Save the Trauma for your Mama: Liveblogging Dr. Johnson at Western Veterinary Conference

When I walked into Dr. Tony Johnson's session on stabilizing canine and feline trauma patients in the ER, the first thing I got was a hug.



Dr. Johnson and I have never met in person, but we recognized each other instantly. He promised to tell lots of jokes when he found out I was blogging this. I'd say "liveblogging," but the totally FUBAR wireless access here -- including on everyone's iPhone, which has lots of Twitter and email-deprived folks fighting over the rare hallway sweet spot -- made that impossible.



At least I'll have a chance to correct my typos.



Although I heard two people in the audience say they were there to heckle, Dr. Johnson was graciousness itself to the near-capacity audience. "Wow," he opened. "What a good looking, totally hot crowd."



Having won them over with flattery, he got onto the difficult ethical issues.



"The conference has asked us to disclose any financial ties," he said. "I don't have any, but donations are gladly accepted. And in the interests of full disclosure, I have a massive hangover, but fortunately did not wake up this  morning with Mike Tyson's tiger -- or baby."



Says he loves triage. Says cats are different to handle -- managing a traumatized cat is a challenge.



Not a lot of veterinary trauma studies in epidemiology. We do know it's a leading cause of death -- it IS the leading cause of death in humans under 35, "a demographic to which I sadly no longer belong."



He asked how many ER docs -- around a third. How many GPs, students? And how many reporters for the SF Chronicle? (As if my scarlet letter badge isn't enough, not only with its neon green "PRESS" ribbon, but the bold-faced, all-caps "NONVETERINARIAN" under my name.)



"Triage is French for cheese."



Triage is deciding priority of care. Things you don't want to linger in the examp room -- trauma/shock, altered/loss of consciousness, hemorrhage, urethral obstruction, dyspnea, burns, dystocia. "And to this list I would also add, from an owner's viewpoint, a broken toenail or reverse sneezing, preferably at 3 AM."



Make sure techs and receptionists are aware of what cases need to be hustled to the back.



Then, ABCs: airway, breathing, circulation. "They often get forgotten, but they need to be part of our intuitive assessment, and will hopefully ground you and get your focus clearly on the case. Before you focus on dramatic wounds, focus on the stuff that's going to kill them first."



Next, formulate a plan and start correcting abnormalities found on primary survey -- establish airway, obstructions, need to entubate, need O2 or to tap chest, evaluate circulatory system for shock, give fluids and CPR if needed, get IV access.



Reviewed signs of shock and how differ dogs to cats.



Then nose to tail exam, including rectal, and consider lab tests, radiographs, ultrasound for evidence of hemorrhage.



Then PAIN CONTROL. is somewhat controversial whether to give when shock is issue. But if animal in agony, give it.



Case study: Priss the cat was missing during thunderstorm, found in yard unresponsive.



Tech rushes her to back, you have two appointments waiting and the owner is in the lobby demanding to be allowed to come to the back and you've been up all night because your child was vomiting. "Welcome to the world of emergency medicine. I hope you enjoy your stay."



Did ABCs, trauma evaluation, said was in early decompensated shock.



Good chance to pull her back from brink.



Not tachycardic, cats don't have to be tachycardic to be in shock, because cats have not been given the rule book, and even if the were, they're ignoring it because they're too busy plotting to take over the world.



Options: rads, tap chest



Tapping chest probably best bet with this cat. "Never never take x-rays on an unstable cat," although sometimes he does.



Then a technical discussion of HOW to tap chest, which yo, we're going to skip so as not to give the "vets are greedy" do-it-yourselfers any ideas.



Says that tapping chest before transporting dyspneic cat can often prevent a "DOA on the way."



So they tap Priss and give O2, she purrs contentedly and you shed a tiny tear of joy.



THEN WHAT?



vascular access and fluid therapy



IV access, 1 or 2 large bore IV catheters, usually only 1 in cats.



If you can, draw samples for labs before fluid therapy.



Rapid IV access, catheter can always be replaced later when stable.



Intraosseous route if unable to place IV , easily done in kittens. hard in older dogs.



More technical stuff we're skipping.



Cats and hypothermia:



Hypothermic cats are unable to regulate blood vessel diameter to match tissue oxygen demands and distributive shock ensues



Aggressive warming and rapildy achieving normothermia is imperative in shock therapy, even more so for cats than dogs.



Overly aggressive fluid tehrapy in a hypothermic cat risks iatrogenic fluid overload. Then you have pulmonary edema on top of everything else.



Cats are really hard to warm up, BAER (?) hugger, heat blanket, they're at 94 then go to 92 then boom they're 105



temp of 98 or better is goal



Suddenly you notice her belly is distended,and now we know: she has a hemoabdomen.



May have overshot the fluids and blown off a clot. "Don't feel bad, I've done it too."



Managing a traumatic hemoabdomen:



Confirm dx -- ultrasound. Had we done one, might have known and avoided this. Look for bleeding, and if you see it tap to confirm.



Consider transfusions, fresh whole blood is ideal but often hard to get hold off, so can do component therapy.



Abdominal pressure wrap is controversial. Some think ischemia/abdominal compartment syndrome



Ideally, measure intra-abdominal pressure via water manometer and urinary catheter (they do in humans)



Most can be managed non-surgically. Surgery only if unable to stabilize



Also could have done auto-transfusion, but could have had a uroabdomen: "It could be blood mixed with pee, which in critical school they taught me was bad." If you have no choice at all, you might risk it. NEVER in a cat give blood if you can't blood type. Never, never. Because if she's a B cat, and gets A blood, SHE WILL DIE. I don't say this about everything, but you have to type a cat every time.



If she's a B, I'd be even more leaning towards taking a chance with autotranfusion.



Probably should have practiced permissive hypotensive resuscitation, small volume fluids just sufficient to get organ profusion and not above. But that's very tricky.



NOW we go on to secondary survey - now you do radiographs.



Priss has numerous superficial dermal abrasions and a broken leg, obtain samples for bloodwork, remainder of exam is normal.



Gave analgesia, gave fentanyl. Likes it for analgesia of trauma patients. Full mu agonist, lasts only half hour or so.



Stabilize leg with soft bandage. For this break, consider a nerve block to help with pain control, lasts 6-8 hours.



An opioid and a benzodiazepine are good choices for sedation in trauma -- valium and fentanyl. Both reversible, too. And minimal cardiovascular depression. No ACE, no NSAIDs -- "I reserve NSAIDs, if I use them at all, for patients who are fully stable".



Priss' outcome after hospitalization, fluids was good.



Cefazolin due to hypotension and dermal abrasions



Fentanyl CRI and something else to top off for breakthrough pain. ("CRI" means "constant rate infusion," which is a steady stream of drug via IV pump.)



And Famotidine



Surgery, they discharged after 36 hours. Happy ending, yay.



Questions: Do you use steroids in shock? "I don't think there's data to support it and it has the potential to make certain things worse."



What do you use for breakthrough pain with the Fentanyl CRI?



Bunch of options. Can bolus a little extra, or maybe small dose morphine or hydro (I'm assuming hydromorphone, Dr. Johnson can correct me if I'm wrong.)



Applause -- first applause I've heard at the conference! Dr. Tony rocks!



Photos: From Christie's iPhone

Comments

[Gina Spadafori]

“Wow,” he opened. “What a good looking, totally hot crowd.”



Man knows how to wow a crowd, that's for sure!



And yes, Dr. Tony totally rocks!

[David S. Greene]

"Triage is French for cheese"!

Thanks for the report, Christie. It's not often that I wish I was in Vegas, but this week I do.

[Darlene Arden, CABC]

Thanks for a great report, Christie. I've always wanted to attend Western States. Maybe next year. I really have to hear this guy in person!

[Cindy]

Come on now! Reverse sneezes can be deadly! ;)

[Gina Spadafori]

You should have openly mocked her more. :)

[Evelyn]

Glad you saved the cat, Dr. Tony!

[Dr. Tony Johnson]

Holy Canoli! Christie, I am humbled and amazed. Thanks for capturing the essence of the talk and all the positivity! I really had fun in Vegas, and I am hoping that some of the knowledge that happened in Vegas won't stay in Vegas.

[Evelyn]

Dr. Tony,



It is good to praise the audience and also the patients' parents.



I finally got my vet to admit I am smart. I asked him point blank today.



I had to fight with my cat this morning to get her to see him and now I am a bloody mess. I need the antibiotic medicine more than she does!



By the way, did you do any gambling in vegas?

[Evelyn]

Here I am again!



I just want to mention that it was exactly a year ago I took my cat, Batman, to the urgent care center. They couldn't save him, but he did have 15 years of life and love from me.