Inside the

Emergency Room
DR BROOKE SCHAMPERS
STEP-BY-STEP DIAGNOSTIC AND TREATMENT GUIDELINES

FOREIGN BODY CHAPTER

 It is a fast-paced life in the emergency room. We act quickly and
decisively to save lives. Often the first 12 hours are the most critical
– this is where I come in. The reality is everyone becomes an
emergency vet the moment a critical patient walks through those
doors. This is the information I want you to know. This book with
cover some of the most common emergencies I see, where the first
12 hours are essential to survival. Case-by-case we will break
down signalment, history and physical exam findings to give us
differential diagnoses and diagnostic plans. Followed by a step-
by-step practical treatment guide. This book contains information
at gold standard care which you can tailor to your practice’s
equipment. It has important notes for the nursing team too. I want
you to feel prepared, empowered and ready to handle what
happens next but also to feel confident guiding the owners
through the conversations required to facilitate treatment.

Disclaimer statement: Please note that the information contained

within this book is based on the editors use personally and
therefore can be slightly different to mainstream opinion. Due to
the changing nature of medical information, the content within this
book is up to date and relevant at the time of publishing. Use of
the information contained is at the readers discretion and
responsibility. Further information may be required from additional
sources. The editors will not assume liability for injury, illness, or
death to persons and animals and damage to property following
the use of the information contained within this book.
 Foreign Body
Signalment: 8mth MN Lab

History: Jimmy has a 24-hour history of vomiting, unable to keep food

or water down. Quiet and lethargic, not himself and a known chewer of
toys. Otherwise well.

Physical exam: HR 120, RR panting, Temperature 37.5, pink mucous

membranes, 2 seconds CRT (capillary refill time) good distal pulses,
quiet but alert mentation, no heart murmur, clear lung sounds, and a
tense abdomen.

Differentials: Gastrointestinal (foreign body, dietary indiscretion,

parasites) vs extra-gastrointestinal (pancreatitis, toxin, hepatic or renal
disease)

Stabilisation:
Administer 0.3mg/kg Methadone IM due to the presence of a tense
abdomen
Place an IV catheter

Diagnostics:
Perform PCV/TP (55/80) to assess hydration status and total
protein – evidence of dehydration with haemoconcentration and
hyperprotinaemia.
Perform blood gas lactate, acid-base status, electrolytes to help
guide IV fluid therapy. Many vomiting patients will have an
alkalaemia with a metabolic alkalosis due to vomiting and loss of
chloride ions and hypokalaemia.
Perform an abdominal ultrasound to assess for organ abnormalities
or free fluid. Often patients with a foreign body will have a dilated
stomach and two populations of small intestines – dilated pre-
foreign body and non-dilated post foreign body. There will be drop
out at the point of the foreign body as the ultrasound beam will not
be able to penetrate it.
Perform radiographs to assess for obstructive gas patterns +
radiodense foreign bodies and organomegaly

Diagnosis: Foreign Body

Continued treatment:
Rehydration and restoration of normal cardiovascular balance is
important for foreign body patients prior to reduce the risk of
underloading and intraoperative hypotension.
Intravenous fluid therapy
Lactated Ringers Solution at 5% dehydration rates for this
patient
Can consider NaCl as this patient has an alkalaemia secondary
to losses of chloride ions, however if you do not have access to
a blood gas machine – recommend using LRS a
Will likely need potassium supplementation
Pain relief
Methadone 0.1-0.2mg/kg IV q4-6 or
Fentanyl CRI 2-4mcg/kg/hr or
Buprenorphine 0.02mg/kg IV
Anti-nausea
Maropitant 1mg/kg IV q24
Ondansetron 0.2mg/kg IV q8-2
Avoid the use of metoclopramide in suspected foreign body
patients as the prokinetic activity will be dangerous in an
obstruction.
Move into surgery once cardio-vascularly stable (often after 4-6
hours on IVF)

Surgical Tips:
Perform a large xiphoid to pubis incision to allow for adequate
visualisation
It is called an ex-lap for a reason – it is essential to assess the
entire abdomen and gastrointestinal tract from end to end to
ensure you identify all possible abnormalities
Start from the stomach – palpate to ensure no obstruction and then
run your fingers along the intestines till you localise the obstruction
and then follow the rest of the bowel through till the caecum.
Never incise into the colon! Once the foreign body has passed into
the large intestine it will not pose a risk of obstruction.
Localise the obstruction + pack it off with lap sponges and isolate it
from the abdomen.
Assess the health of the intestinal tissue affected by the
obstruction – any tissue that is black/dark purple, friable, reduced
blood flow or has evidence of perforation requires a resection.
Place bowel clamps either side of the obstruction or have your
assistant occlude the intestines with their fingers.
Make an incision just past the obstruction, milk the foreign body
towards the incision – careful to ensure not contamination of the
abdomen. You can use suction to draw away any fluid that may be
leaking from the incision. Gentle traction using allis tissue forceps
on the foreign body is often successful.
Once the obstruction has been removed. Close the incision with
3/0 PDS simple interrupted full thickness bites. Lay the first suture
throw flat against the intestine with the second throw/surgical knot
pulled tight. Throw 3-5 sutures on top and continue until the
incision is closed. Locally saline lavage the closed incision to
remove contamination prior to putting the loop of intestine back
into the abdomen and wrap it in omentum.
Leak testing? A controversial topic – leak testing produces an
excessive amount of pressure along the suture line, possibly
resulting in false leakage. I find it is up to the individual as to
whether they leak test or not. Personally, I don’t.
I’ll change gloves at this point prior to lavaging the abdomen.
Saline lavage the abdomen 2-3L
Close in the abdomen three layers as normal
Post-Operative Care:
Recheck PCV/TP, blood gas post operatively
Continue Fentanyl at 2-4mcg/kg/hr post operatively
Encourage eating as soon as possible + consider NG feeding
Monitor blood pressure, HR, CRT, MM closely for 48 hours –
discharge home once these parameters are normal and the patient
is eating and comfortable
Ileus is often a concern – regular walks and considering prokinetics
after 48 hours
Post-operative pain relief options:
Gabapentin (10mg/kg) + Paracetamol (10mg/kg only in dogs)
combination
Oral buprenorphine 0.02mg/kg in cats
Fentanyl Patch (2-4mcg/kg/hr)
Do not use COXII inhibitors like Meloxicam due to it reducing
mucosal blood flow to the gastrointestinal tract and renal
blood flow to the previously dehydrated kidneys
Complications:
Approximately 10% risk of intestinal dehiscence with enterotomy
and 20% risk with enterectomy
Risks of intestinal perforation and necrosis
Prolonged duration clinical signs >72 hours and increased
lactate
Linear material
Increased number of intestinal procedures ie. enterotomies =
slower recovery
Increased complications:
Intestinal R&A
Condition of intestines
Condition of abdomen - peritonitis
Condition of patients - systemic disease
Skills of surgeon
Post op septic peritonitis has a higher incidence of mortality 75%
compared to pre op septic peritonitis 50%

Owner Communication:
I outline my concerns for an obstructive pattern, warning we can never
be 100% certain of a foreign body until we are in surgery. Then I discuss
what the surgery involves - abdominal incision, intestinal incision and
removal of foreign body and include the risks of dehiscence.
Outline recovery time 24-72 hours post operative care in hospital till
eating and comfortable, then strict rest for 10-14 days until suture
removal.
Don't forget to include the costs of surgery PLUS post-operative care