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Author: Florina S. Tseng, D.V.M.
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OCW Zoological Medicine 2008
Avian Emergency Medicine (2008)
F. Tseng, DVM
Cummings School of Veterinary Medicine at Tufts University

1. Learning Objectives and Review

  • Be able to recognize the important avian emergencies presented in this section

  • Be familiar with the clinical signs and treatment for shock in birds

  • Be able to formulate a plan for fluid and nutritional support in the critically ill bird

  • Be familiar with the most commonly used analgesics in birds

Color coded topics also indicate learning objectives that the student should become familiar with. Cases will be presented in class to illustrate some of these topics.

2. Initial Examination

2.1. Initial procedures

  • Telephone communication

  • Prepare for arrival

  • Visual evaluation

  • History

  • Triage

  • Pre-oxygenation if needed

  • Physical examination may have to be performed in stages

(PE) Physical Exam
(PE) Physical Exam

2.2. Preliminary Assessment Guidelines

  • Attitude or degree of depression

  • Body posture

  • Hydration status

Dehydration
Dehydration

  • Nutritional status

  • Respiratory compromise

  • Presence or absence of anemia

  • Evidence of shock

  • Evidence of trauma

  • Preliminary evaluation of the body systems

3. Basic Diagnostic Tests

3.1. Essential information

  • Packed cell volume and total serum solids evaluation

  • Blood glucose determination

  • Blood smear - examination of cell morphology and differential distribution

  • Radiographs

  • Fecal gram stain

  • Microbiological samples

Must weight the value of the test vs. the stress involved in performing the test!

4. Basic Emergency Treatment and Supportive Care

4.1. Cardiopulmonary resuscitation

  • Establish airway - endotracheal tube, air sac cannula (upper airway obstruction)

  • Positive pressure ventilation

    • 10-12 breaths/min

    • < 15-20 mm H20

  • Set up ECG, Doppler (if possible)

  • Closed chest compressions, utilizing thoracic pump mechanism (rapid rate)

  • Monitor body temperature

    Epinephrine (1:1000)

    0.1 mg/kg IT, IV, IC, IO

    Atropine

    (for vagally mediated arrest)

    0.004 - 0.04 mg/kg

    Doxapram

    5 - 10 mg/kg given once IM, IV, SQ

from Seminars in Avian and Exotic Pet Medicine, Vol 13, No 2 (July), 2004

4.2. Air sac cannulation

Air sac cannula
Air sac cannula

Air sac cannula
Air sac cannula

  • Place tube in abdominal air sac to provide oxygen or anesthetic gas and in cases of upper respiratory obstruction

  • Can use cuffed endotracheal tube

  • Placed through skin in the area caudal to the last rib, vetnral to the epaxial muscles and cranial to the leg on either side of the bird

  • Pass tube through body wall and into air sac

  • Suture in place

  • Commercial air sac cannulas are available

4.3. Treatment for shock

Prepare materials before starting treatment!

Suggested set-up for incoming shocky bird:

  • IV or IO fluids: warm lactated Ringers solution (30 ml/kg IV bolus OR 1/2 MEC in ml)

  • Corticosteroids NOT recommended

  • Broad spectrum antibiotic ( e.g. Enrofloxacin)

  • Analgesic drugs

  • Thermal support: heat lamp, hot water bottles, or warm cage

  • 24 gauge butterfly catheter or IV/IO catheter

  • Emergency drugs

  • Hemoglobin based oxygen carriers

Shock
Shock

4.4. Fluid therapy

Fluid therapy choices are similar to those recommended for mammals. Review chapter on Diagnostic and Therapeutic Techniques

4.4.1. Signs of dehydration

  • Mental depression

  • Skin fold elasticity (less reliable than in mammals)

  • Filling time of basilic vein > 1 sec

  • Ocular hydration

  • Pale, tacky mm

  • Cool temperature of extremities

  • Increased heart rate

  • Decreased blood pressure

4.4.2. Types of fluids

Isotonic crystalloids distribute to all body fluid compartments

  • LRS (volume replacement)

  • Normosol®

  • 0.9% saline (recommended in head trauma cases)

Nonisotonic crystalloids

  • 5% Dextrose in water

  • Hypertonic saline

Colloids cannot pass through capillary membranes

  • IV volume expanders

  • Plasma, whole blood

  • Dextrans

  • Hetastarch®

    • Expands to 1.4 x infused volume

    • 10-15 ml/kg bolus up to QID

  • Always give with isotonic crystalloids (40-60% volume)

4.4.3. Fluid administration (see also Avian Diagnostic and Therapeutic Techniques

  • Routes of administration: oral, subcutaneous, intravenous, intraosseous

  • Fluid volumes: Daily maintenance plus deficits and ongoing losses

  • Rates of administration:

    • Up to 60 ml/kg IV bolus or IV, IO drip for shock therapy

    • Replace half of total fluid deficit in first 12 - 24 hr

    • Replace the remaining half over the following 48 hours

4.5. Blood Transfusions

4.5.1. Indications

  • PCV < 10-15%

  • Rapidly dropping PCV

  • Hypoproteinemia

  • Perfusion deficits

4.5.2. Blood donor choices

Closely matched or identical species blood donors are preferable, however, studies have shown that the source of the donor blood may safely come from a different species than the recipient. The use of pigeon, chicken, or raptor blood has proven to be quite safe, and often lifesaving in psittacines as a one time emergency procedure. Interspecies transfusions will not last as long as intraspecies transfusions. Administration of blood is no more difficult than administration of intravenous or intraosseous fluids. A life saving transfusion should be carried out even when crossmatching is not readily available.

4.5.3. Procedure

Suggested set-up

  • Healthy donor bird

  • Isoflurane anesthesia (mask)

  • ACD or CPDA solution or syringe coated with herparin

  • 22 ga. butterfly catheter (collection)

  • 24 ga. indwelling catheter (administration)

  • Blood component infusion set

  • Warm lactated ringers solution

  • B-Complex

  • Iron dextran

Blood Donor - Blood may be collected from the donor bird from either the jugular or brachial veins. Isoflurane anesthesia of the donor may make the procedure easier to perform, although it is not always required. Ten ml of blood per kilogram of body weight may safely be taken without harm to a healthy donor bird. Blood should be collected in some form of anticoagulant. A syringe coated with heparin, EDTA, or containing a citrate solution (9 parts blood to 1 part ACD solution) will suffice. Heparin anticoagulant is preferred over EDTA for smaller recipients in order to avoid adverse effects (hypocalcemia) in the recipient. Following blood collection, the donor bird should receive an equivalent 10 ml/kg intravenous fluid replacement, as well as intramuscular administration of B vitamins and iron dextran. This supportive therapy is especially important if the donor is used repeatedly. Donated blood is best if used within hours after collection. Storage of avian blood results in an increasing potassium concentration that will become dangerous to the recipient over time (days).

ACD solution

9 parts blood to 1 part ACD solution

CPDA solution

1 ml blood to 0.14 ml CPDA solution

Recipient - The recipient may be given blood through any available vein (cutaneous ulnar, jugular, or medial metatarsal vein). The use of an indwelling catheter or a butterfly catheter is prudent. A small blood administration set which includes an in-line filter is commercially available (Blood component infusion set, 4C2223, Fenwal Laboratories, Deerfield, IL). Care must be taken to minimize stress in the severely anemic patient. Pre-oxygenation and/or oxygen administration during the procedure may be required. Anesthesia of the recipient is usually not necessary, and may be risky. The recipient should also receive intramuscular iron dextran and B vitamins as supportive therapy.

Transfusion
Transfusion

4.5.4. Repeat transfusions

Studies have shown an increased mortality associated with repeated transfusions given to a patient from the same donor within 10 days of the first transfusion. Reasons for this observation are not understood. It is recommended that repeated transfusions should not be given to a patient from the same donor within 10 days and preferably 3 weeks of the first transfusion without crossmatching. If this is unavoidable, the recipient should be given dexamethasone sodium phosphate before repeating the transfusion. Crossmatching with unwashed red cells is apparently not valid . Crossmatching with washed and incubated red cells may be valid, showing either hemolysis or agglutination reactions.

4.5.5. Use of Oxyglobin®

There are very good anecdotal reports on the use of Oxyglobin® in birds. No scientific papers or official recommendations for its use in birds are currently available. Since it has become available in 60 ml containers, it is now more practical to use. However, availability is sometimes limited and cost my be prohibitive.

  • Studies in chickens and some psittacine species have used 15 ml/kg slow IV or IO route.

  • Used in hemorrhagic shock, hemodilution, chronic anemia to increase oxygen to tissues

  • No cross matching required

  • No observable side effects seen

  • Increased PCV for short periods of time only (~ 3 days)

4.6. Nutritional support

Nutritional support is very important and should be considered soon in the therapy plan. Birds will tend to deteriorate and lose body energy and protein stores more rapidly than mammals, due to their relatively high metabolic rate. Blood glucose measurements can assist in determining the immediate need for supplementation, but should not be the only criteria. Enteral nutrition is preferred, but oral supplements should not be given to recumbent patients because of the risk of regurgitation and aspiration. The type of enteral supplementation should be chosen to match the species appropriately. Supplements are available from the major avian diet manufacturers: Roudybush, Harrison, Lafeber, etc.

Gavage
Gavage

Gavage feeding

  • Proper restraint is essential for safe administration and to avoid regurgitation

  • Choose a warm enteral product appropriate for the species

  • Maximum stomach capacity 50 ml/kg

  • To ensure proper placement, visualize the feeding tube past the glottis and palpate the tube separate from the trachea in the neck

  • Psittacines are usually gavaged into the crop, other birds are usually gavaged into the proventriculus

  • Consider additional parenteral support

  • Monitor weight, fecal production, and blood glucose levels

4.6.1. Refeeding syndrome

Severe electrolyte and fluid shifts associated with metabolic abnormalities in malnourished patients undergoing “refeeding”, whether orally, parenterally, or enterally. Phosphorus, potassium, and magnesium shift to intracellular space leading to sudden drops in serum levels.

  • Clinical signs are varied, including neurologic dysfunction and cardiac arrhythmias

  • Do not offer emaciated animals (TS < 1.0) whole food initially

  • Always rehydrate animal first

  • Give B vitamins

  • Give oral electrolytes first

  • Tubefeed formula low in carbohydrates, high in fat with adequate protein

  • If the patient is digesting the formula, move gradually on to easily digestible solid food

4.7. Thermal and oxygen support

40% O2 saturation recommended.

Heat sources may include:

  • Incubator

  • Heating pad

  • Heat lamp

  • Circulating warm air devices

  • Heated room

Distress
Distress

4.8. Pain Management Protocols

For all birds with mild to moderate pain

(patient must be euhydrated and not in shock)

Meloxicam PO, SQ

Loading dose 0.2 mg/kg BID (day 1)

0.1 - 0.2 mg/kg BID thereafter

Butorphanol IM

1-4 mg/kg q 2-4 hours

Buprenorphine IM, SQ

0.25 mg/kg BID - TID

5. Common Emergencies

The following common emergencies may be discussed in class :

  • Trauma - Thermal burns, cagemate or predator aggression, flying into objects, owner induced trauma, gunshot, entanglement, fractures, lacerations, wounds, bleeding

  • Respiratory emergencies - dyspnea from upper or lower respiratory disease or extra-respiratory causes (neoplasia, hepatomegaly, egg binding, ascites, thyroid dysplasia)

  • GI emergencies - diarrhea, vomiting, toxin ingestion

  • Neurologic emergencies - seizures, head trauma

  • Reproductive emergencies - egg binding, prolapse

  • Renal emergencies

  • Toxicities - ingested, inhaled, skin contact

  • Other; bloody droppings

5.1. Table of Common Emergencies

Condition

Clinical signs

Emergency

Diagnostics

Treatment

Comments

Fluffed bird (nonspecific)

Anorexia

Depression

Fluffed feathers

History/PE

PCV/TP

Blood glucose

  1. Supportive care - fluids, heat and oxygen

  2. Closely monitor for specific symptoms

The "emergency" fluffed birds may be an acute presentation of a chronic disease, usually evident from PE and/or history.

Trauma

Bleeding

Lameness

Wing droop

Wounds

History/PE

PCV/TP Radiography

  1. Control bleeding

  2. Treat for shock

  3. Stabilize fractures

  4. Treat soft tissue wounds aggressively

  5. Supportive care as required

Trauma is the most common cause of wild bird emergencies.

Lead poisoning

Anorexia

Regurgitation

Diarrhea

GI stasis

Paralysis

Seizures

Hematuria

History/PE

Radiography

Blood lead

CBC

Serum chemistry

  1. Diazepam (seizures)

  2. Remove lead source - Cathartics/oral chelators, endoscopy, proventriculotomy

  3. CaEDTA: 35 mg/kg IM bid x 5d.

  4. Supportive care

Consult references for details on various therapy choices. Begin therapy with any serious suspect before blood results are available.

Do not chelate if metal densities are still present in the GI tract.

Egg-binding

Anorexia +/-

Straining

Abdominal distention

History/PE Radiography

  1. Warm, moist heat

  2. Lubrication

  3. If egg in distal position Oxytocin 0.2-2.0 IU IM Calcium 50-100 mg/kg IM

  4. Treat for shock if needed

  5. If egg in proximal position - laparotomy

There are many variations of egg-binding. Consult references for details in handling these cases. By far the majority of cases respond to moist heat and medical therapy.

Hemochromatosis (Mynahs & toucans)

Respiratory distress

Ascites

Weakness

Anorexia

History/PE

Radiography

Abdominocentesis

CBC

Serum chemistry

Liver biopsy

  1. Abdominocentesis

  2. Furosemide: 0.15 mg.kg IM tid

  3. Oxygen therapy may help

  4. Desferoxamine therapy long-term

  5. Phlebotomy

Poor prognosis. May need to repeat treatment. Diet management recommended.

Hypocalcemia

(African Grey parrot)

Lethargy

Severe weakness

Tetany/Seizures

Fainting/coma

History/PE

CBC

Serum chemistry

Serum calcium

  1. Calcium: 50-100 mg/kg diluted IV or IM

  2. Followed by oral calcium supplementation with Neocalglucon 5 ml/30ml water x 7 days 1 ml/30ml water indefinately

Give calcium slowly.

Polytetra- Fluoroethylene toxicity

(burnt Teflon)

Respiratory distress Rapid death

History

  1. Oxygen therapy

  2. Supportive care

Therapy is usually not successful. Bird most often DOA.

Oil contamination

Hypothermia

Anorexia

Diarrhea

Respiratory distress

Dehydration

History/PE

PCV/TP

Wear proper PPE.

  1. Stabilize with supportive care, incl. heat, nutritional and fluid therapy.

  2. Remove oil 1st with towel , 1-% Dawn dishwashing liquid, rinse thoroughly till waterproof.

  3. Dry completely with warm pet hair dryer, incubator, or heat lamp (be careful not to burn skin!)

  4. Treat with antifungals (selected species)

Wash/rinsing should be repeated until water beads up on the feathers. Use water temp. of 103-104 F. Consult references.

5.2. Table of Respiratory Emergencies

Source

Clinical signs

Differential diagnosis

Diagnostic tests

Initial Treatment

Upper Respiratory

Anorexia +/-

Inspiratory dyspnea

Oculonasal discharge

Obstructed nares

Coughing +/-

Sneezing

Choking

Upper respiratory infection

Foreign body obstruction

Inhaled toxins

Thyroid dysplasia

Tracheal parasites

Choanal culture

Sinus flush/culture

Transilluminte the neck

CBC

Radiographs

Staged PE

Oxygen prn

Nebulization?

Air sac cannulation prn

Lower Respiratory

Anorexia/weight loss

Expiratory dyspnea

Coughing +/-

Severe depression

Voice change

Open mouth breathing

Cyanosis

Pneumonia

Air sacculitis

Asthma

Air sac mites

Toxic inhalation (Teflon)

Heart disease

Radiographs

CBC

Serum chemistry

Laparoscopy/biopsy/culture

Oxygen

Nebulization

Surgical intervention?

Supportive care

Abdominal Compression

Anorexia

Dyspnea

Abdominal distention

Lack of droppings +/-

Neoplasia

Hepatomegaly

Egg binding

Ascites/peritonitis

Radiographs

Physical examination

CBC

Serum Chemistry

Abdominocentesis

Surgical intervention?

Oxygen may or may not help

5.3. Table of Gastrointestinal Emergencies

Source

Clinical signs

Differential diagnosis

Diagnostic tests

Initial Treatment

Upper Gastrointestinal

Anorexia +/-

Dehydration

Regurgitation

Emaciation

Weight loss

Palpable crop abnormality

Oral/pharyngeal lesion

Crop infection

Crop motility disorder

Thermal burns and fistulas

Foreign body obstruction

Proventricular dilatation

Lead poisoning

Behavioral regurgitation

Lower intestinal disease (nausea)

Crop swab/flush (culture and cytology)

Radiographs

Endoscopy

CBC

Fecal examination

Supportive care

Withhold food?

Fluid therapy for dehydration

Surgical intervention?

Treat underlying cause

Lower Gastrointestinal

Anorexia +/-

Dehydration

Diarrhea

Emaciation

Weight loss

Feces color change

Lack of feces

Enteritis

Hepatitis

Pancreatitis

Peritonitis

Psittacosis

Toxicity (Lead poisoning)

Obstruction

Parasitic infestation

Fecal examination

Cloacal culture

Radiographs

CBC

Serum chemistry (incl. bile acids)

Psittacosis titer

Abdominocentesis

Laparotomy/laparoscopy/biopsy

Supportive care

Withhold food?

Fluid therapy for dehydration

Surgical intervention?

Treat underlying cause

5.4. Table of Neurologic, Reproductive and Renal Emergencies

Clinical signs

Differential diagnosis

Diagnostic tests

Initial Treatment

Neurologic Emergencies

Seizures

Severe depression/coma

Head tilt, nystagmus

Ataxia

Blindness

Anisocoria

Paresis/paralysis

Trauma

Lead poisoning

Meningitis/encephalitis

Hypoglycemia

Hypocalcemia

Hepatoencephalopathy

Toxicity

Epilepsy

Thiamine deficiency

Ophthalmologic exam

Blood lead level

CBC

Serum chemistry

Serology

Radiographs

Tx. depending on cause

Head Trauma

NO corticosteroids

IV Mannitol?

Fluids (no dextrose)

Pain medication

Oxygen

Cool environment

Reproductive Emergencies

Abdominal distention +/-

Straining +/-

Cloacal prolapse

Depression

History of egg laying +/-

Egg binding

Chronic egg laying

Follicular cysts

Egg peritonitis

Urogenital tumor

Radiographs

Abdominocentesis

Ultrasound

Surgical exploration

Fluids

Heat

Calcium

Oxytocin

Vitamin A and D

Prostaglandins

Surgical intervention?

Renal Emergencies

Depression

Dehydration

Weight loss

Polyuria

Polydipsia

Hematuria

Change in urate color

Renal failure (e.g. gout, aminoglycosides, toxins, ureteral obstruction, hypervitaminosis D, neoplasia)

Hepatitis (e.g. Psittacosis)

Lead poisoning

Diabetes Mellitus

Stress

Radiographs, IVP?

CBC

Serum chemistry

Urinalysis (glucose, blood)

Laparoscopy/biopsy

Supportive care

Fluids and electrolytes

Antibiotics as needed

Treat underlying cause

6. References and Resources

6.1. Texts and Articles

Altman, Robert B., et al. Avian Medicine and Surgery. Philadelphia. W.B. Saunders Co., 1997. Chapter 48

Altman, RB. Heterologous blood transfusion in avian species. Proceedings of the Annual Meeting of the Association of Avian Veterinarians, San Diego, CA, 1983: 28-32.

Critical care. Agnes E. Rupley, ed. The Veterinary Clinics of North America, Exotic Animal Practice. W.B. Saunders Co., 1998.

Degernes, Laurel A., et al. A preliminary report on intraosseous total parenteral nutrition in birds. Proceedings of the Annual Conference of the Association of Avian Veterinarians, 1995., pp.25-26.

Degernes, Laurel A., ed al. Autologous, homologous, and heterologous red blood cell transfusions in cockatiels (Nymphicus hollandicus). Journal of Avian Medicine and Surgery, v.13 (1) : 2-9, 1999.

Harrison, Gregg J. and Teresa L. Lightfoot. Clinical Avian Medicine. Palm Beach, FL : Spix Pub., c2006. Chapter 7,8.

Jenkins, Jeffrey. Critical care. Seminars in Avian and Exotic Pet Medicine, Vol. 3 (4), October 1994.

Mitchell, Mark and Tully, Thomas. Manual of Exotic Pet Practice. St. Luis, MO. Saunders Elsevier, 2009, Chapter 10.

Morrisey, James K., et al. Comparison of three media for the storage of avian whole blood. Proceedings of the Association of Avian Veteirnarians, 1997: pp.279-280.

Quesenberry, KE, and Hillyer, E. Hospital management of the critical avian patient. Proceedings of the AAV Basic Avian Medicine Symposium, Seattle, WA, 1989: 365-369.

Ritchie, Branson W., et al. Avian Medicine: Principles and Application. Lake Worth, Fla., c1994: Chapter 15.

Samour Jaime. Avian Medicine, Second Edition. New York, NY. Mosby Elsevier, 2008, Chapters 5 & 6.

Stone, E.G. and P.T. Redig. Preliminary evaluation of hetastarch for the management of hypoproteinemia and hypovolemia. Proceedings of the Annual Conference of the Association for Avian Veterinarians, 1994.

Seminars in Avian and Exotic Pet Medicine, Vol 13, No 2 (July), 2004