Veterinary Pharmacy During Disaster

CDR Shayne Blackmon, PharmDFederal Detention Center – Honolulu, HI

LT Selena Ready, PharmDWinslow Indian Health Care Center – Winslow, AZ

Introduction

•Over half of American families are pet-owners.

•Oftentimes, pet-owners will refuse to leave their pets during a disaster.

• It is estimated that 100,000 animals, pets and livestock are separated from their owners and/or lost during a major natural disaster.

Animal Care and Handling: Stressed or Injured Animals

Animal Care and Handling: Stressed or Injured Animals

Animal Care and Handling: Stressed or Injured Animals

U.S. Pets Evacuation and Transportation Standards Act

(PETS)• In the fall of 2006, Congress passed H.R.

3858, the Pets Evacuation and Transportation Standards Act of 2006 (PETS Act). On Friday, October 6, 2006, President Bush signed the PETS Act into law.

• What does the PETS Act do?• When is the PETS Act in operation?• How does the PETS Act work

operationally?

ObjectivesAfter this presentation, the audience should be able to:

• Have a basic understanding of the supportive care necessary for animal patients during a disaster setting  

• Understand how to assist with the triage and physical assessment of an animal patient

• Have a basic knowledge of common veterinary drugs and disease states used in a disaster

• Have a basic knowledge of how to administer drugs to an animal patient

• Be able to identify additional sources of information regarding veterinary emergency preparedness

Animal Care and Handling: During Disaster

•Recent Scenarios▫Extreme Weather

Mongolia▫Flooding

Tennessee▫Earthquakes

Haiti Chile

Triage and Physical Assessment

•Personal Protection▫Wear gloves when handling sick or wounded

animals. ▫Consider use of goggles or face protection if

splashes from contaminated surfaces may occur Do not allow rescued animals to “kiss” you or

lick your face. ▫Whenever possible, caretakers should have

completed a 3-dose prophylactic vaccination series for rabies.

Triage and Physical Assessment

•Basic Triage and Physical Assessment▫ABCs▫Broken Appendages▫Sources of Hemorrhage▫Levels of Consciousness

Common Veterinary Drugs Used During Disaster

• Animal identification• Date of treatment • Name of product

administered

• Name of the individual administering the product

• Name of the supervising veterinarian

Records of individual animal treatments should be kept and include:

Common Veterinary Drugs Used During Disaster

•Vaccinations•Flea and Tick Treatments•Diarrheal Disease•Disinfectants and Antiseptics•Pain Management•Behavioral Meds•Euthanasia

Common Veterinary Drugs Used During Disaster

•Core Vaccinations•Dogs

▫Rabies Personnel should be aware that rabies

vaccines may take as long as 28 days to become effective.

▫ Distemper, Hepatitis, and Parvovirus▫ Kennel Cough Vaccination (intranasal)

Against Bordatella bronchisepta and parainfluenza

Common Veterinary Drugs Used During Disaster

•Cats▫Viral Rhinotracheitis, Panleukopenia and

Calicivirus ▫Feline leukemia

• Leptospirosis risk▫Higher in flood-ravaged areas▫Zoonotic▫Adverse reactions may be higher than for

some other vaccines

Common Veterinary Drugs Used During Disaster

•Diarrheal Disease▫Separate from healthy animals▫ Nosocomial agents of concern that may be

transmitted by feces include parvovirus, panleukopenia, Giardi, and intestinal parasites.

▫ Zoonotic agents of concern for small animals include Campylobacter and Salmonella, which are highly infectious and have been associated with outbreaks in shelters and veterinary clinics.

Common Veterinary Drugs Used During Disaster

•External and Internal Parasite Treatment▫Ectoparaciticides and Anthelmintics▫Flea, tick, and worm coverage

Spot-on, injectible, and oral formulations

Common Veterinary Drugs Used During Disaster

•Antiseptics and Disinfectants▫Rubbing Alcohol▫Chlorhexidine▫Iodine Tincture▫Povidone-Iodine▫Hydrogen Peroxide 3%

Common Veterinary Drugs Used During Disaster

•Pain Management

Opioid AnalgesicsDosageDogs Cats

Buprenorphine 0.01-0.02 mg/kg, SC,BID

0.005-0.01 mg/kg, SC or IM, BID

Butorphanol tartrate 0.2-0.4 mg/kg, IM or SC; 0.55 mg/kg, PO, every 4 hr

0.1-0.2 mg/kg, IV; 0.2-0.4 mg/kg, IM or SC, every 4 h

Meperidine hydrochloride

2-10 mg/kg, IM or SC, every 2 hr

2-10 mg/kg, IM or SC, every 2 hr

Morphine sulfate 0.22-0.88 mg/kg, IM or SC, every 4-6 hr as needed

0.1 mg/kg, IM or SC, as needed

Common Veterinary Drugs Used During Disaster

Opioid AnalgesicsDosageDogs Cats

Nalbuphine 0.5-2.0 mg/kg, SC, every 4-8 hr

1.5-3.0 mg/kg, IV, every 3 hr

Oxymorphone hydrochloride

0.22 mg/kg, IV, IM, or SC, SID

0.1-0.2 mg/kg, IV, IM, or SC,SID

Pentazocine lactate 2-3 mg/kg, IM, every 4 hr; 15 mg/kg, PO,TID

2.2-3.3 mg/kg, IV, IM, or SC

Common Veterinary Drugs Used During Disaster

•Anti-inflammatory Agents

Drug Dosage

Asprin Dogs: 10-40 mg/kg, PO, BID-TID. Horses : 10 mg/kg SID. Cats : (anti-platelet effects in thromboembolic disease)10 mg/kg, PO, q48 hrs, to allow for prolonged metabolism.

Acetaminophen Dogs : 10-15 mg/kg, PO, TID. Toxic to cats!

Phenylbutazone Dog/Bovine/Equine: 1-5 mg/kg PO, IV SID-BID.

Flunixin Meglumine

Cats/Dogs/Bovine: 1.1 mg/kg IV, IM, PO SID. Highly effective NSAID. Potential for hepatotoxicity, gastrointestinal ulceration. May dilute with Vit. B12 inj. to reduce

pain on IM or SQ injection.

Carboprofen (Rimadyl)

Dogs/Cats: 4mg/kg PO SIDNSAID with a wide safety margin in dogs. Limited potential for GI ulceration, hepato or nephrotoxicity compared to other NSAIDs.

Common Veterinary Drugs Used During Disaster

Drug Dosage

Ketoprofen Dog/Bovine: 2.2 mg/kg IV, IM

Derocoxib (Deramaxx) Dog: Osteoarthritis -  1-2 mg/kg, PO, SID

Firocoxib (Previcox) Dog:  Osteoarthritis - 5 mg/kg, PO, SID

Other NSAID info – DO NOT USE Dogs – Indomethacin, naproxen, ibuprofen, piroxicam highly toxic to GI tract

Common Veterinary Drugs Used During Disaster

•Behavioral MedicationsDrug Dosage

Alprazolam0.01-0.1 mg/kg, PO, as needed for phobic or panic attacks‡; start with 1-2 mg for a 25 kg dog

Amitriptyline 1-2 mg/kg, PO, bid to start

Buspirone1 mg/kg, PO, sid-tid (mild anxiety); 2.5-10 mg/dog, PO, sid-tid (mild anxiety); 10-15 mg/dog, PO, bid-tid (severe anxiety)

Carbemazepine 4-8 mg/kg, PO, bid; 0.5-1.25 mg/kg, PO, tid; 4-10 mg/kg/day, divided tid

Chlordiazepoxide 2.2-6.6 mg/kg, PO, as needed

Clomipramine# 1-2 mg/kg, PO, bid; increase to 3 mg/kg, bid if necessary

Alprazolam0.01-0.1 mg/kg, PO, as needed for phobic or panic attacks‡; start with 1-2 mg for a 25 kg dog

Drug Dosage

Clonazepam0.125-1.0 mg/kg, PO, bid; range 0.01-1.0 mg/kg, PO, as needed for phobic or panic attacks

Clorazepate0.5-2.2 mg/kg, PO, at least 1 hr before provocative stimulus; repeat every 4-6 hr as needed; 11.25-22.5 mg/large dog; ~11.25 mg/medium dog; ~5.6 mg/small dog

Diazepam0.5-2.2 mg/kg, PO, at least 1 hr before provocative stimulus; repeat every 4-6 hr as needed

Doxepin 3-5 mg/kg, PO, bid-tid

Fluoxetine 1 mg/kg, PO, sid-bid

Fluvoxamine 1 mg/kg, PO, sid-bid **

Imipramine 2.2-4.4 mg/kg, PO,sid-bid ; 1-2 or 2-4 mg/kg, PO, sid-bid (start low)

Nortriptyline 1-2 mg/kg, PO, bid

Oxazepam 0.2-1.0 mg/kg, PO,sid-bid

Paroxetine 1 mg/kg, PO, sid

Protriptyline 5-10 mg/dog, PO,sid-bid (narcolepsy)

Selegiline 0.5-1.0 mg/kg, PO, sid

Sertraline 1 mg/kg, PO, sid

Common Veterinary Drugs Used During Disaster

Euthanasia• In regard to animals -the act of killing an

animal in a humane manner. •The primary objectives of animal euthanasia

are: ▫relieving pain and suffering of the animal(s) to

be euthanized ▫minimizing the pain, anxiety, distress, and fear

the animal experiences before consciousness is lost

▫inducing a painless and distress-free death

Common Veterinary Drugs Used During Disaster

• Cats and Dogs▫Barbiturates, inhalant anesthetics, CO2, CO,

potassium chloride in conjunction with general anesthesia

• Birds▫Barbiturates, inhalant anesthetics, CO2, CO,

gunshot (free-ranging only), N2, argon, cervical dislocation, decapitation, thoracic compression (small, free-ranging only)

• Horses▫Barbiturates, potassium chloride in conjunction

with general anesthesia, penetrating captive bolt

Vet Medication Administration Techniques

•Wrapping in a blanket or towel is a great restraint technique

•Marshmellows, peanut butter, or cream cheese

•Pill gun•Oral Syringe

Veterinary Pharmacy Resources•Handbook of Veterinary Drugs – for PDAs,

Smartphones, iPhones•The Merck Veterinary Manual•VMAT information

References: • http://www.avma.org/disaster/emerg_prep_resp_guide.pdf• http://veterinarynews.dvm360.com• http://news.nationalgeographic.com/news/2005/09/photog

alleries/hurricane_katrina_pets/index.html• http://www.avma.org/disaster/petsact_faq.asp• http://www.merckvetmanual.com/mvm/index.jsp?cfile=htm

/bc/160201.htm• http://animalsindisasters.typepad.com/wspa/animals-in-dis

asters/• http://www.petalk.com/drug-dosages.html#Code

USPHS LCDR Lauren Davidson

Arctic Crossroads 2009

Arctic Crossroads 2009

•USCG/PHS mission to Barrow, AK, and surrounding villages

•Rabies prophylaxis and vet care provided•5 North Slope Borough village trips•113 vet clinical appts. seen•Approx. 300 rabies vaccinations and 150

distemper/parvovirus vaccines given•26 surgeries performed

Arctic Crossroads 2009

• 9 euthanasia procedures/3 after hr. emergenc.• Pharmacist assistance provided by PHS CAPT

Paulson, USCG• Primary meds used

▫ Isoflurane – gas anesthesia▫Tiletamine/zolazepam (Telazol) – inj. anesth/tranq▫Pentobarbital/phenytoin - euthanasia i.v. soln.▫Praziquantel/pyrantel (Drontal Plus) – int. parasites

Operation Pacific Angel 2010Phase 1 - Philippines

Operation Pacific Angel

•13th AF joint op. with the Phil. armed forces, national police, civilians, and non-gov orgs

• Two mobile veterinary services teams served 41 local villages

•Provided vet. care to 3360 animals/ incl. de-worming and vitamin vacc. to more than 3300 cattle, goats, and caribou

Operation Pacific Angel

•Primary meds used▫Ketamine (Ketalar, Ketaject) 100mg/ml

general anesthetic; high conc. for cattle, swine, etc.

▫Zinc gluconate (Neutersol) – chemical castration

▫Albendazole, atovaquone, ivermectin, quinacrine - antiparasitics

Pacific Partnership 2008PP08 Team in Timor-Leste

•USPHS, U.S. Marines, Navy, Army, Air Force, Navy civilian mariners

•Armed forces of Australia, Canada, India, Indonesia, Portugal, & Republic of Korea

USPHS CDR John Gibbon with Indian Army colleagues

PAPUA NEW GUINEA4-17 Aug

PHILIPPINES29 May-17 Jun

VIETNAM19-29 Jun

TIMOR LESTE12-25 Jul

MICRONESIA22 Aug-1 Sep

5

43

2

1

PACIFIC PARTNERSHIP 2008

USNS Mercy

USPHS LCDR Bryan Buss

Continuing Promise 2009

Continuing Promise 2009

•PHS, Navy, & Army joint op. with military and govt. officials of Haiti & Dominican Republic

•On-site trng. of college students & local vets.•Provided host nation vets. disease-specific

presentations on 40 animal dz of importance•43 general audience presentations – zoon. dz•Provided vet. care to 1849 animals/12 species•Performed 6366 procedures

USNS Comfort

Continuing Promise 2009•Primary meds used

▫Pyrantel (Strongid T, Nemex) – deworming for dogs/cats

▫Rabies, Distemper/Parvo vaccines Exotic Newcastle Disease (PMV-1) vaccine

(poultry)▫Fipronil (Frontline) – fleas and ticks▫Ivermectin – orally for internal and external

parasites (poultry), horses; inj. form for goats/swine/rabbits

▫Hog Cholera (Classical Swine Fever) vaccines

Continuing Promise 2009

•Primary meds used (cont.)▫Vaccination for Clostridium C and D, &

Tetanus▫Vitamin ADE, B12, and iron inj. – goats and

swine▫Anesthetic premedication and anesthesia▫Tetanus toxoid – horses▫Leptospirosis vacc. – cattle▫Moxidectin (Cydectin) – top. for int/ext

parasites cattle▫Brucella abortus vaccine – heifers 3-8 months

Lessons Learned:

Be flexible – systems will be overwhelmed; human/animal pts.

Disaster/humanitarian missions

Demand for services ↑↑↑ People love their pets

Train, train, train – Ft AP Hill 09, RDF 2010, Humanitarian missions

Vets, pharmacists get involved earlier in the planning process – pre-deployment site survey teams, etc

Advanced look at zoonotic dzs in the region (rabies, brucellosis, tuberculosis, tularemia, etc.)

Helps avoid supply shortages/expired meds – common problem (AC09, CP09, etc.)

Engage host nation representatives as to their needs/wishes for the mission

Lessons Learned:

Establish partnerships – DOD, state MRCs (locals - lay of the land)

U.S. Army Vet Corps PACOM – Dev. inventory templates for regions throughout the Pacific

Plan early – many pharmaceutical needs are unique to veterinary medicine and cannot be easily obtained thru normal military supply channels

Ex. High conc. Ketamine (100mg/ml) – pigs, buffalo

Pack light

Bring tools Plumb’s Veterinary Drug

Handbookhttp://www.cdc.gov/nczved/http://www.aavpt.org/

Questions?