So in this seminar we're gonna talk about assessment and treatment of the neatal fall and really focus that on the farm setting and what can be achieved when you're treating folds out in the field. So this is the outline of what I'd like to run through, and we're gonna focus a little bit at the beginning about a physical examination, both of the healthy fall to start with and then of the critically ill fall. Just touch a little bit on differential diagnosis, we won't spend too long on that because obviously that could take a long time.

But then we're gonna focus really on the things that may help you make a decision on the farm, so things like point of care bloods, and then what treatment strategies you can put into place when you're treating with a fall on the farm. And then just touch again on the limits of what can be achieved out in practise, because that, that is an important thing too. So, as all these things, they start with a good history, and it's important that you break the history down into three areas.

So firstly, we need to just think a little bit about the pre-partum phase and whether or not there were any maternal problems. And so that might be something that, you know, there's a signs that the mares run milk pre foaling. That might mean, you know, the, the fold didn't get enough lostrums that might increase your suspicion of sepsis, or there may have been some history of dystopia, the problem.

And then obviously think a little bit about the falling time, you know, was the falling assisted? Did they report any problems? Obviously, again, it's important to think about the level of experience of the people talking to you.

You know, you're very experienced stud farmers are going to give you maybe a more accurate description of what happened. So it's important to be quite specific when you ask people. And then also things like the percent is important, was it checked?

Did it look normal? How long does it take for the foal to stand a nurse? Has the foal been seen to be urinating, passing faeces, and any other particular concerns?

I think this is one of the most important things to think about when, when we're looking at any sort of fold on the farm. The first thing you should do is, yes, take a brief history, but also just take a minute or two to look at the fall before you put your hands on it, because you learn such an enormous amount just observing these folds from a little bit of a distance. So this is really just depicting, you know, sure we all know, but if you think about what happens to a healthy fall.

So a healthy fall would, you know, often be resting when we disturb them. Their initial response should be that they leap up when you disturb them, rush straight to the mare, have a drink. They will often then be seen to urinate, you know, normal foals urinate 4 or 5.

Times an hour, a nice dilute stream of urine. And then they should, you know, be busy avoiding you playing, interacting with a mass. So these are all the sorts of behaviours that we really want to see.

So just standing back and looking at these falls and looking at then the response when you disturb them, gives you a lot of information about what's happening. So these are just some examples of this. Obviously, this fall on the left is still quite a young fall, but you can see this fall's displaying signs of mild discomfort.

You know, that head back position. It also, looking at this one on the right, you can see, you know, it's not responding on this when you've gone into the stable, the falls not responding normally to. You can see the false head looks quite milk stained again.

These are all signs that, you know, something is not well with the situation. And again, this is the other prime example that, you know, so normal foals is they're learning to nurse. So very young foal may have some milk on their head, but, you know, a foal that is, you know, outwardly going through the motions of standing up and going to the mayor's head to nurse, but not actually nursing.

You'll see that the mayor's bag is full and that the foal will have all this milk staining over their forehead. And they're really signs, even from the get-go that, you know, there's something that's not, not going that well with this situation. We're just gonna run through examining a healthy fall only because it's a good prelude to examining any sort of, you know, ill anything else fall.

So just like any of those things, it doesn't matter how you do it as long as you do it in a systematic fashion. I always start at the front, and just start off by looking at the head. Obviously, look at the mucous membranes.

They should be a lovely pale pink, colour. The CR2 should be less than 2 seconds. It should be nice, nice and moist.

And people talk about feeling the palate. You can, you certainly can feel for a cleft palate. They're often quite far back, so it's not usually practical, but certainly making sure there's no melt down the nostrils.

Having a good look at the eyes is important, and especially we're talking about sick falls, because things like uveitis can be apparent. Coronal ulcers, entroa and they're all the sorts of things to look for. Have a quick look in the ears.

That's useful because if we're having a fall, we're concerned about sepsis, you'll sometimes see retiation in the ears, have a fear of the throat latch to look for things like an enlarged thyroid, and then we're gonna move on to examine the chest. Obviously, we can listen to the false heart on both sides. You know, and the fall's heart rate can be pretty fast when you listen, especially if they're a bit stressed, and remembering that that normal fall will, will often have a, pansystolic murmur for the first, certainly a few days, after a couple of weeks of life.

Listen to the chest, remembering that it may be a bit louder than in a, in an adult horse because the rib cage is so thin. But listen to the chest all over, making sure that we're not having any, any adventitious noises. It's also important to remember that if the fall's been lying down, even the healthy fall, you can sometimes hear the occasional wheeze or crackle on the dependent lung just for a minute or two after the fall gets up.

The other thing to think about that we're gonna look at in this picture now is just making sure you palpate the ribs. That's really important. There's a quite a large proportion of holes have rib fractures.

They're often, you know, incidental, but sometimes they can be a cause of the major problems. So you, you want to run your fingers down the rib cage. The place they most often get broken is right in that crook behind the elbow.

That's where the elbows will indent on the chest space as they come through the birth canal. So palpate in that area for any crepitus or pain or swelling. Obviously, they want to have a feel of the umbilicus, make sure that feels normal.

And again, then we take the false temperature. If this was, a bit more of a standard exam, I'd also suggest that you look at the folds standing out on the concrete to have a better look at their confirmation. But certainly, in any sick fold, we should also then make sure we complete an examination of all the joints to look for any signs of joint sepsis or any joint swelling.

So what about when we get faced with this sort of fall? This is obviously it is a collapse fall, in the hospital environment, but it should be exactly the same as if you're examining it out on the farm. You know, how do you go about examining this sort of fall?

Well, the answer is exactly the same, and you should complete in all these situations a systematic physical examination. It is quite amazing how often you can miss something, you know, huge, even things like a broken leg and a fall that's recumbent, you know, so just make sure you've really thoroughly examined the fall. And the things that you want to be thinking about are firstly, obviously specific abnormalities.

So it may be that you, you immediately are able to make a diagnosis, so. This fold in the bottom left obviously is really profoundly it trick. You know, this is quite clearly a fold that's got neonatal isolysis.

This fold on the top rights clearly got diarrhoea, but often these things are multifactorial. So really, when you're examining these folds, make sure you're still systematic, look for concurrent problems. And these are two areas I think you really, you have to think about in every fold.

And the first is circulatory problems, because irrespective of the primary disease, without that maybe sepsis or the maladjustment, Because foals are You know, such frequent nurses, they really rely on a high volume milk diet. If they're not nursing for any reason, they very quickly will develop circulatory problems. And the second thing to always have at the back of your mind is looking for sepsis, because again, you know, this fo that has neonatal iserythrolysis, that may have concurrent sepsis.

Fos with diarrhoea often have concurrent sepsis. So there, there's these things to have at the back of your mind that whatever else you're thinking for, you're also thinking specifically in your head. Is this fall have signs of hama concentration or hypovolemia?

Am I identifying signs of sepsis? So just to run through some of those important things, so hypovolemia obviously means a decrease in circulating volume. These are the sorts of clinical signs that we're looking for.

So obtundation is a common one, especially in these young foals. The cerebral perfusion is not good. They may often be quite obtunded.

You may feel poor pulse quality. They often will have very cool or cold extremities. You may find it difficult to feel a peripheral pulse.

Their ears may be cold. You'll get a prolonged competitive refill time, mucous membranes will be a bit pale, and if you're raising the jugger, it may be a bit slow. Importantly too, you'll see that the urine output is decreased.

That's obviously difficult to assess on an immediate situation, but you certainly will see that. And it's also important to look at heart rates. So if you're identifying a really persistently high heart rate, that is usually a good sign of hypervolemia, but you must be really careful.

Remember that foals actually, they don't always respond in the way you expect to. So you can have a fall that's really hypovolemic, where they actually have a relatively normal heart rate. Even more concerning is a foal that's got a slow heart rate.

That's often showing you're getting myocardial exhaustion. You, you know, you're getting an inappropriate response to hypovolemia. So that's definitely quite a concerning finding.

What about dehydration? So that's sort of more chronic loss of fluid from the institial space. And in these folds, you'll see, you know, reduced skin turga, tacky membranes, slightly sunken eyes.

You know, they often get that slightly dry look to their cornea. And if you do see them urinate, they'll obviously produce less urine and it will be observed to be quite concentrated. And then what about the signs of sepsis?

So all these, these are all obviously extreme examples of the things that you should be looking for. So obviously looking carefully at the full time is important, looking at the membranes, you will often see in these folds, if they start to get a systemic inflammatory responses or sepsis, that we're getting this inappropriate vasodilation to the periphery. So if you think about the fold, that's, maybe getting a bit volume deficient because maybe it You know, it's developed an infection.

It's now not nursing properly. What we should be seeing is we should be seeing vasoconstriction to the peripheries. That would be a normal physiologic response.

But in this falls, often what happens is they're getting this inappropriate vasodilation and you can see in these images, pictures of that where you're getting dilation of those little vessels. They could be a re full times often quite prolonged. And, you know, in extreme cases, you may see other things like petiation.

That's not as common, but certainly is, is something to look out for. I think this is also really useful sign to look for this coronary band on the bottom right. So folds again, that are getting this inappropriate vasodilation.

If you think this fold should be constricted its periphery, and you're seeing this bright red ring of hyperemia and the coronary band, you should really take sepsis seriously. Now that's, that's often an early sign that the folds got a significant systemic inflammatory response syndrome, whether it's bacterial origin or not. And obviously you don't have to look for a single focus of infection too.

And like I said at the beginning, make sure you palpate all the joints. This is a septic stifle. And you may see another obvious source of infection.

So, for example, this, infected looking umbilical stump, and that may be one of the major causes of the problem. And again, make sure you look in the false eyes. If you're seeing things like uveitis, that's a very relatively common, side effect of sepsis and false.

If you're seeing uveitis in the fall, again, think about systemic sepsis. So going back to that clinical examination then, so we're thinking firstly about specific abnormalities, remembering at the back of our minds, we're thinking about whether we see signs of sepsis, or the circulatory systems like. And that may enable you to come up with a diagnosis.

So that might be neonatal maladjustment syndrome, sepsis, diarrhoea. It may not, or you may think you've got concurrent problems, in which case, you're hopefully then being able to develop a sort of problem list, which is, you know, at least telling you, even if you don't know what's causing it, what the main problems you're identifying in this form. So then the sort of next stages we're obviously trying to work out what to do with that, try to assess the, the severity of the disease.

These are all the sorts of diseases, you know, you could write a huge list of all the different denture diagnosis in a full, in a young full. This I focus is on the young foals sort of 7 to 14 days of age, well, you know, up to 14 days of age. These are all the sorts of things that we can think about.

You know, primary colic, sepsis, natalizedrolysis, you will occasionally get a fall that's had trauma, prematurity, your abdomen. These are all the things that you have in the back of your mind, trying to distinguish between them, identify which of these are the most important. But just remember that the clinical signs of many of these diseases are often vague.

That's certainly true of things like sepsis. The most common early sign of sepsis is usually just mild lethargy, slightly reduced frequency of nursing, you know, same for neonatal maladjustment syndrome. But remember that multifactorial problems are common.

It's really common that you will have more than one diagnosis in this age of folds. So certainly, you know, think about your differential diagnosis list, think about what the primary problem is, but just bear in mind that you often may have more than one thing going on. So coming back to this again, you know, we're thinking about what diseases we may have involved, or at least identifying the major problems that we're experiencing with this fall.

But, you know, how do we really work out the disease severity in that farm setting? You know, what other tools do we have, which might be useful for you? And I think you often get to this point where you've run through a brief history, you've done a good physical examination.

You've certainly, I, you know, I've identified the major problems in the fall, but you're kind of at that juncture of trying to decide, you know, How bad is this situation? What can I do about it? Can I manage this fall at home?

Should I be offering the client referral if that's an option? And so, in that farm setting, I think the two useful tools that you have available to you are some basic point of care bloods and using your ultrasound machine. And we'll come on and talk about both those things individually.

So, point of care bloods, we'll first talk about lactate. So the analyzer I just showed you was a Rosh Acutre analyzer. They're not expensive.

I don't, if you don't have one, they're really useful things to have. And lactate does many things. So this table here is not really that important, other than just to list to you and highlight to you.

There are a huge number of reasons why you can get hyperlactatemia in a fall. But actually, the reality is, it's a marker of inadequate tissue perfusion. So if you're having a high lactate, it tells you the false tissues are not being adequately perfused.

The only one slight caveat to that is that folds that have marked sepsis, they often will have poor perfusion, but actually sepsis has a direct influence on some of those, enzymes in there with, metabolic pathway. So sepsis per se can persistently increase your lactate level. So lactate's really useful.

It's a good marker of disease severity, sort of morbidity, mortality. So it, it definitely is useful. You know, how useful is it to measure?

The, the real problems that you come back to, you know, you're out in the field, you look at this fall, you're, you've done your clinical assessment, you're trying to make a decision, you know, how much is lactate really gonna add to it. One of the problems is it's difficult to know what the ideal cutoff. If you look at the literature, having a lactate between sort of 4 and 7.

Predicted and predicted outcome quite well. And actually, there is definitely that linear risk, you know, linear increase in risk. So for every 1 millimole increase in lactate, you will get a 14% increase in risk of death, according to that paper.

And I can certainly provide you with the references if you want them all. So, so certainly lactate can be useful. The problem being is that there's a significant overlap and lactic concentrations between folds that survive and folds that die when you use a single measurement.

So often what you need to do is take a first measurement and then repeat measurement in 2 or 3 hours' time, maybe a bit longer to see what that lactate's doing. And if, if you are giving the full treatment and that lactate is not coming down, that's really concerning. Either suggest you're not giving the right treatment or the fall is the false disease is more severe than maybe you thought, and, and that's definitely associated with the worst prognosis.

I think in reality, what's a good cut off to use practically, I think a lactate of above 6 is a good marker. If you're looking at that fall and you're thinking, I'm not quite sure. Maybe the clients are vaguely interested in referral, and you're looking at that fall and you're thinking, I, you know, it's bad, but maybe not that bad, and you use your lactate machine and the lactate is 6 or 7, then that's a, a good indicator to you that you need to be really fairly aggressive with treatment.

And, you know, that's a fall that needs immediate appropriate treatment, whether that's at home or referral. And certainly, it's just an in, you know, it's a good time at that point to discuss if referral is an option. And definitely following up at home is useful, you know, if you're, if you're doing something, you're giving some fluids or whatever you're doing, follow-up measurement of lactate will help you give it, you know, help give you an idea about what the prognosis is.

Just be a bit careful in newborn folds, newborn falls can actually have a surprisingly high lactate. So if you're looking at a fall that's literally just been delivered, the lactate may well be sort of 3 to 5 and even a perfectly healthy fall. So just be aware of that.

Glucose is the next thing and these, handheld glucose monitors are really cheap. You can often even get them free from, some of the reps. And glucose definitely can be useful.

It, I don't know that it necessarily always gives you that much diagnostically, but it's really helpful if you're trying to think about providing treatment in the field. It's really difficult to predict glucose concentration, you know, we all think historically that These sick folds are hypoglycemic. That's actually not often the case.

Many of these folds that are experiencing stress, will have a hyperglycemia. And that's important because we're starting to think about giving fluids, which we often will if you've got a really ill fall. You know, your temptation is that you want to give them glucose because you're suspecting hyperglycemia.

But actually, if these folds are already hyperglycemic, you give them additional glucose. Actually, often all that will happen is that you'll cause an osmotic diuresis and you, you may make the situation worse rather than better. If you are picking up hyperglycemia, that is often a good indicator of sepsis and so.

So again, if you are picking up a significant hyperglycemia, then that's again to be a a trigger to make you think about whether or not this fall is actually sepsis is the primary disease process. Some of these analysis are not brilliantly accurate, but the good thing is, again, they are usually fairly consistent within themselves. So they may not directly correlate to, if you use the you know, a better machine, but actually you will usually be able to monitor trends with them.

So I think they are really useful tool to have. IGG is obviously really important, and having a snap test in your truck can be a really useful way of helping decide again how much treatment you got. It can be a bit tricky as much as you often won't have plasma with you, so it's not necessarily an immediate fix.

But identifying a low IgG again just can increase your concern about disease severity. So, you know, we all know that failure of passive transfer of immunity is a predisposing factor for sepsis. So it's really important that we measure what IgG and these holes irrespective of their primary disease.

And if you're picking up a low IgG, then, you know, that obviously is going to increase your suspicion of sepsis. But again, you have to just remember that may not be the only thing, because actually, any disease, which means that the foal is not able to nurse well or possibly not even able to absorb the Colostrum, will give you a low IgG and yes, you may have secondary sepsis or risk of sepsis, but actually that may not be the only diagnosis. Just remember if you're using these snalyzer tests that they do have limitations, and actually that generally means that in the mid range they're not that accurate.

So we'd all like an IGG of over 800 MBs per deciliter, . In that 4 to 800 range, it can be a bit inaccurate. That probably isn't such a problem in the acute setting that, you know, what we really care about is identifying those folds where they have a really low IGD and actually the test is reasonably accurate in that range.

So serum amyloid A, that's a stable lab test that's now available to test. That again can be useful if you're picking up a high SAA. Again, it will just increase your suspicion that you've got a significant inflammatory process.

Again, there are some caveats to that. So certainly some folds that have had quite a lot of birth problems have a high serum amyloid A. Folds that have had a lot of artificial colostrum or milk replacer, that does seem to sometimes generate a bit of an inflammatory response in the gut.

Those folds will also sometimes have a high serumyloid A. Again, if you're not sure and you know, you, you can't measure a white cell count on the blood on the farm, measuring a higher amount a day may be useful. Let me just put this on here.

Obviously, this is not something that you can do immediately, but most people have some access to haematology or biochemistry in a relatively short time period. And again, that's just really useful additional information that a low white cell count, again, especially should really make about sepsis, but, Do have it so that is if you're having really profound leukopenia, you should think about EHV1 infection, that one herpes virus, one that's obviously really important not only from the treatment point of view but also from the biosecurity point of view. Yeah, these folds that are born with congenital herpesvirus infection can be highly infectious and it's obviously important that you're identifying that.

And looking at the neutral lymph ratio again if if you've got, sorry, sorry, Emily to interrupt for some reason, the last sort of minute hits your sound, keeps going in and out. I know whether it's your, is your, has your headset moved or anything like that? I don't think so.

You just speak again for me, just is that any better or? Yeah, it just, it was missing like every other word you were saying. Do you mind going back to the, start of this slide?

Yeah, yeah, I'm gonna mute myself again, but if it, if it continues, well, I'll have to interrupt you again. Sorry to do that. So this is the latest, point of care analyzer that's available, and this is the stable lab mammaloid A kit, and this can just give you a point of care measurement of SAA, which obviously is an acute phase protein.

So that again could be another useful way of looking for evidence of sepsis, . It's not totally specific in things like trauma or had lots of artificial cholostrum or milk replacer. They can also cause a small rise in SAA, but especially if you're on the farm and you can't measure a white cell count, this could be another useful tool to help you decide if sepsis is a problem.

So haematology and biochemistry, I've put these on here, not because you can measure them immediately, but most people will have access to these in a short time period. And they definitely can give you a lot of useful information. So, leukopenia, neutropenia, we obviously worry first and foremost about sepsis, and again, just be another reason to be extra concerned about a fall.

But the other things you should always think about, especially if you have a really profound leukopenia. So a whites it out less than one, you should really think about equine herpes virus infection. And obviously that's important not just from the point of view of the foal diagnostically, but it's really important from the biosecurity point of view.

These folds that have, genital equine herpes virus infection can be quite infectious and obviously you want to be, being isolation measures in place to try and prevent the spread of herpes. And if you have a fold that looks premature, having a low neutrophil to lymphocyte ratio can be an indicator of prematurity. Anaemia, severe anaemia is most commonly seen secondly to neonatal isolysis, but you can certainly have anemias subsequent to things like umbilical haemorrhage, or rib fractures with the, hemothorax.

And then biochemistry again, simple biochemistry can be really useful. The sorts of things that helpful for are things like bladder ruptures. And then in any case, in any of these diseases, it can also help you assess a disease of the severity of disease.

So looking at renal markers, proteins, all these sorts of things can help you identify, you know, how much organ dysfunction that you have. So the other really useful point of care test is using ultrasound, and the great thing about folds is that if you have any kind of reproductive ultrasound, then you will be able to perform adequate ultrasound in a full, you know, a young foal. This is a small microconvex, this is M turbo machine.

It's brilliant turns on really quickly. Gives you a good image. It's really user friendly.

They're really robust. You can drop them and they're quite useful. If you have a rectal probe that will allow you to image nearly every part of the fold that you need to.

And for most folks just using surgical spirit will be adequate. And these are just some examples of the sorts of things you might be looking for. So, on the left, left, you've got a picture of some small intestine.

At the bottom left is a meconium ball. You can see that sort of, round ecogenic mixed ecogenetic structure with some gas round it. Bottom, middle picture is a picture of a full ruptured bladder, and that's that really classic appearance.

You've got that small collapsed bladder with the arteries coming off the side and, all that hypoechoic fluid. Obviously the thorax at top right is the fall's got a small pulmonary abscess, and that bottom right is a broken rib and a fall. So with ultrasounds, you can really screen a lot of the fall.

They're the sorts of things looking for, you know. Evidence of lung collapse, lung infection, rib fractures, pneumothorax, hemothorax, and abdominally looking for, you know, distension of the intestine, whether or not you've got inflammation in the wall, the intestine, have you got ponium left is the bladder intact? Are you seeing enlarged umbilical structures so.

Ultrasound can really help you in that situation where you're, you're trying to diagnosis and also can just give you an idea about if you're thinking about moving on to the next ones thinking about feeding for sometimes it just gives you a bit more of a view of what sort of intestinal function you've got on the phone. So we come back to this now again, we've, we've hopefully by now been able to make a decision about the assessment of the severity, got a fairly good idea of what's happening with the fall. The next question that's really important to ask, and it's really important to ask at this point whether or not you can provide effective treatment.

Obviously this is a very valuable fall that's got really severe multisystemic diseases fall was a bit premature, it was born. Following a bad dystopia as well, you're never gonna be able to provide this level of intensive care in the field. So there are certain individuals where I think you are better off just to recommend euthanasia from the outset.

If you're really identifying that this fall's got really severe multisystemic disease, referral is not an option, then often you are better to think about a euthanasia. These are the sorts of falls that I think are very difficult to manage in the field, you know, falls with a severe sepsis are very difficult to manage. Fs that have persistent seizures, folds that remain recumbent for a length of time.

I think also folds that just don't tolerate any feeding over a period of time, they're difficult to manage. And certainly, if you, you know, you're not sure, but you start to treat the foal and you get a really poor response from some resuscitation, that should be a bit of a red flag. But sometimes it just comes back to the fact that you don't have enough time, the client doesn't have enough time.

Maybe the facilities you're in. In that situation, you should really have a discussion with the client about whether or not referral is an option because if you are gonna do it, the earlier you do it the better. Obviously that's not always possible, but it's much better to have had that discussion at this point that you know, the severity is really bad and and it's.

Maybe unlikely will respond to treatment that you can provide in the field. There's lots of folds that are really great to treat in the field. These are all the sorts of things, you know, if you're treating any of these diseases early, you can get a really good response and it's not exhausted, but certainly if you're choosing good case selection, you can, you can have results.

So once you've got to this point, you're then gonna think about making a treatment plan, and these are the five things that I think are really important. So first is maintaining tissue perfusion. Secondly is providing nutritional support.

Thirdly is preventing sepsis or treating sepsis if you already think you have it. And then fourthly, providing really good nurse. In care.

The final one is obviously to treat the primary disease. We're not really gonna talk about that, and that's a whole different spectrum of topics. But obviously, if you have a fall, like a ruptured bladder or a fall that has neonatal iserythrolysis, you may need to think about specific things, be that surgery or blood transfusion, etc.

We're gonna focus on the first floor for the rest of the session, just thinking about how you can provide, provide this basic care in the field. When we think about fluids first, it is important that you just think about, two parts that you're trying to think about. So if you're looking at this fall and you're recognising it's got significant signs of hypovolemia, what you're trying to do is replace it intravascular volume.

So you will need some resuscitation period in that fall. But then you're gonna need to think about changing pack a little bit and providing fluid for ongoing. Management, so that will be to correct more chronic chronic fluid loss, so dehydration, to provide fluid for maintenance and also provide ongoing loss diarrhoea, for example, providing adequate volume to replace that from diarrhoea.

So resuscitation first, just put this in here to say, you know, you can use any type of intravenous cathe you like in the fall. You can use just these really short term short ones. You can use miler, you can use these over the wire catheters.

My personal preference is, if I look at a fall and I think it's just gonna need one or two litres of fluid, I will often use one of these little tiny short casters, just, . Tape it in with some elastic path and then take it straight out. But in my hands, these mylocas, they just don't stand up to prolonged fluid.

You often think at the hub. So if I have a fall, I think it's gonna need, you know, more than 24 hours' worth of care or even 24 hours' worth of care, I will usually put all of these over the wire casters in. Once you get the technique of it, they're very quick to place.

They do tend to be tolerated better in the long term, and they very rarely kink. So that would be my personal available. So when you think about the emergency resuscitation phase, I mean, basically what we're trying to do is to.

You know, give intravascular volume. So we want fluid that's most similar to plasma that we have available. So plasma's on here really just for comparison, and not because you can use that for resuscitation.

Certainly plasma often makes them part of the fluid plan, but yeah, we can't use that as a bowl of fluid just to compare what fluids we have available. So really the isotonic fluids that we have available at Hartman or like paper ringers or full strength sodium chloride. And this is just to really show you that actually mostly available fluid car is definitely the better.

Some people will, will still use sodium chloride, but actually it's not a good fluid for folds because the sodium is really high. And also, if we look at the sodium chloride difference on the right, it's zero, which means that actually it's quite acid. So in, in preference, if you have it available to you, then hearts is definitely the best choice.

If you only have saline and you have a foal that's really hyperthymic, then certainly using it in the short term is is probably OK. How much volume should you give? Well, sort of think about giving the 20 mL per kg bolus and then reassess.

And the theoretical limit for this is sort of 3 to 4 litres for a 50 kg full. I think probably should be a bit cautious of this and recognise that sometimes that's a bit. It's just been the sorts of guidelines that we've used for quite a long time, that thinking that, you know, Up to 80 mL per kg resuscitation fluids.

And actually, I think if you're dealing with a fall that has less severe systemic disease, say for example, a fall that's got diarrhoea, and has become really hypovolemic, they often will need that and tolerate it well. What you have to be really careful is in these folds that have sepsis or severe systemic disease, but they also have endothelial dysfunction. They often won't tolerate that fluid as well.

So I certainly will back off a bit more now and maybe think about 1 to 2 litres, for that type of fall. But you may well need that much in a fault's got diarrhoea. If you give too much volume, obviously the things you're gonna do, you're gonna overload the fold with sodium.

Also, you know, you're gonna create a beam of the institial space. You may find that the endothelial function gets worse and you're starting to get in that cycle of, of general deterioration. But in theory, like I said, you can get up to 3 to 4 litres, or 3 to 4 kilovolts is in the fall.

But what's really important is that you, as you give a bowl or send maybe 20 to 30 minutes, then reassess what you've had if you think you've had improvement, but you may need a bit more, maybe repeat that this once. This is the other thing to say. So what about energy resuscitation?

If you've got this fault collapsed, you don't know what it's glucose is, maybe you don't have a glucose monitor. Should you give them glucose? Well, it's difficult to know.

Like I said, I think in my mind, the best way to do it if you're not sure is to use 50% glucose. You can add it to your resuscitation fluids, because if you give a normal full 5% dextrose, that's usually too much. That will usually make them spill glucose in their urine.

And they, like I said, that will create an lorries. So my personal preference would be to make 1% solution, that would be using 20 mL 50% extra than 1 litre. So what about maintenance therapy, and we get a bit casual about maintenance therapy in adult horses because adult horse kidneys are so good at getting rid of all the electrolytes they don't need.

But foals are much less tolerant of this. They, they have a much greater requirement for true maintenance therapy. And really what we're trying to do is provide free water and some electlytes to distribute into the intra and extracellular spaces.

What's really important is that these folds do need much more free water. The kidneys are not able to get rid of as much sodium as adult horses. So if you give them is tonic crystalids for maintenance, then they will become hypernaemia.

So the fluids that we have available are for the most part, commercially just 5% dextrose on its own, but you can combine that with 5% dextrose and hearts. Over time, there have been some difficult and different maintenance fluids available and you may be able to get them, so sometimes things like Hetman's mashed up with 5% dextrose. Good sort of general starting rates and that is 4 to 6 mil hour.

If you have a fault or diarrhoea, they may need more than that, and certainly these young faults where you're worried about the endothelial function and having to be accepted, you may well need a bit less than that. So just to show you that that's the sort of electrolyte composition you may have if you use other 50% 5% detrose or a combination of the two. And irrespective of what you're doing, make sure you think about monitoring fluid therapy.

The most important is that you're getting improving clinical. We talked already about lactate. If you measured lactate at the beginning, make sure your lactates down.

Seeing urine output is obviously a good sign that you should be seeing, you know, urine output from your fluid therapy. It's, you know, an assessment of the volume of urine if you have a refractometer measuring specific gravity, and that we'd hope that normal will make that 2 m per hour minimum. Thought about this bolus versus continuous infusion.

Obviously, if you're out in the field, it's way easier to be able to provide fluids using pressure bags in a bowler situation. It's, you know, much, much, much labour intensive. And actually, if you have a foleygenophy with diarrhoea that has fairly normal renal function, that, you know, don't have too much dysfunction, they're pretty tolerant of these things.

They're tolerant of the flu bolic is tolerant high sodium load. If you have these really sick folds where they're not able to get much milk, they're not getting much free water through milk. And you know, you're worried about their circulation, it's much more important that you're trying to provide some degree of continuous infusion.

And these are sorts of tools that you have these little dip counters can useful. They can help you manage the fluid rate. You know, most folds, you can, either use a plastic crate or some way to separate them on the farm, try and provide a bit more of a maintenance fluid therapy.

OK, so the second most important thing to think about is nutrition. And this obviously goes without saying that providing energy is really essential to promote recovery and preventing metabolism in these sick folds. Then we know the fault have limited energy reserves.

Actually, because they're, when they're ill, they have a lack of. They actually overall have a lower energy requirement than a healthy full. And overfeeding them can definitely get, especially if you start function, you overfeed the fall, you'll get, pooling of milk and stuff that can set up, you know.

Ilius bacterial translocation from the guts. The target that we usually work on is 50 kilocalories per kilo per day, that's been shown to be maintenance for a sit full. And obviously what we'd like to do in in the ideal situation is just try and get that full nursing there as quickly as possible, but that's obviously not always possible.

If that's not possible and we're having to provide nutrition, this is the standard that we should generally think about. And if you're aiming for 10% of body weight. Per day is initial target that will usually be about right, and the beauty of that is that 10% body weight per day will provide for most folks that basic 50 calories per kilo, but also their basic maintenance fluid requirement too.

If you look at how that might work out, if you have a 50 kg full, if you say, you know, 0.1 times 50, that's 5 litres a day, and then you can obviously divide it up how you want to, if you, if you can feeds every hour, and we find that quite difficult to manage from the the labour point of view. And so if you divide that up, that'll be 400 mLs every 2 hours.

But again, really important that you start conservative and increases you can increase it, maybe start at lower than that and that's all you're really worried about. And just to keep it in context, a healthy thought will consume 25% every day. So if the fall's getting better, you can obviously increase it 10%, they're still not nursing from there.

How do you feed these holes? Bottle feeding certainly can be done, but, I would definitely have that done by someone who's quite experienced. What's really important is that, you know, people feeding the folds are really conscious of what they're doing.

Folds, as you know, will, bunt as you're holding the bottle. So they're real, Real driver that they, they bump the bottle and they crush the bottle up. If you're not careful, what will happen is the bottle gets raised up too high, these folds off and then will pull up the milk and the pharynx and then they'll inhale.

And that actually folds to have a really poor cough reflex. So the fact that foul's not coughing is no indication that you have a foul that's having really a lot of aspiration, and they're not coughing at all. If you use a stethoscope and listen to the after they're drinking, you will be able to hear if there's trick.

So certainly, if you're doing it with experienced people and you're giving people instructions, you can do that. Lots of folds that have a weak pharynx illness for any reason are really prone to aspiration. Obvious that can be a real problem.

If you have folds that you think you're gonna just gonna want a little bit of topping up, you can use these short, folds feeding tubes and easy to pass, then no problem for them. And that would certainly be useful if you're gonna do it just a few times. And any of these folds where you think you're gonna need to feed them for longer than, you know, 6, 12 hours or you need to leave the farm, using these indwelling feeding tubes is brilliant.

You can just pass them down. They come with wire and you can use the, and flush tubes. And you know, people talk a lot about having to check their own position like scoping or X-raying different things.

That's really not necessary. If you pass this tube, into the oesophagus and then you use your hand to cut behind the larynx, you will be able to fill that tube in the proximal oesophagus. And then obviously if we're feeding by these little tubes, making sure we're feeding by gravity flow, we use these little kangaroo bags which, Which allowed the milk to flow in slowly but stops it from spilling everywhere.

And again, similar sort we said about our fluid therapy, make sure you monitor really closely, you know, what's the fold doing your feeding. These are usually the two things that happen. First, this fold on the left is just showing signs of very mild abdominal distension, and that's often the first sign that you see that the fall is just you're slightly overfeeding it.

And, obviously, the other thing you might see that you'll start to get reflux from the fall, and obviously that's the sign again that you're definitely overfeeding the fall beyond what enter trap can cope with. Again, come back to energy, if you can't feed the whole a great deal, you're in that short term where the fogs, you know, that may be quite cold or that the fusion's not very good. You can definitely use intravenous dextrose, just to help to find you in the short term.

I sort of put this 24 hour limit on, you can obviously do it for as long as you want, but if you're thinking about this being that fold only nutrition after about 24 hours, they're obviously gonna become catabolic quite quickly. What we try and aim to do is simulate the rate of energy supplied by the 10, so that's 4 to 8 minutes per minute. If you work that out for a 50 kg full, that's about 12 grammes an hour.

There's two ways you can do that, you can either do it if you're using straight 5% X-rays as your main fluid, you can use that 240 mL per hour, or you can use 50% dextrose and especially if you've got a full where you think that that fluid weight's gonna be too much, you can supplement 50% dextrose any fluid that you're using. So the next section obviously is sepsis. This probably is the most important thing that you do if you, you know, say for example you're treating mary fall, actually preventing that fall from becoming sepsis is probably one of the most important things because, you know, you go from having a fall that's got neonatR adjustment.

That you know you're gonna be able to get better just with a little bit of support and maybe some fluids and some nutrition as if that a fall then developed secondary sepsis, so that's in a very different situation and all these sick folds if they've got any sort of GI dysfunction or then nursing, they're all at high risk for sepsis. So treating them or preventing sepsis is is usually a pro. That's not to say that all falls require microbials and obviously we're under increasing pressure to minimise our e microbials, but what, what I would say to you is that make sure you've considered it to make an informed decision about whether or not the fall needs anything about it.

And there's a whole spectrum of different drugs that you can use, . Depending on the situation and and how bad the situation is, make sure you're using a dose which is appropriate for a fall. So, if you look for example at things like gentamicin on the case, the dose of those things is, is different to what you would use in an adult horse.

Again, things like ey fuel, they're all good choices because they, you know, they're not often talk to the kidneys. They're broad spectrum. Make sure you're using the full specific data to an adult horse we usually use about 2 migs per cake in a fold, you probably want somewhere between 5 to 10 mg per cake.

And then obviously come back to IgG. Make sure you've checked IGG and that, you know, the folds had adequate. If the fold's young, you may still be able to get the bottom if you think that the false intestinal tract will cope with it.

If not, you're gonna have to like give him some plasma. If you have the luxury of being able to use commercial plasma, I usually think that you'll usually gain about 2 grammes or 200 milligrammes the best litre per litre you give. So if you've got a full that's got a complete failure latter cancer, you may need to give more than one bag of plasma over a few days.

If you don't have commercial plasma, you certainly can harvest it yourself, but make sure you're really conscious about infectious disease and things like EIA, pyroplasmosis, all those sorts of things you don't want to be transmitting them to falls. And again, just general things like just making sure that the environment is clean and that you're operating with hygiene, plan to be, you know, maybe wearing, overalls, hand washing gloves, all these sorts of things, foot tips, etc. Especially if you've got lots of folds on the property, you know, you've got lots of older folds that are here.

The last thing you want is any disease transmission back to young foals that are ill. And then just finally to say a bit about nursing care, and again, this is a huge topic, but actually good nursing care is often one of the most important things of looking after these falls. And it can be hugely labour intensive.

You're going from the simple things that may be as simple as just reminding the fall to get up every hour, every couple of hours, to get on the meds and nurse, making sure they're actually nursing well. You know, even the sort of on the bottom left, which has obviously got quite a lot of orthopaedic problems, you know, making sure that they're getting up, they're getting physiotherapy, . You know, making sure they're kept clean and dry.

This is obviously in the top right of all in our hospital, you know, we're trying to get this fall a bit more stimulated by the environment, so we'll take them out into the paddock. It's really good for the mares. It's really important to keep the mares bonded to these folds to try and make their life as pleasant as possible when you can.

No, that's it, but just to summarise, to say that actually on farm, you know, can be very rewarding, but probably the most important thing is that you choose your cases carefully. You know, embarking on treating it full with multi-organ function and sepsis is very unlikely to be successful and it, you know, it's often expensive, time consuming, both in terms of, you know, time and emotionally exhausting as well. And we're looking at these folds, make sure you think about observation, clinical assessments essential, but basically buds can also be useful to help you make your problem list and make a diagnosis and think about your treatment plan.

I'm thinking about treatment, just make sure you've covered the four main areas of of fusion, nutrition, sepsis, and then nursing. Thank you very much.