Episode 9 - Bonus Episode! Acute Vomiting in Dogs and Cats

Episode 9 - Bonus Episode! Vomiting in Dogs and Cats

Vomiting… or is it regurgitation? And how worried should we actually be?

In this bonus episode, we’re diving into one of the most common — and sometimes most stressful — presentations in small animal practice: the vomiting dog or cat.

From working out whether it’s true vomiting vs regurgitation, to spotting the red flags that turn a routine consult into an emergency admission, we talk through how we approach these cases in real-world GP practice.

We cover:

• Vomiting vs regurgitation — and why it matters
 • Emergency presentations and when hospitalisation is needed
 • Practical diagnostic workups (without going straight to “scan everything”)
 • Treatment options, medications, and decision-making in the messy middle
 • Plus the everyday clinical judgement calls that never quite make it into CPD lectures

As always, this isn’t textbook perfection — it’s honest, practical discussion from the consulting room floor.

If you see vomiting cases every day (so… all of us), this episode’s for you.

Transcript

SPEAKER_04 0:09

Hi everyone, welcome back to the Chatty Vets Podcast. I'm Brendan.

SPEAKER_02 0:13

And I'm Charlotte. Thank you for tuning in. We're back again with our next bonus episode. We hope you enjoyed our two-week takedown episode last week, but this week we're changing it up and going back to one of our clinical deep dive episodes.

SPEAKER_04 0:24

In these episodes, we aim to discuss some of the diseases and presentations you may commonly see in general practice, aiming to simplify the complex stuff and add new little helpful nuggets to your everyday bread and butter caseload.

SPEAKER_02 0:37

Today we're tackling vomiting in our dogs and cats, something I'm sure we can all agree that we see constantly, all the time.

SPEAKER_04 0:44

It's probably the most common symptom we encounter daily, partly because it's so visible to owners.

SPEAKER_02 0:49

Yeah, and I always think they're so worried about it, aren't they? They're like, oh my god, they vomited once. And it's, you know, it's this awful thing, and sometimes it can be something of nothing. So, but anyway, before we dive in, maybe let's get back to basics first. It's surprisingly important to remember to define what vomiting actually is because of its symptom cousin, regurgitation. So we all know that dogs can vomit or cats can vomit, they can both regurgitate, but they both can mean really, really different things. So maybe we need to think about what is what before we get started. So when we think about regurgitation, this is where food is brought back up into the mouth almost immediately after eating. But the big thing to remember is there is an absolute absence of abdominal contractions or retching. So it's principally normally a dog issue, but you can see it in other animals too. And it's usually associated with things like esophageal disorders, but it is something that we can see in other animals too. But it's that important really important bit is you don't get that classic abdominal contraction or retching that you do with vomiting. So it's much less severe, if you like, for owners to experience.

SPEAKER_04 1:54

Yeah, I can add to that. You know, when you watch the brackies regurge, they do do a little like as it kind of comes out. And sometimes they do two or three of those and then it comes out, but it hasn't got the abdominal contractions and a really prolonged, you know, when they when a dog really vomits, it's like 30, 40 seconds and they're really kind of going for it with the noise.

SPEAKER_02 2:13

That's quite an important thing to say, as well, is that you know, regurge doesn't come from the stomach. But so you'll get some owners that say, Oh, but it doesn't actually smell that bad, or like it doesn't look that yellow or whatever. And that's because it's not actually come from the stomach. If it's true vomiting, you'll get that horrible, acidic, sickly type smell to it. Whereas if it's a regurge, then often it just looks and smells like food. It's often owners are a lot less bothered by it. And I think w we all know, like when you give a dog Emma dog, and the owners look so worried, don't they?

SPEAKER_00 2:42

They're like, Oh poor baby, they're like because the dog looks so sad, especially if it's like a puppy, if they like sit there with the big puppy dog eyes, oh, it feels so awful.

SPEAKER_02 2:52

Whereas I think with regirs, they're like, What comes out and they're done, they're fine. So it is yeah, it just owners perceive it really differently as well, don't they? I think so.

SPEAKER_04 3:00

Yeah, and yeah, it's a really good example, actually, when you said about giving giving them um apomorphine, because you you do get all the signs, don't you? Obviously, the lip smacking, maybe a bit of drool.

SPEAKER_02 3:09

Yeah.

SPEAKER_04 3:09

Um you definitely get the lip smacking, don't you? Because you're like, oh, thank God it's working, as soon as you see the lips.

SPEAKER_02 3:14

Okay, so so if we've differentiated and sorted out the first question that we're gonna ask, you know, vomiting versus regurgitation, which is it? What do we do next? So if you've got a patient that comes in and you think, okay, it is truly vomiting, what are we gonna do next? Well, obviously, we've already probably asked a few questions to get us to that point anyway, but the next thing we want to do is really dive into our history, isn't it?

SPEAKER_04 3:35

Uh I get yeah, I guess so. Yeah. It's vomiting's such a broad base, isn't it? It's a gastrointestinal causes or it's extra gastrointestinal causes, pancreas, kidneys, liver, uh Addison's, whatever. Yeah, so history, I mean, where I go with my history is well, you do the obvious things, don't you? Because it eaten something a bit different. One of the main things that I'm trying to do with my history is working in my head, I'm making a mental chart of fluid in and fluid out. So if they say, Oh, we had diarrhea three times in the night, I I do want to get a rough idea. Was that like pouring watery, or was it just like little tiny little ones, so that I can get that picture of how much fluid has come out? Same with the vomit, I suppose. And fluid in, so are they drinking, are they being observed to drink, are they holding the water down? So that in my head I can kind of go, could this patient be theoretically dehydrated? You know, sometimes you'll find that there's not actually that much fluid loss, the patient's drinking, and you're starting to think, well, dehydration's coming lower down my list now. Is that fit with what you do, or do you do other things too?

SPEAKER_02 4:29

Yeah. Yeah, I think to be honest, it's one of the important things in terms of establishing how worried do I need to be? Because, you know, if you think that they've not actually lost that much fluid, then you're more than likely just to give it some medication sent at home and see how it goes. Whereas if they've lost a hell of a lot of fluid, you'd be more worried about hospitalization, etc. But I guess in terms of general questions, you want to be asking things like, does this happen often? Has it never happened before? Are they prone to upset stomachs? How are they sensitive to particular foods? Do they have any allergies that you're aware of? Have they had a recent diet change or new treats? Do they tend to be scavengers? Do you think they could have eaten something they shouldn't? Balls, socks, toys, stones, whatever that might be. I've had underwear, period pads, anything that they could have eaten. I always tend to ask as well, is there anything you've noticed going missing recently? Because sometimes owners are like, oh yeah, I put two socks on the stairs this morning and can only find one this evening. And then it twigs and they're like, oh my God, I think they've eaten a sock. Whereas if you ask them, have they eaten anything, they'd have gone, no. So it's worth probing. And I tend to always ask, are they on any medications? But also, are you on any medications? Are there any medications that the dog could have got hold of? Because sometimes people are like, oh yeah, I left some ibuprofen out or some whatever drugs they're on. And I've had some funny ones previously. Um, so it's like, have the have you left any medications out? But and have they did they end up not where you put them? Because sometimes they can have taken something that the owners aren't expecting. So just ask and ask and ask, try and jog people's memory to think, is there something that we're missing?

SPEAKER_04 5:59

Yeah, definitely. I think I think owners have got an underlying sense if their pet eats something they shouldn't as well. So as soon as you kind of get that vibe, and then yeah, prompt away and see to see if you can get something. Because sometimes they've been eating various different things for months, um, but because they've got away with it, the owner doesn't really think about it too hard until you kind of prompt them. I had that really unusual with a cat that ate a little teddy bear leg that was like an inch by half an inch off a teddy, which is so rare for a cat, isn't it? But um yeah, had a oh, I had an intestinal obstruction. But uh yeah, the I mean the the one that thing they do often volunteer, which the in the other direction is if there's blood, vomit in the blood. I think that's um yeah, that really gets me worried.

SPEAKER_02 6:38

Yeah, I mean, how many times do we have it where owners call up and say, Oh my god, there's a little bit of blood and it's vomited once? Probably not that worried when there's like a couple of little specks of blood in one vomit, you're like, eh, it's probably gastritis. Whereas if I think I'm a little bit more worried if they're like, Yeah, yeah, it's been vomiting continuously for like 24, 48 hours, and now there's a lot of blood in the vomit, I'm a bit more worried now. Um, so I think again, how long has it been vomited for vomiting for? But also when they do say there's blood in it, how long has that been going on for? And also how much? Because there's a big difference, isn't there, between like a few little specks in something that's been retching for ages and you think, well, it's got a raging gastritis, it doesn't surprise me, versus lots or pools of blood in the vomit. That is a very different story. So I'd be much more worried if that's what we're hearing. So it's sort of calming them down and saying, sometimes I'm not too worried about blood, but I need you to tell me how much. So yeah, it's asking those kind of questions as well, isn't it? And do do you find that you're seeing hematomesis quite common that you're seeing blood in vomit all the time, are you in these patients?

SPEAKER_04 7:38

In general practice, no. In vets now or in out-of-hours clinics, yeah, really often. And sometimes I think I think it's a different caseload, isn't it? And you sometimes have to handle it. It's hard one to handle carefully. If I've got a really well dog and I've got a relatively small amount of blood and the patient's pretty well, I might even kind of say, Oh, just keep an eye and let's see what the next vomit looks like and see if there's because oftentimes it was just they burst a little blood vessel or whatever through the strain of doing the vomit and the next vomit's perfectly normal. So it's not an immediate panic stations, but it's careful communication is needed because it is a little, it is startling. And when it's your own dog, it it it's a it it worries you, doesn't it?

SPEAKER_02 8:19

Yeah, for sure. I for me as well, it depends whether it's I know obviously we're talking mainly about vomiting, but like you say, vomiting and diarrhea come hand in hand half the time. And if they're saying there's a little bit of blood in its vomit, but now it's like pouring blood from its back end, I'd be like, hmm, I'm a lot more worried now. Or if they say there's a lot of blood coming up in its vomit, then I might be more worried about things like coagulopathies or horrible gastric ulcer versus a bit of gastritis. So it depends how much blood and where it's coming from and if they're seeing it anywhere else as well. But I mean, I have loads of these patients that I see out of hours and they're really quite well in themselves. They just look really nauseous. And I I look at them and I just say, You've not got an obvious foreign body, your clinical exam is fairly unremarkable apart from the fact that you're really nauseous. So some of these I do just give anti-emetics and send them home and say if it continues to vomit or it continues to bleed, then obviously we need to do more. And I warn them that there could be something else going on, but a lot of the time they don't work up anyway. So the majority of them never come back because they're fine. So it's I think if there's blood in it, use it as a warning sign and talk to the owners, make sure you're not missing something scary. But ultimately, I'm not always admitting those patients by any means.

SPEAKER_04 9:27

So I I would admit that I have may have done that on occasions, but I do worry a little bit if I use an anti-emetic that now it it still might have bleeding in its stomach, but it's not being sick, so we don't know about it. But in reality, does that happen? Probably not, but it it just frightens me a little bit.

SPEAKER_02 9:43

I know we're focusing on vomiting in this episode, but it is really important to talk to them about stool consistency. Are their stools completely normal? Are they straining? Have they got looser stools than normal? Is there any blood in their stall? Is it mucusy? All of those questions will lead you down uh the answers will lead you down a completely different route than if they were to say, oh no, their poo's completely normal. There's nothing wrong with their feces at all, they're completely as they normally are. So definitely always take the two hand in hand in that sense. Ask those questions to rule out is it something that's affecting the whole gastrointestinal system in terms of it's causing vomiting and diarrhea or changes in stool consistency or are stalls completely normal? So so we've already spoken about some of the big things that you'd want to ask in your history, and we touched on whether the dog is on or cat is on any medication, whether they could have got hold of any medications, etc. But what do you think are the big hitters, Brendan, that we're worried about if they could have ingested for vomiting? You know, what medications would we be most worried about, knowing whether they've got they've had access to or whether they've been on long term?

SPEAKER_04 10:44

Um well the classic one we get is um um non-steroidal, human non-steroidals, because some of them are more toxic to the gut, aren't they? To the stomach, they get more ulceration than our conventional NSAIDs. I feel like Diclefenac's coming up in my mind as one of those. I can't kind of fully recall which ones, but yeah, there's there's those. I mean, obviously with grapes and raisins, people say, you know, we're gonna get vomiting as our first sign, usually, you know, a little bit later down the line. But I don't think I've actually had that in a in a clinical context. Transfer medicine, tell me where where else have you what else have you got on your mind?

SPEAKER_02 11:17

Yeah, I guess it's if they could have got hold of any of the owner's medication that it could be anything. I mean, I've had someone call up and say that their cat uh I think it was a cat. No, it was a dog. They're I think it might have been a puppy actually, ate their erectile dysfunction medication. And I was like, I don't really know what to say right now.

SPEAKER_00 11:31

I'll just check the doses and check that it's okay, but it was fine.

SPEAKER_02 11:34

Um anyway, so it's just always just worth asking. And if they have got any hold of anything, what is it? But anyway, um, I guess that the biggest one to remember is are they on NSADS or have they been on NSAIDs in the recent, in like the recent months? I mean, we've all seen those horrible upset tummies when they've started on NSAIDs in terms of the acute sense, but especially those ones, big dogs, little dogs, whoever that are on NSAIDs long term, obviously gastric ulceration, etc., and gastric bleeding is something that we're always worried about. So it's really worth asking whether they are on any NSAIDs or have been recently. Okay, so we've now gone through loads of history questions with the owner. We've sort of had a big discussion and been thinking about okay, what could have gone wrong here? Could they have eaten something? Could they have had medications? Is their diet changed? Blah, blah, blah. All those kind of questions that you're going to ask. But another thing that we want to go into onto is our clinical exam. So how do you do your exam in these patients? Obviously, we do our normal nose to tail, but what specifically do you think you're looking for in these guys?

SPEAKER_04 12:32

Okay, so I'm looking for shock. But to some extent, I probably sound like a broken record, for dogs, I want them walking around my console, I want them chilling out. I've taken my history, the dog's chilling out, and I've got my eye just on what they're doing. Um, if they're really terrified and they're just hanging on the owner's leg, then you're not going to get much info. But if I've got a dog that's wandering around the room, sniffing at various things, straight away I'm kind of thinking, well, this sounds a bit positive, really. Um if I've got a dog, obviously, sounds obvious, doesn't it? But if the dog's just lying down, you know, looking at me, and Michael, you know how my consoles drag on for ages. Uh, it's a really good test because if by 15 minutes they're still sitting up looking around and stuff, I think, well, they're not gonna need a blood test, they're fine. Um so I do, I literally do do that. But if they're like lying down, because sometimes the adrenaline will kind of get them going for five, ten minutes, but when they're really poorly, you know, that lively spaniel, even that one, if it's really ill, is gonna lie down. Um so yeah, demeanor, what we kind of wrap into demeanor alertness. And I think when you're a young student, you might not pay as much attention to that. And I think it allows you to get bitten in the bum if you, you know, I think you've got to.

SPEAKER_02 13:35

It's a really big clue.

SPEAKER_04 13:36

Yeah, it is. I think yeah, it's a really important part of it. Um, then get them on the table, and we're looking for signs of shock. So that's scale mucus membranes, a heart rate that's fast. And if I've allowed the dog to calm down uh or the patient to calm down a little bit for five, ten minutes while I'm doing the history, great, because then I'm probably gonna get a more realistic heart rate. Uh pulse quality, it's usually isn't that helpful. But when it is weak, boy, is that a big sign. But I find the vast majority, it's gonna feel okay to me. The CRT, capital refull time, obviously, uh skin tenting, not a sign of shock, but I'm going back to that kind of whole body dehydration, which I think we need to come to the fluids in a bit, the differentiation there. Temperature's really useful for me. I'll often think if they're one or two degrees lower, that's a big deal for me. I'm almost more likely to go for blood test there. If they're high, maybe you're on pyrexia of unknown origin or whatever. I'm gonna weigh it up with everything else, but low, especially in a cat, actually. But certainly in a dog as well, if it's 36, 37, there's something probably going on. Have your antennae at ready. Abdominal pain is a hard one to assess. I'm going back to that, if that dog's wandering around the room exploring, sniffing things, I would venture say it's probably not abdominal pain if you press its tummy and it doesn't like it, especially if it's a nervous dog. So interpret how patient of the abdomen, you know, but putting into mind the dog's demeanour and is it nervous, worried, tensing up because it's hates being at the vets. Anyway, there's a stall.

SPEAKER_02 15:02

I'm really similar. I'm thinking, is this an emergency patient or is it not? Because a cat or a dog, if they're wandering around the consort room and they look like they're doing their normal thing, I'm like, this is probably isn't shocking. It's probably not that bad, it's probably just feeling a bit sick. If they're laying flat, like you, you know, when you take the lid off the cat carrier sometimes when they're just laying there flat and don't move, and you say, you're saying, this isn't very well. Like it gives you even before you've touched it, you're like, don't like that. Yeah. And then I think it it goes back to our basic principles that we spoke about in dyspnea and any emergency patient. You want to check your three major body systems, so your cardiovascular, respiratory, neurological, like you said, mucus membrane colour, CRT, etc., heart rate, pulse quality, murmurs, respiratory. Remember, your big one as well is not only you looking if they're dyspnee or if there's any changes, but remember in your brachies that vomit, they will very likely get aspiration. So always have a good listen, see if you can hear any of those crackles. Um, I guess neurological as well. Are they are they vomiting because they're neurological, or do they look like they're weak and wobbly and they're not actually neurological, they're just weak in their vomiting. So keep an eye on their mentation if they're ataxic, if there's any sort of obvious, I don't know, cranial nerve changes, or if one pupil's blown or whatever, whatever you might see. So they're all things to make note of. The other thing before we go on to shock, one of the the biggest things that I find really sways me in terms of a vomiting case is, you know, when you were speaking about abdominal palpation, obviously you want to have a good feel for, you know, if they've got cranio-abdominal pain, then that might point you a little bit more towards possible pancreatitis type pain. If you're having a good feel and you suspect that you can feel something that's hard and possibly in the intestine or near the outflow tract of the stomach, then you might be like, has it got a foreign body? Can you feel a lump somewhere that you shouldn't be, especially on your older patients? But the big one to remember, if you go to touch that dog abdomen and it is tight and you go to touch it, and they either look like, well, sound like they're gonna scream, or they turn around and bite you and the owner, or try to bite you, and the owner goes, Oh my god, they've never done that before. They've that is really out of character. I'm like, is this a septic abdomen? Before I do anything else. Because if it looks really sick and I go to touch it, because I don't know about you, Brendan, but all of the ones I've had, they are so painful. It's immediately obvious that there's something really serious going on before I've done anything else. But I just find that they're so, so uncomfortable that you just can't even touch them without them screaming. It's only when you get that opioid on board that they feel a bit better.

SPEAKER_04 17:28

Look, how many septic abdomens do I see? Not that many, but the septic abdomens I've seen have in cats have not presented as abdominal pain. And I I've had a really, really juicy septic abdomen. But it was um post-surgical um breakdown of a um a um subtotal colectomy. I can't remember, but uh not my case, but um it broke down and uh so it was literally, you know, as septic as you can imagine, poo in the abdomen. No abdominal pain. So I don't I don't cats seem to have a different thing going on. But I'm not basing that on many cases.

SPEAKER_02 18:04

Yeah. To be fair as well, I think we don't see that many ink cats and the ones that we do, they're normally so collapsed that I'm like, would they really respond if they were in that much discomfort anyway? Whereas I feel like dogs can still walk in with a septic abdomen, they can look really crap, but every single one that I've seen, you go to touch them and they're like, oh my god, don't touch me there. So yeah, basically, if especially if it's a dog and you go to touch them and they have massive abdominal pain, I'd be getting a probe on that dog pretty damn quickly. After you've done your basic clinical exam, that you then want to say, okay, if we're looking at shock, which I guess we're talking about shocking these patients in the sense of hypovolemic shock, is the main thing that we see because they've often lost so much fluid from either just the vomiting or vomiting and diarrhoea that their blood volume has reduced because they've got they don't just don't have as much fluid watery component to their blood than they did before. So the body tries to compensate by going into shock, which are the symptoms that we see. Now, if you have hypovolemic shock, Brendan, in a dog, what do you see? What sort of symptoms are you seeing on your clinical exam?

SPEAKER_04 19:05

Well, your test to read up with a spot. Um extended capillary reflect time, file mucous membranes, theoretically weak pulses. I don't think it goes works for me that well. Um, high heart rate, that's pretty much it.

SPEAKER_02 19:15

Yeah, I think so. Yeah. So the biggest thing to say is that dogs and cats are similar in terms of paleness, increased CRT, poor pulses, but then dogs with hypovolemic shock, they go tachycardic. So you're frequently seeing heart rates of 160 and higher. Whereas in a cat, often they go bradycardic. So quite often you have cats coming in in hypovolemic shock that have a heart rate of 120 or sometimes even lower. In which case, if you have a cat come in that's flat and you think, oh, I can't really feel its pulses that well and its heart rate's low, I'd be thinking, I think this is in shock. I think we need to get some fluids into this pretty quickly. Obviously, if it's had evidence of losses. So that's something to remember. So you're not always expecting a high heart rate. It depends on the animal that you're looking at.

SPEAKER_04 19:57

And their temperature drops, I think. Yeah. I know, I'm not never completely sure if that's dehydration or shock, but yeah, I think the temperatures tend to be low, doesn't it? Those poorly cats.

SPEAKER_02 20:06

Yeah, for sure. Yeah. And like you said before, you'll be looking for your skin tenting, but we're looking for skin tenting and tachymucous membranes in terms of dehydration rather than in terms of hypovolemic shock. So don't get those two confused. Hypovolemic shock is the blood volume issue that's going to kill them quickly. Dehydration is the thing we want to replace over time. So that thing we're less worried about to start off with, it's the shock that we're most worried about.

SPEAKER_04 20:30

Dehydration is like a raisin to a grape, isn't it? It sucks all the fluid out from the tissues, um, and the tissues have got all dry. And then you rehydrate them like a razor. I do you can't rehydrate a razor, but if you could. Yeah, okay. It's very there's very little out there, there's very little there to give you a guide on dehydration. Yes, we have skin tenting and tachymucus membranes, and then you might, if you're lucky, have a recent weight, um, especially if you're in general practice where and obviously if let's say you're five percent dehydrated, we're every everything's five percent dehydrated, isn't it? So that's uh I if in my head, if it's a 20 kilo dog, five percent dehydrated, that's gonna be well, I what I do is I do a tenth of that for 10%, which will be two kilos, which is two litres, half of that is a litre, so or or or one kilo. So that's gonna be one kilo of weight loss in a 20 kilo dog. So you it's measurable, and it's certainly measurable in cats too. So I do that quick kind of mental calculation with the weights. You're factoring it a little bit like have they not eaten, but you know, little things like that, but uh it's still relatively useful for dehydration.

SPEAKER_02 21:32

Yeah, and I I use sunken eyes quite a lot as well, sunken globes, especially in cats. So often if they're dehydrated because they've been losing fluid over quite a long time, you'll notice that their eyes sink back into their orbits a little bit more and their third eyelids come across. So those cats that look and feel crispy because they've got that skin tint, their eyes have retropuls slightly and their third eyelids have come across and they feel tacky on their membranes. I'm like that, cat's dehydrated without a doubt. So, you know, you can get a Lot of clues from from checking those sort of things as well.

SPEAKER_04 22:03

That's a cool one. I've got a slightly cool one. When you clip their abdomen, have you noticed that the skin kind of um forms those all wrinkly? Yeah, wrinkles, yeah. When they're dehydrated. And uh yeah. Also, I find uh it doesn't it interferes with my ultrasound. I don't get quite the perfect, you know. Sometimes you get a lovely ultrasound image, and other times you get a rubbish one. But sometimes that's the hydration of the skin, I think. And those wrinkly cats, because I did so many, yeah.

SPEAKER_02 22:29

It is it's like a geriatric person's skin rather than like a young, plump person's skin. It's different, isn't it?

SPEAKER_04 22:35

I think there is a study actually where they looked at the ventral skin for skin tenting, and I think it is more sensitive.

SPEAKER_02 22:40

Okay, so bringing it back to sort of a clinical scenario, if we've got a dog or a cat that presents to us, we know it's having an acute vomiting episode. We may not have we've obviously may not have worked out why yet. Um, we've done our clinical exam and we think our patient is in hypovolemic shock, what are we going to do next? We need to try and stabilize them. So, first thing we're doing probably is getting an IV catheterin. If you're getting an intravenous catheterin, always remember, like we've harped on about previously, you've got access to a vein, get some blood while you're there. Even if you're getting enough for a minimum database, draw it, you can use it later. Because even if you can get a PCB total solid before you start fluids, it's going to give you a lot of information. So draw a little bit of blood, don't forget to do that. And then one of the first things we're doing before we do much else, alongside other things, is starting them on fluids. And I don't know about you, but I'm a Hartman's girl all the way. Like I don't use, I barely ever use saline anymore. I pretty much use Hartman's for everything. There are a few exceptions and we can discuss them, but pretty much I'm always using Hartmanns. I think with Hartmanns, the good thing to remember is it's it's a balanced solution and it will help to buffer your acidosis and it's going to replace all of your electrolytes in a more balanced way rather than saline, which is not going to be as helpful. So are you the same? Are you using Hartmanns for these patients?

SPEAKER_04 23:57

Not always. Some people think of me as contrarian, and and I don't mean to be here. For example, you know my cat that ate the little teddy bear leg and got obstruction that I assume was alkalotic because it's had lot lots of vomiting, it's lost, it's vomited up all that H plus from the stomach, all that all that acid from the stomach, and now it's become alkalotic. So um I think uh we didn't have an epoch machine because it's in general practice, but the chloride and and the history were making me kind of think, okay, this is likely to be better off with some saline. Um so given that the talk is you know vomiting, I feel like could you say obstruction, suspect obstructions? You might is that one of your exceptions? Because you did have a few, you said.

SPEAKER_02 24:42

To be honest, no, still not, because I felt, and we'll go on to this later when we talk about bloods, but if I'm worried about an obstruction, usually if you've got an upper GI obstruction, yes, you've got a metabolic alkalosis, but you've also got a hypochloremic, hypocalemic alkalosis. So I often find they're potassium, so in which case I've I want to give the Hartmanns. So for me, I'm still convincing myself that Hartman's is the right thing.

SPEAKER_04 25:07

We're gonna have a we're gonna have an emerge off like comp competition then. Because right, my cat with the teddy bear, right? Take this up your hypokalemia. Um, it had saline infusion with added potassium.

SPEAKER_00 25:19

Well, fine, you're balancing it out, fine. That's okay. Yeah, that's fine. Okay, I agree, that's fine.

SPEAKER_04 25:25

So one up me on that. Yeah. And you know what? The funny thing is, I also had it on some Hartmanns too. I had two lines because I have my potassium line, yeah, and I have my Hartman's as well for extra.

SPEAKER_02 25:34

But it what I'm saying is it proves that you've you've thought about it. You know, I think if we're using saline, we should be saying, why are we using this? What's the reason for it? Because for me, if you don't have a reason not to use Hartman's and to specifically use saline, you should be using Hartman's, is my opinion, because I feel like there's only a few cases that it would make more sense to use saline, is what I feel. So if you're ever unsure, go for your Hartman's, is what I say. But when we talk about reperfusing them, so to try and get that blood volume more back up to normal, obviously we want to try and do so quite quickly. So this is where we come into the sort of shock rate fluids. And I know that obviously we need to be careful because we want to give enough quick enough, but we don't want to give too much. And we obviously all know about the glycocalyx now and the damage that fluids can do, so we want to be a bit careful. In terms of your doses for these guys, Brendan, what are you doing for your dogs versus what are you doing for your cats when they're in hypovolemic shock?

SPEAKER_04 26:30

Yeah, uh, so 10 to 20 mils per kilo over about 15 minutes, depending on how desperately sick it's looking for a dog, and five to ten mil per kilo over 15 minutes for a cat. Now, I think I don't know if we want to explain, and that that'll be like one bolus, then we reassess all the vitals. Well, particularly well, it's not often we have lactate multiple times like that, I find, but you could if you had lactate. But yeah, heart rate is the classic one, isn't it? Um normal.

SPEAKER_02 26:59

Yeah. To be honest, when I first started doing fluid boluses, this sounds really stupid, but someone would say, okay, I want to give it 10 to 20 mil per kilo over 15 minutes, and I'd be like, how do I put that into my fluid pump? I found it really difficult to like to compute in my head. So basically the way you want to do it is if you're doing it over 15 minutes, work out, it sounds really stupid, but say you want 10 mil per kilo over 15 minutes, you work out 10 mil times by the dog's body weight. So say it's 10 kilos, then you want 10 by 10. So that's 100 mil that you want going in over 15 minutes. So that means you need to program your fluid pump at 400 mils per hour because you want four times that, because that in theory is how much you'd be doing in an hour, but you've set volume to be infused at 100, and then it'll run in over 15. Now, the only thing I would say is I think the vibe that I'm getting, because I'm doing my cert at the moment in ECC, and the vibe that I'm getting from ECC clinicians is that actually the fluid rates are even changing slightly more in that they're being more conservative with how much, but potentially quicker. So I think if in doubt, I'd potentially be giving a dog, say, 10 mil per kilo, but over 10 minutes, and a cat maybe five mil per kilo over 10 minutes instead of over 15, because I think it's it's more thought now that anything over 15 minutes is not a bolus, it's not going in quick enough. So I think you want to give whatever you're choosing to give over 10 to 15, and it depends how sick your dog or cat is. So, for example, if I have a dog that comes in with a heart rate of 220, I'm like 20 mil per kilo over 10 minutes sometimes because I'm like, get the fluid in there and it needs to start responding really fast. Whereas if it's 160, I might go 10 mil per kilo over 15 minutes. Does that make sense? So you have to base it on how your patient is doing. Like you say, you want a bolus to be making a difference. So if you're giving that much fluid that quickly, you're expecting mucous membrane colour to start getting a bit pinker, a bit better, your CRT to start reducing so it's getting quicker, and you want your heart rate to be coming down, you want your pulses to be getting better. You want to repeat that fluid bolus up to about three times as a bit of an average rule. And ultimately, if you're not responding to fluids, you need to be thinking, have I got this wrong? Is it hypovolemic shock? What else is going on? Because it should be responding. Does it does that make sense?

SPEAKER_04 29:17

Yeah, it's pretty I find in my hands it's not very not very typical for me to go to three boluses one or two more typically. Charlotte, you're doing your certificate. Do you want to explain why it has to be done quick?

SPEAKER_02 29:29

It's basically so if you imagine what we're doing is we're reflooding the vascular system. So we're putting fluid back into the into the blood, if that makes sense. So into the vascular system, and that is where we need the pressure because we need the volume to be able to get our cardiac out, but we need to be able to get the red blood cells where they need to go, etc. It needs to support the vascular system. Now, after a while, so you know when we give normal fluids when we're rehydrating, the fluid, the whole point of your vascular system is well, some of the point of it is to leak some of that fluid into your tissues to be able to rehydrate them. And if you imagine most of these patients are going to be dehydrated as well, so the tissues are going to want to suck it all out of the vascular system to rehydrate themselves. So what's happening is you're bolusing them to get it in quickly to support the vascular system. But if you do it too slowly, you're not going to build up that pressure quick enough. And also you're going to let enough of that seep out into the tissues. Does that make sense? So you need to kind of be doing it quick enough to get that fluid volume back up and to sort of get you to a point where you've got enough fluid volume that you can then start rehydrating them without having significant blood volume drop again. Have I explained that right? Does that make sense?

SPEAKER_04 30:42

Yeah, I think that's it. And I think within that, you've got this um shock is um am I right in saying there's like a spiral where it's descending into from shock to to death, really. So you can reverse it by and get it out of that spiral of of uh of despair as it plummets into towards, you know, from shock to to to more severe problems to orbn dysfunction to death.

SPEAKER_02 31:07

Yeah. And you know, I mean, uh, this is a bit of a different topic because I think we'll go into um acute hemorrhagic diarrhea syndrome probably in a different talk. But a lot of the reason why you might lose a HGE or AHDS patient is because of shock. Because if you don't catch them quick enough, you will struggle to get on top of that, their fluid volumes, which means you can then get a really, really unhappy gut really fast because it's then not perfused in the way that it should do. And then you can get bacterial translocation, they turn septic, and then you're in a whole nother ball game. So it's basically fluids are your mainstay for these guys. And if you get them right quick enough, then you can do the world of good for these patients. So it's yeah, do not do not be worried. If you're convinced you've got a hypovolemic patient, do not be worried about fluid bolusing. If you're not fluid bolusing, you're not getting it in quick enough. And obviously, for cats, they go bradycardic, so you want the heart rate to be coming up. But generally, with cats when they're hypovolemic, I don't know if you feel the same, but they're they're so flat when they present to you. It's mentation more than anything else. It's literally like they're rising from the dead. When you start bolusing them, they're like, oh, I feel a bit better now. And they start getting up and they try and move around. And you're like, oh, they're feeling a bit better. Um, whereas dogs, it's your clinical symptoms because they're still going to be feeling really sick and crap, so they don't often move that much more. But you'll generally notice from their clinical signs in terms of heart rate, etc., that they're getting better.

SPEAKER_04 32:29

That's a good description. Yeah, totally.

SPEAKER_02 32:31

Yeah. And then I guess after we've done bolusing, remember your normal fluid, you still want to replace that dehydration because right then we've not done anything for the hydration. We've just sorted the hypovolemia. So you still want to then work out your rates in terms of maintenance plus replacing the hydration deficit plus ongoing losses that they might have. So remember, you still need to be working that out too and putting them straight back onto those fluids too. So I know we spoke about Brendan, when you're getting that initial IV catheter in, you want to pull a little bit of blood back and potentially run some bloods. In these patients in general practice, because obviously I know I'm running epochs, etc., in Emerge, but in your general practice patients, what what bloods are you running on these guys?

SPEAKER_04 33:13

It it used to be forgotten hematology, but it's so useful because we in EMERG we love a hematocrit, don't we? Because that's another way of seeing has our uh we've got hemoconcentration. If we lose blood volume, our our red blood cells, our hematocrit is going to go up. Um, and our patients in these acute kind of um symptoms will typically have heratocrites, I don't know, 70, the really bad ones, 80, 82, you know, really, really high. And you like you do have two, three shock boluses of fluid, and when you're doing your follow-up bloods, that will be coming, you'll see that really coming down to 60 or whatever. So uh hermatocrit is is is useful, and uh if you're gonna be really th super clever, you might be um looking at low neutrophils, neutropenia, and toxic neutrophils on a blood smear, but you know, that's that that's a little bit more involved. The other thing I really want to know is electrolytes, ruling out typical Addison's if you want to put it like that, but also, yeah, I want to see where everything is because we know we're gonna be doing a lot of fluid fluids here, and it's gonna be cool. It's quite common to get what I think in human human critical care they call disarray. But um, yeah, the acid base is gonna be upset and then the electrolytes are gonna be changed. So I really want that. I think we all know we want to be looking at acetemia, see where we're where we're starting from. Um it's the liver enzymes can be helpful, but remember, like mild increases in liver doesn't really get you very far because it could still be secondary to GI. Moderate elevations of the liver you might still see with pancreatitis, things like that. So have your mind on other causes. And but if the ALT is 600, 500 plus, I guess it's you, you know, you've got to have your mind on the liver as well as a differential.

SPEAKER_02 34:49

Yeah, yeah, especially if they've got elevated bilirubin or you spin them down and there's the plasma or the serum looks like it's ectaric, then yeah. For me, for these guys, I'm running a PCV total solids pretty much straight away because you want to check that they are definitely hemoconcentrated. I mean, they're going to be. So their PCV and total solids will both be really elevated and you want them to be coming down as you reperf as you bolus them and you reperfuse them. Um I think a blood smear is really good, but if you've got hematology in house, then go for it. If you have anything that looks a bit low or you're worried about, like if your platelets look a bit low, make sure you're checking it. Um, but otherwise for me, I ran an epoch because it gives me all of those emergency values, so everything except liver that I really need to know about. But again, for me, it's things like glucose, your electrolytes, you want to know what your potassium and your sodium are doing, particularly. Remember that that possible clue for a foreign body if you've got a metabolic alkalosis, if you're lucky enough to have blood gases. But if you have a hypochloremia and a hypokalemia, then those two things together, especially with an elevated lactate and a painful cranial abdomen, I'd be thinking it could be a foreign body. So you can really use those, your bloods, as a bit of a clue as to what's going on. Sometimes you're just checking for markers of how dehydrated it is, um especially with your azotemia, etc. But sometimes it can give you your answer because if you've got an absolutely horrendous azotemia, reatinine of like 700 800, then you'd be thinking this is probably AKI, in which case, you know, or whether it's a CKD that's decompensated and that's why it's vomiting. Or, like you say, if your liver values are off the scale, it might even give you your answer as to why it's vomiting in the first place. But I think initially we're not, we're not looking for the cause, we're looking for what we need to fix to get them better. Does that make sense? Okay, so we've we've thought about fluid bolus in our patients. We've got a quick blood test and we've talked about possibly wanting to run certain stuff because you've got that blood already. Um in terms of the other emergency things that we want to be thinking out, sort of pretty much at the same time as fluids in these patients, is one, if you've got a patient, a patient that looks collapsed or is very, very weak, or especially if they're not breathing well, oxygen is your best friend. So put them on some oxygen, even if you're using a little bit of flow bi. And the second one, do not forget analgesia. So these patients will generally be quite painful or at least a bit uncomfortable. So what you want to do is make them feel a little bit better.

SPEAKER_04 37:07

Yeah, um, I think I think um we really need to be careful how we use those opioids as well. Definitely, obviously, in the really sick um and certainly really patient, pay poorly patient uh or painful patient who want to get in there with the opioids, they're gonna feel better. But I I'll often go IV paracetamol if I'm a little bit unsure, just because opioids have also got some negative qualities as well. And we need to be really aware of that too. And it's it's a huge thing in human emergent critical care as well, where we're overusing opioids quite a lot. Um, the what obviously is some of the biggest issues for a GI patient, especially if we're just giving it thoughtlessly, because you know, you get your first dose in, and then before you know it, we've got four hourly methadones for the rest of the 24 hours. And and that may be something we should stop doing because shouldn't we be you know much more careful about not just going, well, we're doing another method in four hours, because that might also be harmful too. And um reduced appetite, increased nausea, these the panting and the temperature dysregulations, all these things, slowing of GI, transit, um, all little issues that opioids give you. Now we're we're so used to seeing our patient in an altered opioid state that we actually think that's okay for a sick patient. But we do, you know, be aware of it and use it with care, just like we use fluids with care now.

SPEAKER_02 38:25

Yeah, exactly. And to be honest, one of the things that I quite like in dogs as well is when you're trying to fluid bolus them to get their blood volume back up, IV paracetamol works quite well because you're giving quite a lot of volume as well. So I actually find when I'm resuscit when I'm fluid resuscitating them, I actually quite like giving like a 20 meg per kig dose of paracetamol because one, it's helping to get your fluid volume up. But two, also when you give methadone, especially if you give it IV, it's going to drop your heart rate. So it's in effect, obviously, if they need analgesia, you need to give them analgesia. But sometimes I'm like, oh, is that my fluid sort of work that have dropped that heart rate and made it f feel better? Is it coming out of shock or is it just feeling less painful and that's why its heart rate's dropped? Does that make sense? So sometimes it can be a little bit tricky to know how well you're doing in terms of your reperfusion with your boluses, especially if you're looking at heart rate as one of your things that you're checking. So sometimes IV paracetamol can really help with that because you're making them less painful, but you're not necessarily gonna make them a little bit more bardycardic, which could then hinder what you do next. Does that make sense?

SPEAKER_04 39:26

Because um it's a really good time um efficiency thing too, isn't it? Because sometimes that paracetamol is so annoyingly thick that it's quite handy just to be manually pressing it in. And that means you've got a nurse sitting there putting the paracetamol in, keeping an like one-on-one with your sick patient that's in shock.

SPEAKER_02 39:42

Yeah, exactly. You can put the the put the needle into a port and just give it super slowly that way. So, but yeah, it's something to consider. Um, I don't know about you, but especially if I'm hospitalising these patients, one of the I know it's really controversial, but I always give these patients Muropatin, but I always do, because I it just makes them feel so much better so quickly. And for me, actually, for an acute vomiting patient, I actually find Muropatin is a bit of an emergency drug. I know that sounds a bit silly, but for me it gives them, it makes them feel so much better so fast a lot of the time. And when you palpate your abdomen, you're like, are you really painful or are you just feeling really nauseous when I press your abdomen? So actually, sometimes that can really help as well, because if you give them some Muropatin and they feel less sick, they're doing less vomiting, they're more comfortable, so it makes them feel better too. I think people worry about masking whatever's going on by giving them the Muropatin. Does that make sense? So because if you think if you give them an anti-sickness, they stop vomiting, the the clients think, oh, they're feeling better. And it could still be that they're still feeling equally as crap and they've got a foreign body, but the moropotin has just stopped them vomiting. But then after 24 hours, it just comes back again. So it's then been a 24-hour period where you've not done work up, whereas if you hadn't have given that drug, they would have got worse. Does that make sense? But for me, I use it. No, exactly. And I think for me, I use it in the respect of I just say to the owners, if it vomits through the moropitan, I need to see it back, like ASAP. And if it's not getting any better, so it's not vomiting, but it's still not eating, it's still really lethargic, or you think it's getting worse, just the vomiting stops, I still need to see it back. So I think as long as you're giving those caveats, I wouldn't be worried about giving it anyway. So, but there we go.

SPEAKER_04 41:21

So that leads us very nicely actually to a little distinction because when they in inverticomas vomit through Meropitan, in my opinion, they're often regurging. And Meropitan doesn't stop regurge at all in my in the case in my case when I see it, it doesn't seem to stop it at all. And um they're regurging because they've got an obstruction, the stomach's really full, and they they're getting regurged for that reason. So I don't think they're vomited. I don't know. I don't think they're re-maybey they are, I don't know. My impression is they're not re- vomiting through More often, they're regurging. Um so it's a another case if you should genuinely regurge, it's another great little test. Because if you block the the um the vomiting and they're still bringing stuff up, you go, Oh, actually, was that regurg?

SPEAKER_00 42:01

Yeah.

SPEAKER_04 42:02

I think that's bonkers. I really don't agree with that. That that idea that you don't give mere optimism if you're sending them home. Because what I tell clients as well is by you know, I'm I'm trying to educate the client in fluid in, fluid out, how much is going in, how much is coming out. And if they're sticking up what they drink, you know, that that ain't gonna be very helpful. So I say to them, you know, we're giving this moropis, we're gonna try and help reduce the fluid loss, make sure everything that your your dog's drinking is gonna stay down. Yeah, so you know, we might be then less dependent on needing parental fluids to keep this patient hydrated.

SPEAKER_00 42:33

Yeah.

SPEAKER_04 42:33

So I think as long as you're talking them through it, look, it's clearly going to be getting a lot sicker. That I'm hoping your owner is is going to be better is better communication, you know, yeah, in terms of how the patient's doing than just monitoring the vomit. You know, if the fact that the patient's collapsed and not moving on the floor might be an indication you've got a problem. So I couldn't just I don't know, that's not my way of looking at it.

SPEAKER_02 42:56

Yeah. And I guess that leads us on to if so, say for example, we go back to our clinical scenario, but we've not actually got the really, really sick patient. We've got that patient that walks into the consult room and you still don't quite know why they're vomiting, but you don't know what to do next. To be honest, very generically, because it obviously depends on what's going on or what I'm expecting. To be honest, I normally give my clients a few options. I either say, if it's not that sick, if you're not that worried, you can go home and monitor and see what happens. I say I can give it some moropotent and possibly a bit of pain relief, like some paracetamol if it's a dog, if if you think it's a bit uncomfortable, I could give it like a buprenorphine injection if it's a cat or whatever you think is going on. So you could give it some symptomatic treatment and see what happens. But with those caveats with the moropotent, you could do that and offer them some baseline buds, especially a PCV total solids, because if you get hemoconcentration, then you might be more inclined to say, might just want to have a bit of a better check as to what's going on before we do much else. Or you go full on and offer them abdominal imaging as well as those as as well as those things. I might say, I'm a bit suspicious of something more going on. This is probably what I'd suggest, but in terms of my best option that I would consider for that patient. But I generally always give them the options and then see what they want to do. So but I don't know if it's the same for you.

SPEAKER_04 44:10

It's actually a bit different. And I think there's two things going on here. There's GP versus Emerge, and there's possibly older versus younger. Because I don't think I would give them the options like the way you've stated. Do you know what though? There isn't many voices for general practitioners. But normally a good general practitioner knows their client. We talked a little bit about the consult, you know, and how we're building up trust and talking about values and listening to them. And hopefully, then oftentimes in general practice, if you've been there a few years, you know, you might know their family, you know how they react to things. So we're we're we're guiding them through it. Now, look, there isn't a specialist that's going to do it like this, but they don't understand what our role is as a GP vet and as a general practitioner vet, we're guiding our client through it because we're guiding them through this pet, their other pet, and all the way through their pet's life. What I would say to owners is I would explain why I think this might be the best course of action. So if my patient is wandering around the room and sniffing treats but not quite eating them yet, you know, the vitals are all normal. Obviously, I'm going to say, look, I don't think you need a blood test at this stage. I, you know, because the vitals are normal, the patient's going around the place, I think we can just try this injection, see how you go, but do come back if things get worse. So that would be if the patient flags me up, you know, temperature's a degree or two lower, heart rate's a bit higher, patients, especially if the patient's lying down at the end of the console, obviously I'm gonna say, look, I really think we need to do a blood test and go from there. I normally go in, I might go into ad imagery, but I might just say, let's do a blood test. What we're checking for is, you know, is there something a bit more going on that we need to do more investigations on? Now probably as simple as that. I don't even talk about admission really, because I think I'm gonna get my blood test and then put and then I'll say what we'll do is we'll put everything together, we'll put the symptoms of history and the blood test results together, and then we'll have a chat. I and I'll and I'll normally pre-warn them so they've got a little bit of time just to work things out in the head. But I'll say to them, if we're seeing signs of shock on the blood test, um, then I'll I'll probably want to admit them for for fluids, etc. Um and more investigations. So they've got a heads up. So then when they get the results 20 minutes later, they've had a bit of time to process everything.

SPEAKER_02 46:17

The only thing that I would say is I always mention the other options, even if I don't like if I have a really bouncy dog that I think I'm convinced has just eaten something that I shouldn't have done and it's just got gastritis, then I will be like, it's probably gonna be fifth be fine with just some anti-ometic and going home. But I will say I cannot rule out these other things without doing these things, but do I think they're absolutely necessary at the moment? No. Because and the only reason why I cover myself doing that now is because I have missed the odd gastric foreign body and things like that, where I've been like, ah, I think it's fine. I think it's just eating something that doesn't agree with it, sent them home. And then two days later they've been like, You told me it wasn't anything. And because they are the ones that you'd miss. They're not like a classical foreign body and they they don't present in all the normal ways that you go ding ding ding. I need to open that up. So I think I I would just give yourself a quick one-liner to say, I cannot rule out anything else without doing these things. But do I think it's absolutely necessary at this point? Probably not, no. So, and it it just means that you've planted that seed so that if things don't get better or they get worse, people know what to expect. But again, that's just that might be me being over cautious.

SPEAKER_04 47:19

As you said that, I thought how subtle all this is. Because I think I bet you if if we looked at mine in your consultations, they'd be really remarkably similar.

SPEAKER_02 47:26

But um, anyway, okay, so we've we've spoken about using Moropitent as one of our possible emergency drugs. But obviously, there are other anti-emetics and prokinetics that we can be thinking about. I know that a lot of people in practice will use onansitron, so I think that's something that you can consider, especially if they're feeling really, really sick. Um, but one of the other things that I mean I use all the time is metaclopromide. And I think the really nice thing with this is that I find a lot of my vomiting patients, especially the ones that I'm hospitalizing, also have ileas. So it's really, really nice to use in these patients. But the biggest thing that I would say is be very, very careful. Do not use it if you're suspicious of a foreign body, because I have seen one rupture before. So just be very careful. And again, it's probably anecdotal because I'm not even sure whether there's evidence out there to say whether it's better or not, but I always use a CRI. If I've got a hospitalized patient that's vomiting, I always use a mesclop CRI rather than injections because again, probably anecdotally, I just find it works better. I don't know why, but I just find they feel better faster and they eat faster rather than so if they're inappetent, I just find that they get eaten quicker. And generally, if you're using a CRI, you want, I think it's one to two MIGs pick over 24 hours. And actually, I've got a little CRI calculation, which makes things really, really simple. Because I know before I started doing emergency, CRIs were like really bloody scary. So I've got a little really like CRIs for dummies like calculation that I use all the time. So I can I'll post that on social so that everyone has it. But yeah, so you it that's something that I always use. So I don't know about you, are you using them?

SPEAKER_04 48:58

Yeah, I think I use mesaclophamide in the context of regurgitation mostly. So yeah. So um Ilias, I'd use it then as well. I would use it as a CRI as well.

SPEAKER_02 49:07

Like the only other thing that we want to briefly cover here, because it's a bit of a it's another one of my ranty subjects, is using proton pump inhibitors and acid suppressors in these guys. I feel like when I qualified, I used to give everything a metrazole, like everything. If it vomited, I gave it a metrazole. If it was hospitalized with vomiting and diarrhea, it had a metrazole. I mean, feel free to disagree with me if you do, if you do, Brendan, but I hardly ever prescribe a metrazole now, hardly ever. The only times that I am is if I'm suspicious of a gastric ulcer and or if I think there is considerable GI bleeding, or if I do honestly think that it is an acid reflux problem and which, you know, would would hit your sort of brachies, etc. But to be honest, otherwise, I do not use it. And sometimes I find that patients can that are on a metprozole can actually feel more sick because you've given sometimes I find that the vomiting can be a bit of a side effect or nausea at least. So if you want to use it, just think, why am I actually using it? What difference is it actually going to make? And if you can't give yourself a convincing answer, don't use it. Do you feel the same?

SPEAKER_04 50:13

You put a lot of provisos in there, and I thought, well, that does add up to a few of the patients because your brackets, your e-gurge cases still have it, yeah.

SPEAKER_00 50:21

Yeah.

SPEAKER_04 50:22

Do you know? I don't know if I've come to a conclusion about my HGEs that are vomiting bloody, like red, red, watery vomit. I probably would give them a niprosol, I think. There's that really good study where if humans have an NSAID and a protopart inhibitor, they're more likely to get an ulcer. It's not preventing.

SPEAKER_02 50:41

Yeah. And actually, I was speaking to a specialist a little while ago and they were saying when when you used to prescribe like high doses of steroids to something that, I don't know, if you wanted an immunosuppressive dose or something for an IMHA or whatever, they then said you shouldn't be using a meprazole anymore. It doesn't make any difference. Don't use it. So whether that was one specialist's opinion, but now I just hardly ever use it. And when you say that you're using it in your regurge cases, if it's true regurge, then the stomach's not involved, right? So why are you using it? Is it is it because of your esophagitis? Is that why you're worried? Yeah, fine.

SPEAKER_04 51:12

Yeah, because I don't want acid in my esophagus causing esophagitis, then that's going to really screw up my recovery.

SPEAKER_02 51:17

Just wanted to clear that up. Because if you if because when we were saying obviously regurge is to do with pretty much an esophageal disorder, then we're treating the esophagitis, not the regurge itself. Um I know it's not strictly vomiting, but we see it all the time alongside um alongside vomiting as well. The one other little soapbox I'm gonna step back on as well while we're here. If you have a diarrhea patient, please don't use metronidazole. I think it it was used all it used to be used traditionally all the time. But if you're unsure why I'm saying it, look at the BSAVA guidance in terms of, you know, they have all those posters that protect me stuff. It makes it super, super clear. All of the evidence shows that metronidazole is not needed in your diarrhea patients. If you have evidence that there is an active infection and that metronidazole will treat a specific active infection, that's fine. But it is not indicated in an acute diarrhea case, and I'm just going to put that out there right now.

SPEAKER_04 52:15

Yeah, I do think uh in out of hours, I I feel like people would go in IV with metronidazole sometimes. Is that right? And and that's that seems like really hard to justify to me.

SPEAKER_00 52:26

Yeah.

SPEAKER_04 52:27

Is that something or is that not something anymore? I'm I'm a year out and I can't quite remember.

SPEAKER_02 52:31

Yeah, I think to be honest, to be honest, if people are using IV metronidazole for diarrhea cases, I would I would politely suggest that they have a look at the up-to-date evidence because I don't think it's indicated.

SPEAKER_04 52:43

I thought you were gonna say, I would politely suggest they have a look in the mirror.

SPEAKER_02 52:48

Well, maybe that as well. But I think, you know, don't get if you're if you're treating an infection and you don't have something like Coamox IV and you're having to bundle a couple of antibiotics together to give yourself broad spectrum, then yeah, fine, if you need to use it, then whatever. But you're treating an infection, it's different. Just because they have diarrhea does not mean they have an infection. Don't give the metronidosol.

SPEAKER_04 53:07

In the healthy dog with colitis straining mucus fresh blood perfectly well, it's not that the metrosidosol, metrodidosol, in my opinion, will actually fix them in a day. However, there seems to be fairly average, not great, but some evidence that the microbiome, the gut health is affected long term. But that also seems to be the case for any antibiotic. So this is where there's been like five, ten years of this building up, and I don't think we've really got a clear idea. So I don't want to get too shirty about all of this stuff. I'm actually quite open-minded, but I am just aware that I'm uh with any antibiotic, and certainly with metronizole, that I might be doing long-term harm to the gut. Do I really need to do this? And, you know, we're we're also aware of allergies increasing, all these other problems increasing. Maybe we're contributing to it, but I've got an open mind rather than a this is definitely a bad.

SPEAKER_02 54:04

Yeah. I think it's just that as long as people are can questioning why they're doing it and they're they can have a valid reason why they're doing it, I'm happy. Everybody is different. You know, if you feel that that patient desperately needs it and you've considered it, you've just not gone, it's got diarrhea, I'm giving it to it, then for me that's fine. But it's just don't automatically think that it needs it, is what I would say. But anyway, okay, so I feel like we've banged on a little bit in terms of medications that we can give these patients in terms of symptomatic treatment. And we know that vomiting is a really, really vague symptom and it can be caused by so many different things. But I think maybe we should have a little chat through some of the conditions that we can commonly see with vomiting. So if we were going to get true gastrointestinal conditions as our source of vomiting, what kind of things would we be expecting to see?

SPEAKER_04 54:53

Did you know what for vomiting? There's so many differentials. I'm not sure I even know how to organize in in this in my head, but how do you go about this?

SPEAKER_02 55:01

Yeah, I mean, there's always gonna be ones that are higher up on my list, but I find it easier to do it by age because there are so many things that are gonna be far more common in puppies versus ones, things that are gonna be far more common in your geriatric patients. So, for example, if I have a really young cat or young dog, so less than two, say, my top hitters are gonna be dietary and discretion, foreign bodies or intersceptions, parasites, so giardia is your classic, toxicities, because they're curious, they're into everything, they want to eat everything, they're bouncy, they're all over the place. Infection, obviously, your big one in puppies is your pavo. So that's something to definitely be aware of. And obviously, acute hemorrhagic diarrhea syndrome is always on my list. But they're probably my top hitters in terms of young dogs. When you're going into your middle-aged cats and dogs, yes, the same things are on your list, but then higher on my list for these guys is probably more like food allergies and IBD, um, pancreatitis. In your getting towards older female dogs, pyometra, never forget pyometra can cause vomiting. So obviously, if they've PUPD at the same time, but always, always ask, are they entire? Have they been spayed? Just double check because you do not want to miss that closed pile pio. Equally, in your male dogs, remember to rect all them. There could be a prostate problem. And I've had a lot of prostatitis patients that come in acutely vomiting. So that's worth checking. Um, AHDS, etc., but also coming in more into play here, sort of in your slightly anything over sort of two-ish, I'm more worried about my metabolic conditions, Addison's, diabetes, list goes on. There's so many. So all of the things that could be going on, you know, CKD, etc., all of those things that could be going on that could be wanted to make them vomit. And then I guess for your much older, so your geriatric patients over over eight or nine and a dog, over sort of 11, 12, and a cat and are older. Yes, you've still got all of the previous ones, but then higher on my list are going to be things like CKD, hepatitis disease, neoplasia, etc. And I guess, you know, you've always got other differentials, your gastric ulceration, etc., is always going to be different things that are on there. But I think you're already going to be directed towards those things by your history and medication questions, etc. But I uh if you want rough ballparks of things that are always on my list, I go by age because it's just finds a bit easier to organise. So does that make sense?

SPEAKER_04 57:25

I think um it's I think we've said this, but it's worth emphasizing that um uh we were 30% of our bandwidth is also on is this a chronic problem that's flared up? Even more so in cats. But yeah, but yeah, I I think that's a really good way to look at it.

SPEAKER_02 57:39

Yeah, yeah, we did yeah, we didn't say chronic enteropathy, did we? But they're definitely on there. So yeah, if you've got like your more chronic problems and stuff that's that become more acute, but it's been going on for a while, then yeah, definitely. So okay. So we've had a think about what could be the cause of vomiting in these patients. And we had a little chat about okay, if we had our emergency patients and we had uh hypovolemia and we needed to get them in and get them hospitalized and get them off fluids, blah blah blah, that we'd be doing bloods. So obviously, blood work is one of the first things that you want to do in terms of your diagnostics. And the only other things that you could add in in terms of the bloods that we spoke about before are things like your pancreatic lipase snaps. And I guess probably T4, obviously, is your big one in cats as well. Make sure they're not hypothyroid and that's why they're not vomiting. But apart from sort of your normal blood work, which you would do, which is kind of self-explanatory, and your history will tailor you in terms of what you're going to want to check for, but obviously your next big step is imaging. So we can be talking about ultrasound or abdominal x-rays. And I know you probably got from the Disney episode that we both really love ultrasound. And I think for me, ultrasound is my go-to in any patient that's vomiting before I consider X-rays, even if I'm considering a foreign body, because I find it easier to diagnose on an ultrasound than I do on an X-ray. That's just I find it easier. But are you the same? Are you generally ultrasound in these patients before you're sticking them on an X-ray table, or does it depend?

SPEAKER_04 59:01

I'm yeah, I think some kind of imaging is coming up pretty quick. If I've got a sick patient that's sick enough to need blood work, that's sick enough to need admission, I'm going to do some kind of imaging. And obviously, it's usually easier to get a basic ultrasound in. And it can give you a tiny bit of peace of mind, can't you? But for foreign bodies, I I like both. If I if I had my pick, and cost was not an issue because often it is, then I would be wanting to do abdominal x-ray, right and left lateral abdominal x-rays, and then an ultrasound after I've had the x-ray. So I look at the x-ray and kind of it helps me with framing what I'm doing with the ultrasound a little bit.

SPEAKER_02 59:36

Yeah, I think everyone's going to be different, and you have to play to your strengths here. You know, you have to say, what can I do that's going to give me the best answer? The as in what's going to be the most diagnostic quickest and save the clients a little bit of money as well by not doing every test under the sun. But I generally go for ultrasound first because it gives you the information like, is there free fluid? Do all the organs look normal? Is there peristalsis? So you get a lot of information. Is there obvious chronic gut thickening? Blah, blah, blah. Is there an obvious mass, etc.? So I feel like it gives me more information faster. And for me, actually, when I look for a foreign body on an ultrasound, I'm not actually looking for the foreign body, I'm looking for a few easy things to spot. So if you have two distinct populations of intestine, so one part of your small intestine that's really empty and not moving, and then one part that's super dilated and full of fluid. And often they're hyperkinetic. So they're really trying to push that thing through. But to be honest, by the time they're normally that sick, then usually not moving either. And you normally accompanied with that have a really big stomach. So you've got stomach dilated with fluid and food, and it literally like swirls, doesn't it? You see all the fluid like woo, roo, like swirling around in the stomach, it's gross. And as soon as I see that, I'm like, I think it's got a foreign body. Even if I don't get acoustic shadowing in a particular area or I can't actually see a foreign body, because I'm not often expecting to on an ultrasound. But if I see those things and the history fits with a foreign body, especially if I have a metabolic alkalosis with a hypocharemia, I'm like, there's a foreign body in there, I need to get it out. So, and to be honest, I've opened quite a lot up that have been foreign bodies without even x-raying them because for me, I'm convinced enough. Um, again, if you've got some of those symptoms that you're not sure, absolutely x-ray them as well. Because then if you see a stone, you're like, bingo, there it is.

SPEAKER_04 1:01:24

So, but equally if you feel yeah, I think you should x-ray them at some point, don't you? Because you might see, you might have a blockage, but you might have something else. You might have three.

SPEAKER_00 1:01:32

Yeah.

SPEAKER_04 1:01:32

You know, and two aren't causing a problem yet. Or do you know I think I think once we are at that point where you're prepping for theatre or whatever, you might as well get an an X-ray or two. Yeah, I think I I don't think we're that different actually. Oftentimes I will just do the ultrasound because it's easier and quicker. It depends what the patient's like. But if it's kind of a lively dog, I might kind of go, oh, let's and I'm suspicious of an obstruction, then I might just go, oh, let's give it a little bit of sedation and uh X-ray and then ultrasound. But in other contexts, if it's sick, I probably will go ultrasound first. Yeah, so it doesn't matter, does it? It's it's subtle things.

SPEAKER_02 1:02:05

Yeah. And remember as well, it's worth saying that you know, we can do all of this work up, and sometimes it's that horrible question of is it a foreign body? Isn't it a foreign body? Should I open it up? Should I not? Remember, an X Lap in a way is still a diagnostic tool. So, you know, a negative X LAP isn't necessarily something that's gone wrong because it still tells you there's not a foreign body and it gives you a chance to biopsy tissue that doesn't look normal. So what I would say is actually consider an XLAP or surgery like that as a bit of a diagnostic tool in these cases, because sometimes you just absolutely can't work out why they're vomiting. The other thing that I would say, because this has caught me out at least once in my career, remember you can get esophageal foreign bodies. So if it looks like a foreign body, it smells like a foreign body, but your imaging isn't telling you it's a foreign body, make sure you image the chest because you might go, What's that in the esophagus? So just double double check. Um, I had one once where I took it all the way to theatre for a foreign body, was convinced there was one, couldn't find anything in the GI tract. And then I was like, I looked at my nurse and I said, Did you say that you struggled to get the esophageal stethoscope in? And she went, Yeah, I can't get it in for some reason. And I thought, oh my god, it's in its bloody esophagus. And it was, it was like a massive dog that had eaten a, I think it was like a raw hide, I don't know what it was, it was something big and it was completely stuck in its esophagus. And I managed to pop it into the stomach and get it out via gastrotomy. So, but yeah, anyway, uh that's a bit beside the point. But just make sure you double check the esophagus, don't miss it.

SPEAKER_04 1:03:36

So Yeah, you usually you're unlucky there, because usually esophageal FB will give you like either the hard swallow, and then you have to sit back and watch them, and then every, I don't know, 30 to seconds to a minute and a half, they'll do a little hard swallow, won't they? Or sometimes you get a little bit of um patilism, a little bit of a drool. Um, those those kinds of things are normally going, oh yeah, esophageal. But uh they can be horrible cases too, they can't always be shifted, can they?

SPEAKER_02 1:04:02

And then I guess at this point, you know, hopefully we've got to the point where you've got a diagnosis. And, you know, we were gonna potentially t talk about treatment at this point, but the thing is, is you could be treating for anything because you know, if you've got an Addisonian patient, you're gonna be treating it completely differently to if you've got a Pyometra or if you've got a foreign body, or you know, there could be so many different things that are causing it. So, what I would say is the biggest thing with all vomiting cases is to stabilize them the best you can, give them pain relief, give them anti-emetics, perfuse them in terms of your fluids, and then deal with what you find. So, as always, I feel like we've thrown a lot at you and we've discussed a lot today, all the way from defining what vomiting is versus regurgitation, what workup we might do, what stabilizing stabilization we might do, uh all the way through to what kind of things we'd be looking at in terms of our differentials. So thank you for bearing with us and well done if you've got this far.

SPEAKER_04 1:04:53

Yeah, so um key takeaways really is stabilise before investigating, you know, be really be looking out for signs of shock and uh dealing with that immediately before getting further on with the case. Um, and remember that sometimes what looks like a treatment failure is actually a misdiagnosis, you know, i.e. regurgitation versus vomiting.

SPEAKER_02 1:05:11

We hope this has been somewhat useful and interesting for you. And as always, we'd love you to get to get in contact with any comments or suggestions that you have for us, any questions or topics that you'd like us to cover next.

SPEAKER_04 1:05:21

Thanks again for listening to the Chat Events Podcast, and we look forward to seeing you next Sunday for our next two-week takedown episode, where we'll be covering neutering, when and when not to, Brussella, big topic, and much more. Until then, it's buy from me.

SPEAKER_02 1:05:37

And buy from me. Take care.

SPEAKER_01 1:06:00

For clinical judgment judgment or individualized patient care.

SPEAKER_03 1:06:02

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