Hi, everyone. So my name is Sonia Miles. I am an RCDS recognised advanced practitioner in zoological medicine and a WA VMA certified aquatic species vet, and I work for Highcroft Exotics in Bristol.

And today I'm gonna be taking you through advanced reptile medicine. So because this is an advanced reptile medicine webinar, I'm gonna assume that you guys are familiar with the basic care of various different species and how this is vitally important to the veterinary care of reptiles, as well as obviously being familiar with the correct handling, basic diagnostic testing of these species. So for example, where to take your blood samples, injection sites, etc.

And some basic imaging. We are gonna touch on some imaging a little later on as well, but I'm gonna assume that you know the importance of taking an accurate history and performing an accurate clinical examination. So, knowing the, basics is really absolutely essential to understanding reptile medicine and surgery.

So as a clinician, you're gonna have to be really, really familiar with basic reptile physiology and anatomy and understand these unique features of the reptile cardiovascular system, the respiratory system, and the difference in metabolism in comparison to our mammalian species as well, that's gonna allow you to diagnose and determine what treatments are gonna be immediately necessary. Now there are over 10,000 species of reptiles within the world, and they've all got different body confirmations, behaviours, dietary requirements, and obviously husbandry requirements as well. So this is going to be really daunting to to work with them and thankfully, we obviously we don't see tens of thousands of different species in practise.

And there are various different places that you can kind of go online that will give you information on various different ways of looking after these guys. So it's worth being familiar where you can get information before tackling these more complex, reptile medicine cases. So there have been significant advances in reptile medicine and surgery for that matter, over the years.

And it is a quickly evolving field, which means that the primary reason for this is because there are more vets like myself and my colleagues that are dedicating our time to better our understanding. So, see what I'm going to be lecturing you on today is most information, most up to-date information that we have available to us, but this is gonna change with time, and as veterinary clinicians, it's really important for us to stay up to date. So I'm gonna start with diagnostic sampling, and like I said before, we're going to assume that you guys know how to take blood samples from reptile species, because this is advanced reptile medicine, I'm not gonna go into that in any sort of depth.

I'm gonna assume that you guys know, as well about where to go to avoid lympho dilution. We were gonna touch on that ever so slightly a little later. So I'm gonna start with reptile haematology.

So reptiles have a lower total blood volume than a similarly sized mammal. This is roughly about 5 to 8% of their body weight, which roughly means you can take about 10% of this, so 0.5 to 0.8 mil in a 100 gramme animal.

Obviously, if we've got a sick reptile, then we should be taking smaller volumes. Lithium heparin is generally the anticoagulant that we're gonna be recommending because EDTA has been reported to cause hemolysis. This is specifically an acheonia species.

However, just to confuse things, there are some studies out there that you'll read that are going to say that actually, what might be more accurately, you might get more accurate results using EDTA. So, in short, contact the lab that are gonna be running your haematology and find out how they prefer their samples to get to them. So when it comes to the er erythrocytes of reptiles, they should always involve a PCV total erythrocyte count, and we can perform our manual counts.

So we want to be doing blood smears at the time of our blood sample. It's a really good habit to get into, and most of your labs are gonna thank you for it. To mature reptile blood cells, red blood cells, they are oval, they've got irregular marginated nucleus, so they are nucleated cells, and the immature erythrocytes are smaller and rounder with a more basophilic cytoplasm and a dance denser chromatin in their nucleus.

Now they're going to be made in the bone marrow and the extra medullary sites such as the liver and the spleen, as well as some mature circling cells, circulating cells, sorry, you are gonna form daughter cells as well. So therefore, in the erythrocyte series of reptiles, it's actually quite common to have mitotic figures within them. We're going to be performing a complete leukocyte analysis as well, and this is going to include a total white blood cell count, a differential, and a morphological assessment.

So this is going to be performed in every single case. But because the nucleated nature of our red blood cells, automated methods are gonna be really, really difficult. So this is where your fresh blood smears come in handy as well.

And that means that those automated methods because of the nucleated red blood cells are gonna be really inaccurate. So you're gonna have to perform a manual count. And the estimated count methods performed by counting a total of white blood cells in at least 10 fields at times 40 objective, and then the average number of leukocytes per field is then multiplied by 1500.

Now this is going to result in an estimated leukocyte per microliter. This method is rapid, it is simple, but it can be prone to error if your cells are going to be clumped together. To start with our heteropphils, these are gonna be your most common granular site in reptiles, and they're the same as your mammalian neutrophils.

They're round, they can display a pseudopodia, and they have a clear cytoplasm. They have round, often bilobe nuclei, and it can also have elongated spindle-shaped eosinophilic granules. Toxic changes can be represented by a basophilic cytoplasm, abnormal granules and vacules, and degranulation can also be an indication of toxicity, although sometimes it can be an artefact as well.

Eosinophils, similar size and shape to your heterophylls with an eccentric nucleus. They have rounded granules in comparison to the spindle shaped ones of the heteropphils. Basays, er, smaller granulocytes, darkly staining basophilic granules that can completely obscure the centrally located non-lobed nucleus.

And the morphology of reptile lymphocytes is the same as the mammalian ones, they're gonna be lacking the granules, have a high nucleus to cytoplasm ratio as well and be very, very basophilic. They can also contour the shapes with the adjacent cells as well, so they're not always the same shape. Your monocytes, these are similar to those in mammals, they are the largest of the white blood cells and they can be various different shapes.

So the monocytes of non-squamate reptiles contain azurophilic granules. Now these cells may be reported as a zuropylls or azurophilic monocytes, and they are a variation of a normal monocyte rather than an actual distinct cell type in itself. By contrast, the azurerophils of snakes are a distinct cell type whose function is similar to that of the neutrophils.

This is a snake specific thing. Now they have finer granules and a round nuclei in comparison with the azuropinic monocytes of reptiles, and they have courses of granules and a lobulate nucleus. Reactive monocytes can also contain cytoplasmic vacules.

And finally, we have our thrombocytes. So they are small oval basophilic cells with a central basophilic nucleus and pale blue to colourless cytoplasm. They can sometimes be confused with really small lymphocytes, but the lymphocytes tend to be rounder and darker.

Now, before I get onto the biochemistry, with regards to the reference ranges of the the haematology that we talked about previously, this is actually going to vary massively between species. So this is something that hopefully species, exotic specific labs are going to help you with. You have to bear in mind that with the haematology and the bio Chemistry that we're about to touch on now can massively vary between sex, biological activity.

So whether that's a female and she's nesting, for example. Actually one thing I forgot to mention in the, haematology section is that, if we've got an inclusion bodies in our red blood cells, that can actually be linked to viral disease. So clinicians are really need to be aware that many, many environmental factors can affect the haematology like we touched on, but also, biochemistry as well.

And we want to be using our exotic specific labs, so Pinmore Laboratories, for example, are absolutely fantastic. There are many out there. They were gonna be helping you with your species specifics.

So starting with our plasma proteins, well, these can actually be pretty helpful, which is, a good thing, because there's not many things from a biochemical point of view that's actually helpful with regards to blood sampling in reptiles, but we, we will cover that. So increased concentrations associated with either inflammation or dehydration. And decreased concentrations, can be seen with conditions such as a decrease in protein synthesis, for example, so our maabsorption, or maldigestion, or increased losses of increased losses, so things like nephropathies enteropathies, for example.

Creatine kinase, the same as our other species, can be consistent with muscle damage, so I would expect an elevated CK in just taking a blood sample in itself or restraining a reptile for a blood sample. Glucose, massive, massive variability between species and it's very, very closely linked to an environmental temperature. So I would expect it to be low in a very cold reptile at the time of blood sampling.

Now it can also be artificially decreased if there's a delay in separating the plasma from the blood cells. So if you're sending your blood samples overnight, be prepared for a decrease, just as a standard elev anyway. From an elevation point of view, well, iatrogenic, but bearded dragons like to do a bit of a weird thing.

If they have a gastric neuroendocrine tumour, their glucose is gonna be skyrocketing. It's gonna be very, very, very, very high, sometimes not even reading on a blood glucometer. Some people worry that this might be diabetes.

Actually, diabetes is incredibly rare in our reptile species. And then we have urea and uric acid. So this is going to be species dependent as to which one is going to be more relevant or not.

So terrestrial reptiles, for example, uric acid is gonna be more helpful. But our aquatic species, well, urea, ammonia, and uric acid are gonna be helpful to determine kind of what's going on from a renal point of view. However, Our uric acid levels don't accurately correlate with the severity of renal disease.

Now this is because it's primarily excreted by tubular secretion. Therefore, but concentrations are really not going to be related to glomerular filtration rate at all. So elevations can be seen postpranly in our carnivorous reptiles, obviously with advanced renal disease and gout as well.

But your magnesium can help you. Now this is only gonna be elevated if you've done some hydrogenic administration or if we've got decreased urinary excretion. So that can really help with your understanding of renal function.

From an electrolyte point of view, or sodium and chloride can be pretty helpful when assessing the hydration status of an individual. Potassium, elevations in that can be linked to renal disease, dietary intake, and potentially changes in our acid-based balance or gastrointestinal disease, but our potassium can be falsely elevated if again, our red blood cells are not separated from the plasma fast enough. Calcium and phosphorus, well, protein bound calcium could be massively increased with reproductively active females.

So again, we're going to be having to bear in mind the time of year that we're dealing with these blood samples. So calcium phosphorus ratio, it should remain the same in reproductively active females, but just obviously being massively elevated. And it should be more calcium than phosphorus when we're thinking about that ratio.

If there's an inversion of this ratio, so more phosphorus than calcium, this is another suggestion of renal disease. So, we're talking about elevators in our uric acid changes to magnesium levels, which you can ask your lab specifically, in combination with the inversion of phosphorus calcium ratio. These are things that are all going to be actually screaming renal changes in in reptiles, not just the uric acid elevation.

Liver enzymes, well, really not particularly very helpful, for example, your ALT, LDH, ALP and AST in reptiles lack tissue specificity, which means they're really, really unhelpful when it comes to assessing liver disease in these guys. So your bilirubin also not helpful, because reptiles lack bilibilidin reductase enzymes that only secrete biliverin. There's very few studies that have investigated the use of bile acids in reptiles.

There's a few reference ranges out there, so they've been published in green iguanas, crested geckos and leopard geckos, among some others, and bile acids have been shown to increase certain case results with certain liver diseases. So when I was looking at the literature. There was a case of a green iguana with a cholangiosarcoma and a Pacific gopher snake with a mycobacterial cholecystitis that had elevations in bile acids.

But essentially, biochemical, you can have a horrendous liver disease and normal liver enzymes. So just because they're normal, doesn't mean your liver is normal. From an endocrinological point of view, there are various different endocrine tests.

So hyperthyroidism or hypothyroidism, for example, contact your lab and find out specifically what they want. And lymphodilution. So we need to be careful where we're taking blood samples from.

So let's take a tortoise, for example. Jugular is gonna be your best site, followed by the dorsal tail vein, which we can see we're taking in this picture here. You can see various different flakes of skin that were stuck over my injection site that I removed and and cleaned.

Before popping my needle in there to avoid kind of as much contamination as you possibly can from the tail of a tortoise. This site, unfortunately, is linked to the lympho dilution. So I'll be writing this down on my submission forms to make the lab aware of where I took my sample from.

That's gonna help me interpret my results as well. And then finally, in a tortoise, final blood sampling site, if you can't get it from the jugular in the dorsal tail vein, it's gonna be your subcapaceal sinus. But we can pretty much guarantee with certainty that we're definitely going to get changes, in that instance by by taking the sample there with regards to, to lymphadilution.

And that has massive effect on various different things, not only changes to our haematological slides, but also it's gonna have significant reductions in our glucose, potassium and, and various other different electrolytes, uric acid, total protein, and we mean globulin, our ALP, AST ALT that there's gonna be so many changes, unfortunately, that are gonna be linked to lymphodilution. So we're gonna just have to bear that in mind when interpreting our results. So, I'm gonna touch on nasal flushing.

It's a very, very simple diagnostic test to do, and I know it's a bit silly adding it into, an advanced reptile medicine. However, I do find that it's one that a lot of people just simply forget. So I just want to just cover a more basic thing to start with.

So you're able to obtain small samples by performing nasal flushing. And what I would normally do is have, about 0.5 mL of sterile saline.

Stick it on the nostril of that reptile. So I predominantly do this in our Cheonia species, and squirt it up that nose and grab that sample that inevitably comes out of the hole in the roof of their mouth. Now we can be sending this off for cytological examination, PCR testing for things like, mycoplasmosis, for example, as well as our culture sensitivity testing, so bacteriology and, mycology as well.

Incidentally, some tortoises, you don't need to do a nasal flush. So I, I popped this, old lady here. She actually came in for a, a, a, I think a pre-hibernation check actually.

And I was a funny looking scab on her nose, so I picked it. It turns out it was a dirty great big abscess. So, we could actually Just stick a swab straight into the nasal cavity of, of this tortoise.

And she's still got this big old gaping hole there, this is abscess has caused some kind of quite significant, damage there. So obviously, not all patients are gonna need your nasal flush. Some of them have just got these chronic changes, unfortunately, that these guys tend to deal with really, really well.

So next are traquiel and lung washes. So these are really, really useful when it comes to respiratory disease in a wide variety of, of reptile species. In large species, we can perform this under endoscopic guidance as well.

Sometimes we need to sedate them. So if we've got a particularly fractious reptile, we're gonna be wanting to sedate them, so we don't cause any sort of rogenic trauma. But many of our snake species, for example, we can actually perform one of these tests in a completely conscious individual.

So you wanna intubate them with a sterile endotracheal tube, and as you can see in this picture on the right hand side here, should be wearing gloves, but I promise you I wash my hands after handling the snake. You can see the airways, really, really easy to, to, to intubate these guys, so don't be afraid of doing it. We want to instil between 1 and 5 mL per kilo of 0.9% sterile saline with a cactus.

I, I use a dog urinary catheter, for example. Do a little bit of gentle coupage. I'll have somebody just gently tapping the body of the snake for a few minutes.

And then with the cannula, sorry, the urinary catheter is still in place in that airways, I'm gonna tilt that snsnake head down and try and aspirate my sample. Again, we're gonna be sending this off for cytological examination from my mycology, parasitology, virology, but also performing culture and sensitivity testing. A little bit about faecal testing.

So whenever we're looking at a faecal sample in a reptile, we are gonna be wanting to perform a direct wet mount. So we're gonna be grabbing a small bit of faeces, and we want to be mixing that small little bit of faeces on a slide with a few drops of saline. So that's saline in combined with the heat of the room, the warmth of the light of that microscope, it's gonna stimulate your Motar protozoa and flagellates to start wiggling around.

That's why we want to look at a fresh sample as much as possible as well. And look at it under the x 10 and 40 objective. Next, we want to be performing our faecal flotation.

There are various different methods that you can use. Essentially, it's going to depend on, the equipment that you have as well. But as a general rule of thumb, you want to be mixing a couple of grammes of faeces with some millilitre of your flotation liquid.

Again, depends on the brand that you're using, and transfer that into, something that you're able to strain that liquid with once you've basically turned it into. A poo soup, for want of a better way of putting it. I then, make a meniscus on that, tube, put a cover slip on top and leave it to stand for 20 minutes.

Normally, during that time, I'll be looking at the direct wet mount and, probably do some phone calls in the meantime as well. I can then stick that slide on, that cover slip on a slide and look at that underneath the microscope as well. You've also got some faecal sedimentation that you can consider.

So 2 grammes of faeces, mixed with some tap water, mix that through a tea strainer and transfer that into a centrifuge, tube, so you're taking out the big old clumps of undigested material from there. Spin that. About 3 minutes at 1300 to 1500 RPM, and then we're gonna leave that underserved for about 30 minutes, removing that liquid from the top without without damaging that sediment layer, transferring some of that sediment onto a a slide and looking at that underneath the microscope.

You want to look at that at the x 10 and the 40 objectives. And then you have your McMaster egg counting technique as well. So you wanna accurately weigh out 3 grammes of faeces and mix it with 42 mL of the floatation solution, which is gonna give you 45 mL in total, roughly.

Pour that for a tea strainer, again, taking out the big old pumps and leave it to stand for 30 minutes. I'll then be removing the meniscus that is, made during that, and we're gonna be loading it into a McMaster's chamber on both sides. When I count all the eggs that lie within the light centimetre square of that counting chamber and repeat it for the second one.

And obviously we've got the calculation here. So based on the fact that the depth of the chamber chamber is 1.5 millilitres and the volume of fluid that we're examining is therefore 0.15 mil, which is approximately 1/300 of the original volume of 45 mL, each egg counted is going to represent 300 per 3 grammes or the equivalent to 100 eggs per gramme of faeces.

And the final, diagnostic test, I wanted to briefly touch on urine testing. Now, first off, not all reptiles have a bladder. So, iguanids and tortoises are going to be the most common ones.

And in those, so our tortoises, for example, actually cystocentesis is entirely possible, but I would always recommend doing this under ultrasound guidance. Now it's pretty straightforward in tortoises. You can just do it through the right prefemoral fossa, but you have to bear in mind that urine and reptiles is, is not sterile at all.

It's a combination of renal intesticle intestinal and reproductive secretions. So really can't think of it as being sterile at all. So that means that sometimes it can actually be pretty hard to interpret the results.

Normal reptile urine is clear, it's a kind of pale yellow, we've obviously got this white precipitate in it as well, and that's the urate component. Reptile specific gravity, pretty low, much lower than that in mammals, and the pH is normally alkali. And the normal composition is, uric acids.

You can see the uric acid, the precipitated white bit out in the the picture on the right hand side here. We're gonna see some slough squamous cells. We're gonna see some white blood cells, red blood cells, normally about, what should be less than 5 white blood cells and 5 red blood cells per x 14 field, .

We'll see low levels of bacteria, predominantly Gram-negatives, and sometimes we'll see low levels of motor protozoa. So this is often a contamination from the intestines, but hexamitta, which is a true pathogen inelonia, can also be found specifically in the urine. So we need to know what is, is, is normal in the various different species that you're looking at.

So I'm gonna touch on the the the diagnostic imaging next, and I'm gonna briefly go through radiography, ultrasonography, I'm gonna touch on CT scanning, MRI and then I'm gonna touch on endoscopy as well. From a radiographic point of view, radiography and ultrasonography, I think they are basic, diagnostic tests, but I think interpreting them and doing them well is an advanced skill. So, radiography, well, it's easily accessible in the vast majority of, of practises, but what isn't often present in most practises is horizontal beam radiography, which, in my point of view, is absolutely essential to performing diagnostic radiographs in reptiles.

So we're gonna be wanting to perform whole body views. Now in Tilonia, for example, our small, lizards, and most snakes, we want a dorsal ventral and a laterolateral view. Now, obviously, that's gonna depend on ease, depending on the species, and whether you're gonna need to sedate them or not.

So you've got your dorsoventral, you've got your laterals, but in tortoises, we're also gonna need a cranial caddal. And this is the only way that we're gonna be accurately able to assess the lung fields of that species. Because these guys don't have a diaphragm.

If you tilt your patient to X-ray them, you're distorting the normal anatomy, the normal position of those internal organs. You're gonna be compressing their respiratory tract as well. So we're quite pointless, to be perfectly honest, which is why you're gonna need horizontal beam radiography.

An accurate assessment. And get inventive with, with how you do it. This picture here on the right hand side is a little tortoise that's just sat on a dog food can.

So you can see the limbs hanging to, to, to one side. They're unable to push themselves off, and it's going to give me an accurate view of their lung fields. So like I said, get inventive.

Clear plastic boxes work really well, at the same time as well. And the problem with radiography and why, CT scanning, for example, is much, much better, is obviously we get a lot of superimposition. So you need to be performing your orthogonal views, to limit this, but it's not gonna remove it completely, which is why CT is, is better, but obviously I'll get to that a little later.

Make sure the legs are out of the way and as I said, get inventive on how you can how you can do that. When it comes to, the other species it can be quite challenging sometimes are chameleons. Actually, just getting them to stand and hold on to something.

A lot of them will freeze in place. And with your horizontal beam radiography, you can just take your lateral view. We've got, just the, the, the orthopaedic measures that they use on the kind of like bendy stick with the metal ball on the end, works an absolute treat for comedians to hold on to that as well.

So, just get it, get inventive. From an ultra sonographic point of view, well, it's really, really important. I think ultrasonography and for me, CT because I privileged to have easy access to it.

But ultrasonogram is one of the things that I use the most. I can do it in a conscious patient. I can do it in the consult.

The owners love watching it as well. It's, it's fantastic. But I think it's an advanced skill to understand what you're looking at.

And honestly, I could lecture on its own in ultrasonography in, in, in reptiles. So this is a very brief overview. But it's fast, it is safe.

Most species given correct handling, it can be completely conscious as well. And obviously there's no risk to the, the handler as well from the point of view of kind of ionising radiation, for example. Now, the problem with it is that we don't have much information of what's normal in in reptiles.

For me, it's very much the fact that I ultrasound hundreds of reptiles, a year. So, I become practise in what is normal. What isn't normal because I, I see it on a regular basis.

So we, we, we don't have much information on, on normal reference ranges, in a lot of species. Be the dragons, for example, being incredibly common, well, yeah, we've got some information on those. But one of the studies I looked at, actually information on the specifics of adrenal gland size and spleen size in one of the studies I looked at, well, vets doing the study can actually, find them in most of the reptiles actually.

So, we've still got lots of practise to, to do and lots of information that we need to gain and record. The most helpful probes, well, it's gonna be your linear 7.5 megahertz transducer and a microconvex between 5 and 8 megahertz.

Now, as you can see, my probes the size of the leopard gecko, but got diagnostic answer. We knew this girl was in pre-ovulatory follicular stasis. She hadn't eaten for a number of months.

We spayed her. She was eaten within 12 hours of surgery. So, despite the fact that it looks ever so slightly ridiculous, we still got our diagnostic answers.

So when it comes to our coupling gel, we just use the normal, lubrication gel that we would use in a normal coupling gel that we would use in a normal species. I avoid applying surgical spirit to the skin. In, in reptiles, I don't want to cool them down excessively.

In our aquatic reptiles, as long as we are protecting our probes, because heaven forbid, we don't want those getting damaged, then. We can actually use water that that reptile lives in as an acoustic coupling agent without the gel added in as well. Now, the ease of visualising the organs can be really variable depending on the species.

So our big turtles and tortoises, for example, quite frankly, we are not going to be able to reassess the entirety of the ceramic cavity. And in many of our reptiles, gas in the gastrointestinal tract in the lungs is going to cause a hell of a lot of issues with our, our visualisation. So, It will give us some information, but a lot of the time for me personally, I often combine my radiography and ultrasonography with CT scanning.

This is one of my little guys ICT scans the other day. So it's, it's a lot cheaper than, than, than MRI certainly at my practise, but it's, it tends to be one that, that people go for more from a financial point of view between the more advanced imaging modalities. It is non-invasive and it is quick, really, really fast for the majority of our reptile species.

And we can get so many different views from these guys as well. So whereas radiography is a two dimensional image, we'll get 3 dimensional images from these guys, and that is completely removing the, the superposition that is obviously the the issue when it comes to radiography. Same as radiography.

The denser it is, the whiter it is, essentially. So, it's just like a 3D X-ray, but without the superimposition. And there is information out there performing contrast studies in reptiles too, but it does mean waiting a long time and, and re-scanning them at various different points as well.

So we, we do have to bear in mind, especially in our long-lived reptiles, the benefits of that with, lots of ionising radiation. And a lot of our patients, we might need to perform general anaesthesia or sedation. So, a snake, for example, or a particularly, fidgety lizard, to get our diagnostic images, yeah, I'll probably be giving them a sedation or, a very low plane of anaesthesia.

But some species like this tortoise, and there's a picture of an iguana. On the next slide, completely conscious. I didn't need the legs or the head of, of this girl.

She actually had pre-ovulatory follicular stasis. It's by far, one of the most common reasons that I end up CT scan, CT scan in Tilonia. I didn't care if her legs and head were moving around, which is why they, they, they can do.

I just needed the middle part of her body to stay still. As I mentioned, the iguana here, this is actually my iguana, so he is in a sense an iguana straitjacket. So I've, I've just gently restrained his forelimbs against his thoracic cavity and his hind limbs against his.

Tail, this vet wrap, that's around his, his limbs is not tight at all. I can get a good couple of fingers underneath there, but it's just keeping them still. And I've popped a little bandage around his eyes that's just applying a little bit of pressure there that is stimulating a vasovagal response, but it just really chills him out.

He was like this for. A couple of minutes while we did the CT scan of him, so, he was super chilled afterwards as well. He was a super chilled guy anyway, so, .

With regards to CT scanning, it's actually been demonstrated to be 4 to 6 times more accurate in determining certain things. So, reproductive disease, for example, than compared with ultrasonography. So in CT scanning, and again, the most common reason that I personally use it, is that we can be assessing the size, the shape, the density of very various different eggs and follicular structures within a female reptile's body.

It's also absolutely excellent for respiratory disease as well. It's gonna give you much finer detail. We had a, a tortoise with a, a tracheal obstruction.

You literally follow it all the way from its nasal cavities all the way down to the tracheal obstruction, which you would have completely have missed in, in, radiography, for example. So really good for our respiratory diseases. It's gonna allow earlier detection of issues as well, and it doesn't just go for reptile species, it's all of, our exotic species as well.

We're gonna be able to do 3D rendering, something that I find owners particularly like, they love having a 3D skeleton, to, to, to look at as well. But interpretation can be hard. So, as I mentioned, I'm very fortunate to have a CT scanner at a practise, and we, CT scan hundreds and hundreds of exotic species a year.

So we're becoming very practised at assessing our own radiographs, but places like Vet CT, for example, and like myself, I, I'll happily look at CT scans for, for other people as, as well, if that's helpful for them. And, and then use my, using it as a teaching aid for our interns, to be perfectly honest. But vet CT are fantastic, especially when I first started out.

And there are many other referral centres out there that I imagine if you spoke to them directly, that they would, be more than happy to either help or point you in the direction of somebody who could. And then we have MRI. So much safer diagnostic tool than CT scan, obviously no ionising radiation whatsoever with this.

It is minimally invasive, but it is going to require an anaesthetic, and they are gonna be much longer. The longer the anaesthetic, the higher the associated risk. Now we already know that the anaesthetic associated risk in our exotic species is higher than our cats and dogs, so this is something that we really need to be bearing in mind.

I personally find MRI excellent for the Tilonia species. Contrast studies can be massively advantageous, as well, but we want to be making . Our, radiographers aware that if you are, say, for example, using an MRI, place down the road, more than willing to, run it for you with one of your patients, need to be making sure that the slice thickness is no more than 5 millimetres.

So again, I'm very fortunate to have a, a, a A, a referral service that is able to provide an on-site MRI. But I do know some places that have MRIs at their local referral practise, and they've run exotic MRIs for them. So just making them aware that slice thickness is no more than 5 millimetres.

And then, I'm gonna touch on endoscopy. So, obviously, there's loads of scopes. As far as I'm concerned, as a big, big fan of endoscopy, the more the, the, the, the better.

So I've got various different size, rigid and, and flexible endoscopes available to me from like 1.6 millimetres, flexible scope. But the most versatile one that I have is my 2.7 millimetre 30 degree scope, which you can see in this picture here, I'm performing a celioscopy in a tortoise.

. I can't remember what I was doing in this instance. I think I was doing a liver biopsy, actually. So you're predominantly gonna be able to use your 2.7 millimetre 30 degree scope, that's gonna be your most versatile scope.

We'll do the most, the, the vast majority of the species, but if you've got a dirty great big snake or a monitor lizard, so I had to remove a, a plastic foreign body from the monitor, stomach of a monitor lizard the other day, no way was my 2.7 millimetre scope fitting towards the stomach. I barely got halfway down the oesophagus.

So that's where your flexible scopes come in, handy, and I just, I actually borrowed our first opinion team's gastroscope, which worked an absolute treat. So I'm gonna start with stomatoscopy and gastroscopy. So, the rigid scope and the sheaf is gonna work for the vast majority of your species.

So, yeah, bit of dragons, for example, that are running around the house and picked up something they shouldn't have. I'd start by examining the mouth, make the most of, of having your scope out and have a really good look around in there, look at the buckle cavity, look at the oesophagus as you're going down. As I said, you're gonna meet the stomach in the vast majority of your small lizards and your tlonia, but that's when your flexible endoscopes are gonna be needed to gain access to the stomach with your big snakes and your large lizards.

Now air installation works really well, but personally, to allow the mucosal detail that I want, I'm gonna be using warm saline. If you're using warm saline, goes without saying, intubate your patients, you should be doing that anyway, incidentally, and that's going to be protecting your airway and avoiding aspiration. Start from the front end to the back end.

We got looscopies, so performed by introducing the endoscope into the vent, the cloacal sphincter, and it can be performed in various different species, but as to how helpful it is, well, it, it's gonna be very species dependent. So, one study I read actually said in snakes, pretty limited diagnostic value, to be perfectly honest. And we can again use our rigid endoscope to do this using warm saline to allow irrigation.

And that is gonna allow you unparalleled examination of the the proctoderm, the uroderm, the coproderm as well. And you can look at the distal colon, the cloacal mucosa, you can look at the urogenital papillae of the ductal openings in females, obviously, and I see some of the urethral openings and the bladder as well. Obviously, cystos cystoscopy is gonna be your next step.

So we've just found our urethral openings in your species that has got a, a, a bladder, which we've already touched on. Not all species do. I find it really, really helpful for my elonia species.

They're probably the easiest that I can get my scope into. And you can pop that through the urethral orifice and end up having a look around the bladder. You can actually do this in very, very small ellonia, depending on the size of your scope.

As a method of sexing, you can actually see the the the bladder of these guys is like tissue paper, so go easy when you're scoping around in there. Incidentally, gently instantly. Worn saline can be really, really helpful as well.

You can see through the wall of your bladder and you can actually sex your tortoises that way as well. Not sure why you would want to, the vast majority you can see externally, but it is reported in the literature. And then we've got celioscopy, so performing this under general anaesthesia, this is an example of performing this in a tortoise here on the right hand side.

You're gonna be wanting to aseptically prepare that area, make a small incision through the skin and then through the body wall. This position that you're going to be entering into the salamic cavity is, is gonna vary massively between your species. So I'm using the, the left.

Prefemoral fossa in this tortoise, in, your lizards, paraluba approach, and in snakes, well, they're essentially, they're an entire salamic cavity mostly. So I would be basing your approach in snakes based on, hopefully, some advanced imaging that you've performed a CT scan or an ultrasound, for example, and you've pinpointed your lesion of, of interest, and then you go in that area, obviously. So cut through the skin, pop through the, the muscle with a pair of of of hemostats.

And we can have a look around that salamic cavity insulation works really, really well in that instance. And then we've got our tracheoscopy and our pulmonoscopy. So respiratory disease, absolutely love endoscopy for respiratory disease.

And it's a fantastic way of assessing the degree of respiratory disease that you have present, and hopefully you'll have an inkling of that if you performed a CT scan. But it is fantastic for gaining your samples as well. So, we've seen parasites swim around in the the lungs of of different species.

You can get your samples for viral testing, mycology, and bacterial testing as well. It's a fantastic ancillary diagnostic test in in in reptiles. But the approach is gonna vary depending on the species.

So snakes, for example, is probably the, the most, complex reptile that, that you can, scope, because you've got your tracheal and your transcutaneous approach. Tracheal, go down the trachea, essentially. So have a good look inside the mouth as you're going.

Go down the airways. And you can actually, go quite far down in the vast majority of species. So that's gonna be scope dependent as well.

You can do this in your Gillonia, species as well, but bear in mind that the chelonia's trachea will bifurcate halfway down the neck, so it can impede visualisation past a certain point as well. So you're going down the glottis, down the trachea, these will vary depending on the, the, the species. In some snakes though, you can actually go all the way down, into the lung tissue itself.

Now the transcutaneous approach, normally the lungs and snakes are gonna be about 35 to 45% of the snout to vent length. You go in around that area, in between the 2nd and 3rd rows of lateral scale, so pop a little hole in the skin, obviously aseptic preparation. Pop the, the, the, the, the pair of forceps through the, the, the muscle, locate the air sac that he says.

It's literally like a, a bag of lace is, is what it looks like. And you can exteriorize that, use some stay sutures to hold it in place, perforate the air sac, and pop your scope in. It is genuinely that easy.

And you can do that with or without your operating sheath. It's gonna obviously depend on the size of the species that you are scoping as well. And you want to scope all the way down to the bottom of the lung and you want to turn it around and go back up to the top of it as well.

So have a good look around. There's no point in half assessing the the structures that you're looking at, make sure that you're taking the most of it, grabbing the samples while you're in there as well, performing your lung washes for culture sensitivity testing and psychological examination. Incidentally, also looking back, we've just touched on the fact that the, the reptile lung in most instances is like a very thin bag of lace, you can actually look through that at other internal organs as well, so it can give you a bit of an idea of what else is going on too.

So from an emergency medicine point of view, well, reptile emergencies are an important part of advanced, exotic mammal care, but these true emergencies. And actually what is perceived as a true emergency by the owner are two very, very different things. Now, true emergencies for me personally, fractures, egg binding and dyspnea, like a reptile that just is absolutely gasping for breath.

These are ones that need to be seen as soon as possible. But you have to bear in mind that these diseases have taken a very, very long time to occur. Hopefully, the owners pick them up as quickly as they possibly can.

I hasn't just stared at that reptile for weeks on end, but unfortunately that does sometimes still happen. So I wanted to start with 0 tube placements. This can be done in a wide variety of species, admittedly, predominantly we're gonna be doing it in Archonia, but I, I've placed them in, various different lizard species too, so chameleons, bearded dragons, monitor lizards, etc.

And they are, it's, it's not an emergency procedure, but it will be needed in emergency cases that are inevitably hospitalised for a period of time. Now sometimes you need to get inventive, so I think the smallest, tortoise that I have, have put a, a, a feeding tube into was about 20 grammes. I use a cat urinary catheter, in, in, in that guy.

It works like an absolute treat. It has a tiny little horse field tortoise that unfortunately had a horrible mycoplasma. Infection and just wasn't eating and therefore wasn't able to take any medications.

So we need to be considering placing our, tubes, our feeding tubes in any reptile that is anorexic and obviously going easy with feeding them because these guys can get refeeding syndrome as well. But also, we need to, be, be getting inventive and, and, and making sure that, we are, are placing an appropriately sized tube. We can be doing this in a sedated patient in the most part, however, sometimes your patient is just so unbelievably sick they're comatoseed already and just use some local anaesthesia and appropriate analgesia in these instances is OK as well.

Get everything ready ahead of time. So first picture on the left hand side, I've got everything ready that I'm gonna need ahead of time. I think there are a few things out of the picture actually.

One of the most helpful things that you can have is, an extra pair of hands too. Pre-measure your tube, so picture at the top right. I'm pre-measuring my tube from the mid neck down to the midway along the plastron, and I'm gonna premark that so I know where to go.

Many of the tubes that I use, the NutraSafe, tubes is probably the ones I use the most, they've got little marks on, so I just remember what the number is. When I clean the side of the neck, I use just some Paidine iodine and use a pair of curved hemostats. Push it in the mouth.

Push it along the inside of the oesophagus very gently and just tempt the curved end of the hemostats up and against the neck. Once I've done that, I'm gonna incise over the top of the hemostats. Now, a little tip is actually to just run your finger over the top of the hemostats before you incise just to move any of this very important jugular and carotid blood vessels out of the way.

Once I have incised over the top of the hemostats, pop them through the neck, grab the end of the tube and pull that tube very gently out of the mouth. I will then turn that tube around. This is the bottom left hand side picture here, and push that down towards the stomach.

And, what you can sometimes do in those instances is actually you're pushing it down, down the stomach, the tube that's kind of hanging out of the neck. If you just put some gentle traction on that as you're feeding the stomach the tube down towards the stomach, so and you can pull the tube at the neck. To that pre-measured mark, that can sometimes flip the tube around and actually aim it down the stomach quite nicely.

So it's sort of a combination of feeding the tube down the mouth towards the stomach while simultaneously pulling on the tube at the level of the neck very gently, obviously. And you'll feel it just go ping, and it just turns around. You put that to its pre-measured point before you suture it in, check its position.

So quick radiograph, make sure it's in the stomach that it's not pushed up against the side. And once you know it is in position, suture it in place, and then tape. Promise you really, really helpful to tape it.

So, so you can see here at the bottom right hand picture, I've got some elastoplast. Just on the top of the shell and on the leg on the same side of the tube because these little so and so's will be maybe a smidge uncomfortable, especially if you pulled your sutures accidentally too tight, and they're gonna try and pull that tube out with their leg. They've got some very healthfully sized scales.

On that leg that can just nab your suture. This picture in the lower right hand side, I'm using a Chinese finger trap that you can use a butterfly suture as well, and I'll just literally just pull that straight out and just ruin all your hard work. So make sure that you're taping the legs, nice smooth covering so they're not gonna just yank it straight out.

Next, I wanted to touch on intra-osseous catheterization. So, I would really deem this as an advanced procedure, but it is kind of fairly straightforward. I find many bulk, vets kind of bulk the idea of, of, of doing this, or maybe forget that it is also an option in these species, or maybe you aren't comfortable with the anatomical landmarks that we should be using.

But I, I would deem this as an advanced procedure in reptiles, despite the fact that it's, it's pretty straightforward to, to do it. Now, in most cases, an appropriately sized injection needle is gonna be suitable. So I'm just using a, a, a blue needle here in this, poor female Yemen chameleon that, funnily enough, came in with reproductive problems, like they all do.

In our larger patients, we can be using actual spinal needles of various different sizes as well. Now, as a general reference guide, that intraosseous cavity should occupy between 33 and 67% of that marrow cavity at the thinnest portion. So again, most of the normal injections like needles that we're using, I'm just using a normal bung here, so lots of stuff that people have in practise.

We can be using them for small volumes, placing them under local anaesthesia or sedation. This girl here, she was completely out of it, bless her, she's completely collapsed. So we use just local anaesthesia and made so she has some analgesia on an.

Analgesics on board and I find it very, very easy, in our lizard species. We wanted to make, make sure that it is in place using radiographs and orthogonal views, always, always orthogonal views. We can use them.

In our Tilonia species as well, but pretty difficult, most of the time in our lizard species we're gonna be using the the tibia, so insertion is that the the tibial crest as it is described in mammals and in our ilonia species, we can actually use the the bridge between the carapace and the plastron. So with that bit of bone that goes along the side of them, that will be the intraosseous catheter site in that species. Obviously, snakes, yeah, not happening.

And then I just briefly wanted to touch on blood transfusions before we we touched on cardiopulmonary, cerebral resuscitation. Now, blood transfusions in reptiles, very, very little information on it. I, I have performed it in reptiles before and everything went fine, but just because it went fine doesn't mean it's going to always go fine.

There's very, very little information on blood transfusions or reptiles in the literature. There are anecdotal reports, the one that I've just given you that it's impossible, but it is feasible in the same way that you would do it in other species. However, There are some reports that it can, their blood clots are a hell of a lot faster in mammals, so I wouldn't necessarily say I've seen this in practise, but it certainly seems to be anecdotally reported, so I have to bear that in mind when we're performing it.

As to when we perform a blood transfusion, well, because reptile PCV varies massively between species, the question is, well, how when in which species is it gonna be best. As a general rule of thumb. 10% is a low PCV in a reptile, but I would really only be considering it if it's dropping below 10%.

Definitely it's dropping below 5%. But groups are not described in reptiles, however. Sort of makes sense to take it from the same species.

So I've done it in in in bearded dragons, and it's probably the species that I've done it in the the most. The problem is going, well, I want to take a blood sample from a healthy individual. I can take 2% body weight in blood from that donor.

I want to make sure that they're healthy beforehand and, and let's face it, what reptile in captivity is 100% healthy. So we do have to bear that in mind, that we might not necessarily be putting healthy blood into a sick reptile. We want to look at it as closely as possible, look for, like, blood parasites and inclusion bodies, etc.

As well before doing it, obviously. But sometimes needs must. And see, the ones that the bearded dragons that I've had to do it in, they, the owners have had two bearded dragons, and they've gone, here, have my other one, and, and use his blood.

And it has worked to treat, but there are definitely reports and anecdotal reports in various different sites where it hasn't gone as well. And when we're giving it, obviously we're taking our 2% body weight in blood from the donor, we're gonna be giving 1 to 2 mL per kilo to that recipient and then assessing them afterwards. So in our emergency care, I've included our cardiopulmonary cerebral resuscitation.

It is entirely possible in our reptile species. So we are gonna be wanting to our patient that is crashed, performing a quick clinical examination to determine, OK, well, what's going on, cardiovascular respiratory stability, what's going on there? What's our mentation.

Is there any evidence of trauma or obvious blood loss? If the reptile's not breathing, then, well, yeah, CPCR should be started and basic life support, including the ABCs is exactly the same approach that we should be doing in our reptile species as we do for our other ones. To secure the airways.

We've already seen pictures of a snake. I'm not sure I have actually put any species of the, pictures of the glottis of the Sillonia species. They're probably the hardest to intubate, but you, you bearded dragon here, your glottis is, is right there staring at you.

So nice and straightforward. Most reptiles can be really easily intubated, and we want to be in, want to be, breathing with either room air. Or oxygen, but we'll obviously get on oxygen, in, in reptiles is better it's better with room room air, essentially.

If you're giving 100% oxygen in in reptiles, then you can actually depress their breathing. So we've got an amti bag, works an absolute treat. We want to be doing positive pressure ventilation at a rate of between 4 to 6 breaths per minute.

Check for a heart rate. Use a Doppler, most practises have them. If there is no heartbeat, then give adrenaline.

We can put this down there endotochial tube at 1 mL per 100 grammes. We want to be improving that circulation, as, as much as as possible. So like I said, we could be administering the endotocheal epinephrine with a catheter is down the endotochial tube, we can be given it intravenously, intraosseously if intravenous isn't possible.

Now, we want to be making sure that while we are doing all of this, that our reptile is at its preferred optimum temperature. So whilst we are repeatedly checking for the heart rate, incidentally, noninvasive blood pressure isn't particularly accurate in our, our reptile species, so that. Bother with it.

Well we're repeatedly checking for a heart rate with the Doppler, we are wanting to make sure that that reptile is at its preferred optimum temperature. So really high 30s for a bearded dragon. You're not gonna win your cardio resuscitation if it is, if it's not.

Trends in lactate and pH may be helpful, essentially we need more information on it. And then I briefly wanted to touch on fluid therapy, so there's plenty of reptile fluid cocktails er out there and ideally we should be basing these on bloods wherever possible. Maintenance is gonna vary between 10 to 130 mL per kg per day and anything over 40 mL per kg per day, you could be really dealing with some fluid overload.

So, OK, well, 10 to 30 mL per kg per day, where do I choose for my species? As a general rule, if it's a desert species or somewhere from a very, very arid area, the lower end, if it's a rainforest species towards the top end, so maintenance for a bit of dragon, 10 to 15 mL per kg per day. Whenever we're giving fluid therapy, we want to make sure that our patients are at that preferred optimum temperature like we've touched on before, assuming you, you, you guys are are obviously aware that just everything with reptiles is linked to their temperature.

Now if you have to pick one, you can't go overly wrong with 0.9% sailing. If you, you haven't got the ability to make up all these various different cocktails that we can go through in a, in a second, then sailing is probably your go to.

Take care with using Hartman's. Now, the, the reason that I say this, that sailing is is better over Hartman's is that. That lactate has been suggested to potentially add to the metabolic burden in an already compromised reptile.

So it's not ideal for rehydration, despite the fact that reptiles do have a buffer system which allows them to tolerate high levels of lactate. But why push them further if they have a better option? So if you had to choose between saline and Hartman's, go with, with saline.

But obviously, there are various cocktails reported in the literature as well. These cocktails, they include, combo one. A third of the fluid that you're given is 5% glucose with a 0.9% saline, a third lactated ringers, and a third sterile saline, sorry, sterile water.

Another 19 parts of 5% glucose with a 0.9% saline to 1 part sterile water. We can even basically when it comes to the osmolarity of reptiles, we really do need more information on them and the the osmolarity in one reptile is obviously can be very, very different to the osmolarity in another reptile as well.

So . As a a take home message in regards to fluid therapy, grab your saline first, take care with using hearts. There are various cocktails available in the literature, and it involves mixing glucose and saline with various different concentrations of, of everything else.

But if you have to grab one, then the saline will do for the time being. Now there are obviously various routes as well. Given if you can give it orally, then obviously give it orally, subcutaneously, epistolamically, intravenously, intraosseously and intrasolamically as well, but this is gonna vary on the species and this is basic, so we're not gonna discuss it.

So I'm gonna go through some examples of disease processes that we commonly see in our reptile species, and I'm gonna use the advanced diagnostic techniques that we have touched on to basically take you through how we should be managing various different cases. So I'm gonna start with trauma because it's probably by far one of the most common reasons I see tortoises come to us. Bites can be from other animals.

So whether this is cats and dogs, tortoises being left unattended with, and there the cats and dogs, as they say, they've explored things with their mouth and unwittingly cause sometimes quite substantial damage, or whether that is the owner inappropriately hibernating their tortoise and expose them to, to rodents, for example, that have just come along and snacked on that, that poor tortoise for weeks on end. We want to be swabbing these wounds for culture sensitivity testing, before we want to be thoroughly exploring them. So remove any gross debris, take swabs from our deep, deep areas hopefully are more accurate ones before we start really, really cleaning those wounds, with antiseptic solutions.

And any haemorrhage is gonna need to be immediately stopped, it goes without saying, really. Starting appropriate fluid therapy, which we've already touched on. And hemostasis, we can apply pressure, we can use surgical ligation, electric surgery, reptiles, they are very, very tolerant to, to blood loss.

But in severe cases, well, we've just touched on blood transfusions, so we might need to consider that in this instance as well. Now, primary wound closure can be considered in non-contaminated wounds, less than 12 hours old, but face it, certainly with regards to our tortoises that have been eaten for weeks on end by rodents while being hibernated, these are going to be heavily contaminated wounds, so primary closure is inappropriate in the vast majority of the cases. Assess these wounds.

So this is where CT scanning comes into its own with radiography, although better than nothing, if you don't have access to a CT scan in practise, the CT scan is gonna remove that sin, it's superimposition that we've touched on as well. So it's going to be vitally important for assessing fractures of shells, for example, and whether synomic membranes have been perforated, whether we have internal haemorrhage, so ultrasonography can be quite helpful too. Goes without saying, we should be appropriately analgesic and and giving antibiosis to these patients, which is kind of beyond the scope of this webinar, the time that I have available.

And we can be considering wound dressings as well, so dry dressings, well, up until the point that these tissues are starting to granulate, I'll have them covered in the majority of cases, but I'll be making sure that the owners are appropriately managing these dressings at home as well. Lovely gross picture of a prolapse here. So, the When it comes to prolapses, figure out what is hanging out of that reptile first, obviously.

It can vary. The the tissue that is hanging out can sometimes be so grossly abnormal that actually it's really, really hard to figure out what the hell is hanging out of, of that tortoise. So, is it colon?

Is it bladder? Tortoises have got a single phallus, lizards and snakes have got heney pees, so they've got two penises. You can have oviducts hanging out.

You can have a cloaca tissue, cloacal tissue hanging out as well. Colon, obviously, it's got a, a, a lumen bladder, as we've touched on with our ultrasonography and been able to see through that, sorry, our ultrasonography, our endoscopy and our, cystoscopy, we can see through that bladder and see internal structures and allow sexting of that patient. So, actually, when it's on the outside of the, the body, well, it's literally just a see-through bag, incredibly fragile as well.

Phallus and hemipes, they're actually pretty obvious. Incidentally, the female can also prolapse at her clitoris as well. This is a, a female here that pushed out her colon.

She was egg bound, but you can see that the top part of this prolapse is actually clitoris here. Oviduct is striated and then cloaca, it, it's kind of fairly obvious in itself as well. So, we need to figure out why that tissue is prolapsed.

But in the meantime, we want to be protecting those tissues. So irrigating them, lubricating them, using hypertonic solutions, or a high concentrate of dex dextrose solution to minimise the edemas that allow you to replace it. Why you figure out what the hell is going on with that poor patient.

So, you're doing your biochemistry, your haematology. Taking blood samples for ionised calcium. You're performing your faecal testing looking for parasites.

You're performing your diagnostic images, your CT scan and, your ultrasound scan and, and looking for reproductive disease in females. All simultaneously, while trying to shove everything back in, shove gently, obviously. But there is no point in replacing it and going, ta da, it's done, because we haven't fixed the underlying reason for it.

So. Protect the tissues, by all means replace it, but work out why on earth it happened to start with. Purse string sutures are no longer recommended.

We would recommend putting simple interrupted sutures into the cloaca. And in, in some instances as well, we actually might need advanced surgical techniques like, this tortoise, for example, if the owners hadn't gone for euthanasia in this case, and if it hadn't been so unbeliev. Massive.

And if I had actually been able to push that back in, I could have performed, plastronotomy and actually helped tease that tissue back into the salamic cavity, from the inside, while simultaneously push it from the outside, as well. You can perform PEis. A lot of bladder prolapses might be a result of a bladder stone.

So cystoscopy, cystootomies as well, is something that might need to be considered from an advanced surgical point of view. And while we're touching on prolapses, it'd be wrong of me not to mention the prolapses of tongues in chameleons. Long story short, it's down to hypocalcemia in the vast majority of cases.

If it's female, look for your reproductive diseases, and we've already touched on how to do our lateral view radiography in chameleons by making them hold on to something with using our horizontal beam radiography. Sonography, you'll easily pick up follicles. CT scan of chameleons is beautiful and helpful as well.

So we've got reproductive disease, we want to fix that, obviously. But unfortunately, if their tongue is prolapsed, well, it ain't good. So we can actually completely amputate the tongue of a chameleon.

However, some chameleons do great with that and love being Hand-fed by their owner for the rest of their life. But some are terrified of life. Those are really not candidates to have their tongue amputated because they're gonna need to be hand fed, and these guys can find that very, very stressful.

So it is very, very case dependent as to whether you go ahead with an amputation, whilst simultaneously, again, figuring out what it prolapse to start with, or sadly, we consider euthanasia. Reproductive disease, my favourite, to be perfectly honest, and my main area of interest when it comes to reptiles is often linked to poor care. Now it's not always associated with eggs.

Obviously it's very much associated with eggs and in this poor girl here, very deformed, misshapen eggs and actually fractured eggs in these instances as well. Well, we could also be finding pre-ovulatory follicular stasis. So, is it pre-ovulator or is it post-ovulatory?

That's what you need to figure out. And that is where your imaging comes in incredibly helpful. So a single DV radiograph, yeah, eggs or no eggs.

But a single DV radiograph or even. Any radiograph, to be brutally honest, is useless when it comes to follicular disease. So if you think reproductive disease in a female, do radiographs and you think, oh, there's no eggs there, it can't be reproductive.

Yes, it can, but it might be follicles instead. And that's where your ultrasonography or your CT scanning comes in helpful. Well there can be various different clinical signs in females from lethargy and anorexia to hyperactivity, as well.

So, one of the things that I find a lot in females that are kind of jam packed full of follicles or rammed full of eggs, lameness as well can be really helpful. But your imaging. Samping any synomic effusions that you might find on ultrasonography and sending that off a cytological examination and culture sensitivity testing can be very helpful.

Baseline biochemistry and haematology as we touched on the reproductively active females will have various different elevations, in their calcium levels, for example, and have elevations in the ALP2. We can be forming blood cultures, especially if we have a systemically ill female that may have had festering reproductive issues for sometimes months on end. And the vast majority of these instances, swift surgical intervention is key.

Obviously, we need to stabilise our patient first. We may consider pharyngostomy and feeding tube placements. We may have to consider, doing our fluid therapy as well.

Placing intravenous cannula in to it and give them fluid therapy to hydrate them, and. And, I have actually had to perform, a blood transfusion in a tortoise before, but, unfortunately, had ruptured her over duct, and, the eggs when I went in there, we just kind of sat on the intestines. But she had a substantial amount of haemorrhage and longic coy as well.

So she ended up having a blood transfusion, and, and she did really well. Respiratory disease in reptiles, incredibly common, and we have always, already talked on our diagnostics briefly, talked about respiratory disease during the diagnostics that we touched on earlier. Again, linked to poor environmental conditions, running theme here that most diseases in reptiles are linked to poor environmental conditions.

Clinical signs, well, increased respiratory rate and effort, open mouth breathing, sneezing, oral nasal secretions, and an altered body position. So snakes will actually hold their front part of their body up, pin themselves in the corner of their Bavarian, so our aquatic chia, so this is a little musk turtle here you can see, on the right hand side of the screen, good lung, on the left hand side of the screen, bad lung. And this is our cranial caudal approach again, from our horizontal beam radiography that is allowing us to assess those lung fields.

Now this guy was swinging around lopsided in the tank, was actually just one side up, one side down. And that was what alerted the owners to it, so an abnormal body position. Our imaging, so our radiographs, like in this instance, the CT scan and MRI are gonna be utterly fantastic for this.

And then it's my favourite pulmonoscopy as well. We want to be considered on a biochemical and haematological examination, and in all instances of respiratory disease, we want to be taking a sample from the source, so a tracheal or longwash for cytological examination on our culture sensitivity testing. So, mycology, bacteriology and virology.

Urinary disease, so causes, again, poor care in reptiles, unfortunately. So our chronic dehydration, inappropriate diet, and obviously infection, trauma, fibrosis, and in this instance, neoplasia. So this was a massive, renal, tumour in a, in a tortoise.

Which incidentally just er presented with lethargy and anorexia and then eventually straining as well. And I can actually feel this kidney by sticking my finger into the prefemoral fossa, I can actually feel a dirty great big lump in there as well. So we can have muscle fasciculations in our reptiles that have got er renal disease that might be associated with renal secondary hyperparathyroidism and swollen joints if we're dealing with severe instances of gout.

Diagnosis based on our biochemical and haematological examination, our ionised calcium will be very helpful. And then our advanced imaging techniques. This is a CT scan, but we have actually performed ultrasonography beforehand, and we actually did FNAs of this lesion as well.

We can be performing our urinalysis, we've already touched on, it's not sterile. If there's protozoa there, it could be intestinal it's tortoise, it might be hexamin moving around in there too. Treatment wise, well, I think it's gonna depend, treatment for this tortoise was unfortunately euthanasia, but we want to be considering our fluid therapy.

Our nutritional supports are pacing that O tube like we've touched, touched on. Fixing underlying poor care, obviously goes without saying that we need to fix that in all of these instances, and bearing in mind when it comes to our biochemical analysis, the level of your uric acid is not an accurate way of assessing renal function in reptiles, despite what many people actually believe. So just because it's massively high doesn't necessarily mean the kidneys are completely knackered.

So you have to bear in mind the altered calcium phosphorus ratio and magnesium as well. And then we've got hepatic disease. So hepatic lippidosis picture here on the, on the left hand side.

This is a, really, really, really fatty liver of a bearded dragon on postmortem. By far, one of the most common liver diseases that I'm gonna see in reptiles, specifically these obese bearded dragons, females with prolonged pre-ovulatory. Follicular stasis.

And, oh, sorry. And clinical signs, are gonna involve, usually non-specific ones, anorexia and depression. As we've already touched on, bloods can be completely unremarkable, even in the end stages.

So this bit of dragon, for example, has a completely normal biochemical profile. His liver's destroyed, there was no normal liver tissue left, it was literally just fat, fat and more fat. We did offer doing endoscopic biopsies and histopathology and culture sensitivity testing, but unfortunately in this instance it was declined, but proven that we, our suspicions were in fact valid on postmortem, unfortunately.

And treatment is predominantly supportive. Now I, the reason that I've put cholithiasis in here is I had two cases recently of gallstones in bearded dragons, so they can do some really weird things. Actually both of them, were adenovirus positive.

Bearded dragons as well, and actually reading the literature around it. I actually performed a cholecystectomy in one of these reptiles recently. It's doing really, really, really, really well, which is fantastic.

The and it's completely asymptomatic and no virus for the time being too, . In the literature while I was reading around it, actually, many of these choleliths have been found in annovirus positive bearded dragons. So whether there is a link or not, essentially we, we need more information.

And we always have to bear in mind neoplasia too, one of the most common cancers I find in the liver, I see a lot of melanomas, so worth bearing that in mind too. And then finally, well, as with our advanced avian medicine webinar that we've performed fairly recently. Some cases don't end well.

And in my opinion, it is incredibly important for both clinicians, understanding the owner closure, but especially if we have large groups of exotic animals, postmortems are incredibly helpful. First off, I wanted to make sure that you guys are aware of how to appropriately euthanize a reptile. It's one of the questions that I get asked from our advice service quite often is that, oh, I don't know what I'm doing.

And preparation is the key. And in that preparation, allowing yourself time is really, really important because reptiles do everything slowly and in comparison to our mammalian species, that includes dying slowly too. So make sure that you've got enough time scheduled out, allowing your owner to say goodbye that many of them are just as bonded to their reptile species as they are with their cats and dogs, and they, they often want to be there too, which is always a little bit uncomfortable.

But sedate your patients. If you only wants to be there, sedate them and give them the intravenous injections. But bearing in mind that reptile really does need to be at its preferred optimum temperature to allow these medications to work in the best possible way.

So consider sedation if the owner is wanting to be there and we want to be giving IV arbitone, just the same as we do in our our cats and dogs. So, this bit of dragon, for example, I went ventral coccygeal vein, for its, first volume of, we're using in this instance, monitoring heart rate. These guys completely comatoseed at this point.

So I'm going intracardiac. Once the heart has stopped, so I'll be listening to the heart fade away. Once that is stopped for 10 minutes, it is recommended that we then pith the reptile.

Now that involves destroying the brain before we put that reptile in the freezer. And that is because reptile brains can still perceive noxious stimuli at incredibly low levels of oxygen. So we need to destroy that brain before we pop them in the, in the freezer.

Make sure that the way that you are euthanizing your reptile is going to be appropriate if you're performing a postmortem as well, or at least make your lab that is looking at maybe your your histopathology samples aware of how you've euthanized that reptile as well. And obviously the, the, the method of euthanasia is gonna vary, depending on whether that owner is there or, or not. As a general rule, pretty pointless trying to gas down any reptile.

They're just gonna laugh at you, hold their breath and sit there for, sometimes hours on end, because they don't, they don't need oxygen, much, to be honest. So, you're looking at appropriately sedating, restraining, and then, injecting intravenously, your reptile. And then finally, reptile postmortems.

So we want it on fresh dead specimens. This is a, I see a, a monitor list of a friend of mine, sadly lost him recently, and was in, fairly good body condition, considering how horrendous his liver was. So this was probably about an hour after, we'd popped him, put him to sleep.

Now, before I perform a gross postmortem. Or before I've even euthanized my reptile, we want to take a blood sample just in case I need to send that off. And once I've euthanized my reptile, I'll be performing radiographs, really good way of assessing your bone density in those instances.

Obviously, we want to be doing a full, clinical examination of conscious patient, which inevitably you probably would have already done, and get a full husbandry assessment and signalment from the owner. And you want a systematic approach. So if you're doing postmortems, doing the same way every single time so you don't miss any body systems.

Wanna be doing your external examination and getting an accurate rate. Open up that salamic cavity and examine all of the organs in situ before looking at those organs individually. Start with whatever organ you want as far as I'm concerned, but do it the same way each time so you don't miss anything.

Don't forget to take your tissue samples for your culture sensitivity testing and the histopathology, speak to your lab before time, before the postmortem to find out how they want those samples sent to them as well. And be aware of zoonotic diseases in reptiles. There are lots and lots of them, obviously salmonella, but also mycobacterium and pseudomoa species can cause issues in immunocompromised individuals, so protect yourself and your staff members.

Thank you very much for listening. I'm more than happy to answer any questions. This is my, my work email, so I'm more than happy for for for people to ask me any questions.

I do appreciate this has very much been a whistle stop tour, but thank you very much for listening.