may be artifactually decreased because of
dilution. Remember that you likely will retrieve only a small portion of the fluid that was
instilled.

Additional Reading
Walters JM: Abdominal paracentesis and diagnostic peritoneal lavage, Clin Tech Small Anim
Pract 18(1):32–38, 2003.
Hackett TB, Mazzaferro EM: Veterinary Emergency and Critical Care Procedures, London, 2006,
Blackwell Scientific.
Jandrey KE: Abdominocentesis. In Silverstein DC, Hopper K, editors: Small animal critical care
medicine, St Louis, 2009, Elsevier.

Bandaging and Splinting Techniques

In general, bandages can be applied to open or closed wounds. Bandaging is used for six
general wound types: open contaminated or infected wounds, open wounds in the repair
stage of healing, closed wounds, wounds in need of a pressure bandage, wounds in need of
pressure relief, and wounds in need of immobilization. Box 1-3 lists various functions of
bandages.
The materials and methods of bandaging depend on the type of injury, the need for
pressure and immobilization, the need to prevent pressure, and the stage of healing. In
general, bandage material has three component layers. If pressure relief or immobilization
is required, splint material also may be incorporated into the bandage. The contact layer is
the layer of bandage material that actually is adjacent to the wound itself. The secondary or
intermediary layer is placed over the contact (primary) layer. Finally, the outer tertiary layer
covers the bandage and is exposed to the outside.

Open Contaminated and Infected Wounds

Open contaminated or infected wounds often have large amounts of necrotic tissue and
foreign debris and emit copious quantities of exudate. The contact layer used in an
open contaminated or infected wound should be wide-mesh gauze sponges with no

Box 1-3 Functions of Bandages and Splints

Exert pressure Protect a wound from environmental bacteria

Obliterate dead space Protect the environment from wound blood,
Reduce edema exudate, and bacteria
Minimize hemorrhage Immobilize a wound and support underlying
Prevent pressure on a wound osseous structures
Prevent decubitus ulcers Minimize patient discomfort
Pack wounds Serve as a vehicle for antiseptics and antibiotics
Wet-to-dry bandages—treat deep shearing Serve as an indicator of wound secretions
injuries Provide an esthetic appearance
Absorb exudate and debride wounds
 Emergency diagnostic and therapeutic procedures 9

cotton filling. The sponges can be left dry if the wound has minimal exudate but should
be moistened with sterile 0.9% saline or lactated Ringer's solution if the wound has
high-viscosity exudate. Topical ointments may be applied (silver sulfadiazine, chlor- 1
hexidine ointment) if necessary. The intermediate layer should be thick absorbent
wrapping material, covered by an outer layer of porous tape such as Elastikon (Johnson
& Johnson Medical, Arlington, Texas), or Vetrap (3M, St Paul, Minnesota). Change the
bandages at least once daily or more frequently if strike-through of exudate occurs
through the bandage.
To place a wet-to-dry bandage over a wound, first place the contact layer over the wound.
Next, apply strips of adhesive tape to the patient's paw on either side, if possible. The strips
(stirrups) will be used to hold the bandage in place and prevent it from slipping down the
limb. Wrap the intermediate layer over the contact layer. Turn the adhesive strips around so
that the adhesive layer can be secured to the intermediary layer in place. Wrap the final, or
tertiary, layer over the bandage.
The function of a wet-to-dry bandage is to help debride a wound. The moistened
gauze dries and is pulled off the wound at each bandage change. Dry necrotic tissue and
debris that adhere to the gauze are pulled off with it. In addition, the moistened mate-
rial dilutes the wound exudate and enhances its absorption into the gauze contact layer.
If large amounts of exudate come from the wound, the contact layer and intermediate
layer absorb the exudate, wicking the material away from the wound. Finally, delivery of
medications into the wound can occur to promote the development of healthy granula-
tion tissue.
Open Wound in Repair Stage of Healing
Early Repair
During the early stage of repair, granulation tissue, some exudate, and minor epithelial-
ization are observed. Place a nonadherent bandage with some antibacterial properties
­(petroleum- or nitrofurazone-impregnated gauze) or absorbent material (foam sponge,
hydrogel, or hydrocolloid dressing) in direct contact with the wound to minimize disrup-
tion of the granulation tissue bed. Next, place an absorbent intermediate layer, followed
by a porous outer layer, as previously described. Granulation tissue can grow through
gauze mesh or adhere to foam sponges and can be ripped away at the time of bandage
removal. Hemorrhage and disruption of the granulation tissue bed can occur.
Late Repair
Later in the repair process, granulation tissue can exude sanguineous drainage and
have some epithelialization. A late nonadherent bandage is required. The contact layer
should be some form of nonadherent dressing, foam sponge, hydrogel, or hydrocol-
loid substance. The intermediate layer and outer layers should be absorbent material
and porous tape, respectively. With nonadherent dressings, wounds with viscous exu-
dates may not be absorbed well. This may be advantageous and enhance epithelializa-
tion, provided that complications do not occur. Infection, exuberant granulation
tissue, or adherence of a­ bsorbent materials to the wound may occur and delay the
healing process.
Moist Healing
Moist healing is a newer concept of wound management in which wound exudates are
allowed to stay in contact with the wound. In the absence of infection a moist wound
heals faster and has enzymatic activity as a result of macrophage and polymorphonuclear
cell breakdown. Enzymatic degradation or “autolytic debridement” of the wound occurs.
Moist wounds tend to promote neutrophil and macrophage chemotaxis and bacterial
phagocytosis better than use of wet-to-dry bandages. A potential complication and disad-
vantage of moist healing, however, is the development of bacterial colonization, folliculi-
tis, and trauma to wound edges that can occur because of the continuously moist
environment.