Episode 26 - Bonus Episode! The Dreaded Heatstroke and SIRS

Heatstroke. SIRS. Two words that can make even experienced vets feel uneasy.

In this bonus episode of the Chatty Vets Podcast, we take a proper deep dive into the challenging world of heatstroke and Systemic Inflammatory Response Syndrome (SIRS) — from what’s actually happening inside these patients to how we can realistically manage them when they arrive in practice critically unwell.

These cases can deteriorate incredibly quickly, become extremely complex and, sadly, often carry a very poor prognosis. We explore the pathophysiology behind heatstroke and SIRS, the complications that can develop, what we should be monitoring, and the practical considerations around stabilisation and ongoing treatment.

But this isn't just an ECC-level discussion.

As always, we try to take the complicated physiology and bring it back to everyday general practice. What can you realistically do when a severe heatstroke patient walks through the door? What should you prioritise? What should you monitor? And how can understanding what's happening physiologically help you make better decisions when things start going wrong?

We cover the science, the practical management and the difficult realities of treating some of the sickest patients we see.

Whether you work in GP, emergency or referral practice, this episode aims to leave you feeling a little more prepared for the next heatstroke or SIRS patient that comes through the door.

🎙️ Grab a coffee, get comfortable, and join us for a deep dive into one of veterinary medicine's most challenging emergencies.

Loved this episode and want to hear more about ECC cases? Or still confused and wanting a bit more help with these tricky emergency cases? Come along to our new ECC CPD events! The first session is being held entirely ONLINE on Thursday 24th September 2026, and we'll be covering how to manage DYSPNOEIC CATS in GP practice. Click the link below for information and tickets, get yours NOW before they sell out!

https://www.chattyvets.com/event-details/how-to-ace-emergencies-in-general-practice-dyspnoeic-cats

Interested in the CRI calculation we were discussing? Here's the link:

https://www.instagram.com/p/DV6aZBhDIFW/?utm_source=ig_web_copy_link&igsh=MzRlODBiNWFlZA==&igsi=MzRlODBiNWFlZA==

📖 Read more & explore our blog:
 https://www.chattyvets.com/blog

📲 Follow us for more:
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Facebook: https://www.facebook.com/thechattyvetspodcast

💬 Got thoughts on these topics? We’d love to hear them — drop us a message or join the conversation online.

Transcript

SPEAKER_03 0:09

Welcome back to the Chatty Vets podcast. I'm Brendan. And I'm Charlotte. Thank you for tuning in. We're back again with our extra bonus episode this month, you lucky people. We hope you enjoyed our two-week takedown episode last week, talking about the exciting new GI quest from Karas Animal Health, along with a few new medications that sound really promising for CKD treatment in cats and CHF in dogs.

SPEAKER_00 0:31

Yeah, it was a good one last week. I like that. I had a good old rant as usual. Today we're changing it up and going back to one of our clinical deep dive episodes. We're diving into the pits and chatting through those cases we've all come to dread. Heat stroke and SIRS.

SPEAKER_03 0:46

Yeah, we've we've all seen or heard of those horrible cases of dogs being trapped in cars or French being walked in 30 degree heat, and they're really not the cases that we look forward to. But don't worry, we're here to try and break these cases down for you a little bit and hopefully help them to feel a little bit more manageable in practice.

SPEAKER_00 1:05

Yeah, they're like the worst cases in the whole world. But anyway, before we get started, we wanted to mention we've got a CPD event that we're running soon. You may have heard us chat about it last week, but if you're interested in things ECC and about hearing about topics like SERS and heat stroke, you're gonna love our new CPD stream.

SPEAKER_03 1:23

Yeah, so on Thursday, the 24th of September, we're launching our new ECC stream, How to Ace Emergencies and GP Practice, and we're kicking it off with Dyspnea in Cass. Yeah.

SPEAKER_00 1:34

We're holding a completely online event in the evening. Uh, we hope the session's gonna be really interactive and discussional, helping you to work your way through these scary cases in the madness of GP practice.

SPEAKER_03 1:45

Yeah. So if you're interested in attending, click the link in the show notes and it will take you to our website where you can get all the information you need about the event, plus the link to get your ticket now before they sell out.

SPEAKER_00 1:55

Yes, go and grab yours now. But back to the task in hand today heat stroke and SUS. Such a big topic.

SPEAKER_03 2:03

We've normally all got cases that we can remember very well and probably probably will struggle to ever forget. And I had a horrible one a few months ago, but we'll dive into that a little bit later on in the podcast.

SPEAKER_00 2:14

Yes, sorry. I'm in a really it's too hot here. You've got two layers on. I see you've got your new uh top on. Is that right? You've got your give it Star Trek.

SPEAKER_03 2:23

I am oh thank you. So, yes, well, that's worth us mentioning, actually. So we collaborated with Happy Threads Scrub. So thank you very much, Happy Threads Threads, for sending us our new uniform. So we've now got lovely new jackets, which it's August, but I live in North Wales, so I'm still wearing mine. And we've got some really nice new uniform that we're starting to wear as well. So we'll get some pictures up on socials if we haven't already by the time this gets released. So keep an eye out. So thank you very much to Happy Threads for doing that. And basically, we will be launching a really exciting collaboration with them soon. So keep an eye out on our socials for more information about that. But actually, I feel like it's probably worth us mentioning here, Brendan. We actually have a little third member of the team that's joining us, don't we? We wanted to mention lovely Lauren who's joining us. And so Lauren is she's been a friend of mine for a really long time, um, and she's a registered veterinary nurse who works with Brendan. And basically, she's joining us um to help us with some of our social media, answering emails, and she will start to become a little bit more of a part of our chatty vets team. So you might not hear her hearer on the podcast, but she'll be working away in the background, helping us to run the madness of what has become the chatty vets. So you'll have a little lookout for our socials and you'll get to see who she is. Um, and if you do get in touch with us, it might be her that replies at some point. But um, yeah, so thank you very much, Loss, for coming on board.

SPEAKER_00 3:40

Yeah, definitely needed. I mean, uh yeah, I'm overheating here, so definitely not two layers. I I need a little paddling pool, I've realised, under my laptop so that I can put my feet into it to keep cool because I am I am dying here.

SPEAKER_03 3:53

You need one of those fancy little handheld fans that sprays water at you at the same time.

SPEAKER_00 3:58

I know. And this is very topical, isn't it? We're gonna do a heat stroke, SUS deep dive in the boiling heat, but there you go. Let's do it. Where where do we start off then?

SPEAKER_03 4:06

Yeah, so basically we put in heat stroke and SUS together, and you might be thinking, well, you know, why have they done that? Why don't they just do an episode on SURS and why do an episode on heat stroke? But you can't really talk about one without the other. So what we're gonna do is start off talking about SURS, which is systemic inflammatory response syndromes, to anybody who might not know what we're talking about. And I think it's really important to try to sort of work through that first to actually be able to explain what heat stroke is and how it how it all progresses.

SPEAKER_00 4:30

So I was gonna say, if you think you've not seen SURS before in GP practice, you have. What's what's gone on though is every time you've looked at SERS, you've gone, oh that one's dying. Why is the vet fiddling about with that? Just, you know, because uh I think on in general practice, that's really how you go because you see effectively you're starting to get multi-organ failure. So you might see the breathing getting worse, you might see the kidney function getting worse, or you know, or they start bleeding out or bleed getting bruising or whatever. And they're like, oh my god, they're really dying. Now, when you're in emergency critical care, that's like you just you don't go, oh, they're dying, let's put them to sleep. You go, oh, they've got SIRS. We can let's try and treat that. And okay, you don't have success all the time. You know, it's a hard world, but you can sometimes get a good outcome in these cases. So that's why it's worth talking about.

SPEAKER_03 5:19

Yeah, exactly. So starting from the beginning, I guess, SIRS or systemic inflammatory response syndrome is basically describing a generalized inflammatory response that your body will have to a significant insult. Now that might be infection, which is where you then get into sepsis, or it might be non-infectious, and that's when we lead to like a sterile pancreatitis, trauma can cause it, heat stroke, which is how this plays into today, burns, immune-mediated disease, or sometimes surgery. So if you have really extensive surgery. But it is important to remember sepsis is a type of SERS because it's caused by an infectious insult, but it's not exactly the same thing. So just because you think you've got a SERS patient does not mean that they're septic automatically. They can be septic, but not necessarily. So sepsis is where you have SERS that's caused by an infectious process. So for example, if you've got, I don't know, a pyothorax in a cat that then starts to develop symptoms of SERS, you can then say, okay, that's likely septic because it's developed SERS from a septic insult. Does that make sense?

SPEAKER_00 6:19

So basically is there always a little bit of uncertainty though? Because it's pretty hard to know for sure. I mean, I might even reach for IV antibodies because they're so critically ill without knowing if there's an infection. I don't know where, yeah, we're gonna come to that later, probably.

SPEAKER_03 6:34

Yeah, we'll come onto that a little bit, but sometimes you get that crossover where sometimes you can have a SERS patient that then develops sepsis because of the SERS for certain reasons. So, but yeah, we'll get onto that a little bit later. And sometimes the lines can be a bit fuzzy. The thing that I find really interesting about the beginning of this is how you characterize it in the first place, because everyone is gonna be going, well, you know, fine, you can say that things have this severe inflammatory response syndrome, but how do you characterize it? How do you know which patients are developing it? How do you know which patients are in SERS? Now, there is some really not very useful criteria about the threshold as to when you can say SERS is happening. So in dogs, you need generally two or more of these categories to say that something is in SERS. So it's when they have a temperature of less than 38.1 or more than 39.2, a heart rate of more than 120, resp rate of more than 20 breaths per minute, and a white cell count of less than six or more than 16 times 10 to the power of the nine. But if you all imagine, you get a bouncy Springer Spaniel puppy that comes in and it's slightly warm outside, temperature's gonna be 39.3, it's gonna have a heart rate of 140, and it's gonna have a resp rate of 60 because it's really excited. Now that doesn't mean it's in SERS, it just means that these are sort of for a patient to be in SERS, they have to meet this criteria, but it doesn't mean that every patient that does meet this criteria has SERS. Does that make sense? Um so I would be a little bit careful with interpreting it.

SPEAKER_00 8:00

They're overborrowing here, because in humans they have, I think it's called sofa or whatever, cued sofa or something, where they have very similar criteria. But I think the reason that it's so broad is they they they then funnel that patient off to whatever department in human health that looks after the really sicky ones. Whereas in our world, there isn't a we that generally isn't happening. So I don't know if it's I think that's a little bit yeah, slightly unhelpful, isn't it? But yeah, it's it's still good to have it gives you a rough idea where you're looking.

SPEAKER_03 8:29

Yeah, definitely. And I think if if you want to talk about cats, so we've mentioned the threshold for dogs, but in cats the threshold is a little bit different. So generally, if their temperature is less than 37.8 or more than 39.7, this is Celsius, we're talking about obviously, if their heart rate's less than 140 or more than 225, if their respirate is more than 40 breaths per minute, and if their white cell count is less than five or more than 19.5 times times 10 to the power of 9. Now, remember, cats can be a little bit different because often they go bradycardic when they're sick rather than tachycardic. So that's something to remember, and often they can drop their temperature rather than going hyperthermic. So it's just something to remember.

SPEAKER_00 9:10

Absolutely. That's good. Go on then. I mean, Charlotte, tell me, how are you working these cases out? I mean, yeah, that's not important.

SPEAKER_03 9:17

I th no, exactly. I think to be honest, the time when I'm thinking, okay, something could be going into SERS and potentially sepsis if you've got that infectious process, is when we're looking into the different types of shock that these patients are in. So these patients are not well patients. They are patients that you're you look at and you go, that looks really, really poorly. And then when you start to do your clinical exam, you start to realise how poorly they are. The big reason why we get really worried about SIRS is that if you have this systemic inflammatory response syndrome, it can lead into what we call MODS, which is your multi-organ dysfunction syndrome, which basically means that all your organs start shutting down one by one. And you can say that something had has MODs when you've got more than two organ systems affected. And when you get into that category, you can then start developing things like DIC and eventually the animal dies, which is why we start to really worry. But how do we actually say that something is in SERS in the first place? Now, the first pointer for me to think, is this in SERS? is if the patient is in shock. Now, we spoke a little bit, Brendan, previously, didn't we, about hypovolemic shock. So generally in your ECC patients that come in and in dogs they're normally tachycardic, in cats they can be bradycardic. If they're in hypovolemic shock, they often have these pale gums, they have a sort of faint pulses, and their blood pressure can be low. And usually it's because they're, you know, they're hypovolemic, they need fluid boluses. But there's a different type of shock called vasodilatory shock or distributive shock, which is a little bit different, and it gives you a bit of a pointer that something is more likely to be heading towards the SURS direction. Now, when you have hypovolemic shock, it means that there's not enough fluid in the body, there's not enough fluid in the intravascular space. When you have vasodilatory shock, it's not necessarily that there's not enough fluid, it's just not distributed into the right places. So the vessels become very dilated. So the blood sort of pulls places where it shouldn't be, and you can get things like peripheral edema, so you can get a swelling in the tissues. And really, what you need to happen is those vessels to constrict and get the blood where it really needs to go. So basically, distributive shocks not always caused by surgical sepsis. It can be anaphylaxis, it can be neurogenic shock. So if something's had, I don't know, a horrendous traumatic brain injury, for example, then sometimes you can get vasodilatory shock. But generally, in terms of clinical exam, what you're expecting is more hyperdynamic signs, which are due to the impact of the inflammation. So usually in dogs, especially, you get like a bright red or brick red gums. So they look really, really red rather than being pale. In cats, often they tend to be pale confusingly. The capillary refill refill time tends to be quick rather so like one second, half a second, rather than slow in your hypovolemia. The pulses, instead of being weak, often are bounding, so they're much stronger than you'd expect because they're sort of in that compensatory phase. And often patients can the difficulty is with these is that they can also become hypovolemics, which we'll explain in a minute and can complicate things. But generally, the big things to take away are they still have a low blood pressure, so they're hypotensive, but the pulses are bounding, the gums are normally red, the CRT is very quick, but they're still tachycardic. So that's the way to sort of differentiate them. And when I see those symptoms in a patient, I'm thinking, this looks vasodilatory. Why? Have we had an anaphylactic reaction? Is there something neurogenic going on, which normally is more obvious because you've got neurological signs, or is this CERS or sepsis? So, okay, let's put that into a bit of a clinical context because I know it's all sounds a bit confusing. So if you had say a three-year-old dog comes in and it's collapsed and it's got injected, so these brick red mucous membranes, it's got a CRT of one second, bounding pulses, heart rate of 180, and it's hypotenses with an MAP of 65. What do you think the first thing is that you're going to want to do? Brendan, if you had a patient come in like this, sort of regardless of history, what's the first thing that you're going to want to do for these patients?

SPEAKER_00 13:07

Well, shock fluids in terms of the bounding pulses, right? It's really distinctive, isn't it? It feels like, to me, it feels like someone's tapping your finger, like I'll feel the femoral pulse, and it'd be like a sharp, quick tap. And it's really distinctive rather than a long pulse kind of thing. It's it's boom boom boom. Yeah, uh yeah, uh well, it's shock fluids, oxygen, uh pain relief.

SPEAKER_03 13:27

Yeah, exactly. So generally in these guys, the things you want to do is take them through to prep, give them some pain relief because regardless of the cause, you want to make sure that they're not uncomfortable. Give them some flow by at least, so give them some oxygen, place an IV because you always want IV access in these guys, and you're gonna need it for your shot for your fluids. And while you're there, remember to take blood, like we said before. When you're getting an IV, it's always a perfect opportunity to just grab some blood rather than sticking them again in a minute. Draw some blood, stick it into a multitude of different tubes so you've got anything that you need to use for the moment. But the mainstay to start off with these guys is shock doses. So the difficulty is with these patients is that you cannot categorically say that it's vasodilatory from the get-go. There's always that question of is there a hypovolemic component? So are they fluid responsive? Have they lost those of fluid from, I don't know, so for example, if you've got a HGE or now recognized as like an AHDS patient that comes in, they initially can be hypovolemic and then start to develop curs sepsis eventually. So you can have a component of both hypovolemia and vasodilatory shock. Now, just because you're starting to see some of the vasodilatory symptoms, like your brick red gums, doesn't mean there isn't a component of them that is fluid dependent. So I would always start off shock bolusing these patients just in case. So by shock boluses, we mean normally a Hartman's because usually these patients are acidotic. So Hartman's is great for buffering the acidosis. And generally in dogs, you're starting off at like 10 to 20 mil per kilo, usually over 10 to 15 minutes. And then in cats, we're a little bit more conservative, so we go maybe five to 10 mil per kilo over 10 to 15 minutes. I would keep an eye on their blood pressure, keep an eye on their heart rate and see if they're responding. Now, if they're fluid responsive, I would continue to repeat those boluses the whole time that you're seeing a response. But generally, if you're in vasodilatory shock, even if there's a hypovolemic component of it, they will get to a point where they stop responding. So they've not returned to normal, hemodynamically stable, but they basically stop responding to the fluid boluses, don't they?

SPEAKER_00 15:30

I think I I would approach it a little bit differently in that thing is you normally know, I think you've got a feeling that they're SERS or sepsis because the like the tapping pulse, tachycardia. I don't know the history, usually takes you in a different direction. You know, they're really flat. They're they're really sick animals. So I'm already because I've messed up so many cases by giving them too much fluid. I just I might do one fluid bolus. I'll be looking so carefully because I already know that I could overfluid over fluid. Because I think that's the problem is you give them too much fluid and then they get uh pulmonary edema, and their breathing goes really bad, and really their kidneys start getting worse and everything goes bad. So I think I I probably wouldn't go to my third shot fluid bolus in these cases, because I'd I'd I'd be kind of like holding back because fluid isn't the like you know, they've they've they're dilated, so their blood pressure is really tanked. So I don't know, if I didn't get any response off one bolus, I'd look at the history and try and put the case together a bit.

SPEAKER_03 16:30

Sometimes I have I have noticed in these patients because they can be both, often they can be fluid responsive to start off with because they're responding to the hypovolemia element. So sometimes you can give them one, two, three boluses and they're responding each time. But if they do have a vasodilatory component, you will get to a point where they stop responding and they're still hypotensive, you know, that MAP is still between 60 and 70-ish, and their heart rate is still really tachycardic, and those gums still look that horrible brick red in dogs, or sometimes just still pale in cats. So it you will get to a point where they stop responding. And I think that's where we need to start reaching for the next thing in our arsenal to try and get on top of this. Now, the reason why we're going into sort of treating the shock element first before you sort of really get to your diagnosis is sometimes you can't get to a firm diagnosis or you don't have time to get to a firm diagnosis until you stabilize these patients a little bit more. So that's why we're going through it in this order. But I think the next step in terms of looking at how you'd get on top of vasodilatory shock is sometimes something that people are a lot are really scared to do in general practice. So when I start talking about vaso pressors, I know Brendan, you've obviously done a lot of ECC previously, but I think a lot of GP vets are really scared about them, aren't they? People were a bit nervous to use them or just have never used them before and don't have access to them.

SPEAKER_00 17:45

Yeah, we used to use noradrenaline and I sometimes did adrenaline CRIs as well, actually. So, um which it's probably less done. Yeah, for these for these cases, my main goal is don't give it too much fluid, don't kill it with fluid. I'm kind of frightened of fluids actually in these because their blood pressure's low, they're scary. But yeah, the the vasopressors are your friends.

SPEAKER_03 18:04

It it's it's all about how they're responding. If you're getting responsiveness from giving your fluid boluses, then it's not the wrong thing to do. But if they are not responding to a big dose of fluid, so it's not bringing their heart rate down if they're a dog or up if they're a cat, it's not bringing their blood pressure up, that CRT is not improving and their gum colour is not improving, their pulses are not improving, that patient is not likely to be fluid responsive, in which case, if you keep flooding it with fluid, like Brendan said, you're just gonna overload it. So if they're responding, great, keep going until they stop responding. If they're not responding, then you need to be asking, is there even a hypovolemic component? Because if not, my fluid therapy is not really going to help at this point. So, yeah, absolutely. And that's where we would reach for vasopressors. So when you have this distributive or vasodilatory shock, all of the blood vessels basically become super dilated, and that's what tanks your blood pressure. Now, what we need to do is give something that helps to constrict those blood vessels and sort of reverse the vasodilatory component to try and get that blood pressure up. Now, the most common one thing that we use in the UK to do that is noradrenaline or norepinephrine, whatever you want to call it. So the biggest thing that I would say about this is don't be scared of it. It is something that is necessary in these cases, so don't panic if you feel like you you need to start using it. And the dose range is massive. So, like if you find a number online, it will usually be between 0.1 to 2 micrograms per kilo per minute in terms of CRI. Don't start at the top, start at the very bottom. So I'd start at 0.1, 0.2 mics per kilo per minute and titrate up. So don't be scared of it because in these patients, it's the thing that's going to try and save their lives. Basically, don't be scared. Um, I did put my little handy and well, what I got taught of is a little handy CRI calculation on our social. So I'll put the link to that post in the show notes as well. So if anybody is terrified of CRIs in general, have a little look at that because it works well for norepinephrine as well. Um, but basically the main thing is with this is that noradrenaline works because it has lots of alpha adrenergic activity, so it acts to vasoconstrict vessels, but it also has a little bit of beta adrenergic activity, so it helps a little bit with cardiac contractility. And have you ever found this, Brendan, in your surseptic type patients? When you scan their chest, have you ever noticed changes in their contractility when you look at their heart?

SPEAKER_01 20:24

Yeah, god yeah. Their hearts are rubbish, their hearts are like little, they're just like this, they're hardly doing anything. Yeah, yeah, a little weird. And you look at it, you're like, fuck.

SPEAKER_03 20:34

Yeah, that's scary. Yeah, exactly, exactly. Now, some of you might be going, what the hell are they talking about? Especially if you're not used to pocusing and you're not used to tea pocus. But basically, in any of these patients, so if they're in vasodilatory shock, SERS, sepsis, their cardiac contractility can be extremely poor. And you often can check this. So if you do a T pocus and you just, I mean, I can't do a proper echo, but say you just literally just pop a probe on the heart, you can get a mushroom view or whatever view you can find. And even just subjectively having a look at that heart, and they literally they just move the tiniest amount, don't they? It's like they're fluttering rather than giving a really good contraction. It's horrible to watch you just look at it and go, Oh God, it's yeah, it's horrible.

SPEAKER_00 21:14

I have had that, but I've also had where it's just like slow, yeah, yeah, yeah. Any number all sorts of normal. But yeah, you don't need to be a cardiologist, it's like whoa. And sometimes you look at it is the heart contracting. But I look at your patient like, no, they're still alive. And they're like, oh no, they are.

SPEAKER_03 21:31

Yeah, exactly. And and you know, yeah, don't don't get us wrong, like you can be really clever and do like your fractional shortening in an M mode. But I mean, I don't know, normally even do that. It's just to say, you know, subjectively, does it look like it's struggling to contract really well? And it is normally really obvious. So if you're used to seeing normal hearts, or you can get used to seeing normal hearts when you do see one of these cases, it will be really obvious.

SPEAKER_00 21:52

The problem here is in a perfect world, this would be a referred case and it'd be in a big hospital, and you'd have proper vets dealing with it. But the situation is We can't move these patients. You this is a patient that's arrived on you. We can't transport these patients. They're on your on your place. You can't even get them to the out of ours place because they're with you and they're really sick. So you've just got to do the best you can. You could make a case to go, we're not equipped to do this, we're a general practice, we've got all our other things going on. We haven't got the staff, you know, and we're going to euthanize, have that chat. But often, especially with these he stroke patients, they are younger. They're fit patients. If you can get them through it, you are going to get a good outcome in the end. So yeah, sometimes you just have to do the best you can. And if that means you put the probe on their heart and it doesn't look very contracty, and you know, you can't do anything fancy, then you're still just doing the best you can. That patient's all you've got. You know, they've only got you. So you just do the best you can and give it a blast.

SPEAKER_03 22:45

And sometimes that's all you need. You literally just need to pop the probe on and go, that doesn't look quite right. It doesn't look like it's fully contracting, you know. Then and that's enough to say it's cardiac contractility is probably compromised. So what I do is have a little look before you start your noradrenaline. If it still looks the same on noradrenaline, you can actually use positive inotropes in these patients. So things like pimabendan, don't get me wrong, there's loads of different stuff you can use in ECCL world and in referral, like debutamine CRIs and stuff like that. But I think ultimately, probably the thing that most GP practices are going to have on the shelf is Pimabendan, so vetmedin injectable. Like for your congestive heart failure patients that come in and they're really struggling to breathe, you can use Pimabendon in these contexts as well. I'd use like it, so the normal licensed dose at 0.15 MIG per gig, and you can use it every 8 to 12 hours as you need to, but remember it is really expensive. So obviously it's only going to be a subset of patients or ones that are insured or people that have the funds to be able to cover it, that you can use it in. But it can make a world of difference in these patients and really help their contractility. Um, it's something to consider. And you will be massively surprised you can get a patient from looking like it's on death's door in this horrible vasodilatory shop with a heart rate of 180 to its gum colour looking better, its MAP hitting 80 to 90, and its heart rate coming down to 120 by using these two drugs, so or by using a combination of drugs that are very similar. Um it's a bit scary, but it's something to wrap your head around because it is really life-saving in these patients.

SPEAKER_00 24:12

It's true, yeah. We need to talk about two things. I mean, in a perfect world, noradrenaline is given through a central uh cannula, isn't it? We do use it with a peripheral catheter, but you need to be damn sure it's in. Now, when I was doing out-of-house work, you you could often get with these really sick patients a nurse one-on-one with them. So then they're keeping an eye on your IV cannula that's, you know, it's not going to go perivascular. Because if noradrenaline goes perivascular, theoretically that's super bad because it's going to cause massive vasocontriction. And this is where human patients have lost digits and things. But yeah, you've not it's not something you you're you've got an issue with.

SPEAKER_03 24:45

I think ultimately they're at the point where they're nearly dying anyway. So anything that you can do, and for people that are not used to putting central lines in, I wouldn't be faffing around again when in, I'd just be getting an adrenaline into it because it's gonna die if you don't start giving it, it if you don't start giving it those vasopresses. So I think yes, you want to make sure that Ivy's in, but don't panic about it because the the dog or the cat is already at the point where they are starting to try and die on you. So anything that you do at this point is gonna be trying to help.

SPEAKER_00 25:10

Um the other thing with Pimabendan, I think I might have looked this up, AJ, because I think you've got me into Pimabendan in this context. But um it causes vasodilation, but if the cart's kind of really weakly beating, it'll still have a net benefit effect. Is that have I got that right?

SPEAKER_03 25:26

Is that so theoretically it's it's bad? Yeah, it's it's not the perfect drug to use in this situation, don't get me wrong. And if you were in a big hospital, there are plenty of other inotropes that I would use, possibly over Pimabendan. But I think for the context of in your normal GP practice, what you're gonna have on the shelf. Because I remember when I was in GP World uh really regularly, a lot of practices wouldn't even have noradrenaline. So you can be quite limited as to what you can even use. So, but you're more likely to have Pimabendan injectable on the shelf than you are to have, I don't know, debutamine or whatever else you might want to use. So that's why I'm saying that here there are plenty of other drugs that you can use that would probably work a bit better, but the majority of them you're not gonna keep on your shelf. So it's something that I would definitely consider using, and I have used it and it has really helped.

SPEAKER_00 26:10

Do you know this isn't for everyone, but we're in these kind of where you know it's either euthanasia or not, and then you know, I've um I've done adrenaline CRIs because everyone has adrenaline. And the benefit of adrenaline is it's gonna help your heart and it's gonna cause vasoconstriction. So you've got two, and I know every like noradrenaline is like more pure because it's vasoconstriction, it's just tackling the blood vessels and getting the blood pressure up. But adrenaline's a bit more scatter gun. It's gotta help your heart contract, causes vasoconstriction. But uh, yeah, I've done adrenaline CRIs and they've been okay as well. But um, I don't know what to do.

SPEAKER_03 26:43

I think, yeah, I think you definitely can use them, and I have used it before when I've not had noradrenaline, definitely. Um, what I would say is I won't give you any doses for that because using adrenaline is like firing a rocket at them. So you need to be really careful. Umadrenaline's a little bit more safe, I would say. So if you're getting to the point where you don't have noradrenaline on your shelf and you've just got adrenaline, I would get a referral center on the phone and be like, what dose should I use and how should I use it? Um because in those cases you want to be a bit more careful. But yes, it is something you can use. So if you're thinking, oh God, I'm stuck, I don't have anything in the practice, yes, you could use adrenaline, but just be super, super careful of the dose. So circling back to what we do with these patients and don't worry, we are coming back onto heat stroke. This will all start to make a little bit more sense when we circle back to it in a bit. But I think we really need to understand the SERS and how we get on top of it before we circle back to it. So the other thing to mention in these patients is I've had them before where you put them on noradrenaline and they're responding a little bit, but not as much as you like, and you start titrating the dose up and they're still not quite there. You give them that ionotrope, so something like pimabendan and their contractility is better, but they're still not really doing that well. And there is this sort of weird phenomenon that you can hear about in the literature called Circe. I don't know if have we spoken about this before in the podcast, I think we have done.

SPEAKER_00 27:59

In the cortisol, in the cushing scale episode, yeah.

SPEAKER_03 28:02

Exactly. So there's something called Circe, which is critical illness-related corticosteroid insufficiency. And basically, like Brenda was talking about in that episode, whenever we have an episode of shock and inflammatory disease, shock, etc., will release endogenous cortisol. But sometimes when you have prolonged overstimulation, the tissue responsiveness to that cortisol and the mount that gets released basically means that we have sort of a relative corticosteroid insufficiency. Now, that's not me saying that every shock patient should be given steroids. I'm not saying that. But if you get to a point where you think your vasopressors just aren't really working, your positive ionotropes aren't really working, sometimes it's because they need a physiological dose of cortisol. And I think there have been some people in the literature that have said about using dexamethasone for this because it's generally what people have on the shelf. But I think ideally you do something called hydrocortisone for this and you just give it a super low dose. It's your physiological dose. It's not anti-inflammatory, etc. It's not that high. It's quite a low dose. But again, if you're getting towards that point where you're thinking, I don't know if I need to give steroids, get a referral center on the phone and run everything past them. Because if they do agree with you and they think, yeah, I think it's in Cersei, you need to give it, they'll be able to give you doses over the phone and what to use. So um, these cases are really tricky because sometimes you do feel like you're in a bit over your head, but you can't move them. And that's the really tricky thing. So what we're trying to do today is to say, okay, this is a stepwise approach as to how to do it if you are stuck and you don't know what you you feel like you don't know what you're doing because you just can't get them to somewhere that can help you, which can be really horrible, can't it? It can be a bit scary.

SPEAKER_00 29:41

So So this, yeah, so this is the context would generally be, won't it, in general practice, where they've they've come in, you've given them shock fluids, they're not responding, they're really flat, and uh the blood pressure you just cannot get up.

SPEAKER_03 29:54

Yeah.

SPEAKER_00 29:55

And so then you reach so we're giving you some ideas. Okay, maybe put a probe on the heart. Is the heart really naff and not really contracting very well? Yeah. So you've got Pimabendan, you know, it's on the shelf, you might be able to use it. If you've got noradrenaline CRI, great, you can do that. And if you haven't, well, you've got adrenaline CRI if you feel you want to go there. If you don't feel confident, look, this is not wrong to go euthanasia and have the discussion. You know, because at this point you're gonna be running up a bill, big bill, you're gonna be ruining the whole day for all the other patients. You might be rescheduling appointments because you've got other things coming in. These are not easy to handle in GP practice, not saying this is what you must do. You know, you it's not wrong to kind of go, look, we can't handle this in this environment. The patient's really sick, it's not responding to fluid uh shock fluids, it, you know, we think about euthanasia. But if if you know, if you have got time, if you have got staff, if you are up for it, you know, there are you can, you know, these are some of the tools to give you the outline of how you can try to to, you know, at least give it a try. You might say, look, you know, we're not a referral hospital, but I have heard that, you know, I did put the probe on and the heart does look quite weak, and I've heard that Pym Vendor can help in these. We give a couple of things a try for an hour, but if the patient's still getting worse, maybe we call it a day. And I'll I'll just put that little boundary in so that you're not like six hours of and your whole team's demoralized when you euthanize it, you know. But um, yeah, here's some things to try.

SPEAKER_03 31:20

Yeah, definitely. We went through sort of initial stabilization of these patients first because initially sometimes you're not even taking a history before you take them through the back, their back collapse when they get into you. You're generally just rushing them through and getting verbal consent for this sort of emergency style treatment, and then you're catching up on things as you go. You might be saying to, you know, you might have got an IV in with your nurse, you might have drawn a bit of blood, and then you're like, oh God, I need to think about what I need to run, but I can run that in a second. You're starting to give fluid boluses, you're doing a clinical exam, and then you might be sort of leaving your nurse with that patient and saying, keep an eye on this, I'll be back in five minutes, I'm just gonna go and take a history. And then this is where your history is gonna try and lead you down the direction of what do we think this is? Is this a heat stroke case? Because heat stroke is a type of SERS. So, and obviously the temperature of the patient is gonna help you to wear that out anyway. Also, in terms of the blood work that you might want to do, we just wanted to run you through what you might want to run. And also, if you do run something, what you might expect in these patients. Because I think realistically we can say, okay, from the way that this is presented and the parameters that this patient has when it presents those rubbish thresholds, you can say, okay, this patient's likely in SERS, but what type of SERDs are we looking at? Is it anaphylactic? Is it neurogenic? Is it heat stroke, or are we looking at true sepsis? You know, is there an infectious component? And that's what we're going to try and run through with you now. So, in terms of bloods, don't go too crazy to start off with, go with what you know, stick to your basics. So think about just your normal hematology and your biochemistry. So it will point you in a in a really good direction to start off with. So if you had, Brendan, if you had a patient that was in SERS or sepsis, what would you expect to see on their hematology? Would you what changes do you think you'd expect to see on their white blood cells?

SPEAKER_00 33:00

I don't I think there's an element of privilege about this because in general practice, I don't think you always have this, but I know when we've got them overnight and at the weekend, we'll have several hematologies over time. And uh you sometimes see one, I think one of the things I look for is the platelets dropping, and they might be like 500 and then over like 12, 24 hours they'll be dropping like 400, 300, 100. So I think dropping platelets for me, the super low neutrophil count, and then the machine sometimes goes possible bands or whatever. And I know you meant a check, you know, but you know, if you've got time for all that. Um so toxic neutrophils or left shift on the neutrophils.

SPEAKER_03 33:37

Yeah, absolutely. Generally, it depends what point in the disease progress that you're seeing them at. So earlier on in SERS, you get a neutrophilia, so your neutrophils go up, but then later on, those you usually get a severe neutropenia, and especially with your septic patients, neutropenia is really, really common. A neutropenia is generally a poorer prognostic indicator. So if you've got a really low neutrophil count, I'd be getting quite nervous. So that's something to bear in mind. Usually you get a degenerative left shift, like you said, you can get a bit of a stress response response on your leukogram, but usually you'll see more changes in those anyway. Um, and platelets, like you said, yeah, absolutely. It's really common to see thrombocytopenia in these patients, so their platelet count to be low. And often that can become really quite severe if they start to develop DIC. So DIC is this disseminated intravascular coagulation and big mouthful. But basically, keeping it simple, when you have a patient that goes into SERS, initially they go pro-thrombotic, which means that they're more likely to get little microthrombi and throw clots, but after over a while, all of those sort of clotting factors, the platelets get used up. So their clotting times really increase and their platelet count drops and eventually they can just bleed. So that's one of the really scary things that can happen with these patients. It's worth keeping an eye on their coagulation times if you have in-house clotting times. So if you have APTT and PT in-house, and also if you can check their, you know, anyone can check platelet count on a normal hematology machine. So yeah, it's worth bearing in mind because usually you are seeing those changes. And actually, we'll come back onto this when we delve into heat stroke. But one of the big changes, so generally with your red blood cells, you're just expecting hemoconcentrations, you're expecting your red blood cell account to be elevated. But one of the biggest indicators in terms of outcome for heat stroke patient is whether you're seeing nucleated red blood cells, which sounds really bizarre because we don't really see them in our cats and dogs. But if on a smear, if you feel confident enough to check a blood smear, if you're seeing nucleated red blood cells, generally the higher the level of those that you're seeing, so the higher the number, the poorer the outcome is going to be for that heat stroke patient. So again, you can get a lot of information from your hematology. So does that make sense?

SPEAKER_00 35:51

Yeah, I do know what I'd I'd also say is look, even if you think, God, this isn't for me, I'm not going to be getting involved in this, it's really helpful to know how your patient is doing. And if you're seeing the platelet count dropping, so often I'll see the acetemia is getting worse, not better, or my patient's starting to breathe heavier because their lungs are going into ARDS or acute respiratory distress syndrome. If you start to see all these things, put the package together and go, this case is only getting worse. And but then you've got something to hang your hat on. You're not just going to then go, oh yeah, it's dying. You're going, the, you know, the platelets are dropping. I'm worried that this is turning into a really severe SURS. Owner's not going to understand SERS. I think to some extent with clients, I might even just blur this because every owner understands that sepsis is really bad. So you might kind of go, it's a type of really bad sepsis. I know it's not strictly, but to communicate it to clients.

SPEAKER_03 36:41

I mean, even if you wanted to communicate it as like a sterile sepsis, so it's not, it's a sepsis that's not infectious, if you see what I mean. Yeah, that's true. And that might be an easy way to describe it. But yeah, it can be really, really hard to get owners on board with this because it's quite difficult to understand, isn't it?

SPEAKER_00 36:56

Yeah, I think if you give them like, yeah, I think you have to really you obviously you're gonna go, it's really hard to fix them, but we're monitoring this, this, and this. And if the thing is at GP, you're you're not used to doing a blood test three hours later or whatever, but in these cases you really want to be. And if you're tracking the changes and things are getting worse, not better, it's really cool because you've now got something to go to your client and go, well, the heart rate's still not coming down, the blood pressure's still not coming up, the platelets are going down, this patient's going, and you'll end up euthanizing it sooner. Because when it's a three-year-old to bring a spaniel, you know, you it's easy to go, oh yeah, I'll just euthanise it, but actually it's not when it's really it's been fit and well and now it's suddenly really bad. You might take it much further than you need to. So knowing these changes might help you euthanise it sooner with more authority because you're looking, you're you've got a better idea of of what's going on than it's dying.

SPEAKER_03 37:46

Yeah, exactly, exactly. And I think that's really, really important to keep tracking the blood changes because we can tell you what to expect when that patient arrives to you, but ultimately that's not gonna give you your prognosis because it might give you an idea of oh god, it's really sick when it gets here, but it's not telling you how it's responding to treatment or if it's worsening. So it is gonna be tracking those changes over time that's gonna make a big difference. In terms of our biochemistry, that's again what we're gonna start to see more information. So, in terms of general stirs, one of the biggest things you'll see is a decrease in your albumin. And the reason for that is that you get a reduction in basically your vascular permeability becomes increased. So when you have vasodilatory shock, not only do the vessels dilate, but they also become leaky. So that means you get like third space in your fluid, so you might get bedema of the pores, of the face, etc. Um and basically that's when you can get that really low protein count. And those those cases, especially, are when you need to be really careful of your fluid because you can fluid overload those patients really, really quickly. So be careful. In terms of the rest of your bloods, it depends how sick it is. So if we're in early SARS and you're not currently in any mods, so no multiple organ dysfunction, you might get a really mild azotemia, you might get a mild increase in your liver values, you might get a mild increase in bilirubin. So, but it depends because as the disease progresses, you're likely to see those changes getting worse, which gives you a bit of an idea. But two of the bigger things to check and to track from sort of the minute they get to you, are their glucose. So you can often see a really marked stress hyperglycemia in these patients. So usually their glucose can be really high, but it's when you start to see a low glucose that I get really worried. For these patients, normally they don't have a low glucose from the start, as unless they're septic from the start, in which case they can be. But I use it as a marker of things have really turned a corner now. So if their glucose has been steady and then it drops and it becomes low, at that point I'm thinking this is now really, really bad. So blood glucose wouldn't tell me whether something's in a vasodilatory shock, because remember, you can have it because of anaphylaxis or neurogenic and in SERS, I wouldn't necessarily expect a low glucose, but in sepsis I would. So I am, I mean, I think there was a paper, I might have the figure wrong, so don't quote me on this, but I think there was a paper that in terms of fully septic patients, when they get into the point where they have full sepsis septicemia, you're looking at like an 80% mortality rate. So at the point where you're seeing that in these patients, I would be having a conversation with the owner if you haven't already to say, we are really, really sick. And there is a possibility that we might pull through, but there is a strong possibility that we won't. So I that's how I use it. I use it as a marker of once that glucose starts dropping, I get really, really worried. Does that make sense?

SPEAKER_00 40:29

Well, yeah, I suppose I I'm probably using it as my marker that we've got SERS, but maybe I'm going too far on that. I I sometimes say you see it like at three or something, and you go, oh, hold on, that's a little low. I think that that's it's coming. And you put the whole picture together. But I put a lot of weighting on that. If that glucose is three, okay, no, that's that is looking like we're on SIRS or sepsis, and I'll start my glucose CRI, or be monitoring it like a hawk to look for seeing if it's going lower.

SPEAKER_03 40:58

Yeah. As soon as I see that glucose drop, I'm like, where's the septic component? So I'm already looking for the infectious component. And I think initially, if it's only mildly low, I might give a glucose bolus and then repeat the glucose in half hour and another half hour after that to see if it drops again. And then if it drops, I'm thinking, hmm, it's persistently low, I'm a bit more worried. I repeat my bolus and then I do a CRI. But and again, we'll we'll go into scanning and checking for septic components in a second. But yeah, it's my marker of I need to be a lot more worried about this patient now. In terms of electrolyte changes, again, it depends on the presentation and the severity. So a lot of these patients will be hypochalemic, so they'll have a low potassium, but then when they start to get worse and you're going into MODs and you go into AKI and an urea and renal failure, then they you can then get hyperkalemia. So the main message with these is take a measure of your electrolytes when they present to you and monitor them. Do not only check them every 12 hours because they change really, really fast. And I think that's the big message is treat what you see from the initial onset. So if, for example, the potassium's really low when they get to you, I would start on a potassium CRI, but I would be continuously monitoring that. So every two to four hours, I'd be rechecking them and saying, do I need to adapt my plan? And I know that we don't often, well, a lot of places don't have ionised calcium in-house in a GP practice. So you've only got your normal sort of total calcium on your bloods. Um, but if you do have ionized calcium, it's worth checking in these patients too, because commonly in your more septic patients, so the infectious ones, that calcium can really drop. So sometimes you're needing needing to give them calcium gluconate, and obviously you'd only know that if you were checking them.

SPEAKER_00 42:38

In the really sickies, they're often a bit low, but you know, I don't always supplement, they're often a bit low, not needing supplementation.

SPEAKER_01 42:45

Yeah.

SPEAKER_00 42:45

And well, you can't test it. Just go, you don't mean you have to give up. Just do deal with the things you can deal with.

SPEAKER_03 42:51

Exactly.

SPEAKER_00 42:52

And see how the patient does and tracks. Exactly.

SPEAKER_03 42:54

It's it's like your coags in general practice. If you don't have in-house coags, don't panic. Keep an eye on your platelet count and keep an eye on all the general things that you'd be looking about if something's bleeding. You know, are you getting any patikia on the gums? Is there bruising? Are they bleeding from the place where you've just taken blood from? Avoid your jugular sticks just in case because these patients are likely to start going into DIC. So don't panic if you don't have them. You're you're only going to be able to do for these cases the best that you can. Um, and it's like lactate. A lot of people don't have lactate in general practice. Now, lactate is really, really useful to have in these cases because it it gives you an idea of how good that patient's perfusion is and you can use it to track whether they're improving or worsening. But again, if you don't have it, you've got other markers to tell you what your tissue perfusion is doing. If your heart rate is still through the roof and your pulses are crap and your CRT is crap, you know you've got bad perfusion. So you know your lactate's probably going to be elevated. So just work with what you have.

SPEAKER_00 43:52

I find my communication is better when I understand what's happening because I can now explain the changes to the odor and go, this is why I'm We need to think about euthanasia because this is happening. That is expected. Because that you know, in the next two hours, this or that's going to happen. And if that's going on, things are going bad. We're not winning. And that's helping your client communication. We're going to have better compliance. And you know, they can euthanise the animal rather than you going, I just don't know what I'm doing. The patient's getting worse. I keep giving fluids, and now it's pooling fluid in its lungs. You know, this is why it even in general practice, it's still helpful to have the underlying knowledge and you'll handle everything a bit better.

SPEAKER_03 44:30

Yeah, definitely. So parking our blood work a little bit, because yes, you could look into blood gases and all that sort of stuff, but I think the majority of GP practices, you're not going to have that available to you. So there's no point in us harping on about it too much. But one of the things that most GP practices will have that again is going to really help you in these patients is an ultrasound machine. Now, again, you don't need to be really experienced ultrasonographers to be able to really help these patients, but it gives you a hell of a lot of information. So if, for example, you've got a SERS patient, and you can say, okay, we think this has SERS, but I'm not sure if it's SERS or if it's septic or if it's anaphylactic or exactly what's caused this. Now, your POCUS can be the thing that gives you a hell of a lot of information. So, for example, if you pop a probe on its chest and you can see it's got a pleural effusion, you've got something you can tap. If it's absolutely full of neutrophils, it's probably got a pyothorax, it's probably got sepsis, in which case, great, you know what you're treating. If you pop the scanner on its abdomen and its stomach and its intestines are massively dilated with horrible fluid, then you can say this looks like a really nasty AHGS or HGE case, in which case it probably is SERS and might then be bordering on sepsis because that gut barrier has become really leaky. Again, it can give you a lot of information to help guide you as to what you're going to do next. Does that make sense?

SPEAKER_00 45:50

Yeah. Yeah, it's complex, isn't it? Because we're now going down all these different clinical avenues. The thing about heat stroke is it's not that it's not that we're dealing with the heat per se. It's not that cooling the patient down will fix a lot of patients. But with the really severe heat strokes, cooling the patient down is like 1% of the treatment because the damage from the heat has set off a whole bunch of inflammation that is going into this thing we call SURS. And that's why we need to talk about SIRS because the patients that you call and they're still getting worse, which is the really bad heat strokes, basically. That's how they mostly die, is the SURS, and that's why we need to kind of identify what's happening and how to manage it. It's a whole different ballgame.

SPEAKER_03 46:30

Exactly. And that that does, it segues us really, really well into talking about heat stroke. And exactly like Brendan said, that's why we needed to speak about SERS first, because heat stroke is a type of SERS. It's just you already have the reason for why it's caused. So basically, when we talk about heat stroke, it if you want to give it like a true definition, it's a hyperthermia, so a high temperature associated with a systemic inflammatory response, which can then lead onto your MODs and you can get encephalopathy. So often you get a neurogenic and neurological component of it too. Now, that is obviously the really bad version, but a lot of the heat strokes that we see in practice, the more simple ones, so it might be something that just comes in, it's got a bit of a high temperature, it's a bit got heat exhaustion, or it's just over-exerted itself in the t in the heat, you cool it down and they're fine because they haven't gone into that full SERS process yet. You can sometimes get the earlier on patients, but the ones that go in go into full stroke heat stroke have SERS because of that temperature insult. So that's how they're so related.

SPEAKER_00 47:31

Charlotte, do you think the brackies, I find they're the ones that are more likely you're going to cool them, calm them, and they're going to get better. The ones I've had, the heat strokes that have gone to SERS have been normal breeds more typically. Where the ones I've had, it's shutting car.

SPEAKER_03 47:47

Yeah.

SPEAKER_00 47:48

That's is that yeah, is that a little bit of the same for you?

SPEAKER_03 47:50

Yeah, exactly, exactly. And it's trying to work out why it's happened in the first place. So something, for example, that's been shut in a car for hours is very likely coming into you pretty much already nearly dying because its body's already jutting down, where it's massively intersters already, it's already developing mods, it's so, so sick. Now your brachies sometimes I think look a bit more scary when they present because if you have a heat stroke that's been trapped in a car, they collapse when they get to you. So you so I know it sounds strange, but you're almost less likely to panic because the o the patient's not really moving. So you feel like you've got time to do what you need to do. Whereas those brachies that come in and they look so distressed and they have those big, bulgy eyes, and they are really struggling to breathe and they're going blue, and you look at them and you think, oh my god, what the hell am I going to do to you? They're actually, like you say, tend to be the patients that can do a little bit better because if you calm them and you cool them down, usually you fix the problem.

SPEAKER_00 48:42

Because with those brachies as well, they come in. I find I don't know if you notice this, they're uh coughing up a thick white saliva, and don't let that take you down a different road that I find that's one manifestation of these hypothermic brachies for some reason. Um that's something I felt like I used to notice as an out of ourswit.

SPEAKER_03 49:01

So sticking with brachies, if you have typical thing is, I don't know, brachies got really distressed. It can happen if they've, I don't know, had a spinal injury and they get really, really panicked. If they've been out and it's been a bit too hot and they've panicked and haven't been able to breathe properly, can happen for a number of reasons. But if for whatever reason they get stressed, they get hot, they come in, their temperature is 41, 42 degrees C, they're going blue, they're struggling to breathe properly. The biggest and best thing you can do for those patients is either sedate them and intubate them or or give them a full anesthetic and intubate them, obviously, depending on how flat they are already, provide them oxygen and cool them down. And usually, once by the time you've done those things, usually their body's going, Oh, I feel a bit better now. And you can slowly recover them, wake them up, and they do okay. But it's those patients that are already in the full SERS and going into mods that are the ones that are really, really sick.

SPEAKER_00 49:51

When they they come in, you don't easily know which way they're gonna go. So you I I normally get them in the tub tank and I'm pouring water over them to cool them down. And um this is the the benefit of where you've got the staff. We'll have some staff putting the IV cannula in and grabbing some blood. We'll have people cooling while they're in the tub tank. In general practice, yeah, you sometimes can do this as well. But I would also have someone getting the ET tubes out, smaller ones than you think you're gonna need. Um the circuit set up. So you are ready for if it does go the wrong way, intubate. Obviously, you know, life's gonna get so much better for that patient once they're intubated.

SPEAKER_03 50:28

Yeah, it's a good thing.

SPEAKER_00 50:29

Um, yeah, I'd have that at the ready, yeah.

SPEAKER_03 50:31

Yeah, it completely depends on how they present, doesn't it? I generally am more worried about them if you know it's been going on for hours. So I mean I get it all the time where people have called up and they've been like they're not settled and they've not been breathing properly for like four hours, but they don't have the money, so they've not been wanting to come in sooner. And they come in and they're already blue and you think, oh god, they've been heat stroking for four or five hours, in which case they definitely are going into SERS and much more sick, in which case I'm a hell of a lot more worried about them. If they say, I just took him out for a walk and you know, he's not been able to calm down for the last ten minutes. I'm really worried. He comes to you, he's not blue, but you're like, oh, it's just really stressed and it's a bit hot. You reduce the stress with sedating, you give them oxygen, you you cool them down, and usually you're sending them home within sort of two, three hours, and normally they're okay.

SPEAKER_00 51:14

They're quite variable. Some of them, you can't get them off the the you inch you extubate them and they're puffy and panty. Yeah. And you need to just wind them down with a a low-level metatomidine CRI or low low dose metatomidine just to take the edge off and just get them to to chill out. But yeah, I've definitely had them in hospital for 24 hours where it's it's like they're they keep getting recurrently hot because their airways are presumably so nah where maybe there's a bit of distress as well going on. Do you steroid them?

SPEAKER_03 51:42

Yes, I do. Yeah, I do. Unless there's a unless I find there's a contraindication for whatever reason in that particular case, I do, because I just think that airways are so inflamed. So I normally give them an anti-inflammatory dose to reduce inflammation in their airway. And I love metatomidine in bracies, I think it's great, especially if you've managed to get them under anesthetic and you're going to try and wean them off and wake them up, but you're worried about how inflamed the airways are. Basically, if they get stressed when they wake up, you're just going to need to re-intubate them. So I love putting them on a metatomidine CRI and then slowly titrating them off it because they just wake up beautifully. So I had one a few weeks ago actually that that had a boas crisis after surgery. Um we did, we just uh GA'd it, intubated it, I put it on a metatomidine CRI, and it sat on a metatomidine CRI, no propofol, no other drugs, no ISO, and it just sat with its tube in all night under the sedation until I titrated it down to a low enough dose, it was like, oh, okay, I don't need the tube anymore, it woke up beautifully. So um it's just keeping an eye.

SPEAKER_00 52:39

Right, we're we're gonna have an arm wrestle, we're gonna have a full-on punch up about this because right, for general practice, because you know how I like my ACP here, because in general practice, look, I've done metatomedine CRIs and we don't always have a strange driver in general practice. We kind of have a when I've got my metatomidine CRI going on for these patients post-propofol, I'll have a one-on-one pet nurse there that's really experienced. We'll have the multi-parameter monitor there, monitoring everything, and we're titrating the metatomidine CRI to the I can't do that in general practice. So I I think ACP is a really good drug for these. ACP causes reduced core body temperature, it's long-lasting. So, you know, it's gonna be affecting for eight to twelve hours, which is great. I'm not gonna be having to do such ardent monitoring of my parameters as much. I haven't got as much risk that the patient's gonna need intubating, at which point I might not have the staff or the situation to manage things. So I think a shout out for ACP in this context, because yeah, especially in general practice, I just think it's more manageable and it's probably a dying bunch of people, but there's probably a still a bunch of vets that are really quite familiar with ACP, so it's kind of like a drug, that's always a good thing, isn't it? If it's a drug that you're comfortable using. Yeah, yeah. So they are that's my shout-out for ACE.

SPEAKER_03 53:54

Yeah. I think the one thing I would say about ACP is I think it can be a really great drug for brackies that are in this scenario. But in my experience, the really mild cases where they're a bit stressed, they're getting a bit hot, ACP works really well. When they come in and they're really distressed and then they're basically BOAS crisising and their temperature's 42, it's not enough. I feel like I could give ACP and they're just going to continue to get worse because it's not enough. I feel like they sometimes need a whack of metatomidine to properly chill them out because unless you take that distress away, they're just not going to improve. So I think it it's very case-dependent, and it also depends on, like you say, it's what you're used to. Like I feel much more comfortable with metatomidine than I do with ACP generally, because I use it all the time. You just have to be careful about your dosing and how you're using it.

SPEAKER_00 54:43

Yeah, I no, I totally agree with everything you just said there. And we haven't mentioned my other the other wonder drug in these, uh, which is butorphenol or torpedesic. And make the dose as high as the formulary will allow you. Um, because I don't think you can overdo these on Torb, but a big, big dose of IV torb with a bit of IV ACP, at least before you start out getting into those cases that are so hard to manage because now they're on a metatomidine CRI or whatever, or intimated, is can work. So you've got to look at your clinic. This is gonna look there's no one answer for every practice, is there? And even at different times of the day, you might have a day where you've got far less nurses than usual because it's three on a holiday and one's ill. And you can't do all that intensive management, and you might have to make a clinical decision. Oh, you know what, you know, let's have a try with some IVACE and an IV torb because you know, I'm not sure we've got the staff to cope with this in a different way. So courses for courses, different times, different situations.

SPEAKER_03 55:43

Yeah, I taub nearly every patient of those that comes in. Yeah, absolutely. Because one, it's gonna help with your slight sedative component, but also it's gonna help with the breathing. So I'd use it for any dyspnec case or any case that's struggling to breathe. It's a great drug. I love it. Um, and you can repeat it if you need to as well. So, yeah, I mean, generally I I go for like a 0.3 meg pic, generally, but like you say, you can go all the way up to like 0.5 megpic. So um, yeah, it's a great drug, and I use it all the time. Yeah, I think they're probably gonna be the more common heat stroke cases you see in practice. It's normally your BOAS patients, and usually they're they're a heat stroke, but they're not a true really, really bad SERS heat stroke, if you like. Now, if we go on to the more classical heat stroke, the much more scary ones, the ones trapped in your cars, so generally your typical ones, or your status epilepticus patients that have been seizuring for a really long time and their temperature's been really, really hot by the time they get to you. Now, these are the ones that are bloody horrible. And I think that's why we've gone on so much about SERS management, because it's pretty much exactly the same as what you'll be doing for these patients, because by the time they get to you, they are in SERS. Now, I I think it's sometimes easier to talk about it from a case management perspective and talking about an actual case. And I had one fairly recently, I won't say where either, and this dog was accidentally trapped in a car. It was pure accident, it was nothing that the owners did on purpose, and it was trapped in a hot car in about 32, 33 degree heat for about four hours. So, how it was still even alive when it got to us, I'm not sure. But these cases they come in and they are completely collapsed. No, they come in, they're completely collapsed.

SPEAKER_00 57:23

But did I ruin the interversion except?

SPEAKER_03 57:25

Well, yeah, yeah. Shock it. Shock it died. Yeah, yeah.

SPEAKER_00 57:29

Don't don't get the temperature down and go, oh yay, we're done. No, no. Because over the next six hours, it's all hell is gonna break loose. By the way, should we just quickly say when the when they get really hot, it basically serves too much inflammation, yeah? Because inflammation is good in that it dilates the blood vessels to the bad area and it makes the capillaries more leaky, so the white blood cells can go out and fight all the infection off. But then if you have too much of it, then you get really dilated blood vessels, really leaky uh capillaries, and this is our vasodilatory shock, is that right? And that's where we get in this SURS situation.

SPEAKER_03 58:07

Inflammation, in essence, is a good thing initially because it's your body's response to what's going on. It's just when it becomes overwhelming, and that's the problem, is then when it becomes overwhelming, that's when you get this vasodilatory component, and when basically the body starts to starts to not be able to compensate, and that's when it becomes more scary. But the really horrible thing with these patients, I mean, this dog, for example, it came in, it was completely collapsed. Sometimes they come in panting, sometimes they come in and they're they have a lot of respiratory effort and often they're tachidnic, but sometimes they're so collapsed that their respiratory muscles are quite weak and they're actually really struggling to breathe. I think it came in and its temperature was like 42 and a half or 43. It was really high.

SPEAKER_00 58:46

Sometimes their temperature is not far off normal either. And you're like, what's happened? But normally the history gives you it. But yeah, it can be a bit unclear, can't it?

SPEAKER_03 58:54

And it it depends whether the owners have tried to call them on the way in as well, because sometimes they get to you and they still look awful, but their temperature's normal because the owners have been actively cooling them on the way to on the way to you. Now, the best advice that I can give you for these cases to start off with is to stabilize them in the same way that you would any SERS patients. So analgesia or butorphenol if they're distressed, plus some analgesia, oxygen, and to be honest, the majority of these patients are so collapsed that I'd be intubating them. Um, little tip, always cuff the T tube and raise their head because I will tell you why in a minute, but it's very, very important to do that. Get your IV candy in.

SPEAKER_00 59:30

The nasal insulation is great, isn't it? If you've got the little prongs, nasal prongs. Yeah.

SPEAKER_03 59:34

Yeah, exactly. Yeah.

SPEAKER_00 59:35

So they're the best.

SPEAKER_03 59:36

They can be really good as well. Get your IV candy there in, draw some bloods for all the reasons we said about previously, and treat for distributive shock, hypovolemic shock, etc. If it's above 39 and a half degrees, you have to actively call these patients. Unless you actively cool them, you've got no chance of getting them better. And by actively cooling them, exactly like Brendan said, go ham, get them in a tub sink or on a table and just put loads of towels on the floor. And I would be throwing water over these patients. Like I'm not talking like a little bit of a spray, like jugs of water, throw it over them, get it on them. Obviously.

SPEAKER_00 1:00:10

Not one jug of water. How many times have I seen me pull one jug over their back? Yeah, yeah, yeah. But if you when you part the fur, the skin's bone dry. You have to like get it right right in there. You have to soak it. Exactly.

SPEAKER_03 1:00:23

Yeah, exactly. So I would be getting them soaking wet with the nearest water source you can find. Now, they do say it shouldn't be really cold water because cold water will cause peripheral vasoconstriction and then potentially means that you're not cooling them as quickly as you should be. So they say lukewarm, but ultimately just get some tap water, get some tap water and bung it over them as quick as you can. If they are a big, thick furred, fluffy patient, clip the buggery out of them. Warn the owner that you're going to clip them. And I mean clip them. I mean go ham. It doesn't matter what it looks like, this patient could die. So just get the fur off them. Under their belly, around their sides, get it off because you need to cool them down. Sometimes I put surgical spirit on their pores. Um, you can put fans on them. If you have ice packs or a cooling, you have one of those fancy cooling things for your IVFT, get that on there. Um, one thing that I have seen a lot at the same time.

SPEAKER_00 1:01:15

Stick a fan, get the AC on Max, get a fan. I know it's like water electrical things. I always like to worry that someone's gonna get like just hope your electrical system has got good fuses on it. Yeah, but yeah, fan away from the water but blowing or the AC on Max. Yeah.

SPEAKER_03 1:01:29

Exactly. Yeah. And one thing that I do see people do quite often, which please don't do, is I think people think that if you put a wet towel over them, it's gonna cool them down. Please don't do that. Don't cover them with anything because you're gonna insulate them. So you're gonna keep the heat in. So pour the water over them, take any towels off. So you want to get them as as really, really as cool as you can quite quickly. Now, in terms of when you stop cooling, once you hit 39 and a half degrees, stop. No more active cooling, dry them off because I don't know if you've had this, Brendan, but nearly every case I've ever actually cooled as a heat research. They always go hypothermic. Usually after 39 and a half, I'm drying them off and then I'm covering them with a blanket because at that point I find that I can't then keep their temperature up. So you have to be a bit careful. But yeah, 39 and a half, definitely stop. Um, with these cases, they can be horrible. And obviously, you're at that point, you'll have some blood results. You'll say, okay, if you've got low glucose, you'll want to be treating that. If you've got um, if you've got low potassium, then you're going to want to be treating that. And you have a bit of an idea as to what's going on. You might do your POCUS, and like with this patient, I could see that there were B lines on either side of its chest. They quite normally quite regularly get aspiration pneumonia from when they're panicking so much and they start breathing in saliva and etc. Everything that they're bringing up. So aspiration pneumonia is really common, in which case you might want to start them on some antibiotics and make sure you're giving them adequate oxygen. You want to get a sort of POCUS on their abdomen to say, okay, are they developing? Heat stroke patients really, really commonly get a horrible, almost like the equivalent of HDE or AHDS. They basically sloth their intestinal lining. It's disgusting. And it nearly always, if you have a patient that is a true heat stroke that's going into SERS, they will pour bloody diarrhoea out their back end. And you'll see it on the PUCUS, it's normally really obvious. And that's why I say cuff the ET T tube and elevate their head, because not only does it come out their back end, but they regurge like crazy as well. So try and protect their airway as much as you can.

SPEAKER_00 1:03:28

Could I say at this point, if you've got the history, they've been trapped in the car for several hours, they come in, you cool them down, but they're still really poorly, they start getting hemorrhagic diarrhea. Do get on the phone to the owner and go, We are not, this is not going to be really gonna struggle with this. Yeah, this patient might die and just say, Look, you know, every half an hour and an hour we need to re-look into this. Euthanasia might be coming up, and you might want to pre-warn them that this could be going back. It's really good to get that conversation in now before another hour has gone, and then we'll come into all the different things that go on here. But the you know, the patient you're then having to phone them and go, no, this is going in, you know, in a bad, bad, bad way. Exactly. Because these can unravel in front of your eyes in in a in one to four hours. Yeah. And uh yeah, so you want to get that conversation in nice and early. It's because the owner might come in and think, well, it's cool them down and they're gonna be okay. But uh these particular ones, yeah, that's that's not typically the case, I think.

SPEAKER_03 1:04:28

No, exactly. I mean, this patient, for example, I placed a fecal folio because I was like, I it wasn't coming yet, but I was like, I know it's coming. And about half an hour after I placed it, it started pouring blood out of its back end. And and I'm luckily I'd cuffed its EG tube because it started regurging. It I placed a urinary catheter, and the reason for that is not because you're worried about it weeing everywhere, but because you need to monitor the urine output. So if they're going to go into mods, AKI you see super commonly, and often these guys can go an urix. I ran some coags, I ran some full bloods, and basically what we ended up doing with this patient is he was on analgesia, he was on oxygen, he he went really hypotensive, which what I expected. So I put him on noradrenaline. I scanned him and his contractility was actually okay, so I didn't use any ionotropes with him to start off with. But his glucose started to drop, so I started giving him glucospolices, and it persistently continued uh continued to stay low, so I put him on a CRI and I gave him some broad spectrum antibiotics. And the reason for that was because he was softening his intestine. I thought you've probably now developed sepsis because your bacterial gut lining has become so weak and leaky that you've probably got bacterial translocation, or some people will argue with how that works, but ultimately this patient might needed antibiotics at this point. He had beelines all over his chest, so I was like, You've got wet lungs, so you've either got aspiration pneumonia or you've got a pulmonary edema for whatever reason.

SPEAKER_00 1:05:48

ARDS, uh acute respiratory discussion syndrome. I mean essentially in my GP world, I just think of it, lungs are going bad.

SPEAKER_03 1:05:55

Yeah, exactly. Lots of badness everywhere. Yeah, lots of badness everywhere. Um And he his urine output started to really drop and it got to the point where he wasn't producing any urine. So I ended up starting to give him ferosomide to see whether I could try and start getting some urine out of him, which when you're getting to that point is pretty much a no uh your end of the game anyway, pretty much. Um I'd check some coags and his PT and APTT, so his clotting factors were through the roof. So I actually started to use fresh frozen plasma with him to try and replace some of his clotting factors to see whether it was going to make any difference at that point. So you can use plot plasma in these guys and it can help. So basically for about eight, uh nearly eight hours, I was chasing my tail with this dog, and they're horrible because sometimes they go, things have improved slightly, and then they tank a little bit more, and then you go, Oh, maybe things have improved a little bit more, and then they tank again. And it got to the point where I had to say to the owners, I was like, basically, I was getting peripheral swelling, I was getting bleeding from all of the cathetocytes that we had, I was getting peticia in the gums and bruising on the body. We had beelines all over the chest because we were going into ARD. Glucose was horrendously low, so I think it was septic. It stopped producing urine, so it was in an aneuric AKI and it was just sloughing, bloody diarrhoea from its back end. It was just continuously pouring out of it. And the reason why I actually put it to sleep in the end is I was already having the conversation with the owners because they'd come down to see the dog, and I was saying, This is really, really bad. I don't think we're gonna come back from this now. And at that point, it started to look like it was trying to agonal gasp. You know, when you've got a really sick patient that's on the edge anyway, and then they get to the point where their lungs go, I've had enough of this now, and they stop their normal respiratory rate and they just go, hold their breath for a while, and then they do another one, and then they do another one, and you're like, okay, their respire their respiration's really shutting down, or they just start to get to a respiratory rate of, I don't know, four when it had been holding steady at 3640. So we ended up getting to the point where we made the decision to euthanise because I think if not, this patient was going to do it for us. The reason why I'm telling you this is not to say every single heat stroke case is hopeless, because that is not the case. But when you see a bad one, they are horrendous. And it is sort of expected that you are likely to lose that patient's knowing your head from the get-go, know that it's unlikely that that patient is going to survive. It will be less difficult for you to wrap your head around when it doesn't go your way because they are some of the worst cases you can have in your career, and I will remember that dog till the day I die. It's horrible.

SPEAKER_00 1:08:30

You missed out one. You have your ECG on and the Lego arrhythmic as well. Yes, they do. It's just like you are being attacked. Well, like as a veteran. Every single angle. But I feel like, yeah. And that's why you it's like if you're gonna try and do it, clear your diary for six hours.

SPEAKER_03 1:08:46

Yeah, yeah, yeah.

SPEAKER_00 1:08:47

Because it will you'll have all of these things will happen progressively over a few hours. And your nurse, you know, it's you and the nursing team. It's like all hands on deck because you've got you've got regurge and vomit, you've got bloody diarrhea, you've got kidney failure, you've got heart arrhythmies, you've got lung dysfunction, and you know, they are they are horrid. So that's why you're understanding what you're getting into. And if you start seeing any of these things, even at the point you get the hemorrhagic diarrhea, you've got to be like, right, I'm gonna talk to this owner again in an hour, I'm gonna tell them this is really bad and we might not make it, and then you know, and be watching everything, you know, because it doesn't matter what the temperature is, don't be lulled into oh my god, the temperature's 38.2, doesn't matter. That's it's the damage to the organs. Is and the knock-on effect, it yeah, I've I've had the same Charlotte. They're horrible.

SPEAKER_03 1:09:36

And don't get me wrong, like when we talk about mods as multi-organ dysfunction, if you can catch that in an early stage and they're azotemic and their liver values are up, but you're you're sort of in sort of the first hour or so of that heat insult, you can sometimes claw that back. Like if you can get a patient with an AKI for whatever reason, quite often with the right treatment, they can resolve. So it's not to say that it is always going to be hopeless, but often when you're starting to get multiple organ dysfunction, when their clotting times are going through the roof, their ECG is all over the place, their blood pressure is through the floor, their glucose is low, their potassium might be through the floor, or eventually goes to eight and goes really high perkalemic because they're no longer producing urine, all of those things together, that dog or that cat is more likely a dog, let's be honest. I mean, whenever you when do you ever see heat stroke cats? It just doesn't really happen. But it's, you know, it's you get to that point and you just think we are fighting a losing battle. You're just fighting fires, you can't fix the underlying problem, you're just trying to treat what you see in front of you. But all you can literally all you can do is take it step by step, get it set up as if it's like a really unstable anesthetic. So get all your multiparameter monitor on it, get it intubated, or at least have nasal prongs or a really tight-fitting oxygen mask, at least, give it some oxygen, give it pain relief, try and sort its blood pressure, get it on fluids, give it vaso presses if you need to. Think about do I need to give it stuff to help its contractility of its heart, treat any issues you can see on its bloods, and just do your best. And yet and yeah, remember there is always someone on the end of the phone. So, say for example, it's a really busy afternoon and you're the only one that's out the back and you you don't have any help, get a referral center on the phone and be like, I've got this happening, what do I do next? If you've completely forgotten everything we've said or you think, oh god, I'm really worried about using noradrenaline or whatever it might be, get somebody on the end of the phone. There is always someone that can help you. They're not easy cases, and talking them through with someone will make the world a difference. So yeah, just know that you are not going to be the only one that feels the way that you do when you're managing these cases because they're not nice, are they?

SPEAKER_00 1:11:41

No, managing the client is is one of the biggest parts of this as well. Yeah. Make sure they're they're fully on board. You don't have to be a hero and do like a million things you can't do in general practice, but understanding the mechanism will really yeah, yeah, changes your communication with the client.

SPEAKER_03 1:11:57

And I think the other thing that we've not really spoken about too much yet in these cases is how emotionally difficult it is for these owners because especially if they've been trapped in a car, the guilt that they feel, even if it's a complete accident, the guilt that they feel is horrendous. And I mean, this last patient that I had, the owner after we put it to sleep, just turned around to me and she was like, I've just killed my dog. And it's it's awful because it's you know, it that was a pure accident, and that I don't put any blame on those owners whatsoever. It was something that just could have happened to anyone. But I think one thing that will help is setting the owners' expectations from the get-go. And if they come in and they're collapsed and you know that they've been hot for a long time, I would be having a big discussion about prognosis from the start. And you say, you know, I will try my absolute best, but it is very likely that this is not gonna end well, and you need to know that because saying to them, Oh, yeah, we're just gonna cool them down and see what happens, people just think they've got hot, you're gonna call them and they're gonna be fine. It's very, very different a lot of the times.

SPEAKER_00 1:13:01

Yeah, twice maintenance fluids ain't gonna cut it.

SPEAKER_03 1:13:04

No, no.

SPEAKER_00 1:13:05

But that is seriously what can happen. Do you know it's it's really hurt uh I feel the pain for the client and in emergency work that's such a frequent situation. I say to them sometimes something like, Look, this this incident, because it can there's so many I don't want to reel off all the awful things I've seen in my career, which have been accidents that have ended up with the patient dying, but I've seen many. But so what I say to them is this could have happened to anyone. You can talk to any pet owner and there'll be near misses. There'll be times when it could have gone the other way, and you know, they they slipped off the lead and they ran into the road, but they got away with it because there wasn't a car, or all sorts of other things where it could have in one out of a hundred times the certain such situation of things happen, and it has gone in that really bad way. It can and I do emphasise it could happen to anyone, it's just that really rare event that different things happened. I had one lady she shut a car door on her dog's head and it came in, it was like in seizuring and died. And it's just you know, she was just going to the supermarket, she shut the door, but this time the dog decided to leap after her. You know, so many like just tragic things anyway. It's very emotive, very upsetting.

SPEAKER_03 1:14:17

Yeah, but we know it's been a heavy one, but we hope you've enjoyed the pod all the same today, and that hopefully you've got some useful little nuggets of information to take into day-to-day practice so that if you do see a case like this, then fingers crossed, you'll you'll have somewhere where you know where to start at least.

SPEAKER_00 1:14:31

So hey, that's that's yeah, that's a bit of a I feel a bit down now because I I know I think young I'm the same as you actually, I think because they're fit dogs that were ten hours ago or whatever, yeah, they were living their best life and totally happy. I think and they're young and fit and and it's yeah, that's why they're I think they're one of the most gutting situations, aren't they? And that yeah, they are. And it's also the other thing is the death is over such a long period of time, whereas it even some like the cat hit by car, hit on the head, dies in a second. That's you know, I can in a way I can but these Sirs following heat stroke are are are horrible to watch. Yeah. Shout out to Sam, the nurse, by the way, who really helped me with two of these cases once. We didn't get them through as many years ago now, but she is a phenomenal nurse, and uh I was in awe of uh she had two cases on her own to deal with going back of many years and yeah, just hats off to her. What an amazing nurse. But uh yeah, tough. You really need a really good nursing team for these cases, don't you? They're full on. You need the whole team.

SPEAKER_03 1:15:36

Definitely, definitely. But anyway, um, hopefully you've still managed to enjoy today. And again, like always, please get in contact with any comments or suggestions you have for us, any cases that you've had like this that you want to share and or topics that you'd like us to cover next. And remember you can contact us via our blog, on our website, WhatsApp, or via our socials channels as well.

SPEAKER_00 1:15:57

So thanks again for listening to the Chatty Vets podcast to join us again next week for our next two-week takedown where we're covering everything from catastrophic aspiration pneumonias, the issues we're seeing with giant dogs and that welfare debate, and burnout in vet bed.

SPEAKER_03 1:16:12

Yeah, we're looking forward to it already. Until then, it's bye from me.

SPEAKER_00 1:16:15

And bye from me.

SPEAKER_03 1:16:16

Take care.

SPEAKER_00 1:16:31

This podcast is intended for license pet from professionals as provided for educational discussion purposes only. Whilst it is publicly accessible, it is not intended as advice for pet owners.

SPEAKER_03 1:16:40

The views shared are based on our own clinical experience and interpretation and do not replace individual clinical judgment. We accept no responsibility for decisions made based on this content, and all cases should be assessed on an individual basis.

SPEAKER_00 1:16:50

Any references to medications, treatments, or products are made for educational discussion only and are not intended to promote or advertise veterinary medicines to the general public. Veterinary medicine should only be used under the direction of a prescribing veteran surgeon and in accordance with UK veterinary medicine regulations.