Document 21536

Triage and Approach to the Acute Abdomen
Elisa M. Mazzaferro, MS, DVM, PhD
The presentation of a patient with acute abdominal pain often is
both a diagnostic and therapeutic challenge for the veterinary
practitioner. Rapid physical examination and assessment of the
patient’s cardiovascular status are critical to initiating appropriate and often aggressive medical management as diagnostic
tests are being performed. A number of diagnostic tests can be
performed, including complete blood count, serum biochemistry
profile, serum amylase and lipase, abdominal radiographs, abdominal ultrasound, abdominal paracentesis or diagnostic peritoneal lavage, cytology, and fluid analysis. In some cases, surgical exploration may be indicated, depending on each patient’s
clinical signs and response to therapy. Of the most important
aspects of medical management of the patient with acute abdominal pain is to maintain oxygen delivery to tissues and to treat
aggressively for pain or discomfort. The initial triage and approach to the patient with acute abdomen are discussed.
Copyright 2003, Elsevier Science (USA). All rights reserved. .
and C receptors,
events leading
the free nerve endings, initiates the cascade of
to nociception
and recognition
pain.3 First order neuron stimulation,
of abdominal
via afferent type A- and C
fibers, transmits nerve impulses to the dorsal horn of the spinal
cord. Synapse occurs here, and the ascending
transmitted
via spinothalamic
signal is further
and spinoreticular
tracts to the
thalamus, or reticular area of the brain.4 The tracts synapse with
third order neurons
cortex, ultimately
that transmit
resulting
the signal to the cerebral
in the conscious
perception
of the
painful stimulus.
Visceral pain is often a dull aching pain that is poorly localized. C fibers within
caudal peritoneum
the abdominal
organs,
mesentery,
and
transmit this type of pain. Sensory stimula-
tion of the chemoreceptor
stretch
receptors
within
nausea
and vomiting
trigger zone, as well as activation
the abdomen,
may also initiate
that may accompany
visceral
of
the
pain. In
many cases, the patient with visceral pain is restless and ambulatory in an attempt to relieve discomfort.4
P
resentation
of the patient with acute abdominal
an uncommon
abdomen
occurrence
in veterinary
is defined as a sudden abdominal
sites within
or outside
of the abdomen
prompt diagnosis and immediate
tion to prevent deterioration
medicine.
Acute
pain arising from
cavity, necessitating
medical or surgical interven-
of the patient.l
Somatic pain, also known as parietal pain, is a sharp pain that
pain is not
Clinical signs may
can be localized
to a specific area.2 Type C and type A- fibers
arising in the parietal peritoneum
which is often immobilizing
presents with clinical signs of acute abdominal pain. The source
of the pain/discomfort,
however, is at a site in the periphery that
shares a common nociceptive
gastrointestinal
way. Spinal referred
peritoneum,
urogenital
hepatobiliary
system,
system,
spleen,
mesentery,
and extra-abdominal
sites,
common
of abdominal pain is a complex process
stimulus activates free nerve endings
of the patient
present a diagnostic
the possible
the
tient’s signalment
tissue
associated
with
the parietal
neum.2-4 The inciting stimulus may be associated
of an organ capsule,
subcapsular
mediators
hemorrhage
or organ swelling.
can lead to ischemia
that stimulate
nociceptive
dominal pain. Inflammation
flammatory
stance
stimulate nociceptive
Regardless
Decreased
blood
eicosanoids,
causes of acute abdomen.
etiology of acute abdomen.
panleukopenia
younger
including serotonin,
and bradykinin,
insub-
can also
virus, or intussusception
of type A- A
parvoviral
history.5
Older German
ated with splenic neoplasia.
in
or nonexistent
Shepard and Golden Reof hemoabdomen
associ-
Large to giant breed dogs such as
Great Danes, Irish Wolfhounds,
ards, and Doberman
of the
enteritis,
is more common
dogs and kittens with a questionable
Irish Setters,
German
Pinchers have a higher incidence
dilatation and volvulus (GDV)[email protected]’ Deep-chested
more predisposed
activation
In some cases, the pa-
For example,
and the release of
leading to ab-
pain can
A complete
may lead to a higher index of suspicion
triever dogs have a higher incidence
pathways,
stimulus,
for the practitioner.
vaccination
pathways.
of the inciting
with acute abdominal
challenge
such as caused by
and the release of associated
mediators and cytokines,
P, histamine,
with stretch
such as that seen with mass effects or
flow to an organ or site within the mesentery,
trauma or thrombosis,
perito-
are among the most
and detailed history must be obtained from the owner regarding
within the wall of hollow organs, the capsule of solid organs, or
connective
segment within the central path-
pain and neoplasia
causes of referred pain in the veterinary patient.
Evaluation
most notably spinal referred pain.2
The pathophysiology
in which an inciting
of pain,
pain is known as referred pain.3 The patient with referred pain
be vague and nonspecific, or may clearly point to the source of
pathology. Seven major sources of abdominal pain include the
tract,
carry this source
for the patient. The third type of
Shep-
of gastric
breeds may be
to splenic torsion. Intact male dogs may be at
higher risk for the development
of severe prostatitis,
whereas
intact female dogs may develop pyometra, uterine torsion, uterine rupture, or dystocia. IO,11Female Miniature
From the Small Animal Emergency and Critical Care Clinician,Wheat
Ridge Animal Hospital, Wheat Ridge, CO.
Address reprint requests to: Elisa M. Mazzaferro, MS, DVM, PhD,
Wheat Ridge Animal Hospital, 3695 Kipling Street, Wheat Ridge, CO
80033. E-mail: [email protected]
Copyright 2003, Elsevier Science (USA). All rights reserved.
1096-2867/03/l
801-0007$35.00/O
doi:l 0.1053/svms.2003.36616
Clinical Techniques
in Small Animal
Practice,
pear to be predisposed
higher
incidence
to pancreatitis.5
of hemorrhagic
Schnauzers
ap-
Small breed dogs have a
gastroenteritis.
Animals
of
any age can be exposed to garbage, foreign bodies, or toxins, all
of which can cause clinical signs of acute abdomen.
important
history
questions
complete list of differential
Vol 18, No 1 (February), 2003:
An important
pp l-6
to ask is noted
A list of
in Table
1.l A
diagnoses is listed in Table 2.
detailed history should be performed
to deter-
1
TABLE 1. General and Specific Questions
to Ask Clients of Patients Presenting
with Acute Abdomen
General questions
What are
When did
Have the
Has your
Has your
the most important signs that made you bring your pet here?
these signs first start?
signs been getting worse, staying the same, or improving?
animal ever had any other medical problems prior to this?
animal ever demonstrated any signs similar to those now?
Toxin
Does your animal have access to any toxins?
Does your animal run loose unattended?
What is the physical status of other animals in the household?
Has your animal ingested garbage recently?
Are they sick?
Foreign body
Does your animal play with or chew on toys? Underwear? Cloths?
Have you noticed anything missing?
Do you sew? Does your animal play with string, thread, or yarn?
Vaccination
Other material?
status?
Is your animal vaccinated?
How many vaccinations has the puppy/kitten
received since you first obtained
Does your animal come in contact with other animals?
When was your animal last vaccinated?
him/her?
Appetite
Has there been any change in your animal’s appetite?
Have you noticed any weight loss or weight gain?
Has there been any increase or decrease in water consumption?
Do you feed table scraps? If so, what kind and when did your animal last get some?
Do you allow your animal to chew on bones?
Trauma
Is there a possibility that your animal has been hit by a car?
Does your animal run loose unattended or have access to the street?
Does your animal play rough with other animals?
Has your animal been in a fight recently to your knowledge?
Urination/Defecation
Have you noticed any change in urination or defecation
Have you noticed any diarrhea?
Have you noticed any straining to defecate?
What is the color of the feces?
Is there blood in the feces?
Does the feces appear black in color?
habits?
Vomiting
When did you first notice vomiting?
How many times has your animal vomited?
When was the last episode of vomiting?
What does the vomitus look like?
Is there blood or coffee ground material in the vomitus?
What color is the vomitus?
Does the vomiting episode have an active abdominal component and retching,
Is the vomitus digested or undigested food?
Does the animal vomit food and water, or just food?
Does the animal vomit soon after eating or at times not related to meals?
Does the vomitus smell malodorous, or like feces?
mine whether there is a possibility of toxin or foreign body
exposure. This author often asks the same question in multiple
formats to be very specific. Questions regarding vaccination
status and exposure to other animals can lend insight to the
possibility of viral enteritis. If a patient is vomiting, the owner
should be carefully questioned as to when the vomiting first
started, how many times the animal has vomited, and when the
last episode of vomiting was. What is the nature of the vomitus?
Is it digested or undigested food? Is it only food or does the
animal vomit water, as well? Is there blood in the vomitus? How
soon after eating does the vomiting occur? What is the color of
the vomitus? Does it smell like feces? Projectile vomiting or
vomiting soon after eating is often associated with a high GI
obstruction. Hematemesis or vomitus with coffee ground appearance is suggestive of gastric ulceration. Obstruction in the
lower intestinal tract may be malodorous and smell like feces.
Physical examination of the patient should begin by a rapid
primary survey of the severity of the clinical condition.i-3J2
First, briefly observe the patient from a distance. Is the patient
restless or recumbent? Do you notice any attempts to vomit? Is
2
or is it passive in nature?
the vomiting or retching episode(s) productive or nonproductive? Does the abdomen appear distended? Is the animal displaying any abnormal postures? Some animals with abdominal
pain will adopt a characteristic “prayer” position in which the
front end and forelimbs are bowed toward the ground or in
sternal recumbancy, while the hind end remains elevated in a
standing position. Other animals may adopt a stretched posture
in lateral recumbancy. Animals with abdominal pain may have
an abnormal gait with short choppy steps or a stiff stilted gait.
Others may have excessive salivation due to nausea. Careful
observation from afar can lead to a clinical impression of severity of disease and perhaps increase the index of suspicion toward a definitive diagnosis.
Physical Examination
Animals presenting with acute abdomen can be initially classified into one of three categories. Nonsurgical patients do not
require surgery and can be managed medically. Critically ill
animals require immediate surgery following rapid stabilizaELISA M. MAZZAFERRO
TABLE 2. Differential
Abdomen
Abdominal
Diagnoses
for Cause of Acute
wall
Trauma
Abscess
Bruise/Hematoma
Body wall hernia
Gastrointestinal
Gastric dilatation
Gastric dilatation-volvulus
(GDV)
Gastrointestinal perforation
Gastric ulceration
Gastrointestinal obstruction
Luminal foreign body
Linear foreign body
Mesenteric volvulus
/eysplasia
lntussusception
Gastroenteritis
Bacterial
Herrrhagic
gastroententrs
Parasitic
Toxin ingestion
Obstipation
Colonic ulceration
Colonic perforation/rupture
Dehiscence of stomach, small intestine, or colon
Hepatobiliary
Hepatic inflammation (toxin, infectious)
Hepatic abscess
Hepatic neoplasia
Liver lobe torsion
Cholecystitis
Cholelithiasis
Gall bladder mucocele
Rupture of biliary tree
Cholangiohepatitis
Pancreatic
Pancreatitis
Pancreatic abscess
Pancreatic neoplasia
Splenic
Traumatic splenic laceration
Splenic neoplasia (benign or malignant)
Splenic nodular hyperplasia
Hemangiosarcoma
Hemangioma
Splenic abscess
Extramedullary hematopoiesis
Lymphoma
Splenic torsion
Urogenital
Toxicosis (nephrosis)
Pyelonephritis
Renolithiasis
Ureterolithiasis
Cystic calculi
Urethral obstruction
Renal trauma
Avulsion
Rupture
Neoplasia
Adenocarcinoma
Lymphoma
Transitional cell carcinoma
Renal thromboembolism
Prostatitis
Prostatic neoplasia
Prostatic cyst
Testicular torsion
Testicular abscess
Uterine torsion
Pyometra
Uterine rupture
Dystocia
Ovarian cyst
Metritis
Uterine neoplasia
Peritonitis
Bacterial peritonitis
Chemical peritonitis (pancreatitis,
biliary tree rupture, uroabdomen)
Viral (FIP)
Blunt abdominal trauma
Penetrating abdominal trauma
Lymphadenitis
Mesenteric avulsion
Mesenteric arterial thrombosis
Sclerosing peritonitis
Extra-abdominal
sources of pain
Intervertebral disk disease
Discospondylitis
Meningitis
Polymyositis
Steatitis
Toxicities
Heavy metals
Envenomation
Black widow spider
Brown recluse spider
TRIAGE AND APPROACH
TO THE ACUTE ABDOMEN
tion. Mesenteric volvulus, GDV, splenic torsion, splenic hemorrhage, and pyometra are examples of animals in this category.
Urgent patients require surgery, but have the added benefit of
buying time with medical stabilization.2 After initial assessment
of the patient from a distance, the physical examination should
be performed, paying particular attention to the “ABCs,” that is,
the airway, breathing, and cardiovascular status of the patient.
A complete physical examination of all body systems should
eventually be performed; however, priority should be placed
first on systems that apply to the immediate clinical condition
at hand.1 Many authors agree that examination of the patient
abdomen should occur last, to avoid inadvertently missing important findings that may be present in other organ systems.l
Additionally, examination of the abdomen may elicit pain and
discomfort that may prevent further evaluation of the patient.
Careful observation of the patient’s cardiovascular perfusion
parameters such as mucous membrane color, capillary refill
time, heart rate, heart rhythm, pulse quality, and character
should carefully be evaluated. 2~12Dehydration parameters including skin tenting, mucous membrane tachyness, and
sunken appearance of the eyes should also be noted to subjectively estimate percent dehydration. Neurologic status including patient’s mental status and a perfunctory neurologic examination including posture, reflexes, and spinal palpation should
be performed to help rule out spinal referred pain. A rectal
examination should be performed, evaluating the pelvic urethra, colon, sublumbar lymph nodes, and color and consistency
of fecal material, including whether hematochezia or melena is
present. The prostate should be palpated in male dogs. The
vulva should be examined in female dogs for the presence of
abnormal discharge or malodorous material. Rectal temperature may be normal, hyperthermic, or hypothermic, depending
on the nature and stage of the disease process. Finally, abdominal examination can proceed.
Visual inspection of the external abdomen should first occur.
Is the abdomen distended? Is there an obvious mass effect
associated with neoplasia or hernia? Is there any external blood
on the fur? Are there any obvious penetrating wounds or swelling? Is there skin bruising associated with trauma or coagulopathy? Careful observation of the periumbilical area for evidence
of reddening or hemorrhage may lead to a diagnosis of hemoabdomen. It may be necessary to clip abdominal fur to fully
evaluate the skin and underlying structures.
After visual inspection of the abdomen is performed, the
clinician should next auscult the abdomen for borborygmi to
characterize gastrointestinal sounds. Ingestion of toxins, acute
intestinal obstruction, and gastroenteritis may cause an increased frequency and character of gut sounds. Conditions
such as ileus, anorexia, chronic intestinal obstruction, and abdominal effusions (including peritonitis) can cause decreased
frequency and character of gut sounds. The clinician should
auscult the abdomen carefully for 2 to 3 minutes to determine
whether gut sounds are actually absent.l Abnormal gut sounds
are not pathognomonic for any disease process. Additionally,
early in the course of illnesses such as posttrauma or early
peritonitis, gut sounds may remain normal.
Following auscultation, the clinician should next proceed
with percussion and ballottement of the abdomen. Hyperresonant areas of the abdomen may indicate the presence of intraabdominal air, usually within, but sometimes outside of a hollow organ. Decreased hyporesonance is indicative of ascites,
intra-abdominal fluid. Ballottement can be performed by press-
3
ing gently on the side of the abdomen
for a fluid wave effect. Additionally,
in intra-abdominal
and watching
abdominal
fluid may rebound
carefully
viscera floating
against the examiner’s
hand.
Various
stages of abdominal
and other
structures
palpation
abnormalities.
Palpation
is helpful in detecting
may react vigorously
splinting
are used to detect
mass effects, plication
of the superficial
and localizing
and become
their abdomen
of the intes-
tense,
in response
pain. Animals
thus guarding
to superficial
or
palpation.
in fecal white blood cells may be associated
After blood, urine, and fecal samples
diagnostic
pain, organ enlargement,
tines,
growth. Elevations
with Salmonella spp. infection.
diagnostic
tests and monitoring
associated
with evaluating
that should be performed
and electrocardiogram.
synchrony.
Blood pressure can be evaluated using noninvasive
yelping, or attempting
the palpa-
metric method
size and consistency
caudal abdomen.
of structures
Performing
manner
can potentially
agnoses
or a presumptive
within the cranial, mid-, and
the physical examination
in this
lead to a revised list of differential
diagnosis.
di-
During cardiac auscul-
tation, the femoral pulses should be palpated for character and
means such as Doppler method
next to evaluate the
are
and respiratory
status of the patient. Heart rate and rhythm should be evaluated
by auscultation
groaning,
tion. Deep palpation should be performed
further
The first and foremost
the cardiovascular
Other more violent reactions may include vocalizing,
to bite the person performing
are obtained,
testing should be performed.
described
should
(dogs).
elsewhere
(dogs and cats) or by oscillo-
Details of these techniques
in detail. 13,14 Auscultation
be performed,
listening
carefully
have been
of the thorax
for the presence
of
pulmonary crackles that can be associated with aspiration
pneumonitis secondary to vomiting. Mucous membrane cyano-
Cranial abdominal
pain
sis may be present
can be associated with hepatobiliary disease, pancreatitis,
troduodenal ulceration, or perforation. Caudal abdominal
gaspain
can occur due to hypoxemia, or can be associated with pain. An
arterial blood gas is useful in distinguishing between the two.
may be associated with diseases of the urogenital
tatitis, pyometra,
stipation.
Diffuse pain often is associated
may also be observed
obstruction.
system (pros-
uterine rupture, urethral obstruction)
with peritonitis,
with gastrointestinal
In many cases, sequential
or obbut
foreign bodies or
arterial blood gas with electrolytes
in determining
the patient’s acid-base
Tachypnea
can be useful
status. Severe hypoper-
fusion with resultant lactic acidosis can occur in the hypovolemic or septic patient.
If lactic acidosis
is suspected,
a serum
High pyloric obstructions
domen as described allows the clinician to accurately assess the
be associated
alkalosis
patient’s clinical status and help determine the prioritized order
loss of chloride and hydrogen ions in the vomitus. A decrease in
of diagnostic
ionized calcium has been demonstrated
measures
of the ab-
patients.
lactate should be measured.l5J6
tests and therapeutic
examination
Additionally,
in severe hypoxemic
that must be per-
formed.
nostic
with a metabolic
indicator
oximetry
Diagnostic Testing
Blood
and urine samples
ing intravenous
evaluation
should
fluid therapy, if possible,
of organ function.
cell volume (PCV),
trolytes, azostick,
before
initiat-
to establish baseline
In unstable patients, stat packed
total protein,
urine-specific
serum glucose, venous elecgravity, and activated clotting
time are useful to evaluate for the presence of anemia, intravascular volume contraction/dehydration,
hypoglycemia,
sufficiency,
and coagulation
electrolyte
Remember
abnormalities,
that splenic contraction
for a complete
panel, including pancreatic
suspected.
hemorrhage.
diagnostic
is
trypsin-
like immunoreactivity
for definitive diagnosis
in dogs, if later
indicated.
A complete
blood count, including
platelet and re-
ticulocyte
count, is also helpful in aiding a diagnosis of anemia.
and white blood cell mor-
phology are useful in cases in which inflammation
is suspected.
thrombin
A complete
time, activated
degradation
products,
ruling out the presence
coagulation
profile,
and D-dimers,
A complete
urinalysis
pro-
time, fibrin
is potentially
of disseminated
useful in
intravascular
tion. Urine should be obtained via cystocentesis
tra is suspected.
or infection
including
partial thromboplastin
venous
catheters
(jugular
useful for fluid delivery,
and measurement
of the patient’s cardiovascatheter should be
crystalloid fluids.
or medial saphenous)
ease of subsequent
dehydration
volumes
are
blood sampling,
of central venous pressure
First, estimated
(CVP) .iQ
should be calculated
using the following formula:
Body weight
in kg X estimated
Se-
amylase and lipase, if pancreatitis
White blood cell count, differential,
evaluation
status, an intravenous
placed and the patient started on intravenous
x 1000
laboratory
Serum can later be evaluated for pancreatic
of pulse
status.
can occur, causing an arti-
factually normal PCV in the face of ongoing
rum should be submitted
renal in-
cular and pulmonary
Central
In lieu of
the less invasive method
can also be utilized to evaluate the patient’s oxygen-
ation status.18 Following
be obtained
to be a negative prog-
in cats with acute pancreatitis.ir
arterial blood gas sampling,
may
caused by excessive
coagula-
unless pyome-
should be analyzed for
Calculated dehydration
percent
dehydration
= mls fluid deficit
estimated should be replenished
over a
period of 12 to 24 hours.
Shock volumes
situations:
of crystalloid
when dehydration
fluids are indicated
in several
is severe enough to cause intra-
vascular hypovolemia
or hypotension,
orrhage is suspected,
if GDV is present,
if intra-abdominal
hem-
or if a patient is inap-
propriately vasodilated and has a decreased effective circulating
intravascular volume, as observed in sepsis. Appropriate crystalloid fluids for volume replacement
include Plasmalyte-A
(Baxter Scientific,
oratories,
Laboratories),
Deerfield,
McGaw Park, IL), Normosol-R
(Abbott Lab-
Abbott Park, IL), Lactated Ringers solution
and 0.9% sodium
IL). Calculated
(Abbott
chloride
(Baxter Healthcare,
shock volumes
of fluid administra-
bactiuria, pyuria, glucosuria, crystalluria, proteinuria, and renal casts. A sterile aliquot of the urine sample should be saved
tion for the dog and cat are 90 ml/kg/h and 44 ml/kg/h, respec-
for bacterial culture and susceptibility,
shock fluid volume,
if indicated.
Fecal sam-
tively.20 This author prefers to start with l/4 of the calculated
and reassess
the patient’s
parameters
present.
pressure, blood pressure, and urine output after each incremen-
intestinal
presence
4
The feces should
parasite
be evaluated
ova, and observed
for the presence
microscopically
of
for the
of white blood cells and Clostridial spp. spore over-
of heart rate, capillary
cardiovascular
ples should be saved for possible bacterial culture, if diarrhea is
tal fluid bolus. If perfusion
necessary
to provide
refill time, central venous
parameters
an entire
improve, it may not be
calculated
shock
ELBA
volume
for ’
M. MAZZAFERRO
resuscitation.
Conversely,
ongoing fluid losses or severe vaso-
dilation may require an entire shock volume, with or without
an added colloid for intravascular
fluid support. Large volumes
of crystalloid fluids can potentially be detrimental by diluting
out clotting factors21 red blood cells, and serum proteins. The
net effect is to diminish oxygen-carrying
colloid oncotic pressure.
or packed red blood cells can be administered
if ongoing hem-
orrhage or anemia is present. Plasma can be administered
Synthetic
albumin
colloids such as Hetastarch
maceuticals,
Wilmington,
Baxter Healthcare)
and clotting
(Hespan;
can be administered
ml/kg/d.20 Stroma-free
purified hemoglobin
rate infusion
Pharbo-
patients,
rate infusion
of 20
(Oxyglobin;
MA) can also be administered
boluses or as a constant
Bio-
in 3 to 7 mUkg
of 20 to 30 mYkg
for its
colloidal effects and as an oxygen carrier in the anemic patient.
Definitive
following
diagnostic
stabilization
Ancillary
diagnostic
dominal
radiographs,
evaluation
Abdominal
diagnostic
ultrasound,
diagnostic
fluid, when present,
and bacterial peritonitis.
findings will allow the clinician
versus surgical intervention
include
ab-
or four-
lavage, tho-
contrast
studies.
should be evaluated
uroperitoneum,
tests in combination
status.
single
peritoneal
and possibly radiographic
dence of hemorrhage,
perforation,
cardiovascular
tests that may be performed
quadrant abdominocentesis,
racic radiographs,
of the patient can proceed
of the patient’s
abdominal
pancreatitis,
for evi-
biliary tree
In many cases, results of
with physical
to determine
examination
where medical
is appropriate.
One of the most important therapies in the patient with acute
abdominal pain is the administration of analgesic agents. Analgesic agents should be administered
surgical management
in all cases of medical or
in which immediate
pain cannot be accomplished.
relief of abdominal
A wide armamentarium
gesic agents is available to the veterinary
of anal-
practitioner.
A list of
analgesic agents and doses is shown in Table 3. Other important
treatment priorities include preventing vomiting and hypotension. Opioid agents such as morphine,
ers, may induce vomiting
may be less appropriate
quilizers
should
in the ambulatory
not be used. Although
they have no analgesic properties,
sion thorough
while potent pain relievpatient, and thus
than other agents. Phenothiazine
pounds such as chlorpromazine
Ondansetron
0.1-l .O mg/kg IV slowly ql2-24 hours (dogs)
0.1-i .O mg/kg q8-12 hours (cats)
0.3 mg/kg (dogs)
l-2 mg/kg/d IV CRI (dogs and cats)
0.1-0.5 mg/kg SQ, PO TID (dogs and cats)
Dolasetron
Metoclopramide
IV = intravenously; CRI = constant rate infusion; SQ = subcutaneously; q = every; TID = three times daily.
(Gentran-70;
in 5 to 10 mVkg
should be followed by a constant
pure, Cambridge,
Dose
at a
factors.
DuPont
DE) and Dextran-70
luses to provide oncotic support. In hypoproteinemic
boluses
Drug
capacity and effective
Natural colloids such as whole blood
dose of 20 mL/kg for providing
TABLE 4. Antiemetic Agents for Use in the Veterinary
Patient with Acute Abdomen
phenothiazine
are potent antiemetic
and may potentiate
their or-adrenergic blocking vasodilatory
trancomagents,
hypoteneffects.
Additional
therapeutics
use of antiemetic
as metoclopramide,
dolasetron
Dose
Morphine
0.5-l .O mg/kg SQ IM (dogs)
0.1 mg/kg/h IV CRI (dogs)
0.05 mg/kg/h IV CRI (cats)
0.1 mg/kg IV (dogs and cats)
0.2-0.4 mg/kg SQ (dogs)
0.005-0.02 mg/kg IM, IV, SQ q6-12 hours (dogs)
0.005-0.01 mg/kg IM, IV, SQ q6-12 hours (cats)
2 mcg/kg IV bolus, followed by
l-5 mcg/kg/h IV CRI (dogs and cats)
0.1-0.2 mg/kg IM, IV, SQ (dogs and cats)
Butorphanol
Buprenorphine
Fentanyl
Hydromorphone
SQ = subcutaneously;
infusion; q = every.
TRIAGE AND APPROACH
IM = intramuscularly; CRI = constant rate
TO THE ACUTE ABDOMEN
A list of dosages is provided
in
also acts as a promotility
if gastrointestinal
Positive inotropes
pg/kg/min IV constant
such
such as
obstruction
such as dobutamine
rate infusion
[CRI])
is
(3 to 10
and vasopressors
such as dopamine (5 to 10 pg/kg/min IV CRI) may be necessary
in cases of refractory
starting
hypotension.
broad spectrum
Gram-negative,
Combination
Many
antibiotics,
aerobic,
authors
covering
and anaerobic
advocate
Gram-positive,
bacterial
therapy such as Ampicillin
times per day) and Enrofloxacin
spectrum.
(22 mg/kg IV three
(2.5 to 5 mg/kg IV twice per
day) is an appropriate
choice. Another choice is a second gen-
eration
such as Cefoxitin
cephalosporin
times per day). Metronidazole
(22 mg/kg IV three
(10 to 15 mg/kg IV three times
per day) may also be added to the antibiotic
tional anaerobic
Triage and assessment
apeutic challenge
tive diagnosis
regimen for addi-
coverage.
pain and associated
of the patient with acute abdominal
clinical signs remain a diagnostic
to the veterinary
and ultimate
clinical stabilization
practitioner.
treatment
and ther-
While defini-
are the primary
of the patient’s cardiovascular
goals,
and respira-
tory status is of utmost importance,
often taking priority over
invasive and noninvasive
testing until the patient’s
condition
diagnostic
is more stable. Many diagnostic
nor sensitive for.one particular problem,
use a combination
of history,
and results of diagnostic
therapy. Prognosis
physical
tests are not specific
so the clinician must
examination
findings,
testing to guide specific and definitive
and definitive treatment
ultimately
depend
on each individual patient’s primary problem and the presence
of secondary
complicating
nostic and therapeutic
dominal
Drug
uptake inhibitors
metoclopramide
agent, its use is contraindicated
a possibility.
include the
dopamine antagonists
and serotonin
and ondansetron.
Table 4. Because
sis, diagnostic
TABLE 3. Analgesic Agents for Use in the Veterinary
Patient with Acute Abdomen
that should be considered
agents, including
anesthesia,
abdomen,
factors. Further
modalities,
peritoneal
lavage, cytologic
fluid, radiographic
and surgical
is mentioned
interpretation,
approach
discussion
including
of diag-
abdominocenteevaluation
of ab-
ultrasonography,
to the patient
with acute
elsewhere in this issue.
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ELISA M. MAZZAFERRO