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Emergency triage and first aid of exotic patients

Exotic patients are often more critical on presentation than canine and feline patients, due to their nature of hiding signs of illness

01 October 2020, at 7:35am

Exotic animals are inherently prey species and as such hide evidence of minor illnesses. Because of this, by the time an exotic patient is showing signs of dis­ease it is often in the advanced stages and likely has been ongoing longer than the owner has noted signs of illness. This results in a greater proportion of emergency presenta­tions in our exotic patients than we see in our canine and feline patients. Whilst many veterinarians find the prospect of a consultation with a sick exotic patient a daunting task, often early intervention can be the difference between life and death. Any ill exotic patient should be seen within 24 hours of initial contact; however, some conditions should be assessed in consultation without any delay (Box 1).

Box of contents
BOX (1) Some emergency presentations of exotics require immediate consultation and assessment

The principles of emergency triage and first aid in exotic species is very similar to that of companion animals, bar­ring some minor physiological differences. Every practice is equipped with the tools they require to provide emergency care to exotic patients, even if just in the short term to sta­bilise the patient and refer to an exotics practice if required.

All staff members should be informed of the patient’s state and estimated arrival time, if known in advance, and the patient taken immediately for assessment on arrival. Initial assessment of the emergency patient takes less than a minute. Assess the patient’s mentation, respiratory rate and effort and, if possible, their heart rate and rhythm. Any collapsed patient should be immediately assessed for respiratory or cardiac arrest with cardiopulmonary resus­citation (CPR) commencing without delay if necessary. Chest compressions in exotic species should be replicated as close to their resting heart rate as possible, as minimal study data exists for the rate of compressions in exotic species (Onuma et al., 2017).

Drug therapy can also be instigated, including the use of adrenaline and atropine. The use of atropine in rabbits is not recommended as rabbits can have circulating serum atropinesterase, which degrades atropine and renders it ineffective, so glycopyrrolate should be used instead (Licht­enberger, 2007). Emergency drug doses are available in many exotic formularies, and a “cheat-sheet” of drug doses is recommended for easy access in case of emergency. The patient should be intubated if possible, after clearing the oral cavity of any food that may be present, to facilitate oxygenation. If the patient is not able to be intubated then a tight-fitting face mask can be used (Lichtenberger and Lennox, 2012).

If the patient is dyspnoeic then oxygen should be admin­istered as soon as possible. Some small mammal patients will tolerate oxygen provision with a face mask (Figure 1A); however, the use of an oxygen chamber reduces stress compared to mask placement (Figure 1B; Lennox, 2007). Care should be taken to monitor a patient placed in an oxygen chamber to ensure they do not decompensate, or cause damage to the chamber (in the cases of parrots and small rodents) or themselves. Low-dose sedation may be required if the patient is overly anxious (Lichtenberger and Lennox, 2012). Ideally, the oxygen chamber should be warmed, as exotic patients often have a larger surface area to volume ratio and lose heat quickly when they are ill. If the patient is not dyspnoeic then it should still be placed inside a warm, quiet brooder or provided with supplemental heat (Bowles et al., 2007) unless heat stroke is suspected.

Vascular access should be obtained in dull or obtunded patients. In larger mammals such as rabbits, ferrets and guinea pigs, placing an intravenous catheter is straight­forward, with access sites well documented (Figure 2; Lichtenberger and Lennox, 2012). In smaller mammals and reptiles, the placement of an intraosseous catheter may be required with a combination of sedation and local anaesthesia (Lichtenberger and Lennox, 2012). Common sites for intraosseous catheterisation include the proxi­mal femur and the proximal tibia (Lennox, 2007). In larger avian patients an intravenous catheter can be placed in the medial metatarsal vein; however, in collapsed and smaller avian patients, intraosseous catheterisation can be technically easier, with common sites including the dis­tal ulna and the proximal tibiotarsus (Bowles et al., 2007). If no vascular or intraosseous access can be gained, then subcutaneous fluid therapy can be utilised.

Fluid therapy should be commenced in situations where the patient is in hypovolaemic shock (Lichtenberger and Hawkins, 2009). Administering fluid therapy as boluses should be considered, as constant rate infusions are poorly tolerated by most exotic patients and, unless con­stantly monitored, there is a high risk in most species of chewing the giving set (Rosenwax, 2018), resulting in possible exsanguination. Any fluids administered should be warmed prior to administration (Maclean and Raiti, 2004). Choice of fluids depends on the clinician’s preference, species and any metabolic derangements; however, the author pre­fers the use of lactated Ringer's solution in the first instance and through the majority of most patients’ treatment.

Any specific treatments should be carried out once vascular access has been achieved and the patient is not in arrest or distress. Covering any wounds, temporary fixation of any fractures and minor sampling (for example blood glucose, crop swab, faecal samples) can be taken at this time. Once the patient has been stabilised, a history can be taken from the client. It may be useful for one team member to take a history whilst other team mem­bers work on stabilising the patient. A detailed review of the patient’s husbandry should be taken alongside a medical history.

A more in-depth examination can be completed once the patient is more stable; however, a low-dose sedation may be required to achieve this if the patient becomes distressed with handling. Low-dose midazolam is often useful in these situations (Lichtenberger and Lennox, 2012). Emergency presentations are varied, and each requires a different approach once the cause has been identified. Medical or surgical therapy can be commenced once the patient has been stabilised. It is important to remember that most drugs administered to exotic patient are “off-licence” and the prescribing cascade must be followed (Headley, 2020). If administering off-licence drugs to an exotic patient at any time, informed consent must be gained from the owner. In addition, meat and egg withholding periods need to be considered when treating food-producing animals such as poultry.

Every veterinary practice has the resources available to provide emergency first aid to exotic patients. Technical skills such as intubation and intravenous catheterisation take time and practice; however, as described above, substitutions can be made. Having an emergency toolkit with small-gauge catheters, small-diameter endotracheal tubes, emergency drugs and warming equipment can save time in an emergency. Multiple resources are available to assist with emergency care of exotic patients, both in print and online, and exotic referral practices are available to give advice or accept referrals as required, if consented by the owner. Exotic patients are often much more critical on presentation than canine and feline patients, due to their nature of hiding signs of illness, and examination and treatment should never be delayed.

References
Author Year Title
Bowles, H., Lichtenberger, M. and Lennox, A. 2007 Emergency and critical care of pet birds. Veterinary Clinics of North America: Exotic Animal Practice, 10, 345-39
Hedley, J. 2020 BSAVA Small Animal Formulary - Part B. Gloucester: British Small Animal Veterinary Association (BSAVA)
Lennox, A. 2007 Shock and cardiopulmonary-cerebral resuscitation in small mammals and birds. Veterinary Clinics of North America: Exotic Animal Practice, 10, 275-291
Lichtenberger, M. and Hawkins, M. G. 2009 Rodents: physical examination and emergency care. In: Keeble, E. and Meredith, A. (eds.) BSAVA Manual of Rodents and Ferrets. Gloucester: British Small Animal Veterinary Association, 18-31
Lichtenberger, M. and Lennox, A. 2012 Critical care of the exotic companion mammal (with a focus on herbivorous species): the first twenty-four hours. Journal of Exotic Pet Medicine, 21, 284-292
Maclean, B. and Raiti, P. 2004 Emergency Care. In: Girling, S.J. and Raiti, P. (eds.) BSAVA Manual of Reptiles (2nd ed.). Gloucester: British Small Animal Veterinary Association, 63-70
Onuma, M., Kondo, H., Ono, S., Murakami, A., Harada, T. and Sano, T. 2017 Retrospective investigation of cardiopulmonary resuscitation outcome in 146 exotic animals. Journal of Veterinary Medical Science, 79, 1611-1614
Rosenwax, A. 2018 Hospitalization and basic critical care. In: Chitty, J. and Monks, D. (eds.) BSAVA Manual of Avian Practice: A Foundation Manual. Gloucester: British Small Animal Veterinary Association, 156-171

Ashton Hollwarth, BSc, BVMS, CertAVP (Zoo Med), MRCVS, studied in Western Australia and moved to England following graduation. She is currently enrolled in an ECZM residency in Avian Medicine and Surgery at Great Western Exotics. Ashton gained her Certificate of Advanced Veterinary Practice in Zoological Medicine in 2020.

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