AVIAN PATIENT INITIAL STABILIZATION OF THE GREGORY J COSTANZO, DVM RESIDENCY TRAINED IN ABVP (AVIAN PRACTICE)

INITIAL STABILIZATION OF THE AVIAN PATIENT:INTRODUCTION LECTURE OUTLINE Anatomy & Physiology Initial Examination Definition of Shock Treatment of Shock Diagnostics Useful references

ANATOMY AND PHYSIOLOGY OF THE AVIAN PATIENT

INITIAL STABILIZATION OF THE AVIAN PATIENT:A&P CARDIOVASCULAR SYSTEM They have a heart And blood vessels 1=Clavicular 2=Cervical 3=Cr. Thoracic 4=Ca. Thoracic 5=Abd main function- transport oxygen rich blood to tissues

INITIAL STABILIZATION OF THE AVIAN PATIENT:A&P RESPIRATORY SYSTEM Nares/Nasal Cavity/Paranasal sinus Oropharynx Trachea Syrinx Primary Bronchi Air sacs Secondary Bronchi Parabronchi 1=Clavicular 2=Cervical 3=Cr. Thoracic 4=Ca. Thoracic 5=Abd The right side displays opening of the major bronchi supplying the respective air sacs. Songbirds- cervical and clavicular air sac do NOT enter the humerus Raptors-

INITIAL STABILIZATION OF THE AVIAN PATIENT:A&P RESPIRATORY SYSTEM Nares/Nasal Cavity/Paranasal sinus Oropharynx Trachea Syrinx Primary Bronchi Air sacs Secondary Bronchi Parabronchi IMAGE MODIFIED AFTER KING AND MCLELLAND, 1984 1=Clavicular 2=Cervical 3=Cr. Thoracic 4=Ca. Thoracic 5=Abd The right side displays opening of the major bronchi supplying the respective air sacs. Songbirds- cervical and clavicular air sac do NOT enter the humerus Raptors-

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY RESPIRATORY SYSTEM BSAVA MANUAL OF RAPTORS, PIGEONS, AND PASSERINE BIRDS unidirectional path through the majority of the lung tissue for the majority of the respiratory air

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY RESPIRATORY SYSTEM - INSPIRATION Parabronchus Alveoli MAMMAL Blood Capillaries Air Capillaries AVIAN unidirectional path through the majority of the lung tissue for the majority of the respiratory air The parabronchi, being tubes and not dead-end sacs like alveoli, allow for continuous gas exchange in the avian lung

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY RESPIRATORY SYSTEM - EXPIRATION Parabronchus Alveoli MAMMAL Blood Capillaries Air Capillaries AVIAN unidirectional path through the majority of the lung tissue for the majority of the respiratory air The parabronchi, being tubes and not dead-end sacs like alveoli, allow for continuous gas exchange in the avian lung

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY MUSCULOSKELETAL SYSTEM The skeletal system of birds is characterized by weight reduction in order to facilitate flight and, in compensation, by strengthening structural features. PROXIMAL Higher mineral content than mammals Pneumatized bones DISTAL CLINICAL ANATOMY AND PHYSIOLOGY OF EXOTIC SPECIES, B. O MALLEY lateral view of leg increased mineral content is the reason for fractures to consist mostly of splits (birds) vs. breaks (mammals)

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY MUSCULOSKELETAL SYSTEM DISTAL PROXIMAL CLINICAL ANATOMY AND PHYSIOLOGY OF EXOTIC SPECIES, B. O MALLEY ventral view of wing

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY SPECIAL SENSES - VISION Vision is a bird s most important sense Weight of the eye exceeds or at least equals that of the brain Structure of the eye is adapted to the bird s need for threedimensional orientation during flight and to specific behaviors red-shouldered hawk - cataract right eye

INITIAL STABILIZATION OF THE AVIAN PATIENT:ANATOMY&PHYSIOLOGY DIGESTIVE SYSTEM Beak Oropharnyx Cervical Esophagus Crop Thoracic Esophagus Proventriculus Ventriculus Small Intestines Cloaca

INITIAL PRESENTATION OF THE AVIAN PATIENT

INITIAL STABILIZATION OF THE AVIAN PATIENT:INITIAL PRESENTATION VISUAL PHYSICAL EXAMINATION Critically sick or injured birds are often too weak for an extensive examination when first presented! Be organized and efficient! Intermittent steps may be necessary to decrease restraint periods and reduce stress Eyes & Eyelids: symmetry, appearance, shape, discharge, wounds, swellings Beak: appearance, grooves, cracks, splits, shape Nares: symmetry, shape, foreign materials, discharge Oropharynx: color, swellings, caseous masses, blunted papillae, foreign bodies (eg, bones, tendons, string) Ears: symmetry, foreign bodies (eg, sand, ectoparasites), discharge Neck/crop: swellings, wounds, impaction Body: wounds, swelling, pectoral muscle mass, ectoparasites Cloaca: urate/feces seepage, swelling, masses Wings: symmetry, wounds, swellings, fractures, feather integrity Tail: swellings, feather integrity Uropygial gland: size, shape, quantity and consistency of oil Legs: symmetry, wounds, swellings, fractures Feet: symmetry, grip strength, skin condition,temperature, swellings, wounds, talon condition

INITIAL STABILIZATION OF THE AVIAN PATIENT:INITIAL PRESENTATION VISUAL PHYSICAL EXAMINATION Eyes & Eyelids: symmetry, appearance, shape, discharge, wounds, swellings Beak: appearance, grooves, cracks, splits, shape Nares: symmetry, shape, foreign materials, discharge Oropharynx: color, swellings, caseous masses, blunted papillae, foreign bodies (eg, bones, tendons, string) Ears: symmetry, foreign bodies (eg, sand, ectoparasites), discharge Neck/crop: swellings, wounds, impaction Body: wounds, swelling, pectoral muscle mass, ectoparasites Cloaca: urate/feces seepage, swelling, masses Wings: symmetry, wounds, swellings, fractures, feather integrity Tail: swellings, feather integrity Uropygial gland: size, shape, quantity and consistency of oil Legs: symmetry, wounds, swellings, fractures Feet: symmetry, grip strength, skin condition,temperature, swellings, wounds, talon condition

SHOCK IN THE AVIAN PATIENT

INITIAL STABILIZATION OF THE AVIAN PATIENT:DEFINITION OF SHOCK SHOCK a syndrome precipitated by a systemic derangement of perfusion leading to widespread cellular hypoxia and vital organ dysfunction the state in which profound and widespread reduction of effective tissue perfusion leads first to reversible, and if prolonged, irreversible cellular injury inadequate blood volume - most commonly hypovolemic shock effective tissue perfusion may be reduced by either global reduction of systemic perfusion (cardiac output) increased ineffective tissue perfusion due to maldistribution of blood flow, or a defect of substrate utilization at the subcellular level

INITIAL STABILIZATION OF THE AVIAN PATIENT:DEFINITION OF SHOCK SHOCK a syndrome precipitated by a systemic derangement of perfusion leading to widespread cellular hypoxia and vital organ dysfunction the state in which profound and widespread reduction of effective tissue perfusion leads first to reversible, and if prolonged, irreversible cellular injury WHAT THE HECK DOES THAT MEAN? inadequate blood volume - most commonly hypovolemic shock effective tissue perfusion may be reduced by either global reduction of systemic perfusion (cardiac output) increased ineffective tissue perfusion due to maldistribution of blood flow, or a defect of substrate utilization at the subcellular level

INITIAL STABILIZATION OF THE AVIAN PATIENT:ASSESSMENT OF SHOCK, THE ABC AIRWAY Ensure that the patient has a clear airway Endotracheal intubation or air sac tube placement may be warranted ET or air sac tube placement

INITIAL STABILIZATION OF THE AVIAN PATIENT:ASSESSMENT OF SHOCK, THE ABC BREATHING Dyspneic or collapsed birds may be placed in oxygen enclosure while treatment is considered and organized Respiratory rate and effort closely monitored Upper vs. Lower Respiratory Oxygen supplementation Manual ventilation 1 breath per 4-5 seconds if intubated/air sac tube placed

INITIAL STABILIZATION OF THE AVIAN PATIENT:ASSESSMENT OF SHOCK, THE ABC CIRCULATION Maintenance of cardiac output and circulatory volume is essential to ensure adequate tissue oxygenation Control hemorrhage if present Assess ulnar/basilic/jugular vein filling time (>0.5s is indicative of poor peripheral perfusion) Mainstay of this is fluid therapy Birds deal with hemorrhage better than mammals respiratory tract Hypovolemic shock is commonly seen and caused by inadequate blood volume. Absolute hypovolemia occurs due to hemorrhage from trauma, coagulopathies or gastrointestinal tract bleed. Relative hypovolemia occurs with severe dehydration from the GIT or with extreme loss of fluids into a third body space (e.g., abdominal ascites.)birds tolerate hemorrhage better than mammals but if there is severe ongoing hemorrhage monitor the PCV and give intravenous or intraosseous fluids. Give vitamin K, calcium and antibiotics as necessary. The use of steroids in hemorrhage and hypovolemic shock is not currently recommended.

TREATMENT OF SHOCK IN THE AVIAN PATIENT

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg/hr Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) Maintenance: 50-100 ml/kg/day SQ administration per site: <25 ml/kg Crystalloids vs. Colloids Warm! Intraosseous- proximal tibiotarsal bone or distal ulna* PROS: instant absorption and stabilization of blood pressure, aids in quick correction of dehydration CONS: can be incredibly painful and stressful to place the awake patient thus requiring anesthesia in most cases; maintenance of catheter Intravenous- jugular, basilic, or media metatarsal veins very difficult to achieve in a very shocky patient PROS: same as intraosseous CONS: sometimes difficult to hit a vein; fragile Subcutaneous- back, inguinal web, and skin over the breast muscle PROS: quick and simple CONS: absorption not as quick as IV or IO

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* Intraosseous- proximal tibiotarsal bone or distal ulna* PROS: instant absorption and stabilization of blood pressure, aids in quick correction of dehydration CONS: can be incredibly painful and stressful to place the awake patient thus requiring anesthesia in most cases; maintenance of catheter Intravenous- jugular, basilic, or media metatarsal veins very difficult to achieve in a very shocky patient PROS: same as intraosseous CONS: sometimes difficult to hit a vein; fragile Subcutaneous- back, inguinal web, and skin over the breast muscle PROS: quick and simple CONS: absorption not as quick as IV or IO

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* 10% DEHYDRATED AMERICAN KESTRAL- 100 G *1 KG = 1000 G IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg for 1st hour only Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) Maintenance: 50-100 ml/kg/day TO CONVERT G TO KG DIVIDE BY 1000 TO CONVERT KG TO G MULTIPLY BY 1000 Correct dehydration over 24-36 hrs, if able

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* 10% DEHYDRATED AMERICAN KESTRAL- 100 G *1 KG = 1000 G IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes (20 ml/kg) x (0.1kg) = 2 ml over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg for 1st hour only Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) Maintenance: 50-100 ml/kg/day TO CONVERT G TO KG DIVIDE BY 1000 TO CONVERT KG TO G MULTIPLY BY 1000 Correct dehydration over 24-36 hrs, if able

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* 10% DEHYDRATED AMERICAN KESTRAL- 100 G *1 KG = 1000 G IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg for 1st hour only (20 ml/kg) x (0.1kg) = 2 ml over 5-10 minutes (90 ml/kg) x (0.1kg) = 9 ml over 1st hour Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) Maintenance: 50-100 ml/kg/day TO CONVERT G TO KG DIVIDE BY 1000 TO CONVERT KG TO G MULTIPLY BY 1000 Correct dehydration over 24-36 hrs, if able

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* 10% DEHYDRATED AMERICAN KESTRAL- 100 G *1 KG = 1000 G IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg for 1st hour only Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) (20 ml/kg) x (0.1kg) = 2 ml over 5-10 minutes (90 ml/kg) x (0.1kg) = 9 ml over 1st hour (10[%]/100) x (100g) = 10 ml Maintenance: 50-100 ml/kg/day TO CONVERT G TO KG DIVIDE BY 1000 TO CONVERT KG TO G MULTIPLY BY 1000 Correct dehydration over 24-36 hrs, if able

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK FLUID THERAPY* 10% DEHYDRATED AMERICAN KESTRAL- 100 G *1 KG = 1000 G IO/IV/SQ Shock bolus (IO/IV): 10-30 ml/kg over 5-10 minutes Shock Rate (IO/IV): 90 ml/kg for 1st hour only Rehydration: Fluid deficit (ml) = estimated dehydration (%/100) x body weight (g) Maintenance: 50-100 ml/kg/day (20 ml/kg) x (0.1kg) = 2 ml over 5-10 minutes (90 ml/kg) x (0.1kg) = 9 ml over 1st hour (10[%]/100) x (100g) = 10 ml (50mL/kg/day) x (0.1kg) = 5 ml TO CONVERT G TO KG DIVIDE BY 1000 TO CONVERT KG TO G MULTIPLY BY 1000 Correct dehydration over 24-36 hrs, if able

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK PAIN MANAGEMENT* Meloxicam (Metacam, Boehringer Ingelheim) - Non-steroidal antiinflammatory 0.1-1 mg/kg PO SID-BID Tramadol HCl - opioid-derivative 10-30 mg/kg PO BID Butorphanol tartrate (torb, torbugesic) 0.5-2 mg/kg PO q4-6hrs Nalbuphine HCl No steroids if suspect heavy metal, consider lower dose of meloxicam or an opioid instead

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK WARM, DARK, AND QUIET* Small cages fitted with curtains and maintained in quiet, semi-dark rooms Tail guard? Handling kept at minimum Talking kept to minimum Warmth - 80-90 degrees F Oxygen support? careful with warmth and head trauma

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK COME UP WITH A TREATMENT PLAN What medications will be continued? What is the prognosis and probable outcome of the injury? What diagnostics will be needed? Do you have the facility to rehabilitate this animal or is transfer necessary?

INITIAL STABILIZATION OF THE AVIAN PATIENT:TREATMENT OF SHOCK ANTIMICROBIALS? Ask your veterinarian for the best antibiotics for the specific case Overuse or unnecessary addition of antibiotics to cases causes resistance!! Consider aerobic +/- anaerobic infections If a very young bird (or species at risk), may want to consider antifungal, too

INITIAL STABILIZATION OF THE AVIAN PATIENT:DIAGNOSTICS (TESTS) WHAT IS WORTH DOING/RUNNING? PCV/TS Uric Acid (UA) Bile Acids Complete Blood Count Radiographs (x-rays) Fecal float Lead/Zinc? West Nile Virus? risks vs. benefits

CLINICAL AVIAN MEDICINE, HARRISON ET AL ventrodorsal sedation!

right lateral CLINICAL AVIAN MEDICINE, HARRISON ET AL

CLINICAL AVIAN MEDICINE, HARRISON ET AL right lateral mention Cranial-Caudal for wing fracture!!!!

INITIAL STABILIZATION OF THE AVIAN PATIENT:USEFUL REFERENCES WEBSITES, BOOKS, & JOURNALS mwrawildlife.org nwrawildlife.org theiwrc.org avianmedicine.net BSAVA Manual of Raptors, Pigeons and Passerine Birds Edited by John Chitty and Michael Lierz Exotic Animal Formulary, 4e Authored by James W. Carpenter The Journal of Wildlife Management Edited by Paul R. Krausman Journal of Wildlife Diseases Edited by Daniel M. Mulcahy and James N. Mills

EMERGENCY CASE!

GOOGLE IMAGE SEARCH, WIKIMEDIA.ORG found on side of road with right wing drooping in transport (covered dog crate) gave a drop of midazolam in nares to help a little with anxiety

Back at the center Weight- 1kg ~10% dehydrated ====== 100 ml ulnar vein refill time = 1s SQ fluids elected ==== 25 ml per site x2 BID Daily maintenance fluid requirement = 50 ml/day Torb, Meloxicam (careful!) Bandage (figure-8) Cage rest

Back at the center Weight- 1kg ~10% dehydrated ulnar vein refill time = 1s SQ fluids elected Torb, Meloxicam (careful!) Bandage (figure-8) Cage rest

several hours later. deemed stable enough for anesthesia and radiographs to assess wing

DO NOT USE INFLATABLE CUFF!

closed mid-diaphyseal fracture of humerus with moderate displacement

4.5wks post-op

patient stabilized another day

Happy Halloween www.seavs.com/wildlife Notes will be up on October 31st