k9 tactical emergency casualty care (k9-tecc) guidelines "the

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K9 Tactical Emergency Casualty Care (K9-TECC)

Guidelines

"The Operational K9 … our Companions, our Teammates, our Defenders … Let’s

protect those who protect us …”

DIRECT THREAT CARE (DTC)

GOALS:

1. Accomplish the mission with minimal casualties

2. Expect to keep the K9 team (handler and K9) maximally engaged in neutralizing the

existing threat (e.g. active shooter, unstable building, confined space HAZMAT, etc.)

3. Maintain team safety by ensuring, when feasible, that the K9 handler is always

involved when handling an injured K9.

4. Move the downed K9 team to a safe position and prevent any human or K9 casualty

from sustaining additional injuries

5. Treat immediately life-threatening hemorrhage.

6. Minimize public harm

PRINCIPLES:

1. Establish tactical control and defer in depth medical interventions if engaged in ongoing

direct threat (e.g. active fire fight, unstable building collapse, dynamic post-explosive

scenario, etc.).

2. Threat mitigation techniques will minimize risk to casualties and the providers. These

should include techniques and tools for rapid casualty access and egress.

a. It is highly recommended that Operational K9s operating in a tactical environment

wear a body type harness to assist in extraction and deployment.

b. Choke, pinch, and electronic type collars alone are unable to be employed as a

physical control device in an emergency and may potentially cause further injury

to a downed K9.

3. K9 Handling and Restraint: Consider applying a muzzle prior to handling a conscious

K9 when no contraindications to muzzling exist and it is tactically feasible. (e.g.,not

tactically feasible, upper airway obstruction, respiratory complications, severe facial trauma,

heat-related injuries, vomiting, comatose, etc.).

a. Consider Muzzling a Conscious K9 (when tactically feasible and warranted).

b. Any injured or stressed K9 is considered unpredictable and may bite, even its own

handler.

c. Handlers should always carry a quick application type muzzle in a known, easily

accessible location for expedient handler /team use when and if needed.

d. It is strongly urged to have at least two alternate team members or select first

responders (EMS, Fire, etc.) trained on basic K9 handling techniques for situations

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when the handler is down. When feasible, these personnel should have a well-

established and positive rapport with K9s they support. It is recommended that

only select members are granted this level of rapport to prevent decreasing the

reliability of the asset.

NOTE:

During DTC, threat mitigation to rescuer and casualty takes priority.

DO NOT delay extraction time to “safe” zone for the sole purpose of

applying a muzzle on an injured K9.

Consider when muzzled, the K9 will no longer be able to protect the

downed Handler, in situations where a threat reappears. The Handler

must weigh the benefits and risks of muzzling the K9 based upon the

likelihood of a re-emerging threat.

4. Triage should be deferred to a later phase of care. Prioritization for extraction is based

on resources available and the tactical/operational situation.

5. Limited first aid at the “Point of Injury” (POI) is warranted

6. Consider deferring airway management until Indirect Threat Care if appropriate based

on the tactical situation

7. Consider hemorrhage control for life-threatening bleeding in an injured K9 if tactically

feasible

a. Direct pressure is the primary “medical” intervention to be considered during

Direct Threat Care for the K9 casualty. Consider securing packing material in

place with application of a circumferential pressure wrap as tactically feasible.

b. Consider an improvised tourniquet application as a last resort for distal

extremity or tail wounds or amputations where hemorrhage cannot be

controlled by direct pressure alone.

NOTE: Commercially-designed human Combat Application Tourniquets (C-A-T) are not

tactically effective in K9s due to the anatomical differences of the K9 extremity as

compared to humans.

8. Consider quickly placing or allowing the injured K9 to remain in a position of comfort

that protects the airway, permits ease of respiration, and is least stressful.

a. Depending upon the situation the position of comfort in most K9s is sternal (e.g.,

prone) recumbency. They may also prefer to sit or stand which is acceptable as

long as it is amenable to the tactical situation.

DTC GUIDELINES:

1. Mitigate any threat and move to a safer position (e.g. Return fire, utilize less lethal

technology, assume an overwhelming force posture, extraction from immediate structural

collapse, fire, etc.).

2. Keep the injured K9 (or team) ENGAGED in any tactical operation if appropriate.

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3. Casualties should be extricated from burning vehicles or buildings and moved to places

of relative safety. Do what is necessary to stop the burning process.

4. Extract the injured K9 / K9 Team to a safer position

a. Secure and extract the K9 to a safe location in the safest way possible.

b. If an injured K9 is able to ambulate, the K9 should be lead to safety.

c. When the K9 Handler is injured and team members and or responders are not close

to assist, then the handler (if possible) should:

i. Engage the threat, then immediately apply self-aid when feasible

ii. Secure the K9 by any quick expedient method to prevent a loose K9 (e.g.,

“wrist wrap” the leash)

d. If the K9 team is down and unresponsive, the scene commander or team leader

should weigh the risks and benefits of a rescue attempt in terms of manpower and

likelihood of success. Remote medical assessment techniques should be considered.

e. If the downed K9 team is responsive but cannot move, a tactically feasible rescue

plan should be devised.

f. Recognize that threats are dynamic and may be ongoing, requiring

continuous threat assessments.

5. Stop Life Threatening External Hemorrhage if tactically feasible:

a. Performance of the following steps will be based on Scene safety and Situational

operation.

b. Consider quickly moving to safety prior to application of direct pressure or

application of the TQ if the situation warrants.

c. Direct pressure secured with a circumferential pressure dressing remains the

primary tenet of controlling external hemorrhage in K9s. Hemostatic agents may be

considered if the tactical environment allows their use (requires 3-5 minutes of continuous

pressure).

d. Immediately apply direct pressure over the site of bleeding. Use hand pressure

initially until bandage material or hemostatic agents can be obtained.

e. Apply hemostatic dressing or standard gauze pads directly over the wound

f. Secure the dressing or packing material in place with a circumferential pressure

wrap to maintain constant pressure on the wound.

g. If the tactical scenario permits, consider packing the wound with hemostatic gauze

or standard kerlix roll gauze

i. Use the entire roll of gauze to pack the wound all the way down to the base.

ii. Do not remove dressing or relieve pressure to check the wound. Add more

dressing to control hemorrhage if original dressing becomes saturated.

iii. Hemostatic Impregnated Gauze – QuickClot Combat Gauze™; CELOX™ or

ChitoGauze® are all acceptable options.

h. Elevate the injured area above the heart to reduce blood flow to that area.

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i. Commercial human C-A-T tourniquets tend not to adequately control

upper extremity hemorrhages in K9s (due to the anatomical conformation of

the K9 limb)

i. When needed, apply an Improvised Tourniquet (ITQ). ITQs may be

constructed from material such as a cravat, long sleeve shirt, or back

pack strap in conjunction with a stick, small metal bar or even a long

blade knife (firmly seated in its sheath) as the torsion device.

ii. DO NOT attempt to apply a tourniquet as a first line approach for

controlling extremity hemorrhage unless:

1. Extremity hemorrhage appears life threatening, AND

2. Bleeding remains refractory to other methods of hemostasis (e.g.,

direct pressure, pressure dressing, etc.), AND

3. The anatomical site is amenable to TQ application

OR

4. The K9 has suffered a complete traumatic limb or tail

amputation.

iii. Apply the TQ as proximal-- high on the limb or tail-- as possible or at

least 2 – 3 inches above the wound.

iv. Tighten until cessation of bleeding or loss of palpable distal pulses.

v. EXPOSE & CLEARLY MARK all tourniquet sites with an indelible marker

indicating the time of application.

j. Immobilize the area once bleeding has stopped. Keep the K9 as calm as possible

to lower blood pressure.

k. Consider quickly placing the K9 casualty in position to protect airway if tactically

feasible

Skill Sets:

1. Move to Safety

2. Make “Safe” (e.g., muzzle, restain, etc.) the K9

3. Massive Hemorrhage Control

Direct pressure

Wound packing with hemostatic agents or gauze

Application of Improvised TQ as last resort for distal extremity or tail hemorrhage

4. Casualty movement and extraction

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INDIRECT THREAT CARE (ITC)

GOALS:

1. Goals 1-6 as above with DTC care

2. Stabilize the K9 casualty as required to permit safe extraction to dedicated

treatment sector or medical evacuation assets

PRINCIPLES:

1. Maintain tactical control and complete the overall mission.

2. As applicable, ensure safety of both first responders and K9 casualties by always:

a. Always keeping the K9 handler involved when handling or treating an

injured K9

b. Consider muzzling the K9 when no contraindications to applying muzzle

exist (e.g., respiratory complications, heat-related injuries, vomiting, comatose,

etc) and if not performed during DTC

c. Consider early use of chemical restraint for injured Operational K9s that

are fractious and potentially aggressive due to pain, stress, and / or fear.

d. Medical providers with the likelihood for treating injured K9s should be

trained in safe K9 handling techniques.

3. Conduct dedicated patient assessment and initiate appropriate life-saving

interventions as outlined in the ITC guidelines. DO NOT DELAY casualty

extraction/evacuation for non-lifesaving interventions.

4. Consider establishing a Casualty Collection Point if multiple casualties are

encountered.

5. Unless in a fixed casualty collection point, triage in this phase of care should be

limited to the following categories:

a. Uninjured

b. Deceased / expectant

c. All others

6. Establish communication with the tactical and/or command element and request or

verify initiation of casualty extraction/evacuation.

7. Prepare casualties for extraction and document care rendered for continuity of

care purposes.

ITC GUIDELINES:

1. Properly restrain K9 per Guidelines described under DTC.

a. Consider early use of chemical restraint for injured Operational K9s that

are fractious and potentially aggressive due to pain, stress, and / or fear.

b. Ketamine: 2 – 4 mg / kg IM + Midazolam: 0.2 – 0.5 mg/kg IM

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2. BLEEDING (REASSESS FOR MASSIVE HEMORRHAGE):

a. Reassess interventions for Massive Hemorrhage performed during DTC

b. Assess for any other unrecognized hemorrhage and control all sources of major

bleeding.

c. DIRECT PRESSURE: If not already done, apply direct pressure and pressure

dressing with deep wound packing to control life-threatening external

hemorrhage.

d. HEMOSTATIC DRESSINGS AND AGENTS:

i. For compressible hemorrhage apply a hemostatic agent (e.g., Combat Gauze TM) in accordance with the directions for its use along with an appropriate

pressure bandage.

ii. When using Hemostatic agents apply firm direct pressure for prescribed

time IAW manufacturer’s instructions (at least 3 – 5 minutes for Combat

Gauze™)

iii. For Standard Roll Gauze or Gauze Pad apply firm direct pressure for at least

10 minutes.

1) Impregnated Hemostatic Gauze may be repacked as necessary to stop

any continued bleeding.

2) Standard roll gauze: Do not remove dressing or relieve pressure to

check the wound. Add more dressing to control hemorrhage if original

dressing becomes saturated.

iv. QuickClot Combat Gauze™; CELOX™ or ChitoGauze® are all acceptable

options for Hemostatic Impregnated Gauze.

e. Immobilize and elevate the area of bleeding whenever feasible.

f. TOURNIQUET: If a TQ was initially applied during DTC, consider removing TQ if

bleeding can be controlled by other methods such as with direct pressure and

pressure dressing.

i. Tourniquets applied hastily during DTC phase that are determined to be

both necessary and effective in controlling hemorrhage should remain in

place if evacuation to definitive medical care will be less than 30 minutes.

ii. If any potential delay in evacuation to care (> 2 h), expose the wound fully

and reassess need for TQ.

iii. Identify an appropriate location 2-3 inches above the injury, and apply a

new tourniquet. Once properly applied, the prior tourniquet can be

loosened.

iv. Before releasing any tourniquet on a K9 casualty who has received IV fluid

resuscitation for hemorrhagic shock, ensure a positive response to

resuscitation efforts (e.g. improving mentation and peripheral pulses normal in

character)

v. If loosen previously placed Tourniquet (TQ):

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1) Loosen the new tourniquet slowly (but leave in place).

2) Observe for bleeding

3) Apply direct pressure w/ hemostatic impregnated gauze or gauze

padding if wound is still bleeding. Apply circumferential pressure

dressing if bleeding remains uncontrolled.

4) If a TQ is not needed, use other techniques to control bleeding and

remove the TQ.

5) If bleeding is not controlled without the TQ, re-tighten the TQ and

leave in place.

6) For any traumatic complete tail or limb amputation, a TQ should be

applied or remain in place regardless of bleeding.

vi. When time and the tactical situation permit, a distal pulse check should

be accomplished on any limb where a TQ that remain in place.

vii. If a distal pulse or visual hemorrhage is still present, consider

additional tightening of the tourniquet or the use of a second

tourniquet, side by side and proximal to the first, to eliminate

hemorrhage and or distal pulse.

viii. EXPOSE AND CLEARLY MARK all tourniquet sites with the time of

tourniquet application.

ix. Reasons NOT to remove TQ include:

1) The distal extremity or tail is a complete amputation

2) The K9 casualty remains in Shock or is suffering TBI

3) The tourniquet has been on for > 6 hours

4) Medical treatment facility is within 2 hours after time of application

5) Considered Inadvisable to Transition to other hemorrhage control

methods based off tactical or medical situation

NOTE: If the casualty will be delayed beyond 2 hours, re-assess the need for the

tourniquet at the 2-hour point

g. JUNCTIONAL TOURNIQUETS: Consider using a junctional TQ for difficult to

control junctional hemorrhages (e.g., axilla and inguinal placements) in K9s.

Human-derived junctional tourniquets have not been evaluated in K9s. A

study in swine demonstrated that the Abdominal Aortic & Junctional

Tourniquet (Speer Operational Technologies, Greenville, SC) adequately impeded

femoral artery flow without inducing any gross or histological adverse

effects. (Scwhartz RB, McPherson J; Georgia Regent’s University).

3. AIRWAY MANAGEMENT:

a. Unconscious casualty WITHOUT airway obstruction:

i. Place the K9 casualty in the recovery position, this typically in a sternal

(prone) position.

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ii. Tilt head slightly back and extend neck,

iii. Physically open the mouth and pull tongue forward to help open the

airway and examination of the mouth & pharynx

iv. Consider using a roll of tape as a Mouth Gag to keep the mouth open

b. Conscious K9 Casualty WITH airway obstruction or impending airway obstruction:

i. Clinical Signs:

1) Pawing at mouth, gagging, excessive drooling, frequent swallowing

motions, extended head and neck, elbows and upper legs held out

from the chest (e.g, “tripod position”), reluctant to lie down, cyanosis

(bluish gums) as a late sign.

ii. Evaluation:

1) In a conscious K9, use caution to avoid getting bit by the distressed K9.

Use a rope or leash to secure the K9. Consider sedation in order to gain

access to the mouth and to clear the airway in a conscious, fractious

K9.

2) First position the K9 in any position that allows the K9 to breath with

minimal restriction of air flow and protects the airway, even if that

involves a sitting position

3) Listen for labored or noisy breathing

4) Palpate throat and trachea

5) Open airway as described above in para. 3.a.

iii. Intervention:

1) For patients with an observable obstruction. Quickly remove any

obvious moveable foreign material from the mouth or throat.

2) BE CAREFUL not to push the object down further into the airway

3) Ideally it is not advised to stick your hand into the mouth of a

conscious K9’s mouth. Consider team safety for not suffering bite

wounds:

a) Use a leash, rope or roll gauze looped behind the upper Canine

teeth pry the mouth open.

b) If in your scope of practice, consider sedating the K9 IAW with

K9-TECC chemical restraint options (SEE Para. 1.a.).

4) If foreign material is not readily visible, then take 2 fingers and SWIPE

AND CLEAR the mouth and pharynx

5) You may also attempt abdominal thrusts for moveable Foreign Bodies.

For K9 casualties:

a) “Bear hug” the K9 or lay on the K9 on its side

b) Place Fist just below sternum or behind ribs

c) Compress abdomen with 5 quick upward thrusts

d) Check to see if object dislodged

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e) Repeat 1-2 times if not successful

NOTE: NEVER attempt the abdominal thrusts if sharp objects such

as sticks or bones are present.

6) If attempts to clear or remove the object or obstruction from the

airway have failed and the K9 collapses provide artificial

ventilation via Bag-Mask-Valve technique or Mouth to Snout, as

some air may be able to get around the object then pursue advanced

airway techniques.

7) PARTIAL AIRWAY OBSTRUCTIONS (where some air is able to flow into the

lungs) transport ASAP and continuously monitor for progression to

complete airway obstruction.

c. ADVANCED AIRWAY TECHNIQUES: If previous measures are unsuccessful at

clearing the airway, you are properly trained, and is within you scope of practice

then perform:

i. BLIND AIRWAY INSERTION DEVICE (BAID), OR OROTRACHEAL INTUBATION

(OTT)/ENDOTRACHEAL INTUBATION (ETT):

1) OTT / ETT (preferred in K9s): To facilitate ETT placement ensure head

and neck are in-line’; extended and not flexed. This will allow a direct

“line of site” or path from the oral cavity, through the oropharynx into

the trachea.

a) A laryngoscope may not be required for K9 OTT

b) Common sizes: 9 – 11 mm internal diameter

2) BIAD: Consider placing a 37 – 41 Fr Comitube (Tyco, Kendall-Sheridan

Corporation)

3) NOTE: IF Cervical Spinal Cord Injury is suspected, try and maintain

the Head and Neck in a neutral position; avoid excessive flexion or

extension of the neck.

ii. NEEDLE OR SURGICAL CRICOTHYROTOMY

1) Use the same procedure as described for humans.

2) Use chemical restraint (see Para. 1.a.) and local lidocaine if conscious

iii. NEEDLE OR SURGICAL TRACHEOSTOMY

1) Not recommended as first-line intervention considering it is consider

more invasive, time consuming, and possesses a higher rate of complications

as compared to cricothyrotomy.

2) Use chemical restraint (see Para. 1.a.) and local lidocaine if conscious

3) Use lidocaine if conscious

d. Consider administering oxygen supplementation if available

e. If no spontaneous ventilations provide artificial respirations

f. Monitor SpO2% (if available); Normal values > 94% on room / atmospheric air

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i. Probe placement in order of preference: tongue (if unconscious), lip, ear pinna,

prepuce (male)/vulva (female)

4. RESPIRATION / BREATHING:

a. All OPEN AND/OR SUCKING CHEST wounds should be treated by immediately

applying a vented or non-vented occlusive seal to cover the defect.

i. If feasible -- Rapidly clip hair around the wound, to allow the seal to

become airtight.

ii. If hair clippers are not available place water soluble lube on the underside

of the chest seal to form an occlusive seal between the skin and the chest

seal; secure in place on all sides with adhesive tape.

b. Monitor the casualty for the potential development of a subsequent tension

pneumothorax (PTX)

c. In the setting of known or suspected thoracic trauma, consider the presence of a

tension PTX with the following clinical signs:

i. Progressive respiratory with rapid, shallow and open-mouth breathing while

acting agitated or unable to get comfortable

ii. Head and neck extended

iii. Asynchronous breathing pattern – abdomen and chest move in opposite directions

during inspiration

iv. Also minimal chest excursion – more abdominal component

v. Lack of drive and response to even basic commands, unwillingness to move,

vi. Elbows and upper front legs held out away from body

vii. Reluctant to lie down

viii. Cyanotic (blue) gums (late finding)

ix. Collapse

d. If tension pneumothorax is present or develops, consider:

i. Needle decompression should be performed with a 14-gauge, 3.25 inch (8 cm)

needle/catheter. Potential decompression techniques include:

a) Insertion in the 7th to 9th intercostal space midway up the lateral

thoracic wall.

b) Ensure that the needle enters cranial (towards the head) to the rib

c) Insert the needle perpendicular to the chest wall

d) Once in the pleural space direct the needle ventral or caudal and the

lay the needle against the thoracic wall. Ensure the bevel of the needle

faces away from the inner thoracic wall.

e) Decompress the chest on BOTH SIDES

(**K9s have a communicating mediastinum that allows air to infiltrate both

sides).

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e. In place of or in addition to needle compression, consider “BURPING” the

occlusive chest seal.

f. PENETRATING thoracic foreign body: (e.g., knife, arrow, rebar, etc.)

i. If still in place --- DO NOT REMOVE

ii. Seal edges of occlusive seal by covering with gauze and occlusive material

(e.g., Saran wrap) to control air loss and securing with adhesive tape.

iii. Secure the foreign body (e.g. bandaging) and prevent further injury

iv. Perform needle decompression as needed

v. Transport (injury up) ASAP with no pressure on penetrating object

5. CIRCULATION (INTRAVENOUS (IV) / INTEROSSEOUS (IO) ACCESS):

a. If evacuation to definitive care is > 30 minutes, place at least an 18-gauge IV

catheter (or larger bore) in at least one peripheral vein (cephalic vein preferred) if

indicated

b. If resuscitation is required and IV access is not obtainable, use the IO route (per

agency protocol). Recommended IO locations in the K9 (in order of preference):

i. **Flat medial surface of the proximal tibia (1 to 2 cm distal to the tibial tuberosity)

ii. Tibial tuberosity

iii. Trochanteric fossa of the femur

iv. Greater tubercle of the humerus

v. Wing of the ilium

6. TRANEXAMIC ACID (TXA) OR EPSILON AMINOCAPROIC ACID (EACA):

a. If casualty is anticipated to need significant blood transfusion (e.g. presents with

hemorrhagic shock, one or more amputations, penetrating torso trauma, or evidence of

severe bleeding) consider administration of one of the following as soon as possible

and NO LATER than 3 hours post-injury:

i. 10 mg/kg TXA in 100 mL NS or LR IV slowly over 15 min

ii. 150 mg/kg EACA in 100 mL NS or LR slowly over 15 min

(NOTE: Evidence supporting the appropriate dosage of TXA or EACA in K9s is

currently limited)

7. FLUID RESUSCITATION:

a. Assess for hemorrhagic shock.

i. Altered mental status (in the absence of head injury) and weak/absent

peripheral femoral pulses are the best field indicators of shock.

ii. Abnormal vital signs

1) Systolic Blood Pressure (SBP) < 90 mm Hg and Heart Rate > 140 bpm,

or a shock index > 1 (HR/SBP).

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STAGE OF SHOCK HR* CRT MM MENTATION PULSE

QUALITY SBP

NORMAL (at rest) < 120 < 2 s Pink Bright, alert Strong > 90

ACUTE

COMPENSATORY > 120 < 1 s Red Normal Fair > 90

EARLY

DECOMPENSATORY > 140 > 2 s Pale Depressed Weak < 90

TERMINAL < 80 absent Pale Obtunded Absent Low

*NOTE: Normal values are for a RESTING state. Exercise/activity will result in higher HRs

b. If NOT in shock:

i. No IV fluids necessary

ii. Per Os fluids permissible if:

1) Conscious, can swallow, and has no injury requiring potential

surgical intervention

2) Confirmed long delay in evacuation to care

c. If IN SHOCK use the following guidelines based on available resources:

i. Non-Hemorrhagic or Controlled Hemorrhagic Shock (in order of preference)

1) Hypertonic Saline (HTS) + Synthetic Colloid

a) 75 mL HTS : 75 mL Colloid (or 5 mL/kg HTS : 5 mL/kg Colloid)

b) Limit HTS administrations to no more than 2 aliquots

c) Avoid using HTS in situations involving uncontrolled

hemorrhage or where definitive hemostasis cannot be achieved.

HTS will cause the BP to spike too high and disrupt any

thrombus formation leading to further blood loss.

2) Synthetic colloid (low-molecular weight 130/0.4 preferred

a) Administer in 250 mL aliquots (or 10 mL/kg)

b) Reassess perfusion parameters after each 250 mL bolus

3) Isotonic, balanced electrolyte crystalloid:

(Ex: Lactated Ringers or Plasma-Lyte A)

a) Administer in 500 mL aliquots (or 20 mL/kg)

b) Reassess the casualty after each 500 mL IV bolus

c) Current TCCC recommendation is to avoid 0.9% sodium chloride if

possible

4) Continue resuscitation until:

a) A palpable femoral pulse,

b) Improved mental status, or

c) Systolic BP of 80-90 mmHg

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5) Discontinue fluid administration when one or more of the above end

points has been achieved

6) K9 casualty with an altered mental status due to suspected TBI with a

weak or absent peripheral pulse:

a) Resuscitate as necessary to restore and maintain a normal

femoral pulse

b) If BP monitoring is available, maintain a target systolic BP of at

least 90 mmHg.

7) Reassess the casualty frequently to check for recurrence of shock.

8) If shock recurs, recheck all external hemorrhage control measures to

ensure that they are still effective and repeat the fluid resuscitation as

outlined above.

ii. Traumatic Shock with ACTIVE, UNCONTROLLED HEMORRHAGE

OPTIONS FOR RESUSCITATION ARE IN THE ORDER OF PREFERENCE

1. K9 Stored Whole Blood, 450 – 500 mL

2. K9 pRBC: FFP @ 10mL/kg of each (Ex: 25kg dog give 250 mL pRBC: 250 mL FFP)

(Note K9 blood units are not standard; not all the same standard size)

DO NOT give human blood products to an injured K9

4. Colloid only: 125 mL aliquots (or 5 mL/kg)

5. Isotonic crystalloid Only: 10 mL/kg ONLY as a last resort if no other above

fluids are available and anticipated evacuation times are > 30 min (repeat only

twice)

*Note:

Colloids may be repeated in 125 mL aliquots to achieve palpable femoral pulse. Not to

exceed of a total volume of 500 mL

Isotonic Crystalloid repeated in 250 mL aliquots to achieve palpable femoral pulse. Not to


RESUSCITATIVE GOALS

Hypotensive Resuscitation

Palpable femoral pulse; improved mentation; MAP = 40-60; SBP = 80 mm Hg

Maintained until definitive hemostatic control is achieved

8. HYPOTHERMIA:

a. Minimize casualty’s exposure to the cold elements

b. Move patient from cold environment / element to warm shelter

i. Transport patient in a horizontal / sternal position

c. Remove any wet outer wear (e.g., vests, booties, etc)

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d. GENTLY pat dry any wet tissues or hair coat.

e. Place the casualty onto an insulated surface as soon as possible

f. Cover the casualty with a commercial warming device (e.g, mylar blanket), dry

blankets, poncho liners, sleeping bags, or anything that will retain heat and keep

the casualty dry.

g. ALWAYS handle markedly hypothermic patients (< 86°F or 30°C) gently to avoid

triggering cardiac dysrhythmias

h. Primary efforts should concentrate on treating and preventing hypothermia (as

described above) and transporting patient gently to a medical care facility

NOTE: For K9 casualties with head trauma, CONSIDER not actively warming the

casualty, but consider permissible hypothermia to a temperature of 96 -97°F (35.5 –

36.1°C).

9. OCULAR (EYE) TRAUMA:

a. Flush the affected eye and adjacent tissues with copious amounts of sterile

saline or ophthalmic rinse.

b. Non-Penetrating injuries

i. Gently coat the eyeball with the entire contents of one tube of eye

ointment or copious amount of eye irrigation solution or aqueous tears.

ii. NOTE: Rigid eye shields designed for humans do not fit K9s; Consider

using a plastic (e.g., Dixie cup) or Styrofoam cup as a shield if available.

iii. If no “hard” shield is available, consider covering and lightly securing 5-

8 gauze sponges moistened with eye irrigation solution over the eye.

iv. If not material is available to cover the injured eye, leave the eye un-

bandaged and prevent the K9 from scratching at the eye. If available,

place a commercial or improvised (e.g., bucket with bottom cut out) E-

collar on the K9 to prevent self-trauma.

v. Consider covering the uninjured eye to reduce the level of anxiety as

well as reduce eye movement that would cause the injured eye to move

as well.

c. Penetrating Eye Trauma

i. If a penetrating eye injury is noted or suspected, protect the eye from

external pressure and stabilize any impaled object to prevent movement

during extraction.

ii. Stabilize the foreign body in place:

1) Form a doughnut ring made out of 2-inch role gauze

2) As you make the ring, adjust the size of the inner diameter to fit

around the eye

3) Place the ring around the object without bumping the object

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4) Secure the gauze doughnut to the eye using roll gauze bandaged

around the head

5) Cover the uninjured to prevent eye movement which would cause

the injured eye to move as well.

10. REASSESS CASUALTY:

a. Performed at the scene or en route to the hospital

b. Perform full body examination checking for additional injuries; Includes

i. Inspection (visual observation), palpation (hands-on assessment), and

auscultation (auditory assessment) of the injured K9

c. Perform focused assessment of identified injured areas

d. Reassess Vital Parameters

11. INSPECT AND DRESS KNOWN WOUNDS AND FRACTURES

a. IMPORTANT: Handle an injured K9 with a fracture with extreme care and

proper restraint.

b. Consider administering chemical restraint and analgesia before manipulating

the fractured site.

c. Check for additional wounds and Closed and Open Fractures

d. Closed Fractures

i. Basic immobilization for fractured extremities

ii. Attempt to stabilize one joint above and below the fracture

iii. Elevate limb to reduce edema swelling

e. To stabilize injuries of the distal thoracic limb, apply splints on the caudal

aspect of the leg. To stabilize injuries of the distal pelvic limb, apply splints on

the lateral aspect of the leg.

f. IMPORTANT: DO NOT splint limb fractures above the knee (stifle) or elbow

(e.g., fractures of the femur or humerus). Attempting to splint femoral or humeral

fractures can increase distraction on the fracture resulting in greater injury

(basically the splint acts as an anchor on the fracture site).

g. IMPORTANT: DO NOT attempt to straighten or reduce an open fracture.

h. For displaced fractures that are angulated:

i. If distal limb pulses are absent, attempt to realign to fracture to neutral

position using mild traction. If significant resistance or pain is met, stop

immediately and splint in position found.

ii. If distal limb pulses are present, splint in position found.

iii. Recheck pulse of the effected limb after splint application, if feasible

i. Open wound or fracture:

i. Remove and Flush gross debris from the wound with isotonic

crystalloids(preferred) or sterile water

16

ii. Open Wound (no exposed or protruding bone): cover wound with a non-

adherent pad and secure the non-adherent pad in place with a clean

soft-padded bandage/wrap.

iii. Open Fracture (exposed and/or protruding bone): cover bone/wound with a

wet-to-dry bandage or moistened gauze and secure in place with a

clean soft-padded bandage/wrap.

iv. Open abdominal wounds: Rapidly identify open abdominal wounds

1) Cover any exposed organs with sterile dressing (or available

material) moistened with saline or other sterile/clean, isotonic fluid

2) Apply a sterile circumferential belly bandage/wrap to secure the

moistened dressing in place and decrease further contamination

3) DO NOT attempt to push any exposed organs or tissues back into

the abdomen.

j. Antibiotics: Recommended for all open fractures. Consider using potentiated

aminopenicillin (e.g., amoxicillin/clavulanic acid, ampicillin/sulbactram) or

cephalosporin (e.g., cephalexin or Keflex®, cefotetan)

12. ANALGESIA / SEDATION:

a. Provide adequate analgesia as necessary for the injured.

b. IV, IO, or IM pure mu-agonist opioids (e.g., morphine or fentanyl) are most

effective. Start at a low dose and titrate to effect (NOTE: Oral opiates are not

effective while, intranasal / transmucosal opiates have not been evaluated in

K9s)

c. For Operational K9s ABLE to continue mission suffering MILD pain:

i. DO NOT use any human-derived non-steroidal anti-inflammatory

medications (e.g. aspirin, acetaminophen, ibuprofen, naproxen, ketorolac,

etc.)

ii. MILD pain consider:

1) Tramadol: 3 – 5 mg/kg PO q 6 – 8 h (75 – 125 mg for a 25 kg K9)

2) Butorphanol or nalbuphine: 0.1 – 0.5 mg/kg IM (if available) q 2 h

PRN

d. If the Operational K9 is UNABLE to continue the mission due to

MODERATE to SEVERE pain:

i. Consider use of opiate IV, IO, or IM [e.g., hydrocodone, oxycodone,

morphine, and/or Ketamine (at analgesic dosages)]

17

SUGGESTED K9 DOSAGES

MORPHINE:

Single injection or loading bolus: 0.2–0.5 mg/kg IV or IM q 1-4 h

Infusion rate: 0.1–0.3 mg/kg/h

Note: For IV morphine, start with low dose and administer slowly over 3-5

minutes

FENTANYL

Single injection or loading dose: 2–5 mcg/kg IV* (preferred) or IM q 20 – 30 min

Infusion rate: 3 – 6 mcg/kg/h

For INTRACTABLE pain (ideal to use in combination with opiate)

Ketamine: 0.5 to 1 mg/kg IV or 2-4 mg/kg IM

in combination with

*Midazolam (IV/IM) or Diazepam (IV or rectal): 0.2 - 0.5 mg/kg

*(to reduce ketamine-induced muscle hypertonicity / myoclonus)

18

13. ANTIBIOTICS:

a. Consider initiating antibiotic administration for K9 casualties with open

wounds/fractures and penetrating eye injury when evacuation to definitive

care is significantly delayed or infeasible.

b. This is generally determined in the mission planning phase and requires

medical oversight.

c. If antibiotics are warranted select either a cephalosporin or potentiated

penicillin (e.g., amoxicillin-clavulanic acid, cephalexin (Keflex), etc.)

14. BURNS:

a. IMPORTANT: Provide adequate analgesia for all burn patients

ANALGESIA NOTES

K9 Casualties may need their muzzle removed when administered an opiate

in anticipation of opioid-induced vomiting

Ketamine may be a useful adjunct to reduce the amount of opioids required to

provide effective pain relief. It is safe to give ketamine to a casualty who has

previously received an opiate. IV Ketamine should be given over 1 minute.

ALWAYS start at lowest dose and titrate to clinical effect

Ketamine should be administered with a benzodiazepine in K9s to reduce

ketamine-induced muscle hypertonicity / myoclonus.

Document a mental status exam prior to administering opioids or ketamine

For all casualties given opioids or ketamine – monitor airway, breathing, and

circulation closely (NOTE: Opioid-induced respiratory depression is less of a risk in

K9s as compared to humans)

If respirations are noted to be reduced after using opioids or ketamine,

provide ventilatory support with a bag-valve-mask or mouth-to-mask

ventilations.

Have naloxone (1 mg or 0.04 mg/kg IV/IM/IO) readily available whenever

administering opiates

Consider adjunct administration of anti-emetics (Ondansetron 4 – 6 mg IV or

24 mg PO) prior to administering opiates

Eye injury does not preclude the use of ketamine. The risk of additional

damage to the eye from using ketamine is low and maximizing the casualty’s

chance for survival takes precedence if the casualty is in shock or respiratory

distress or at significant risk for either.

Reassess – reassess – reassess!

19

b. Clinical Signs / Indicators in K9s:

i. Liquids (water, oil, gas) often run under hair coat and burns are not

readily evident

ii. Look for singed hair, redness, blistering or charring

iii. Swelling and pain present

c. Interventions

i. FACIAL BURNS, especially those that occur in closed spaces, may be

associated with inhalation and corneal injuries:

1) Aggressively monitor airway status and oxygen saturation (SpO2) in

such patients and consider early definitive airway management for

respiratory distress or oxygen desaturation. **Consider (SpO2) may

appear may normal as most devices do not differentiate between carbon

monoxide and oxyhemoglobin

2) Consider treating ocular / corneal injuries

ii. SMOKE INHALATION, particularly in a confined space, may be associated

with significant carbon monoxide (CO) and cyanide toxicity (CN).

Patients with signs of significant smoke inhalation plus:

1) Significant symptoms of carbon monoxide toxicity should be treated

with high flow oxygen if available

2) Significant symptoms of cyanide toxicity should be considered

candidates for cyanide antidote administration (if available);

3% Sodium Nitrite: 10 mg/kg IV; followed by

20‑25% Sodium thiosulphate: 500 mg/kg IV (12.5g for a 25

kg K9) (Oruc1 HH, et al., 2006)

3) Consider in K9s, supplemental oxygen in combination with sodium

thiosulfate alone, has been shown to be effective for treating

combined CO + CN exposure. (P H Breen et al., 1995; C J Vesey et al.,

1985)

4) Consider hydroxocobalamin 150 mg/kg over 10 minutes

iii. Estimate total body surface area (TBSA) burned to the nearest 10% using

the “RULE OF NINES”: (Accuracy of formula has not been validated in K9s)

1) Head and neck (H/N) = 9%

2) Each forelimb (front leg) (RFL, LFL) = 9%

3) Each Hind limb (back leg) (RHL, LHL)= 18%

4) Ventral trunk (thorax and abdomen) = 18%

a) Ventral thorax (VTx) = 9%

b) Ventral Abdomen (VAb) = 9%

5) Dorsal trunk (entire length of back) = 18%

a) Dorsal thorax (Dtx) = 9%

b) Dorsal Abdomen/Pelvis (DAb/P) = 9%

20

TBSA = H/N + RFL + LFL + VTX + VAB + DTX + DAB

iv. Clip hair gently around wound or burn area

v. Minor (superficial) burn treat:

1) Cool burned skin with cool to cold water (sterile fluid if available)

within 20 minutes of burn incident

vi. Do not apply ice directly on tissues with partial to full thickness (2nd to 4th

degree) burns

vii. Cover the burn area with dry, sterile dressings and initiate measures to

prevent heat loss and hypothermia once cool irrigation is completed

viii. If burns are greater than 20% of TBSA, fluid resuscitation should be

initiated under medical control as soon as IV/IO access is established. If

hemorrhagic shock is also present, resuscitation for hemorrhagic shock

takes precedence over resuscitation for burn shock as per the K9-TECC

fluid guidelines.

ix. All previously described casualty care interventions can be performed on

or through burned skin in a burn casualty.

x. Analgesia in accordance with K9 TECC guidelines should be considered

for all burn wound patients

xi. Aggressively act to prevent hypothermia for burns > 20% TBSA

BURN SHOCK (SEVERE BURN INJURY > 20% TBSA)


"Consensus Formula”

1: Isotonic Crystalloid: 4 mL/kg per TBSA burned to be administered over the first 24 h

Give ½ of this amount within in the first 8 h post burn-incident, and the remaining half over

the next 16 h.

*Ex: 25 kg K9 with burns to 20% of its body surface area would require 4 x 25 x 20 = 2,000 mL of

fluid replacement within the first 24 hours.

2: Colloid: 5 mL/kg aliquots (125 mL) as needed to maintain perfusion parameters

**Do not exceed more than 500 mL

RESUSCITATIVE GOALS

If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence

over resuscitation for burn shock. Administer IV/IO fluids per K9-TECC Guidelines,

Section 7 Targeted perfusion parameters

Palpable femoral pulse; HR < 140; improved mentation MAP > 65; SBP >100 mm Hg

(NOTE: Accuracy of formula has not been validated in K9s)

15. MONITORING:

21

a. Periodically, obtain and record vital signs (temperature, pulse, respiration, pulse

quality, mucous membrane color, capillary refill time, mentation)

b. If available electronically monitor:

i. Pulse oximetry (SpO2)

1) Tongue (if unconscious), lip, ear pinna, prepuce or vulva, rectum (if

rectal probe available)

ii. ECG

iii. ETCO2 (if intubated)

iv. Non-Invasive Blood pressure

16. PREPARE K9 CASUALTY FOR MOVEMENT:

a. Consider environmental factors for safe and expeditious evacuation.

b. Secure casualty to a movement assist device when available.

c. If vertical extraction required, ensure casualty is secured within appropriate

harness, equipment is assembled, and anchor points are identified.

17. COMMUNICATE with the K9 casualty to provide reassurance

a. If available, ensure K9 Handler travels with the K9 to provide restraint,

comfort, and reassurance (this is important for both the handler and the K9)

b. Encourage and provide positive reassurance to the injured K9 by stroking the

K9’s hair coat and or patting the K9 on the head they are not aggressive.

18. CARDIOPULMONARY RESUSCITATION:

a. May have a larger role during the EVACUATION phase especially for patients

with electrocution, hypothermia, non-traumatic arrest or near drowning.

b. Typically not recommended for animals suffering cardiopulmonary arrest

(CPA) in conjunction with:

i. Severe TRAUMATIC BRAIN INJURY (TBI)

ii. Massive NON-COMPRESSIBLE THORACIC hemorrhage

iii. Massive NON-COMPRESSIBLE ABDOMINAL hemorrhage

iv. SUSPECTED SEVERE PULMONARY CONTUSIONS leading to CPA

c. NOTE: Consider bilateral needle decompression for casualties with thoracic

or blunt polytrauma with no respirations or pulse to ensure tension PTX is

not the cause of cardiac arrest prior to discontinuation of care.

d. BLS (airway, breathing, circulation)

i. ONE RESCUER: Provide “Mouth-to-Snout”

1) Chest compression to ventilation ratio of 30 compressions:2

breaths

2) Hand placement: widest portion of chest while in lateral

recumbency

22

3) Perform at least five rounds of a 30:2 C:V cycle before soliciting

more assistance

ii. TWO RESCUERS: Provide simultaneous continuous compressions +

ventilation:

1) Compression rate: 100 – 120 beats per minute

2) Ventilation: 8 – 10 breaths per minute, with 1 second inspiratory

hold

3) Compression Cycle: Perform at least and no more than 2 minutes of

continuous compressions before switching compressors

4) Do not allow more than 10 seconds to pass between compressions

cycles

iii. Consider use of an impedance threshold device to enhance circulation

e. ALS – Perform based on transport time, availability of resources, and

responder’s expertise and scope of practice:

i. EPINEPHRINE: 0.01 mg/kg IV/IO/IT

ii. VASOPRESSIN: 0.8 U/kg IV/IO or (1.2 U/kg IT)

iii. ATROPINE: 0.04 mg/kg IV/IO/IT

iv. For K9s that have received reversible anesthetic/sedative medications,

administer reversal agents (e.g., NALOXONE 0.04m mg/kg IV/IO/IT)

v. AVOID use of CORTICOSTEROIDS

vi. SODIUM BICARBONATE (NaHCO3): 1 mEq/kg; ONLY recommended

after prolonged cardio-pulmonary arrest (> 10 – 15 minutes)

vii. For drugs administered via IT:

1) Consider using 2 – 10 times the recommended IV dose

2) Dilute with 5 – 10 mL of sterile water, 0.9% saline, or other

available isotonic, sterile intravenous infusate

3) Flush down OTT tube using a catheter ideally longer then the OTT

19. DOCUMENTATION OF CARE:

a. Document clinical assessments, treatments rendered, and changes in the

casualty’s status in accordance with local protocol.

b. Forward this information with the casualty to the next level of care.

c. Consider implementing a K9 CASUALTY CARE CARD (see addendum) that can

be quickly and easily completed by non-medical first responders.

Skill set:

1. Hemorrhage Control:

a. Apply Direct Pressure

b. Apply Pressure Dressing

23

c. Apply Wound Packing

d. Apply Hemostatic Agent

e. Apply Tourniquet

2. Airway:

a. Clear Airway (2 Finger Sweep)

b. Perform Endotracheal Intubation

c. Perform Surgical Cricothyrotomy / Tracheotomy

3. Breathing:

a. Application of effective occlusive chest seal

b. Assist Ventilations with Bag Valve Mask

c. Apply Oxygen

d. Apply Occlusive Dressing

e. Perform Needle Chest Decompression

4. Circulation:

a. Gain Intravascular Access

b. Gain Intraosseous Access

c. Administer IV/IO medications and IV/IO fluids

d. Administer blood products

5. Wound management:

a. Protect the Injured Eye

b. Apply Dressing for evisceration

c. Apply Extremity Splint

d. Initiate Basic Burn Treatment

e. Initiate Treatment for Traumatic Brain Injury

6. Prepare Casualty for Evacuation:

a. Move Casualty (drags, carries, lifts)

b. Apply Spinal Immobilization Devices

c. Secure casualty to litter

d. Initiate Hypothermia Prevention

7. Other Skills:

a. Perform Hasty Decontamination

a. Initiate Casualty Monitoring

b. Establish Casualty Collection Point

Note: Care provided within the ITC guidelines is based upon individual first responder training, available

equipment, local medical protocols, and medical director approval.

24

EVACUATION / COLD ZONE:

Goals:

1. Maintain any lifesaving interventions conducted during DTC and ITC phases

2. Provide rapid and secure extraction to an appropriate level of care

3. Avoid additional preventable causes of death

Principles:

1. Reassess the casualty or casualties.

2. Utilize a triage system/criteria per local policy that considers priority AND

destination.

3. Utilize additional resources to maximize advanced care.

4. Avoid hypothermia.

5. Communication is critical, especially between tactical and non-tactical EMS teams.

6. Maintain situational awareness- In dynamic events, there are NO threat free area

(e.g. green or cold zone)

Guidelines:

1. Reassess all interventions applied in previous phases of care, DTC and ITC. If

multiple wounded, perform primary triage for priority AND destination.

2. BLEEDING (See ITC)

a. Fully expose wounds to assess for unrecognized hemorrhage. Control all sources

of major bleeding by applying appropriate pressure dressing with deep wound

packing.

b. Avoid use of tourniquets to control bleeding, except for areas that are

anatomically appropriate for tourniquet application and where

i. Massive limb and or tail hemorrhage that remains uncontrolled with

application of direct pressure dressing and or hemostatic agents, or

ii. There is a traumatic total or partial amputation of an extremity

c. If a tourniquet is used, it should be applied as high as possible or at least 2-3

inches above injury and a date and time of application should be noted on the

patient and or treatment sheet.

d. Reassess all tourniquets placed prior to transport by exposing the injury and

determine if a tourniquet is actually needed or need to be adjusted.

i. If deemed ineffective for controlling hemorrhage apply a new

tourniquet directly to the skin 2-3 inches above the injury. Once the

25

second tourniquet is properly applied, the prior tourniquet may be

loosened.

ii. Tourniquets applied in prior to transport that are determined to be both

necessary and effective in controlling hemorrhage should remain in

place if the casualty can be rapidly evacuated to definitive medical care

(e.g. less than 2 hr)

iii. If there is a delay to definitive care longer than 2 hours, an attempt

downgrade the tourniquet to the use of direct pressure, pressure

dressing and or hemostatic agent may be attempted.

iv. Avoid periodically releasing the tourniquet as this will result in greater

blood loss and an overall greater risk of mortality.

v. A distal pulse check should be performed on any limb where a

tourniquet is applied. Consider additional tightening of the tourniquet

if a distal pulse is still present or applying a juxtaposed second

tourniquet, side by side and proximal to the first, to eliminate the distal

pulse.

vi. EXPOSE AND CLEARLY MARK all tourniquet sites with the time of

tourniquet application. Use an indelible marker.

3. AIRWAY MANAGEMENT:

a. The principles of airway management in Evacuation Care are similar to that in ITC

with the addition of increased utility of endotracheal intubation.

b. Unconscious K9 without airway obstruction: Same as ITC

c. Downed K9 with airway obstruction or impending airway obstruction:

i. Initially, same as ITC

ii. If previous measures unsuccessful, it is prudent to consider, BAID,

OTT/ETT, or surgical cricothyrotomy/tracheostomy (with lidocaine if

conscious).

d. If intubated, reassess for respiratory decline in patients with potential

pneumothoraces.

e. Consider the mechanism of injury and the need for spinal immobilization.

f. Spinal immobilization is not necessary for downed K9s with penetrating trauma

if the K9 appears neurologically intact.

4. BREATHING:

a. Immediately apply on occlusive bandage to all open and/or sucking chest

wounds that were not treated prior to transport.

b. Monitor the casualty for the potential development of a subsequent tension

pneumothorax. Clinical signs of a tension PTX in K9s include: (e.g. progressive

26

respiratory distress, hypoxia, and/or hypotension in the setting of known or suspected

thoracic trauma).

c. Treat tension pneumothorax burping chest seal or performing needle

decompression. Repeat steps as needed to mitigate respiratory distress.

i. ALWAYS tap both sides of the chest in K9s

ii. For situations with prolonged transport times that require multiple

decompressions, then consider placing a thoracostomy tube (again

pending the provider experience and scope of practice)

d. If clinical signs of respiratory distress improve, repeat above steps as needed.

e. If available, consider administration of oxygen for all traumatically injured

patients and any K9 with:

i. Low oxygen saturation by pulse oximetry (SpO2 < 90%)

ii. Injuries associated with impaired oxygenation (e.g., p`ulmonary

contusion, smoke inhalation, etc.)

iii. Unconsciousness

iv. Traumatic Brain Injury (TBI) (maintain oxygen saturation > 90%)

v. Circulatory shock

vi. Casualties with pneumothoraces

4. TRANEXAMIC ACID (TXA) OR EPSILON AMINOCAPROIC ACID (EACA):

a. If casualty is anticipated to need significant blood transfusion (e.g. presents with

hemorrhagic shock, one or more amputations, penetrating torso trauma, or evidence of

severe bleeding) consider administration of one of the following as soon as

possible and NO LATER than 3 hours post-injury:

1) 10 mg/kg TXA in 100 mL NS or LR IV slowly over 15 min

2) 150 mg/kg EACA in 100 mL NS or LR slowly over 15 min

5. CIRCULATION (See ITC)

a. Reassess casualty for hemorrhagic shock (e.g., altered mental status in the

absence of brain injury, weak or absent peripheral pulses, and/or change in pulse

character)

b. If BP monitoring is available, maintain systolic BP 80-90 mmHg.

c. Establish IV or IO access if not performed already performed in ITC

d. Restore perfusion as recommended in ITC with the following addition for

hemorrhagic shock:

i. If suffering hemorrhagic shock and blood products are not available

or not approved under scope of practice / local protocols, resuscitate

as recommend under ITC Section 6.

27

ii. If suffering hemorrhagic shock and blood products are available

AND approved under scope of practice / local protocols, consider

resuscitating using the following guidelines:


1. K9 Stored Whole Blood, 450 – 500 mL (is equal to 1 unit)

2. K9 pRBC: FFP @ 10mL/kg of each (Ex: 25kg dog give 250 mL pRBC: 250 mL FFP)

(Note K9 blood units are not standard; not all the same standard size)

DO NOT give human blood products to an injured K9

3. Colloid only: 125 mL aliquots (or 5 mL/kg)

5. Isotonic crystalloid Only: 10 mL/ kg ONLY as a last resort if no other above

fluids are available and anticipated evacuation times are > 30 min (repeat only

twice)

*Note:

Colloids may be repeated in 125 mL aliquots to achieve palpable femoral pulse. Not to


Isotonic Crystalloid repeated in 250 mL aliquots to achieve palpable femoral pulse. Not to


RESUSCITATIVE GOALS

Hypotensive Resuscitation

Palpable femoral pulse; improved mentation; MAP = 40-60; SBP = 80 mm Hg

Maintained until definitive hemostatic control is achieved

e. Further administration of IV fluids to maintain hemodynamic stability must

take into the consideration transport time as well as the adverse effects on the

patient that may be invoked by using large volume fluid resuscitation.

i. If transport times are anticipated to exceed 2 hours, consider

administering small aliquots of fluids to maintain targeted BP / clinical

perfusion parameters or consider starting a low-rate infusion of:

1) Synthetic colloids at 1 mL/kg/h, or

2) Isotonic Crystalloids at 2 mL/kg/h if synthetic colloids are not

available.

f. Casualties with an altered mental status due to suspected TBI that also have a

weak or absent peripheral pulse:

i. Resuscitate as necessary to maintain a desired SBP of at least 90mmHg

or a palpable femoral pulse.

28

ii. Use a low-volume approach utilizing a HTS: HES combination to

restore perfusion as well as provide hyperosmotic therapy for any

potential cerebral edema.

RECOMMENDATION: Avoid large volume isotonic crystalloids to avoid

exacerbating resuscitative injury, increased cerebral edema, and elevated

intracranial pressure

6. NEUROLOGICAL TRAUMA (Traumatic Brain Injury (TBI) & Acute Spinal Cord Injury):

a. Prevention of hypotension and hypoxia are critical in management of

neurological trauma.

b. If suspected TBI and casualty is not in shock:

i. Keep the head and neck raised to 30 degrees

ii. Avoid jugular compressions and or kinking the neck

iii. Administer oxygen therapy to maintain SpO2 > 92%

iv. Consider administering hyperosmotic therapy

1) 4-6 mL/kg HTS, or

2) 1 – 1.4 g/kg mannitol [NOTE: Avoid mannitol in hypotensive patients

(SBP < 90 mm Hg) as it may potentiate the hypotension]

v. For suspected TBI casualties, consider not actively warming and

allowing mild permissible hypothermia 35°C - 37°C (95°F – 98.6°F)

c. Suspected or Known Acute Spinal Cord Injury (SCI):

i. Before transport, immobilize the spine by placing the casualty in lateral

recumbency onto a rigid stretcher (if available) or a flat board.

ii. If available provide a thin layer of soft padding to prevent pressure

sores once the casualty is secured to the rigid support.

iii. Place the rigid support adjacent to the patient’s spinal column:

1) With two hands, scruff the dog’s fur along the dorsal neck and

dorsal rump, and gently and equally with both hands pull/slide the

casualty onto the rigid support.

2) Secure the patient to the support with tape or nylon straps.

a) Immobilize the limbs to prevent forward, backward, and /

or rotational movement that could cause further SCI.

b) Avoid placing straps or tape over the thorax or abdomen to

allow adequate chest excursion for ventilation.

c) Secure over bony prominences – base of skull behind ears,

shoulder, hips, etc. Place a thin layer of padding between

the straps or tape and the K9 to avoid discomfort.

iv. Align the head and neck to maintain the cervical spinal cord in a neutral

in – line position. This requires placement of a soft pad under the head

29

to align it in a straight line with the cervical spine. Avoid keeping the

head and neck in a hyperextended position

1) Do not attempt placement of the head and cervical region in a

neutral in – line position if there is:

a) Resistance to movement

b) Immediate deterioration of clinical neurological signs

c) Compromise of airway and ventilation

2) Do not attempt to align the head with the cervical spine before

securing the patient to the rigid support.

7. PREVENTION OF HYPOTHERMIA:

a. Minimize casualty’s exposure to the elements.

b. If not performed already, remove any wet over garments and dry the casualty

c. Place the casualty onto an insulated surface as soon as possible.

d. Cover the casualty with commercial warming device, dry blankets, poncho

liners, sleeping bags, or anything that will retain heat and keep the casualty

dry.

e. If available ad required to maintain perfusion, provide warm IV fluids

f. EXCEPTION: For suspected TBI casualties, consider not actively warming

and allowing mild permissible hypothermia 35°C – 37°C (95°F – 98.6°F)

8. MONITORING




i. Pulse oximetry

ii. EKG

iii. EtCO2 (if intubated)


9. PERFORM SECONDARY SURVEY

a. Check for additional injuries once all life-threatening injuries are attended too

b. Inspect and dress known wounds that were previously deferred.

c. Splint known/suspected fractures and recheck pulses of bandaged limbs.

d. Attend to any suspected or known blunt or penetrating eye injuries:

i. Protect the eye from external pressure

ii. Stabilize any impaled object to prevent movement during transport and

movement

10. INSPECT AND DRESS KNOWN WOUNDS AND FRACTURES

30

a. Check for additional wounds as well as Closed and Open Fractures

b. Rapidly identify open abdominal wounds

i. Cover any exposed organs with sterile dressing (or available material)

moistened with saline or other sterile, isotonic fluid.

ii. Apply a sterile circumferential belly bandage to secure the moistened

dressing in place and decrease further contamination

iii. DO NOT attempt to push any exposed organs or tissues back into the

abdomen.

iv. Need to TRANSPORT IMMEDIATELY

c. Attempt to apply basic immobilization for fractured extremities as feasible

i. Attempt to stabilize one joint above and below the fracture

ii. Recheck pulse of the effected limb after splint application, if applicable

iii. Elevate limb to reduce edema swelling

d. IMPORTANT: Handle an injured K9 with a fracture with extreme care. Ensure

they are properly restrained and administer appropriate analgesia before

manipulating the fractured site.

e. IMPORTANT: DO NOT splint limb fractures above the knee (stifle) or elbow

(e.g., fractures of the femur or humerus). Attempting to splint femoral or humeral

fractures can increase distraction on the fracture resulting in greater injury

(basically the splint acts as an anchor on the fracture site).

f. IMPORTANT: DO NOT attempt to straighten or reduce an open fracture.

g. Antibiotics: Recommended for all open fractures. Consider using potentiated

aminopenicillin (e.g., amoxicillin/clavulanic acid, ampicillin/sulbactam) or

cephalosporin (e.g., cephalexin or Keflex®, cefotetan)

h. Open wound or fracture:

i. Remove and Flush gross debris from the wound with isotonic

crystalloids (preferred), sterile water, or clean water.

ii. Open Wound (no exposed or protruding bone): cover wound with a non-

adherent pad and secure the non-adherent pad in place with soft-

padded bandage/wrap.

iii. Open Fracture (exposed and/or protruding bone): cover bone/wound with

a wet-to-dry bandage or moistened gauze and secure in place with

clean available bandage material.

11. ANALGESIA / SEDATION:

a. Provide adequate analgesia as necessary for the injured.

b. IV, IO, or IM pure mu-agonist opioids (e.g., morphine or fentanyl) are most

effective. Start at a low dose and titrate to effect (NOTE: Oral opiates are not

effective while, intranasal / transmucosal opiates have not been evaluated in

K9s)

31

c. For Operational K9s ABLE to continue mission suffering MILD pain:

i. DO NOT use any human-derived non-steroidal anti-inflammatory

medications (e.g. aspirin, acetaminophen, ibuprofen, naproxen, ketorolac,

etc.)

ii. MILD pain consider:

1) Tramadol: 3 – 5 mg/kg PO q 6 – 8 h (75 – 125 mg for a 25 kg K9)

2) Butorphanol or nalbuphine: 0.1 – 0.5 mg/kg IM (if available) q 2 h

PRN

d. If the Operational K9 is UNABLE to continue the mission due to

MODERATE to SEVERE pain:

i. Consider use of opiate IV, IO, or IM [e.g., hydrocodone, oxycodone,

morphine, and/or Ketamine (at analgesic dosages)]

ii. See ITC Section 11 for “Recommended K9 Drug Dossages”

32

7. ANTIBIOTICS:

a. Consider initiating antibiotic administration for K9 casualties with open

wounds/fractures and penetrating eye injury when evacuation to definitive

care is significantly delayed or infeasible.

b. This is generally determined in the mission planning phase and requires

medical oversight.

c. If antibiotics are warranted select either a cephalosporin or potentiated

penicillin (e.g., amoxicillin-clavulanic acid, cephalexin (Keflex), etc.)

8. BURNS:

a. IMPORTANT: Provide adequate analgesia for all burn patients

ANALGESIA NOTES

K9 Casualties may need their muzzle removed when administered an opiate

in anticipation of opioid-induced vomiting

Ketamine may be a useful adjunct to reduce the amount of opioids required to

provide effective pain relief. It is safe to give ketamine to a casualty who has

previously received an opiate. IV Ketamine should be given over 1 minute.

ALWAYS start at lowest dose and titrate to clinical effect

Ketamine should be administered with a benzodiazepine in K9s to reduce

ketamine-induced muscle hypertonicity / myoclonus.

Document a mental status exam prior to administering opioids or ketamine

For all casualties given opioids or ketamine – monitor airway, breathing, and

circulation closely (NOTE: Opioid-induced respiratory depression is less of a risk in

K9s as compared to humans)

If respirations are noted to be reduced after using opioids or ketamine,

provide ventilatory support with a bag-valve-mask or mouth-to-mask

ventilations.

Have naloxone (1 mg or 0.04 mg/kg IV/IM/IO) readily available whenever

administering opiates

Consider adjunct administration of anti-emetics (Ondansetron 4 – 6 mg IV or

24 mg PO) prior to administering opiates

Eye injury does not preclude the use of ketamine. The risk of additional

damage to the eye from using ketamine is low and maximizing the casualty’s

chance for survival takes precedence if the casualty is in shock or respiratory

distress or at significant risk for either.

Reassess – reassess – reassess!

33

b. Clinical Signs / Indicators in K9s:

i. Liquids (water, oil, gas) often run under hair coat and burns are not

readily evident

ii. Look for singed hair, redness, blistering or charring

iii. Swelling and pain present

c. Interventions

i. FACIAL BURNS, especially those that occur in closed spaces, may be

associated with inhalation and corneal injuries:

1) Aggressively monitor airway status and oxygen saturation (SpO2) in

such patients and consider early definitive airway management for

respiratory distress or oxygen desaturation. **Consider (SpO2) may

appear may normal as most devices do not differentiate between carbon

monoxide and oxyhemoglobin

2) Consider treating ocular / corneal injuries

ii. SMOKE INHALATION, particularly in a confined space, may be associated

with significant carbon monoxide (CO) and cyanide toxicity (CN).

Patients with signs of significant smoke inhalation plus:

iii. Significant symptoms of carbon monoxide toxicity should be treated with

high flow oxygen if available

1) Significant symptoms of cyanide toxicity should be considered

candidates for cyanide antidote administration (if available);

3% Sodium Nitrite: 10 mg/kg IV; followed by

20‑25% Sodium thiosulphate: 500 mg/kg IV (12.5g for a 25

kg K9) (Oruc1 HH, et al., 2006)

2) Consider in K9s, supplemental oxygen in combination with sodium

thiosulfate alone, has been shown to be effective for treating

combined CO + CN exposure. (P H Breen et al., 1995; C J Vesey et al.,

1985)

iii. Estimate total body surface area (TBSA) burned to the nearest 10% using

the “RULE OF NINES”: (SEE ITC)

iv. Clip hair gently around wound or burn area

v. Minor (superficial) burn treat:

1) Cool burned skin with cool to cold water (sterile fluid if available)

within 20 minutes of burn incident

vi. Do not apply ice directly on tissues with partial to full thickness (2nd to 4th

degree) burns

vii. Cover the burn area with dry, sterile dressings and initiate measures to

prevent heat loss and hypothermia once cool irrigation is completed

viii. If burns are greater than 20% of TBSA, fluid resuscitation should be

initiated under medical control as soon as IV/IO access is established. If

34

hemorrhagic shock is also present, resuscitation for hemorrhagic shock

takes precedence over resuscitation for burn shock as per the K9-TECC

fluid guidelines.

ix. All previously described casualty care interventions can be performed on

or through burned skin in a burn casualty.

x. Analgesia in accordance with K9 TECC guidelines should be considered

for all burn wound patients

xi. Aggressively act to prevent hypothermia for burns > 20% TBSA

BURN SHOCK (SEVERE BURN INJURY > 20% TBSA)


"Consensus Formula”

1: Isotonic Crystalloid: 4 mL/kg per TBSA burned to be administered over the first 24 h

Give ½ of this amount within in the first 8 h post burn-incident, and the remaining half over

the next 16 h.

*Ex: 25 kg K9 with burns to 20% of its body surface area would require 4 x 25 x 20 = 2,000 mL of

fluid replacement within the first 24 hours.

2: Colloid: 5 mL/kg aliquots (125 mL) as needed to maintain perfusion parameters

**Do not exceed more than 500 mL

RESUSCITATIVE GOALS

If hemorrhagic shock is also present, resuscitation for hemorrhagic shock takes precedence

over resuscitation for burn shock. Administer IV/IO fluids per K9-TECC Guidelines,

Section 7 Targeted perfusion parameters

Palpable femoral pulse; HR < 140; improved mentation MAP > 65; SBP >100 mm Hg

(NOTE: Accuracy of formula has not been validated in K9s)

9. MONITORING:




i. Pulse oximetry (SpO2)

1) Tongue (if unconscious), lip, ear pinna, prepuce or vulva, rectum (if

rectal probe available)

ii. ECG

iii. ETCO2 (if intubated)


10. PREPARE K9 CASUALTY FOR MOVEMENT:

35

a. Consider environmental factors for safe and expeditious evacuation.

b. Secure casualty to a movement assist device when available.

c. If vertical extraction required, ensure casualty is secured within appropriate

harness, equipment is assembled, and anchor points are identified.

11. COMMUNICATE with the K9 casualty to provide reassurance

a. If available, ensure K9 Handler travels with the K9 to provide restraint,

comfort, and reassurance (this is important for both the handler and the K9)

b. Encourage and provide positive reassurance to the injured K9 by stroking the

K9’s hair coat and or patting the K9 on the head they are not aggressive.

12. CARDIOPULMONARY RESUSCITATION:

a. May have a larger role during the EVACUATION phase especially for patients

with electrocution, hypothermia, non-traumatic arrest or near drowning.

b. Typically not recommended for animals suffering cardiopulmonary arrest

(CPA) in conjunction with:

i. Severe TRAUMATIC BRAIN INJURY (TBI)

ii. Massive NON-COMPRESSIBLE THORACIC hemorrhage

iii. Massive NON-COMPRESSIBLE ABDOMINAL hemorrhage

iv. SUSPECTED SEVERE PULMONARY CONTUSIONS leading to CPA

v. NOTE: Consider bilateral needle decompression for casualties with

thoracic or blunt polytrauma with no respirations or pulse to ensure

tension PTX is not the cause of cardiac arrest prior to discontinuation

of care.

c. BLS (airway, breathing, circulation)

i. ONE RESCUER: Provide “Mouth-to-Snout”

1) Chest compression to ventilation ratio of 30 compressions:2

breaths

2) Hand placement: widest portion of chest while in lateral

recumbency

3) Perform at least five (5) rounds of a 30:2 C:V cycle before soliciting

more assistance

ii. TWO RESCUERS: Provide simultaneous continuous compressions +

ventilation:

1) Compression rate: 100 – 120 beats per minute

2) Ventilation: 8 – 10 breaths per minute, with 1 second inspiratory

hold

3) Compression Cycle: Perform at least and no more than 2 minutes of

continuous compressions before switching compressors

36

4) Do not allow more than 10 seconds to pass between compressions

cycles

iii. Consider use of an impedance threshold device to enhance circulation

d. ALS – Perform based on transport time, availability of resources, and

responder’s expertise and scope of practice:

i. EPINEPHRINE: 0.01 mg/kg IV/IO/IT

ii. VASOPRESSIN: 0.8 U/kg IV/IO or (1.2 U/kg IT)

iii. ATROPINE: 0.04 mg/kg IV/IO/IT

iv. For K9s that have received reversible anesthetic/sedative medications,

administer reversal agents (e.g., NALOXONE 0.04m mg/kg IV/IO/IT)

v. AVOID use of CORTICOSTEROIDS

vi. SODIUM BICARBONATE (NaHCO3): 1 mEq/kg; ONLY recommended

after prolonged cardio-pulmonary arrest (> 10 – 15 minutes)

vii. For drugs administered via IT:

1) Consider using 2 – 10 times the recommended IV dose

2) Dilute with 5 – 10 mL of sterile water, 0.9% saline, or other available

isotonic, sterile intravenous infusate

3) Flush down OTT tube using a catheter ideally longer then the OTT

13. COMMUNICATION AND DOCUMENTATION OF CARE:

a. Contact and relay the following information to the receiving veterinary

facility:

i. Estimated Time of Arrival

ii. Kinematics of the injuries sustained (e.g., smoke inhalation, blunt

versus penetrating trauma, etc)

iii. Initial and trends in vital parameters

iv. Patient’s known or suspected injuries and overall condition or status

(e.g., vitals, mentation, hemodynamic, neurological, etc)

v. Interventions performed

vi. Patient response to interventions

b. Continue or initiate documentation of clinical assessments, treatments

rendered, and changes in the casualty’s status in accordance with local

protocol

c. Transfer information with the casualty to the next level of care either verbally

or in writing.

d. Considering implementing a K9 CASUALTY CARE CARD (SEE APPENDIX)

Skills:

1. Familiarization with advanced monitoring techniques

37

2. Familiarization with transfusion protocols

3. Advanced airway management

40

K9 TECC

Skill Set Based on Provider Level

Provider Level

Pressure

Bandage

w/

Packing

Hemostatic

Agents TQs

Needle

Decompression

Surgical

Airway

K9 Handler X X X

LEO X X X

EMR or

equivalent X X X X***

EMT or

equivalent X X X X***

Advanced

EMT or

equivalent

X X X X X

Paramedic X X X X X

*** Only with special training, specialized protocol, and OMD approval. Ideally,

this skill set should be performed by all providers, but need safety and

efficacy prior to inclusion of additional provider levels.

Other EMS/medical related skills such as patient assessment, chest seal

placement, splinting, and hypothermia management should be considered

standard for all levels of providers. Additional skills can be considered with

agency approval.

41

K9 TECC CONTRIBUTORS

K9-TECC CHAIRS

Lee Palmer DVM, MS, DACVECC, NREMT (MAJ, USAR Veterinary Corps)

Allen Yee MD, FACEP, FAAEM

K9 TECC COMMITTEE MEMBERS

Bruce Carlton NRP, TACMED

Kevin Nelmes NRP, TACMED, EDD K9 Handlers

Janice Baker DVM, DACVPM (LTC, US Army Reserve Veterinary Corps)

Melissa Edwards DVM, DACVECC

Sean Smarick DVM DACVECC

Ethan Costain, Search and Rescue

SA Jeremy Smith, USMS, EDD K9 Handler

SA Frank Kruchten, USMS, EDD K9 Handler

Ryan Parr, BLM K9 Handler

Robin Van Metre VMD

Major Tom Edwards DVM (US Army Veterinary Corps)

TSgt Rick Maricle, NRP (USAF MWD Handler)

Major Desiree Broach (US Army Veterinary Corps)

Richard Dostal, TSA K9 Handler

Darci Palmer LVT, VTS-Anesthesia

Jay Shields, NRP, TacMed

Jo-Anne Brenner, EMT-I / T

KaLee Pasek, DVM

Shay Cook, SAR K9 Handler

Terrance Wilson

Dan Schwartz, MD, FS, FACEP

Gerald Beltran, DO, MPH

EX OFFICIO / ADVISERS:

Kelly Hall, DVM, DACVECC, Chair ACVECC Veterinary Committee on Trauma (VetCOT)

Rita Hanel DVM DACVIM, DACVECC, Lead VetCOT Prehospital Committee

Cindy Otto, DVM, PhD, DACVECC, DACVSMR, Executive Director, Penn Vet Working Dog

Center

Mark Jacoby, MD, NREMT-P, Medical director National Parks Service (NPS) *Honorary

Member* Chris Boyer, Executive Director, National Association Search and Rescue (NASAR)

Ben T. Ho MD, Capt MC USN (Ret) – Urban Search and Rescue (USAR)

42

REFERENCES

1. National Association of Emergency Medical Technicians (NAEMT). Pre-

Hospital Trauma Life Support. 8th ed. Burlington: Jones & Bartlett Publishers;

2016.

2. Joint Theater Trauma System Clinical Practice Guideline. Clinical

Management of Military Working Dogs. [Internet]. 2012 [cited 20 Feb 2015].

Available from:

http://www.usaisr.amedd.army.mil/assets/cpgs/Clinical_Mgmt_of_Military_

Working_Dogs_Combined_19_Mar_12.pdf

3. Palmer LE, Martin L. Traumatic coagulopathy-Part 2: Resuscitative Strategies.

J Vet Emerg Crit Care 2014; 24(1): 75–92.

4. Tactical Emergency Casualty Care (TECC) Guidelines. [Internet]. 2014.

[updated 2014 Jun 1; cited 2015 Feb 20]. Available from: http://www.c-

tecc.org/images/content/TECC_Guidelines_-_JUNE_2014_update.pdf.

5. Callaway DW, Smith ER, Cain J, McKay SD, Shapiro G, Mabry RL. The

Committee for Tactical Emergency Casualty Care (C-TECC): Evolution and

application of TCCC Guidelines to civilian high threat medicine. J Special

Operations Medicine. 2011; 11(2): 84-89.

6. Taylor WM. Canine tactical field care part one - thoracic and abdominal

trauma. J Spec Oper Med. 2008 Winter;8(3):54-60.

7. Canine Tactical Combat casualty Care (C-TCCC). U.S. Special Operations

Command Advanced Tactical Paramedic Protocols Handbook, 8th edition. J

Spec. Oper Med. 2014: 243 – 252.

8. Kakiuchi H1, Kawarai-Shimamura A, Fujii Y, Aoki T, Yoshiike M, Arai H,

Nakamura A, Orito K. Efficacy and safety of tranexamic acid as an emetic in

dogs. Am J Vet Res. 2014 Dec;75(12):1099-1103.

9. E. Kelmer1; G. Segev1; V. Papashvilli2; N. Rahimi-Levene2; I. Aroch1; S.

Klainbart1

43

10. Effects of Intravenous Administration of Tranexamic Acid on Hematological,

Hemostatic and Thromboelastographic Analytes in Healthy Dogs

International Veterinary Emergency and Critical Care Symposium 2013

11. Hansen IK, Eriksen T. Cricothyrotomy: Possible first-choice emergency

airway access for treatment of acute upper airway obstruction in dogs and

cats. Vet Rec 2014;174(1):17

12. James T, Lane M, Crowe D, Pullen W. A blind insertion airway device in dogs

as an alternative to traditional endotracheal intubation. Vet J. 2015

Feb;203(2):187-191

13. P H Breen; S A Isserles; J Westley; M F Roizen; U Z Taitelman. Effect of

oxygen and sodium thiosulfate during combined carbon monoxide and

cyanide poisoning Toxicol Appl Pharmacol. October 1995;134(2):229-34.

14. C J Vesey; J R Krapez; J G Varley; P V Cole. The antidotal action of thiosulfate

following acute nitroprusside infusion in dogs Anesthesiology. April

1985;62(4):415-21.

15. H H Oruc1; R Yilmaz; D Bagdas; M O Ozyigit. Cyanide poisoning deaths in

dogs. J Vet Med A Physiol Pathol Clin Med. December 2006;53(10):509-10.

Polderman, Kees H. (2004). Application of therapeutic hypothermia in the ICU:

Opportunities and pitfalls of a promising treatment modality. Part 1:

Indications and evidence. Intensive Care Medicine 30 (4): 556–75.

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