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Small Animal Surgical Emergencies
Small Animal Surgical Emergencies

Second Edition

Edited by

Lillian R. Aronson
Professor of Surgery
School of Veterinary Medicine
University of Pennsylvania
Philadelphia, PA, USA
This second edition first published 2022
© 2022 John Wiley & Sons, Inc.

Edition History
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Library of Congress Cataloging-­in-­Publication Data

Names: Aronson, Lillian R., editor.
Title: Small animal surgical emergencies / edited by Lillian R. Aronson.
Description: Second edition. | Hoboken, NJ : Wiley-Blackwell, 2022. |
Includes bibliographical references and index.
Identifiers: LCCN 2022000548 (print) | LCCN 2022000549 (ebook) | ISBN
9781119658535 (cloth) | ISBN 9781119658610 (adobe pdf) | ISBN
9781119658627 (epub)
Subjects: MESH: Surgery, Veterinary–methods | Pets–surgery |
Emergencies–veterinary | Animal Diseases–surgery | Wounds and
Injuries–veterinary
Classification: LCC SF914.3 (print) | LCC SF914.3 (ebook) | NLM SF 914.3
| DDC 636.089/7–dc23/eng/20220209
LC record available at https://lccn.loc.gov/2022000548
LC ebook record available at https://lccn.loc.gov/2022000549

Cover Design: Wiley

Cover Images: Courtesy of Hunter Piegols, Courtesy of Marie Burneko

Set in 9.5/12.5pt STIXTwoText by Straive, Pondicherry, India

10 9 8 7 6 5 4 3 2 1
 March 3, 1963

This textbook is dedicated to my amazing parents, Raphael and Dorothea Aronson. Growing up, my parents created a wel-
coming home filled with warmth, love, and constant laughter. They stressed the importance of family and community and
have always been incredible role models, instilling in me the importance of honesty, respect, to always remain humble and
to do the right thing even when it is not popular. From a very young age, my parents supported and encouraged me to
follow my passion for veterinary medicine. I wouldn’t be where I am today if it wasn’t for their love and support. I consider
myself the luckiest girl in the world, to be their daughter.
 vii

Contents

Contributors xii
Preface xvii
Acknowledgements xviii
About the Companion Website xix
Daisy’s Story xx

1 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient 1
Dana Clarke

2 Operating Room Nursing Tips for Emergency Surgical Procedures 20

Cami Elliott, Michelle Capps, and Michael McCallum

Section I Gastrointestinal System 49

3 Emergency Stabilization of the Acute Abdomen Patient 51

Nyssa Levy and Matthew Beal

4 Esophageal Foreign Bodies 58

Ivan Doran

5 Gastrointestinal Foreign Bodies 70

Amie Koenig and Mandy L. Wallace

6 Intussusception 81
Janet Kovak McClaran and Yekaterina Buriko

7 Rectal Prolapse 88
Jennifer L. Huck

8 Gastric Dilatation and Volvulus 93

Michael S. Tivers and Sophie Adamantos

9 Intestinal Volvulus 108

Elizabeth LaFond and Kristina Kiefer

10 Colonic Torsion 115

Chloe Wormser

11 Peritonitis 119
Adrienne Bentley and Anusha Balakrishnan
viii Contents

12 Surgical Intervention Post-­Celiotomy 141

Michael B. Mison

13 Biliary Emergencies 146

Lori Ludwig and Sean Smarick

14 Hemoperitoneum 164
Cassie N. Lux, William T. N. Culp and Steven E. Epstein

15 True Abdominal Hernias 178

Daniel D. Smeak

16 Traumatic and Incisional Hernias 190

Todd Hamilton

17 Perineal Hernias 199

Karen M. Tobias

18 Pancreatic Abscessation 216

F. A. (Tony) Mann

19 Hepatic Emergencies 226

James A. Perry, Steven E. Epstein, and William T. N. Culp

20 Bleeding Gastrointestinal Ulcers 238

Yekaterina Buriko, David Holt, Laura Ateca, and Lesley King

21 Enteral Feeding Tubes 251

Aarti Kathrani

Section II Urinary System 263

22 Stabilization of the Uremic Patient 265

Kari Beer and Kenneth Drobatz

Section IIa Urinary System - Urinary Tract Trauma 277

23 Renal and Ureteral Injury 279

Dan Degner and Chloe Wormser

24 Approach to the Uroabdomen 285

Sara Colopy, Adam Townsend, and Dale Bjorling

25 Urethral Injury 297

Sara Colopy, Adam Townsend, and Dale Bjorling

Section IIb Urinary System – Urinary Obstruction 311

26 Ureteral Obstruction 313

Daniel Degner, Dana Clarke, and Chloe Wormser

27 Urethral Obstruction 331

Heidi Phillips and Sara Colopy
 Contents ix

Section III Respiratory System 351

Section IIIa Respiratory System – Upper Airway Disease 353

28 Stabilization Techniques for Patients with an Upper Respiratory Obstruction 355

Meredith Maczuzak and Deborah C. Silverstein

29 Tracheostomy 364
Nathaniel Lam

30 Brachycephalic Airway Syndrome 372

Mike Schlicksup

31 Laryngeal Paralysis 383

Georga T. Karbe

32 Laryngeal Trauma 391

Eric Monnet

33 Tracheal Collapse 395

William T. N. Culp and Matthew D. O’Donnell

Section IIIb Respiratory System – Pleural Space Disease 405

34 Stabilization Techniques for Patients with Pleural Space Disease 407

Erica Reineke and Jen Savini

35 Diaphragmatic Hernia 417

MaryAnn Radlinsky

36 Pyothorax 425
Lori S. Waddell and David A. Puerto

37 Hemothorax 433
Chad W. Schmiedt and Benjamin M. Brainard

38 Pneumothorax 441
David A. Puerto and Lori S. Waddell

39 Lung Lobe Torsion 451

Jacob A. Rubin and Jaime Green

40 Surgical Approach to the Thoracic Cavity 459

David A. Puerto and Jacob A. Rubin

Section IIIc Respiratory System – Chest Wall Disease 467

41 Stabilization Techniques for Patients with Chest Wall Disease 469

Nolan Chalifoux and Deborah Silverstein

42 Pectus Excavatum 475

Krista N. Adamovich-­Rippe and William T. N. Culp
x Contents

43 Flail Chest 483

Eric Monnet

Section IV Cardiovascular System 487

44 Pacemaker Therapy 489

Caryn Reynolds and Katrine Saile

45 Pericardial Effusion 501

Augusta Pelosi and Amy Koenigshof

46 Open-­Chest Cardiopulmonary Resuscitation 514

Jasper Burke and Deborah Silverstein

Section V Reproductive System 525

47 Cesarean Section 527

Stephen D. Gilson

48 Pyometra 534
Jacqueline Davidson and Dorothy Black

49 Penile and Testicular Emergencies 541

Susan P. Gregory

50 Prostatic Abscessation 553

Richard A. S. White

51 Uterine and Vaginal Prolapse 565

Pieter Nelissen

Section VI Wound Management 573

52 Bite Wounds 575

David Holt and Vincent Thawley

53 Burn Injury 586

Caroline Garzotto and Dana Clarke

54 Penetrating Injury in the Dog and Cat 600

Steve J. Mehler

55 Necrotizing Fasciitis 613

Karol A. Mathews and Ameet Singh

56 Degloving and Shear Injuries 626

Bryden J. Stanley and Susan W. Volk

57 Skin Flaps and Grafts: Managing Complications 645

Michael B. Mison
 Contents xi

58 Incisional Infections 652

Brandy A. Burgess

Section VII Ocular Emergencies 659

59 Ocular Emergencies 661

Deborah C. Mandell and Rosalie M. Atkins

Section VIII Oral Surgical Emergencies 685

60 Oral Surgical Emergencies 687

Alexander M. Reiter

Section IX Orthopedic Emergencies 701

61 Approach to the Septic Joint 703

Samuel P. Franklin

62 Surgical Management of Open Fractures 715

Kimberly Agnello

63 Traumatic Joint Luxation and Reduction 725

Anna Massie and Po-­Yen Chou

Index 739
xii

Contributors

Sophie Adamantos BVSc CertVA DACVECC DECVCC Adrienne Bentley DVM DACVS
MRCVS FHEA Staff Surgeon
Clinical Director Cornell University Veterinary Specialists
Paragon Veterinary Referrals Stamford, CT, USA
Wakefield, UK
Dale Bjorling DVM DACVS
Krista N. Adamovich-­Rippe DVM DACVS Professor of Small Animal Surgery
Associate Surgeon University of Wisconsin-­Madison
Central Texas Veterinary Specialty and Emergency Hospital School of Veterinary Medicine
Austin, TX, USA Madison, WI, USA

Kimberly Agnello DVM DACVS Dorothy Black DVM MPVM DACVECC

Associate Professor of Surgery Criticalist and Owner
University of Pennsylvania, School of Veterinary Medicine Rex Vet, Inc., San Mateo, CA, USA
Philadelphia, PA, USA
Ben Brainard VMD DACVAA DACVECC
Laura Ateca VMD DACVECC Professor of Small Animal Critical Care
Attending Criticalist Director of Clinical Research
Emergency and Critical Care Service, Guardian Veterinary Department of Small Animal Medicine and Surgery
Specialists University of Georgia, College of Veterinary Medicine
Brewster, NY, USA Athens, GA, USA

Rosalie M. Atkins DVM DACVO
VCA Northwest Veterinary Specialists,
Clackamas, OR, USA
Anusha Balakrishnan BVSc DACVECC
Triangle Veterinary Referral Hospital,
Durham, NC, USA
Matthew Beal DVM DACVECC
Head of Interventional Radiology Services,
Head of Emergency and Critical Care Medical Services
Department of Small Animal Clinical Sciences
Michigan State University, College of Veterinary Medicine
East Lansing, MI, USA
Brandy A. Burgess DVM MSc PhD DACVIM-­LA DACVPM
Associate Professor, Director of Infection Control
University of Georgia, College of Veterinary Medicine
Athens, GA, USA
Kate Buriko DVM DACVECC
Assistant Professor, Emergency and Critical Care
University of Pennsylvania, School of Veterinary Medicine
Philadelphia, PA, USA
Jasper Burke VMD
Resident in Emergency and Critical Care
University of Pennsylvania, School of Veterinary Medicine
Philadelphia, PA, USA

Kari Santoro Beer DVM DACVECC Michelle Capps CVT

Emergency and Critical Care Specialist Surgical Nursing Staff Supervisor
Oakland Veterinary Referral Services University of Pennsylvania, School of Veterinary Medicine
Bloomfield Hills, MI, USA Philadelphia, PA, USA
 Contributors xiii

Nolan Chalifoux DVM Cami Elliot CVT

Resident in Emergency and Critical Care Nashville Veterinary Specialists and Animal Emergency
University of Pennsylvania, School of Veterinary Medicine Nashville, TN, USA
Philadelphia, PA, USA
Steven E. Epstein DVM DACVECC
Po-­Yen Chou BVM MVM DACVS Professor of Emergency and Critical Care
Assistant Professor of Small Animal Orthopedic Surgery Department of Surgical and Radiological Sciences
Department of Surgical and Radiological Sciences University of California-­Davis, School of Veterinary
University of California-­Davis, School of Veterinary Medicine
Medicine Davis, CA, USA
Davis, CA, USA
Samuel P. Franklin DVM MS PhD DACVS DACVSMR
Dana Clarke DVM DACVECC ACVS Founding Fellow, Minimally Invasive Surgery,
Assistant Professor, Interventional Radiology and Small Animal Orthopedics
Critical Care Kansas City Canine Orthopedics, Kansas City, KS, USA
University of Pennsylvania, School of Veterinary Medicine
Philadelphia, PA, USA Caroline Garzotto VMD DACVS
Staff Surgeon
Sara Colopy DVM, PhD, DACVS Mount Laurel Animal Hospital
Clinical Assistant Professor, Small Animal Surgery Mount Laurel, NJ, USA
University of Wisconsin, School of Veterinary Medicine
Stephen D. Gilson DVM DACVS
Madison WI, USA
ACVS Founding Fellow in Surgical Oncology
Indigo Veterinary Specialists
William T.N. Culp VMD DACVS
Phoenix, AZ, USA
Professor of Small Animal Surgery
Department of Surgical and Radiological Sciences
Jaime Green DVM, DACVS
University of California-­Davis, School of Veterinary
Maine Veterinary Medical Center
Medicine
Scarborough, ME, USA
Davis, CA, USA
Susan P. Gregory BVetMed PhD DVR DSAS (Soft Tissue)
Jacqueline Davidson DVM MS FHEA MRCVS
Clinical Professor Professor of Veterinary Nursing (retired)
Veterinary Medical Teaching Hospital, Texas A and M Royal Veterinary College, Department of Clinical Science
College Station, TX, USA and Services
North Mymms, Hatfield, Hertfordshire, UK
Daniel Degner DVM DACVS
Animal Surgical Center of Michigan Todd Hamilton VMD DACVS
Burton, MI, USA Maine Veterinary Medical Center
Scarborough, ME, USA
Ivan Doran BVSc CertSAS DSAS(Soft Tissue) MRCVS
RCVS Specialist in Small Animal Soft Tissue Surgery David Holt BVSc DACVS
Highcroft Veterinary Referrals Professor of Small Animal Surgery
Bristol, UK University of Pennsylvania, School of Veterinary Medicine
Philadelphia, PA, USA
Kenneth Drobatz DVM DACVECC
Professor of Small Animal Emergency and Critical Care Jennifer L. Huck DVM DACVS
University of Pennsylvania, School of Veterinary Assistant Professor of Surgery
Medicine University of Pennsylvania, School of Veterinary Medicine
Philadelphia, PA, USA Philadelphia, PA, USA
xiv Contributors

Georga T. Karbe Dr Med Vet MRCVS DACVS Mike McCallum CVT

Department Head: Soft Tissue Surgery Director of Operations
University of Veterinary Medicine Hannover, University of Pennsylvania, School of Veterinary Medicine
Hannover, Germany Philadelphia, PA, USA

Aarti Kathrani BVetMed PhD DACVIM DACVN FHEA MRCVS Meredith Maczuzak DVM DACVECC
Senior Lecturer in Small Animal Internal Medicine Emergency Medicine Specialist
Royal Veterinary College, Clinical Science and Services Pittsburgh Veterinary Specialty and Emergency
Department Center – BluePearl
Hatfield, Hertfordshire, UK South Hills, PA, USA

Deborah C. Mandell VMD DACVECC

Kristina Kiefer DVM PhD CCRP DACVSMR
Professor, Clinical Emergency and Critical Care
Surgical Coach
University of Pennsylvania, School of Veterinary Medicine
VetSSMART LLC
Philadelphia, PA, USA
St Paul, MN, USA
F.A. (Tony) Mann DVM MS DACVS DACVECC
Amie Koenig DVM, DACVIM DACVECC
Professor and Small Animal Soft Tissue Surgeon
Professor of Emergency and Critical Care
Director of Small Animal Emergency and Critical Care
Department of Small Animal Medicine and Surgery
Services
University of Georgia, College of Veterinary Medicine
University of Missouri-­Veterinary Medical Teaching
Athens, GA, USA
Hospital
Columbia, MO, USA
Amy Koenigshof DVM MS DACVECC
Two by Two Animal Hospital Anna Massie DVM DACVS
Berrien Springs, MI, USA Assistant Professor of Surgery
University of Pennsylvania, School of Veterinary Medicine
Janet J Kovak McClaren DVM DACVS DECVS MRCVS
Philadelphia, PA, USA
Staff Doctor
London Veterinary Specialists
Karol A. Mathews DVM DVSc DACVECC
London, UK
Professor Emeritus of Emergency and Critical Care
Ontario Veterinary College, University of Guelph
Elizabeth LaFond DVM DACVS DACVSMR
Guelph, ON, Canada
Veterinary Specialists of Sydney
Miranda, NSW, Australia Steve J. Mehler DVM DACVS
Main Line Veterinary Specialists
Nathaniel Lam DVM DACVS Devon, PA, USA
Chief of Surgery
VCA Oahu Veterinary Specialty Center Michael B. Mison DVM DACVS
Pearl City, HI, USA Surgery – MedVet Salt Lake City
Salt Lake City, UT, USA
Nyssa Levy DVM MS DACVECC
Assistant Professor, Emergency and Critical Care Medicine Eric Monnet DVM PhD FAHA DACVS ECVS
Department of Small Animal Clinical Sciences Professor of Surgery
Michigan State University, College of Veterinary Medicine Department of Clinical Sciences
East Lansing, MI, USA College of Veterinary Medicine and Clinical Sciences
Colorado State University
Lori Ludwig VMD MS DACVS Fort Collins, CO, USA
Mobile Veterinary Surgery
Charleston, SC, USA Pieter Nelissen DVM CertSAS DECVS MRCVS
European Specialist in Small Animal Surgery, RCVS
Cassie N. Lux DVM DACVS Recognized Specialist in Small Animal Surgery (Soft Tissue),
Associate Professor of Surgery Founder and Director, Department Head of Surgery
Department of Small Animal Clinical Sciences Frontier Veterinary Specialists
College of Veterinary Medicine, University of Tennessee Munich, Germany
Knoxville, TN, USA
 Contributors xv

Matthew D. O’Donnell DVM DACVS Katrine Saile DVM, MS, DACVS

Central Texas Veterinary Specialty and Emergency Associate Surgeon
Hospital Blue Pearl Pittsburgh Veterinary Specialty and
Austin, TX, USA Emergency Center
Pittsburgh, PA, USA
Augusta Pelosi DVM DACVS DACVIM (Cardiology)
Cardiologist Jennifer Savini DVM DACVECC
Veterinary Heart Institute Emergency and Critical Care Specialist
Boca Raton, FL, USA VRC Specialty Hospital
Malvern, PA, USA
James A. Perry DVM PhD DACVIM (Oncology) DACVS
Veterinary Cancer and Surgery Specialists Mike Schlicksup DVM DACVS
Milwaukie, OR, USA Columbia Veterinary Emergency Trauma and Specialty
Columbia, SC, USA
Heidi Phillips VMD DACVS
Associate Professor of Small Animal Surgery Chad Schmeidt DVM DACVS
University of Illinois, College of Veterinary Medicine Professor of Small Animal Surgery
Urbana, IL, USA University of Georgia, College of Veterinary Medicine
Athens, GA, USA
David A. Puerto DVM DACVS
Center for Animal Referral and Emergency Services Deborah Silverstein DVM DACVECC
Langhorne, PA, USA Professor of Critical Care
University of Pennsylvania, School of Veterinary Medicine
MaryAnn Radlinsky DVM MS DACVS Philadelphia, PA, USA
Founding Fellow, Minimally Invasive Surgery
Small Animal Soft Tissue Ameet Singh BSc DVM DVSc DACVS
Salt River Veterinary Specialists Associate Professor of Surgery
Scottsdale, AZ, USA Ontario Veterinary College, University of Guelph
Guelph, ON, Canada
Erica Reineke VMD DACVECC
Associate Professor of Emergency and Critical Care Sean Smarick DVM DACVECC
University of Pennsylvania, School of Veterinary Independent Consultant
Medicine North Huntingdon, PA, USA
Philadelphia, PA, USA
Daniel D. Smeak DVM DACVS
Alexander M. Reiter Dipl Tzt Dr med vet DAVDC DEVDC Vice President, Surgical Models, Inotiv; Fort Collins
FF-­AVDC-­OMFS Emeritus Professor of Surgery
Professor of Dentistry and Oral Surgery Colorado State University
University of Pennsylvania, School of Veterinary Medicine Fort Collins, CO, USA
Philadelphia, PA, USA
Bryden J. Stanley BSc BVMS MACVSc MVetSc DACVS
Caryn Reynolds DVM DACVIM (Cardiology) Emeritus Professor
Cardiologist Michigan State University, College of Veterinary Medicine
Dove Lewis Emergency Hospital East Lansing, MI, USA
Portland, OR, USA
Vincent Thawley VMD, DACVECC
Jacob Rubin DVM DACVS Assistant Professor, Clinical Emergency and Critical Care
Maine Veterinary Medical Center University of Pennsylvania, School of Veterinary Medicine
Scarborough, ME, USA Philadelphia, PA, USA
xvi Contributors

Michael S. Tivers BVSc PhD CertSAS DECVS MRCVS Lori S. Wadell DVM DACVECC
Head of Surgery Professor of Clinical Critical Care Medicine
Paragon Veterinary Referrals University of Pennsylvania, School of Veterinary Medicine
Wakefield, UK Philadelphia, PA, USA

Karen M. Tobias DVM MS DACVS Mandy L. Wallace DVM MS DACVS

Institute Professor, Department of Small Animal Assistant Professor
Clinical Science University of Georgia, College of Veterinary Medicine
University of Tennessee, College of Veterinary Medicine Athens, GA, USA
Knoxville, TN, USA
Richard A.S. White BVetMed PhD DSAS DVR FRCVS
DACVS ECVS
Adam Townsend DVM
European and RCVS Specialist in Small Animal Surgery,
Resident, Small Animal Surgery
RCVS Specialist in Veterinary Oncology, ACVS Founding
University of Wisconsin-­Madison, School of Veterinary
Fellow, Surgical Oncology
Medicine
Clinical Director, Smart Paws GmbH
Madison, WI, USA
Special Professor of Small Animal Surgery
University of Nottingham, Nottingham, UK
Susan W. Volk VMD PhD DACVS
Associate Professor, Small Animal Surgery Chloe Wormser VMD DACVS
University of Pennsylvania, School of Veterinary Elite Veterinary Surgery
Medicine Northway Animal Emergency Clinic
Philadelphia, PA, USA Gansevoort, NY, USA

Preface
As the management of small animal surgical emergencies
is constantly evolving, the purpose for writing this second
edition is to have an up-­to-­date resource for the veterinary
surgeon, critical care specialist, and general practitioner
that builds on information presented in the first edition
and provides updated information on preoperative
stabilization, new and innovative treatment options and
aftercare. Similar to the first edition, the majority of
chapters are authored by two, and occasionally three,
specialists in the fields of both surgery and emergency/
critical care to combine the expertise of individuals from
these two disciplines. In addition to approximately 70
authors who contributed to the first edition, 18 new authors
have agreed to share their knowledge and expertise with
the reader. The layout of the second edition is similar to the
first edition, with many of the chapters covering step-­by-­
step information on emergency stabilization, diagnostic
approach, operative techniques, postoperative care,
common complications encountered, and how to
troubleshoot such complications should they occur.
Relevant anatomy, imaging and full color illustrations and
drawings have been incorporated into each chapter to
support the text. Case presentations have also been
included when appropriate.
To strive to enhance the content of the first edition, nine
new chapters have been added based on advice received
from respected colleagues. Following the introductory
chapter, Triage and Initial Stabilization of the Emergency
Small Animal Surgical Patient, a new chapter, Operating
Room Nursing Tips for Emergency Surgical Procedures, has
been added to the beginning of the book to assist veterinary
nurses and operating room technicians who may be
working with these critical patients. This chapter provides
xvii
information on patient positioning and preparation in the
operating room, essential equipment, and appropriate
sterilization techniques. For the section on the
gastrointestinal system, four new chapters have been
added, including Rectal Prolapse, Colonic Torsion, Surgical
Intervention Post-­Celiotomy, and a chapter on Enteral
Feeding Tubes. Including the chapter on nutritional sup-
port reiterates the importance of appropriate stabilization
and aftercare to the ultimate success of the emergency sur-
gical patient. In the cardiovascular system section, a chap-
ter has been added on Open-­Chest Cardiopulmonary
Resuscitation, and in the section on wound management,
two new chapters have been added, including The Failed
Flap and Incisional Infections. Finally, for the section on
orthopedic emergencies, in addition to updating chapters
from the first edition on the Approach to the Septic Joint
and the Surgical Management of Open Fractures, a chapter
on Traumatic Joint luxation and Reduction has been added
to provide a comprehensive resource when faced with an
orthopedic emergency.
Although there are veterinary textbooks that focus on
small animal surgery and those that focus on critical care
medicine, this is the only book that focuses on the
combination of these two disciplines, filling a niche
currently vacant in the veterinary literature. Additionally,
this book is unique in that the majority of the chapters are
co-­authored by experts in both fields. Because surgical
emergencies are common in veterinary medicine, this
textbook should have a wide audience, including surgical
and critical care residents in training, veterinary surgeons
and criticalists, and veterinary practitioners who work in
emergency medicine or those who have an interest in
surgery.
xviii

­Acknowledgements

I would like to thank the staff at Wiley, with special thanks to Meryl Le Roux and Erica Judisch, for all their help and
encouragement throughout this process. Without their support and guidance, completion of this project would not have
been possible.
The impact of Covid-­19 on many of the authors who contributed to this textbook cannot be overstated. The disruption in
normal work, family routine, health issues, and economic hardship resulted in significant fear and anxiety. I truly want to
thank all the authors for their dedication and commitment to this project – I know it wasn’t easy.
Finally, since the publication of the first edition, many of us lost a dear friend and colleague, Dr. Lesley King. Lesley was
a Professor of Critical Care at the University of Pennsylvania and was instrumental in the development of intensive care as
a veterinary specialty. Lesley made significant contributions to the veterinary literature including as a contributor to the
first edition of this textbook. Lesley was not only a colleague, but also a good friend, and will be dearly missed.
 xix

­About the Companion Website

This book is accompanied by a companion website:

www.wiley.com/go/aronson/surgical

The website includes:

●● Case Studies
●● Video clips
●● References
xx

Daisy’s Story

ICU recovering. During times of COVID-­19, a new normal

developed and owners were unable to visit their pets dur-
ing their hospital stay. Daisy’s owners decided on the next
best thing – Facetime! Here she is being read a story during
one of her virtual visits with Mom and Dad.

Daisy’s story can be found in Chapter 54 (Case

Report 54.2). After an encounter with a porcupine, Daisy
underwent two major surgeries and spent weeks in our

Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
Dana Clarke
University of Pennsylvania, School of Veterinary Medicine, Philadephia, PA, USA
­Introduction
One of the most challenging aspects of emergency medi-
cine is being presented with patients who have a variety of
clinical signs and disease severities to assess, prioritize, sta-
bilize, and provide with definitive care. The veterinary cli-
nician is reliant on information provided by the client,
their physical assessment, and initial diagnostics to deter-
mine severity of illness and injury, and therefore, urgency
of care. Efficient identification and treatment of respira-
tory, cardiovascular, urinary, and neurologic derangements
is essential for successful patient outcomes. When emer-
gency surgical intervention is required, it is crucial to
appropriately stabilize the patient for anesthesia without
unduly delaying surgical care.
­Triage and Initial Assessment
Triage is an essential tool in the setting of emergency
medicine to assess and prioritize critically ill patients [1,
2]. This is particularly true of patients that may require
emergency surgical intervention, as the time to provide
appropriate stabilizing care and definitive surgical ther-
apy likely impacts patient outcome.
In many veterinary hospitals, nurses obtain pertinent
historical information and perform a basic assessment to
determine whether the patient needs immediate further
evaluation or is stable enough to be seen in turn. In general,
over-­triage is preferred to under-­triage in veterinary medi-
cine, as the severity of signs presented by the patient and
observed by the pet owner may not be fully appreciated by
untrained individuals. Triage and training systems in patient
assessment are used routinely in human emergency medi-
cine. A variety of triage systems exist for human patients,
Small Animal Surgical Emergencies, Second Edition. Edited by Lillian R. Aronson.
© 2022 John Wiley & Sons, Inc. Published 2022 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/aronson/surgical
1
which when combined with education of the medical staff
on the system’s guidelines for prioritizing medical care,
reduces inconsistencies in decision-­making [3]. In veteri-
nary medicine, no uniformly accepted triage system exists.
Veterinary healthcare professionals therefore use historical
information and intuition to make rapid decisions regarding
the need for immediate care and order in which patients will
be seen. The animal trauma triage (ATT) score was devel-
oped retrospectively and assessed prospectively to help to
classify and prognosticate for a heterogenous patient group.
For each patient, six categories are assessed (perfusion, car-
diac, respiratory, skeletal, neurologic, and eye/muscle/integ-
ument) and scored from 0 to 3, with 0 being unaffected or
only slightly affected to 3 indicating severe injury. The six
scores are added together with a maximum possible score of
18. In both the retrospective and prospective populations,
the mean ATT score of survivors was significantly lower
than non-­survivors and for each one-­point increase in
ATT, the likelihood of survival decreased 2.3–2.6 times
[4]. Another veterinary triage system, adapted from the
Manchester triage system, uses a five-­category system using
color-­coding to indicate urgency. Examples of “red” emer-
gencies (those which need to be seen immediately) include
severe respiratory distress, decompensated shock, life-­
threatening hemorrhage, and active seizures. Very urgent
emergencies, including moderate respiratory distress, evi-
dence of aortic thromboembolism, and urethral obstruction,
were classified as “orange.” Urgent emergencies, such as
mild hemorrhage, moderate dehydration and open fracture
were classified as “yellow,” while non-­urgent disease pro-
cesses such as localized inflammation, soft-­tissue swelling,
stranguria and recent isolated seizure were classified as
“green” [5]. The study determined that the use of a veteri-
nary triage list by nurses upon triage corresponded better to
retrospectively reviewed patient status than when individual
2 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
judgment and intuition upon triage were employed [5].
Multicenter, prospective evaluation of this veterinary triage
list is warranted to determine whether patient care is
improved and time to be seen can be better estimated.
Irrespective of the need for a formal veterinary triage sys-
tem, a brief, but thorough physical exam remains the gold
standard for recognizing critical patient status. The initial
triage assessment includes visual examination and assess-
ment of four key body systems: cardiovascular, respiratory,
neurologic, and urinary [6, 7]. Information regarding the
patient’s mentation and responsiveness, as well as respira-
tory rate and effort, are obtained quickly on brief visual
exam, often before performing any parts of a physical
examination. Thoracic and cardiac auscultation with con-
current pulse palpation and a more thorough assessment
of neurologic status, if indicated, follows visual examina-
tion. After cardiovascular, respiratory, and neurologic sta-
tus is determined, if the patient is stable enough for further
evaluation, urinary triage can be performed. Any signifi-
cant pain must be addressed urgently to improve patient
comfort and so that the effects of pain do not alter interpre-
tation of cardiovascular and respiratory findings.
Additionally, aggression should not be considered a sign of
patient stability, as many scared and stressed patients will
be aggressive in the face of severe shock.
­Respiratory Assessment
Before any physical examination, all patients should have
their respiratory rate, effort, noise, and pattern observed
from afar. If a patient is showing any changes in respira-
tory pattern or effort, oxygen supplementation should be
provided immediately. If there is any respiratory compro-
mise, the patient should be presumed to be in hypoxemic
shock until proven otherwise and oxygen supplementa-
tion should be provided. Further respiratory triage involves
auscultation of the upper airway, trachea, and thorax.
During abbreviated thoracic auscultation, emphasis
should be placed on determining heart rate, rhythm, the
presence of murmur(s) or arrhythmia(s), and lung sounds
in all lung fields. Visual and auditory assessment of res-
piratory pattern and noise combined with thoracic auscul-
tation should help localize the anatomic origin of the
respiratory distress. The impact of pain, stress, and anxiety
on respiratory rate and effort should not be underesti-
mated (Figure 1.1).
If respiratory noise is localized to the upper airway, dis-
eases associated with an upper airway obstruction, includ-
ing laryngeal paralysis, laryngeal collapse, brachycephalic
airway disease, tracheal collapse, the presence of a tra-
cheal, laryngeal, or pharyngeal mass, and the presence of a
Figure 1.1 Cat with open mouth breathing secondary to the
pain associated with an aortic thromboembolism.
foreign body should be ruled out. See Chapter 28 for stabi-
lization of the patient with upper airway obstruction.
If decreased lung sounds relative to respiratory effort are
heard dorsally, pneumothorax should be suspected.
However, if decreased lung sounds are heard ventrally,
pleural effusion should be considered. Lung sounds may
not be completely absent in the presence of pleural effu-
sion or pneumothorax, they may be reduced relative to the
other lung fields but still present. See Chapter 34 for stabi-
lization of the patient with pleural space disease. Diseases
of the chest wall such as masses, rib fractures, and flail seg-
ments may also result in abnormal auscultation of the pul-
monary parenchyma. For more information on chest wall
disease, see Chapter 41.
For patients in respiratory distress with a heart murmur,
arrhythmia, pleural effusion, or pulmonary crackles pre-
sent on auscultation, cardiogenic and hypoxemic shock
should be considered as possible differentials. This is par-
ticularly important since fluid therapy is often contraindi-
cated in most patients with cardiac dysfunction or failure
and must be ruled out, to the best of the clinician’s ability
on triage, prior to administering intravenous (IV) fluid
therapy.
Hypoxemic Shock
Hypoxemic shock occurs secondary to decreased arterial
blood oxygen content. Common causes of hypoxemic shock
include pulmonary parenchymal disease, such as pneumo-
nia, severe anemia, and hypoventilation (Figure 1.2). Many
veterinary patients in hypoxemic shock are at the limits of
their physiologic reserves, and are intolerant of excessive
handling, restraint, and manipulation; they should be han-
dled carefully. Clinical signs include weakness, mental

Figure 1.2 Lateral thoracic radiograph showing cranioventral
pulmonary infiltrates creating an alveolar pattern consistent
with aspiration pneumonia.
depression, pale mucous membranes, dyspnea, crackles or
increased bronchovesicular lung sounds, or decreased lung
sounds ventrally (pleural effusion) or dorsally (pneumotho-
rax), and cyanosis. Patients with diaphragmatic hernia may
have decreased lung sounds dorsally or ventrally. Cyanosis
is only seen with severe hypoxemia (at least 5 g/dl of deoxy-
genated hemoglobin), and thus the absence of cyanosis
absolutely does not rule out hypoxemia. In anemic animals,
cyanosis is unlikely to be detected due to decreased hemo-
globin concentration, and therefore should not be relied
upon to diagnose hypoxemia [8].
In any patient with suspected hypoxemic shock, sup-
plemental oxygen should be provided until the ability to
adequately oxygenate is confirmed. Diagnostics that can
be helpful for the patient in hypoxemic shock include
pulse oximetry (peripheral capillary oxygen saturation,
SpO2), arterial blood gas analysis, thoracic radiographs,
thoracic/trauma computed tomography (CT), and tho-
racic ultrasound. SpO2 may be less effective with bright
lighting, poor perfusion, high motion, and pigmentation
of the skin. It is convenient since it can noninvasively
determine percentage of oxygenated hemoglobin, and,
for sedentary patients, can be left in place for continuous
monitoring (Figure 1.3). Many patients in respiratory dis-
tress will not tolerate the restraint necessary for arterial
blood gas collection and thoracic radiographs, especially
on presentation. If obtaining an arterial blood gas is fea-
sible, findings may include decreased SpO2, decreased
partial pressure of carbon dioxide (PaCO2) consistent
with hyperventilation, increased PaCO2 consistent with
hypoventilation, decreased partial pressure of oxygen
­Respiratory Assessmen  3
Figure 1.3 Continuous pulse oximetry assessment in a laterally
recumbent dog receiving oxygen supplementation via
nasal prongs.
(PaO2) consistent with hypoxemia, and an increased par-
tial pressure of alveolar–arterial oxygen gradient P(A–a)
O2). Calculation of the P(A–a)O2 gradient provides objec-
tive information on pulmonary function by removing the
influence of ventilation on PaO2. When a patient is
breathing 21% oxygen, the P(A–­a)O2 should be less than
10–15 mmHg. When a patient is breathing 100% oxygen,
the P(A–a)O2 should be less than 150 mmHg. If the
P(A–a)O2 gradient is greater than 15 mmHg while breath-
ing 21% oxygen, it is consistent with pulmonary dysfunc-
tion. For A–a gradient calculation, see the formula
in Box 1.1.
Preliminary evaluation of the ratio of SpO2 to fraction of
inspired oxygen (FiO2) to the partial pressure of oxygen in
arterial blood to FiO2 (PaO2/FiO2) showed good correlation
between the two values in dogs. It is possible that with fur-
ther investigation, the SpO2/FiO2 may become a reliable,
less invasive alternative to determining PaO2/FiO2 [9].
Thoracic radiographs may show pulmonary parenchy-
mal infiltrates ventrally consistent with pneumonia,
caudodorsally consistent with non-­cardiogenic pulmo-
nary edema, and in the perihilar region consistent with
congestive heart failure. In the trauma patient,
4 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient

and pericardial effusion, pneumothorax, and pulmonary

Box 1.1 Formula Used for A–a Gradient Calculation
parenchymal infiltrates [15–20]. It is particularly useful
The partial pressure of alveolar–arterial oxygen in patients that are not stable enough for thoracic radio-
(P(A–a)O2) gradient provides objective information on graphs, as well as a monitoring tool to assess for response
pulmonary function by removing the influence of venti- to therapy. Thoracic ultrasound may be performed with
lation on PaO2. the patient in sternal or lateral recumbency. Pleural effu-
P A-a O2 PAO2 PaO2 sion is generally visible in the cranial and/or caudoven-
tral pleural space. Ultrasound guidance to localized fluid
PAO2 FO2
i Patm PH2O PaCO2 / R
pockets can be helpful to guide thoracocentesis. When
PAO2 = alveolar gas equation evaluating for the presence of pneumothorax, the caudo-
FiO2 = percentage of inspired O2 dorsal thorax is evaluated for the lack of a “glide” sign,
Patm = atmospheric pressure (760 mmHg used at which is diagnostic for pneumothorax. A glide sign is
sea level) created by the normal back and forth respiratory motion
PH2O = water vapor pressure (53 mmHg 39°C for dogs/ of the interface between the visceral and parietal pleura
cats; 47 mmHg at 37°C in humans) (Video 1.1). Free air in the thoracic cavity obliterates the
R = respiratory quotient (approximately 0.8–0.9) glide sign [15–17]. Cellular or fluid infiltrate into the
pulmonary parenchyma, as with edema, hemorrhage,
Example Blood Gas
and pneumonia can be assessed using ultrasound in four
PaCO2 = 24.2 windows in each hemithorax (caudodorsal, cranial, mid-
PaO2 = 59.5 dle lung lobe regions, and perihilar) for the presence of
PAO2 = (0.21 × (760 – 53)) – (24.2/0.9) increased penetration of ultrasound, which manifest as
PAO2 = 121.6 hyperechoic lines (B-­lines) in parallel with the ultra-
P(A–a)O2 = 121.6–59.5 sound beam, that can be individual or coalescing
P(A–a)O2 = 62.1 (indicates hypoxemia is due to (Figure 1.4 and Video 1.2) [18–22].
pu­lmonary dysfunction)
Video 1.1 TFAST showing a normal glide sign, which is
created by the respiratory motion of the visceral and pari-
etal pleural interface sliding back and forth.
pulmonary contusions, which can be present in any lung
field(s), may not become radiographically apparent for
Video 1.2 TFAST showing coalescing B-­lines created by
up to 48 hours, although peak opacification has been
marked pulmonary infiltrates allowing ultrasound pene-
shown to occur at 6 hours in human trauma patients [10].
tration into the pulmonary parenchyma.
Additionally, up to 30% of human trauma patients do not
have radiographic evidence of contusions on initial tho-
racic radiographs, which is why CT is often proposed as
the preferred method of thoracic imaging [10–12]. In a
study of dogs that had succumb to vehicular trauma,
thoracic radiographs underestimated the presence of
contusions, while also overestimating their severity. The
same study also noted that thoracic radiographs were
less sensitive than CT for detecting rib fractures [13].
Initial investigation in the use of thoracic ultrasound for
detection of pulmonary contusions in dogs with vehicu-
lar trauma showed a high sensitivity for diagnosing con-
tusions compared with CT, and even noted improved
sensitivity compared with thoracic radiographs [14].
Therefore, cautious respiratory monitoring and repeat
thoracic imaging may be indicated in any patient with a
history of known or suspected trauma.
Thoracic ultrasound, also known as thoracic focused
Figure 1.4 TFAST ultrasonographic appearance (still image) of
assessment with sonography for trauma, triage, and a B-­line, which is created by increased infiltrates in the
tracking (TFAST), allows clinicians to assess for pleural pulmonary parenchyma allowing ultrasound penetration.

­Cardiovascular Assessment
The most important part of the cardiovascular assessment
during emergency patient triage is the determination
whether the patient is in shock. If shock is suspected, the
type of shock and need for fluid therapy must then be
determined. The common feature in all shock patients is
inadequate cellular energy metabolism, which is most
commonly due to poor perfusion. However, metabolic and
hypoxic shock can occur with normal perfusion, so one
must be careful to not rule out shock on the basis of normal
perfusion parameters alone [23, 24].
For cardiovascular triage, mucous membrane color, tem-
perature, and capillary refill time (CRT) can be used to
assess perfusion. Signs of poor perfusion during mucous
membrane assessment include pale pink to white mucous
membranes, cool temperature, and prolonged to absent
CRT (> 2 seconds). Bright pink or red mucous membranes,
injected capillaries, and rapid CRT can be seen with dis-
tributive shock. However, depending on the patient’s stage
of cardiovascular compromise and the degree of compen-
sation, even patients with shock can have normal mucous
membrane appearance. Heart rate and rhythm should be
assessed simultaneously with pulse palpation to determine
pulse pressure quality and for deficits. Both femoral and
dorsal metatarsal artery palpation is preferred to appreciate
discrepancies in proximal and distal perfusion. Extremity
temperature on limb palpation and rectal temperature
should be noted to complete the patient’s perfusion clinical
picture [23–26].
Following physical examination of the cardiovascular
system, emergency diagnostic tools that can aid cardio-
vascular triage include indirect blood pressure, electro-
cardiogram (ECG), venous or arterial blood gas, packed
cell volume/total solids (PCV/TS), lactate, and left atrial
to aortic root ratio on ultrasound. Indirect blood pressure
methods, such as Doppler or oscillometric technologies,
provide rapid noninvasive determination of arterial
blood pressure. Doppler is particularly useful in small
patients, cats, and those with cardiac arrhythmias.
Oscillometric methods are convenient as they can be pro-
grammed to cycle at predetermined intervals, such that
repeated measurements can be obtained automatically.
For both methods, cuff size selection in relation to limb
diameter is essential for accurate results. Cuff diameter
should be approximately 40% of the limb circumference
in dogs and 30% in cats. Cuffs that are too large will gen-
erate falsely low blood pressure results, and falsely high
results will be obtained from a cuff that is too small [27].
In hypotensive patients, noninvasive methods have been
shown to have the greatest variability compared with
­Cardiovascular Assessmen  5
direct measurements [28]. Direct arterial blood pressure
is considered the gold standard for blood pressure deter-
mination, and offers the additional benefits of continu-
ous, real-­time results that are accurate with arrhythmias
and decreased perfusion. However, placement of an arte-
rial catheter is technically challenging, especially in dis-
tressed or hypotensive patients and cats, uncomfortable
for the patient during placement, and requires constant
monitoring to ensure the catheter is not inadvertently
dislodged. ECG is helpful to evaluate for the presence of
cardiac arrhythmias, which can be the primary cause of
shock (cardiogenic), or secondary complications of hypo-
volemic, metabolic, hypoxic, or distributive shock.
Venous blood gas monitoring, particularly for pH, partial
pressure of carbon dioxide in venous blood (PvCO2), par-
tial pressure of oxygen in venous blood (PvO2), electro-
lytes, and base excess/deficit is important to help
determine the underlying cause of cardiovascular com-
promise, assess cellular oxygen delivery and metabolism,
and response to therapy. Similarly, PCV/TS are essential
to evaluate for blood and/or protein loss, dehydration,
and appropriate hemodilution response if fluid therapy
is used. Lactate can be a marker of anaerobic metabolism
and is often increased in shock patients (type A lactic aci-
dosis), although less reliably in cats. It can support clini-
cal assessment of poor perfusion and trended over time
with treatment of the primary cardiovascular distur-
bance. It has been associated with outcome in gastric
dilatation and volvulus, pyometra, and immune-­
mediated hemolytic anemia [29–35]. It is important to
remember that type B lactic acidosis, which is hyperlac-
tatemia in the face of normal perfusion, does not resolve
with fluid therapy. Causes of type B lactic acidosis
include liver failure, neoplasia (especially hematopoi-
etic), diabetes mellitus, sepsis/systemic inflammatory
response syndrome, and various drugs and toxins [30].
Comparing the left atrium diameter with the root of the
aorta (LA : Ao), when using a short axis view from the right
parasternum, is helpful to assess left atrial volume. The
LA : Ao ratio was originally developed to support a diagnosis
of congestive heart failure, but it can also be used to evaluate
for left atrial volume underload, which can occur with hypo-
volemic shock. In dogs, the normal LA : Ao ratio is 1.3,
whereas the ratio is 1.5 in cats [36, 37]. Baseline LA:Ao ratio
on triage can help support a diagnosis of cardiogenic shock
secondary to congestive heart failure if the LA : Ao ratio is
increased. When the ratio is decreased, hypovolemic shock
may be present, especially if found in conjunction with other
parameters that support hypoperfusion. Changes in the ratio
with treatment, whether intravenous fluids or diuretics, can
be useful for monitoring response to therapy.
6 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
The use of point of care ultrasound techniques in dogs
has been used to objectively assess vascular status and
may be used as an adjunct diagnostic to guide fluid and/or
vasopressor therapy. In normal dogs with furosemide
induced hypovolemia, the caudal vena cava to aorta ratio
measured from the right intercostal space in left lateral
recumbency corresponded with decreasing body weight
consistent with volume loss [38]. This ratio was also
decreased after blood donation in healthy dogs [39]. In
greyhounds, the iliac location for this ratio did not detect
volume status changes before and after blood dona-
tion [40]. While additional work is needed in canine clini-
cal cases of hypovolemia as well as normal and critically ill
cats, this technique appears to be a promising method for
non-­invasive volume assessment.
Hypovolemic Shock and Fluid Therapy
Hypovolemic shock, which is the most common type of shock
seen in veterinary medicine, can be due to blood loss, fluid
loss, or inadequate intake, and results in decreased tissue
delivery of oxygen. Clinical signs consistent with hypovolemic
shock are mental depression, weakness, pale mucous mem-
branes, prolonged CRT, tachycardia, weak peripheral pulses,
cool extremities, and tachypnea.
To treat hypovolemic shock, intravascular volume
replacement is essential and generally accomplished with
intravenous crystalloids, colloids, blood products, or a
combination of the fluid replacement options. “Shock”
doses of fluid therapy are based on the blood volume for a
given species, and amounts for replacement are based on
the percentages of volume loss to cause cardiovascular
changes secondary to hypovolemic shock. Blood volume is
approximately 90 ml/kg in dogs and 45–60 ml/kg in cats.
Generally, patients are given portions of their shock dose
of fluids, such as 10–30 ml/kg of balanced isotonic crystal-
loid solutions or 5–10 ml/kg of colloid solutions as a bolus
over 15–20 minutes and assessed for improvement in per-
fusion parameters. The bolus is repeated if indicated.
Hypertonic saline (7.5%, 3–5 ml/kg IV over 15–20 minutes
in dogs, 2–3 ml/kg IV over 15–20 minutes in cats) is also
effective for rapid volume expansion in hypovolemic
shock but should only be used in patients with normal
hydration. The decision about whether crystalloids or col-
loids should be chosen as the initial resuscitation fluid is
controversial and has yet to be determined in both human
and veterinary medicine [41–47]. In veterinary patients,
the decision is often based on availability, cost, and
whether there are concerns about the patient’s colloid
osmotic pressure and the ability to maintain fluid within
the intravascular space. In June 2013, a boxed warning
was placed on hydroxyethyl starch (HES) solutions, such
as hetastarch, due to concerns for increased mortality,
severe renal injury, and risk of bleeding associated with
their use in critically ill adults, including those with sepsis
and admitted to the intensive care unit. VetStarch® (Abbott
Laboratories, Chicago, IL), a veterinary specific HES solu-
tion, is commercially available as a synthetic colloid for
plasma volume expansion. Preliminary veterinary studies
have conflicting evidence on association between the use
of synthetic colloids and acute kidney injury in dogs; they
should be used with caution until further research is avail-
able [48, 49].
Hypovolemic resuscitation or controlled intravascular
volume replacement titrated to a mean arterial blood pres-
sure (MAP) of 60 mmHg is widely used for human and vet-
erinary patients with hemorrhagic shock [50–54]. The goal
is to preserve perfusion to the vital organs, particularly the
kidneys and cerebral circulation, without supranormaliz-
ing blood pressure, to prevent disruption of any clots tem-
pering further hemorrhage. Experimental evidence in a
swine model shows that rebleeding occurs when MAP is
greater than 60 mmHg, while maintaining the MAP at
approximately 60 mmHg maintains renal and cerebral
blood flow [54]. Recommendations for decreased volume
fluid resuscitation for crystalloid boluses are between 20
and 30 ml/kg and 5 ml/kg for colloid boluses titrated to
effect and target blood pressure [52].
Transfusion with packed red blood cells (pRBC; 5–10 ml/
kg), fresh frozen plasma (FFP; 10–20 ml/kg), or whole
blood (10–20 ml/kg) may be indicated for patients with
anemia and/or coagulopathy. While there is no absolute
PCV below which a transfusion is required, consideration
of the chronicity of anemia, cardiovascular stability, con-
tinuing losses, anticipated surgical intervention, and pul-
monary function all impact the decision of whether or not
to transfuse a patient. It is also important to remember, that
in many critically ill patients, even after control of hemor-
rhage, coagulopathy may persist due to dilution, consump-
tion, delayed liver production of clotting factors, and liver
dysfunction, so repeated dosing of FFP may be needed
even once coagulation parameters have normalized.
Regardless of the fluid type chosen for cardiovascular
resuscitation, it is imperative that frequent reassessment of
the patient’s cardiovascular parameters in response to treat-
ment be performed. That same physical exam parameters
and initial diagnostics used to diagnose shock should be
reevaluated. Additional diagnostics that may be helpful for
determining whether a patient is appropriately or maximally
fluid resuscitated, especially if shock persists, include cen-
tral venous pressure (CVP) and central venous oxygen satu-
ration (SCVO2). CVP, which is a measure of the hydrostatic
pressure within the intrathoracic (cranial or caudal) vena
cava, is used to approximate right atrial pressure, or preload.

Normal CVP is 0–5 cm H2O. CVP values less than 0 cm H2O
are consistent with hypovolemia or decreased venous tone
secondary to vasodilation [55]. Increased CVP (> 7–10 cm
H2O) can be seen with volume overload, pleural space dis-
ease (pneumothorax, pleural effusion), pericardial disease
(restrictive pericarditis, pericardial effusion), tricuspid valve
disease, myocardial disease, and intraabdominal hyperten-
sion [55, 56]. The value of CVP monitoring for guiding fluid
resuscitation has been questioned in both human and veteri-
nary critical care in recent years. In addition to CVP, central
catheters can also be used to measure SCVO2, which is an
assessment of global tissue oxygenation and is the percent-
age of saturated hemoglobin within the cranial or caudal
vena cava or right atrium. Alterations in SCVO2 reflects
imbalance between oxygen delivery and consumption.
Decreased SCVO2 is seen with increased oxygen consump-
tion relative to delivery, as with hypovolemia, anemia, car-
diac dysfunction, pulmonary dysfunction, fever, and
hyperthermia. Increased SCVO2 is seen with decreased oxy-
gen consumption relative to delivery, as with hypothermia
and mitochondrial dysfunction [57–59]. In critically ill dogs,
a decrease in SCVO2 below 68% within the first 24 hours of
hospitalization was associated with poor outcome with pro-
gressive increase in mortality with decrease in SCVO2 [59]. In
septic dogs that underwent surgery for pyometra, survivors
had lower lactate, base deficit and their average SCVO2 was
74.6%. Non-­survivors in this study had an average SCVO2 of
62.4% [33]. Co-­oximetry, which is not widely available, is
needed for SCVO2 determination; this is likely the reason for
its limited clinical use in veterinary patients.
Cardiogenic Shock
It is important to differentiate hypovolemic shock from
cardiogenic shock, as many of the physical exam find-
ings can overlap but the treatment is usually vastly dif-
ferent. Fluid therapy is generally contraindicated in
most patients with cardiogenic shock. Cardiogenic
shock can be due to forward (left-­sided) or backward
(right-­sided) failure of blood flow. Common causes of
cardiogenic shock include congestive heart failure,
s­ystolic dysfunction, as with dilated cardiomyopathy,
diastolic dysfunction, as with hypertrophic cardiomyo-
pathy, and arrhythmias [25, 26]. Clinical signs of cardio-
genic shock include pale mucous membranes, heart
murmur and/or arrhythmias, poor or variable pulse
quality, pulse deficits, and tachycardia or bradycardia.
Findings consistent with right-­sided heart failure
include decreased ventral lung sounds consistent with
pleural effusion, jugular venous distension, ascites, and
hepatomegaly. Clinical signs seen with left-­sided dys-
function and left-­sided heart failure include increased
­Cardiovascular Assessmen  7
respiratory rate or effort, respiratory distress, pulmonary
crackles (pulmonary edema), and decreased lung sounds
ventrally consistent with pleural effusion (cats).
In addition to history and physical examination find-
ings, other diagnostics often needed to diagnose cardio-
genic shock include ECG, blood pressure, pulse oximetry
(SpO2), thoracic radiography, and TFAST. TFAST can be
used to determine cardiac contractility, myocardial
thickness, and cardiac chamber (atria and ventricle)
size. Focused echocardiography training for emergency
veterinarians has been shown to improve their diagnos-
tic capabilities for determination of several cardiac
abnormalities [59]. Treatment may involve oxygen sup-
plementation, pericardiocentesis, diuretic therapy, anti-­
arrhythmics, vasopressors, or vasodilators depending on
the etiology of cardiogenic shock.
Distributive/Septic Shock
Distributive shock is defined as a maldistribution of blood
flow, most commonly due to altered systemic vascular
resistance (SVR). Decreased SVR is the most common
SVR alteration, and vasodilatory shock secondary to sep-
sis is one of the most readily recognized forms of distribu-
tive shock. Distributive shock can also be secondary to
obstructive disease processes, such as gastric dilation and
volvulus, pericardial effusion, and neoplasia causing vas-
cular obstruction (such as adrenal tumors with invasion
into the vena cava) [25]. The clinical signs of distributive
shock in dogs are often very different from other forms of
shock. In dogs, the mucous membranes are often bright
pink (Figure 1.5), CRT is decreased (< 2 seconds), and
peripheral pulses can be bounding or more prominent
than normal. Cats with septic shock generally do not
demonstrate the hyperdynamic signs seen in dogs and
instead have pale mucous membranes, bradycardia, and
decreased rectal temperature [60].
Many patients with distributive shock also have a com-
ponent of hypovolemic shock (absolute or relative), so
fluid therapy to correct intravascular volume deficit is
essential. In humans with severe sepsis and septic shock,
early goal-­directed therapy is shown to improve patient
outcome when compared to traditional management strat-
egies. In two landmark human studies, hemodynamic
parameters such as direct arterial blood pressure, CVP, and
SCVO2 measurement, and treatment with crystalloids, col-
loids, pRBC, and catecholamines to improve cardiac con-
tractility and/or vasomotor tone were used until prescribed
endpoints were achieved [61, 62]. Standardized goal-­
directed therapy does not yet exist for veterinary patients,
therefore, normalization of routinely monitored cardiovas-
cular and perfusion parameters, including heart rate and
8 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
Figure 1.5 Bright pink mucous membranes in a dog with septic
peritonitis.
rhythm, rectal temperature, mucous membrane color and
CRT, blood pressure, CVP, PCV/TS, lactate and base deficit
are recommended [31, 63, 64].
When fluid therapy fails to normalize hemodynamic
parameters, particularly blood pressure in septic patients,
vasoactive catecholamines may be necessary [65, 66].
Commonly used vasoactive catecholamines used in critical
care are dopamine, dobutamine, and norepinephrine
(Table 1.1). Vasopressin, also known as antidiuretic hor-
mone, is a peptide synthesized in the pituitary that binds
vasopressin specific receptors on vascular smooth muscle.
Vasopressin stores can become depleted with prolonged
shock or sepsis resulting in vasoplegia despite intravenous
fluid and vasoactive catecholamine therapy. Vasopressin
deficiency has been documented in people with refractory
hypotension, and positive benefit has been shown with the
addition of intravenous administration of vasopressin.
Experience with vasopressin is growing in veterinary medi-
cine [67, 68].
Early administration of broad-­spectrum antibiotics has
been shown to improve survival in human patients with
sepsis and septic shock when combined with early goal-­
directed therapy. When antibiotics were given within one
hour of triage in combination with early goal-­directed
therapy, mortality decreased from 33.3% to 19.5% [69]. In
veterinary patients with septic shock, antimicrobials
should be given as soon as reasonably possible, especially
for those that will undergo emergency anesthesia and sur-
gery. In critically ill septic patients anticipated to undergo
surgery, perioperative first-­ and second-­generation cepha-
losporins likely do not provide adequate antimicrobial
coverage and should not be used in favor of more broad-­
spectrum medications. In the absence of confirmatory cul-
ture and sensitivity testing, broad-­spectrum therapy should
be used until a diagnostic culture result is obtained and
antimicrobial therapy can be de-­escalated. Intravenous
administration is preferred in all cardiovascularly unstable
and critically ill patients as oral, intramuscular, and subcu-
taneous absorption may not be predictable. Antibiotics that
can be considered for first-­line broad-­spectrum therapy
include ampicillin and clavulanate (Unasyn®, Pfizer,
22–30 mg/kg IV every 8 hours); ampicillin (18–22 mg/kg IV
every 8 hours) combined with enrofloxacin (10–15 mg/kg
IV every 24 hours), cefoxitin (30 mg/kg IV every 6 hours),
and clindamycin (10 mg/kg IV every 12 hours) combined
with cefotaxime (40–50 mg/kg IV every 6 hours), or ceftazi-
dime (30–50 mg/kg IV every 6–8 hours with dosing at the
lower end of the range for cats and higher end for dogs).
Metabolic Shock
Metabolic shock is defined as dysfunction of cellular
metabolism, which generally occurs in the face of ade-
quate perfusion and oxygenation. Examples include
severe pH derangements, hypoglycemia, adrenal insuf-
ficiency, and certain toxicities such as cyanide. The clini-
cal signs seen with metabolic shock closely resemble
those in hypovolemic shock and are related to the under-
lying etiology. Mental depression is the most universally
recognized sign of metabolic shock. The same diagnos-
tics used for patients in hypovolemic shock are indicated
for the patient in metabolic shock. Treatment may
include correction of acid–base derangements with IV
fluids and/or bicarbonate, dextrose supplementation,
and steroid administration, if adrenal dysfunction is
demonstrated or highly suspected [70–74].
­Dehydration
The management of hypovolemic shock focuses on resto-
ration of intravascular volume for improvement in
cardiovascular function, rather than normalization of
hydration. Dehydration is a reflection of interstitial fluid
balance, and while imperative to assess, treat, and monitor
for improvement, treating hypovolemic shock must take
 ­Dehydratio  9

Table 1.1 Commonly used vasopressors used in the emergency room and intensive care unit.

CRI dose Effect Additional information

Dopamine 1–4 μg/kg/minute
5–10 μg/kg/minute
10–20 μg/kg/minute
Dobutamine 2–20 μg/kg/minute (dogs)
2–5 μg/kg/minute (cats)
Norepinephrine 0.05–2 μg/kg/minute
Vasopressin 0.5–2 mU/kg/minute (dogs)
Vasodilation (renal) Mixed data for renal effects
Increased contractility, some
vasoconstriction
Vasoconstriction, variable contractility
effects
Increased contractility, little
vasoconstriction
Increased contractility, little Can cause seizures in cats
vasoconstriction
Potent vasoconstriction
Potent vasoconstriction (even in acidosis) Limited clinical experience in
dogs, no dose established for cats

Source: Adapted from Simmons and Wohl [65]. CRI = constant rate infusion.

priority. Interstitial fluid losses are generally gradual and
are therefore corrected over time. Prolonged or severe
dehydration can lead to hypovolemic shock. The percent-
age of dehydration (5–12%) is estimate based on physical
exam (skin turgor, sunken eyes, urine output) and objec-
tive criteria, such as PCV/TS, loss of body weight, and
urine specific gravity. The fluid deficit is determined using
the percentage of dehydration and the patient’s lean body
weight. Estimation of lean body weight is imperative
when determining the fluid prescription for obese patients,
especially cats, as significant overhydration can result if
overweight or obese body weight is used. The deficit is
then corrected over a period of 12–48 hours depending on
chronicity, patient’s tolerance to fluid therapy, mainte-
nance fluid needs, and any continuing fluid losses
(Box 1.2). In small animal patients, maintenance fluid
rates are generally 2–3 ml/kg/hour in dogs and 1–2 ml/kg/
hour in cats [75].
Electrolyte monitoring should be performed routinely
(Table 1.2) in patients with dehydration and shock. This is

Box 1.2 Fluid Therapy Prescription Formula

This formula incorporates fluid deficit (dehydration), ongoing losses, and maintenance fluid needs. It should be used
only after intravascular volume deficits (hypovolemic shock) have been corrected.
Fluid prescription fluid deficit liters continuing losses including insensible losses maintenance fluid needs
Fluid deficit liters %dehydration lean body weight kg
Rate of deficit correction is generally over 12–36 hours depending on patient stability, chronicity of dehydration, and
tolerance for IV fluids.
Maintenance needs are generally 2–3 ml/kg/hour for dogs and 1–2 ml/kg/hour for cats.
Example Fluid Prescription Calculation
25 kg mixed breed dog (lean body condition)
Estimated to be 8% dehydrated based on physical exam findings (tacky mucous membranes, prolonged skin tent,
slightly sunken globes, hyperviscous saliva in the corner of the mouth).
No conditions that would make the patient fluid intolerant; plan to correct over 24 hours.
The dog is losing approximately 60 ml in vomit every hour, no excessive gastrointestinal or urinary losses.
Deficit = 0.08 × 25
Deficit = 2000 ml
Rate of deficit correction = 2000/24 = 83 ml/hour
Fluid prescription (per hour) = 83 ml (deficit) + 60 ml (losses) + 50 ml (maintenance)
Fluid prescription = 193 ml/hour
 Table 1.2 Monitoring parameter guidelines and frequencies for dehydrated patients and those in hypovolemic, distributive, and hypoxemic shock.

Urine output/
Physical assessmenta Blood pressure SpO2 specific gravity PCV/TS/BG/Azo Stick® VBG/ABG/electrolytes

Dehydrationb 8–12 hours 8–12 hours 12–24 hours 8–12 hours 12–24 hours 12–24 hours
Hypovolemic 1–2 hours initially, then 4–6 hours 1–2 hours initially, 4–6 hours 4–6 hours 4–6 hours initially, 4–6 hours initially, then
shock once stabilized then 4–6 hours then 6–8 hours 6–8 hours
Distributive 1–2 hours initially, then 4–6 hours 1–2 hours initially, 4–6 hours 4–6 hours 6–8 hours 6–8 hours
shock once stabilized then 4–6 hours
Hypoxemic shock 1–2 hours initially, then 4–6 hours 2–6 hoursc 1–4 hoursc 4–6 hoursc 12–24 hours and after 12–24 hoursc
once stabilizedc pRBC transfusionc
a
Physical assessment parameters include hydration evaluation, mucous membranes, capillary refill time, respiratory rate and effort, cardiac and thoracic auscultation, pulse quality, and
temperature.
b
Dehydrated patients should also be weighed every 8–12 hours.
c
Frequency of diagnostics will depend on patient stability and amount of stress caused to the patient with handling, evaluation, and blood sampling.
ABG, arterial blood gases; BG, blood glucose; PCV, packed cell volume; SpO2, peripheral capillary oxygen saturation; TS, total solids; VBG, venous blood gases.

0005276422.INDD 10 04-15-2022 07:54:22

 Table 1.3 Analgesics, sedatives, and anxiolytics used in small animal medicine.

Generic drug Brand (manufacturer) Dose Comment

Opioids:
Buprenorphine Buprenex® (Reckitt & 5–20 μg/kg IM, IV q 6–8 hours μ-­partial agonist
Colman) Cats: 10–20 μg/kg PO q 6–8 hours Excellent oral absorption (cats)
Difficult to reverse
Butorphanol Torbutrol®, Torbugesic-­SA® 0.1–0.4 mg/kg IM, IV q 1-­4hours κ-­agonists
(Zoetis) Partial μ reversal: 0.05–0.1 mg/kg IV μ-­antagonist
CRI loading dose: 0.1 mg/kg IV Variable analgesia
CRI: 0.1–0.4 mg/kg/hours IV Sedative and anti-­tussive
Fentanyl Abstral® (Abbott Dog loading dose: 1–2 μg/kg Can cause SIADH with prolonged use
Laboratories) Dog CRI: 2–5 μg/kg/hours
Cat loading dose: 1 μg/kg/hours
Cat CRI: 1–4 μg/kg/hours
Fentanyl transdermal Duragesic® (Janssen Cat or dog < 5 kg: 25 μg patch Topical heat can increase absorption
patch Pharmaceuticals) Dog 5–10 kg: 25 μg patch Caution for abuse potential/ingestion by
Dog 10–20 kg: 50 μg patch children
Dog 20–30 kg: 75 μg patch
Dog >30 kg: 100 μg patch
Hydromorphone HCl Dog: 0.05–0.2 mg/kg IM, SQ, 0.05–0.1 mg/kg IV administration can cause vomiting
IV every q 4–6 hours
Cat: 0.05–0.1 mg/kg IM, S, 0.03–0.05 mg/kg
IV every q 3–4 hours
Methadone HCl Dog: 0.1–0.4 mg/kg IV every q 4–6 hours Tends to cause less sedation and vomiting
Dog: 0.2–2 mg/kg SQ, IM every q 4–6 hours than morphine
Cat: 0.05–0.2 mg/kg IV every q 4–6 hours
Cat: 0.1–1 mg/kg SQ, IM every q 4–6 hours
Morphine (preservative Dog: 0.25–1 mg/kg IM, SQ every q 4–6 hours IV administration must be done slowly to
free) Cat: 0.05–0.5 mg/kg IM, SQ every q 4–6 hours avoid histamine release, IV administration
Loading dose: 0.15–0.5 mg/kg IV can cause vomiting
CRI: 0.1–1 mg/kg/hour
Morphine sulfate (with Dog: 0.5–2 mg/kg IM, SQ every q 4 hours
preservative) Cat: 0.05–0.4 mg/kg IM, SQ every q 3–6 hours
Naloxone Narcan® (DuPont Pharma) Opioid reversal: 0.002–0.2 mg/kg IM, IV, SQ May need to be repeated after 20–30 minutes
as required
(Continued)

0005276422.INDD 11 04-15-2022 07:54:22

 Table 1.3 (Continued)

Generic drug Brand (manufacturer) Dose Comment

Oxymorphone Numorphan® (Endo Labs) Dog: 0.02–0.2 mg/kg IV every q 1–4 hours
Dog: 0.05–0.2 mg/kg IM, SQ every q 2–6 hours
Cat: 0.01–0.05 mg/kg IV every q 2–4 hours
Lidocaine:
Lidocaine 1% Dog loading dose: 1–2 mg/kg IV Controversial for IV use in cats
preservative free Dog CRI: 20–80 μg/kg/minute
NMDA antagonists:
Ketamine KetaFlo® (Abbott Sedation: 2–10 mg/kg IV, IM Caution with hypertension, heart disease
Laboratories) Loading dose: 0.5–1 mg/kg IV Controversial in head trauma, increased
Ketaset® (Fort Dodge CRI: 0.1–0.6 mg/kg/hour ICP/IOP, renal disease (cats)
Animal Health)
Vetamine®
(Schering-­Plough)
Alpha-­2 Adrenergics
Dexmedetomidine HCl Dexdomitor® (Pfizer) Sedation: 1–10 μg/kg IV, IM Caution with cardiovascular disease or
Loading dose: 0.5–1 μg/kg IV instability
CRI: 0.25–3 μg/kg/hour
Atipamezole Antisedan® (Pfizer) Alpha-­2 Adrenergic reversal: 0.05–0.2 mg/ Same volume as dexmedetomidine given IM
kg IV, IM
Benzodiazepines:
Midazolam 0.1–0.5 mg/kg IM, IV
CRI: 0.1–0.5 mg/kg/hour
Diazepam 0.1–0.5 mg/kg IV Propylene glycol vehicle; avoid prolonged IV
CRI: 0.1–0.5 mg/kg/hour use or IM injection
Flumazenil Benzodiazepine reversal: 0.01–0.02 mg/kg May need to be repeated after 20–30 minutes
IV as required
Phenothiazines:
Acepromazine Aceproject® (Fort Dodge 0.005–0.01 mg/kg IV every 4–6 hours Caution in hypovolemia
Animal Health) 0.01–0.05 mg/kg IM, SQ every 4–6 hours Do not exceed 2 mg/kg in large dogs
Non-­steroidal anti-­inflammatory drugs:
Carprofen Rimadyl® (Pfizer) Dogs: 2–4 mg/kg IV, SQ (single dose) IV or SQ should only be given when
Dogs: 2 mg/kg PO 12 or 4 mg/kg PO once normothermic/normotensive
daily24 hours
Deracoxib Deramaxx® (Novartis) Dogs: 1–2 mg/kg/day

0005276422.INDD 12 04-15-2022 07:54:22

 Generic drug Brand (manufacturer) Dose Comment

Meloxicam Metacam® (Boerhringer Dogs: 0.1–0.2 mg/kg IV, SQ (single dose) Black box warning for cats
Ingelheim) Dogs: 0.1 mg/kg PO or transmucosal once Transmucosal oral spray for dogs > 2.5 kg
OroCAM® (Abbott daily
Laboratories)
Piroxicam Feldene® (Pfizer) Dogs: 0.3 mg/kg PO once daily
Robenacoxib Onsior® (Novartis) Dogs: 2 mg/kg SQ 30 minutes before start of Do not divide/break/crush feline tablets,
surgery then every q 24 hours for a therefore, dose range in cats of 1–2.4 mg/kg
maximum of 3 days Do not use in dogs or cats less 4 months of
Dogs: 1–2 mg/kg PO once daily age
Cats: 2 mg/kg SQ 30 minutes before start of Do not use tablets in cats < 2.5 kg
surgery then every q 24 hours for a
maximum of 3 days
Cats: 1 mg/kg PO once daily for a maximum
of 3 days

Source: Adapted from Quant and Lee JA [105] and Perkowski [106].
CRI, constant rate infusion; ICP, intracranial pressure; IM, intramuscularly; IOP, intraocular pressure; IV, intravenously; NMDA, N-­methyl-­d-­aspartate; PO, per os (orally); SIADH, syndrome
of inappropriate anti-­diuretic hormone.

0005276422.INDD 13 04-15-2022 07:54:22

14 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
particularly true in anorexic patients or those with renal
dysfunction, which may require supplementation with
potassium and/or phosphorus. Additionally, as many flu-
ids used in veterinary medicine are designed as “replace-
ment” and not “maintenance” fluids, sodium values may
increase in patients receiving prolonged intravenous fluid
therapy, particularly in patients with continued free water
loss, such as renal, gastrointestinal, skin, and respiratory
loss. Fluids with lower sodium concentrations such as
Normosol-­M, 0.45% NaCl, and dextrose 5% in water (D5W)
may be necessary to prevent or manage hypernatremia
associated with prolonged fluid therapy and/or concurrent
hypotonic fluid losses.
Fluid therapy in the burned veterinary patient requires
special consideration, especially with respect to percentage
of total body surface area affected. For information on fluid
therapy for the burned patient, see Chapter 53.
Regardless of fluid type and rate used to treat shock and
or dehydration, frequent patient reassessment is critical.
General recommendations for patient re-­evaluation are
listed in Table 1.2.
­Neurologic Assessment
Initial neurologic assessment often occurs concurrently
with respiratory and cardiovascular triage. Patients with
normal consciousness are alert and aware of their environ-
ment. Obtunded patients have decreased responsiveness
that can vary in severity. Stuporous patients are only
responsive to noxious or excessive stimuli, whereas coma-
tose patients do not respond to any stimuli. Decreased cer-
ebral perfusion and oxygenation from hypovolemic,
hypoxemic, distributive, and cardiogenic shock can have
profound effects on mentation, so the patient’s initial neu-
rologic assessment must be made with patient’s global per-
fusion status in mind. In both veterinary and human
patients with traumatic brain injury, most have also sus-
tained concurrent injuries to other major body systems
that can have secondary neurologic consequences [76, 77].
Hypoglycemia (metabolic shock) can also lead to decreased
mentation and must be treated before an accurate neuro-
logic examination can be performed. As with other body
systems, frequent neurologic reassessment is imperative.
While performing the neurologic evaluation, until ade-
quate oxygenation is confirmed, supplemental oxygen
should be provided by mask, flow by, or placement of the
patient in an oxygen cage. In patients with head trauma,
nasal prongs or nasal oxygen catheter are avoided to
decrease the risk of sneezing, which can increase their
intracranial pressure (ICP). Heart rate and blood pressure
values can also provide important insight about the pres-
ence of increased ICP. The Cushing’s reflex, which is
hypertension and reflex bradycardia, is commonly seen in
patients with cerebral edema, hemorrhage, skull fractures,
and intracranial masses. To maintain cerebral perfusion
pressure (CPP) in the face of intracranial hypertension,
arterial blood pressure (MAP) is increased, since CPP
equals MAP minus ICP. Pressure receptors in the aortic
arch and carotid bodies trigger a decreased heart rate in
response to the increase systemic blood pressure. Treatment
of intracranial hypertension is imperative and is accom-
plished with a combination of patient positioning and
pharmacologic intervention with mannitol or hypertonic
saline. If there is any evidence of or concern for head
trauma or ICP, the patient’s head should be elevated
15–30 degrees using a flat board or other rigid surface.
Pillows should not be used to elevate the patient’s head, as
this can cause compression of the jugular vein(s), which
impairs cerebral venous outflow. Jugular venipuncture
should also be avoided. Mannitol (0.25–1 g/kg IV over
15–20 minutes) is an effective osmotic diuretic to decrease
intravascular volume and facilitate fluid movement from
the central nervous tissue, as with cerebral edema. The
resultant diuresis will lead to dehydration if mannitol
administration is not followed by intravenous fluid therapy
in patients that cannot or will not drink. Hypertonic saline
(7.5%, 3–5 ml/kg IV over 15–20 minutes in dogs, 2–3 ml/kg
IV over 15–20 minutes in cats) is also effective for treating
intracranial hypertension secondary to cerebral edema and
works via free water osmotic shifting out of the tissue and
into the hypertonic intravascular space created by the
increased sodium load [78]. Concentrated (21%) sodium
chloride can be combined with 0.9% saline to create a 7.5%
solution by mixing 17 ml of 21% saline with 43 ml of crys-
talloid. The use of corticosteroids is contraindicated in
patients with head trauma, as they can contribute to gas-
trointestinal ulceration, especially after an episode of
hypoperfusion, and precipitate hyperglycemia, which has
been associated with a worsened neurologic injury in vet-
erinary patients [79].
Veterinary patients with any history of or concern for cer-
vical or spinal trauma should be secured to a backboard until
a complete assessment of injuries is performed. In trauma
patients, assessment of cranial nerves, visual examination for
external signs of head trauma, and any abnormalities of body
position, spinal reflexes, and the presence or absence of pain
sensation should be determined before administration of
drugs that may impact interpretation of findings, including
analgesics and atropine. However, assessment for the pres-
ence of a head tilt, physiologic nystagmus, and postural
reflexes should only be performed if it is safe to move the
patient’s neck and limbs. Body position changes that can be
seen in patients with trauma, spinal cord lesions, or intracra-
nial disease include Schiff–Sherrington (forelimb extensor
rigidity and hindlimb flaccidity associated with a T2-­L4

spinal cord lesion), decerebrate rigidity (neck extension,
hyperextension of all four limbs, and decreased conscious-
ness), and decerebellate rigidity (thoracic limb hyperexten-
sion, variable changes in the pelvic limbs, and appropriate
consciousness).
A veterinary modified Glasgow Coma Scale score
(mGCS) has been developed and evaluated retrospectively
for assessing the severity of neurologic injury [80]. Scores
are determined after assessment of level of consciousness,
cranial nerve function, and motor function with higher
scores (15–18) being associated with a better prognosis
than lower scores (3–8 for grave prognosis and 9–14 for
poor to guarded). Scoring and exact prognostication should
be performed with caution however, since the mGCS has
not been prospectively evaluated and patient scores may
improve with therapeutic intervention and time. In a study
of injured dogs and cats for whom the mGCS was used as
part of trauma scoring for a veterinary trauma database,
mGCS scoring system corresponded with outcome in dogs
and cats with known head trauma [81, 82].
For patients with deficits in conscious proprioception,
motor function, and pain sensation, spinal reflexes should
be used for neurolocalization of spinal cord dysfunction to
segments C1–C5, C6–T2, T3–L3, L4–S1, and S1–S3.
Common causes of spinal cord disease in veterinary
patients include intervertebral disc disease (IVDD),
trauma, neoplasia, vascular events, and infectious/inflam-
matory processes. Surgical intervention could be indicated
for traumatic, neoplastic, and IVDD, especially those con-
ditions resulting in neurologic dysfunction. Patients with
rapidly progressive neurologic changes and loss of deep
pain may require emergency diagnostic imaging and surgi-
cal intervention, especially if IVDD is the cause. Patients
with cervical lesions (C1–C5) are at risk of ventilatory fail-
ure due to phrenic and intercostal nerve involvement, par-
ticularly after surgical decompression, as there will be the
added impact of secondary surgical swelling and hemor-
rhage. Respiratory pattern, effort, and objective measures
of ventilation (PvCO2 or PaCO2) should be monitored very
closely. Changes in oxygenation (PaO2 and SpO2) as a result
of ventilatory failure may be late findings and should not
be the sole determinant of effective ventilation and respira-
tion. Mechanical ventilation may be necessary in patients
with cervical lesions and should be anticipated in all post-
operative patients with cervical neurolocalization.
­Urinary Assessment
Many injuries and abnormalities of the urinary tract are
not readily apparent on initial triage and physical examina-
tion. Historical information from the pet owner regarding
changes in water consumption, urine production, stranguria,
­Urinary Assessmen  15
pigmenturia, and recent trauma can raise suspicion for
urinary tract dysfunction, however, some patients have vague
and non-­specific historical signs. For example, many male
cats with urethral obstruction present for lethargy and/or
constipation, as many owners are unable to differentiate
stranguria from tenesmus.
After respiratory, cardiovascular, and neurologic assess-
ments have been performed and treatment of urgent
abnormalities initiated, assessment of the urinary tract can
be performed. Palpation for a urinary bladder should be
performed in all patients to assess for urethral obstruction,
which causes a large, firm, painful, bladder that is unable
to be expressed. Palpation of a bladder in trauma patients
does not rule out injury and leakage, as small tears may not
completely decompress the bladder. Additionally, lack of a
palpable bladder is not always synonymous with rupture,
as the bladder may not be palpable due to small size from
dehydration, recent expression, or anuric or oliguric renal
failure. Ultrasound is a useful tool in the emergency room,
especially for urinary tract assessment. A standardized
technique for abdominal ultrasonographic assessment in
veterinary trauma patients has been created and validated.
In human medicine, a similar technique has largely
replaced the need for diagnostic peritoneal lavage in blunt
abdominal trauma patients. Focused assessment sonogra-
phy for trauma (FAST) has been validated to determine
whether free fluid is present in the abdominal cavity after
trauma [83]. It is a more sensitive diagnostic for free fluid
than the presence of a palpable fluid wave, which requires
at least 40 ml/kg of fluid within the peritoneal cavity. Using
ultrasound in transverse and longitudinal planes, and the
patient in lateral recumbency, the abdomen is evaluated at
the gravity dependent and independent flanks (in the
region of the kidneys), over the bladder, and below the
xiphoid. If needed, ultrasound guidance or blind abdomi-
nocentesis via a one-­ or four-­quadrant closed needle/
syringe technique can be used to collect any free fluid. In
many patients with significant dehydration, free fluid may
not be present in the peritoneum initially, and serial moni-
toring as the patient is rehydrated should be performed.
Once fluid is obtained, PCV/TS, glucose, lactate, creati-
nine, potassium, cytology, and culture can help determine
the etiology of the effusion. In dogs, a fluid to blood creati-
nine ratio of greater than 2 : 1, and fluid to blood potassium
ratio of greater than 1.4 : 1 is supportive of a diagnosis of
uroabdomen [84]. In cats, a fluid to blood creatinine ratio
of 2 : 1 and fluid to blood potassium ratio of 1.9 : 1 is sup-
portive of a diagnosis of uroperitoneum [85, 86].
Initial bloodwork may reveal azotemia, which could be
due to prerenal, renal, or post-­renal causes. Assessment of
urine specific gravity in conjunction with azotemia and
PCV/TS can help to determine the etiology, but it may not
be feasible or safe to obtain a urine sample during triage
16 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient

and before initiation of fluid therapy. This is especially true

of female dogs and cats, and male cats where sedation for
catheter placement is often necessary. Cystocentesis may
be contraindicated in patients where there is any concern
for coagulopathy, thrombocytopenia, or thrombopathia.
An assessment of prerenal azotemia is therefore often
made on physical examination findings and evidence of
hemoconcentation without concurrent urine specific grav-
ity. In these cases, improvement or resolution of azotemia
in response to fluid therapy and rehydration helps to sup-
port the diagnosis of prerenal azotemia. For stabilization of
the uremic patient, please refer to Chapter 22. (a)
Urine drainage techniques can be useful for exact urine
production quantification and management of urine
leakage. Urinary catheterization can be very helpful in
patients with urinary trauma to document appropriate
urine production, maintain bladder decompression in
patients for whom concern over bladder or urethral
trauma exists, and for patient comfort and ease of man-
agement in non-­ambulatory patients. However, this use is
controversial owing to the risk of ascending urinary tract
infections, particularly in a hospital setting. Urinary cath-
eterization is easy to perform in most male dogs without
sedation, but placement in female dogs and male and (b)
female cats requires heavy sedation and can be more tech-
Figure 1.7 Distal end of a locking loop, or pigtail, catheter. The
nically challenging, especially in small female dogs catheter coil is straightened over a stylet and trocar for
(Figure 1.6). Urinary drainage with locking loop or “pig- placement (a), and then locked into the loop configuration using
tail” catheters in the peritoneum can be helpful to facili- the suture upon removal of the stylet and trocar (b).
tate urine drainage and permit patient stabilization in
preparation for surgical intervention when a uroabdomen nephrostomy tube when there is a ureteral obstruction or
is present (Figure 1.7a,b). The same catheters can be used ureteral injury [86, 87].
in the bladder for decompression when transurethral
catheterization is not possible, and in the renal pelvis as a
­Vascular Access

Vascular access is critical in emergency patients, especially

Figure 1.6 Cadaveric dissection of the urethral papilla in a
female dog, which is the major landmark used when performing
urinary catheterization.
those undergoing surgery. Peripheral venous catheters are
most commonly used, since they are relatively inexpensive,
widely available, and can be placed quickly in emergency
situations. However, they do not usually allow for repeated
blood sample collection and are not appropriate for hyper-
osmolar fluids, including total or partial parenteral nutri-
tion (TPN, PPN). These catheters can also be dislodged,
soiled, and if a small-­bore catheter is used, they will not
permit rapid administration of large volumes of fluids or
medications. Vessels commonly used for peripheral cathe-
ters in small animal patients are the cephalic or accessory
cephalic veins, lateral saphenous vein, or distance branches
the medial saphenous vein [88]. Clipping of the hair and
sterile preparation of the site are preferred, but not possible
in all emergency situations. Failure to adequately prepare
the skin prior to catheter placement has been associated

with increased positive bacterial cultures compared with
those that were aseptically placed [89]. In severely hypov-
olemic patients for whom these vessels cannot be cannu-
lated percutaneously, surgical cut-­down to facilitate
vascular access can be performed quickly and safely in
small animal patients. Catheters placed without adequate
skin preparation and sterile technique or with an emer-
gency surgical cut-­down procedure should be considered
temporary and removed once additional vascular access is
obtained and the patient is more stable to prevent infection.
When repeated blood sample collection is anticipated, or
for administration of multiple fluids or medications simulta-
neously, including TPN or PPN, central venous catheteriza-
tion should be considered. Central catheters can have up to
four lumens, which is convenient for concurrent adminis-
tration of several intravenous therapies. If administration of
parenteral nutrition is anticipated, one lumen should be
reserved specifically for this use and labeled accordingly.
Central catheters are generally placed in larger vessels,
including the jugular vein and medial and lateral saphenous
veins. They are most commonly placed using the Seldinger,
or over the wire, technique (Video 1.3). Surgical cut-­down
for vascular access for Seldinger technique or venotomy and
through the needle (BD Intracath, Argon Medical Devices,
Franklin Lakes, NJ) catheters can also be used. Regardless of
the technique for placement, since a large vessel is being
accessed, adequacy of primary and secondary hemostasis
must be confirmed prior to placement [88, 90]. Strict aseptic
technique must be followed. It is also important to have ade-
quate patient restraint, which generally requires sedation or
anesthesia, since maintenance of positioning and discom-
fort of vessel dilation is not well tolerated by many awake
patients. The catheter is secured to the skin with sutures,
and the insertion site covered by a protective wrap.
Video 1.3 Placement of a jugular multi-­lumen catheter
using Seldinger technique after a peripheral catheter has
been placed in the jugular vein.
When intravenous catheterization is not possible, which
is often the case in neonatal and small pediatric patients,
intraosseous (IO) catheterization provides a rapid, safe
method for delivery of fluid therapy and medications. This
is because the capillary network within the marrow cavity
is in direct communication with the nutrient and emissary
veins that drain into the central circulation. Crystalloids,
colloids, blood products and medications, including those
for cardiopulmonary resuscitation, can be administered via
the IO route and can be absorbed rapidly enough to be
effective for the treatment of hypovolemic shock and car-
diopulmonary arrest [91–96]. Sites commonly used for IO
catheterization include the trochanteric fossa of the femur,
proximal tibia, tibial tuberosity, wing of the ileum, the
­Vascular Acces  17
ischium and greater tubercle of the humerus [88, 92], with
the trochanteric fossa and tibia used most commonly.
Contraindications of placement of an IO catheter include
fracture of the bone intended for cannulation, pneumatic
bones in birds, and evidence of infection near the intended
catheter site. Bone growth is not impacted by IO catheteri-
zation [95]. IO catheterization can be achieved with a vari-
ety of techniques, including standard hypodermic needles
and spinal needles, IO infusion needles, a spring-­loaded
penetration injection gun (Vet B.I.G Bone Injection Gun
(15-­G), WaisMed Ltd, Houston, TX) and an automatic
rotary insertion drill (EZ-­IO (15-­G Pediatric Needle Set),
Vidacare Corporation, San Antonio, TX.). In a cat cadav-
eric study comparing these devices, the injection gun was
found to be faster and easier to use, but there were no dif-
ferences detected between insertion site (humerus or tibia),
complications or success between the injection gun, rotary
drill or manual IO catheter [96].
Direct arterial blood pressure measurement should be
considered in any hemodynamically unstable patient. It
allows for continuous, accurate pressure determination in
the face of hypotension, hypertension, and arrhythmias.
Indwelling arterial catheters can also be used to obtain
blood samples, particularly for arterial blood gas analysis.
Arteries generally accessible for percutaneous placement
of an arterial catheter include the dorsal metatarsal artery
(most commonly used), the coccygeal artery in the tail, the
auricular artery in the dorsal pinna, the femoral artery, and
the radial artery [88, 97–99]. Maintenance of arterial cath-
eters in all locations, except for the dorsal metatarsal artery,
is difficult in mobile patients and is generally reserved for
use in sedated or anesthetized patients. Femoral, dorsal
metatarsal, and coccygeal artery catheters can also become
contaminated with urine and/or feces, so consideration of
these issues is important prior to catheter placement. Cats
tend to have poor collateral circulation. It is not recom-
mended to leave arterial catheters in cats for longer than
six to eight hours because of concern for ischemic injury to
the tissues distal to the catheter [97]. Contraindications for
arterial catheterization include lack of close monitoring
capabilities, thrombocytopenia, thrombocytopathia, and
coagulopathy.
Once the course of the artery is determined by palpation
and the site is aseptically prepared, an over-­the-­needle cath-
eter is used to puncture the artery from an angle of
15–30 degrees above the vessel. Pulsatile blood flow will be
observed in the hub of the catheter upon successful arterial
cannulization. If percutaneous placement of an arterial cath-
eter is not possible, access to the dorsal metatarsal or femoral
artery can be achieved with a surgical cut-­down or ultra-
sound guidance [98]. Care must be taken to avoid damaging
the artery, femoral vein, or sciatic nerve during the initial
18 Triage and Initial Stabilization of the Emergency Small Animal Surgical Patient
skin incision and approach to the femoral artery. The cathe-
ter is secured with tape and/or sutures depending on the
catheter type placed and placement method use. Once the
arterial catheter is in place, it can be used to collect arterial
blood samples after an adequate pre-­sample of blood is taken
(generally 3–6 ml of blood into syringes with small amounts
of heparinized saline). Clear labeling of an arterial catheter is
imperative to ensure that only heparinized saline is injected
into the artery. Blood collected from the artery as a pre-­
sample and medications should never be injected into the
arterial catheter. The catheter can also be connected to non-­
compliant tubing with heparinized saline and a pressure
transducer for continuous arterial blood pressure monitoring.
­Analgesia, Sedation and Anxiolytics
The need for sedation and anxiolytics in the stressed or scared
veterinary patient and timely analgesics for those in pain
cannot be overstated. This is particularly true in patients
needing emergency surgery, as many conditions requiring
emergency surgical intervention create significant discom-
fort or pain. Anxiety and stress are present in many patients
with respiratory compromise, especially those with upper
airway obstruction, and should be addressed immediately to
provide relief for the patient and more accurate patient
assessment. As with other body systems, frequent reassess-
ment is necessary to ensure adequate analgesia and patient
wellbeing. Pain can be challenging to assess accurately in
hospitalized feline patients, as they tend to be quieter and
more reserved than canine patients [100, 101].
If a patient is assessed to be in pain, analgesics should
be administered as soon as possible. It is not appropri-
ate to withhold analgesia because of concerns about
creating cardiovascular or respiratory instability or
masking changes in patient status. When titrated doses
of cardiovascular sparing analgesics and anxiolytics are
used, primary cardiovascular or respiratory depression
should not result. Instead, if hypotension or respiratory
changes are seen after drug administration, it is more
likely that the patient’s cardiopulmonary instability was
uncovered by relief of pain-­induced tachycardia,
tachypnea, and catecholamine release with secondary
vasoconstriction [100].
Multimodal analgesia is preferred in many patients, espe-
cially those with marked pain, as the complexity of pain
pathways often renders single agent therapy ineffective, irre-
spective of dose escalation [101]. The addition of local anal-
gesics is often beneficial to decrease the systemic dose. The
addition of anxiolytics may also be helpful to decrease
the stress and agitation associated with hospitalization,
recumbency, and activity restriction present in many surgical
patients, and therefore decrease systemic analgesic dosing.
Opioids are often the first choice of analgesia in critical
veterinary patients as they have rapid onset of action, can
be titrated to an individual’s needs, are reversible, and are
cardiopulmonary sparing medications. They can be used
alone or in combination with other analgesics and anxio-
lytics and administered as a bolus or constant rate infusion
(CRI). Common adverse effects include initial excitatory
phase, nausea, vomiting, bradycardia, decreased gastroin-
testinal motility, and respiratory depression at high doses.
Cats tend to be more prone to developing an excitatory
period, so the dose of opioids in cats is generally half the
canine dose. Rapid intravenous administration of mor-
phine or meperidine can cause histamine release, vasodila-
tion, and hypotension. If adverse effects result from opioid
administration, naloxone is a pure antagonist for opioid
reversal. Naloxone will reverse both the positive and nega-
tive effects of opioids, which may result in pain, excite-
ment, and agitation. Fentanyl transdermal patches are
effective ways to provide potent analgesia in an outpatient
setting, but they can become displaced or ingested, and
have the potential for misuse and abuse by owners, includ-
ing ingestion by small children.
Lidocaine is effective as a local anesthetic and epidural
analgesic. It can also be administered as an intravenous
CRI, generally combined with an opioid such as morphine
or fentanyl, with or without the addition of a ketamine
CRI. When given intravenously, it should be used cau-
tiously and titrated carefully in cardiovascularly unstable
patients, as it can cause cardiac arrhythmias, tachycardia,
and seizures. This is especially true in cats, and some
debate exists as to whether this medication should be given
intravenously to cats for analgesia.
N-­methyl-­d-­aspartate (NMDA) antagonists such as keta-
mine are very effective, owing to their multiple sites of
action and effects, including analgesia, neuroprotection,
and sedation. Ketamine has limited cardiopulmonary
depression but can increase cardiac output and myocardial
oxygen consumption, and it can cause muscle tremor activ-
ity. Controversy exists over its use in patients with head
trauma as there is concern that ketamine contributes to
increased ICP. It should be used with caution in patients
with hypertension and cardiovascular disease. In cats, it is
renally excreted so consideration for renal function with
use and dose should be given.
Alpha 2 (α2) adrenergic agonists, such as dexmedeto-
midine, bind central α2 receptors to result in sedation,
muscle relaxation, and analgesia. Additional effects
include vasoconstriction, reflex bradycardia, and diure-
sis. Dexmedetomidine should be used cautiously in criti-
cally ill patients and should be reserved only for patients
without cardiovascular disease or compromise. At low
doses (1–5 μg/kg IV), dexmedetomidine is synergistic
with opioids for analgesia and can be used as a bolus or

CRI. Its effects can be reversed with the α2 receptor
antagonist atipamezole. The volume of atipamezole used
for reversal is the same volume as the administered dex-
medetomidine. Intramuscular administration of atipam-
ezole is preferred to prevent rapid drug reversal, which
can cause hypotension or aggression [102–104].
Benzodiazepines are effective for mild sedation and anxi-
olysis with minimal cardiovascular compromise. They are
commonly combined with opioids for analgesia and seda-
tion and can decrease the dose of opioids needed to achieve
the desired effect. Midazolam and diazepam can be given
intravenously, but only midazolam can be given intramus-
cularly and is preferred for CRI therapy due to the propyl-
ene glycol vehicle of diazepam. Reversal of both agents can
be accomplished with intravenous dosing of flumazenil.
Phenothiazines, such as acepromazine, provide no
analgesia but are potent anxiolytics in veterinary medi-
cine. They must be used cautiously in cardiovascularly
unstable patients as they can cause profound vasodila-
tion and hypotension. They are especially useful in
patients with respiratory distress, particularly upper air-
way obstruction. However, intravenous acepromazine
­Analgesia, Sedation and Anxiolytic  19
takes approximately 15 minutes to achieve maximal
effect, so this delay in onset of action should be antici-
pated in patients [101]. This is important in patients in
respiratory distress, for whom this delay may not be tol-
erated, and more rapidly acting medications should be
selected.
Non-­steroidal anti-­inflammatory drugs (NSAIDs) have
a limited role in treating pain and inflammation in many
emergency patients, especially those with gastrointesti-
nal and renal disease or cardiovascular compromise.
Even NSAIDs that can be administered parenterally
should be used with extreme caution in patients with
perfusion abnormalities, as they can increase the risk of
gastrointestinal ulceration, hepatic insult, and kidney
injury. NSAIDs are generally not recommended for cats,
unless given as a single dose in healthy, hydrated, and
normovolemic cats. An NSAID designed for safer use in
cats (robenacoxib) is available, but extensive clinical
experience is lacking. However, postoperatively, when
perfusion is restored and normalized, many surgical
patients benefit from control of inflammation and the
analgesia achieved with NSAID therapy.
20
Operating Room Nursing Tips for Emergency Surgical Procedures
Cami Elliott1, Michelle Capps2, and Michael McCallum2
1
Nashville Veterinary Specialists and Animal Emergency, Nashville, TN, USA
2
University of Pennsylvania, School of Veterinary Medicine, Philadelphia, PA, USA
­Gastrointestinal System
Most gastrointestinal procedures can be performed with
routine instruments, with a few additional items supplied
as needed. It may be beneficial to establish a routine soft
tissue instrument set, such as the one listed in Box 2.1.
Unless otherwise noted, patients will be placed in dorsal
recumbency for gastrointestinal surgeries. It is also of ben-
efit to have a variety of sizes of containers and formalin
available for biopsies taken during gastrointestinal surgery.
Esophageal Surgery
A lodged esophageal foreign body is the most common
indication for esophageal surgery and the location of the
foreign body will determine the approach. The cervical
esophagus is exposed through a ventral midline approach
and the thoracic esophagus is approached via a lateral thor-
acotomy. Recommended instruments will depend on the
approach chosen and are listed in Box 2.2.
Gastrointestinal Foreign Bodies
When preparing the operating room for a gastric or intesti-
nal foreign body surgery the technician should keep in
mind that a gastrotomy, enterotomy, or intestinal resection
and anastomosis could be performed. To prepare for these
events, consider that preventing the spillage of ingesta into
the abdominal cavity is of key concern. Sterile lap sponges,
lavage, and suction are crucial in preventing contamina-
tion and peritonitis. Portable suction machines are availa-
ble if the operating room is not equipped with wall suction
(Box 2.2, Figures 2.1 and 2.2).
Small Animal Surgical Emergencies, Second Edition. Edited by Lillian R. Aronson.
© 2022 John Wiley & Sons, Inc. Published 2022 by John Wiley & Sons, Inc.
Companion website: www.wiley.com/go/aronson/surgical
Rectal Prolapse
A prolapsed rectum can be reduced and retained in its nor-
mal position by applying a purse-­string suture around the
circumference of the anus. Nylon suture (3-­0) on a straight
needle is ideal for this purpose. Prior to reducing the pro-
lapse, white granulated sugar can be applied to the pro-
lapsed tissue to alleviate some of the tissue edema. A
routine soft tissue instrument set should be sufficient, with
the addition of a culturette due to the location of the sur-
gery and concern for contamination. The patient is posi-
tioned in sternal recumbency in Trendelenburg position if
the surgery table tilts. Alternatively, a rectal stand to ele-
vate the caudal end of the patient to approximately shoul-
der level of the surgeon can be used.
Hemoabdomen
When preparing an operating room for a patient with a
hemoabdomen, the first step upon entering the abdomen
will be to remove the accumulated blood to visualize the
source of hemorrhage. See Figure 2.1 for suction and lav-
age instrumentation. In addition to the routine soft tissue
instrument set, sterile suction tubing to connect to wall-­
mounted or portable suction and additional suction can-
isters should be available, depending on the volume of
fluid to be removed. A Balfour retractor will be helpful
for abdominal wall retraction while the surgeon com-
pletes a thorough examination of the abdomen to iden-
tify the source of hemorrhage. Monopolar cautery and a
bipolar vessel-­sealing device (LigaSure™) are helpful in
controlling hemorrhage and expediting the surgical
procedure.
 ­Gastrointestinal Syste  21

Box 2.1 Routine Soft Tissue Instrument Set

●● 3 straight and 1 curved carmalt forceps
●● 4 Allis tissue forceps
●● 8 Kelley forceps
●● 6 mosquito forceps
●● 4 large Backhaus towel clamps
●● 10 small Backhaus towel clamps
●● 2 needle drivers
●● Poole suction tip
●● 2 Army Navy retractors
●● 2 Parker retractors
●● 2 basins
●● #3, #4 scalpel handles
●● Debakey thumb forceps
●● Brown–Adson thumb forceps Figure 2.1 Balfour retractor (bottom left), Poole suction tip (top
left), sterile suction tubing (bottom right), and suction canister
●● Rat-­tooth forceps
(top right) for abdominal lavage.
●● 20 4 × 4 gauze sponges

Box 2.2 Instruments for Gastrointestinal Surgery

●● Routine soft tissue instrument set
●● Balfour retractor (used for ventral midline abdominal
approach)
●● Sterile suction tubing
●● Suction canister
●● Monopolar and bipolar cautery (bipolar cautery
should be available for esophageal surgery)
●● Doyens intestinal clamps
●● Lap sponges
●● Suture for enterotomy closure
●● 25-­gauge needle and 5–10 cc syringe for performing
a leak test after enterotomy closure
●● See Box 2.12 for additional instruments necessary for
a lateral thoracotomy approach and closure.

Biliary Emergencies Figure 2.2 Portable suction machine.

In cases of biliary obstruction due to choleliths, cholecysti-

tis, pancreatitis, neoplasia or gallbladder mucocele, either Box 2.3 Instruments for Biliary Surgery
biliary duct stenting for reversible obstruction or cholecys-
Routine soft tissue instrument set
tectomy or cholecystoenterostomy for non-­reversible
●●

Monopolar and bipolar cautery

obstruction can be performed. Instruments recommended
●●

Balfour retractor
for biliary emergencies are listed in Box 2.3.
●●

●● Sterile suction tubing

●● Suction canister
Liver Lobectomy ●● Lap sponges
Culturette
For a liver lobectomy procedure in which there is potential
●●

Hemoclips® or Surgiclips™
for significant hemorrhage, a bipolar vessel sealing device
●●

± Covidien™ feeding tube and red rubber urethral

(LigaSure) can be beneficial in providing hemostasis in areas
●●

catheter (Kendall™) for common bile duct stenting

where ligations by hand would be difficult. The LigaSure
22 Operating Room Nursing Tips for Emergency Surgical Procedures

handpieces come in a variety of shapes, such as the Precise,
Impact, and Atlas. The Atlas comes in an assortment of
lengths, diameters and with blunt and tapered tips. In addi-
tion, Hemoclips, Ligaclips®, and Surgiclips are valuable
additions to your operating room instrumentation when
there is high risk for hemorrhage because they can be
applied quickly and securely to vessels. Removal of the
affected liver lobe can be achieved using a stapling device,
such as the TA™ or GIA™ vascular stapler, which applies
two to four rows of interlaced staples. For reference, the TA
Auto Suture vascular stapler by Covidien comes in cartridge
lengths of 30 mm, 55 mm, or 90 mm, with staple widths
ranging from 3–4 mm and staple height ranging from
2.5–4.8 mm. For larger tissue resections, the GIA stapler
comes in cartridge lengths of 50 mm, 60 mm, 80 mm, and
90 mm, with staple widths from 3–4 mm and staple heights
ranging from 2.5–4.8 mm. Other hemostatic agents include
Vetspon® absorbable hemostatic gelatin sponge (gel foam)
and oxidized regenerated cellulose (Surgicel®). Both are
applied to a site of hemorrhage to aid in clot formation and
can be left in place indefinitely until eventually absorbed or
removed during surgery once hemostasis is achieved. The
instruments needed are listed in Box 2.4.
­Urinary System
Ureteral Surgery
Instruments used for ureteral surgery are listed in Box 2.5
and shown in Figures 2.6–2.10.
Urethral Surgery
Perineal Urethrostomy in Cats: Patient Positioning
A perineal urethrostomy can be performed in sternal
recumbency with the patient’s hind legs hanging over the

Box 2.4 Instrumentation for Hepatic Surgery

●● Routine soft tissue instrument set
●● Balfour retractor
●● Monopolar cautery
●● Sterile suction tubing
●● Multiple suction canister
●● Lap sponges
●● Stapling equipment (Figure 2.3 and Table 2.1)
●● Vessel sealing device (LigaSure) (Figure 2.4)
●● Weck Hemoclips®, Ethicon Ligaclips®, or Covidien
Surgiclips® (Figure 2.5)
●● Vetspon absorbable hemostatic gelatin sponge
(Figure 2.5)
●● Oxidized regenerated cellulose (Figure 2.5)

Figure 2.3 Stapling device and cartridge options.

Table 2.1 Stapling cartridge information chart.

Staplesa
Instrument
cartridge Width × height (mm) Closed height (mm) Configuration

TA 30. 55. 90 blue 4.0 × 3.5 1.5 Double staggered row of staples
TA 30. 55. 90green 4.0 × 4.8 2.0 Double staggered row of staples
TA 30–V3 whiteb 3.0 × 2.5 1.0 3 staggered rows
GIA 50 4.0 × 4.0 1.75 4 staggered rows of staples with a cut
GIA 60 3.0 × 2.5 1.0
GIA 60 or 80 3.0 × 3.85 1.5 between 2
GIA 90 4.0 × 4.0 1.75
a
Absorbable staples: PDS and glycolic acids; stainless steel 316 l.
b
Vascular.
 ­Urinary Syste  23

Figure 2.5 An assortment of Hemoclip® and Ligaclip® sizes,

Figure 2.4 The bipolar vessel sealing device (LigaSure,
Medtronics, Dublin Ireland), comes in many size and shape
options. The device aides in decreasing intraoperative and
postoperative hemorrhage.
Surgicel®, Vetspon® (Gel-­foam®), and Surgiclip® applicator
(bottom). Both Gel-­foam and Surgicel are applied to a site to
aid in clot formation and can be left in place indefinitely until
eventually absorbed, or they can be removed during surgery
once hemostasis is achieved.

instruments are listed in Box 2.6 and illustrated in

Box 2.5 Instrumentation for Ureteral Surgery
Figures 2.13 and 2.14.
●● Routine soft tissue instrument set
●● Balfour retractor Retrograde Hydropulsion in Dogs
●● Sterile suction tubing Retrograde hydropulsion in dogs can be used to flush ure-
●● Suction canister thral calculi back into the urinary bladder to relieve ure-
●● Sterion® Silicone vessel loops thral obstruction prior to a cystotomy for stone retrieval.
●● Weck-­Cel® cellulose eye spears Instruments necessary for this technique are listed in
●● Microsurgical needle holders (cats and small dogs) Box 2.7.
●● Microsurgical scissors (cats and small dogs)
●● Microsurgical forceps (cats and small dogs) Urethrostomy and Urethrotomy in Dogs:
●● Bipolar cautery Patient Positioning
●● Mixter forceps The patient will be positioned in dorsal recumbency for a
●● Surgical loupes prescrotal or scrotal urethrostomy or urethrotomy and in
●● Operating microscope (recommended for cats and sternal recumbency, with the patient’s hind legs hanging
small dogs) over the end of the table and the tail retracted cranially for
●● 5-­0 to 8-­0 sutures a perineal urethrostomy or urethrotomy. Depending on the
size of the animal, magnification may be warranted.
Recommended instruments are listed in Box 2.8.

end of the table and the tail retracted cranially, as long as

there is padding to prevent obturator nerve compression. A
roll of bubble wrap can be used, or towels placed under the
patient’s pelvis (Figure 2.11). Alternatively, the patient can
be placed in dorsal recumbency with the hind limbs
retracted gently cranially (Figure 2.12). The necessary
Contrast Studies
For some patients, the use of an iodinated contrast material
(Omnipaque™) in conjunction with radiography or fluor-
oscopy can provide preoperative or intraoperative informa-
tion about the location of an obstruction, as well as the
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