Sunday, 3 January 2010

Uncharted Waters

I was reading Trauma Queen blog and his comment about fitting in a patient (although it was more complex than that and fitting was only a part of it) reminded me of some of the cases l have been involved with.

One of the ones that sticks in my mind was the 2 Labradors (not the real breed) that came in both fitting. You do not get that unless they have access to toxins but the owners swore blind they did not.
We pinned the dogs and got iv catheters in and a hopeful bolus of diazemuls/weight to stop the fitting.
They bolus did nothing so a second then a third followed. This stopped them for about one minute and they started again, going by that the dogs were in deep trouble and would need stronger drugs.

The first test on a simple glucometer with the blood from the catheter stylet drew paydirt part one, they had almost no blood sugar in them. We drew up a “hit” of glucose and put it into them.

The fitting continued and we tried another cocktail of anticonvulsants this slowed them for a couple of minutes but they still twitched. A quick ear prick to check glucose and it was 1. That was crazy it should have been climbing upwards. I called the results over to vet who was gazing at the drugs wondering which he should do and his cussing matched mine.

The vet got me to double the glucose bolus and went to speak to the owners. Coming back with the info the owner was a diabetic on insulin tablet control but swore blind he had all his tablets. The most likely case was he had miscounted in a panic at the dogs fitting, there was no blame as there shouldn’t be in accidental cases, they are that accidents. Ultimately reasons didn’t matter. The 2 dogs were in deep trouble and uncharted waters.

The vet went for the big guns. He set up 2 Propofol infusions using a high dose glucose drip (extra glucose added to a glucose saline drip). Propofol is a drug that looks like milk and used in humans and animals to induce anaesthesia. If you have had a general anaesthetic and the Dr looked like he was about to inject milk, he was probably using Propofol.

Being mixed into a drip and going into the patient at a set rate sends patients into a deep anaesthetic and stops the fitting. The time the patient is under varies on the condition the main criteria being “the shortest possible time” for the problem to resolve.
The patient is allowed to wake up slowly over a period and is observed to see that the fitting has stopped. If it hasn’t or starts again and is not controllable with other drugs they are once again seen into a deep sleep.

The 2 dogs continued to fit so we pumped more and more glucose into them. The magic barrier was 2.5 on the glucose scale. Not for any reason other than it was higher than we seemed able to get and hold them. They would get to 2 and within minutes they would slide back again towards 0.7.

With each glucose bolus “hit” the fitting would slow down to a twitch then within 5 minutes would start to fit. Without the Propofol control they were totally out of control. The longer (and harder) they fitted the more chance their brains would overheat burn out and their organs would be permanently damaged. Not counting what was being done to them with the lack of glucose.
I cooled them as best as l could with wet towels, fan’s and ice packs. The night was luckily quiet on patients and callers so it allowed us to concentrate on these two.

By about 4am we were becoming desperate for glucose. We woke the practice manager and made his night by getting him to go and raid the other surgeries for all their glucose products. We were throwing everything at these dogs, glucose syrup on the gums, Glucagon, injectable iv glucose and glucose No18 drips. The highest we got their glucose was 2 for a short time mostly it was around 0.7 to 1.5.

Around 4:45am we were loosing the patients. The dogs had come in at about 24:00 and had been uncontrollable since then. If we could control the fitting the glucose may have a chance to work, depending on what else had gone wrong that was not showing yet.

We used to have a drug called Sagital which is basically Pentobarb, the drug used to put animals down with but at a much lower concentration. This was discontinued in around 2004 and much lamented, it was ideal for fitting animals. It was then we switched to Propoflo drips.
I remember when the word came out about it going to be withdrawn and the vet l was on with checked out the % difference between Sagital and Pentobarb (for putting animals down).. just in case. I also wrote the dilution down as l worked with different vets.

Taking a breath l asked the duty vet what about diluting down Pentobarb to the Sagital dose and using that as a last ditch. He is very experienced and was a certificate holder in anaesthesia, even he baulked at the idea but we had run out of ideas. He rang the owners for permission as there was a good chance even diluted we would kill them in their state, permission was given.

He diluted the drug down and took a deep breath. Slowly he trickled it into the first dog and the fitting slowed and stopped. Then number 2 dog and the same result. We stood and stared at them and the clock.
2minutes... no fit…
3minutes... no fit…
5minutes... no fit…An ear prick at 5mins showed the last glucose bolus had taken the glucose from 0.6 to around 1.7 things had to be looking up the dogs were due a lucky break.

By 10 minutes there was no fitting but the glucose was dipping to 1 so more glucose bolus.

20 minutes and they still hadn’t fitted; they had more glucose boluses as their blood glucose fluctuated like a fluttering butterfly wing.

25minutes and they hit the magic 2.5 were we to early to think the prayed for miracle was coming that the 2 dogs may just make it against all odds.

30 minutes and 2.8 on the glucometer..

Suddenly then the dreaded twitches on dog two followed almost at the same time by dog one, more of the dilute pentobarb and it stopped again, but the glucose continued to fall back to 0.7 we managed to stop it there.

The glucose wouldn’t climb any more but the fitting had stopped, ok one out of two we could work on those odds just so long as we had glucose we hoped to hold the tide until it turned back in our favour.

By 6am the first dog had started to deteriorate and show other signs to the fitting. The vet rang the owners for permission to put the dog out of his misery they agreed, and were warned that dog two would probably end up the same as the first dog within a short time, probably minutes as they had mirrored each other step for step. In fact as the vet spoke on the phone dog two was showing similar signs.
The owner requested euthanasia for both dogs. As brothers in life they were inseparable, in death they would still be together.
I confirmed the request with him for the vet as it was over the phone and not in writing, a job l hate as you have to get the owner to repeat the request, not nod or just sign a piece of paper.

Wherever the insulin had come from, and it could only be that, it had done its job and pulled the glucose from the bloodstream.

By 06:10 both dogs were dead, the war was lost.

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