Heatstroke.

RE: Heatstroke.

Aine Seavers — Mon, 26 Aug 2019 05:10:35 GMT

Glad you liked it Julie. I too am an older vet and the day I stop learning is the day I quit. Only a fool knows everything so I am a big believer in asking for help and then sharing it on. I have a large client post on our website-it has gotten over 1/4 million hits on Facebook and reproduced many times by CVE Sydney Uni. It is very much written to help clients not wrtitten as peer paper document level but it can help vets not used to daily heat stroke patient presentation and includes client aid posters and images vets can and do download and use in their clinics.-happy for anyone to use it if they wish. https://www.oakflatsvet.com.au/simple-affordable-ways-keep-pet-cool-safe-summer/ .Because of spam and bots, we had to turnn of comments on our website generally in case anyone thinks we deleted their comment.

RE: Heatstroke.

Julie Turner — Sun, 25 Aug 2019 19:45:04 GMT

Thank you so much Aisne, that’s brilliant advice..I have been betwixt and between over what to do with the (thankfully few) heatstrokes that I have encountered and thought that it was just me that was uninformed/(fill in your self-bruising comments here fellow vets)

It sounds like cooling by whatever means without closing down the peripheral circulation or stopping it closing down is the way to go. GA seems a good idea for the Brachycephalics due to the effort they use in breathing.

This was such a useful and (not meaning to demean the seriousness of it) comforting thread to an older but still learning vet..

RE: Heatstroke.

Anthony Todd — Fri, 09 Aug 2019 13:30:32 GMT

40.3 = 104.54

RE: Heatstroke.

Anthony Dennison — Fri, 09 Aug 2019 12:50:48 GMT

[quote user="Anthony Todd"]Any temperatures recorded? We are really short of this vital parameter when related to outcome![/quote]

Yes. 40.3degC on admit, then monitored every 30 minutes during cooling - actually overshot it a bit and dog became slightly hypothermic.

RE: Heatstroke.

Aine Seavers — Fri, 09 Aug 2019 12:10:44 GMT

Again, great questions-the nb is not the absolute value of the temp but the time spent at that temp so have had an obese Eng bulldog arrive at an RSPCA type millions paws walk-only 5mins from its home-but got so excited by the short car trip and all the dogs then waiting in line for vet check. It was winter's day-aroun 19C-My husband spotted it in line- walked down to it and grabbed it from owner and threw it holus bolus in the nearby lake (lake Illawarra-bigger than Lake Geneva) and the lovely site of the walk. The dog had gone limp just as he got there and woke up in the lake with a very wet vet holding it. Temp then was off the readable scale of any thermometer. He shouted at the owner to run her car air con-he r-eemreged from lake-put the wet dog on back seat and told her drive to our clinic-3 mins away where I had already headed- IWetook over in it in steel tub running cold water on axilla, groin and head (did not know about carotids then or ice) via nurse and i did cold water enema. Dog was fine within an hour. Have had others at 42c for 3 hours and they parboiled and died. Cats normally have to be old or hypert4 to even notice if amb temp > 38C so just don;t see heat distress in them.

Re Greyhounds-they race here-the greyhound vets doing great research and so some of the cooling collars etc being looked at on the back of the work done on ice baths and carotid ice packs in horses.

My advice-if you want info on heat stroke-don't use a reference before 2017-the knowledge base and advice before that is seriously out of date.

Treat all cases one by one-never give up until the animal does-and running water and avoiding cooling the pads more than the axilla or inguinal or carotids is your sweet zone.

Hope that helps

RE: Heatstroke.

Anthony Todd — Fri, 09 Aug 2019 11:00:58 GMT

[quote user="Aine Seavers"]Its a bit like doing a survey of FAD-heat stroke is as common as FAD so no need for trialling theories when up to date data there.[/quote]

All I want to know is some data on prognostic temperature against time after signs, so that there is some idea around when cases are presented in the UK this summer.

In the paper published above 105.8 seems to be mentioned but I don't think this is related to outcome or diagnostic confirmation?

BTW how hot do dogs [or greyhounds] get after prolonged exertion in hot weather?

I'd hate to see a dog PTS for simple exhaustion as the presenting signs could be similar and "heat stroke" seems a flavour of the month.

PS: Still haven't seen the defining rectal temperature to establish a diagnosis...... Surely it isn't just visual or owner descriptive?

RE: Heatstroke.

Aine Seavers — Fri, 09 Aug 2019 09:27:54 GMT

[quote user="Iain Richards"]Do OOH see more heatstroke mortality than local OOH? Just wondering about journey times[/quote]

Good question-what is the max distance/travel time you can have your A/H vet be away from your clinic?

In Oz a client can travel a long distance to get anywhwere which is why we nail the =how -to get here- rules so much when tne client rings in-which again is where the new rules on using ice have proven handy as easier to transport ice than water on a hot day.

RE: Heatstroke.

Aine Seavers — Fri, 09 Aug 2019 09:21:52 GMT

[quote user="Arlo Guthrie"]As far as this particular research goes, the first question is who would lead the research? Then finalise the research question. Would a grant be needed, I wonder (if so, for what?). Not sure how long the grant process takes, but if not needed, presumably we could crack on quite quickly ...[/quote]

Kinda reinventing the wheel here-given that most Australian and African and Some USA states vets will have done this all already-heat stroke is as much a general practice and specialist field and here in Oz it flows across both. All of your questions answered if you look at right places:-). Its a bit like doing a survey of FAD-heat stroke is as common as FAD so no need for trialling theories when up to date data there.

RE: Heatstroke.

Iain Richards — Fri, 09 Aug 2019 09:18:37 GMT

Do OOH see more heatstroke mortality than local OOH? Just wondering about journey times

RE: Heatstroke.

Aine Seavers — Fri, 09 Aug 2019 09:16:11 GMT

Ice is in since 2018. Carotids and inguinals and axilla-hit with cold/chilled water and keep it running.

We have home made tubular ice packs to fit into these areas as fasted to get cool.

FANS kill because owners too stupid to realise the dogs need to be wet for them to work -and so depend on fans-so be wary how you advise use of fans as should never be a stand alone sentence.

We get them in up to way beyond end of thermometer range and they survive if only short time at that temp but the 30-42s do fine even if longer.. Running water best. The Carotid cooling points in man and horse very interesting-some new work being done in greyhounds to see if the slight difference in anatomy is an issue.

The trick is not to let the owners kill them on way in-get cooling at home-get damp and put into already cooled air cond car or cooled with windows down moving-so many wrapped up and into hot car to come in that so much worse just doing that.

The emergency specialists vets here who see dozens in a week reckon shaving the dogs has a huge impact of better survival.

Do a post mortem on a dead one that arrives-it is very very errie-the hot air bursts out of the abdomen like a warm wind and then the whole site is dry-bloodless and quiet-with curled organs-sad to think of the pain that animal was in cooked alive.

I have often wondered about putting an air way vent in to get the hot air out of the abdomen as well as cold enema usual stuff

RE: Heatstroke.

Anthony Todd — Thu, 08 Aug 2019 19:02:06 GMT

[quote user="Anthony Dennison"]Yes, the one we put to sleep yesterday collapsed at 1pm but wasn't brought in until 7pm. The person caring for the dog said they had been using cold towels during the afternoon.[/quote]

Any temperatures recorded? We are really short of this vital parameter when related to outcome!

RE: Heatstroke.

Iain Richards — Mon, 05 Aug 2019 20:02:02 GMT

A conversation with a friend on this and they went for the KISS approach - it's hot, so cool it with water and support CVS. And as Ian says, if most survive, the actual treatments probably don't matter. A further point was that if there was to be practice based research, we'd not want the protocol to delay treatment. It woudl be unethical to have an untreated group for a control trial too.

So a literature review would be a sensible start point. Perhaps also trying to recruit practice data

RE: Heatstroke.

David Mills — Mon, 05 Aug 2019 19:30:54 GMT

[quote user="Arlo Guthrie"]Very, very interesting David Mills, and again, I think there is potential for VS to facilitate first-opinion research. Time for another pint?![/quote]

If you're buying again, sure. But yes, of course.

I agree with Ian that this does end up in a lot of talk. It may be worth doing a small retrospective study on this to try and identify trends and the most promising treatment groups. I'm happy to collate ours and upload these, to VSurgeon, or Google document, or wherever. Are there any others out there with the time and inclination to do similar? I'd say we need about 30-40 cases It would be perfect for a BSAVA clinical research abstract, whose submission is coming round again. Arlo, time permitting, is there a role for you here to create a group (on here or email) so we can get the ball rolling?

RE: Heatstroke.

Anthony Todd — Mon, 05 Aug 2019 10:23:14 GMT

[quote user="Arlo Guthrie"]we could crack on quite quickly ...[/quote]

Not if we are going to make it sound like a BBC project meeting, about the colour of their tea cups, and take as long.....

Is the KISS protocol still alive and valid?

Not here I suspect.

PS: In the comprehensive paper with the summary quoted above there is no mention of how the diagnosis is established that I can see??

Would have thought it was easy and obvious ie "An animal presented with a temperature above x degrees with a history only of exposure to a localised environmental heat source"?

RE: Heatstroke.

Arlo Guthrie — Mon, 05 Aug 2019 09:07:23 GMT

[quote user="Ian Ramsey"]

An example question might be:-

What factors (such as body weight etc.) affect any significant difference between two methods of treatment of hyperthermia of dogs weighing less than 40kg when using time taken for rectal temperature to decline to normal as the primary outcome marker? These two methods would be (I suggest but no expert) immersion in cool water (from cold tap, no ice) when compared to those sprayed with water for 2 minutes and then placed near a fan blowing at 200 rpm.

*All dogs to get IV fluids at presentation at 3 x maintenance. No dogs to get bladder irrigation or enemas. If the attending clinician wishes to do this differently then this has to be recorded in the study records. These cases may be withdrawn from the study or may be included.

The aim would be to take 2 methods that are likely to work and ask which is better.

I am sure there are a lot more things that people could think about and would add to this protocol but I think the first step is to see if anyone is interested ? Or is it just something that is discussed online but without a result? [/quote]

Hi Ian Ramsey - I'd be confident (very) that we could recruit enough participants via VetSurgeon to make this work

(especially if ...

[quote user="Anthony Todd"]Arlo could offer 2 weeks. for the whole practice, including upgraded flights, in Los Vegas for the highest survival temperature recorded.................[/quote])

[quote user="David Mills"]As a passionate believer (indeed my PhD thesis will go in strongly on this point) of first opinion based research (97% of vets!) this would be something I would be interested in, absolutely, but for this kind of presentation, maybe not. [/quote]

Very, very interesting David Mills, and again, I think there is potential for VS to facilitate first-opinion research. Time for another pint?!

[quote user="Ian Ramsey"]A communal document that people can work on is one way to get buy in and more ideas to come out. Google Drive?[/quote]

We can create communal working documents here on VS too.

As far as this particular research goes, the first question is who would lead the research? Then finalise the research question. Would a grant be needed, I wonder (if so, for what?). Not sure how long the grant process takes, but if not needed, presumably we could crack on quite quickly ...

RE: Heatstroke.

Anthony Todd — Sun, 04 Aug 2019 11:18:46 GMT

[quote user="Ian Ramsey"]So, from the point of view of any study into hyperthermic dogs, I would suggest either TM thermometers are used or normal rectal thermometers used [/quote]

I was imagining that a dog or cat would be pretty flat so not object to anything much, making a rectal thermometer placement easy and the readings repeatable and accurate for prognosis and treatment monitoring.

The important thing is to get useful data easily cheaply and quickly!

Could have a fair bit on here by September?

RE: Heatstroke.

Ian Ramsey — Sun, 04 Aug 2019 10:49:28 GMT

[quote user="Anthony Todd"]

I realise that, but rectal transmitting thermometers are expensive and require other electronics as far as I can see.

The bare skin in a collapsed dog's inguinal area may be good; who knows unless it's tried?

[/quote]

When it comes to measuring body temperature I hope I can perhaps help a little as colleagues of mine have done some studies at Glasgow on this (who says clinical academic research can’t also be practical?) (Ref 6 and 10). I am not aware of any studies looking specifically at inguinal temperatures but (with no evidence than common sense) it is unlikely that results would be different from axillary. The great advantage of axillary temperatures is of course that you can use standard rectal thermometers. The other alternative is auricular (also known as tympanic membrane, TM) temperatures but these need to be measured using specific thermometers which use pyroelectric sensors to measure infrared radiation emanating from the tympanic membrane (TM). Corneal detectors have been tried but were not a success in the initial study.

There have been several studies examining the validity of measuring axillary and TM temperatures as an alternative to rectal temperatures (which have been shown to be pretty reliable indicators of core body temperature when using things like oesophageal thermometers as gold standard) ^1-11. Axillary temperatures are well tolerated by animals but may be less reliable than rectal temperatures in overweight dogs and those with thick coats ^1,2,6. Although the various studies have produced conflicting results, most authors agree that axillary temperatures should not be used interchangeably with rectal temperatures. If a hyperthermic dog was being rapidly cooled then the axillary temperature may well fall before the rectal temperature and therefore I would suggest this would not be a good idea.

If rectal temperature measurement is not possible in dogs, then TM temperature is usually recommended over axillary temperature as it is better tolerated and significantly fewer dogs have clinically unacceptable differences of more than 0.5°C (0.9°F) ⁶. Dedicated auricular thermometers are also quicker and better tolerated than rectal thermometers. However, they show greater variability between repeated measurements than rectal temperatures ^5-7.^.

Incidentally, when rectal temperature measurement is not possible in cats, then axillary temperature is recommended over TM temperature as it is better tolerated and significantly fewer cats have clinically unacceptable differences of more than 0.5°C (0.9°F) ^8,10.

So, we try to teach our students to use axillary temperatures in aggressive cats or those with rectal disease but in dogs that cannot have a rectal temperature taken to use a TM thermometer if available (which I confess we do not have even in our clinic! - note to self, must get one for demonstration purposes at least).

So, from the point of view of any study into hyperthermic dogs, I would suggest either TM thermometers are used or normal rectal thermometers used - in both cases every X minutes (X = 5 ?) - presumably this would be within the bounds of normal clinical practice and therefore would be under the VSA rather than A(SP)A?

Best wishes

Ian

PS I should explain that I did not write this all for this post! It haas been adapted from the Fever chapter in the most recent Ettinger, which I co-wrote with Severine Tasker. There have been a couple of more recent studies* but on reading the abstracts they don't seem to have altered the underlying message.

1. Goic JB, Reineke EL, Drobatz KJ. Comparison of rectal and axillary temperatures in dogs and cats. J Am Vet Med Assoc 2014;244:1170-1175.

2. Gomart SB, Allerton FJ, Gommeren K. Accuracy of different temperature reading techniques and associated stress response in hospitalized dogs. Journal of veterinary emergency and critical care 2014;24:279-285.

3. Greer RJ, Cohn LA, Dodam JR, et al. Comparison of three methods of temperature measurement in hypothermic, euthermic, and hyperthermic dogs. J Am Vet Med Assoc 2007;230:1841-1848.

4. Konietschke U, Kruse BD, Muller R, et al. Comparison of auricular and rectal temperature measurement in normothermic, hypothermic, and hyperthermic dogs. Tierarztl Prax Ausg K Kleintiere Heimtiere 2014;42:13-19.

5. Kunkle GA, Nicklin CF, Sullivan-Tamboe DL. Comparison of body temperature in cats using a veterinary infrared thermometer and a digital rectal thermometer. J Am Anim Hosp Assoc 2004;40:42-46.

6. Lamb V, McBrearty AR. Comparison of rectal, tympanic membrane and axillary temperature measurement methods in dogs. The Veterinary record 2013;173:524.

7. Sousa MG, Carareto R, Pereira-Junior VA, et al. Comparison between auricular and standard rectal thermometers for the measurement of body temperature in dogs. The Canadian veterinary journal La revue veterinaire canadienne Can Vet J 2011;52:403-406.

8. Sousa MG, Carareto R, Pereira-Junior VA, et al. Agreement between auricular and rectal measurements of body temperature in healthy cats. J Feline Med Surg 2013;15:275-279.

9. Southward ES, Mann, F.A., Dodam, J. A comparison of auricular, rectal and pulmonary artery thermometry in dogs with anesthesia-induced hypothermia. J Vet Emerg Crit Care 2006;16:172-175.

10. Smith VA, Lamb V, McBrearty AR. Comparison of axillary, tympanic membrane and rectal temperature measurement in cats. Journal of Feline Medicine and Surgery 2015;17:1028-1034.

11. Robinson JL. Body temperature measurement in paediatrics: Which gadget should we believe? Paediatr Child Health 2004;9:457-459.

* Recent studies

Agreement of Axillary and Auricular Temperature with Rectal Temperature in Systemically Healthy Dogs Undergoing Surgery.

Cichocki B, Dugat D, Payton M.

J Am Anim Hosp Assoc. 2017 Nov/Dec;53(6):291-296. doi: 10.5326/JAAHA-MS-6500. Epub 2017 Sep 11.

Comparison of axillary and rectal temperatures for healthy Beagles in a temperature- and humidity-controlled environment.

Mathis JC, Campbell VL.

Am J Vet Res. 2015 Jul;76(7):632-6. doi: 10.2460/ajvr.76.7.632.

RE: Heatstroke.

Anthony Todd — Sat, 03 Aug 2019 08:15:13 GMT

[quote user="Anthony Dennison"]Bit more complicated than that Tony - too many variables could make it more difficult to record and compare.[/quote]

The diagnosis and treatment is in the name isn't it. and is a "high body temperature"........????

[quote user="Anthony Dennison"]dog's groin wouldn't be as accurate.[/quote]

I realise that, but rectal transmitting thermometers are expensive and require other electronics as far as I can see.

The bare skin in a collapsed dog's inguinal area may be good; who knows unless it's tried?

It may be, with time-based recording we will know which methods of cooling work quickest and best.

[quote user="Anthony Dennison"]A competition based on us doing our job. I can imagine there is a better use of money.[/quote]

[sigh] Jeepers, that was my very obvious attempt at humour, or so I thought!!

The important thing is to get data somehow, so treatment and survival rates will improve!!

RE: Heatstroke.

Anthony Dennison — Fri, 02 Aug 2019 15:33:39 GMT

[quote user="Anthony Todd"]

[quote user="Anthony Dennison"]One of the measurements that needs to be taken yes (and is always taken in suspected heat stroke cases) - would likely be used a an entry criteria for the case in to the study.[/quote]

Eureka, should be so easy this summer!

Could even record time to normal with various cooling regimes and outcomes?

Ball-park anecdotes are much better than nothing!!

Anyone got a plug into a computer [or] phone?] rectal thermometer??

[/quote]

Bit more complicated than that Tony - too many variables could make it more difficult to record and compare.

[quote user="Anthony Todd"]PS lots of cheap recorders for babie on eBay ; could go in the dog's groin; records to phone, it seems.[/quote]

You've just said rectal temp was important, dog's groin wouldn't be as accurate.

[quote user="Anthony Todd"]Arlo could offer 2 weeks. for the whole practice, including upgraded flights, in Los Vegas for the highest survival temperature recorded.................[/quote]

A competition based on us doing our job. I can imagine there is a better use of money.

RE: Heatstroke.

Anthony Todd — Fri, 02 Aug 2019 15:12:04 GMT

Eureka, should be so easy this summer!

Could even record time to normal with various cooling regimes and outcomes?

Ball-park anecdotes are much better than nothing!!

Anyone got a plug into a computer [or] phone?] rectal thermometer??

Arlo could offer 2 weeks. for the whole practice, including upgraded flights, in Los Vegas for the highest survival temperature recorded.................

PS lots of cheap recorders for babie on eBay ; could go in the dog's groin; records to phone, it seems.

RE: Heatstroke.

Anthony Dennison — Fri, 02 Aug 2019 13:35:02 GMT

[quote user="Anthony Todd"]

Surely rectal temp. on admission should be the most important parameter?

Instant, [after a minute] easy anywhere and cheap.....

Probably critical for prognosis and the data should be easy to amass?

[/quote]

One of the measurements that needs to be taken yes (and is always taken in suspected heat stroke cases) - would likely be used a an entry criteria for the case in to the study.

Could this be something we could work through Vetsurgeon.org? Is it possible to apply for a PetSaver grant centrally and then allocate funds as seen fit or does it have to be used solely by the applicant? I would imagine as a community we could gather a lot more data than just a single person.

Possibly could make it retrospective but that does always introduce bias.

RE: Heatstroke.

Beats — Fri, 02 Aug 2019 10:41:15 GMT

[quote user="Ian Ramsey"] to accept an aspect of randomisation[/quote]

I always believed, perhaps erroneously, that randominsation pushed one into the auspices of the Animal (Scientific Procedures) Act in the UK, thus leading to the need for a Home Office license, at least technically?

RE: Heatstroke.

Anthony Todd — Fri, 02 Aug 2019 08:57:19 GMT

Surely rectal temp. on admission should be the most important parameter?

Instant, [after a minute] easy anywhere and cheap.....

Probably critical for prognosis and the data should be easy to amass?

RE: Heatstroke.

Iain Richards — Fri, 02 Aug 2019 06:43:06 GMT

I'd suggest any dog entered into the project should have bloods taken, even if not immediately analysed. There may be a specific marker for prognosis

RE: Heatstroke.

Ian Ramsey — Thu, 01 Aug 2019 16:32:10 GMT

Dear all

Had put a bit of thought into this in conversation with Ian Richards and it seems timely to put down on paper. I am no expert in heatstroke or critical care but have done quite a few clinical research projects, some good - some, TBH, not so much.

The first stage would be to do a literature review. Important to try to avoid repeating previous studies unless there is some reason and to make sure what is known vs what is opinion.

Secondly decide the question - it has to be specific, answerable, achievable and relevant. We cannot investigate everything but rather we want to compare 2 groups that are similar as far as possible except for the different intervention.

Thirdly decide the measurement methods. From what I have seen written on this forum so far that death is too uncommon in the UK to be a useful outcome measure. So perhaps the time to achieve normal rectal temperature and (or?) normal creatinine and potassium could be the primary measure? I think there are some markers as well that might be useful as secondary measures (e.g other routine blood values, acute phase proteins) but these would be identified from the literature review.

Fourthly decide what factors are going to be allowed - for example body weight, breed, coat length, coat density (e.g. scored on an agreed 0, 1, 2 scale) age, time from first signs to admission (or time dog last seen to be normal), rectal temperature on admission.

Then decide how many cases are needed - this will depend on the question, information from the literature review and may need some help from a stats person (also useful to review study design).

Finally write a protocol (including the random allocation to treatment groups) and we approach a relevant ethics committee. This requires a careful choice of words and it is important that nothing is done that would not be done to the animal anyway. Having got this then practices will need to be recruited. They have to agree to follow the protocol!

When we have all of this then the grant application can be written and hopefully get the money to do the study. Grants will cover things like rectal probes, additional tests and in some cases paying for the statistical help. Grants rarely cover the investigators time

An example question might be:-

The aim would be to take 2 methods that are likely to work and ask which is better.

A communal document that people can work on is one way to get buy in and more ideas to come out. Google Drive?

Hope this helps

Ian