43

6 Initial Management of Acute Intoxications

TELEPHONE TRIAGE

The initial contact with a patient client is often over the telephone. It is imperative that reception asks the appropri-ate questions to better instruct the client on what further steps need to be taken. One of the fi rst queries should be to obtain the animal ’ s signalment: species, breed, age, and approximate body weight. The information obtained from this question can greatly impact the course of treatment. A toxicant that may not affect a 100 - pound Great Dane could greatly harm a 5 - pound Devon Rex. Other informa-tion that should be obtained includes the type of exposure or ingestion, the length of time elapsed since the said exposure or ingestion, and the amount of potential toxi-cant. It is also important for reception to ask about the patient ’ s mental state (i.e., alert, disoriented, reduced responsiveness, unresponsive). Although a client ’ s estima-tion of the pet ’ s mentation may not be completely accurate, a general idea about the pet ’ s level of consciousness can be formulated. After this information is obtained, recep-tion can then ask a veterinary medical staff member on duty whether the patient should seek medical attention. If there is a doubt on the patient ’ s stability, the client should be advised to seek medical attention immediately.

Clients should be advised to bring any material or pack-ages to which the patient may have had access. It is also advised that any vomitus from the patient be collected in a sealed container and brought into the hospital.

HOSPITAL PRESENTATION

Triage and History

An emergency can be described as any situation that arises suddenly and unexpectedly resulting in a sudden need for action. Upon presentation to the hospital/clinic, a member of the medical team should triage the patient. Triage refers to an initial, brief assessment of the emer-gency patient. It is performed immediately on presentation and should take less than 5 minutes. Triage involves a cursory evaluation of the four major organ systems (car-diovascular, respiratory, neurological, and renal) while simultaneously obtaining an abbreviated history. Conver-sation should be limited to signifi cant points only, avoid-ing unrelated details. The history should include the primary complaint, duration of the problem, and any current drug therapy. The basic principles of emergency patient assessment should be applied even in the face of a potential poisoning.

The goal of triage is to determine whether the patient can be categorized as stable or unstable, allowing appro-priate prioritization of care. A stable patient is one that is not in an immediate life - threatening condition. An unstable or emergent patient is one that is experiencing life - threatening signs and requires quick judgment and timely action. If any of the major body systems are sig-nifi cantly abnormal, the patient should immediately be

Small Animal Toxicology Essentials, First Edition. Edited by Robert H. Poppenga, Sharon Gwaltney-Brant.© 2011 John Wiley and Sons, Inc. Published 2011 by John Wiley and Sons, Inc.

Elisa Petrollini - Rogers and Bridget McNally

44 Section 1 / Fundamentals of Veterinary Clinical Toxicology

veterinarian. Other abnormal fi ndings include labored inspiration and/or labored expiration or paradoxical respi-ration (chest wall and abdominal wall do not move syn-chronously). Postural adaptations associated with respiratory distress may be seen is distressed patients as well (e.g., standing rather than sitting, abducted elbows, abdominal effort, extended neck, head lifted, etc.).

Cardiovascular System

Assessment of the cardiovascular system includes deter-mination of mucous membrane color, capillary refi ll time, heart rate, and rhythm and pulse quality.

Normal mucous membrane color should be pink. Muddy or gray color suggests poor perfusion. Pale or white color suggests anemia, shock or pain; brick red mucous mem-brane color (hyperemic) is seen in situations including sepsis, hyperdynamic states, and hyperthermia. Dark blue (cyanotic) mucous membranes suggest hypoxemia from a variety of causes (cardiac dysfunction, pulmonary insuffi -ciency, etc.). Yellow or icteric mucous membranes occur in cases of hepatic dysfunction, hemolysis, or biliary obstruc-tion. Brown mucous membranes and blood are seen in cases of methemoglobinemia, which in companion animals is most commonly seen with acetaminophen toxicosis.

Normal capillary refi ll time (CRT) is 1 – 2 seconds. If the CRT is prolonged, this indicates poor perfusion. Rapid CRT indicates a hyperdynamic state or hemoconcentration.

Normal pulse rates for canines are 80 – 120 beats per minute (bpm) with < 70 bpm suggesting bradycardia and > 140 bpm suggesting tachycardia (Plumb 2005 ). For felines, normal pulse rates range from 130 – 140 bpm with < 100 bpm suggesting bradycardia and > 180 bpm suggest-ing tachycardia. When assessing heart rate, it is important to consider the animal ’ s mental status, because excitement from being transported and handled may spuriously elevate the rate, and sleeping or comatose animals may have lower heart rates.

The pulse quality should be strong and synchronous with heart rate. Weak pulses indicate poor perfusion. Pulse quality feels “ tall and thin ” when associated with anemia; “ bounding ” pulses suggest hypertension.

Central Nervous System

The patient ’ s central nervous system can initially be assessed by the evaluation of its gait (ataxia, loss of motor function), level of consciousness, and pupil size and posi-tion. Muscle twitching may be observed with some toxic exposures such as pyrethroid, chocolate, or ethylene glycol toxicoses. The following levels of consciousness can be observed:

taken to the main treatment room of the emergency room to be assessed by the veterinarian.

In the emergent patient who has been exposed to a toxi-cant, the history is one of the most valuable pieces of information (Fitzgerald, 2006 ). Acquiring a detailed history can be the most diffi cult step, and further information on history - taking is found in Chapter 4 . It is not uncommon for clients to be unaware that the patient was exposed to a toxicant. Recognizing clinical signs of common toxicants is an important skill in emergency medicine. The diagnosis of toxicant ingestion is generally based on a history of a witnessed exposure and/or suspicious clinical signs exhib-ited by the patient. It is not an uncommon occurrence for clients to believe that the patient has been poisoned in the face of an acute illness. Common diseases may imitate toxicant ingestion, and vice versa

If a toxic substance is known or suspected, but treatment options are not known or are immediately unavailable, a poison control center should be contacted. The ASPCA Animal Poison Control Center (1 - 800 - 548 - 2423) has the largest accumulation of veterinary toxicologists special-izing in the effects of toxicants in animals (rather than people). Pet Poison Helpline (800 - 213 - 6680) is staffed with an array of board specialized veterinarians (toxicol-ogy, critical care, internal medicine) as well as toxicolo-gists specializing in human toxicology (PharmDs). Both poison control centers charge consultation fees. More information on this and other toxicology information resources can be found in Chapter 2 . Treatment can then be initiated in accordance with the recommendations pro-vided for the specifi c toxicant.

Initial Assessment

The initial assessment should include assessment of the major organ systems and vital signs, obtaining vascular access, and an initial database followed by development of the emergency plan.

Respiratory System

One always determines the patency of the airway fi rst. Ideally, patent and clear breath sounds should be heard. If the patient is in distress, upper airway noise (stridor/stertor) and/or distress with inspiration associated with stridor may be noted. This can be assessed without the use of a stethoscope.

The respiratory rate should be also be noted; normal for dogs and cats is considered to be 12 – 32 respirations per minute (rpm). If tachypnea (increased respiratory rate); slow, prolonged breathing; or apnea (no respiration) is noted, the patient should be immediately assessed by a

Chapter 6 / Initial Management of Acute Intoxications 45

determined, the direct effects and any secondary conse-quences of it can be predicted. In situations where the toxicant is not known, the diagnostic approach must be based upon clinical signs, a thorough history, and response to symptomatic therapy.

Once the patient has been appropriately triaged and vital signs stabilized, a systematic approach to diagnostics should be taken. If possible, during venous access, blood samples should be collected. A serum chemistry/electrolytes, blood gas, and complete blood cell count (CBC) should be analyzed as a baseline assessment. Depending on the history and clinical signs, ECG, blood smear, coagulation panel, and urinalysis may also reveal further evidence of a toxicosis. Other diagnostics that may provide useful information include radiographs, illicit drug screening, or ethylene glycol testing .

Blood Gases

Blood gas analysis is a great tool used to assess the patient ’ s acid - base status. Many intoxicated patients will present with a history of vomiting, diarrhea, respiratory distress, or seizures. Although these clinical signs may be secondary, patients will likely present with some degree of acid - base derangement. The rapid evaluation of blood gas parameters is highly useful and can provide great insight to the patient ’ s acid - base status.

Metabolic acidosis is characterized as a pH of < 7.2 with a base excess of < 4 (Waddell 2004 ). Mild acidosis may be corrected with intravenous fl uid therapy and management of the underlying disease, whereas more severe metabolic acidosis may require sodium bicarbonate therapy.

Respiratory acidosis may be present in the intoxicated patient, this is characterized by a pH of < 7.2 and PCO 2 of > 45 (Waddell 2004 ). Respiratory acidosis may be due to the effect of the toxicant on the respiratory center in the central nervous system (CNS) as well as interference with innervation of the intercostal muscles. There is also the potential for respiratory acidosis to occur with the use of medications causing respiratory depression, resulting in hypoventilation. This is especially important with patients treated with high doses of anticonvulsants or opioids.

Lactic acidosis is due to the large amounts of lactic acid produced in response to excessive muscle activity. This can occur with seizure activity or with toxicants causing tremorgenic activity such as pyrethroid toxicosis or trem-orgenic mycotoxin ingestion. This type of acidosis will generally resolve on its own once the seizures or tremors have been controlled. In other situations, hypoperfusion may result in lactic acidosis, requiring intravenous fl uid therapy to resolve.

Alert: Normal Depressed: Quiet, unwilling to perform normally;

responds to environmental stimuli Obtunded: Minimally responsive to auditory or tactile

stimuli Stuporous: Unresponsive to environmental stimuli;

responds to painful stimuli Comatose: No response to environmental and painful

stimuli

Renal System

On triage, the renal system is assessed with abdominal palpation when urinary blockage is suspected. Other emer-gencies affecting the renal system are identifi ed while assessing the patient ’ s cardiovascular status.

VASCULAR ACCESS AND THE EMERGENCY DATABASE

Intravenous access should be obtained in any critically ill patient for administration of fl uids and drugs. The most common vessels used for intravenous catheterization are the cephalic or lateral saphenous veins. Central venous access the medial femoral or jugular vein allows for a larger diameter catheter to be placed, which is ideal for allowing achievement of higher drug concentrations in the coronary vessels as well as rapid fl uid administration. These vessels are not as accessible as the peripheral vessels. In neonates, the easiest and most expeditious way to obtain vascular access is via intraosseous catheter place-ment. Ideally, at this time a blood sample may be collected and stored for future toxicological analysis, because some medications that may subsequently be administered may interfere with diagnostic tests (e.g., propylene glycol in diazepam injectable solutions will cause a false positive on ethylene glycol tests (Thrall et al. 2006 )).

After the patient has been stabilized and decontami-nated (if appropriate) and vascular access obtained, a medical problem list should be generated in the order of most to least life - threatening. Each problem should then be addressed in that order. Categories that should be covered include fl uid therapy, medications, diagnostics, and treatment orders.

Emergency Database

Most modern veterinary hospitals are well equipped and have the ability to provide in - house diagnostics. Using these tools, rapid evaluation of the poisoned patient ’ s metabolic and hydration status can be performed. This information will aid in the overall approach to and outcome for these patients. If the exact toxicant has already been

46 Section 1 / Fundamentals of Veterinary Clinical Toxicology

glycemia can occur due to conditions such as sepsis, liver dysfunction, neonatal/juvenile hypoglycemia, insulin or insulin - like factor secreting tumors, xylitol ingestion (dogs) or alpha - lipoic acid ingestion. A transient hypergly-cemia can occur in overly stressed patients (particularly felines). True hyperglycemia is most commonly due to diabetes mellitus.

Blood Urea Nitrogen

Determination of the BUN provides an estimate of renal and hepatic function as well as hydration status. Low BUN concentration may be the result of fl uid diuresis. Other causes can be polydipsia/polyuria or decreased production of BUN due to liver disease or a portal - caval vascular shunt. BUN can be elevated due to prerenal, renal, or postrenal mechanisms, and all of these should be consid-ered when an increase in BUN is detected.

The amount of information obtained from the emer-gency database in regard to the patient ’ s status should not be underestimated. This information combined with a solid history and thorough physical exam can often assist in confi rming a diagnosis or providing direction for further investigation.

Serum Chemistry and Electrolytes

Serum chemistry and electrolyte panels are important to assess because some alterations in these measurements may be a direct result of the toxicant. Many toxicants affect renal function (i.e., ethylene glycol). If there is evi-dence of azotemia or acute renal failure, one then can move forward with diuresis and other appropriate therapy. Some toxicants (e.g., xylitol) may result in acute hepatic failure or necrosis, which will be refl ected in the liver enzymes. Blood glucose, calcium, sodium, potassium, or chloride concentrations can also be altered by various toxi-cants, such as calcium channel blockers, digitalis, or vitamin D – based rodenticides. Evaluation of serum chem-istry and electrolyte results can provide clues into the original cause of the abnormalities and provide feedback on response to therapy.

Hematology

Complete blood cell count (CBC) and peripheral blood smear analysis are useful tools in diagnosing hematologi-cal abnormalities. The CBC provides information on the oxygen - carrying capacity of the blood by measuring red blood cell parameters. The CBC helps classify anemia as acute or chronic as well as determine whether regeneration is occurring, all of which can assist in formulating a list of differential diagnoses. Measurement of white blood cell

If a patient presents with severe vomiting or diarrhea, a blood gas may reveal a metabolic alkalosis (pH > 7.4, base excess > 4). In the case of ongoing gastrointestinal losses (i.e., potassium, chloride), it is important to treat the under-lying cause and provide appropriate therapy for the vomit-ing and diarrhea to resolve the metabolic alkalosis.

Hyperventilation can cause a respiratory alkalosis. Based on a blood gas, this can be defi ned as a PCO 2 of < 35 mmHg. This type of disturbance is most commonly seen in patients presenting hypoxemic or who have ingested something causing excitement, therefore stimu-lating the respiratory system. Respiratory alkalosis can also result from excessive ventilation in the patient that is being mechanically ventilated.

Hematocrit and Total Solids

The packed cell volume (PCV; aka hematocrit [Hct]) and total solids (TS) are generally interpreted in conjunction with each other. The changes in the two parameters often parallel each other in situations of free water loss or hem-orrhage. Decrease in both PCV and TS suggests hemor-rhage. Acute blood loss will not immediately affect PCV and TS because it takes time for interstitial fl uid to move into the vascular space and dilute out the remaining red blood cells and proteins. In canines, splenic contractions secondary to catecholamine release may actually cause a transient increase in PCV in the face of acute hemorrhage. The changes in packed cell volume will become immedi-ately apparent with intravenous fl uid replacement. Because of this phenomenon, some consider TS to be a more sensi-tive indicator of blood loss than PCV. A decreased PCV with normal TS indicates red blood cell destruction or decreased red blood cell production. Anemia of chronic disease is characterized by a decreased PCV with normal TS. The foremost clinical signifi cance to a decreased PCV is reduced oxygen - carrying capacity of the blood. Decreased total solids may occur due to loss from hemor-rhage, protein loss into third spaces, or external loss through the intestines or kidneys. Hypoproteinemia results in decreased intravascular oncotic pressure. This may result in loss of fl uid from the intravascular space and decreased ability to maintain vascular volume and blood pressure. Increases in both TS and PCV are most com-monly due to dehydration.

Blood Glucose

Blood glucose readings are an essential portion of the emergency data base. Normal blood glucose ranges from 80 – 120 g/dl, and severe aberrations (either elevations or depressions) can be life - threatening to the patient. Hypo-

Chapter 6 / Initial Management of Acute Intoxications 47

tion of clotting factors, which results in uncontrolled hem-orrhage. Because most animals have a “ reserve ” of clotting factors, exposure to these rodenticides generally will not result in prolongation of PT or aPTT until 36 – 48 hours postingestion.

Illicit drug screening has become an invaluable tool used in cases where illicit drug ingestion is suspected. There are several types of these tests available at most pharmacies, designed for home monitoring of drug use. The tests are easy to perform, inexpensive, require only a small amount of urine, and provide results within a matter of minutes. The kits can screen for two to ten substances including amphetamines, barbiturates, benzodiazepines, cocaine, methadone, methamphetamine, nicotine, opiates, phencyclidine, and tricyclic antidepressants. Most of the tests for amphetamines will cross - react with sympathomi-metic drugs such as pseudoephedrine or ma huang, so they can sometimes be helpful if ingestion of these legal drugs is suspected. Based on clinical experience, in many kits, the test for marijuana apparently does not give consistent results (i.e., gives false negatives), possibly due to differ-ences in the metabolites excreted between humans and dogs. Other than the issue with marijuana, the kits appear to work very well in a clinical setting. These tests have not been validated in nonhumans, meaning they would not stand up in a court of law, but they have great utility in assisting veterinary staff in diagnosis of suspected drug ingestion. Keep in mind that any positive result based upon the use of a drug screening kit is not considered confi rma-tory, and false positive or negative results can occur. If someone wishes to pursue a case legally following a posi-tive on an OTC test kit (i.e., suspected malicious poison-ing), blood and urine should subsequently be submitted to a validated diagnostic laboratory for analysis that will be acceptable in a court of law. Some clients may be reluctant to have the test performed for fear of police authority involvement. As an animal care provider, it is very impor-tant to reassure clients that the only concern is for appro-priate therapy for their pet. The cooperation of the client and the ability to provide illicit drug screening allows for a targeted treatment plan that can greatly improve the overall outcome of these patients.

Ethylene glycol testing is used in detecting the presence of high serum concentrations of ethylene glycol. Ethylene glycol (EG) is the major component found in many com-mercial antifreeze products. This test is most reliable in the fi rst 4 hours after ingestion; however, based on the amount of EG ingested, levels may be detectable in excess of 12 hours postingestion. False negatives and false positives can occur with the existing tests available for

parameters can assist in identifying and characterizing infl ammatory or infectious mechanisms.

Peripheral blood smear analysis is performed to evalu-ate the appearance of the cellular components of the blood (red blood cells, white blood cells, platelets), identify the presence of hematologic infectious agents (e.g., Dirofi -laria or Babesia ) and identify any other changes that may assist in diagnosis. For example, the presence of Heinz bodies and methemoglobinemia can put acetaminophen toxicosis on the list of differential diagnoses. During acute toxicosis, some changes may not be evident in the fi rst 24 – 48 hours and it may be necessary to reevaluate a CBC at a later time. For patients who may need a transfusion, blood typing should be performed and potential appropri-ate donor animals identifi ed. If blood typing is unavailable, the “ universal donor ” blood may be administered (DEA 1.1 Negative in dogs and Type A in cats).

Urinalysis

Urine should be collected for a baseline screening in the toxic patient, especially in patients who have ingested or have been exposed to nephrotoxic substances such as eth-ylene glycol or lilies. A complete urinalysis will provide useful information in determining the ability of the kidneys to concentrate urine. The presence of hemoglobinuria, glu-cosuria, proteinuria, cellular or granular casts, pigments, and crystals can aid in narrowing down the cause of renal dysfunction. For example, patients with ethylene glycol toxicosis may develop calcium oxalate crystalluria within 6 – 8 hours of exposure; however, absence of oxalate crys-tals does not rule out ethylene glycol as a potential toxi-cant, because not all patients will develop detectable crystalluria.

Additional Testing

During the course of patient management, additional testing may be indicated based on the clinical status of the patient or changes in historical information received from clients. Tests such as coagulation profi les, illicit drug screening, other drug or chemical screening, radiography, electrocardiography, and ultrasound can assist in identify-ing causes and measuring response to therapy.

Coagulation profi les are used to detect changes in the clotting parameters of the blood, especially prolonged pro-thrombin time (PT) and partial thromboplastin time (aPTT). These profi les (or individual tests) are often per-formed at the clinic and are helpful in diagnosing coagu-lopathy from a variety of causes, including anticoagulant rodenticide toxicosis. Anticoagulant rodenticides interfere with recycling of vitamin K in the body, leading to deple-

48 Section 1 / Fundamentals of Veterinary Clinical Toxicology

Electrocardiography (ECG) may help detect arrhyth-mias a patient may be experiencing. Many patients intoxi-cated with substances such as methylxanthines, amphetamines, cocaine, or albuterol will present with sinus tachycardia or ventricular tachyarrhythmias. Brady-cardia and bradyarrhythmias may present in patients exposed to substances such as organophosphorous insec-ticides, pharmaceuticals (e.g., beta - adrenergic blockers), and alcohol. Bradyarrhythmias can also occur in patients with severe electrolyte abnormalities (e.g., hyperkalemia) secondary to a toxicosis (e.g., digitalis toxicosis). The use of appropriate antiarrhythmic medication will be dictated by the veterinarian based on the type and severity of the abnormal rhythm. Continuous ECG monitoring is recom-mended when treating these patients.

CONCLUSION

There are a variety of reasons that animals may present to an emergency service, including infectious, infl ammatory, metabolic and toxic processes. In many circumstances involving poisoning, the cause of the animal ’ s condition may not be known, particularly in cases where exposure to a toxicant was not witnessed. Having a systematic approach to these patients is paramount to identifying the major health issues present. Patient stabilization is essen-tial to keeping the patient alive while the underlying problem is diagnosed and treated. Evaluation of the patient ’ s clinical status and detailed historical information are often necessary to identify the inciting cause and provide prompt and appropriate treatment.

in - house use in veterinary clinics. Details of these issues can be found in the discussion on ethylene glycol in Chapter 28 .

Human hospital laboratories may be helpful in deter-mining exposure to a variety of toxicants, including EG and acetaminophen. When in - house EG testing is not available, or there is concern that the test result may be a false positive, human hospital laboratories can run an EG test that will give a specifi c level of EG in the blood. For dogs, the level of concern is 50 mg/dl or greater and for cats the level of concern is 20 mg/dl or greater. Tests run in human hospitals for EG are very sensitive and specifi c, so the false positives and negatives seen in the in - house veterinary EG tests are not an issue. In many situations, there is concern that a cat or dog may have been exposed to acetaminophen. In these cases, human hospitals can analyze blood for acetaminophen levels, which can tell whether the animal was exposed; unfortunately, nomo-grams do not exist for dogs and cats to determine subtoxic doses from toxic doses, but these test can help with the question “ Did he/she eat it? ”

Radiography may be useful in providing evidence of a metallic foreign body. Common radiopaque materials include batteries, screws, galvanized metal, and coins. Some heavy metals are proven to be highly toxic. For example, a patient presenting with acute hemolytic anemia should have radiographs taken to look for coins (pennies minted after 1982) to rule out zinc toxicosis. If radiographs are diagnostic, an endoscopy or a gastrotomy will be required after patient stabilization.

1. Initial triage of a poisoning patient includes quick assessment of the function of which of the following systems? a. Neurologic b. Renal c. Cardiovascular d. Respiratory e. All of the above

2. List the four parameters that are used during the assessment of cardiovascular function.

3. Tiffany, a 10 - week - old female intact Siamese kitten presents 3 hours after the owner applied a spot - on canine fl ea control product containing amitraz to the kitten ’ s skin. During the initial assessment, Tiffany is found to be recumbent and drooling. She appears minimally aware of her surroundings but does react to sudden noises (such as the sound of a cage door

closing) or to being touched by lifting her head and jerking slightly. Her level of consciousness is best assessed as a. Alert b. Depressed c. Obtunded d. Stuporous e. Comatose

4. Tiffany has a heart rate of 70 bpm, capillary refi ll time of 5 seconds, gray mucous membranes, and thready pulses. Which of the following assessments best match Tiffany ’ s cardiovascular status? a. Bradycardic, hypertensive b. Bradycardic, hypotensive c. Normal heart rate, hypotensive d. Tachycardic, hypertensive e. Tachycardic, hypotensive

CHAPTER 6 STUDY QUESTIONS

Chapter 6 / Initial Management of Acute Intoxications 49

5. Tiffany ’ s body temperature is 96 ° F and her blood glucose (via quick enzymatic strip test) is > 200 mg/dl. Which of the following is the correct assessment for Tiffany? a. Hyperthermic, hyperglycemic b. Hyperthermic, hypoglycemic c. Hypothermic, hyperglycemic d. Hypothermic, normoglycemic e. Hypothermic, hypoglycemic

6. What is the most appropriate next step to take after Tiffany ’ s initial assessment? a. Obtain a detailed history from Tiffany ’ s owner. b. Put Tiffany in a cage with a hot water bottle.

c. Give Tiffany some insulin to drop the blood glucose.

d. Insert intravenous catheter and initiate IV fl uid therapy using warmed fl uids.

e. Bathe the fl ea product off of Tiffany. 7. Tiffany is stabilized, bathed, and placed in a cage with

a heating pad. What parameters should be monitored closely over the next several hours? a. Heart rate b. Capillary refi ll time c. Fluid ins and outs d. Body temperature e. All of the above

ANSWERS

1.e. All of these systems must be assessed during patient triage.

2. Determination of mucous membrane color, capil-lary refi ll time, heart rate and rhythm, and pulse quality.

3.c. Obtunded animals are minimally responsive to tactile and auditory stimuli.

4.b. A heart rate of < 100 bpm in a kitten is bradycar-dia, and the prolonged capillary refi ll time, mucous membrane color and poor pulse quality are consistent with hypotension.

5.c. Body temperature < 100 ° F is hypothermia, and blood glucose levels > 120 mg/dl indicate hyperglycemia.

6.d. Following assessment, steps should be taken to stabilize the patient. In this case, fl uid therapy is indicated to help manage the hypotension. Obtaining a history and bathing the cat should be done after the kitten is stabilized.

7.e. All of these parameters should be monitored closely.

REFERENCES

Plumb , Donald C. 2005 . Plumb ’ s Veterinary Drug Handbook , 5th ed . Ames, Iowa : Blackwell .

Fitzgerald , Kevin T. 2006 . Taking a toxicological history. In Small Animal Toxicology , 2nd ed , edited by Michael E. Peterson and Patricia A. Talcot , pp. 38 – 44 . St. Louis : Saunders .

Thrall , Mary A. , Connally , Heather E. , Grauer , Gregory F. , and Hamar , Dwayne . 2006 . Zinc phosphide. In Small Animal Toxicology , 2nd ed , edited by Michael E. Peterson and Patricia A. Talcot , pp. 38 – 44 . St. Louis : Saunders .

Waddell , Lori S. 2004 . Evaluation and Interpretation of Blood Gases . Proceedings of the Western Veterinary Conference, Reno Nevada .