Uh-oh ... It Went Neuro: Triaging the Acute Neurologic Patient

TRIAGING THE ACUTE NEUROLOGIC PATIENT
UH-OH ... IT WENT NEURO:
Monday, September 18, 2023
8:30 AM-10 AM
Todd M. Bishop, DVM, DACVIM
(Neurology)
Board-Certified Veterinary
Neurologist
UVS Co-owner
Recruiting member
Risk Management member
Neurology and Neurosurgery
------------------------------------------
Upstate Veterinary Specialties
152 Sparrowbush Road, Latham,
NY 12110
T: 518.783.3198 | F:
518.783.3199
www.uvsonline.com
9/26/2023

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 Emergency seizure control (cluster seizures and status
epilepticus)
 Acute vestibular disturbance
 Traumatic brain injury (TBI)
 Acute spinal cord injury (ASCI)
TOPICS TO COVER
9/26/2023
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 Recognize a true neurologic emergency
 Conduct a quick but thorough neurologic exam
 Hit the highlights
 See the forest from the trees
 Perform point-of-care diagnostic testing
 Provide initial critical (first-responder type) therapeutic intervention(s)
 Prognosticate for the client
 Know which cases to refer and when
GOALS OF THIS LECTURE
9/26/2023

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 Pause
 Take several deep cleansing breathes
 Relax
 You’ve got this!
 It’s hard to make things any worse than they are right
now!!
FIRST STEPS WITH ANY NEUROLOGIC EMERGENCY
9/26/2023

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 Emergency seizure control (cluster seizures and
status epilepticus)
TOPIC TO COVER
9/26/2023

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 Other episodes masquerading as seizures
 Vestibular event
 Syncope
 Dyskinesia (muscle contraction/movement disorder)
 Narcolepsy (cataplexy)
 Painful event (esp. cervical muscle spasms)
 Neuromuscular weakness/collapse
 Metabolic derangement/toxin exposure
 Sleep associated movement disorder
 http://www.neurovideos.vet.cornell.edu/Video.aspx?vid=18-20
FIRST … IS IT DEFINITELY A SEIZURE?
9/26/2023

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• Generalized
• Tonic-clonic seizure
• Myoclonic
• Absence
• Atonic
• Partial
• sometime called a “focal” seizure but that’s an EEG
diagnosis
• Simple
• Complex
ASSUMING SEIZURES … TYPES OF SEIZURES
9/26/2023
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cd.textfiles.com

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 Rigidity
 Paddling
 Loss of consciousness
 Elimination (urine and/or stool)
 Vocalizing
 Salivation
 Chewing
 Erratic eye movements
 Piloerection
GENERALIZED SEIZURES
9/26/2023
www.canine-epilepsy.net

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 Twitching
 Tremors
 Spasms
 Fly-biting
 Vague stare
 Temporary weakness, collapse or balance loss
 Repetitive muscle contraction (myoclonic)
 And everything in between (drooling, whisker twitching, tail chasing,
hyperesthesia, fearfulness, eliminations)
PARTIAL SEIZURES
9/26/2023
https://magazine.medlineplus.gov/article/understanding-different-kinds-of-seizures

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 Cluster seizures (CS)
 2 or more seizure in any 24-hour period
 Status Epilepticus (SE)
 Continuous seizure activity for > 5 minutes
 2 or more seizures where the patient does not regain normal
mentation
CLUSTER SEIZURES AND STATUS EPILEPTICUS
9/26/2023

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 Signalment, signalment, signalment (age, breed, etc.)
 Basic followed by a detailed medical history
 General physical followed by a neurologic exam
 Emergency minimum database
 Basic medical work-up
 Advanced medical work-up
 Referral for intracranial work-up as needed
OUTLINE OF THE DIAGNOSTIC APPROACH
9/26/2023

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Basic HX/PE
IV cath
MDB
Stabilize Complete HX/PE
Neuro exam
Basic Medical Workup:
CBC/Chem/UA/T4
CXR +/- AXR
BP +/- EKG
Maintenance
Anticonvulsant
therapy
Advanced Medical Workup:
Abd U/s
Echo
SBA
Thyroid panel
Infectious disease titers
Intracranial Workup:
MRI
CSF tap
Refine
Tx
Adjust
Tx

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 Why is Signalment so
IMPORTANT?
 1.5 yo Pug = Encephalitis
 2 yo German Sheppard =
Epilepsy
 12 yo Golden Retriever =
Neoplasia
 3 yo i/o DSH = Infectious
SIGNALMENT, SIGNALMENT, SIGNALMENT
9/26/2023
http://www.restkultur.net/boxer-dog-pictures-id-35687.html
=

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 When did the seizures occur/first start (or at
what age)?:
 What do the seizures look like (severity)?:
 Do you have a video?:
 How often are they occurring (frequency)?:
 How long do they last (duration)?:
 Do they come in clusters (2 or more in 24
hours)?:
 Does your pet ever experience continuous
seizure activity lasting 5 minutes or longer
without recovery (status epilepticus)?:
BASIC TRIAGE SEIZURE HISTORY
9/26/2023
https://www.pinterest.com/pin/types-of-seizures-in-dogs--23010648082915360/

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 What happens immediately after a seizure (post-ictal
phase)?:
 How long does the post-ictal phase last?:
 Are there any triggers or hints that a seizure may occur
(aura)?:
 What anticonvulsants have been tried and at what
doses?:
 How long have they been on these medications?:
 Any recent dose changes?:
 Any recent dietary changes?:
 Has there been a change in drug supplier/manufacturer?:
 When was the last dose given?:
 Any side-effects of these medications?:
A MORE DETAILED SEIZURE HISTORY ONCE STABLE
9/26/2023
http://www.hockeydino.com/2011/08/sports-blah-blah-football-blah.html

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 Arrhythmia?
 Murmur?
 Pulse deficits?
 Muffled heart sounds?
 Jugular pulses?
 Adventitial lung sounds?
 Peritoneal fluid wave?
 Abdominal masses?
 If the answer is “yes” to ANY of these
questions … are the client’s really
observing syncope?
GENERAL PHYSICAL EXAM
9/26/2023
http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Medicine/Pericardial_effusion2.htm

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 Mentation
 Vague, distant, depressed, lethargic, dull,
obtunded
 Anxious, agitated, hyperactive, hyperesthetic
 Cranial nerves
 Loss of menace response unilaterally or
bilaterally
 Mydriasis
 Loss of PLR
 Gait/Posture
 Wandering, pacing, circling
 Hemiparesis
 Postural reactions
 Hopping or placing (“CP”) deficits
 Spinal reflexes
 Less important in assessment of seizures
 Muscle size and tone
 Increased extensor tone
 Nociception (“deep pain”)
 More important in spinal cord cases
WHAT TO LOOK FOR ON YOUR NEUROLOGIC EXAM
9/26/2023
* Use caution when interpreting the neuro exam results in the post-ictal phase!

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 Packed cell volume (PCV)
 Total solids (TS)
 Blood glucose (BG)
 Electrolytes (Na+, K+, Cl-,
Ca2+)
 Blood gases
 I-stat
 NOVA
EMERGENT “POINT OF CARE” DIAGNOSTIC TESTING
9/26/2023
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 Complete Blood Cell Count (CBC)
 A comprehensive biochemistry
profile
 Urinalysis
 Total T4
 Ultrasound (TFAST/AFAST)
 Thoracic +/- abdominal
radiographs
 A BLOOD PRESSURE!
 +/- EKG depending on auscultation
 Anticonvulsant levels
BASIC MEDICAL WORKUP (ONCE STABLE)
9/26/2023
https://vetgirlontherun.com/veterinary-continuing-educationdoppler-blood-pressure-vetgirl-video/

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 Abdominal ultrasound
 Echocardiogram
 A complete thyroid profile
 Serum bile acids
 Urine protein:creatinine ratio
 Infectious disease testing
 Canine: 4Dx
 Feline: Feline serology panel
ADVANCED MEDICAL WORK-UP (IF NECESSARY)
9/26/2023
https://www.miniature-schnauzer-australia.com/liver-shunt/

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 Systemic/metabolic diseases can cause affect the brain!
 Liver disease (hepatic encephalopathy)
 Kidney failure (renal encephalopathy)
 Hypertension (pheochromocytoma, hyperthyroidism, glomerular disease,
Cushing's disease)
 Hypoxemia (cardiovascular or pulmonary disease)
 RBC diseases (anemia or polycythemia)
 Hypothyroidism
 Profound electrolyte disturbances (hyper/hypoNa)
 Hypoglycemia (insulinoma, insulin overdose)
 Nutritional deficiencies (don’t forget about thiamine)
 Toxins (lead, ethylene glycol, organophosphates, strychnine, metaldehyde,
mycotoxins)
WHY THESE DATABASES ARE SO IMPORTANT!
9/26/2023

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 Intravenous access (IV catheter placement)
 Midazolam 0.2-0.5 mg/kg IV bolus
 Can be repeated for 3 more times (a total of 4 doses or 2 mg/kg
total)
 Can be given at 1 mg/kg intranasally
 +/- 2 mg/kg rectally
FIRST-RESPONDER THERAPEUTIC INTERVENTIONS
9/26/2023
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 Cats: 0.5 mL
 Small Dog: 1 mL
 Medium Dog: 2 mL
 Large Dog: 3 mL
 XL Dog: 4 mL
DON’T HAVE A CALCULATOR HANDY?
9/26/2023
http://domania.us/gts-today/zzz-Tues-Bbss-Bethlehem-Mens-EMAIL.html

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 Q: When should I consider a CRI?
 A: When a single bolus or two stops the current seizure
but the seizures recur within minutes to hours (4-6 hrs) of
the initial/last injection.
CONSTANT RATE INFUSION (CRI)
9/26/2023
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 Deliver 0.5 mg/kg/hr or the volume of midazolam that was effective
at stopping the initial seizure activity, each hour
 Best to utilize a syringe pump
 Protect the syringe and IV line from light
 Wean slowly, ideally over 24 hrs
 Reduce the dose (rate) by 20-25% every 4-6 hrs
 If seizures recur during the taper:
 REPEAT the bolus injection
 Restart the CRI at the last effective dose
MIDAZOLAM CRI
9/26/2023
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 Use a buretrol.
 What if I don’t have a buretrol?
 Stop making excuses and
 Use a fluid bag and fluid pump
WHAT IF I DON’T HAVE A SYRINGE PUMP?
9/26/2023
https://www.medicalexpo.com/prod/baxter/product-78000-875002.html
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 Calculate the patient’s hourly maintenance fluid rate (ie. 2.75
mL/kg/hr or 1.25 mL/lb/hr)
 Use 0.9% NaCl to avoid drug precipitation
 Note the volume of the Midazolam that was needed to stop
the seizure(s)
 Remove that volume of NaCl from the bag and replace it with
your Benzo of choice
 Run at maintenance fluid rate
QUICK AND DIRTY MIDAZOLAM CRI
9/26/2023

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 Example: 100 lb. (45.5 kg) cluster seizure dog
 Maintenance IV fluid rate: 100 lb. x 1.25mL/lb/hr =125 mL/hr
 Same as 2.75 ml/kg/hr
 Midazolam dose “guestimate” = 4 mL (XL dog)
 Actual dose 45.5 kg x 0.5 mg/kg = 22.75 mg / 5 mg/mL = 4.6 mL
 Make up a 8 hr complement: 8 hrs x 4 mL= 32 mL Midazolam.
 Remove 32 mL of NaCl from a 1L bag and replace with 32 mL of
Midazolam.
 When run at maintenance rate of 125 mL/hr and voila!
 Midazolam CRI at 0.5 mg/kg/hr
MIDAZOLAM CRI CALCULATION
9/26/2023

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 Make sure you truly have venous access!
 Consider other drugs:
• Phenobarbital
• Levetiracetam
• Ketamine
• Propofol
• Inhalant gas anesthesia (iso- or sevoflurane)
• Bromide
WHAT IF MIDAZOLAM ISN’T WORKING?
9/26/2023
www.canine-epilepsy.net

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 Loading dose: 16-24 mg/kg over 24 hrs
 Typically given as 4 mg/kg boluses every 4-6 hrs x 24 hrs
 Can be given in 1-2 larger boluses but watch for significant
sedation, weakness, ataxia, hypotension, respiratory
depression.
 Be prepared to intubate.
 I prefer several smaller doses and serial monitoring.
 “You can always give more but you can’t give less once it’s
given.”
 Ideally allow 20-30 minutes between doses to judge
efficacy.
 Can be given IM if no venous access
PHENOBARBITAL LOADING
9/26/2023
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 Levetiracetam loading:
 60 mg/kg IV
 Followed by 30-40 mg/kg IV q 8 hrs
 May go back to 60 mg/kg IV q 8 hrs if seizures recur
 Wide dose range (20-60 mg/kg) and safety margin
 Minimal sedation which is ideal in cases of cluster seizures, status
epilepticus or structural brain disease where mentation monitoring is
important
 Little to no hepatic metabolism so ideal for liver cases (ie. PSS)
WHAT ABOUT KEPPRA?
9/26/2023
https://memes.com/m/myWd-2-dWxK

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 Well times have changed!
 BTW it’s also ok to use Acepromazine in seizures cases now too!!
 A newish paper found it was effective in treating CS and SE
patients:
 https://www.frontiersin.org/articles/10.3389/fvets.2021.547279/full
 5 mg/kg IV bolus followed by 5 mg/kg/hr CRI if needed
 That’s right … I said 5 mg/kg not 0.5 mg/kg
 I know, I was scared the first time too!
I THOUGHT WE WEREN’T SUPPOSED TO USE KETAMINE?
9/26/2023
https://dana.org/article/the-dazzling-promise-of-ketamine/

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 Propofol
 Bolus: 1-6 mg/kg IV slowly (too affect)
 Dog CRI: 0.1-0.6 mg/kg/min
 Cat CRI: 0.1-0.5 mg/kg/min (can cause Heinz
body anemia!)
 Maintain for 4-6 hrs then try to wean
 Employ typical anesthesia monitoring
equipment
* Be prepared to intubate and ventilate!!!
THEY ARE STILL SEIZING!!
9/26/2023
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 INHALENT ANESTHESIA
 Either Isoflurane or Sevoflurane is fine
 Intubate and be prepared to ventilate
 Utilize standard anesthetic monitoring equipment
 Maintain at the lowest MAC possible to extinguish
all physical manifestations of seizure activity
 Treat for 4-6 hrs, wean and observe for
recurrence
 Be sure to continue loading other drugs (ie. PB,
Keppra) simultaneously
I ALREADY TOLD YOU I DON’T HAVE AN INFUSION PUMP
9/26/2023
https://collection.sciencemuseumgroup.org.uk/objects/co185567/bottle-of-chloroform-united-kingdom-1896-1945-chloroform

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 Potassium bromide can be loaded orally or rectally
 Loading dose = 400-600 mg/kg
 100-150 mg/kg q 4-24 hours x 4 doses
 Side-effects are often intolerable
 Significant sedation, paresis and ataxia
 Nonambulatory status that prolongs hospital stays
WHAT ABOUT BROMIDE?
9/26/2023
http://www.canine-epilepsy.net/basics/basics_index.html

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 Hyperthermia
 Coagulopathies (DIC)
 Hyperglycemia or hypoglycemia
 Electrolyte abnormalities
 Acid-base derangement
 Cerebral hypoxia
 Cerebral edema
 Aspiration pneumonia
 Myoglobinuria -> acute kidney injury
 Kindling?
COMPLICATIONS ASSOCIATED WITH CS AND SE
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 One study found a 25% mortality rate in all CS and SE
cases.
 Another study found a 5% mortality rate but a 33%
euthanasia rate!
 Survival times for SE are 0.1-5.9 yrs (median 9.5 months).
 Hospitalization times: 51.6 +/- 42.6 hrs (2-4 days).
PROGNOSIS
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 After initial evaluation/assessment
 After a minimum database has been collected and analyzed
 After cluster seizures and/or status epilepticus have been
treated and ideally stabilized
 After a preliminary conversation with clients about
expectations, cost, prognosis, etc.
 Please don’t put an actively seizing patients into a car for transfer.
 Please do not hesitate to call a neurologist for advice.
WHEN TO REFER THE CASE?
9/26/2023

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 Emergency seizure control (cluster seizures and status
epilepticus)
TOPIC TO COVER
9/26/2023

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 Recognize the clinical signs
 Correlate with a basic neurologic exam
 Perform point-of-care diagnostic testing
 Provide initial therapeutic intervention(s)
 Know when to refer
* Making an anatomic (ie. central vs. peripheral) and differential diagnoses will NOT be
emphasized in this talk
ACUTE VESTIBULAR DISTURBANCE
9/26/2023
https://shop.petlife.com/blogs/news/why-do-dogs-tilt-their-heads

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 “I think they had a stroke!”
 Head tilt
 Balance loss; walking as if “drunk”
 Eyes or eyebrows jerking
 Globe deviation
 Nausea, vomiting, drooling
 Wide-based stance
 Inability to stand
 Listing, leaning, falling to one direction
 Rolling to one side (“alligator rolling”)
 http://www.neurovideos.vet.cornell.edu/Vide
o.aspx?vid=12-01
WHAT THE CLIENT SEES (AKA CLINICAL SIGNS)
9/26/2023
https://veteriankey.com/neuroophthalmology/
https://jcfuji.com/menu/alligator-roll/

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 Mentation
 Alert and responsive in peripheral cases
 Depressed/dull/obtundation in in central
vestibular cases
 Cranial nerves
 Head tilt, nystagmus, strabismus
 +/- Facial paresis/paralysis +/- Horner
syndrome
 Gait and Posture
 Vestibular quality ataxia- listing, leaning,
drifting, rolling to one side
 Postural reactions deficits
 Delayed hopping and placing in central
vestibular cases
WHAT YOU SHOULD LOOK FOR (AKA THE NEURO EXAM)
9/26/2023

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 Complete Blood Cell Count (CBC)
 A comprehensive biochemistry profile
 Urinalysis
 Total T4
 Ultrasound (TFAST/AFAST)
 Chest +/- abdominal radiographs
 A BLOOD PRESSURE!
BASIC MEDICAL WORKUP
9/26/2023
https://vetgirlontherun.com/veterinary-continuing-educationdoppler-blood-pressure-vetgirl-video/

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 Thyroid panel
 Otoscopic exam
 +/- nasopharyngeal exam
 Think polyps in cats
 Myringotomy
 Culture and sensitivity
 +/- cytology
 Sedated skull radiographs
ADVANCED MEDICAL WORKUP
9/26/2023
www.rawstory.com

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 A simple total T4 will suffice for cats
 Dogs need a complete thyroid panel
 HYPERT4→high BP→cerebrovascular
disease→vestibular signs
 hypoT4→atherosclerosis→cerebrovascular disease
(ischemic stroke)→vestibular signs
 hypoT4→abN metabolism in VIII→vestibular signs
THYROID TESTING
9/26/2023

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OTOSCOPIC EXAM
9/26/2023
http://www.petearclinic.com/images_video.htm
 Don’t neglect the importance
of a good otoscopic exam
 Otitis externa (OE) may have
penetrated the tympanum to
cause otitis media-interna
(OMI)
 Can spot polyps and
neoplasia
 Can assess the benefit of a
myringotomy

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MYRINGOTOMY (TYMPANOCENTESIS)
9/26/2023
http://glomed.biz/products.php?sub_id=40
http://www.neuralstainkit.com/Laboratory_Supplies.php
http://www.welchallyn.com/apps/products
http://www.rush.edu/webapps/rml/RMLTestEntryDtl.jsp?id=3264

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SKULL RADIOGRAPHS
9/26/2023

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 IV fluids
 Antivertigo medications
 Antiemetics
 Benzodiazepines
 Antibiotics
 Corticosteroids?
* almost irrespective of the underlying etiology
BASIC THERAPEUTIC INTERVENTIONS OVERVIEW*
9/26/2023
ricklondon.wordpress.com

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 Rehydrate after vomiting
(hypovolemia)
 Maintain vascular volume
(hypodipsia)
 Combat ongoing losses (drooling)
 Promote cerebral profusion
(especially important in ischemic
cerebrovascular disease)
WHY INTRAVENOUS FLUIDS?
9/26/2023
https://www.pinterest.com/pin/15058979977501353/

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 Dimenhydrinate (Dramamine)
 Antihistaminic (H1), antiemetic and anticholinergic effects
 Block acetylcholine stimulation of the vestibular and reticular systems
 4-8 mg/kg PO TID
 12.5 mg/cat PO TID (cat)
 25–50 mg/dog PO TID (dog)
 Meclizine (Bonine, Antivert)
 Antihistamine with sedative & antiemetic effects
 H1 receptor blocker
 2-4 mg/kg q 12-24 hrs
 6.25 - 12.5 mg / cat / day
 12.5 – 50 mg / dog / day
ANTIVERTIGO/MOTION SICKNESS MEDICATIONS
9/26/2023
essex1.com
insightpharma.com

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 Cerenia
 Maropitant (mar-oh-pit-ent) Citrate
 Acts in the vomiting center to treat motion
sickness
 Neurokinin (NK1) Receptor Antagonist
 Inhibits Substance P a neurotransmitter
 Practical dosing: 1-2 mg/kg IV/PO q 24 hrs x
4+ days
 Possible dosing: 8 mg/kg PO q 24h for up to 2
consecutive days
ANTIEMETICS
9/26/2023
http://www.benhelm.com/cerenia-1

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 Ondanestron
 Zofran
 5-HT3 (seratonin) receptor antagonist
 vagal nerve terminals and chemoreceptor trigger zone (CRTZ)
(CRTZ)
 0.1 – 1 mg/kg PO, SQ, IM, IV q 8-12 hrs
 https://onlinelibrary.wiley.com/doi/10.1111/jvim.16504
ANTIEMETICS
9/26/2023
https://www.abcam.com/products/biochemicals/ondansetron-hydrochloride-5-ht3-receptor-antagonist-ab142531.html#lb

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 Midazolam
 0.2 -0.5 mg/kg IV bolus
 0.2 - 0.5 mg/kg/hr IV CRI over 24-72 hrs
 Sedative effect
 GABA is the major inhibitor neurotransmitter in the
vestibular system
* Its also the “antidote” for Metronidazole toxicosis
WHY BENZOS?
9/26/2023
bipolarblast.wordpress.com

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 Empiric treatment for OE and OMI
 Staphylococcus and Streptococcus sp.
 Cephalosporins
 Cefazolin, Cephalexin, Cefpodoxime
 Fluoroquinolones
 Enrofloxacin, Marbofloxacin, Orbifloxacin, Pradofloxacin
WHAT ABOUT ANTIBIOTICS?
9/26/2023
https://www.freepik.com/free-photos-vectors/antibiotic-cartoon

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 Should ideally be employed only
after a definitive diagnosis has
been made
 Can be added if all other empiric
therapies have failed and clients
are not moving forward with
advanced work-up
 If using empirically, consider an
anti-inflammatory dose (ie.
Prednisone 0.5 mg/kg BID)
WHAT ABOUT CORTICOSTEROIDS?
9/26/2023
https://www.dailycartoonist.com/index.php/2019/06/27/popeye-on-spinach-is-popeye-on-steriods/

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 It’s hard to say
 “I’m feel dizzy, do you think it’s fatal?”
 Prognosis depends highly on the diagnosis
 Central vestibular localizations carry a more guarded
prognosis than peripheral vestibular disease
PROGNOSIS
9/26/2023

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 After a patient has been assessed and stabilized
 Once preliminary testing is complete
 If there is no response to the symptomatic/supportive care
 Whenever central vestibular disease is suspected
WHEN TO REFER A CASE
9/26/2023

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 The injury formally known as “head trauma”
 Very basic pathophysiology
 Clinical signs
 Neurologic exam
 Diagnostic testing
 Therapeutic interventions
 Prognosis
 When to refer
TRAUMATIC BRAIN INJURY (TBI)
9/26/2023
http://www.paems.org/eWebquiz/tbi/image4.jpg
https://www.twincities.com/1993/06/09/from-the-archives-prince-changes-his-name-to-an-unpronounceable-symbol/

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 Hit by car (HBC)
 Bite wounds
 Blunt trauma
 Fall from a height
MOST COMMON CAUSES OF TBI IN VET MED
9/26/2023

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 Primary brain (direct) injury
 contusion, compression, laceration, hemorrhage
 Secondary brain (indirect) injury
 ischemia
 swelling (cerebral edema)
 Can lead to brain herniation
 Intracellular accumulation of Na+ & Ca++
 activation of the coagulation, complement, & arachidonic acid cascades
 oxygen free radical production
 ATP depletion
 cytokine induction
 extracellular accumulation of glutamate, NO, lactic acid
PATHOPHYSIOLOGY
9/26/2023
https://emojiisland.com/products/exploding-face-emoji

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 Altered mentation
 Anisocoria
 Depressed vestibulo-ocular reflex (VOR)
 Pupillary light reflex (PLR) alterations
 Decerebrate rigidity
 Decerebellate rigidity
 Altered respiratory patterns
 Systemic hypertension w/ bradycardia (Cushing’s reflex)
SIGNS OF INCREASED INTRACRANIAL PRESSURE (ICP) -
OVERVIEW
9/26/2023

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 Lethargic -> Depressed – drowsy but rousable; inactive;
inattentive
 Dull -> Obtunded – sleep state; rousable with strong stimuli
 Stuporous (semi-coma) – response only to noxious stimulus
 Pinching base of the digit(s) with hemostats
 Corneal reflex with Q-tip
 Nasal septal sensation with hemostat
 Cold saline down the ear canal
 Coma – no response to noxious stimulus
ALTERED MENTATION
9/26/2023
https://www.mspca.org/angell_services/practical-approach-to-the-small-animal-neurologic-examination/

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ANISOCORIA
9/26/2023
de Lahunta, A.

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 Aka Oculocephalic or “Doll’s eye reflex”
 A crude test of brainstem function (VIII→MLF →III,IV,VI)
 Swing head from side to side and watch for physiologic nystagmus
 Move head horizontal to RIGHT
 Smooth pursuit LEFT
 Saccade beat RIGHT
VESTIBULO-OCULAR REFLEX (VOR)
9/26/2023
www.drtbalu.com

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 Rostral brainstem lesion (midbrain-pons)
 Stupor or coma
 Pinpoint or widely dilated, nonresponsive pupils
 Opisthotonic posture
 Extensor rigidity of all 4 limbs
 POOR PROGNOSIS
DECEREBRATE RIGIDITY
9/26/2023
https://www.researchgate.net/figure/a-Decerebellate-rigidity-involves-extension-of-the-head-and-neck-with-rigid-extension-of_fig2_281100633

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 Cerebellar lesion
 Normal mentation
 Normal pupils
 Thoracic limb extension
 Opisthotonos
 Pelvic limb flexion
 Prognosis better than decerebrate rigidity
DECEREBELLATE RIGIDITY
9/26/2023
https://www.vetlexicon.com/felis/internal-medicine/articles/brain-cerebellar-disease/

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THE CUSHING’S REFLEX
9/26/2023

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 Lacerations, contusions
 Skull fractures, SQ
emphysema
 Proptosis, scleral
hemorrhage
 Oral and Aural bleeding
 Fractured mandible, maxilla
or hard palate
NON-NEUROLOGIC EXAM FINDINGS
9/26/2023
https://www.texvetpets.org/article/traumatic-brain-injury/

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 A - airway
 B - breathing
 C - cardiovascular status (IV access)
* Assess and treat the ABC’s prior to the neurologic exam!
* Hypoxemia and hypovolemia (hypotension) are common
comorbidities observed with TBI
INITIAL ASSESSMENT. ITS AS EASY AS 123 …
9/26/2023
https://www.pryor.com/blog/the-abcs-of-an-abc-analysis/

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 Packed cell volume (PCV)
 Total solids (TS)
 Blood glucose (BG)
 Electrolytes (Na+, K+, Cl-, Ca2+)
 Blood gases
 I-stat
 NOVA
 Blood Pressure
 Pulse Oximetry
 ETC02 if intubated
MINIMUM DATABASE
9/26/2023
https://www.vettimes.co.uk/pulse-oximetry-is-great-but-know-its-limitations/

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 Crystalloids*:
 80-90 ml/kg (dogs)
 50-60 ml/kg (cats)
* use low pressure resuscitation as not to exacerbate cerebral
edema
 Hetastarch: 5 ml/kg IV over 5-10 mins.
 7.5% NaCl: 4-5 ml/kg IV over 3-5 mins.
FLUID THERAPY
9/26/2023

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 Dose: 0.5-1.0 grams/kg IV over 10-20 minutes (it’s a large
volume)
 Via a blood filter
 Effects of Mannitol last for 2 – 5 hours
 Caution if giving more than 3 doses in a 24-hour period
(hypernatremia)
 Monitor serum sodium levels
 Furosemide synergy: 2-5 mg/kg IV a few minutes prior to
Mannitol
* Give after patient is fluid resuscitated and is hemodynamically
stable
MANNITOL THERAPY*
9/26/2023

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MANNITOL THEORY
9/26/2023
 Osmotic diuretic that ↓ ICP via:
 reflex cerebral vasoconstriction
due to ↓ blood viscosity (first 2-3
minutes)
 Osmotically drawing fluid
(vasogenic edema) from the EVS
to IVS (within 15-30 minutes)
 ↓ CSF production
 Free-radical scavenging
https://pedemmorsels.com/tag/mannitol/

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 Hypernatremia and hyperosmolarity
 Rebound hypertension
 Exacerbation of intracranial hemorrhage
 Reverse osmotic shift
POTENTIAL MANNITOL SIDE-EFFECTS
9/26/2023
https://www.everypixel.com/image-5209295988565854808

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 Hypoxemia is common in TBI
 Pneumothorax
 Pulmonary contusions
 Non-cardiogenic pulmonary edema (NCPE)
 Attempt to maintain PaO2 >90 mmHg using:
 Nasal cannula @ 100 ml/kg/min
 Transtracheal catheter @ 50 ml/kg/min
 Oxygen cage/tent (40%)
 Flow-by or face mask
 HIGHFLOW OXYGEN THERAPY!
OXYGENATION
9/26/2023
https://www.mspca.org/angell_services/hfot/

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 Hypoventilation is also common in TBI
 End-tidal CO2 monitor
 Arterial blood gas (PaCO2)
 Goal is to maintain ETCO2 btwn 25-35 mmHg
 ETCO2 > 35 → vasodilation → ↑ ICP
 ETCO2 < 25 → vasoconstriction → ↓ CPP (CBF)
* Some patients may require manual or mechanical ventilation
HYPERVENTILATION*
9/26/2023
https://equip4vets.com/home/shop/veterinary-products/veterinary-monitoring/veterinary-etco2-monitors/veterinary-etco2-monitor-memo-vet/

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 Elevated head 15-30° to dec. ICP
 Avoid jugular vein compression
 Lubricate eyes to avoid corneal ulcers
 Palpate & express bladder (vs. UCS)
 Change recumbency to avoid pressure sores
 Passive range of motion
MISCELLANEOUS THERAPIES
9/26/2023
https://1family1health.com/product/optixcare-eye-lube-lubricating-gel/

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 No longer the standard of care in TBI
 May provide some free-radical scavenging activity
 Adjunctive treatment in patients:
 not responding to typical resuscitative attempts
 cerebral edema confirmed on brain imaging
 Anti-inflammatory dose
 Prednisone 0.5 mg/kg BID
9/26/2023
http://darbydrug.com/prodimage/2286712.jpg

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 Cardiovascular:
 HR, rhythm, pulses, MM, CRT,
 blood pressure & cECG
 Resp:
 note RR/RE, serial auscultations
 pulse ox & blood gases
 Neuro:
 seizure watch
 mentation check
 Note pupil size/symmetry
 Abdomen:
 note discomfort, distention, etc.
 record urine production
POST-TBI MONITORING
9/26/2023

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 Complete physical exam
 Finish the neurologic exam (often reveals multifocal CNS signs)
 Thorough orthopedic exam
 Thoracic auscultation; Abdominal palpation
 Thoracic radiographs
 Abdominal radiographs vs. ultrasound (AFAST/TFAST)
 CBC, Chem profile, UA, Coag panel, EKG (traumatic
myocarditis)
 Serial blood pressure monitoring
SYSTEMIC WORK-UP ONCE STABLE
9/26/2023

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 Skull and cervical vertebral column radiographs still
hold value!
DIAGNOSTIC IMAGING AT THE PRIMARY CARE LEVEL
9/26/2023
Glass, EN
Olby N, et al. J Am Anim Hosp Assoc 2002;38:321-326.

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 cardiac dysrhythmias (brain-heart syndrome)
 coagulopathies
 neurogenic pulmonary edema
 central diabetes insipidus (CDI)
 aspiration pneumonia
 meningitis
 post-trauma epilepsy
COMPLICATIONS ASSOCIATED WITH TBI
9/26/2023
https://www.health.com/condition/stroke/heart-complications-after-stroke-future-cardiovascular-events

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 Overall prognosis always guarded!
 Stuporous or comatosed with dilated, unresponsive pupils
(poor)
 Coma lasting >48 hrs (grave)
 Absent brainstem reflexes – VOR, caloric test negative, BAER
(grave)
 EEG the standard of care in people.
 AI and fMRI the future?
 https://news.westernu.ca/2023/09/ai-predict-brain-injury-recovery/
PROGNOSIS
9/26/2023

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 CT lesions do not correlate with prognosis
 MRI injury grades do, esp. midline shift
 Gender, weight, age and presence of skull fractures do
not predict survival
 Hyperglycemia is a negative prognostic indicator in
people, but not proven in vet med
PROGNOSIS
9/26/2023

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A PROGNOSTIC TOOL: MODIFIED GLASGOW COMA SCALE
(MGCS)
9/26/2023
Platt SR, et al. J Vet Intern Med. 2001 Nov-Dec;15(6):581-4.

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 After the following has been performed:
 Initial assessment (ABCs)
 Minimum database
 Preliminary resuscitation
 +/- Basic systemic work-up
 Once the patient is stable
 When a patient is not responding to typical medical
interventions
WHEN TO REFER A TBI CASE …
9/26/2023

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 Depressed skull fractures w/ neurologic signs
 Penetrating or contaminated wound (bone fragments,
foreign material)
 Patients whose signs are not improving or deteriorating
despite aggressive medical treatment
 Patients with persistent cerebrospinal fluid leakage
 Progressive extra-axial hemorrhage causing ↑ ICP
INDICATIONS FOR NEUROSURGICAL INTERVENTION
9/26/2023

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INDICATIONS FOR NEUROSURGICAL INTERVENTION
9/26/2023

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 Basic neurologic assessment
* Spinal cord neuroanatomic localization not included in this discussion
 Disease processes specific to ASCI
 Preliminary diagnostic testing
 Initial therapeutic interventions
 Complications
 Prognosis
 When to refer
ACUTE SPINAL CORD INJURY (ASCI)
9/26/2023

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 Myelopathy - any disease process affecting the spinal cord
 -paresis - weakness
 -plegia - paralysis
 Tetra- all 4 limbs affected
 Para- two limbs affected, typically hind limbs
 Mono- one limb affected
 Hemi- one side affected
 Ataxia – incoordination
SOME DEFINITIONS SO THAT WE ARE SPEAKING THE SAME
LANGUAGE
9/26/2023

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 Spinal cord consists of four
(4) basic segments
 Cervical (C1-C5)
 Cervical intumescence (C6-
T2)
 Thoracolumbar (T3-L3)
 Lumbar intumescence (L4-
S3)*
* May be subdivided into L4-L6 and L6-S1
FUNCTIONAL ANATOMY
9/26/2023
THE NEUROLOGIC EXAM
Modified from: Vernau, KM. “Localization of Spinal Cord Disorders.” Western Veterinary Conference, 2006.

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 Spinal cord contains two (2)
basic neurons:
 Upper motor neurons (UMN)
transmit signals from brain down
the spinal cord in the white
matter
 Lower motor neurons (LMN)
originate in the grey matter of the
spinal cord and transmit signals
from the spinal cord to the limbs,
bowels, bladder, and tail.
BACK TO BASICS (AUDIBLE GROANING SOUNDS FROM THE
CROWD)
9/26/2023
THE NEUROLOGIC EXAM
Modified from: Sharp JH, Wheeler SJ. Small Animal Spinal Disorders-Diagnosis and Surgery, 2nd Edition, 2005. Elsevier Mosby. p. 6.

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SO WHICH SEGMENT IS AFFECTED?
9/26/2023

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 Is the patient’s problem neurologic or orthopedic in origin?
 Which limb(s) are affected (thoracic, pelvic, both, one-
sided)?
 Is the problem involving the UMN, LMN, or both?
 How do I make an anatomic diagnosis?
 Do a neurologic exam!
FIRST ASK YOURSELF …
9/26/2023

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 Gait evaluation
 On the ground
 not on the gurney or exam table
 on a nonslip surface (carpeting preferred)
 Can they stand? Walk? Advance the limbs (“hip flexion”)?
 Posture assessment
 Low head carriage?, kyphosis? Root signature? Low tail carriage?
 Postural reactions
 Hopping and proprioceptive placing (so called “CPs”)
 Spinal reflexes
 Patellar, withdrawal (flexor reflex- not deep pain), cutaneous trunci, perineal
 Muscular size and tone
 Flaccid? Spastic?
 Atrophy?
 Don’t forget anal, bladder and tail tone!
THE ABBREVIATED NEUROLOGIC EXAM
9/26/2023

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 UMN PARESIS
 Stiff
 Spastic
 Long-strided
 Floating
 Over-reaching
(hypermetria)
 Delay in protraction
 LMN PARESIS
 Short-strided
 Choppy steps
 Looks lame
 Trouble supporting
weight
GAIT ANALYSIS
9/26/2023
THE NEUROLOGIC EXAM

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 Look at the position of the head, neck, trunk, limbs and tail
 Low head carriage: neck pain; cervical muscle weakness (hypokalemic cats)
 High head carriage: back pain, Schiff-Sherrington syndrome (more about this
later)
 Head and/or neck turned to the side: torticollis or pleurosthotonus
 Back arched (kyphosis): back pain; imbalance of the spinal extensor/flexor
muscles
 Scoliosis: curvature of the vertebral column left or right (think syringomyelia)
 Low tail carriage: behavioral, pain, flaccid tail tone (lumbosacral stenosis, limber
tail)
 Palmargrade or plantargrade stances: LMN paresis vs. ligament or tendon
compromise
 “Root signature”: limb vs. nerve pain
POSTURAL ASSESSMENT
9/26/2023
THE NEUROLOGIC EXAM

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SOME EXAMPLES OF ABNORMAL POSTURES
9/26/2023
THE NEUROLOGIC EXAM

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 Primary Assessments
 Hopping
 Proprioceptive placing (so called “CPs”)
 Secondary Assessments
 Wheelbarrowing
 Extensor postural thrust
 Hemistand/hemiwalk
 Visual or tactile placing
POSTURAL REACTIONS
9/26/2023
THE NEUROLOGIC EXAM

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 If UMN lesion
 Slow
 Delayed
 Scuffing
 Knuckling
 If LMN lesion
 Normal (if supported)
POSTURAL REACTIONS
9/26/2023

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 Most important
 Patellar
 Femoral nerve (L4-L6)
 Withdrawal (flexor)
 Thoracic limb – entire cervical intumescence (C6-T2)
 Pelvic limb – Sciatic nerve (L6-S1/2)
 Cutaneous trunci (not panniculus)
 Sensory - segmental spinal nerves in T-L region
 Motor – Lateral thoracic nerve (C8-T1)
 Perineal (not peroneal)
 Pudendal nerve (S1-S3)
SPINAL REFLEXES
9/26/2023
THE NEUROLOGIC EXAM

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 If UMN lesion
 Normal to increased (“brisk”)
 If LMN lesion
 Decreased to absent
SPINAL REFLEXES
9/26/2023

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 If UMN lesion
 Increase muscle tone
(spastic)
 Minimal atrophy
 If LMN lesion
 Decreased muscle tone
(flaccid)
 Significant neurogenic
atrophy in as little as 5 days
MUSCLE SIZE AND TONE
9/26/2023
THE NEUROLOGIC EXAM

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 Don’t forget to assess:
 Anal tone
 Tail tone
 Bladder tone (ease of bladder expression)
 NOTE: a normal bladder can not be expressed
WHILE YOU ARE THINKING ABOUT MUSCLE TONE …
9/26/2023
THE NEUROLOGIC EXAM

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 Inspect the paraspinal muscles for any visible or palpable muscle
fasciculations or spasms.
 Start with light palpation feeling for any discomfort, heat, swelling,
deformity.
 Palpate more firmly by applying dorsal pressure in the thoracolumbar and
lumbosacral vertebral column (spinous processes).
 Palpate along the cervical and lumbosacral vertebral column by applying
lateral compression feeling for muscle spasm or abdominal splinting
(transverse processes).
 Single out the lumbosacral space for direct dorsal compression.
 Manipulate the tail by applying flexion, extension, lateral bending and
traction.
 Note any focal or diffuse spinal hyperpathia.
VERTEBRAL COLUMN PALPATION
9/26/2023
THE NEUROLOGIC EXAM

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 First off … it’s called nociception not “deep pain”
 One can not truly differentiate superficial from deep pain on a clinical veterinary
neurologic exam
 Second: it does not need to be checked in an ambulatory patient!
 Loss of nociception is the last bit of function to go in a complete spinal cord injury.
Why?
 Because they are the “deepest” tracts (adjacent to the grey matter). The descending motor
tracts would be compromised by the time these tracts are affected.
 The only exception is central cord syndrome.
 Decreased sensation is call hypalgesia
 Loss of nociception is called analgesia.
WHAT ABOUT CHECKING “DEEP PAIN”
9/26/2023
THE NEUROLOGIC EXAM

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LET’S REVIEW …
9/26/2023

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NOW YOU KNOW THE ANATOMIC DIAGNOSIS
9/26/2023
From: Sharp JH, Wheeler SJ. Small Animal Spinal Disorders-Diagnosis and Surgery, 2nd Edition, 2005. Elsevier Mosby. p. 28.

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 If the thoracic limbs are normal and the pelvic limbs are
abnormal, then the lesion must be caudal to T3.
 If both the thoracic limbs and the pelvic limbs are
abnormal, then the lesion must be cranial to T3.
 With one important exception …
A TIP FOR SPINAL CORD LOCALIZATION … T3 IS THE KEY!
9/26/2023
THE NEUROLOGIC EXAM

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 caused by an severe, peracute lesion in the thoracolumbar or lumbosacral spinal cord
segments
 Disruption of long interneurons (border cells) traveling in fasciculus proprius (adjacent to the
grey matter in the L1-L5 region) that synapse on the cell bodies of the LMN to the thoracic
limb extensor muscles in the cervical intumescence
 causes increased tone (spasticity) in the thoracic limbs that is especially obvious when
patient is lying in lateral recumbency
 BUT does not affect motor function, postural reactions or reflexes to the thoracic limbs
 commonly confused with a cervical lesion when in lateral recumbency
 stand the patient up and assess motor function in the thoracic limbs to rule-out a C1-C5
myelopathy
 Often occurs with “spinal shock”: hypotonicity and loss of spinal reflexes to the pelvic
limbs despite an UMN lesion
SCHIFF-SHERRINGTON SYNDROME!
9/26/2023
THE NEUROLOGIC EXAM

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SCHIFF-SHERRINGTON SYNDROME!
9/26/2023
THE NEUROLOGIC EXAM
https://veteriankey.com/small-animal-spinal-cord-disease/

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 hypotonicity and loss of spinal reflexes despite an UMN lesion
(opposite what would be expected)
 Occurs with severe, peracute “upstream” UMN lesions
 Most common in the thoracolumbar spinal cord but can occur in the
cervical region
 Loss of LMN function due to lack of faciliatory UMN input
 build up of glycine (Inhibitory neurotransmitter) in the LMN cell bodies?
 Can last hours to 10-14 days!
 http://www.neurovideos.vet.cornell.edu/Video.aspx?vid=10-02#
WHAT IS SPINAL SHOCK?
9/26/2023
THE NEUROLOGIC EXAM

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 Grade 0 – normal
 Grade 1 – painful w/o paresis/ataxia
 Grade 2 – ambulatory paresis/ataxia
 Grade 3 – non-ambulatory paresis/ataxia
 Grade 4 – tetra/paraplegia with intact nociception
 Grade 5 – tetra/paraplegia with loss of nociception
GRADING ASCI
9/26/2023

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HERE’S THE PROBLEM!
9/26/2023

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 I prefer to qualify rather than quantify ASCI using
descriptors:
 Severe non-ambulatory flaccid paraplegia with intact nociception
 Moderate non-ambulatory spastic right hemiparesis
 Mild ambulatory spastic tetraparesis with GP ataxia
QUALITATIVE GRADING SCHEME
9/26/2023

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 IVDD
 These may all have varying degrees of epidural hematoma causing secondary spinal cord
compression
 Intervertebral disk extrusion (IVDE) – classic type I
 Acute noncompressive nucleus pulposus extrusion (ANNPE)
 Hydrated nucleus pulposus extrusion (HNPE)
 Fibrocartilaginous embolic myelopathy (FCEM)
 Vertebral column fracture-luxation
 Decompensation from spinal neoplasia
 Diskospodylitis – epidural empyema
DIFFERENTIAL DIAGNOSES FOR ACSI
9/26/2023
https://www.elwoodvet.net/back-pain-dogs

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 Routine CBC and chemistry panel
 Chest x-rays
 Abdominal x-rays vs. AFAST
 Sedated vertebral column radiographs
POINT-OF-CARE DIAGNOSTIC TESTING
9/26/2023
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 Radiographic signs
 Osteolysis
 Osteoproliferation
 Fractures
 Luxations
 Disk calcification
 Collapsed disk spaces
 Foraminal stenosis
 Spondylosis deformans
 Disease Processes
 Vertebral neoplasia
 Vertebral osteomyelitis
 Diskospondylitis
 Vertebral column fracture/luxation
 Traumatic
 Pathologic
 IVDD
 Vertebral canal stenosis
DO NOT UNDERESTIMATE THE POWER AND UTILITY OF SURVEY
RADIOGRAPHS
9/26/2023

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“SPINAL” RADIOGRAPHS
9/26/2023

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 Most cases of traumatic ASCI are polytrauma patients!
 Don’t be distracted by the obvious spinal fracture/luxation
as they are rarely life threatening (cervical excluded)
 Assess the whole patient and make sure the patient is
cardiovascularly stable before turning your attention to the
spinal assessment.
 “A traumatic event severe enough to fracture the spine will
cause serious internal organ damage!”
DON’T FORGET THERE IS A PATIENT ATTACHED TO THAT
SPINE!
9/26/2023

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DON’T FORGET THERE IS A PATIENT ATTACHED TO THAT
SPINE!
9/26/2023

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 Polytrauma comorbidities
 Pneumothorax
 Pulmonary contusions
 Traumatic myocarditis
 Gall bladder rupture
 Urinary bladder rupture
 Liver laceration
 Kidney avulsion
 Splenic hematoma
 Hemoabdomen
 Systemic assessment
 PCV/TS/BG/Lytes/blood gas
 Lactate
 SpO2 and ETCO2
 CBC/Chem panel
 Chest/abdominal x-rays
 AFAST/TFAST
 ECG
 Blood pressure
 Coag assessment (Plts, PT, PTT)
DON’T FORGET THERE IS A PATIENT ATTACHED TO THAT ASCI!
9/26/2023

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 Immobilization until fracture/luxation is ruled in/out
 Strict crate/cage confinement
 Routine recumbent patient care
 IV fluid therapy
 Bladder care
 Pain management and sedation
 Basic physical therapy
* Almost regardless of the etiology!
EMPIRIC TREATMENT OF ASCI - OVERVIEW*
9/26/2023

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 Clean, dry, and well-padded
 Frequent turning (if no
Fx/Lux)
 Soft padded bedding
 Bathing and drying as
needed
 Passive range of motion
RECUMBENT PATIENT CARE
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 More important than corticosteroids!
 Replaces blood volume lost due to
hemorrhage (hypovolemia->hypotension)
 Counteracts the vasodilatory effects of
shock
 Promotes spinal cord profusion
IV FLUID THERAPY
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 Indwelling urinary catheter (good)
 Intermittent urinary catheterization (Better)
 Bladder expression (BEST)
 Use antibiotics cautiously with indwelling urinary catheters to avoid resistant UTIs
 Prazosin:
 1 mg/dog (NOT mg/kg) PO 2-3 times daily for dogs weighing less than 15 kg (33
lbs);
 2 mg/dog (NOT mg/kg) PO 2-3 times daily for dogs weighing more than 15 kg (33
lbs)
 Consider oral Diazepam 0.25-0.5 mg/kg PO 30 minutes before expression
 Tamsulosin (Flomax): 0.01-0.2 mg/kg SID (0.4 mg tabs)?
URINARY BLADDER CARE
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 Morphine: 0.3 mg/kg IV slowly
 Fentanyl: 5.0 mcg/kg IV
 Hydromorphone: 0.1-0.2 mg/kg IV q 6 hrs
 Methadone: 0.1-0.2 mg/kg IV q 4-8 hrs
 Buprenorphine: 0.01-0.02 mg/kg IV q 8hrs
 Rimadyl: 2.2 mg/kg SQ q 12 hrs
PAIN MANAGEMENT (INJECTABLE)
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 Fentanyl: 2-5 mcg/kg/hr
 Ketamine: 0.1-0.6 mg/kg/hr
 (note 10x lower than seizure doses)
 Morphine-Lidocaine-Ketamine
 Morphine: 0.1 mg/kg/hr
 Lidocaine: 50 mcg/kg/min
 Ketamine: 3 mcg/kg/min
PAIN MANAGEMENT (CRI)
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 Gabapentin: 5-10 mg/kg q 8-12 hrs
 Carprofen: 2.2 mg/kg q 12 hrs
 Methocarbamol: 30 mg/kg q 8-12 hrs
 Amantadine: 3-5 mg/kg q 12-24 hrs
 Pregabalin: 0.2-0.4 mg/kg q 8-12 hrs
 Oxycodone: 0.2-3 mg/kg q 4-12 hours
 Tylenol: 5-15 mg/kg q 8-12 hrs (dogs only)
 Codeine: 1 – 2 mg/kg q 4 to 6 hours
 Tramadol: I’m not using this any longer (efficacy?, controlled!)
PAIN MANAGEMENT (ORAL)
9/26/2023
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 Cold laser therapy
 Assisi loop
 TENS
 Acupuncture
INTEGRATIVE PAIN MANAGEMENT
9/26/2023
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 Solumedrol (MPSS) boluses at 30mg/kg IV are no longer
the Standard of Care
 Avoid “shock” or high-dose steroid doses altogether (i.e.,
2-4 mg/kg Dexamethasone IV)
 Use low-dose Dexamethasone sparingly (0.07 mg/kg IV
SID-BID) due to GI ulceration in ASCI
 Prednisone at 0.5 mg/kg PO BID instead of NSAIDs is OK
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 Dexmedetomidine:
 Bolus 1-2 mcg/kg IV once then
 CRI 0.5-2.5 mcg/kg/hr
 Acepromazine: 0.005 - 0.02 mg/kg IV q 6h PRN
 Butorphanol: 0.1-0.2 mg/kg IV q 4-6 h PRN
 Trazodone: 3-7 mg/kg PO q 8-12 hrs
 Gabapentin:20-30 mg/kg PO q 8-12 hrs
SPEAKING OF SEDATION … IS ANYONE STILL AWAKE?
9/26/2023
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 Pneumonia
 Urinary tract infection
 Thrombosis
 Pressure sores
 Urine scalding
 Muscle atrophy
COMPLICATIONS ASSOCIATED WITH ASCI
9/26/2023

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 Drawn mainly from studies of dogs with IVDD and vertebral
fractures
 Based on the:
 severity of the injury (see grading scheme)
 onset and progression of clinical signs
 area of the spinal cord affected
 Patient size and age
PROGNOSIS
9/26/2023

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 Grade 0 – 4 injuries have a good prognosis with a high chance
of recovery to function levels
 IVDE: ~85-95%
 ANNPE: ~65-85%
 FCEM: ~75-95%
 Grade 5 injuries (loss of nociception) carry a poor to grave
prognosis with ~ 50% of IVDD patients recovering and as low
as ~10% in cases of vertebral column fracture/luxation!
PREDICTED OUTCOMES
9/26/2023

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 When a spinal fracture or luxation is suspected BUT after
initial assessment, systemic workup and cardiovascularly
stable!
 When medical management is failing.
 Ideally before paralysis occurs (if possible).
 Immediately if pet loses nociception.
WHEN TO REFER A CASE?
9/26/2023

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9/26/2023
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Todd M. Bishop, DVM, DACVIM (Neurology)
Board-Certified Veterinary Neurologist
UVS Co-owner
Recruiting member
Risk Management member
Neurology and Neurosurgery
------------------------------------------
Upstate Veterinary Specialties
152 Sparrowbush Road, Latham, NY 12110
T: 518.783.3198 | F: 518.783.3199
www.uvsonline.com

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