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What%to%expect%before%entering%clinics…%%
Justine A. Lee, DVM, DACVECC, DABT CEO, VetGirl [email protected] @VetGirlOnTheRun @drjustinelee
%
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Introduc7on%
Jus7ne%A.%Lee,%DVM,%
DACVECC,%DABT%
CEO,%VetGirl%%
%
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Find us on social media
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VetGirl%
! VetGirl%ELITE%($199)%=%free%for%veterinary%students!%
! Call%in%from%Smart%Phone!%
! Email%/%contact%with%ANY%ques7ons%
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Come%prepared%
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HOW$TO$GET$A$GOOD$HISTORY$
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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!%
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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…?�%
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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%
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#1%Physical%examina7on%
• Efficient%• Easily%repeatable%
– Serial%exams%
• Inexpensive%• Fine^tuned%%• Focused/targeted%• Subjec7ve%
• Tips:%%– Palpate%aler%euthanasia%– Palpate%under%anesthesia%– Palpate%abnormal%
%
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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)%
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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!%
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THE$ICU$SHEET$
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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%%%
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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!%
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Examples%of%documenta7on%
• Catheter%placement%
• Labeling%catheters%
• Unblocking%a%cat%–%what%was%it%like?%
• Subjec7ve%–%does%the%pa7ent%look%nauseated?%
• FAST%ultrasound%exam%%
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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%
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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%
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Don’t%get%biuen…%
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FORMULAS$TO$KNOW…$
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• 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%
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CLINICOPATHOLOGIC$TESTING$
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BIG%4%vs.%CBC/CHEM/UA%
• ER%=%40%%outpa7ent%
• Would%you&spend%$300%for%blood%work%each%7me%your%dog%vomited?%
• BIG%4%+%EG8%vs.%complete%blood%work%
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↓ PCV/ N TS (i.e., 25%/7 g/dL) ↑ PCV/N TS
(i.e., 65%/7 g/dL) N PCV/↓ TS (i.e., 40%/5 g/dL)
N PCV/↑ TS (i.e., 40%/9 g/dL)
↑ PCV/↑TS (i.e., 66%/8 g/dL)
↓ PCV/ ↓ TS (i.e., 25%/5 g/dL)
Hemolytic anemia Polycythemia vera Protein-losing enteropathy (PLE)
Multiple myeloma Hemocon- centration Chronic blood
loss (Melena) Aplastic anemia Hyperthyroidism Protein-losing
nephropathy (PLN)
Feline infectious peritonitis (FIP) Blood loss
(subacute)
Pure red blood cell aplasia Cushings Liver failure (lack
of production of albumin)
Chronic globulin stimulation (i.e., dental, skin disease)
Anemia of chronic disease Hemorrhagic
Gastroenteritis (HGE)
Acute blood loss (with splenic contraction)
Severe dehydration + anemia (i.e., CRF)
Is the sample hemolyzed? Icteric? # IMHA
EPO-producing tumor (renal) Third spacing Lipemic serum
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BIG%4:%%Don’t%forget%that%blood%smear!%
• Checking%for%the%presence%of%WBC%
– Parvovirus%puppies%
• Checking%for%the%presence%of%platelets%– Epistaxis,%bruising%from%ITP%
– 1%plt/HPF%=%10,000%–%15,000%plt%
• Checking%for%the%presence%of%spherocytes%– DDX:%IMHA%
– Found%in%80%%of%IMHA%pa7ents%
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Coag%Quickies%
• Prothrombin%(PT):%extrinsic%+%common%– Elevated%quickly%with%Vitamin%K%roden7cides%– Vitamin%K%dependent%factors:%II,%VII,%IX,%X%– Half^life%of%VII:%7%hours%
• Ac7vated%par7al%thromboplas7n%7me%(PTT):%intrinsic%+%common%
• Ac7vated%clo{ng%7me%(ACT):%intrinsic%+%common%+%platelets)
• ACT%=%PTT%
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Coag%quickies:%
• PT/PTT%never&affected%by%thrombocytopenia!%
• Buccal%mucosal%bleeding%7me%(BMBT)%and%ACT%– If%thrombocytopenic%(<50,000),%don�t%bother%
• Clinical%thrombocytopenia%– <%20^30,000%platelets%%
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DRUG$CALCULATIONS$
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Basic%calcula7ons%
• %%=%�0�%+%mg/ml%
• Lasix%5%%=%50%mg/ml%
• 50%%Dextrose%=%500%mg/ml%
• 25%%Mannitol%=%??%
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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%
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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%
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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%
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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%
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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%
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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%
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VENOUS$BLOOD$GASES…$JUST$GUESS$METABOLIC$ACIDOSIS$
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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%
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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%
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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%
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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
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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]
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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%
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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%
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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%
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ASSESSING$FLUID$NEEDS$(HYPOVOLEMIA$VS.$DEHYRATION)$BETTER$
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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!%
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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
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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%
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Not%assessing%hydra7on%beuer!%
• Sp.%gravity%1.015^1.018%
• Urine%volume%
• Drinking%water%in%the%cage%
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SQ%fluids:%%How%much%can%you%give?%
• Dose%=%�maintenance%fluids�%
• 30%kg%dog%X%50%ml/kg/day%=%1500%mls%
• 1%L%SQ%once%
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BEING$SCARED$TO$PENETRATE$BODY$CAVITIES$
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%[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%
%
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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%%
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Abdominocentesis%
• Shave%a%large%area%• Alcohol%spray%%
– 2%minute%contact%7me,%degreaser%
• Scrub%• Gloves?%
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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.%
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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%
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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…%
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• 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%
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%@VetGirlOnTheRun%%%VetGirlOnTheRun%%%[email protected]%%[email protected]%%%%%%%%
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Dr.$JusGne$Lee$• April%22^24,%2014:%Russian%Veterinary%
Conference,%Moscow,%Russia%
• May%1^4,%2014:%Interna7onal%Veterinary%Seminars,%New%Orleans,%LA.%
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Associa7on,%Dover%Downs,%DE%
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