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141 Cards in this Set

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what are seven common general etiologies from the DAMNIT-V scheme that lead to hypertension?
1. drugs
2. metabolic
3. neoplasia
4. iatrogenic
5. idiopathic
6. trauma
7. vascular
what is the largest group of diseases that cause hypertension?
metabolic
what is TOD?
- target organ dysfunction
- an organ that is damaged specifically by hypertension
without TOD, what BP is considered hypertensive?
> 160 mmHg
what BP values are for low risk, mild, moderate, and severe hypertension?
- low risk: < 150/96
- mild: 150-160/95-100
- moderate: 160-180/100-120
- severe >180/120
what are two hormonal systems that increase blood pressure by elevating blood volume?
1. RAAS
2. ADH
what are the three basic components of the body's regulation of blood pressure
HR, SV, vascular tone; (MAP = CO x PVR)
what controls systolic/diastolic cardiac function, which in turn, contributes to blood pressure?
sympathetic tone
comment on BP and sight hounds
sight hounds (esp. greyhounds) have BP roughly 10-20 mmHg higher than other breeds of dog
what are five non-physiologic factors that can increase blood pressure?
1. "white coat effect" (esp. cats)
2. age (slight increase with age)
3. breed (sight hounds)
4. obesity (dogs)
5. sex (males > females)
what are the two basic types of hypertension and which are most common in animals?
- primary (essential): most common in humans; salt or non-salt sensitive
- SECONDARY: most common in dogs/cats
what is the most common way in which renal disease causes high BP?
activation of the RAAS
what renal diseases associated with high BP are most common in:
- dogs?
- cats?
- dogs: glomerulonephritis, acute kidney injury (ARF)
- cats: chronic interstitial nephritis
what is the typical age of a cat that will develop hypertension as a result of chronic interstitial nephritis?
7 years
which species most commonly has hypertension associated with renal failure?
cats
why should BP be evaluated with PLN?
if an animal has PLN, over time, this disease will increase BP, which in turn, will cause more PLN: a positive feedback of disease
by what mechanism does adrenal disease cause hypertension? In which species is this most common?
- increased TPR
- dogs
what two basic diseases of the adrenal glands cause hypertension?
1. hyperadrenalism
2. pheochromocytomas
what are the three types of hyperadrenalism that are found to cause increased TPR and therefore hypertension?
1. pituitary dependent
2. cortical tumors
3. iatrogenic disease
what is a common iatrogenic cause of adrenal hypertension?
long-term corticosteroid therapy (e.g. for atopy); can ↑ BP and also damage kidneys and other organ systems
characterize the hypertension brought on by pheochromocytomas
intermittent release of catecholamines from this tumor of the renal medulla will cause paroxysms of intermittent hypertension
what are three mechanisms by which hyperthyroidism can cause hypertension?
1. increase HR, SV, ejection velocity
2. increased β-adrenergic stimulation - RAAS
3. hyperplasia - adenomas in cats; carcinomas in dogs (uncommon)
what causes thyroid hyperplasia in cats and in dogs and how common are they?
- cats: adenomas (benign): 30-90%
- dogs: carcinomas: uncommon
how does hypothyroidism cause hypertension?
hypotension → atherosclerosis → increased TPR
which species most commonly gets diabetes mellitus?
dogs
why does hypercalcemia cause hypertension?
it is vasoconstrictive (↑TPR), long term, due to increased intracellular calcium levels
what are two common causes of hypercalcemia (which leads to hypertension) in the dog?
1. lymphosarcoma
2. hyperparathyroidism
how does DM cause hypertension?
1. increases PVR
2. causes renal disease
what are four signs of TOD that are associated with hypertension?
- ocular (eye)
- neurologic (brain)
- renal (kidney)
- cardiac (heart)
what are five clinical signs of ocular TOD?
1. decreased vision
2. blindness (detached retinas, hemorrhage)
3. tortuous vessels
4. edema
5. hemorrhage
comment on the color of retinal hemorrhage
the redder it is, the more recent it is; if it is dark, it could be an old lesion
what are two clinical signs of hypertension that may appear before an animal is going to go into renal failure?
1. PU/PD
2. GI (vomiting, diarrhea, weight loss)
what are five renal signs of hypertension (TOD)
1. proteinuria
2. inflammatory sediment
3. PU/PD
4. azotemia
5. renal failure
what are three characteristics of neurologic TOD due to hypertension?
1. acute onset
2. area affected (e.g. CVA - "stroke")
3. seizures
what is CVA?
cerebral vascular accident (a stroke)
what accompanies seizures brought on by hypertension?
other neurological signs such as head tilt
what are four cardiac signs of hypertension?
1. systolic murmurs
2. gallop sound (S3)
3. left ventricular wall thickening
4. cardiomegaly
common on the association of hypertension with a murmur in the cat versus the dog
in cats, murmur is often associated with hypertension; not as common in the dog
what is the gold standard of diagnosing hypertension?
direct arterial catheterization
what are five ways to diagnose hypertension by measuring blood pressure?
1. direct arterial catheterization
2. palpation (e.g. < 50-60 mmHg, no femoral pulse)
3. doppler
4. oscillatory
5. photoplethysmography (PPG)
what are three examples of when directly measuring blood pressure via catheterization is useful?
1. anestheitized patients
2. old age
3. critical care (e.g. shock)
which blood pressure reading is doppler most accurate at reading?
systolic (diastolic is not accurate)
why is doppler more accurate in measuring BP in cats and small dogs, versus oscillatory?
because there are not trembling artifacts
what are three locations in the cat to place a blood pressure cuff?
1. proximal front leg
2. rear leg (above hock)
3. tail
what does an oscillometric BP reader measure?
1. systolic pressure
2. diastolic pressure
3. mean pressure
4. heart rate
in which animals does oscillometric BP reading work best?
larger dogs (because they don't shake as much)
in which animals does oscillometric BP reading not work very well and why?
cats and small dogs because they tend to shake
what are six principles for an accurate clinical assessment of blood pressure?
1. multiple readings → average
2. same environment (beginning of visit): 3-5 reading in exam room, with owner, etc., to minimize "white coat effect"
3. same equipment
4. same personnel
5. same region of the body
6. is there TOD or primary disease?
what are the three main goals of therapy of hypertension?
1. get it below 150 mmHg systolic
2. treat the primary disease
3. treat hypertension if clinical signs are present (TOD or increased risk of TOD)
what are two common non-pharmacologic treatments for hypertension?
1. weight reduction
2. low sodium chloride diet (note sodium AND chloride)
what are five classes of drugs used to treat hypertension, and what is their pharmacological effect?
1. diuretics: ↓volume; ↑Na+ excretion
2. CC blockers: ↓HR, ↓TPR
3. β-blockers: ↓HR, ↓RAAS
4. ACE inhibitors: ↓ dilates renal efferent arterioles
5. α-blockers: ↓ TPR
what is the first line of drugs used to treat hypertensive cats with chronic renal disease
CC blockers (doesn't work as well in dogs)
comment on diuretics as anti-hypertensives
they are not a good first-line of therapy
when are β-blockers most indicated for hypertension
hyperthyroidism and some adrenal diseases
to lower BP in dogs with proteinuria, which type of drug would you use first and why?
ACE inhibitors, because they lower the BP of renal efferent arterioles
what are some signs of CPA? (8)
- Absence of palpable pulse
- No audible heart sounds
- Apnea/agonal breathing
- Centralized and dilated pupils
- No eye reflexes
- Unconsciousness
- Pale/cyanotic/greyish mucous membranes
- Under anesthesia: sudden change in depth, monitor failure with no audible heart sounds, no surgical bleeding
what are the steps for CPR? (7)
- Immediately start chest compressions (±100 comp/min) and discontinue anesthesia if applicable
- Establish a patent airway and start ventilation (±10bpm) with oxygen
- Give drugs (epinephrine, vasopressin, atropine, etc.)
- Establish venous access (if IV cath in place, give drugs IV)
- Connect monitors
- Defibrillate if indicated
- Reassess, repeat steps as needed
what is the best route to administer drugs in CPR?
central line
what are three routes to give CPR drugs other than a central line?
- Peripheral IV catheter: always flush the line
- Intra-osseous
- Intra-tracheal: sometimes the first route available, always dilute
what are safe CPR drugs to use IP? Comment on dosage.
- Safe drugs IT: epinephrine, vasopressin, atropine, lidocaine, naloxone
- Use higher doses than IV, 2-3x for all drugs, except epinephrine (3-10x)
what is the least desirable site for CPR drug injections and why?
- Least desirable: intra-cardiac, unless chest is open and left ventricle is directly visualized
- Blind IC injections can lead to coronary laceration, lung perforation, puncture of large vessels, myocardial ischemia, pneumothorax
how long should you wait for CPR drugs to take effect?
1-2 minutes
what are four mechanisms by which epinephrine works?
- Alpha-1 adrenergic agonist: vasoconstriction (all over)
- Beta-1 adrenergic agonist: +chronotrope and +inotrope
- Beta-2 adrenergic agonist: bronchodilation
- Increases myocardial oxygen consumption
when doing closed-chest compressions (in a large dog), how long do you wait until you do open chest?
5 minutes
giving epinephrine for CPR:
- routes of administration
- when do you give it?
- how often do you repeat
- which other drug do you use it with and how?
- Can be given IV, IT, IC, IO
- Give as soon as CPA is recognized
- Repeat every 3-5 min if needed
- Alternate with Vasopressin
what are three mechanisms of vasopressin when used in CPR?
- Non adrenergic pressor peptide: peripheral, coronary, and renal vasoconstriction
- May increase cerebral perfusion: cerebral vasodilator
- Agonist at different receptors including V1A receptor (vessels)
what are three advantages of using vasopressin in CPR?
- Less constriction of coronary and renal vessels than periphery: shunting of blood and preferential myocardial perfusion (maintains adequate coronary perfusion pressure for ROSC after defibrillation)
- Associated with higher survival in humans in asystole
- Response is maintained in acidotic environment (not epinephrine)
what are two mechanisms of atropine when used in CPR?
- Anticholinergic (antagonist at muscarinic receptors)
- Used to increase automaticity at SA node: +chronotropic agent
atropine:
- routes of administration
- when is it ineffective?
- what is its advantage over glycopyrrolate?
- how often do you give it?
- what can slow the response of the drug?
- Can be used IV, IT, IO, IC (BUT ONLY IV IS USEFUL)
- Ineffective during asystole or V-fib
- Faster onset than glycopyrrolate; but IT STILL WORKS if atropine is not within reach
- Can be given every 3-5 minutes up to 3 times
- Response is decreased in hypothermic patients
if a crashing patient's pulse is very low, what drug do you use?
atropine
if you give an IV drug during CPR, when is IT administration indicated?
it is not indicated
when is lidocaine indicated during CPR?
in ventricular tachycardia
what is the best route of injection in open chest CPR?
- if you can see the heart, intracardiac
- if not, then don't do it unless you are desperate
what is the mechanism of lidocaine?
Class 1b anti-arrhythmic: stabilizes membranes via Na+ channel blockade
why don't you use lidocaine in ventricular fibrillation?
Increases the defibrillation threshold and decreases myocardial automaticity
lidocaine:
- route of administration (how fast?)
- comment on using lidocaine in cats with ventricular tachycardia
- To be given slowly IV, IO, IC, or IT
- Careful with cats, only use if true potential benefit: increased CV depressant effects and more sensitive to toxic effects. Use 0.2 mg/kg IV
when is sodium bicarbonate indicated during CPR?
Only to be used if pre-existing severe metabolic acidosis or hyperkalemia; and only after circulation has been restored; if animal was not acidotic before CPA, acid/base should return after ROSC
what are three things contraindicated with respect to sodium bicarbonate use in CPR?
- DO NOT use if ROSC has not been achieved: aggravation of respiratory acidosis and paradoxical CNS acidosis
- Not recommended to treat acidosis resulting from CPA: return of spontaneous perfusion and ventilation will reestablish acid-base equilibrium
- DO NOT use IT: too caustic for the lung, will damage the alveoli and destroy surfactant.
when is calcium gluconate administration indicated in CPR? How is it given? Route of administration?
- Given to hypocalcemic or hyperkalemic animals, or calcium channel blocker intoxication (amlodipine, verapamil, diltiazem, etc..); No real benefit to give just as inotropic agent
- Give very slowly IV: over 15-20 minutes (0.5-1.5 mL/kg IV)
- DO NOT give IT
when is glucose indicated in CPR?
not indicated unless hypoglycemic
when is defibrillation indicated?
ventricular tachycardia and ventricular fibrillation
IV fluids in CPR: when is it indicated?
- Do not use shock dose routinely, only if patient was hypovolemic before CPA
after ROSC:
- what physical parameters do you monitor?
- what clin path things do you monitor?
- Mental/neurological status, ECG, pulse oximetry, blood pressure, temperature, urine output, heart rate, respiratory rate and pattern, lung sounds, CRT, mm color, central venous pressure
- Clin Path: acid-base status, PCV/TP, electrolytes, blood glucose, lactate
comment on the supportive care you give after ROSC
Supplemental oxygen, IV fluids, inotropes, blood transfusion, dextrose, rewarming, etc.
what are the three basic components fo shock?
1. inadequate systemic oxygen and nutrient delivery
2. impaired utilization of oxygen
3. poor tissue perfusion
when in shock, what three pathophysiological mechanisms result in poor tissue perfusion?
1. vasoconstriction
2. decreased cardiac output
3. vasodilation
what are the four basic forms of shock and their basic mechanism?
1. hypovolemia (loss of fluid from vascular space)
2. distributive (relative hypovolemia; pooling of blood in veins)
3. cardiogenic (impaired cardiac output)
4. septic (combination of the above types)
how can cats respond to septic shock differently than dogs?
- Cats often have bradycardia in early shock
- This happens when shock is near terminal
when is magnesium sulfate indicated in CPR?
hypomagnesemia, refractory ventricular fibrillation, torsades de points (polymorphic V-tach)
what parasites does a direct fecal smear show?
Protozoan trophozoites only
what parasites does a direct fecal SNAP test show?
Giardia
What are positive and negative parasite factors of fecal flotation using zinc sulfate (33%)
- positive: Basic flotation solution, best for Giardia
- negative: Misses tapes, other dense eggs, crystal formation if sits
What are positive and negative parasite factors of fecal flotation using Sheather’s sugar solution
- positive: Basic flotation solution; Picks up eggs of higher density--tapes
- negative: Sticky, viscous, Misses more Giardia
What are positive and negative parasite factors of fecal flotation using Sodium nitrate (Fecasol)
- positive: Basic flotation solution
- negative: Collapses Giardia cysts, crystal formation if sits
what are two important aspects of successfully diagnosing parasitism with fecal flotation?
1. ALWAYS SPIN FLOTATIONS
2. The person reading the fecals should be trained
what are five parasites that cause acute diarrhea (character of diarrhea)?
- Hookworms (melena)
- Trichuris (hematochezia)
- Toxocara ±
- Giardia (cow pie)
- Isospora (uncommonly bloody)
what are six parasites that cause chronic diarrhea? What is one that does not?
- Hookworms (melena)
- Trichuris (hematochezia)
- Toxocara ±
- Giardia
- Cryptosporidium--cats
- Tritrichomonas -cats
- NOT Isospora
what are three reasons that we treat subclinical parasite infection?
- Infected animals contaminate environment
- Stress can shift balance
- Public health importance
what is an important factor of the parasite when scheduling a treatment regimen?
prepatent period
what is the dose schedule for hookworms?
On diagnosis, repeat in 2 weeks
what is the dose schedule for roundworms?
On diagnosis, repeat in 3 weeks
what is the dose schedule for whipworms?
On diagnosis, repeat in 3 weeks, 3 months
which GI worms does pyrantel treat?
Ascarids, hookworms
why don't you use dog pyrantel in cats?
because the dose is 4x higher in cats
which GI worms does fenbendazole treat?
Hooks, rounds, whips (3 days), Taenia (5 days), Giardia (3 days if subclinical; 5 days or more if clinical)
what should be given with fenbendazole so that it is more effective?
with food, so it doesn't fly through the GI tract
what is the difference between febantel and fenbendazole?
- only with Drontal Plus
- only requires one dose
what is in Drontal Plus and what parasites does it kill?
- Pyrantel, febantel, praziquantel
- kills hookworms, roundworms, whipworms, tapeworms
- kills Giardia, but must use 3 days
when is febantel contraindicated?
in pregnant animals
Profender:
- what drus are in it (mechanism)
- animals indicated
- route of administration
- what does it kill?
- how long does it last?
- emodepside (flaccid paralysis) and praziquantel
- Cats only, 8 weeks or older
- Topical
- Effective against hookworm, roundworm, tapeworms (praziquantel)
- Product lasts 1 month, don’t give more often
why is there no claim for ivermectin in intestinal parasites?
because the doses are too high to kill them
what is a macrolide that is safe enough to give in high enough to kill GI parasites in the dog?
milbemycin
what is a macrolide that is indicated to kill GI parasites in the cat?
selamectin
comment on the unique pharmacokinetics of moxidectin in dogs and cats. Why is this important?
- Moxidectin levels gradually increase until a steady-state level is achieved after about 4-5 months in dogs (Blood level associated with efficacy unknown)
- Steady state in cats after about 3-5 months
- this may prevent hookworms
what are the four most important aspects of parasite control, especially with regards to zoonosis?
- REMOVE FECES!!
- Cover sand boxes
- Disinfectants
- Rodent control
what are the three phases of septic shock and the clinical signs associated with them?
1. compensatory phase: red MM, short CRT, mild tachycardia, normal to bounding pulses: very shocky cats may have bradycardia
2. early decompensatory phase: hypotension, tachycardia, weak pulses, slow CRT, cold extremities
3. late decompensatory phase: same as #2, but with bradycardia, worsening of all signs, anuria, sever depression
what is the pathogenesis of the compensatory phase of shock?
vasoconstriction due to neurohumoral influences: SNS, Angiotensin II, ADH
what is the initiating factor in septic shock and what causes it?
vasodilation caused by cytokine release
what are two pathogenic mechanisms for vasodilation in the decompensatory phase of shock?
1. local vasodilatory substances (autacoids) are released in response to decreased tissue oxygen delivery
2. ultimately, arterioles and venules are not responsive to vasoconstrictive substances
what is the primary goal in the treatment of shock?
restore adequate delivery of oxygen and nutrients to tissues
what are three effects of IV fluid administration in the treatment of shock?
1. increase preload and this increase cardiac output
2. improve tissue perfusion
3. decrease compensatory response
what are four contraindications in the treatment of shock with crystalloids?
1. active hemorrhage (fluids may take slow bleeding to a lot of bleeding)
2. pulmonary contusions (dyspnea, cyanosis increase with fluids)
3. head trauma
4. impaired cardiac function
what is the shock dose for the dog and how is it given, practically?
- Shock dose = 90 ml/kg
- Give bolus 0f 30 ml/kg as fast as possible and assess
- Follow with 10-20 ml/kg/hr if good response
what are five possible reasons why there may be an inadequate response to a shock dose of fluids?
1. continued hemorrhage
2. advanced hypovolemic shock
3. severe septic shock
4. pericardial effusion?
5. pneumothorax?
hypertonic saline:
- concentration
- how much do you give?
- how long does it take to work?
- what is the duration of its effect?
- what do you chase it with?
- 3-7% NaCl
- Administer small volume
- Interstitial fluid moves into vascular space
- Maximum effect in 5-10 min
- Duration of effect short (similar to balanced electrolyte solutions)
- Co-administer balanced electrolyte or colloid
colloids:
- duration of action
- mechanism of action
- how do you give for shock?
- colloids stay in the vascular space longer than crystalloids
- they work by osmosis
- for shock, give a slow bolus over 3-5 minutes and repeat as necessary
what are four indications for giving colloids during shock?
1. Hypoalbuminemia
2. Poor response to crystalloids
3. Large fluid requirements
4. Head trauma, pulmonary contusion
oxygen as a treatment for shock:
- indications
- reason for giving oxygen
- ways of administering oxygen
- limitations
- Should be administered to all animals in shock
- Will increase blood O2 content in all animals
- Nasal O2 catheter, mask, O2 cage
- Will not correct decreased O2 delivery to peripheral tissues that is central to shock
in shock, when is transfusion indicated?
if PCV < 20-25%
what are six physiological parameters to monitor in the shocky patient?
1. Heart rate
2. Systemic arterial blood pressure
3. CRT, mm color
4. Urine output
5. Temperature
6. Blood gases
monitoring systemic arterial blood pressure in shock:
- MAP should be at least what?
- systolic pressure should be at least what?
- MAP > 70 mmHg
- systolic pressure > 100 mmHg
what is an essential medical treatment in septic shock that may or may not be indicated in other forms of shock?
antibiotic therapy
what are four antibiotics/antibiotic "cocktails" used in septic shock?
1. cephalosporins
2. aminoglycoside + ampicillin +/- metronidazole
3. fluoroquinolone + clindamycin or metronidazole
4.ampicillin + beta-lactamase inhibitor
in septic shock, in addition to fluids and antibiotics, what else do you want to administer to the patient to mitigate the clinical signs?
analgesics
what is the effect of pain in producing the clinical signs of shock and what type of analgesics are best (and why)
- pain causes catecholamine release, which increases HR, causes vasoconstriction, and can cause arrhythmias
- opioids are most often used because they are safe and reversible
why are GI protectants indicated in shock? What type of GI protectants are used?
- GI ulceration is common in shock
- H2 blockers or proton pump inhibitors are used
why must you be careful when using cimetidine (a proton pump inhibitor) as a GI protectant in shock?
this drug inhibits CYP450 and could inhibit the metabolism of some drugs
when is sodium bicarbonate indicates in shock?
when acidosis is confirmed: pH < 7.2; HCO3 < 14, pCO2 < 12-14
what is the dose of sodium bicarbonate in shock? How is it administered?
- 0.3 x BW (kg) x base deficit = bicarbonate dose in mEq
- administer half of calculated dose over 15-20 minutes, then re-check acid/base status
when are vasopressors and inotropes indicated in shock?
in life-threatening hypotension unresponsive to fluid therapy
list four vasopressors/inotropes that are commonly used in shock (and their receptors)
1. dobutamine (β1 - increases CO)
2. dopamine (dopamine receptors > β > α)
3. epinephrine (α1, β1, β2)
4. vasopressin (ADH)