Hypokalaemia and hypoglycaemia in collapsed cat with shock

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Thu, 04 Dec 2014 16:12:13 GMT

[quote user="Kate Richardson"]Except this case was hypoglycaemic.[/quote]

Oh dear, it gets more complicated by the day! [I thought I was definitely right!!!]

With regard to hypoglycemia, the condition can mimic acute stroke or symptoms of transient ischemic attack (TIA).^{[2, 3, 4]}

and

Symptoms caused by hypoglycemia can occur suddenly and fluctuate, suggesting a vascular etiology.

from

http://emedicine.medscape.com/article/1162340-overview

But I was criticised for extrapolating from humans to cats so I can ignore this......

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Dennison — Thu, 04 Dec 2014 15:32:58 GMT

[quote user="Kate Richardson"]Except this case was hypoglycaemic. But yes you can get severe hypokalaemia in cats with DKA; Last few I remember had only mild hypokalaemia on presentation, however you can assume they are whole body depleted and insulin therapy will lower it further, hence the need to really supplement the iv fluids well with potassium, higher than you would usually use for the level of hypokalaemia seen initially.[/quote]

Interesting, I thought the hypokalaemia would correct itself once you corrected the acidosis with fluids and started insulin therapy? Vague memories of being told not to supplement potassium. Though I might have that mixed up with bicarb...

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Thu, 04 Dec 2014 00:09:17 GMT

[quote user="Evelyn Barbour-Hill"]I'd be very surprised if people are not always scanned (assuming the facility is available of course).[/quote]

It sounds as if they are:

Even if the physical symptoms of a stroke are obvious, brain scans should also be carried out to determine:

if the stroke has been caused by a blocked artery (ischaemic stroke) or burst blood vessel (haemorrhagic stroke)
which part of the brain has been affected
how severe the stroke is

and

Everyone with suspected stroke should receive a brain scan within 24 hours and some people should be scanned within an hour of the onset of symptoms, especially those who:

might benefit from clot-busting drugs (thrombolysis) such as alteplase or early anticoagulant treatment
are already on anticoagulant treatments
have a lower level of consciousness

from

http://www.nhs.uk/Conditions/Stroke/Pages/Diagnosis.aspx

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Glen McIntosh — Wed, 03 Dec 2014 21:40:17 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Anthony Todd"]

[quote user="Laura Kidd"]I think like people, the only way to confirm stroke vs bleed vs tumour etc. is MRI ( or PM)[/quote]

Do they always scan people or do they diagnose it on clinical examination and sudden onset?

[/quote]

I'd be very surprised if people are not always scanned (assuming the facility is available of course).

[/quote]

Yeah, I reckon would be essential to get a definative diagnosis in people since ischaemic stroke would be treated with thrombolytics - and that is a treatment you definately would not want to give in a haemorrhagic stroke case.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Laura Kidd — Wed, 03 Dec 2014 18:17:12 GMT

I believe where possible an MRI would be performed as best diagnostic option. CT is quicker though so really depends on how soon at hospital and presumably who else may be using the MRI!

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Evelyn Barbour-Hill — Wed, 03 Dec 2014 15:06:08 GMT

[quote user="Anthony Todd"]

[quote user="Laura Kidd"]I think like people, the only way to confirm stroke vs bleed vs tumour etc. is MRI ( or PM)[/quote]

Do they always scan people or do they diagnose it on clinical examination and sudden onset?

[/quote]

I'd be very surprised if people are not always scanned (assuming the facility is available of course).

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Thomas Johnson — Wed, 03 Dec 2014 14:55:47 GMT

[quote user="Kate Richardson"]

Re vestibular= stroke, do we have any further information on what causes idiopathic vestibular syndrome? Do we know if it could potentially be caused by a cerebrovascular incident? In other words, could it actually be a 'stroke'? (Just in case you ask, I don't diagnose it as a stroke, I call it what it is!)

[/quote]

As far as I am aware idiopathic vestibular syndrome is a peripheral disease, so wouldn't be caused by any brain event.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Wed, 03 Dec 2014 14:55:41 GMT

[quote user="Laura Kidd"]I think like people, the only way to confirm stroke vs bleed vs tumour etc. is MRI ( or PM)[/quote]

Do they always scan people or do they diagnose it on clinical examination and sudden onset?

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Thomas Johnson — Wed, 03 Dec 2014 14:30:46 GMT

[quote user="Kate Richardson"]

[/quote]

My understanding is that the clinical signs in idiopathic vestibular syndrome are peripheral rather than central, so very unlikely to be caused by any sort of brain event.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Laura Kidd — Wed, 03 Dec 2014 14:15:43 GMT

I think like people, the only way to confirm stroke vs bleed vs tumour etc. is MRI ( or PM)

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Wed, 03 Dec 2014 14:10:06 GMT

[quote user="Robin Grimmer"]I don't think you can quote a paper on human stroke victims and compare it with cats. As others have said, whether strokes occur in small animals is debatable as they don't get atherosclerosis.[/quote]

They may get bleeds though?

We still haven't had a positive diagnosis, apart from the clinical signs which seem only to suggest a "stroke" or at least some sort of catastrophic brain event

I don't see why the cat's brain would be so different from humans in this scenario?

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Wed, 03 Dec 2014 14:06:17 GMT

[quote user="glen mcintosh"]

[quote user="Anthony Todd"]Glen went on to comment on the cause of stroke as only being caused by a thrombus and didn't mention a bleed, also a cause of stroke in humans.[/quote]

Actually, no I didn't, I said:

[/quote]

Sorry misread what you said, meant someone else..

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Kate Richardson — Wed, 03 Dec 2014 12:51:38 GMT

[quote user="Thomas Johnson"]

[quote user="Katie Blackburn"]

Started on warmed shock doses of hartmanns, in incubator on heat pad etc. Bloods show hypokalaemia at 1.2 and hypoglycaemia at 2.3. K+ added to CRI and IV glucose given

[/quote]

I've been doing a little bit of reading in Small Animal Internal Medicine (Nelson and Couto), and was wondering if the hypokalaemia could be secondary to diabetic ketoacidosis, and apparently hypokalaemia can cause an acute hepatic encephalopathy due to increased renal ammonia production.

[/quote]

Except this case was hypoglycaemic. But yes you can get severe hypokalaemia in cats with DKA; Last few I remember had only mild hypokalaemia on presentation, however you can assume they are whole body depleted and insulin therapy will lower it further, hence the need to really supplement the iv fluids well with potassium, higher than you would usually use for the level of hypokalaemia seen initially.

I test a lot of cats potassium levels, and I have only ever seen it that low in Conns cats, or hypokalaemic myopathy cats. So I still strongly suspect Conns in this case with a 'stroke/cerebrovascular/hypertension CNS lesion. I have always poo pooed the idea that animals have strokes, but over the last 10 years since becoming much aware of hypertension related pathology, I feel it is a valid 'diagnosis', however, as others have said, imaging is necessary to definitively diagnose.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Robin Grimmer — Wed, 03 Dec 2014 12:08:34 GMT

I[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]

How would a 'stroke' have caused the low potassium? Isn't a stroke what you tell the owners when you haven't got a clue what's wrong with it?

[/quote]

I don't know ,but see the link I posted previously in which low potassium was linked to a poor prognosis after a stroke, and this among lots of links:

http://www.ncbi.nlm.nih.gov/pubmed/9400554

And cherry picking again:

CONCLUSIONS:

Hypokalemia post stroke is common and may be associated with a poor outcome.

Nobody seems to be able to tell me how to diagnose a stroke positively in a cat anyway, apart from the history and looking at the cat.?

For once, just because there isn't a blood or any other test doesn't mean you can't make a diagnosis....

[/quote]

[quote user="Anthony Todd"]

[quote user="Robin Grimmer"]

How would a 'stroke' have caused the low potassium? Isn't a stroke what you tell the owners when you haven't got a clue what's wrong with it?

[/quote]

I don't know ,but see the link I posted previously in which low potassium was linked to a poor prognosis after a stroke, and this among lots of links:

http://www.ncbi.nlm.nih.gov/pubmed/9400554

And cherry picking again:

CONCLUSIONS:

Hypokalemia post stroke is common and may be associated with a poor outcome.

Nobody seems to be able to tell me how to diagnose a stroke positively in a cat anyway, apart from the history and looking at the cat.?

For once, just because there isn't a blood or any other test doesn't mean you can't make a diagnosis....

[/quote]

I don't think you can quote a paper on human stroke victims and compare it with cats. As others have said, whether strokes occur in small animals is debatable as they don't get atherosclerosis.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Dennison — Wed, 03 Dec 2014 11:01:03 GMT

[quote user="glen mcintosh"]One thing that does bug me is clinicians who diagnose vestibular syndrome as stroke. You don't need an MRI to recognise vestibular syndrome because the signs are so classic (although you probably need one to definitively diagnose the underlying cause), so there is no excuse for clinicians who label that condition as a stroke, since it is well accepted that in the vast majority of cases "stroke" is not the cause.[/quote]

With you on that one!

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Glen McIntosh — Wed, 03 Dec 2014 10:32:42 GMT

[quote user="Anthony Todd"]Glen went on to comment on the cause of stroke as only being caused by a thrombus and didn't mention a bleed, also a cause of stroke in humans.[/quote]

Actually, no I didn't, I said:

[quote user="glen mcintosh"]Strokes are also known as CVA's - cerebrovascular accidents, and are classified as either ischaemic or heamorrhagic.[/quote]

and:

[quote user="glen mcintosh"]

But strokes occur for reasons other than artherosclerosis.

For example - haemorrhagic strokes are unrelated to artherosclerosis, and the same causes of this that occur in people also occur in cats and dogs.

[/quote]

Haemorrhagic stroke = bleed.

My point was that strokes occur in dogs and cats, including bleeds, but just not as a result of the most common cause of strokes in people - atherosclerosis. Strokes are therefore much less common in dogs and cats compared to people, but they do occur. I would guess that they probably occur with about the same frequency in dogs and cats as they do in people if you exclude strokes caused by atherosclerosis in people.

[quote user="Evelyn Barbour-Hill"]I can't think of any way to diagnose it positively without a CT scan (or do I mean MRI scan?)[/quote]

I think you mean MRI and I agree that that is really the only way to diagnose "stroke" definitively, antemortem.

It is a difficult diagnosis to confirm in veterinary medicine. Because people do complex things like speak and play the piano, the more subtle signs of stroke in people are jumped on quickly by our medical colleagues, and so investigations like MRI are done much more frequently. It is often very difficult to get a 17 year old cat with severe clinical signs even as far as blood tests, let alone MRI, so advanced investigations are much less common in animals and so definitive diagnosis of stroke is much less common.

Death is also a relatively common sequele of stroke. Unlike the case with people, it is much less common for unexplained death cases in cats and dogs to go to post mortem, and so, again, the diagnosis is often not definatively confirmed.

[quote user="Robin Grimmer"]Isn't a stroke what you tell the owners when you haven't got a clue what's wrong with it?[/quote]

Yes, I am definitely guilty of that. It is a bit like spider bite in Australia, which one of my early bosses referred to as "the last refuge of the diagnostically destitute."

I have no issue with "stroke" being included in a list of possible differentials, but to say that a particular case is a "stroke" to the exclusion of all other possibilities just from clinical examination and blood tests is bad medicine.

One thing that does bug me is clinicians who diagnose vestibular syndrome as stroke. You don't need an MRI to recognise vestibular syndrome because the signs are so classic (although you probably need one to definitively diagnose the underlying cause), so there is no excuse for clinicians who label that condition as a stroke, since it is well accepted that in the vast majority of cases "stroke" is not the cause.

Having said that, one of the MRI definitively diagnosed stroke cases that I have seen presented with classic vestibular syndrome symptoms.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Dennison — Wed, 03 Dec 2014 10:09:58 GMT

[quote user="Evelyn Barbour-Hill"]I can't think of any way to diagnose it positively without a CT scan (or do I mean MRI scan?)[/quote]

I would think it would probably be an MRI scan for a bleed within the tissue, think it is more sensitive? You could still get a lot of information from a CT scan though.

But yes, only way to definitively diagnose a stroke is with advanced imaging. Which is why I made the comment about unknown cause of neurological symptoms being blamed on a 'stroke' when there are many other things it could be.

Anthony, I accept your point about the hypokalaemia, but there are also many things that could have caused this too.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Thomas Johnson — Wed, 03 Dec 2014 10:05:49 GMT

[quote user="Katie Blackburn"]

Started on warmed shock doses of hartmanns, in incubator on heat pad etc. Bloods show hypokalaemia at 1.2 and hypoglycaemia at 2.3. K+ added to CRI and IV glucose given

[/quote]

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Tue, 02 Dec 2014 23:41:26 GMT

[quote user="Evelyn Barbour-Hill"]Well, in humans a bleed has considerably worse results and it matters a lot.[/quote]

Oh dear, I meant, as far as the owner, the cat and the prognosis, it doesn't matter.

In humans you are quite right according to this link which seems to be pretty comprehensive.

http://www.uhnj.org/stroke/types.htm

But how do we tell the difference in a cat already showing major signs?

It may be worth checking the blood pressure as high BP seems to be associated with bleeds rather than clots.

http://www.mayoclinic.org/diseases-conditions/stroke/diagnosis-treatment/diagnosis/dxc-20117291

seems to give most of the human techniques and tests and CT or MRI seems to be needed.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Evelyn Barbour-Hill — Tue, 02 Dec 2014 23:33:47 GMT

[quote user="Anthony Todd"]Nobody seems to be able to tell me how to diagnose a stroke positively in a cat anyway apart from the history and looking at the cat.anyway?[/quote]

I can't think of any way to diagnose it positively without a CT scan (or do I mean MRI scan?)

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Tue, 02 Dec 2014 23:30:00 GMT

[quote user="Robin Grimmer"]

How would a 'stroke' have caused the low potassium? Isn't a stroke what you tell the owners when you haven't got a clue what's wrong with it?

[/quote]

I don't know ,but see the link I posted previously in which low potassium was linked to a poor prognosis after a stroke, and this among lots of links:

http://www.ncbi.nlm.nih.gov/pubmed/9400554

And cherry picking again:

CONCLUSIONS:

Hypokalemia post stroke is common and may be associated with a poor outcome.

Nobody seems to be able to tell me how to diagnose a stroke positively in a cat anyway, apart from the history and looking at the cat.?

For once, just because there isn't a blood or any other test doesn't mean you can't make a diagnosis....

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Evelyn Barbour-Hill — Tue, 02 Dec 2014 23:23:41 GMT

[quote user="Anthony Todd"]

[quote user="tess"]Ok maybe I'm being a bit thick here, but I thought that in humans a stroke was caused by a blood clot on the brain causing a localised hypoxia to brain tissue.[/quote]

Or a bleed, same result: either or, but does it matter?

[/quote]

Well, in humans a bleed has considerably worse results and it matters a lot.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Robin Grimmer — Tue, 02 Dec 2014 23:13:44 GMT

How would a 'stroke' have caused the low potassium? Isn't a stroke what you tell the owners when you haven't got a clue what's wrong with it?

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

Anthony Todd — Tue, 02 Dec 2014 19:18:55 GMT

[quote user="tess"]Ok maybe I'm being a bit thick here, but I thought that in humans a stroke was caused by a blood clot on the brain causing a localised hypoxia to brain tissue.[/quote]

Or a bleed, same result: either or, but does it matter?

Still waiting for alternative diagnoses since GME has been kicked into the long grass, IMHO.

Re: Hypokalaemia and hypoglycaemia in collapsed cat with shock

tess — Tue, 02 Dec 2014 19:10:03 GMT

Hit reply too soon! The low K could have caused such muscle damage that reflexes were affected.