CVC Highlight: Evil foreign bodies and more cautionary tales

This critical care specialist shares 13 lessons he learned the hard way while practicing emergency medicine.
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Dec 01, 2011

For many diseases in veterinary patients, the diagnosis is straightforward once you have the clues to add the possibilities to your rule-out list. Here are a few of my hard-learned lessons that I hope will help you when you see patients on emergency.

1. Migrating foreign bodies are evil, particularly porcupine quills. A single quill left behind may end up in the brain, lung, or pericardium—several days to months after the porcupine encounter. So do your best to find and remove them all.

2. Only serious problems cause pleural effusion. Pyothorax, heart failure, and cancer are common causes of pleural effusion, but you can help patients in distress with thoracocentesis. If you're not afraid to perform cystocentesis, don't fear thoracocentesis; it can be lifesaving.

3. Pericardial effusion is more common than you think. It's an often missed diagnosis by referring veterinarians. Clinical clues may include a patient with collapse, jugular venous distention, vomiting (perhaps within the week preceding presentation), hyponatremia, ascites (especially in animals with chronic pericardial effusion), and a large vena cava seen radiographically (conversely, in animals with hypovolemic shock, the vena cava looks small on radiographs). In a crisis, pericardiocentesis can be lifesaving.

4. A drop in a patient's total solids indicates bleeding. Remember that because of splenic contraction, the hematocrit doesn't decrease right away with hemorrhage.

5. The type of fluid you choose in an emergency seldom matters, except in animals with heart failure or severe hypochloremia.

6. Wounds aren't always what they seem, especially in patients with impalement injuries. Be aggressive in exploring stick wounds whenever you can; sticks leave a long track of debris that can quickly lead to sepsis.

7. Dog breeders may know more than you do about some reproductive issues, so listen to their concerns and treat accordingly.

8. A fever doesn't always indicate an infection—so if a febrile patient doesn’t improve within 24 to 72 hours of treatment with a reasonably chosen antibiotic and supportive care, stop and reevaluate.

9. Your diagnosis is probably wrong if a patient isn't responding to antibiotics.

10. Cats that are in heart failure are hypothermic. So if you see a dyspneic cat with a temperature > 100 F, think respiratory disease. If its temperature is < 100 F, think heart failure.

11. Animals with head trauma can make amazing recoveries. So give them at least 24 hours to show improvement with treatment.

12. Age is not a disease. While age-related diseases exist, an ill older animal may live quite awhile if the disease is managed appropriately.

13. If you can't have fun doing it, it's not worth doing!

Scott P. Shaw, DVM, DACVECC
Department of Clinical Sciences
Cummings School of Veterinary Medicine
Tufts University
North Grafton, MA 01536