ECG of dog with abdominal pain. Is this relevant?

Re: ECG of dog with abdominal pain. Is this relevant?

Rob Loxley — Sat, 01 Sep 2012 18:32:12 GMT

[quote user="Jillian Hall"]The dog has gone for referral today to be assessed by far greater minds than mine[/quote]

Any update?: the suspense is too much!

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Fri, 31 Aug 2012 09:47:03 GMT

[quote user="Mike Martin"]

[quote user="Rajat"]human research seems to suggest they perform ablation in Atrial flutter[/quote]

Yes they do it, and in clinical cases, regularly. It will be viable in veterinary some day in the distant future. But at present it is still very early days, the skill level is not there yet. Edinburgh have ablated 14-15 cases, but these are single 'spot' ablations. A Flutter needs a continuous linear ablation that is very difficult to achieve, except in greatly experienced hands.

[/quote]

ahh I see makes sense Thanks!

Re: ECG of dog with abdominal pain. Is this relevant?

Mike Martin — Fri, 31 Aug 2012 09:03:02 GMT

[quote user="Rajat"]human research seems to suggest they perform ablation in Atrial flutter[/quote]

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Thu, 30 Aug 2012 23:09:19 GMT

Here is a full text version: http://www.rvc.ac.uk/Staff/Documents/dbrodbelt_thesis.pdf

Re: ECG of dog with abdominal pain. Is this relevant?

Anthony Todd — Thu, 30 Aug 2012 22:20:02 GMT

Thanks Michael

Re: ECG of dog with abdominal pain. Is this relevant?

Michael Woodhouse — Thu, 30 Aug 2012 21:03:52 GMT

[quote user="Anthony Todd"]Sorry, not disputing what you say, but have you got the reference please.[/quote]

There's a summary here and a full reference, but you'd have to pay for that

Linky

Re: ECG of dog with abdominal pain. Is this relevant?

Anthony Todd — Thu, 30 Aug 2012 19:58:53 GMT

[quote user="robloxley"]see David Broadbelt's work[/quote]

Sorry, not disputing what you say, but have you got the reference please.

[I'm just thinking of the percentage of blocked bladders that died at Penn. which is at variance with my experience]

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Thu, 30 Aug 2012 17:49:03 GMT

[quote user="robloxley"]As a proportion, neither all nor most (see David Broadbelt's work). Many healthy animals do die with anaesthetics, but the risk of anaesthetic mortality is significantly higher for unwell than well animals (same reference). [/quote]

Exactly! the risk is much much higher and this is borne out in several human studies where co morbidities and ASA score heavily influence the anaesthetic mortality rates. I'm not reluctant for e.g. with this one because it is sick but because I'd have wagered its probs were due to its heart, but then I'm not the person examining the dog etc so its just a relatively un informed opinion

Thanks Mike - interesting re ablation tho some of the human research seems to suggest they perform ablation in Atrial flutter though I didn't read up into it in much depth. I wonder what the difference is in dogs vs people length of tract to ablate etc...?

Best

Raj

Re: ECG of dog with abdominal pain. Is this relevant?

Rob Loxley — Thu, 30 Aug 2012 16:52:04 GMT

[quote user="Anthony Todd"]Would it be fair to say that most/all/many anaesthetic complications or deaths occur in young healthy animals having a routine procedure?[/quote]

As a proportion, neither all nor most (see David Broadbelt's work). Many healthy animals do die with anaesthetics, but the risk of anaesthetic mortality is significantly higher for unwell than well animals (same reference).

Re: ECG of dog with abdominal pain. Is this relevant?

Anthony Todd — Thu, 30 Aug 2012 14:58:08 GMT

[quote user="Mike Martin"]Anaesthesia Well I for one am always amazed at what can 'get through' GA. I sometimes agree that we are overly worried about GA in too many cases. There is very little I would not GA and probably a few I advise a degree of risk. If this dog turned out to need a laparotomy - then it needs it. [/quote]

Would it be fair to say that most/all/many anaesthetic complications or deaths occur in young healthy animals having a routine procedure?

Anyway, how's the dog doing? Did it finally pass my KFC corn cob?;-)?

Re: ECG of dog with abdominal pain. Is this relevant?

Mike Martin — Thu, 30 Aug 2012 14:34:58 GMT

[quote user="Rajat"]Atrial flutter- seems the sawtooth 'f' waves are typical for Aflutter which is faster whereas Atac is slower and doesnt have the sawtooth [/quote]

You found the answer, before I was back on here. I did struggle to understand your abbr 'Atac' which I've worked out means atrial tachycardia. A flutter can be clockwise or anticlockwise and one gives the sawtooth pattern but the other gives rapid 'P-like' deflections.

Yes, these are all types of Supraventricular tachycardias (SVTs). The common ones being: Macro-reentrant tachy (AVRT), focal atrial tachy (FAT) and atrial flutter. Technically AF is also an SVT, but since it is distinctive, it is classified on its own.

Anaesthesia Well I for one am always amazed at what can 'get through' GA. I sometimes agree that we are overly worried about GA in too many cases. There is very little I would not GA and probably a few I advise a degree of risk. If this dog turned out to need a laparotomy - then it needs it.

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Wed, 29 Aug 2012 23:28:45 GMT

IMHO, ex lap is a bit of a GA risk with his heart condition..I'd be hesitant to open him up at all without a screaming acute abdomen but that's just me, right or wrong, more often wrong than right

So I did some reading as I was embarassed not to have 'caught' the Atrial flutter- seems the sawtooth 'f' waves are typical for Aflutter which is faster whereas Atac is slower and doesnt have the sawtooth tho Aflutter can present without the sawtooth as well tho Atrial flutter is a form of atrial tachycardia.

(http://www.revespcardiol.org/en/revistas/revista-espa%C3%B1ola-cardiologia-25/clinical-approach-to-atrial-tachycardia-and-atrial-90113988-arritmias-2012)

And an ex lap doesn't allow us to look at his heart lol

Best

Raj

Re: ECG of dog with abdominal pain. Is this relevant?

Anthony Todd — Wed, 29 Aug 2012 22:43:02 GMT

[quote user="Jillian Hall"]He has only vomited once and had kept down food, passed faeces etc. all week[/quote]

Yes I must say, knowing that , it doesn't sound much like a FB but, if it had been,a week would be too long to wait and the complications, comparative cost and immediacy of an ex-lap, IMHO, outweigh the possible negative findings.

A quick ex-lap gives you virtually all the abdominal info. you'll ever get from lab tests and imaging. You take take biopsies if you're in doubt, and be certain that the moving corn cob stocking or penetrating FB won't come back and bite you.

Re: ECG of dog with abdominal pain. Is this relevant?

Jillian Hall — Wed, 29 Aug 2012 19:51:11 GMT

The dog has gone for referral today to be assessed by far greater minds than mine.

I think the FB theory is perfectly reasonable. And I had mentioned to the owner that if we really weren't able to find any other reason for his symptoms that an ex-lap would be an option. The only hesistancy was the complete lack of anything on the rads that in any way suggested an obstruction. We're talking no gas build up at all. And I did look several times. He had abdo rads ealier last week, which I repeated on Saturday, then did a Barium series on Sunday just to be absolutely sure. Abdo pain was always poorly localised. He has only vomited once and had kept down food, passed faeces etc. all week

I know on it's own none of that rules out a FB but fortunately there was enough of a gut feeling that it wasn't to hold off ex-lap long enough to pick up the arrythmia.

I'm glad that others think he was an odd case- I supected I was possibly being a bit thick wanting to post the ECG at all - but it's very reassuring to know that the explanations were not obvious. I feel a bit less thick now!

Re: ECG of dog with abdominal pain. Is this relevant?

Anthony Todd — Wed, 29 Aug 2012 14:13:07 GMT

[quote user="Jillian Hall"]This is a 5yo lab with sudden onset lethargy and reduced appetite 7dys duration. Initially vomiting but nothing for 6 days. Nothing on bloods, X-rays or scan but does seem diffusely painful on abdominal palp

[/quote]

Far be it for a dinosaur to enter this stratospheric discussion, let alone presume to comment , but the history of a lab. of any age vomiting then having a painful abdomen screams FB to me.

I wonder if the arrhythmia isn't secondary to electrolyte disturbance and not too significant in the diagnosis?

I have to suggest , having apologised for my crass intrusion, that my old colleague [MJV] and most of our generation, would have opened it up between consults and 99 times out of 100 have the moving obstruction out and the animal home that night.

Awaiting manure storm under large rock or sarcophagus.

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Wed, 29 Aug 2012 09:32:27 GMT

[quote user="Mike Martin"]Its atrial flutter with variable conduction. In the top tracing it looks like 2:1 conduction. In the rhythm strip there are blocked f waves[/quote]

Thanks Mike! Trying to getmy head around it (always tough to do for me with ecgs! ) , do the blocked f waves give you the diagnosis of flutter and would an Atac not show these if there were p waves that are not conducted?i.e. how do you differentiate the two?

thanks

Raj

Re: ECG of dog with abdominal pain. Is this relevant?

Mike Martin — Wed, 29 Aug 2012 09:03:41 GMT

Its atrial flutter with variable conduction. In the top tracing it looks like 2:1 conduction. In the rhythm strip there are blocked f waves.

The heart rate is dictated by the conduction rate. The heart rate is what effects BP and haemodynamics. If the heart rate is very fast (>250-300) then the dog will be compromised and the heart rate response needs slowing (controlling). I would also focus on the primary medical disease, however A flutter is often idiopathic and unrelated either medical or primary heart diseases. It can be very difficult to manage.

Ablation is very difficult and Edinburgh have not performed ablation in an A Flutter case. It requires a long line of ablation to block the pathway, so really very difficult. Hence drug control is the best way forward in dogs. If diltiazem is giving good control, stick with it.

Ideally a scan with a cardiologist is needed too. I'd suggest this rare and complicated case should go to a Specialist, if being referred.

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Mon, 27 Aug 2012 21:22:18 GMT

Cool , thanks.

Re: ECG of dog with abdominal pain. Is this relevant?

Jillian Hall — Mon, 27 Aug 2012 19:46:40 GMT

I'm not on duty today so have kept a bit of distance from work, but at last update he was fine. Unchanged. No dramatic response to diltiazem ( has had about 1.3mg/kg) with heart rate at 200 but will continue to monitor and nudge up the dose. Will do an echo and BP msmt in the morning ( I'm capable of picking up massive LA enlargement or pericardial dz on a scan but wouldn't trust myself on much else- as thoracic rads were unexciting I'm expecting more subtle pathology so I'll leave that to someone else. ) Electrolytes all WNL. Measured twice. Thanks guys! Will update tomorrow.

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Mon, 27 Aug 2012 19:01:31 GMT

[quote user="Christopher Saul"]

I'd third it too. I have seen vomiting secondary to signficant arrythmias too.

Raj is a cardiologist where I am not, so he might correct me on this but my theory is that arrythmias can cause wild fluctuations in blood pressure and hence fluctuations in perfusion of both the chemoreceptive trigger zone and the splancnic circulation, causing nausea.

[/quote]

I have no clue about the mechanism TBH! Chris you being a medic means you have far more general knowledge than us, I just remembered to keep an eye out for heart disease with abdo pain without abdo pathology that's all. I like your theory and cant think of anything better but did wonderre neural mechanisms - vagal/adrenergic on CRTZ from the tachycardia as a potential cause. Still like your theory better tho.

I think BP measurement is prob gonna be low yield, certainly no harm in it- yes if he is very hypertensive then phaeo may be likely, the dogs I have seen with phaeos are older than this, have Sinus tachycardia as the predominant rhythm and not Atac. Not to say it cannot cause it, I just cannot remember reading of a phaeo doing this. I'd put a tenner on this not being a phaeo (any takers have to bet now before we find out what it is!). Like Chris said it will affect BP and he will almost certainly be hypotensive during the arrhythmia.

Other things to consider running are electrolytes- hypokalemia and hypomagnasemia can predispose to tachyarrhythmias.

How is the dog today?

Best

Raj

Re: ECG of dog with abdominal pain. Is this relevant?

Christopher Saul — Mon, 27 Aug 2012 12:21:18 GMT

I'd third it too. I have seen vomiting secondary to signficant arrythmias too.

Also, Utlendigur may have hit upon somehting with the pheo theory, for the reasons I have outlined above. I would second measurement of BP - will add some information but not sure it will be diagnostic though because the arrythmia itself will influence blood pressure.

this patient really could do with an echocardiogram and ideally also a radiologist to ultrasound scan the abdo; Do you have any visiting imagers in your area???

Chris

Re: ECG of dog with abdominal pain. Is this relevant?

Utlendigur — Mon, 27 Aug 2012 11:06:50 GMT

Long shot but phaeochromocytoma??? Could you measure his BP (particularly during one of the episodes)?

I'd second the cardiac/abdo pain link having recently seen a 2yr old lab which presented with abdo pain and had vomited once - we xrayed for a FB (as you would with a 2yr lab) and found he had massive cardiomegally and turned out to have DCM

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Mon, 27 Aug 2012 08:16:59 GMT

Hi Jillian

If you have someone with cardio cert then referral 'may' not be needed asap- as you said he would benefit from an echo to start. Depending on what he has (as a mechanism for the arrhythmia) and where you are other therapies and diagnostics can be considered- holter monitor and 'zapping' of the abnormal circuit if it is appropriate (at Edinburgh). The main thing I guess is to start treatment and monitor response to it. Then we can figure out if he has underlying structural heart dzs.

Diltiazem kicks in pretty quickly - about 45 minutes for peak plasma levels in dogs with a short half life though, so it is definitely a TID drug. You may need to titrate the dose upwards to clinical response. SVTs usually require far higher doses around 2-3mg/kg TID and you can even go upto 4mg/kg TID.You don't HAVE to have the cont monitoring, just nice to see if the drug is working and whether you need to change the dose or drug and so on.

I'd have done the same as you i.e. investigate his abdomen for any potential badness but as nothing has been found I'd have attributed the previous symptoms to his cardiac disease. Could be wrong but thats how I'd play it

[quote user="Jillian Hall"]A direct resutls of being on call for too long I think.[/quote]

I know how you feel!!

Best

Raj

Re: ECG of dog with abdominal pain. Is this relevant?

Jillian Hall — Mon, 27 Aug 2012 07:46:08 GMT

Thanks very much for the advice.

I meant to type 'previous symptoms' not 'previous questions' above. A direct resutls of being on call for too long I think.

I've given him 20mg of Diltiazem this morning. No Sotalol available. Any thoughts on how long it's likely to take to kick in? Minutes, hours, days or weeks?

We have a cardio cert holder in the practice that can do echo on Tues. We dont have facilities for continuous ECG monitoring, just paper trace, so I'll discuss referring him anyway.

Thanks again

Jillian

Re: ECG of dog with abdominal pain. Is this relevant?

Rajat — Sun, 26 Aug 2012 23:51:51 GMT

[quote user="Jillian Hall"]A few mins after being back in kennel he started whimpering and puffing/ panting and was quiet again. Could whatever cardiac pathology is responsible for these arrythmias cause chest pains? [/quote]

If the atrial rate triggers a fast ventricular response you can get chest pains from it - do you have tog hooked upto a continuous ECG monitor to see if quietness/whimpering correlates to fast ventricular rates?

[quote user="Jillian Hall"]Also, this dog has been seen several times this week and HR measured several times (108 and 120) and no arrythmia mentioned[/quote]

The dog may not show clinical signs at normal heart rates. The paroxysmal nature of the problem means it can be absent on examination and come and go as you mentioned.

[quote user="Jillian Hall"]how does it fit w previous questions[/quote]

Sorry I am confused- do you mean previous questions as to whether this is significant? abdo/chest pain? yes to both if so.

[quote user="Jillian Hall"] The dog seems haemodynamically to be coping OK so haven't tried any meds yet[/quote]

I bet he is not coping when his ventricular rate is 300! Almost certainly will cause signs of low perfusion to organs including the heart. Persistent tachycardia will cause myocardial failure. I have seen a dog die from SVT, not sure how long it had been in it, history of one week before we saw him - first job, many years ago, about 2 months into the job! It wasn't my case but I was there when we did the ECG and then the dog died while an IV cath was being placed.

Things you can try - diltiazem and sotalol.

Best of luck!

Raj