Feline Medical Emergencies: Part 1

In the May open access episode of Chattering With iCatCare, Yaiza Gómez-Mejías is joined by feline specialist Nicki Reed to navigate the high-pressure world of feline medical emergencies. This episode focuses on the critical first seconds of triage and the stabilization of cats in respiratory and circulatory distress.

Together, they explore why the "piecemeal" exam is a vital tool for the dyspneic patient and how the latest RECOVER guidelines have updated our approach to feline CPR. Nicki highlights the specific ways cats differ from dogs in shock and explains how point-of-care tools can help you make life-saving decisions before a full workup begins.

For further reading material please visit:

Rational approach to feline medical emergencies: part 1

2024 RECOVER Guidelines

Host:

Yaiza Gómez-Mejías, LdaVet MANZCVS (Medicine of Cats), RCVS CertAP (Feline Medicine), iCatCare Veterinary Community Co-ordinator

Speaker:

Nicki Reed, BVM&S CertVR CertSAM DipECVIM-CA DSAM(Feline) FRCVS, Internal Medicine & Feline Specialist

Creators and Guests

Host

Yaiza Gomez-Mejias

Veterinary Community Co-ordinator @ International Cat Care

What is Chattering with iCatCare?

Welcome to Chattering With iCatCare, the official monthly podcast of International Cat Care, hosted by Yaiza Gomez-Mejias (Veterinary Community Co-ordinator). Each month, we chatter about cats and cat-friendly practices with industry experts and contributors to The Journal of Feline Medicine and Surgery. Each episode contains highlights from our longer discussions and interviews, which are accessible to iCatCare members at portal.icatcare.org. If you would like access to our full episodes, would like to become an iCatCare Veterinary Society Member, or find out more about our Cat-Friendly schemes, visit icatcare.org.

Yaiza Gomez Mejias: So welcome back to Chattering with iCatCare. I'm Yaiza Gomez, iCatCare Community Coordinator and today we're diving into something that often gets vets hearts racing, medical emergencies. We are incredibly lucky to be joined by Nicki Reed, a feline specialist and the author of a fantastic JFMS spotlight review series on this subject.

Yaiza Gomez Mejias: Very welcome, Nikki.

Nicki Reed: Thank you Yaiza, and thank you for inviting me to do this podcast.

Yaiza Gomez Mejias: So your first article tackled everything from that initial oh no moment, to the full workup of very complex cases. You mentioned that sometimes for cats with respiratory distress, we need to do the physical exam in stages.

Yaiza Gomez Mejias: I think you call it like the piecemeal exam. What are the most important elements of the clinical exam in those first few seconds?

Nicki Reed: I don't think you can underrate a visual observation. These cats can either be getting oxygen by flow by in a table, or if you have got an oxygen kennel, they can be put in there and you can just visually watch them for a minute or two, observe their pattern of breathing, get an indication of just how distressed they are whilst they're getting that oxygen supplementation.

Nicki Reed: Then I would focus on auscultation as my next stage. But try to do that as quickly as possible, and then give them a break while they, again, are getting some more oxygen before maybe moving on to something like POCUS or TFAST thoracic ultrasound to assess for things like fluid. I'm a little bit hesitant to be doing things like opening the mouth and and checking colour maybe immediately. I will delay things like abdominal palpation until I feel that breathing pattern is a little bit better controlled.

Yaiza Gomez Mejias: Yeah, I feel that sometimes we feel that the more urgent the case, the more we have to do. Every member of the team is rushing, but just observing and actually observing is a lot.

Nicki Reed: That lets you know is it upper respiratory tract?

Nicki Reed: Is it lower respiratory tract? And that degree of abdominal effort that lets you know, are we getting paradoxical breathing? That's an indication of a severely distressed cat. So that doesn't even rely on a stethoscope. That's just your eyes that are telling you that.

Yaiza Gomez Mejias: The vet's eyes. Yeah, we have to value our eyes.

Yaiza Gomez Mejias: The 2024 recover guidelines introduced some changes in the approach to cardiopulmonary resuscitation. What compression techniques should we now be training our teams to use on cats?

Nicki Reed: Yeah, so previously the guidance was effectively one position with your four fingers of your palm underneath the cat and your thumb used for compression.

Nicki Reed: That can actually be quite a fatiguing technique to use. I would struggle to maintain that for a minute, which is the recommended time before swapping out. So you now have an option of, you can use a kind of single palm to compress the chest whilst using your other hand to steady the back to stop the cat moving away from you, which can be another issue.

Nicki Reed: Or you can use both palms of the hand or four fingers of the hand underneath the cat, and both thumbs on top of the cat to compress down and that again, is a little bit less fatiguing, but still not to use that kind of double palm compression that's often used in dogs because that will compress the thorax too deeply and you're risking causing trauma in cats 'cause their chest just can't take that pressure.

Yaiza Gomez Mejias: And cats are famous for hiding things. What are the main difference between cats and dogs in shock?

Nicki Reed: One of the big things that we don't see is, we don't see that kind of compensatory or hyperdynamic phase of shock that we get in dogs.

Nicki Reed: Often when we see cats presenting in shock, they've progressed to the stage where they can actually be bradycardic, very often hypothermic, altermentation, reduced blood pressure, and I think bradycardia is, is very often underrated in cats. I get very twitchy at a heart rate of 140 or even 160 in a cat because most cats that are alert and aware in a veterinary clinic environment are going to have a heart rate of at least 180. So yeah, bradycardia is something that we need to put on the alerts and hypothermia can be associated with the poor prognosis as well. So we should be taking these temperatures and warming them and improving their circulation to get that perfusion better so their temperature comes up.

Yaiza Gomez Mejias: And talking about temperatures, where do you measure the temperature in this cat?

Nicki Reed: I think when they're in shock your rectal temperature is probably going to give you the most accurate reading. The axillary temperatures we tend to reserve more for cats that get distressed by that.

Yaiza Gomez Mejias: Yeah. I think we all feel more confident with the rectal temperature because we've been doing it for our entire life as well.

Nicki Reed: And just going back to the other thing that you said about the difference between cats and dogs in, in terms of shock, I think the other thing that we need to be mindful of is the fluid volume that's given for resuscitation. Over the last sort to 10 years or so we have moved steadily away from shock doses into more boluses to potentially reach up to a blood volume of fluid over a period of an hour.

Nicki Reed: But people sometimes forget that cats have a smaller blood volume, typically 60ml per kilogram compared to a dog of 90ml per kilogram. So we need to adjust our volume doses down the way to compensate for that. So we're looking at 10 to maybe 15ml per kilogram bolus compared to 20ml per kilo in a dog, and giving that over sort of 15, 20 minutes. If that doesn't work, give another incremental bolus. But typically stopping maybe after about three boluses rather than aiming to get up to that total volume of 60ml and just monitoring their parameters and assessing for blood pressure coming up, heart rate coming up as as well.

Yaiza Gomez Mejias: When a cat presents in shock, what point of care tools can help us quickly rule out cardiac disease or, rule it in or out before we reach for the intravenous fluids?

Nicki Reed: Yeah. Ultrasound is emphasised a lot by emergency care practitioners and obviously they get very good at doing TFAST and evaluating some of the more unusual signs like shared signs for pneumonia.

Nicki Reed: I think for your average practitioner who maybe isn't doing a pocus two, three times a day, these more subtle things can be challenging, but I think the right parasternal view to assess the size of the left atrium is a very good starting point because if that left atrium to aorta ratio is enlarged, it's fairly easy to measure it, and that is an indicator if it's more than 1.5, that you need to be cautious with your fluids because heart failure could be contributing here.

Nicki Reed: And certainly if you've got pleural effusion you also have to be a wee bit cautious with your fluids until you've established whether that pleural effusion is cardiac in origin or some other cause. Arrhythmia generally you're maybe gonna get an indication from your auscultation. Murmurs are not always easy to find and not all cats in heart failure are going to have murmurs as well. You can't entirely exclude it. You also are thinking about aortic thromboembolism, in which case you're evaluating your pulses and your limb extremities. So yeah, I think the category that's maybe a little bit more challenging is the pleural effusion cases, because what I would probably do in those cases is maybe be a wee bit more judicious with my fluids until I've drained the chest, got an idea of what that fluid is, and potentially evaluated whether that could be cardiac in origin. Obviously if you're getting purulent fluid out, then that's unlikely, but if you're getting a modified transudate, and again, that's where you want to pay a bit closer attention to your heart, and if you do have the proBNP test in house, I quite often will use that if I haven't got a cardiologist available.

Nicki Reed: So that, that, that's a wee useful one if you're not confident about ultrasound as, as well.

Yaiza Gomez Mejias: I think the other thing you mentioned to the review was the B, the B lines, the beta lines.

Nicki Reed: Yeah, so these are like hyperechoic reverberations that you see when you're evaluating the lung tissue. The bright parallel line that reverberates down and you will commonly pick up maybe two or three when you scan the thorax, but if you're picking up more than that, it does suggest what we call wet lung, which can commonly be associated with pulmonary oedema, but you can't rule out that that isn't also associated with inflammation in that lung as well.

Yaiza Gomez Mejias: Yeah. There are other differentials, so it's much more practical to assess the left atrium or aorta ratio for sure.

Yaiza Gomez Mejias: So thank you for that tip. Let's pass on to sepsis, which can be subtle in cats. Which clinical parameters should make us suspect a cat in septic shock rather than just a severe dehydration?

Nicki Reed: These are the patients that often don't respond to fluid resuscitation. We've effectively got a kind of distributive shock, so we've lost tone in the blood vessels.

Nicki Reed: So although you're giving a, a good volume of fluid, often that is not restoring your blood pressure and it can actually leak out of the vessels and start to build up in interstitial tissue. And that is a challenge actually, in terms of assessing when you have over hydrated these patients. So we're seeing a poor response to fluid resuscitation. If we've got our haematology we can see neutrophilia, but we can also see neutropenia. We need to remember that when we get neutrophilia in cats, it's rarely as marked as we get in dogs. So if I get a neutrophil count of 2022 in a cat, to me that's quite significant. And similarly, in a peracute stage, we can get neutropenia because the neutrophils have all migrated to the septic focus.

Nicki Reed: And then there is the challenge of identifying where is that septic focus and what samples do I need to take? But we also rarely get the pyrexia that we will see in the dogs. So you have to maybe rely a little bit on your history at this stage. Has the cat been unwell for a couple of days? Has it shown any evidence of urinary problems for example? Has it had difficulty breathing for a couple of days? That might suggest a pyothorax, for example. Could it have eaten anything that might have penetrated and given you a septic abdomen as a result of intestinal rupture, for example. The problem that you have is in terms of trying to get your investigations done to identify where your septic focus is, can take a good couple of hours, maybe even longer, and some of them you can't do until your patient is stabilised.

Nicki Reed: So I think if you do have any kind of suspicion of sepsis, this is where you're playing a balancing act between the antimicrobial stewardship of not using antibiotics unnecessarily versus the sepsis guidelines, which in people, the surviving sepsis guidelines show that there can be a significant worsening of sepsis if you delay starting antimicrobials, and then also if I start antimicrobials, is that going to affect my ability to get a diagnosis in terms of culture results?

Nicki Reed: So it very much is a challenge, but I think if you've got a very sick cat in front of you, you potentially have very little to lose in terms of giving some intravenous amoxicillin clavulanate, or cefuroxime for example, and maybe some metronidazole at least to buy you some time for an hour or two while you try and figure out what is going on with that patient.

Yaiza Gomez Mejias: That's very helpful too because nowadays the use of antimicrobials is also very challenged due to all the new approaches and the new regulations. Thank you for that.

Nicki Reed: The other thing, it isn't in the article, but we should remember that bilirubin can be a marker of sepsis as well, because we often think of bilirubin as just been an indicator of gallbladder or biliary pancreatic disease, liver disease.

Nicki Reed: But actually what happens in sepsis is the transporters and the cells effectively get paralysed by the presence of sepsis. So it does build up, the movement of the bile gets inhibited, and that's why we get elevated bilirubin and that's why we can see it with things like FIP for example, which can also be a form of sepsis as well.

Nicki Reed: So that can be another marker on the blood panels to give you an indication as well.

Yaiza Gomez Mejias: Another helpful marker. Thank you. Going on to respiratory disease, upper airway noise is often obvious but for cats with rapid, shallow breathing, how do we differentiate the underlying problem?

Nicki Reed: So if we've got rapid shallow breathing, we're either thinking of pulmonary parenchymal disease or pleural effusion, for example, that's restricting the expansion of the lungs.

Nicki Reed: So you can rule out that latter category quite easily with your focused ultrasound. But if we're looking at pulmonary parenchymal disease, yes, we can get some information from ultrasound, but getting your definitive diagnosis again can be a little bit challenging so we can look at trying to stabilise these patients again with our oxygen.

Nicki Reed: Butorphanol can be quite good for just calming them a little bit as well, because these patients do get distressed by not being able to breathe, and these are our category where we probably may need to consider thoracic radiographs rather than trying to get a diagnosis from ultrasound. And I think people do shy away a little bit from anaesthetising these patients where they think sedation is safer, but actually sedation could be a bit more stressful to the cat who is dyspneic. So I think you can consider anaesthetising them in order that you can get an endotracheal tube in which is gonna facilitate their oxygenation, get you some good quality images, and get, say, a bronchial lavage which may improve your diagnostics.

Nicki Reed: But if these patients are too fragile to deal with that, then you have to think about what could be underlying this? What are the chances of this being a parasitic infection? Could this be toxoplasmosis? Is it viral? Is it severe asthma? I will hold my hand up and say that we've often had these severely dyspneic cases and we don't know what's causing it, and we feel they are too fragile and they will often end up getting a spot on warmer, they'll get some steroid, they'll get a bronchodilator and potentially get a, an antibiotic as well if we don't feel it's cardiac in origin.

Yaiza Gomez Mejias: Yeah, it's amazing how vets have got to be adjusting our tolerance to uncertainty all the time because in these cases our uncertainty will be great. We still have to do something about it.

Nicki Reed: I wish there was an easy test for it but sometimes we have to just keep the patients alive and just accept that we maybe didn't absolutely get the answer as to what was going on.

Yaiza Gomez Mejias: I think that's a very clear goal that we should keep in mind. A last question to finish with this first part of your review series, when we think that transfusion may be needed, how should we interpret the PCV and the hematocrit values?

Nicki Reed: So I think we have to look at two things. We need to look at the figures and we need to look at the cat because it isn't an always an absolute value. It can depend on how quickly that has happened.

Nicki Reed: Some cats who say have been hit by a car and their PCV has dropped quite dramatically within a matter of hours. It may not have dropped that low, but if it has gone down from 40% to 20% in two hours, that cat hasn't had time to adapt from that and will potentially be affected by it more than a cat who has say a non regenerative precursor hemolytic anaemia, and their PCV has dropped from 35 to 15 over a period of two, three months.

Nicki Reed: That 15% sounds like it maybe needs a transfusion, but that cat is probably coping with it quite well, whereas the cat sitting at 20 isn't coping so well because it hasn't had time to adapt with that and that can be things like upregulating release of oxygen to the tissues from the red blood cells. So we need to look at things like, what's the heart rate doing?

Nicki Reed: What's the respiratory rate doing? What's the mentation doing? To decide whether or not that patient is clinically compromised by it. If we've got an acute blood loss situation, some of those signs may just be due to perfusion, hypervolemia, and you then need to reassess them once they've had some fluid resuscitation and see what's happening there. So it isn't as clear cut as this cat's PCV is at 14%. It needs blood. This cat's PCV is at 15%. It'd be fine. You need to take onboard what the cat looks like as well.

Yaiza Gomez Mejias: Nicki, thank you so much for writing these very practical reviews. It's very reassuring to know that even with limited resources a calm methodical approach can make a world of a difference for these patients.

Yaiza Gomez Mejias: And I would also like to thank our listeners and suggest to check our part one of Nicola's review in the Journal of Feline Medicine and Surgery, and in July we will have the opportunity to discuss part two, where we will tackle blocked cats, seizures, kidneys, and diabetes. See you there.