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Surgical Nursing And Analgesia Flashcards

1
Q

Features of laryngeal paralysis

A

Can be congenital - severe polyneuropathy and unable to work or feed
Acquired - degenerative disease of the recurrent laryngeal nerve resulting in crico-arythenoideus dorsalis muscle incompetence

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2
Q

Diagnosis of laryngeal paralysis

A

Cervical and chest X-rays to check for megaoesophagus or consolidation
Ultrasound
Direct visualisation
Laryngoscopy with light GA

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3
Q

Emergency treatment of laryngeal paralysis

A 
Oxygen
Anti inflammatories but not NSAIDS
ACP to sedate if necessary
Tracheostomy 
Cool down the animal with fan or wet towels
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4
Q

Surgical considerations of laryngeal paralysis

A

Laryngeal tie back
Clip with angle of mandible in centre, half of next to corner of eye
No intraoral sutures
Partial laryngectomy will cause stenosis from inflammation

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5
Q

Post op care and prognosis of laryngeal paralysis

A

Local blocks instead of pain and sedation post op to prevent regurg/aspiration pneumonia due to open glottis
Careful with anaesthesia protocol
20-30% complication rate
Short term prognosis is excellent
Long term risk of aspiration, megaoesophagus, neuro conditions

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6
Q

Features of tracheal collapse

A

Dynamic obstruction of the upper airway
Tracheomalacia
Common cause of cough
Can affect cervical region, intrathoracic segent or both

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7
Q

Diagnosis of tracheal collapse

A

Radiography
Fluoroscopy - best method
Endoscopy with BAL sample

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8
Q

Treatment of tracheal collapse

A

Medical tx first - anti tussives, antisecretory, bronchodilators, antibiotics

Extra luminal prosthesis - syringe round trachea in cervical region
Intre luminal prosthesis - stent which can be used anywhere. Less morbidity but anti tussives to start as Fb in throat until surrounded by mucosa

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9
Q

Indications for permanent tracheostomy

A

Permanent UAO - laryngeal collapse, laryngeal neoplasia

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10
Q

Surgery considerations for a permanent tracheostomy

A 
Ventral midline approach
Good apposition
Monofilament non absorbable
Large stoma as will reduce over time
Suture trachea to skin
Skin fold plasty
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11
Q

Aftercare for a permanent tracheostomy

A

Keep clean
No collar
Suction
Nebuliser to reduce swelling and discomfort

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12
Q

Complications of a permanent tracheostomy

A 
Mucous and secretions plug if not kept clean
Stenosis/ stricture
Obstruction
Dehiscence 
Granulation tissue formation
Skin fold obstruction 
Infection
Impacts quality of life - no swimming
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13
Q

What is cholesteatoma

A 
Epidermoid cyst with keratin debris
Expansive lesion of the middle ear
Locally destructive 
Non neoplastic 
Most commonly secondary to TECA-LBO
Erodes bone
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14
Q

Symptoms of cholesteaoma

A 
Head shaking
Discharge
Pain opening mouth
Head tilt
Facial palsy
Ataxia
Nystagmus
Neuro signs - poorer prognosis
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15
Q

How to diagnose cholesteatoma

A

Radiographs - oblique views
CT - osteolysis, sclerosis, expanded bulla
MRI - expanded bulla with varying intensity

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16
Q

Treatment for cholesteatoma

A

Surgical resection to remove all abnormal tissue

Medical tx of antibiotics long term

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17
Q

Prognosis of cholesteatoma

A

Frequent recurrence

Neuro signs make prognosis worse as well as inability to open mouth and temporal bone lysis

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18
Q

What is primary secretory otitis media

A

Poor venting of et orifice in naso pharynx
VBO/TECA don’t treat the cause
Place plastic hollow tube to connect middle ear and external ear - grommits

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19
Q

Features of a subtotal TECA

A

Preserves most proximal portion of ear canal
Less dissection so less post op pain
Dogs and cats can have it
Vertical part of the external ear canal is dissected and cut proximally
Cartilage is sutured proximally
Dissection follows as per normal TECA

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20
Q

Symptoms of a para-aural abscess or fistula

A 
Head pain
Pain when opens mouth 
Head tilt
Lethargy
Swelling or draining sinus over surgical site
Occurs 3-9months post op
Only in dogs
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21
Q

Pathophysiology of para-aural abscess or fistula

A 
Inadequate debridement of middle ear
Not all ear cartilage is removed
Osteomyelitis 
Parotid gland damage
Can occur with TECA and cholesteatoma
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22
Q

Diagnosis of para-aural abscess or fistula

A 
Can be FB or neoplasm
Plain X-rays 
Contrast fistulogram
CT and contrast
MRI if showing neuro signs
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23
Q

Treatment of para-aural fistula

A

Medical - antibiotics

Surgical - lateral approach, central if confined to bulla or ventral to it

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24
Q

Complications of para-aural abscess or fistula

A

Facial nerve paralysis
Otitis interna
Head tilt

Sx is more successful than medical tx

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25
Features of a ventral bulla osteotomy
Performed in cats to treat nasopharyngeal polyps Can be done on dogs with recurrence of cholesteatoma or diseases limited to bulla but need to incise a lot deeper in dogs than cats
26
Principle of the chest drain
Drain placed in pleural space to remove air and fluid
27
Indications for a chest drain
``` Pneumothorax Chylothorax Haemothorax Pleural effusion Post thoracic sx ```
28
Equipment needed for chest drain placement
``` Clippers Prep Chest drain - soft and fenestrated and radiopague Sterile gloves and swabs Basic surgical kit Local blocks ```
29
How to place a chest drain
Lateral recumbancy Clip 4th to 11th rib and prep Local block 7-8th IC Incision over rib 10 under skin and muscle to 7
30
How to care for a chest drain
Keep clean Keep end covered if not continuous suction Check stoma site for discharge and air leaks Check drain for damage, leaks Record output Remove when production decreases Cats tolerate poorly
31
What are the two types of chest drains
Intermittent | Continuous
32
Drainage of intermittent chest drains
Fluid and air Every 2-4hours Check for dyspnoea Use a 3-way tap
33
Drainage of a continuous drain
Heimlich valve - valve closes on inspiration, passive system, dogs bigger than 10kg Collecting bag and concertina Different methods Closed chest drainage system
34
Complications of a chest drain
``` Internal trauma Air leaks Obstructions Arrhythmias Infection ```
35
What is pneumothorax
Air in chest Common cause of non traumatic pneumothorax is pulmonary blebs and bullae which burst open Medical tx of thoracocentesis or thoracostomy tube placement
36
Describe the use of a chest drain for pneumothorax
``` Small lumen Fenestrate Soft Flexible Easily placed - no GA Continuous suction ```
37
What is pyothorax
Accumulation of septic pleural effusion Gram negative or anaerobic bacteria Treated my surgical exploration and debridement Drainage and antibiotics
38
Describe the use of a drain for pyothorax
Wide lumen Can place at the same time as the surgery Place one on each side incase one gets blocked Central position as draining heavy liquid Flush chest Continuous
39
Patient prep for thoracic sx
Foreleg to last rib clip - needs to be large Cover drape Legs extended cranially Sandbags
40
Instruments for thoracic sx
Right angle lahey forceps Pledgeted sutures Satinsky clamp for atraumatic clamping of hilar bronchus Mechanical staplers - gold standard for lobectomies. Staple proximally to lesion
41
What should the trolley be stocked with for foal emergencies
``` Syringes/ needles Blood tubes Glucose/ lactate reader Hibiscrub Spirit Catheter kit Clippers Fluids Feeding tube Oxygen Foal resuscitator ```
42
What is normal behaviour off the foal post parturition
``` Sternal - 2/3 minutes Suckle reflex - 30 minutes Standing - 60 minutes Standing and suckling - 2 hours Active/ playful - 6-7 hours ``` Healthy foal should avoid being caught and have a close affinity with the mare
43
What is a foals normal TPR
T 37.2-38.9 P 40-80bpm at birth which increases to 120-150 when trying to stand. First week 80-100bpm R 60-80 at birth then 30-40 Rectal temp usually reflects that of environment so doesn't indicate infection. Holosystolic murmers normal and disappear after 3 days
44
Clinical examination of a neonatal foal
Is there suck reflex Look for entropion of eyelids and corneal ulceration Look for colour changes in mm, coronary bands and ear pinnae which may indicate sepsis Fungal plaques on tongue are a sign of ill thrift or systemic infection Check for cleft palate and malocclusion of jaw Milk at nostrils may show swallowing deficit - dummy foal Palpate thorax for fractures Check for abdo distension and hernias Check umbilicus for swelling Check genitalia - scrotal hernias, vulval petechiations Monitor limbs closely for lameness from infection or contracted tendons Extremities should be warm Dilute urine should be passed frequently Faeces should be pasty and toffee coloured once meconium passed If born covered in meconium - stressful birth so monitor closely
45
How to tell if a foal is showing abnormal behaviour
Sick foals deteriorate rapidly Low head carriage Droopy ears Appears to sleep standing up Stand under the mare but will not latch or form a complete seal to nurse properly Mares run milk which splashes onto foals face
46
What are the most common diseases in neonatal foals
Sepsis Neonatal maladjustment syndrome - dummy foals deprived of o2 Prematurity All 3 can occur together
47
How to nurse the recumbent foal
``` Keep sternal to improve oxygenation Well padded bed, lots of support Keep clean and dry Check eyes with fluoroscein for ulcers Change recumbency every 2 hours Blankets and hair huggers for warmth Beware bedsores Encourage to stand or walk with support Physio if can't walk ```
48
When to use enteral or parenteral nutritional support with a sick foal
Prematurity or diarrhoea will worsen if feed orally Dummy foals can have NG tube placed and fed milk from mare as they're not nursing properly IV 5% glucose in isotonic fluids Check for gastric reflux, GI sounds, abdo distension 45kcal/kg/day
49
What is failure of passive transfer and how to treat
``` No absorption of antibodies from the mare in the colostrum Check IgG levels >8g/L is a pass 4-8g/L is a partial failure < 4g/L is a fail ``` Boost with a plasma transfusion via NG tube if <6hrs old otherwise give IV
50
What is meconium impaction
Foal struggles to pass meconium Obstructs rectum and colon Common cause of colic Commercial enema or homemade retention enema
51
When would you perform CPR on a neonatal foal
If born by assisted vaginal delivery following correction of dystocia or delivered by caesarean
52
What are the most common spinal disease categories in cats and dogs
Dogs - degenerative, traumatic, neoplasia, anomaolous Cat - inflammatory/infectious, traumatic, neoplasia
53
What is a disc protrusion or extrusion
Disc extrusion - annulus tears and degenerate nucleus extrudes out to compress spinal cord Disc protrusion - annulus bulges / protrudes which compresses the spinal cord - larger breeds
54
What colour should spinal discs be on MRI scans
White as they have water in them - become degenerate and turn black on imaging
55
What is cervical spondylomyelopathy
``` Canal stenosis Disc protrusion Facet hypertrophy Flávio ligamentum hypertrophy These all compress the cord ``` Facet joints not stable so disc degenerated - body makes more bone to stabilise but squishes cord in multiple directions Poor prognosis
56
What is degenerative lumbosacral disease
Disc protrusion Facet hyperplasia Soft tissue proliferation Subluxation These impinge on caudal equina and directly or blood supply to it Causes sciatic pain, affects urinary and fecal continence, v. Painful
57
What's the most important thing to do when suspecting a spinal fracture or luxation
Radiograph two views
58
What are anomalous cysts
Sub arachnoid diverticula Abnormal adhesion between layers of meninges Causes a collection of CSF which compresses the spinal cord or causes inflammation in the cord
59
What is discospondylitis
Infection in the intervertebral disc and end plates of surrounding vertebrae Compresses cord or causes instability with a compressive component
60
How do surgical diseases cause neuro signs
``` Through pathology of Laceration Compression Contusion Ischaemia Infiltration and dysfunction of cells directly or indirectly by affecting their environment ```
61
What spinal injuries can be medically managed
Laceration can be preventable Ischaemia Infiltration and dysfunction with drugs or radiations
62
How do you nurse a patient presenting with spinal laceration
Immobilise- spinal board - Bandages to form a neck brace - Spinal brace
63
How do you nurse a patient presenting with spinal ischaemia
Ensure ventilating appropriately - give o2 if necessary Check cardiac output is sufficient Ensure blood volume and blood pressure is appropriate - patient may be in shock
64
What are the 6 common surgical spinal procedures
``` Dorsal laminectomy Facetectomy Foraminotomy Hemilaminectomy Ventral slot Stabilisation/ fusion ```
65
What is a dorsal laminectomy
Removal of the laminae of the dorsal vertebral arch and dorsal spinal process allowing access to the dorsal spine
66
What is a facetectomy
Removal of the articular facet
67
What is a foraminotomy
Enlargement of an intervertebral foramen to relieve pressure on a nerve or nerve root
68
What is a hemilaminectomy
Removal of one half of the lateral vertebral arch to allow access and partial access to the ventral or dorsal aspect of the spinal column
69
What is a corpectomy
Lateral approach with removal of part of the vertebral body and end plates either side of a intervertebral disc aswell as removal of part of the disc For thoracic/lumbar cord without going through thorax or abdomen
70
What is a ventral slot
Ventral approach in endplates of the vertebral body and removal of part of the disc in the cervical spine
71
What is stabilisation of the spine
Removing motion between adjacent vertebrae using implants and bone grafts
72
What is useful surgical kit for spinal surgery
``` Retractors - gelpi, odd leg gelpi, McKee Spinal burr and burrs Rongeurs Bone punch forceps Microrongeurs Periosteal elevator Nerve hook Curette Scaler Bone wax Surgicell PVA Duragen Surgical patties ```
73
What is crucial for recovery of spinal surgery
Physiotherapy | Team effort
74
Why is physiotherapy important
``` Prevents pressure sores Reduces pain Supports respiratory system Forms bond between rehabilitation team Promotes motor recovery ```
75
When do you start physio
24 hours post op Nervous system needs to relearn by generating the movement Only 10% spinal cord axons are needed to work
76
Where does physio act
Blood and lymph flow, relaxation, and promotes early ambulation Maintains joint health, prevents muscle wastage, keeps tendons mobile Improves core stability, retrains gait patterns, stimulates proprioceptive relearning
77
What physio actions are performed
``` Massage Passive Active assisted Active Proprioceptive Hot/cold therapy ```
78
Why is massage important
``` Venous and lymphatic drainage Analgesia Dermal stimulation Bonding Warm up ```
79
Why is passive range of movement exercise important
Joint health Flexibility and elasticity Gait patterning
80
Why is active assisted exercise important
Provides assistance during muscular contraction | Helps train the gait
81
Why are proprioceptive exercises important
Challenges the body recognition of limb position in space
82
What should be considered when making a physio plan
``` Expectation of the owner Temperament of the dog Previous activity Previous ailments Clients involvement of time and expertise Physical exam Neuro exam Disease process ```
83
Why can skin disease occur in spinal patients
Boredom Sensory dysfunction - neuropathic pain causing self mutilation Recumbancy - bed sores Bladder / faecal dysfunction - leads to scalding
84
Why do skin sores develop
Lack of movement Mechanical loading causing tissue compression Ischaemia due to reduced pulsatile blood flow and venous blood return, repercussion injury and Bp anomalies following sx Consequence of tissue break down - deep tissue first then skin - see wound after damage already caused
85
How do you prevent skin sores
``` Turning every 2 hours Good bedding - sling bed, porous mattress, non slip floors, inco sheets Bandage doughnuts around bony prominences Physio Inspect skin Barrier creams Relieve bladder often Avoid unnecessary bandages No tape on skin ```
86
How do you treat skin sores
Clean Debridement Antibiotics if needed Bandage
87
How do you manage wounds from spinal surgery
Cryotherapy 15mins q4 48-72hrs Dorsal approaches have skin movement and there is risk of layer separation and seroma formation Care as may have loss of skin sensation
88
Why do many spinal patients have bladder impairment
Cells to bladder have nerves in s1-s3 to pons that cause contraction and relaxation of sphincter
89
What does lack of voluntary urination lead to
Uti from urine stasis Bladder distension leading to atony where pacemaker fires but bladder cells can't communicate with each other Distension of ureters causing visceral damage Skin sores
90
How to you manage the bladder and bowel of spinal patients
Manual expression x3 daily - only get 50% out but stops levels being dangerous Catheter - indwelling or intermittent Drug therapy to relax sphincter or contract bladder wall
91
What method of bladder management would be appropriate for a lower motor neurone bladder in a very aggressive dog that has urine scalding
Floppy bladder wall tone Leaks urine constantly Detrusor muscle stimulant
92
What is an upper motor neurone bladder
L1-L7 Increased tone to muscle wall but sphincter is tight Difficult to express Urine in lots of spurts as pressure is too great
93
What are the types of pain
Inflammatory - tissue damage Neuropathic - dysfunction in transmission of nociception both peripherally or centrally Acute Chronic
94
Why do you need to monitor the respiratory system of spinal patients
Especially cervical lesions | Prone to hypoventilation, atelectasis, pneumonia
95
What are the 3 types of surgical site infections
Superficial incisional - skin and sub cut tissue Deep incisional - deeper soft tissue involved Organ / space infection - any other structures
96
What are th disadvantages of surgical infection
``` Poor cosmesis Delayed healing Increased cost to practice and owner Animal welfare More surgery to correct Client relationship may be damaged Increased use of antibiotics - resistance ```
97
What is a biofilm
Bacteria attach to a surface in communities which allows them to intersect and adapt to changing environments Resistance to hosts immunity and antibacterial agents Quiescent so give negative cultures so hard to diagnose Implants are high risk for biofilm formation
98
How do you manage a surgical site infection
Antibiotics once culture and sens is back - give antibiotics before for what it's most likely to be Barrier nurse Cover wound and debride Record the bacteria, surgery, treatment and if it was successful
99
What factors may predispose a patient to infection
Patient Environmental Treatment
100
What are patient factors predisposing to infection
Geriatric or young animals have a diminished immune response Obese animals - more weight on surgical areas like joints and less oxygen able to get through fat Malnourished patients - decreased albumin levels in blood Immunosuppression - chemo, steroids, diabetes mellitus Remote infection - skin disease Recent surgery Rerioperative temperature - vasoconstriction
101
What are the environmental factors predisposing to surgical infection
Patient prep - separate area, don't pre clip Cross contamination - hand washing Aseptic technique Proper theatre conduct Cleaning methods - damp dusting, disinfectants Inadequate ventilation
102
What are the treatment factors predisposing to surgical infection
Surgical time Experience of surgeon Antibiotic administration Use of a drain - benefits have to outweigh the risks Emergency procedure Surgical implants Suture material - multifilament vs monofilament. Triclosan coated
103
What are the Halsteads principles
``` Gentle tissue handling Adequate haemostasis Preservation of blood supply Strict aseptic technique Minimum tension at wound closure Good tissue approximation - maintain good blood supply Obliteration of dead space ```
104
When to use antibiotics after surgery
Implants When infection of wound would be catastrophic Surgery more than 90 mins Clean contaminated and contaminated procedures Selection based on most likely contaminant Start 30mins before sx IV Likely to be no benefit continuing antibiotics post op other than already infected wounds, suspected infected wounds or bacteraemia
105
Post op care for surgical wounds
Cover for 24-48 hours and don't change if strike through Once fibrin seal has formed bandage no longer necessary Avoid patient interference Good drain management Good nutrition - protein good for wound healing
106
``` Troy 7y MN poodle Retching post meal sudden onset Lying down and unwilling to go out HR 180, weak puls, pale mm RR 48' increased effort bilaterally Obtunded but appropriate Distended abdo What does this mean and what to do? ```
Severe hypoperfusion IV catheter IVFT Oxygen Blood sample- PCV/TS, haem, biochem, clotting times Opiates for analgesia- methadone, fentanyl, morphine - sedative effect Radiographs
107
What are the risk factors of GDV
``` Breed Body shape Age Anxious temperament Diet composition Number of meals Speed of eating ```
108
What are the local and systemic effects of GDV
``` Local effects on the gastric wall and spleen Systemic effects - reduced venous return - reduced cardiac output - hypotension - poor tissue perfusion - acidosis/inflammatory indicators - ischaemic reperfusion injury Sepsis ```
109
How is percutaneous decompression done
14-16G catheter Point of maximal gaseous distension Removes gas only Must have ex lap soon afterwards - examine site of needle penetration
110
How is Oro-gastric decompression done
``` Can be done in conscious dog Measure tube Place bandage in mouth as gag Pass tube Fluid and gas ```
111
What is the aim of surgery to correct GDV
Gastric decompression and repositioning Gastroplexy Assessment of viability of abdo organs and resection of devitalised tissue
112
What anaesthetic plan would you have for a patient with GDV
``` Opiates and maybe diazepam Induction Iso Avoid nitrous oxide IVFT Antibiotics ```
113
Apart from gastric necrosis what is also associated with GDV
Splenic torsion
114
Why perform a gastroplexy on GDV patients
No gastroplexy means 80% mortality More chance of recurrence if don't do Use incisional, belt loop or tube technique
115
What is the post op care for a GDV patient
``` Monitor parameters PCV / TS Urine output ECG / Bp IVFT Opiates NSAIDs when normotensive, normovolaemic and eating ```
116
Complications of GDV surgery
Arrhythmias- VPCs, caused by myocardial injury, electrolyte imbalance. Asses effect. Lidocaine 1-2mg/ bonus then CRI Hypotension/ hypoperfusion Aspiration pneumonia Abnormal gastric motility - metoclopromide, gastroprotectants Gastric necrosis Sepsis
117
How can you prevent GDV and what advice to give to owners
``` Breed predisposed - elective sx? Laparoscopic gastroplexy Prevention better than cure Warm of risk of recurrence Feed multiple times daily Avoid stress ```
118
What do the thyroid glands do
Produce thyroxine which has metabolic effect on all organs
119
What are the clinical signs of hyperthyroidism
``` Polyphagia Weight loss PUPD increased activity V+/D+ Goitre - swelling in neck ```
120
What other diseases are associated with feline hyperthyroidism
Heart disease - tachycardia | Kidney disease - often masked by hyperthyroidism
121
What are the treatment options for hyperthyroidism
Medical - methimazole to decrease thyroxine production Surgical - thyroidectomy Radioactive iodine treatment
122
What is the aim of a thyroidectomy
Removal of one or both thyroid glands Preservation of parathyroid tissue to avoid post operative complications - dissect around it Stabilise medically before sx
123
Post op care for thyroidectomy
``` IVFT Analgesia Monitor renal function - avoid NSAIDs Watch out for laryngeal paralysis Hypocalcaemia ```
124
Why is hypocalcaemia a risk for thyroidectomy patients
Inadvertent removal or damage of parathyroid glands Monitor for 2-7 days Check ionised calcium Seizures, muscle twitching, facial pruritus
125
Treatment of hypocalcaemia
10% calcium gluconate 0.25-1.5ml/kg slow IV Calcium drip 10ml calcium gluconate in 250 hartmanns 60ml/kg 24 hours Oral vit D and calcium Taper medication over 4 weeks and monitor ionised calcium
126
What is the anatomy and function of the parathyroid glands
Pair of parathyroid glands for each thyroid gland Secrete parathyroid hormone Cause increased calcium in the blood and decreased phosphorous
127
What are the features of parathyroid tumours
Older dogs Adenoma Increased secretion of parathyroid hormone and loss of normal inhibition Increased ionised calcium
128
Diagnosis of a parathyroid tumour
Hypercalcaemia PUPD Parathyroid mass on ultrasound
129
Treatment of parathyroid tumours
Diuresis for high calcium - IVFT saline Diuretic Parathyroidectomy Partial thyroidectomy
130
What is the pancreatic endocrine function
Beta cells produce insulin and glucagon Regulates glucose metabolism Insulin decreases blood glucose levels and causes storage of glucose
131
Features of an insulinoma
``` Carcinoma of endocrine pancreas Aggressive Secretes insulin Causes hypoglycaemia Dogs Weakness Seizures Ataxia Muscle tremors ```
132
Diagnosis of hypoglycaemia
``` Bloods Wipples triad- clinical signs associated with hypoglycaemia - fasting glucose <2.2mmol/l - improvement in signs following feeding or glucose administration Increased serum insulin Imaging for metastasis Ultrasound CT ```
133
Treatment of insulinoma
Emergency treatment - sugar solution, glucose IV 0.25g/kg Medical management - frequent meals, glucocorticoid steroids, diazoxide Surgery - partial pancreatectomy with 5% dextrose infusion to prevent hypoglycaemia
134
Post op care for insulinoma
Monitor BG Complications - transient hyperglycaemia - persistent hypoglycaemia - pancreatitis Prognosis of 785 days, over 1000 days of has medical management following relapse
135
Function of the adrenal glands
Adrenal cortex secretes aldosterone, cortisone, sex hormones Adrenal medulla secretes noradrenaline and adrenaline
136
What diseases to adrenocortical tumours cause
Cushings - dogs | Conns syndrome - cat, hyperaldosteronism
137
Clinical signs of cushings
``` PUPD Polyphagia Panting Abdo enlargement Alopecia Muscle weakness Lethargy Weight gain ```
138
How do you diagnose cushings disease
Low dose dexamethasone suppression test
139
What is phaeochromocytoma
``` Tumour of adrenal medulla Excess production of cathecholamines Weakness and collapse Panting Tachycardia Muscle wastage Can cause intermittent hypertension ```
140
How are adrenal tumours diagnosed
Ultrasound | CTto show metastasis and involvement of vena cava
141
What is the pre operative surgical stabilisation for adrenal tumours
Cortical tumour - trilostane pre op Pheaochromocytoma - phenoxybenzamine is an alpha-adrenergic blocker - give 2 weeks pre op - propranolol if persistent tachycardia
142
Surgical considerations for adrenal cortical tumour
Delayed healing | Pulmonary thromboembolism
143
Surgical considerations for pheaochomocytoma
Surgical manipulation can cause surges in catecholamine release - hypertension, tachycardia, arrhythmias, cardiac arrest Monitor anaesthetic carefully Propranolol for tachycardia Lidocaine for arrhythmias
144
Surgical approaches of adrenal tumours
Midline laparotomy to removal cabal thrombosis Flank approach Laparoscopy Risk of haemorrhage so have donor blood available
145
Post op care of adrenal tumours
Adrenocortical tumours - hypocortisolism post op Steroid supplementation - dexamethasone peri op, prednisolone post op Mineralocorticoid supplementation - monitor electrolytes as can have decreased sodium and increased potassium. Fludrocortisone
146
Features of conns syndrome in cats
``` Adrenocortical syndrome Increased sodium and water retention Hypertension Hypokalaemia Episodic muscle weakness Collapse ```
147
What is the hepatic blood supply
Hepatic artery - 20% blood, 50% oxygen Hepatic vein Hepatic portal vein - 80% blood, 50% oxygen
148
What is the function of the liver
``` Synthesis and clearance of albumin Metabolises glucose Production and activation of clotting factors Clearance of toxins Lipid metabolism Reticuloendothelial function Gastrointestinal function Storage of vitamins, fats, glycogen, copper ```
149
Symptoms of hepatic insufficiency
Hypoproteinaemia Hypoglycaemia Coagulopathy Hepatic encephalopathy
150
Assessment of the liver
Clotting times APTT and PT Liver, bile and gall bladder samples for culture to determine if antibiotics peri op are necessary - normal for bacteria to be in liver - amoxycillin
151
How to do liver samples
Ultrasound guided FNA or tru cut | Surgical biopsies are more accurate and safer
152
What are the indications for liver lobectomy
Biopsy Mass removal - benign or malignant Abscess Liver lobe torsion
153
Features of a liver lobectomy
Partial or complete Can remove up to 70% liver Blood type as risk of haemorrhage - DEA 1.1 dogs, AB cats
154
Indications for biliary tract sx
Extra hepatic biliary tract obstruction - cholelithiasis, gall bladder mucocele, pancreatitis, neoplasia Biliary tract rupture and bile peritonitis
155
Clinical signs of a problem with biliary tract
``` Non specific Lethargy Anorexia V+ Abdo pain Icterus Hypovolaemic shock in severe obstruction or bile peritonitis ```
156
What will haem and bio tell you if there's a problem with the biliary tract
Decreased albumin Increased bilirubin, cholesterol, ALP, ALT Decrease vit k - 3 doses vit k at 0.5-1.5mg/kg sx Coagulation abnormalities - fresh frozen plasma in emergencies 10ml/kg
157
Causes of bile peritonitis
Disease vs trauma Therefore sterile or septic Manage the peritonitis and treat the underlying cause
158
Surgical considerations for bile tract problems
Cholecystectomy Cholecystoenterostomy Better to preserve common bile duct rather than gall bladder
159
What is the outcome of extrahepatic biliary surgery
Often systemically unwell Significant mortality Poor prognosis in cats for neoplasia compared to inflammatory conditions
160
Post op care for extra hepatic biliary surgery
``` Intensive nursing Analgesia Monitor - usual paramenters, Bp, leakage of bile, signs of haemorrhage Haem and biochem Antibiotics only if infection present Monitor for sepsis or SIRS ```
161
What is a congentital portosystemic shunt
Vessel connecting the causal vena cava and hepatic portal vein Can be extraheptatic - yorkies, westies Can be intrahepatic - labradors, Irish wolf hounds
162
Clinical signs of Portosystemic shunt
``` Failure to gain weight Small Neuro signs - hepatic encephalopathy Urinary tract signs Gastrointestinal signs Drug intolerance ```
163
What does haematology and biochem show for portosystemic shunts
``` Microcytosis Anaemia Increased clotting times Decreased urea, albumin, cholesterol, hypoglycaemia Increased ALP and ALT Decreased USG ```
164
How do you test the liver function
Ammonia tolerance - ammonia converted to urea in liver. Very labile. Abnormal in most portosystemic shunts Dynamic bile acids - 100% sensitive
165
How do you diagnose portosystemic shunt using imaging
Ultrasound Portovenography - fluoroscopy provides info on shunt configuration, confirms shunt and gives info on intrahepatic vasculature
166
How do you medically manage a portosystemic shunt
``` Treat the clinical signs Manage hepatic encephalopathy Restricted protein diet Lactulose Antibiotics Seizure medication Manage for 2-3 weeks before sx ```
167
What are the goals of portosystemic shunt sx
Attenuate shunt - complete of partial ligation or use a gradual attenuation device Restore normal portal blood flow Resolve hepatic insufficiency and clinical signs
168
How is portovenography done
Catheter into jejunal vessel during surgery | Inject with contrast under fluoroscopy guidance
169
Surgical complications of portosystemic shunt
``` Portal hypertension Haemorrhage Neuro complications Hypoglycaemia Mortality 10% Complications greater if intrahepatic shunt Better outcome if complete attenuation ```
170
What history do you need to know for an orthopaedic exam
Medication Duration of lameness Onset Is it static, progressive, deteriorating, improving Is the lameness continuous or intermittent Alters with exercise or rest Altered by the ground surface Which limbs does the owner perceive to be the problem Is the animal a working or pet dog Any concurrent problems
171
What does a lame animals gait look like
``` Head bobs down on good leg Shortened stride of good leg Scuffed nails Stifle pain limb is circumducted Hip pain - spinal scoliosis. Lateral sway or bunny hopping ```
172
What does ataxia mean
Pelvic limb in coordination
173
What does paraplegia mean
Neurological deficits and no motor function
174
What does paraperesis mean
Neurological deficits but motor function is present
175
How will a lame animal stand
Paw of limb taking the most weight is flatter and will be difficult to lift Inward or outward pointing of the paw Weight may be shifted onto thoracic limbs Scoliosis of spine Frequent sitting - pelvic lameness Frequent lying down - thoracic limb lameness
176
How should you perform a physical exam for an orthopaedic patient
Examine the animal standing fully | Exam in lateral position working from the toes of each limb upwards
177
How should you examine joints
``` SPIRM Swelling Pain Instability Range of motion Manipulation ```
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How do you examine limbs
SAP Swelling muscle Atrophy Pain
179
What are the specific tests for a stifle
Cranial draw Tibial thrust Patella luxation
180
What are the tests for the hip
Ortolani test
181
What equipment is needed for an arthrocentesis
``` Spinal needle 5ml syringe Clippers Prep Sterile gloves Microscope slides EDTA tube Culture bottle ```
182
When do dogs usually show signs of elbow dyslpasia
From 5 months of age and before 2 years
183
What radiographs should be taken when elbow dysplasia is suspected
Craniocaudal Mediolateral Flexed lateral
184
What is an ununited anconeal process
Anconeal process does not fuse Elbow stability compromised Osteoarthritis forms Radius is longer than ulnar creating a shear which separates the anconeal process from the ulnar as it rubs against the humeral trochlear
185
What is short radius syndrome
Short radius compared to ulnar Incongruity of joint surfaces Weight bearing on the medial aspect of the joint Causes cartilage wear and fragmentation of the medial coronoid process and cartilage wear on medial humeral condyle
186
What is osteochondritis dissecans
Affects medial humeral condyle | Thicken flap of cartilage on humeral trochlea overlying a deep subchondral bone defect
187
Fragmented medial coronoid process
Most common pathology of elbow dysplasia Craniolateral aspesct of medial coronoid Appear dead and yellow in appearance compare to red well vascularised bone of the rest of the joint
188
What is arthroscopic debridement
Used to treat elbow dysplasia Remove fragments via arthroscopy The underlying subchondral bone is then treated with abrasion arthroplasty or micro fracture to encourage fibrocartilagenous repair Joint flushed with sterile saline
189
What is abrasion arthroplasty
Hand burr or power shaver burr is spun to remove subchondral bone over the ware a of the lesion Bleeding needs to be observed diffusely from the lesion bed Lavage joint to remove debris
190
What is microfracture technique
Micro pick inserted into joint and press tip against subchondral bone surface Tap handle once or twice Apply diffusely across diseased area and check for resulting bleeding Lavage to remove debris
191
What is a long bone osteotomy
Transfers weight bearing from medial aspect of the humerus to the lateral Specific SHO plate used Complications include humeral fracture, implant breakage
192
What are the indications for arthroscopy
Exploration of joints for discharge agnostics through observation, biopsy and culture Removal of loose bodies Microfracture and abrasion arthroplasty can be performed to treat osteoarthritis Joint debridement and lavage Arthroscopic assisted joint stabilisation or fracture repair
193
What are the advantages of arthroscopy
``` Decreased morbidity Rapid recovery Less complications Improved outcomes Decreased surgery, anaesthesia and hospitalisation times ```
194
Disadvantages of arthroscopy
High level of skill needed Equipment is expensive Expensive for client
195
What equipment is needed for arthroscopy
``` Arthroscope Camera mount Light post Cannula Irrigation Egress system - usually a needle in the joint Instrument cannulas Hand or power tools Electrocautery Patient prep Waterproof drapes ```
196
What are the causes of cruciate ligament disease
Traumatic due to a fall or stuck down rabbit hole Degenerative is most common Inflammation - rheumatoid arthritis
197
How do you diagnose cruciate disease
Mediolateral and craniocaudal views of both stifles
198
What is the first line of treatment for cruciate disease
Lead walk for 6 to 8 weeks
199
What is the aim of cruciate surgery
Confirm diagnosis by arthrotomy Debride the ruptured ligament Check and remove torn pieces of menisci Stabilise the stifle joint
200
What does TPLO stand for
Tibial plateau levelling osteotomy | Decrease tibial plateau angle to 7 degrees from 24
201
Post op care for cruciate ligament surgery
``` Lead walk for 6 weeks Cage rest Physio Hydrotherapy Gradual return to exercise after 6wk post op X-rays ```
202
What types of surgery is there to correct cruciate ligament rupture
Lateral suture - extra articular stabilisation Tibial plateau levelling osteotomy TPLO using LCP plate Cranial closing wedge ostectomy
203
Features of meniscal injuries
Medial usually more damaged | Subsequent to cranial cruciate ligament disease
204
Features of hip dysplasia
Presents 4-5months age Laxity develops in joint capsule Size of dog, rate of growth, diet and exercise Thickening of joint capsule from inflammation Erosion of acetabulum Femoral head flattens May see luxation
205
Clinical signs of hip dysplasia
``` Bunny hopping Difficulty rising Pelvic limb lameness or stiffness Exercise intolerance Clunking of hips Lateral swaying of spine Muscle atrophy of glutes ```
206
Conservative management of hip dysplasia
``` First line of treatment Most dogs should become sound by 15months old Lead walks Hydrotherapy Control food intake to slow growth NSAIDs ```
207
What is juvenile pubic symphysiodesis
Simple inexpensive procedure Can be done when neutering Fusion of pubic symphysis by electrocautery Preventative measure Less growth of ventral pelvis resulting in bilateral acetabular ventroversion allowing for increased femoral head coverage
208
What is triple pelvic osteotomy
Preventative measure Increases dorsal coverage of the femoral head Corrects subluxation Restores hips weight bearing surface area 4-8months of age Painful hips with no osteoarthritis Pelvis cut in 3 places to free acetabulum Acetabulum rotated 20 degrees
209
What is a femoral head and neck excision
Femoral head and neck removed Fibrous pseudoarthritis form Salvage procedure
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Post op care of femoral head and neck excision
Rapid return to exercise key to prevent muscle wastage | Physio 2 days post op
211
What is a total hip replacement
``` New femoral head and acetabulum Chronically painful and arthritic hips No concurrent problems Conservative tx no longer effective Luxation pre op increases risk of luxation post op leave 6 weeks between contralateral hips ``` Cemented or non cemented systems in place
212
Complications of total hip replacement
``` Luxation Osteomyelitis Aseptic loosening Femoral fractures Implant failure Subsidence Sciatic neuropraxia Cement granuloma Pulmonary embolism ```
213
Post op care of total hip replacement
Lead walks for 6 weeks Physio Avoid slippery floors and jumping or playing Gradual return to exercise after 6 week check
214
What are the clinical effects of opioids
Analgesia Sedation in unhealthy or young Dysphoria if too high a dose given Cough suppression Bradycardia due to stimulation of vagal tone - fentanyl. Atropine to correct Respiratory depression by Mu receptor - fentanyl but unlikely in awake animals Vomiting - morphine Reduced gut motility and GI sphincter closure Pupillary constriction Can cross placenta and cause resp depression in neonatal - naloxone under tongue to manage
215
What receptor does butorphanol bind to
Kappa
216
Name some full Mu agonists
Methadone Morphine Fentanyl
217
Name a partial Mu agonist
Buprenorphine
218
Name an opioid antagonist
Naloxone | Blocks Mu receptors but does not provoke a biological response
219
What does potency mean
Concentration of a drug required to elicit half the maximum biological response of the agonist Buprenorphine is the most potent
220
What does efficacy mean
Maximum possible biological effect a drug can achieve following binding to the receptor. Maximum possible analgesia that can be achieved Morphine, fentanyl and methadone are most efficacious
221
Surgical considerations of nasopharyngeal atresia/ stenosis
Acquired or congenital Sneezing, stertorous, URT obstruction Diagnosis - rhinoscopy, CR, MRI Open sx and resection of stenotic area through soft palate using endoscopy Endoscopy guided stent placement works really well but is expensive
222
Duration of opioids
``` Fentanyl- 10 to 15 minutes. Given as CRI intraoperatively Butorphanol - 90 mins Methadone - 3-4 hours Buprenorphine - 6 hours Recuvyra - 96 hours ```
223
Why use opioids as a pre med
Increase sedation of alpha 2 agonists, acepromazine or benzodiazepines Lower doses of sedative agent to be used Reduced cardiovascular and respiratory effects Preventative analgesia in healthy animals
224
How does methadone work as an analgesic
NMDA receptor antagonist so blocks up regulation of pain pathway
225
What opioids should be used intraoperatively
Methadone can be given as a bolus Fentanyl cri to decrease volatile agent May need IPPV Stop cri 15 mins before end of surgery to ensure spontaneous respiration
226
Post operative administration of opioids
IV preferable | Pain score first
227
What doses of opioids should be given
Bup 20microg/kg Methadone 0.3-0.5mg/kg Morphine cri 0.2-0.25mg/kg/hr diluted Fentanyl cri 5microg/kg/hr
228
Features of opioid CRIs
Constant plasma conc of the drug Avoids peaks and troughs pain relief Given via syringe driver Label syringe with drug, dose, patient name, drug concentration Give loading dose to ensure patient is comfy Keep in separate bags
229
Features of opioid epidural
Morphine and bupivicaine 12-18hours Do not need to adjust the amount of opioid given systemically if epidural also given but usually means a lower dose needs to be given
230
What drug should be given for chronic pain
NSAIDs
231
What are the potential side effects of NSAIDs
Vomiting Diarrhoea Gastric ulcers Reduced renal blood flow from dehydration or fluid loss Elevation of liver enzymes Prolong blood clotting depending on COX1:COX2 selectivity
232
When are NSAIDs contraindicated
If hypertensive or dehydrated If on corticosteroids History of ulceration Reduced renal function should be monitored as blockage of vasodilator prostaglandins may decrease the GFR in a GA Liver disease - reduce dose Cardiac disease Hypoproteinaemia- NSAIDs protein bound so will increase free fraction and elevate side effect risk
233
What should you monitor following nsaid therapy and how often
Body systems where effects are most likely - GI, renal, liver, cardiovascular Underlying disease conditions or concurrent disease Problems will occur 14-30days but depends on animal. Educate owner to recognise nsaid toxicity early and know the side effects
234
Assessment of NSAID efficacy
7-10days after starting therapy Then 1 to 2 monthly periods Owner keep diary about animals demeanour and activity level to determine QoL If not tolerated or efficacious then change the nsaid used or give adjunctive therapy to increase analgesia
235
How can the GI system be monitored when on nsaid therapy
Has owner seen vomiting o diarrhoea, nausea or inappetance Examine for signs of GI pain Monitor body weight, PCV, TS
236
How do you monitor the renal system when on nsaid therapy
Urine sample Any changes in drinking Monitor plasma urea, creatinine, Bp Monitor potassium is on pot supplements
237
How to monitor the hepatic system if on nsaid therapy
Any signs of lethargy Monitors liver enzyme levels Monitor serum bile acid conc if has pre existing liver dx to see if there's changes in liver function
238
How to monitor cardiovascular system when on nsaid therapy
Ask about exercise tolerance Monitor Bp Monitor platelet count and function if going into sx
239
Mechanism of action of local anaesthetic agents
Block conduction of action potentials in nerves by preventing depolarisation Decrease sensory input to spinal cord and brain Sodium ion channels blocked Reversible and not asssociated with loss of consciousness
240
Physio chemical characteristics of local anaesthetic drugs
Amide linkage - stable and can withstand heat sterilisation and pH changes Metabolised in the liver Lidocaine, bupivicaine, mepivicaine
241
What determines the potency of a local anaesthetic
Lipid solubility. Higher the lipid/water partition coefficient the more potent the drug
242
What determines the duration of effect of local anaesthetic
Protein binding. Highly bound drugs stay in the lipoprotein of nerve membranes longer
243
What effects the speed of onset of local anaesthetic
pKa determines the ratio of ionised to unionised drug The lower the pKa, the more unionised base is present Only unionised drugs can enter nerve membranes so the lower pKa the faster the onset
244
Features of lidocaine
``` Relative potency 2 Relative lipid solubility 3.6 pKa 7.7 Protein binding % 65 Onset fast 90-200mins action ```
245
Features of bupivicaine
``` Relative potency 8 Relative lipid solubility 30 pKa 8.1 Protein binding % 95 Onset medium 180-600 mins action ```
246
Why are myelinated nerve fibres more resistant to local anaesthetic
Local anaesthetic must prevent depolarisation in 3 to 4 nodes of ranvier Internodal distance increases with diameter so need higher conc of local anaesthetic Motor nerves less sensitive than sensory nerves
247
Wh are unmyelinated fibres more susceptible to local anaesthetic
Smaller length of the nerve fibre membrane must be blocked Advantageous as a concurrent motor nerve block is usually undesirable Sensory fibres blocked first - lower conc of drug needed
248
Characteristics of lidocaine
``` Stable in solution Unlicensed Short duration and onset Wide safety margin Addition of adrenaline prolongs duration ```
249
Characteristics of mepivicaine
Less toxic than lidocaine Good for equine lameness diagnosis Medium duration of action
250
Characteristics of bupivicaine
``` Stable Slow onset and long duration 4 times more potent than lidocaine Good motor and sensory separation Do not give IV ```
251
How can systemic toxicity of local anaesthetics occur
Vascular sites cause rapid absorption so reduce dose if going into area with good blood supply Drug dependent Speed of injection when given IV Adrenaline causes vasoconstriction causing slow absorption
252
What effects do local anaesthetics have on the cardiovascular system
``` Slowing of conduction of myocardium Myocardial depression Peripheral vasodilation Hypotension Bradycardia Cardiac arrest ``` If adrenaline added - tachycardia and hypertension
253
What are the effects of local anaesthetics on the central nervous system
Seizures Convulsions CNS depression Coma
254
How do you reduce the risk of toxicity following administration of a local anaesthetic
Small needle Calculate the safe maximal dose depending on body weight Draw up drug using appropriate sized syringe Dilute with NaCl Draw back and give slowly
255
Why apply local anaesthetic to mucous membranes
Produces analgesia within 5 mins Lidocaine Ocular exam, intubation, nasogastric tube placement EMLA cream takes nearly an hour to work and must be applied thickly
256
What is infiltration analgesia
Local anaesthetic injected into skin at the edge of the previous weal Only one needle prick felt Used to close wounds, remove small growths and take biopsies
257
Using local anaesthetic for thoracotomy
``` First dose under GA Q8hrs Bupivicaine 1mg/kg in saline Give each side Stings so can give some lidocaine first ```
258
Anatomy of the eye
Ciliary body and iris rich in vessels and pigments Limbus has stem cells that allows the cornea to heal Optic nerve goes into optic disc Lens behind cornea Fundus at the back
259
What usually causes eye problems
Secondary to poor conformation of the eye
260
What are bulging eyes at risk from
Corneal ulceration Serous discharge Sclera visible which has more pigmentation to make tissue tougher and more resistant to irritation Often blood vessels extend to cornea - sign of irritation Corneal dryness
261
What should dogs eyes be tested for
Progressive retinal atrophy As from 4years are night blind From 8years can be day blind Inherited condition
262
What equipment is needed for an ophthalmic exam
``` Pen torch Ophthalmoscope Fluorescein Schirmer tear test strips Tropicamide to dilate pupils Tonometer 20D condensing lens to look at retina and fundus ```
263
What are the different light filters for on a ophthalmoscope
White - direct illumination Redfree light - differentiates vessels and pigments on the retina Blue cobalt - to detect ulcers after fluorescein staining
264
When doing an eye exam what history do you need to know
Previous ocular conditions and response to treatments Concurrent dx Current ocular complaint - characterisation, onset, progression, duration Question how well the animal can see
265
How is a distance ocular exam done
Body condition Attitude Face - symmetry, discharge Eyelids - swelling, colour, size, palpebral fissure Eyeballs - position in the orbit, size of the globe, direction, movements Pupil - symmetry, size, shape, PLR Use direct ophthalmoscope
266
How do you test vision
Menace response Tracking response Visual placing response
267
What are the clinical signs of neuro-ophthalmology
Strabismus - deviation of visual axis Nystagmus Aniscoria - different pupil sizes Eyelid ptosis- drooping
268
What is the schirmer tear test
Tests for dryness Tests the quantity of tears produced Normal 15-25mm in a minute
269
What must be done before any diagnostic drops are used
Corneoconjunctival culture
270
How do you test for the quality of the tears
Use fluorescein and blue filter Maintain lids open and measure time for dark spots and lines to appear after last blink Normal 20s Quicker they appear the poorer the quality Difficult to perform
271
How do you perform an adnexa and anterior segment exam
Close exam with ophthalmoscope To examine cornea, conjunctiva, eyelids and anterior segment Use white light
272
What can you use fluorescein for
Corneal ulceration detection Permeability of the nasolacrymal duct system Tear break up time - tear quality test
273
What is the normal intraocular pressure measurement
10-20mmHg
274
How do you examine the lens, vitreous and fundus of the eye
Tropicamide | Wait 30 mins
275
How do you examine the posterior segment of the eye after pupil dilation
Monocular indirect ophthalmoscope to view fundus | Direct ophthalmoscope to visualise lesions in detail
276
How do you increase the concentration of eye drops and what order do you give multiple tx
Increase the frequency not the number of drops | Give in order of viscosity- solution, suspension, lubricant
277
Features of bandage contact lenses
Shields migrating epithelial cells | Complications not common
278
What topical antibiotics can be used on the eye
1st intention - fucidic acid, chloramphenicol 2nd intention - gentamycin 3rd intention - ofloxacin acts against pseudomonas aeruginosa
279
Topical corticosteroids that can be used on the eye
Reduce inflammation Prednisolone 1% Dexamethasone 0.1%
280
Topical NSAIDs that can be used on the eye
Multimodal therapy with steroids to reduce frequency of admin Ketorolac Bromfenac
281
Immunosuppressant drugs that can be used on the eye
Cyclosporine Tacrolimus To treat keratoconjunctivitis
282
What antiproteolytic therapy can be used in case of ulcers
Serum EDTA Administer every hour if deep ulcer
283
How do you treat glaucoma
Reduce the production and increase the drainage of aqueous humor in the eye Carbonic anhydrase inhibitors Prostaglandin analogues
284
What can be used to treat intraocular inflammation
Atropine - mydriatic agent
285
What are common eye complaints in consultation
``` Red eye Cloudy Blind Purulent Painful ```
286
What can cause an eye to look red
Inflammation - can be urgent Haemorrhage - can be urgent Vasodilation - can be urgent Neovascularisation associated with corneal ulnar - urgent Need to see that day if possible
287
What is exophthalmos
Abnormal protrusion of the eye ball | E.g. Orbital foreign body
288
What is globe proposes
Eye has come out of the socket Try to save Tell owner to keep moist and come quickly Suture eyelid over eyeball until swelling goes down
289
What is enophthalmos
Recession of the globe into the orbit | Horner syndrome
290
What is a macropalpebral fissure
Eyelids not big enough to cover whole eye | Lubricant and sx
291
What is ectropion
Exposed conjunctiva | Dryness and impaired eyelid function
292
What is entropion
Eyelid is inverted Can be primary or secondary Sx to treat
293
What does a normal conjunctiva look like
Pale in cats | Light pink in dogs
294
What does blue cornea mean
Lesion of the superficial layer of the cornea Causes water uptake in the cornea - corneal oedema Urgent
295
What does a red cornea mean
Corneal neovascularisation Sign of a superficial ulcer Fine vessels with no branching is a sign of a deep corneal lesion
296
What does a white cornea mean
Corneal scar | Lipid keratopathy - lipid deposits associated with hyperlipidemia
297
Stages of a corneal ulcer
Epithelial layer and involvement of stroma to give melting appearance Deep ulcer is very vascular and has purulent discharge Corneal perforation has fibrin surrounding it
298
What are the clinical signs of cataract
Lens opacity
299
What are the signs of ocular pain
``` Increased blinking Rubbing at eye Redness Photophobia Increase lacrimation ```
300
How do you treat third gland prolapse - cherry eye
``` Sx Buster collar 1st line antibiotics Lubrication NSAIDs ```
301
What is keratoconjunctivitis sicca
``` Immune mediated Dry eye - no tear production Ocular pain Mucoid discharge Inflammation Decreased vision and progressive corneal disease Use schirmer tear test ```
302
What is the treatment for keratoconjunctivitis sicca
Lubrication Immunomodulating agent Broad spectrum antibiotic Topical anti inflammatory
303
How do you treat an infected ulcer
``` Antiobiotics hourly Serum hourly Lubrication NSAIDs Reconstructive corneal sx ```
304
History taking for animal presenting with a mass
When first noticed Has it grown Changed appearance Any other masses visible
305
What tests can be done to see what a mass is
FNA submit for cytology Biopsy of FNA inconclusive - tru cut, incisional, excisional - bear in mind future sx Biopsy can cause metastasis of mast cell tumours
306
Tumour staging
TNM
307
How do you stage the actual tumour
``` Size Growth rate Location Local invasion Histological type and grade ```
308
How do you tell if a tumour has spread to lymph nodes
Assess draining nodes Palpation FNA Surgical biopsy
309
How do you tell if a tumour has metastasised
Lung - inflated radiographs and CT | Look in the abdomen, brain, skin etc
310
What are the considerations for tumour excision
Tumour type and grade Tumour stage Size and location
311
What surgery can be performed on tumours
``` Incisional biopsy Debulking Marginal excision Wide excision Radical excision e.g. Maxillaectomy ```
312
Why do you need histopathology after tumour removal
Look at cells at the edge of the sample to see if tumour has been removed Fill out forms comprehensively Essential Ink margins
313
Best way to close after tumour removal
Keep simple Avoid tension Place drain Post op chemo or radiography
314
Considerations for drain placement after tumour removal
Entry point as close to surgical incision as the tract is now part of the wound If sx needs to be devises the tract also needs to be removed as can now contain cancer cells
315
What are the reasons for wound breakdown post sx removal of a tumour
``` Patient factors rare Concurrent disease Nutrition Chemotherapy Radiotherapy Steroids Neoplasia Tension Tissue handling Motion Sutures - wrong technique Infection Patient interference ```
316
What areas are a problem for tumour removal
Distal limb Axilla Bony prominence Consider axial flaps
317
How do you treat wound breakdown post sx
Do not resuture | Heal by 2nd intention
318
How do you prevent seroma formation
``` Prevent dead space by placing drains Halsteads principles - treat tissue with respect Rest Leave alone Pressure bandage Provide further drainage ```
319
How do you treat infection after a tumour has been removed
Drainage Heal by 2nd intention Antibiotics after culture and sensitivity Wound exploration if necessary
320
Why might there be tumour recurrence
Dirty margins First cut is the best as don't want revision sx May already be metastasis
321
What types of sub dermal plexus flaps are there
Advancement flaps Rotational flaps Transposition flaps Skin fold flaps
322
What are the principles of sub dermal plexus flaps
``` Wider base than body Limit size Avoid narrowing Undermine panniculus Atraumatic surgical technique Take from area with ample skin Avoid excessive stress or motion at donor site ```
323
What is an advancement skin flap
Flap parallel to line of least tension Stretched into defect Loose skin adjacent to wound Prone to dehiscence
324
What is a rotational skin flap
Skin rotates to close triangular defect | Radius of rotation is the length of the wound
325
What is a transposition flap
Flap parallel to tension Rotated into the defect Maximise width of base Length equal to pivot arc
326
What is a skin fold flap
Axillary or inguinal skin folds Versatile and large Sternal and groin wounds
327
What are the complications of skin flaps
Seroma Dehiscence due to too much tension Flap necrosis from technical error or trauma
328
What are axial pattern flaps
Involve a direct cutaneous artery Superficial landmarks Flap dimensions depend on conformation
329
What are the indications for axial pattern flaps
``` Large wounds on flank or proximal limb Reconstruction post tumour excision Chronic non healing wound Avascular wound bed Need to cover exposed bone Provision of muscle bulk ```
330
What are the advantages of axial pattern flaps
``` Durable full thickness skin Blood supply Normal hair growth Morbidity less likely Can be larger than subdermal plexus flaps ```
331
What are the four major axial pattern flaps
Caudal superficial epigastric Thoracodorsal Omocervical Deep circumflex iliac
332
Features of a thoracodorsal axial pattern flap
Thoracodorsal artery cutaneous branch Shoulder, forelimb, elbow, axilla, thorax, carpus Large, durable and robust
333
Features of a caudal superficial epigastric axial pattern flap
External pudendal and caudal superficial epigastric artery Caudal trunk, inguinal, perineum, pelvic limb to hock Mammary tissue remains functional
334
What are the post op care considerations for skin flap sx
Bandage to remove dead space and immobilisation of limb Drain care Analgesia Antibiotics if needed
335
What are the complications of axial pattern skin flaps
``` Necrosis of flap Seroma Failure to adhere Dehiscence Infection ```
336
``` 18mnth m(n) dlh cat Missing 24hrs Large wound in inguinal region Recumbent but responsive How would you approach this case ```
``` Major body system assessment Place catheter Pain relief no NSAIDs IVFT if needed Full body exam Minimum database Wound classified as dirty ```
337
How would you manage a day old dirty wound
``` Ga Clip area around wound Lavage with saline Sx debridement Swab Broad spectrum antibiotics Keep patient warm ```
338
After cleaning a dirty inguinal wound what is the next step
Wet to dry dressing to provide debridement Nappy style bandage Tie over dressing Urinary catheter Feeding tube Long stay catheter in saphenous vein or jugular line
339
Once a wound has been suitably debrided what dressing would you use
Intrasite - osmotic effect causing gentle debridement Alleyvn as very absorbable and is semi permeable so allows O2 Will give intrasite in and stop drying out
340
``` 7yr m(n) cross breed Wound over left hock Possible bite Previous partial tarsus arthrodesis How would you manage this wound ```
``` Clip Lavage Swab Surgical debridement Wet to dry dressing Intrasite or homey with alleyvn Antibiotics Remove bone plate and drill holes in bone to encourage granulation tissue over exposed bone ```
341
What are the indications for a free skin graft
Wounds on distal limb Primary closure not possible Healthy granulated wound
342
What are the contraindications for a free skin graft
Wounds on head and trunk as rely on blood supply from local area so can't have any movement, can immobilise limbs Infection Incomplete granulation bed Debris
343
How should you care for skin grafts
``` Aseptic technique Immobilisation of graft Prevention of fluid accumulation Sedation or ga for dressing changes as don't want movement Keep bandages on for 2-3 days ```
344
Pros and cons of skin grafts
``` Cover distal limb deficits Labour intensive and time consuming Grafts take time to be fully functional Variable cosmetic and functional outcome Other reconstruction techniques preferred when possible ```
345
What are the main concerns of dog bite wounds
Contaminated Superficial skin wound but crushing injury to underlying muscle Puncture wounds to deeper structures
346
How should dog bite wounds be managed
``` Ga Clip fur Lavage Explore Swab Antibiotics ```
347
What are your concerns for a dog bite to the neck
Damage to jug vein, carotid artery, recurrent laryngeal nerve, trachea which could cause emphysema, crepitus or pneumonia Always always explore
348
What are the goals of wound management
``` Prevent further conta,inaction Remove debris and contamination Debride dead and dying tissue Promote a viable vascular bed Patient considerations Select appropriate method of closure ```
349
What is the initial care for an equine fracture
Do not move horse until need for stabilisation is known Sedate Treat wound - clip, clean, sterile bandage Stabilise fracture Meds
350
What clinical signs would you see with a suspected equine fracture
``` Sweating Shock Pain Lameness Palpable instability Crepitus Soft tissue swelling ```
351
What are the goals of fracture stabilisation
Stabilise fracture Reduce discomfort and distress Minimise further trauma to bone, soft tissue and vasculature Prevent further contamination if open wound Include joint above and below fracture and splint to way above fracture line
352
What are the options for a stabilising bandage
Robert jones Splint using anything available Cast
353
What medication would you give a horse with a fracture
Antimicrobials Analgesia - NSAIDs and opioids Tetanus toxoid IVFT to treat shock and haemorrhage
354
What do you need to have ready for when an equine fracture comes in
``` Drugs Bandage material Splints Cast material Catheter Fluids Turn radiography equipment on ```
355
What surgical equipment do you need for an equine fracture repair
``` Drapes General kit Fracture kit - 4.5mm set and screws - 5.5mm set and screws - locking plate and screws Drill Intraoperative imaging and gowns Arthroscopy equipment Bone reduction forceps Plate bender Hand held retractors Self retaining retractors Clippers and prep Fluids Bandage cart Cast material Suture material Ropes Support stands for legs ```
356
Patient prep for equine surgery
Cover feet and tail Clip hair 10-15cm radius from surgical incision Clean skin Disinfect skin
357
What are the assisted recovery options post equine surgery
Head and tail rope Sling recovery Pool recovery
358
What is the post op care for equine fractures
Analgesia and antimicrobials Monitor vitals - HR should be less than 40 Monitor comfort, appetite, faecal output, catheter Check cast for breakage, discharge, heat Frog support on opposite limb Rest 4 months
359
What are the complications of equine orthopaedic surgery
Infection Unstable fixation - pain and longer healing Laminitis common in other foot
360
Before an equine arthroscopy what should be done before
Radiographs Catheter Meds Prepare theatre
361
What are the components of arthroscopic equipment
``` Arthroscope Video camera Tv screen Light source and light cable Fluid irrigation system Motorised equipment ```
362
What surgical instruments are needed in an arthroscopy
``` Egress cannula Forceps Probes Osteotome and elevators Cutting instruments Curettes ```
363
What is the post op care for an equine arthroscopy
``` Monitor lameness - stifle usually sore for 24hrs. Other joints should be sound walking Temperature Bandage Appetite Faecal output ```
364
What are equine emergency surgeries
Colic Lacerations Dystocia
365
What history do you need to know for colic
``` How long How severe Response to meds Had colic before Had sx before Had a foal Age Geography Breed ```
366
Clinical exam for equine colic
``` Abdo discomfort HR Temp of ears and feet Pulse quality Mm Rectal temp Resp rate Abdo distension GI sounds Rectal exam Ultrasound abdo Abdominocentesis ```
367
What do you need to have ready for when a colic comes in
``` Sedation Buscopan NSAIDs Stethoscope Clippers and prep Catheter NG tube and bucket Rectal sleeve and lubricant Ultrasound machine ```
368
What are the two types of colic
True colic - gastrointestinal | False colic - urofenital tract, resp system
369
Preparation for colic surgery
``` Catheter Clip abdo Meds Pass NG tube Prep patient Prep theatre ```
370
What equipment do you need for colic surgery
``` Clippers Urinary catheter Prep Fluids CMC carboxymethylcellulose General set Drapes ```
371
What instruments do you need for small intestinal colic
``` Doyen clamps Penrose drains Separate drapes Suture material Fluids for lavage Staples for anostomosis Fresh clean table with new instruments to close ```
372
What instruments do you need for large intestinal colic
``` Colon tray Drapes Separate table as contaminated Hose with tap water for lavage Sterile fluids for lavage ```
373
How much care do colic patients need post op
If systemically healthy need minimal care - pain meds and systemic antimicrobials - gradual refeeding Systemically compromised need intensive care - endotoxemia - ileau - anostomosis not functional
374
Monitoring of colic patients post op
``` HR Pulse quality Mm Hydration - PCV/TP/USG GI sounds Defecation Check for nasogastric reflux - up to 5l/hr Comfort - laminitis and colic Appetite Temp Surgical wound Abdo bandage ```
375
What is the intensive care for a colic patient
``` Meds IVFT PE every 4-6 hours PCV/TP/USG every 4-6 hours Gradual refeeding Walking helps to kickstart GI system ```
376
What are the most common wounds for horses
Distal limb lacerations | 60% of all wounds
377
Why are distal limb wounds in horses so challenging
Extensive crushing or avulsion of soft tissue Exposure of bone Vascular compromise Severe contamination Less skin to mobilise More likely to dehisce Increased exuberant granulation tissue Decreased contraction and epithelialisation May include many critical synovial and supporting structures which can result in permanent loss of use or death
378
How do you manage an equine wound
Cleansing Exploration Radiographs Determine if synovial structures are involved Debridement with lavage of synovial structures Suture Antimicrobials
379
How do you cleanse an equine wound
Clip hair around wound but protect the wound whilst doing so Irrigation - 18g needle and 60cc syringe - saline or tap water and an antiseptic (povodine iodine or chlorhexidine) Prep skin
380
Why and how do you explore an equine wound
Determine extent of wound, if there's a FB and if synovial structures are involved Use a probe Radiographs for Fb and to check for fracture, look for air around synovial structures Contrast studies for synovial structures
381
Why is it important to check for involvement of synovial structures in an equine wound
Less than 6-8hours before they are contaminated If not recognised chronic injuries massively reduce prognosis - prognosis is good if treated aggressively from the start Know the anatomy of the joint pouches and sites of injection
382
What do you need to have ready for when an equine wound comes in
``` Clippers and prep Fluids for lavage Probe Gloves Catheter Radiography equipment turned on Sedation Antimicrobials Pain med Bandage cart ```
383
What equipment do you need to close an equine wound
``` Clippers and prep Fluids for lavage Standard kit Arthroscopy equipment Bandage cart Drains ```
384
What is the post op care for equine wounds
Systemically healthy Bandaging Meds Monitor usual parameters
385
What are the normal stages of equine labour
1 - relaxation cervix and uterine contractions - restlessness, pacing, pawing, posture to urinate 2 - 10-15min up to 70min - onset rupture chorioallantois and delivery of foal 3 - passing foetal membranes
386
At what point does equine labour become dystocia
Stage 2 longer than 30 mins | Likelihood of dead foal increases by 16% every 10mins
387
What history do you need to know for a mare with dystocia
``` Signalment Gestational age Pertinent medical history Time of stage 2 onset Has assistance already been attempted ```
388
What do you need to evaluate with a dystoic mare
``` Physical exam - pale mm and low HR Determine foetal orientation Determine the viability of the foal - always assume alive unless proven otherwise Ask if foal or mare is the priority Cost Distance to referral hospital How healthy is the mare ```
389
What are the methods for equine dystocia resolution
Assisted vaginal delivery Controlled vaginal delivery Csection Fetotomy
390
Features of equine assisted vaginal delivery
``` Maintain hygiene Lubricate Manually reposition foal Sedation Clenbuterol to relax uterus Epidural anaesthesia ```
391
When is a fetotomy performed
Non viable foal Cost Need experience to do
392
Features of equine controlled vaginal delivery
GA with mechanical ventilation Hind limbs elevated 15mins max Simultaneously prep for c-section
393
Features of an equine c-section
``` Ventral midline laparotomy Localise uterine horn and exteriorise Hysterotomy Exteriorise foal Control haemorrhage Routine closure Should be 20mins max until foal extraction ```
394
Post op care for mare that had dystocia
``` Antimicrobials and NSAIDs Oxytocin every hour - if retained placenta for more than 6 hours then infuse 80IE over 30 mins Hydrotherapy vulva Stimulate GI system and adapt diet Uterine lavage ```
395
Why perform a terminal c-section
Mare with terminal illness - laminitis, cardiac failure, neuro Full gestation and in parturition Options for euthanasia- captive bolt, GA or sedation with local anaesthesia
396
If neonatal foal not breathing
Intranasal O2 8-10l/min Mouth to nose Intubate and ventilate
397
What should you do if a neonatal foal has bradycardia or no heartbeat
``` Should be 80-120bpm Thoracic compressions 100/min After 40secs IV adrenaline Antagonise medication used on mare Stop when heart rate is more than 60 Bp and spontaneously breathing more than 16/min ```
398
What are the complications of dystocia
``` Trauma of the reproductive tract - lacerations or rupture Retained placenta Delayed uterine involution Bladder prolapse Metritis Peritonitis Arterial haemorrhage Uterine prolapse Neuropraxia Pressure necrosis ```
399
What are the stages of orthopaedic healing
Post op 24-48 hours - pain, oedema, healing tissues Regeneration day 5- 3 weeks - new collagen fibres forming. Still fragile so relative rest Remodelling and bone healing 6 weeks to 1 year - consolidation, maturation (10wk to 1 yr), bone regeneration (bridging and callous forms) and remodelling
400
Treatment in post op stage of orthopaedic healing
Analgesia - need to know if sufficient or too much Cryotherapy - 10 mins x3 Rest Easy movement only - supported weight bearing
401
What is the treatment for the regeneration phase of orthopaedic patients
Controlled lead exercise Passive and active ROM exercises Can help reduce swelling
402
When considering non emergency orthopaedic surgery what can you do as prep beforehand
Weight loss especially if obese | Hydrotherapy but stop post op until sutures removed
403
Immediate post op care for joint surgery
Cryotherapy If haemorrhage then pressure dressing for 12-24hrs PROM to maintain normal ROM, blood and lymphatic circulation. Stimulates sensory awareness Massage can reduce oedema Pain management
404
Post op care for joint sx
Therapeutic exercises after a few days to encourage muscle strengthens and re-education Weight bearing exercises and if not weight bearing then weight shifting exercises Low impact initial exercises Hydrotherapy If in cast then PROM on adjacent joints Hot therapy after 5 day inflammatory period can be done If normal gait function not expected - sit to stand exercises to build glutes and prevent fibrosis and loss of motion Luxation - Rehab as soon as sling removed. Weight bearing exercises limited. Don't abduct or adduct limb
405
How to treat animals who have a total hip replacement
Lead walk v slowly Keep patient calm and settled - sedate if needed Clear signage so people know how to handle them
406
Anatomical types of fractures
Articular - joint Physeal - growth plates Condylar - long bone
407
Commonly seen fractures
Humeral condylar fractures - Spanials, check other limb Maxillary or mandibular - cats. Tube feeds Radial/ulnar - RTA, horse kick, dropped Femoral - sciatic nerve damage. Lots of physio Tibial/fibular - RTA/ trauma Pelvic - assess bowel/bladder care, care with ,offing and ensure stable. Can be completely recumbent or still able to walk
408
Features of external fixations
Can be difficult to apply treatments Can apply ice to parts of limb PROM achievable with linear or ring fixators May be reluctant to flex/extend limbs so active exercises useful Work on extension of distal limb Care for the pin tracts don't excessively clean or cover too much and trap air Ensure patient comfort
409
Common tendon injuries
Lacerations Seen in conjunction with wound Supraspinatus tendon calcification common with agility dogs
410
Rehabilitation for tendon injuries
PROM after 3 weeks rest Limited exercise for 3-6 weeks Tendon still not at full strength at 6 weeks
411
When rehabilitating any patient what do you need to consider
``` Client and you have the same goals Communication is key with clinician Have a plan Know how progress will be assessed How will you communicate progress with the client Do you have access to a physiotherapist ```
412
What are the primary goals of rehabilitation of the orthopaedic patient
Get patient weight bearing Active range of movement Muscle building
413
What are the effects of atropine if dosed wrong
Too low dose - more bradycardia | Too high dose - tachycardia - wait it out

Finals (3 decks)

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