All right, thank you very much. All right, so here we are. We're gonna talk about hemoabinence tonight I was invited to speak about these.

And so I've titled the presentation, Approach to the hemoabdomen, and I, I subtitled the of forgotten differential, and this is more kind of geared toward, I think more the general practise audience in that, that this is a differential that I think we forget as general practitioners, ER doctors were. Like hyper ready for hemolabins and everything, the hemoabbin will proven otherwise. But I know when I was in practise, because I did do the 3 years of practise.

I know I missed a couple of these initially because it wasn't something that I was necessarily thinking about given especially some of the historical stuff. So we'll talk a little bit about, so we'll talk a little bit about, the cause of hemolabin, but then I'm gonna talk a little bit about the clinical presentation because I think the history and how they present can sometimes be really tricky with these, and then, you know, we'll go through how to diagnose them, which is fairly straightforward. And then just at the end I'll talk real briefly about treatment options because that's a whole another can of worms that we could get talk about for 2 hours.

So I won't spend a lot of time on that. I'll I'll, I'll kind of do it more from the angle of, you know, when the case comes in, how do we diagnose it and then what do we tell the owner as far as like options that they have to pursue. So, first of all, what is the definition of a hemoabdomen?

So hemoabdomen or hemo peritoneum simply means accumulation of blood inside the perineal space. It doesn't tell us any more than that. It doesn't tell us why the blood is there.

The blood is simply there and shouldn't be there. And so we generally divide up into three big categories traumatic causes, coagulopathic causes, big example being anticoagular adenocides or neoplastic causes. And the most likely organs to bleed are going to be your spleen, your liver, your kidney, although certainly there's weird cases where we have bleeding from other locations, of course, but those are by far the top three locations.

So kind of looking at it kind of in a schematicy format, which I borrowed from a journal published in 2000. You know, again, we kind of, they, they can divide up the big three causes into, you know, groupings of traumatic and non-traumatic. And so again, we've got our traumatic causes which would be hit by cars, blunt trauma, penetrating traumas like stab wounds, bite wounds, things like that.

And then even the iatrogenic traumas like I took you to surgery and the ligature fell off, or, this happened to us two nights ago here. We did a percutaneous liver biopsy and you bled afterwards, things like that. So something that we did that causes the bleeding.

And then under the non-traumatic causes, you can stick the neoplastic causes and the coagulopathic causes under there. So whichever way it makes sense in your mind to organise them, I think the big thing to remember is that, you know, you can have a strong history that leads you to hemoabdomen such as the dog was in the street and got hit by a car, and then you can have things like the neoplastic or the coagulopathic causes where there isn't really anything in the history necessarily right away that signals you to think about hemo abdomen, and you have to come to hemoabdomen kind of in a more roundabout way. So let's talk a bit about the clinical diagnosis.

And so I've put up kind of the poster children. So if I was to think about who's going to be the, the hemoabdomen that walks in the door in ER clinic, I'm gonna think about the ones that are the generally speaking the non-traumatic, because those are the ones we see more often. And I think about these older breed dogs, goldens, Labradors, things like that, that tend to get hemoabins from neoplasia.

But remember, other breeds and other ages can definitely have hemoins also. So, so I think hemo. Come in two flavours.

There's the dramatic historical one, which is like the real emergency that comes rushing in the door, and this is the one that was hit by the car. Somebody saw it was hit by a car, or the dog dragged himself back up to the house, or, you know, it's been out unattended, and I suspect my dog was hit, you know, that sort of thing where you know comes in with a really strong history of something that you, you go, wait a minute, that definitely could be, you know, hemoin because we could have, you know, a traumatic, you know, could have been trauma in the past, that sort of thing. Then there are, you know, the other type of, dramatic presentations where nobody knows what happened to the dog, but they found the dog collapsed at home or they found their dog too weak to stand up or a dog that can get up to its feet and then it lays right back down, or you've got the owner that lifts the lip and notices their dog is really, really pale.

And really, really white looking and they come rushing as well. So both of those, you know, both the ones that we've got the traumatic history, but also the ones, where the animal seems to have collapsed to be super duper weak will come rushing into us as well. And those are the ones where, you know, obviously everyone's on their feet, everyone's rushing over to look at the animal, that sort of thing.

The ones I think that are more tricky are the less dramatic ones where they come in with really non-specific histories. And so they come in with these histories of a dog's been lethargic or just not himself, you know, on and off for the last couple of days to weeks, you know, he eats well one day, maybe he doesn't eat as well the next. Day, but you know, we definitely have good days in between.

Those intermittent histories are the really tricky, difficult to diagnose hemolains, the ones where you have to remember to put hemolabin on your list to diagnose, because the, the, and the reason for these signs that that they're intermittent typically is that a lot of these hemoabs will bleed. And then during the time they're bleeding, the animal will be weak or not want to eat or be off. And then when the hemo, whatever the cause of hemoabin stops bleeding, they'll reabsorb the blood and auto transfuse and feel a whole lot better and be back to quote unquote normal for a day or two or whatever and then have it happen again.

And those, those are the ones that are really, really tricky and a lot of the animals that come in with these non-specific signs. Because they tend to be of the non-traumatic flavour are like the, the, the older dogs with neoplasia, for example, as the poster child for this, and, you know, everyone's like, oh, my older dog, yeah, he's slowing down a little bit. He's just not moving around as much, but there may be more to it than that.

And so that's why I think those are the challenging ones to diagnose. OK, so I'm gonna go over a couple of cases kind of throughout sprinkle in here to give you some examples. So the first case that we'll kind of go to here is Bogie.

He was a 4 year or he is a 4 year old male neutered Labrador who came in with a history of having vomited once 2 days prior to pre presentation, and the owners had bromethylin rodeoide on the property which was missing. And if everyone doesn't remember, bromemetholin is gonna be your neurotoxic rodenticide. And so that's the one that was missing from the property.

So one day prior to presentation, so 2 days the bromethyl's missing and he vomits once, then he seems OK. Then 1 day prior to presentation, the owner describes a PUPD sort of situation with him, and then the day the dog came in, he was not eating and had a little bit of hematuria. So it was a very weird non-specific history, especially given that the adenocide that was missing was not the anticoagulant one.

It would be the, you know, the brin should not cause a bleeding problem, and so this is a very weird, strange history that he came in with. In contrast, we had Lucian, who is a 2 year old or a case number 2, who is a 7-15 year old male neutered husky shepherd mix, who came in with a history of 2 days prior to presentation simply eating his food slower than usual. One day prior to the presentation, not finishing his food, and then the owner noticed that perhaps his abdomen looked a bit distended and he seemed a bit lethargic, and then she brought him in because the day of presentation he was less active and laid down after going outside, although he did eat normally weirdly that day.

So again, this is another example of kind of a different type of non-specific history, but a trick, kind of a weird non-specific waxing waning history as well. OK, so what do I do with these cases? These cases come in and the history health fair doesn't, but then I'm gonna do a rapid assessment.

And so as an emergency doctor, it's all part of your triage situation, right? So we're gonna kind of eyeball the dog from a distance when he comes in. How does he look?

Is he breathing OK? You know, do we, do we have any indication I need to rush over there and intubate the dog or worry about, you know, his airway being obstructed? And that's just kind of your standard natural triage that we do, right?

And from there we decide is he kind of non-urgent where he can wait a couple of minutes? Do I need to do something with him more immediately or not? I was saying I'm gonna also take a look at things like the heart rate.

What is the rhythm and what is the rate and what is the pulse character because it is important as part of our triage to check that because I've been fooled many times with dogs that look visually pretty darn good, and then you walk over to him and the heart rate's 220 and you're like, wait a minute, you know, you're not as good as I thought you were, you know, that sort of thing, or you have the crazy arrhythmia where they have, tonnes of pulse deficits and things like that which are, which is something obviously I'm gonna need to look at sooner rather than later in these guys as well. And then obviously lift the lip, take a look what's their colour, what's their CRT, that sort of thing. So you know, start off with your standard triage with these guys.

And then at this moment, if you decide that they're in shock based on tachycardia, poor pulses, you know, you've done a blood pressure which is low, they're pale, regardless of what their CRT is, things like that, you have reason to believe they're in shock. You're going to stop, not do anything except try to stabilise the shock. And so again, you know, hypothermia, tachypnea, tachycardia, the pallor, being obtunded, all those things would tell you that you need to stop and think about this animal being in shock first and then we'll come back around and figure out why he's in shock later.

And so obviously I won't spend a lot of time on this, but the animal in shock needs a bolus of crystalloids, and so we'll give them somewhere between 125% and 1/3 of the quote unquote shock fluid amount. The shock fluid amount in a dog is typically 90 mL per kg per hour. Cats is somewhere closer to 60 mL per cake per hour, and we'll try to make sure we give this bolus less than in a less than 10 minute time span because we know that those crystalloids will leave the vasculature.

75% of them will leave the vasculature within 20 to 30 minutes. So I want to make sure I get the fluids on board quickly to increase the vascular volume and allow for better perfusion right away. And then I'll reassess the patient.

And if I can get to the point where their heart rate's something less than 160, their temp is greater than 99, and they note here, you know, unreasonably to Kipnick, and I can get their systolic blood pressure somewhere above 90 with decent pulses. They feel warm at the tips of their fingers and toes, and, you know, you don't put your hand on their paw and their, their, their, toe tips are frozen solid, and, and they, and often they've urinated after I've resuscitated them, meaning I've given them enough fluid. Is that perfuse their kidneys, I would say, OK, this animal's pretty stable and I can go back around to doing more diagnostics.

And I will kind of emphasise 11 thing that I, I harp on with our interns that I think is an underutilised thing is when I give you a bowls of fluids, have you urinate at a reasonable time or have I at least seen the bladder has gotten bigger because I think, you know, dealing with a lot of interns or rookie doctors here at our institution, I think the number one thing that we tend to do as rookies is to give not quite enough fluids like you give. Enough fluids to partially resuscitate them, and they're better, but you don't give enough to quite get them over the hump, where they're not gonna slide backwards and be in shock again in 2 hours, you know, that sort of thing. And I think seeing them urinate for me is one big thing that I look for, and I say, OK, if you're peeing, I've given you enough, fluid that you, you've gotten perfusion to all your organs, including your kidneys.

And so typically at that point I've gotten them up enough over the hump that they hopefully won't go back into shock, you know, in the near future. OK, so, if I'm having any trouble with resuscitation, I repeat the bolus. I consider colloids with these guys if I'm having trouble resuscitating them, and I'll tend to give colloids in 5 to 10 milk per cake style bolus again within a 10 minute span, and I'll just keep reassessing them and kind of play the resuscitation game as long as we need to.

And, if I'm at all, you know, once I get to the point where I'm I'm, I'm confident that they're stable, I'm feeling pretty good that they're stable, you know, I'll stop repeating boss, but I'll keep repeating the boss as long as I need to. And if you're having trouble getting them, stabilised, don't forget to check things like the PCV. Or the glucose on these patients because potentially if your your animals are hypoglycemic, you won't be able to resuscitate them or if they become super anaemic and and you know, during the course of their disease slash your resuscitation, you may need to use something like red blood cells to actually totally resuscitate them.

And obviously, the harder it is to resuscitate them, the more you're worried that these animals who have come in are having a continual bleeding, like a constant consistent bleeding right now, right now as you're seeing them, rather than having past tense blood at home and come in. And those are actively haemorrhaging are gonna be much harder to stabilise obviously than those that have stopped bleeding and I'm now just catching up with what happened because they've led. OK, so once I get to the point where I, I'm confident that they're not in shock and I could take a decent look at them and do a full physical and if they're not in shock, I'll obviously do a full physical right off the bat.

Things that I'm gonna look for that might be consistent with the hemoabdomen would be, you know, you know, when you, you, you may see things like the hypothermia if they, if they bled recently, however, you might not. You may see pale mucous membranes, but it depends a little bit on how, how much they bled and how anaemic they are. The CRT in these patients can be very variable.

So if they're in shock, I might see either a prolonged or a rapid CRT. If they're not in shock, honestly, the CRT is probably fairly normal on these guys. They may have tachycardia that's mild even when they're not in shock.

So if I bled and have less blood volume, maybe I'm gonna see heart rates in the in the 150s, 160s instead of the 120s, that sort of thing, but not fast enough where I'm like, oh my goodness, you're in shock, you know, that sort of thing. Don't forget to pay close attention to what the heart sounds are like during your exam if hemolado is anywhere on your list because don't forget that we can also get pericardial effusions. And some of the animals that have splenic masses, concurrently have pericardial masses.

Some of these animals that have adenoci intoxication can bleed into more than one spot, things like that. So, always I pay close attention to what the heart sounds like. Lymph nodes should be normal in hemo abdomens.

They should be able to walk. There shouldn't be a reason that they cannot physically walk. They may feel too lethargic to walk, and it's important to distinguish that when you're assessing them.

Neurologically, they should be pretty normal, although they may be mildly tended to just kind of QAR, simply because they don't have as much oxygen going to the brain because they're a little bit anaemic from their bleeding. And then I always make sure I'm looking closely at the genital area and the rectal area and doing a good, good rectal exam because you want to remember things like melana or hematochezia if you're dealing with coagulopathies, and hematurias and vaginal bleeding happens a lot, especially with platelet problems where they're bleeding because of thrombocytopathy or thrombocytopenia. So be sure to check on those things because those are areas we often don't pay as much attention to as maybe we should, in these cases.

And obviously you're looking at the skin as I'm showing you right here for indications of bruising and things as well. So we've got some petichia on the picture on the left, a little bit more of an ecchymotic lesion on the picture on the right or the middle, and more peti on the right. So definitely look for things like that because all those things can be, suggestive or consistent with having coagulopathies, especially in these patients.

Now, do, do definitely look at the area of incisions and, and just around the ventral midline for sure as well, because, you know, if you do have a hemoabdomen, a lot of times, if let's say the hemoabdomen after a surgical event, you can have blood that's gone between the layers between the sub Q and skin layers or between . The fat layers and and the sub Q and potentially as the blood gets into those tissue layers you can potentially start to see it almost looks like ecchymoses but it's not because it's just blood that's leaking out of the abdomen. So definitely key in on that and also even if the animal pretend there's no incision here and you see bruising like this around the umbilical area, if the if animals have hemoabdomens, you.

And sometimes get blood that goes between the layers right around the umbilicus and causes, it's called the colon sign where you see bleeding that looks similar to this picture, but there's no incision and it's right around the umbilical region. That's, that's actually a very, very, it's, it's an uncommon sign of hemoabdomen, but if you have it, you probably have a hemoabdomen. So keep an eye for the colon sign also.

All right. And then obviously if, if the abdomen is one of the areas that I'm worried about, I'm gonna, I'm gonna do my abdominal exam kind of in a specific sort of way. And so first thing you want to look for with a hemoabdomen is, do you see any visible distention or other deformity of the abdomen?

Because obviously those are a little bit easier like the second case. Mention where the owner actually thinks that there's some abdominal distension. If you can see it with your eyes, that's obviously gonna make you key in on the abdomen as potentially a source of your problem.

And then again, we talked about the bruising and things like that. Look for wounds from bite wounds, look for wounds from trauma, you know, if there's a surgical wound, things like that. So first you start off just just kind of looking over the area.

Then a lot of times you can sculpt the area. I'll admit I don't do this as much as I should. It tends to be more of something I think of a of a large animal veterinarian is doing, but honestly you can get a lot of information from this in a small animal as well.

And so if you're hearing a lot of lung sounds. I'm sorry lung sounds gut sounds, or you're listening for gut sounds and they sound decreased or they sound like you're not having as much gut motility as you should. One of the reasons why you'll hear that can be a fusion.

So if you're worried about hemo abdomen, hearing less gut noises can actually be very consistent with the fact that you have a hemoabdomen. And then obviously if you're worried that there is fluid, definitely try to percussor at the abdomen. And if you hear kind of that dull sounding, as you tap your fingers on there and you you hear like a dull sound and or you feel a fluid wave, that's consistent with fluid, obviously.

And then eventually the last thing I do is actually palpate. So I kind of want to do these things that are less painful and less invasive first, and then the last thing I'll do is actually try to palpate and I'll start off with a, with a light superficial palpation and go to a deeper palpation. And a lot of hemo abdomens are painful, especially in the mid to cranial abdomen, because if they've got something like a splenic mass or a liver mass, and the capsule on the mass stretches, it's actually very uncomfortable.

And so if you palpate and are, are, are getting in the area of that mass, it actually can be pretty, pretty uncomfortable for the animal. So definitely pay attention to that. And sometimes that's the only thing that I find on the palpation is some weirdly non-specific discomfort in the mid to cranial abdomen, and that's it.

Like I don't notice on the exam that there's fluid. I just notice the discomfort. And again I brought up the colour sign keep your eye out for that, which is the bruising around the actual umbilical region.

OK, so going back to our two cases that we had, so Bogie was the first case. He was a young Labrador who had the weird history over 3 days. And so when he came in, his TPR was pretty unremarkable.

Heart rate was pretty low and otherwise looked good. He was nice and pink with a, with a normal CRT. He was quiet, but it didn't seem abnormally quiet.

But he did have that kind of weird pain in the cranial abdominal region that I just mentioned when we were palpating him, but no obvious fluid wave or anything of that nature, and rectal exam was unremarkable. In contrast, Lucian was a dog who like didn't eat well, didn't eat all this food, and then like went outside and laid down and didn't want to come in. So when he came in, he was a little bit hypothermic, which is actually a little odd, but although his heart rate and respiratory rate were pretty normal, he had pretty pink mucus membranes.

CRT was normal. He was bright and alert, but he did definitely have the abdominal distension on his exam that his owner noticed. We definitely agreed with that, and we could actually feel a fluid wave on him, and he had a normal rectal exam.

So he definitely was the one that we were like, oh, we need to look in the abdomen and see what's going on, whereas the first dog, not so much necessarily, minus the fact that there was some discomfort. So what leads us to the hemoabdomen? So obviously the obvious ones are distended fluid-filled abdomens that it may or may not be painful.

Obviously, I'm thinking fluid in the abdomen and one of the most common fluids is gonna be a hemoabdomen, right? Tell me because membranes make me think of bleeding, which makes me worry about at least have hemoabdomen on my list for sure. If they come in in shock with no history of trauma, hemoabdomen should be on my list.

As well, and to me, if you're seven-ish years old and older and you're a mid to, you're a medium to larger breed dog, I'm gonna think of hemoabdomen pretty early on because I think of these guys getting a lot of cancer from the age of about 7 and above and so obviously hemoabin a lot of times linked to cancer when there's no history of trauma, especially. And then for me, I've learned over the years I've been finally been doing this long enough I can say this, but, but over the years I finally realised that if you get this waxing and waning sort of history of changes in lethargy, changes in, energy and appetite, that you should definitely at least have hemoabin somewhere on your differential list and rule it out because I've been burned enough times now in my life that I actually remember to keep this to keep hemo hemoab on the list for this kind of a history. And then if you do see things like petia ecchymosis or melana, actually for me I think coagulopathy.

I think of platelet issues, to be quite honest with you most of the time, which, which are less associated with hemoabdomens, but potentially if you do have enough of a thrombocetopenia in in a in a patient, you could get a hemoabdomen, even with, thrombocetopenia or thrombocytopathia. OK, so now let's pretend the patient's reasonably stable. I have some time to think about what I'm doing.

What would I do? So I kind of divide up into what I would do right away and what I would do later. So stuff I can do right away is stuff I can do quickly and get some information back.

So PCPs and glucoses, blood pressures and ECGs, for me, I don't necessarily honestly reach for blood gas. Analysis all the time, but if I am worried about electrolytes and stuff, I could do that bedside and then definitely if I'm, you know, is there asking myself is there free abdominal fluid and analysing the fluid if it's there? So that's kind of the stuff I can do kind of in the ER without walking too far.

I just like reach over and grab what I need from our drawers and I don't have to take them out of the room and go do anything too exciting. And so another thing I can definitely look at is ECGs, in the ER. And so if I see things like ventricular tachycardia, so wide and bizarre QRS complexes with usually rates somewhere greater than 170, 180 in these dogs, the, you know, when you see VTA, VTAC almost always is secondary to something else and it's not heart disease, and I think of increase, I think of changes in, in, vagus nerve tone.

And so anything that increases pressure in the abdomen, such as fluid in the abdomen, can definitely cause things like VTA, so for. Chemola is automatically on my list if I'm doing ECGs, and if I'm seeing ventricular or just VPCs where I see intermittent wide bizarre QRS complexes, and they may come in a regular pattern like on this this strip here or they may be intermittent or they may come 2 or 3 in a row, intermittent VPCs, same thing, changes in vagal tone will cause it, and abdominal disease such as anything that caused the hemoabdomen potentially can cause that as well. So I always tell the students if you're seeing ventricular complexes, they should be a sentinel for something else.

Oh, I'll also mention that back to the first rhythm. It doesn't always have to be ventricular tachycardia. You can also have the idioventricular rhythm, which looks exactly the same as ventricular tachycardia, wide and bizarre QRS complexes, but the rates are less 140, 130, something like that.

So you have a normal rate with an abnormal rhythm if you were to print it out on the ECG. And so the idioventricular rhythm is caused by the same exact things as VTA or VPCs, changes in vagal vagal tone in the abdomen and being one of the big ones. And the example would be hemoabdomen.

OK, so once I've gotten gotten, so if I've gotten to the point where I'm thinking that this patient has free abdominal fluid, I want to check for that. Let's have a just a brief moment on how do we actually sample the fluid. So for me, maybe I'm old fashioned.

I tend to do 4 quadrant taps first. They're actually quite a bit less expensive on on our clinic to do that rather than reaching for like we're gonna talk. With the ultrasound in a minute but like reaching for the ultrasound.

So for me, stick a needle in the abdomen. If you get something out, great. If you don't get something out, then it's, you know, then OK, good information as well.

And so to do a 4 quadrant tap, all you need are 4 needles or 4 catheters. I don't know why I have 3 in the picture, but I do. I just need 4 of each of either one of those, your choice.

You need scrub and clippers to make sure there's no fur right around the umbilical region, and then we need some tubes and slides. And so generally what you do is you have the animal lay in lateral recumbency. He identify the umbilicus.

You don't have to clip this wide. This dog was getting something else done. You can just clip right around the umbilical region, and I scrub it and here I use some beta dy.

And then I just go ahead and insert needles in and I just kind of pick one spot and then I insert the needles around it. And generally speaking, we're gonna identify the quadrants because I'm gonna go with the ventral midline. And then I'm gonna draw a line perpendicular to the ventral midline through the umbilicus and those create my four quadrants.

And so these needles are in 11 1 needle is in each of the four quadrants, and I'll stick one in, see if anything comes out. If nothing comes out, I stick in the next one, etc. Etc.

And I'll leave it, leave them in until I get up to 4 needles in place. As soon as you start to see something coming out, you don't have to put any more needles in. But if I put all 4 in and nothing happens, I'll still wait at least 1 or 2 minutes at least if not a little bit longer to just just in case it's a small amount of fluid to give it time to kind of work its way to the needles and come out.

The only downside, so the 4 quarter of the reason I love it is it's relatively noninvasive. It's so cheap. It's the cost of 4 needles and I don't know, a few dollars for my time, and that's it.

But you get a tonne of information potentially from it. Also, the only downside to it is that you do need, 20 mL per kilogramme of fluid in the abdomen to yield a fluid sample. So there is a reasonable, you know, scenario where there could be fluid in there that you wouldn't find.

So that's the only problem is you can get false negatives with the, with the four quadrant tap. But if you get a positive, there's definitely fluid there and it's quick too, so quick, and here I forgot drawn in the quadrant. So here the quadrants drawn in for you on the slide.

OK, so now when the fluid starts to come out, how do we collect it? So for me, I always collect here in the middle. I always collect the slide first because I don't know how much fluid is gonna come out.

It may only be a drop. It may be multiple drops. It's hard to say.

So if you only get a drop, the biggest bang for your buck is always to do cytology. So I always grab a drop on a slide so I can make a slide from it. And then I'll put, some in a tube and then generally I'll do the purple top tube first and the red top second for most fluids.

However, when I'm worried about hemo abdomen, I'll actually fill the red top first and then if I have some additional, I'll fill the purple top later and I'll go over why in a second. I'm just showing you, you here in the upper right slide that if you are gonna suction, do not latch the needle on and suction because what happens is you set up a lot of vacuum against the needle and it pulls the . you know meant to right up against the needle and then you don't get any fluid out even if it's there.

So if you're gonna use a syringe, you need to like not lock it in and just kind of suck what's in the hub out rather than locking it in and making you get a false negative because you tend to get more false negatives if you lock the syringe in. Now, obviously you're all sitting there thinking, well, that doesn't make any sense because I've totally locked the needle on or the syringe on the needle, and I've totally drawn back and gotten a syringe full. And you will have those scenarios like there's enough fluid in there, you will be able to fill a syringe.

But in the cases where maybe there's not that much fluid, you can definitely get a false negative by locking your syringe to your needle. So I've just kind of done it this technique because you won't be wrong no matter what situation's going on. OK.

So a brief moment about the FAST scan. So obviously your other option if you don't want to do the 4 quadrant tap or perhaps if I get a negative 4 quadrant tap would be to go ahead and just double check that there's no fluid with the fast scan. And so the advantage of the or the the ultrasound, I'm sorry, and by doing a fast scan, and so the advantage of doing.

The old ultrasound technique is you should be able to find fluid in much lesser quantities than you would, you know, then you need to have to get fluid out with needles. So if I just take needles in, you know, like I say, if I have 10 mL per kg of fluid, I won't get necessarily any fluid out, but I should still see that, for example, with my ultrasound. And so I won't spend a lot of time in this is a million billion billion publications on this and lectures on it, but essentially you go to 4 spots.

I go under the diaphragm and kind of point my probe forward, toward the sternum. I go over each, kidney and I go over put my probe in the bladder and I look around it. And the key with the kidneys in the bladder is when you do find those organs.

With your probe, you wanna make sure you rotate your probe cranially and caudally and then and then twist it 90 degrees and rotate again cranial and caudally because you want to see all sides like you wanna see the margin of the bladder on all sides and the margin of the kidneys on all sides because you might miss potentially a small amount of fluid if you haven't visualised around each of the organs entirely. And so the third technique, so those are the most common two techniques would be to do the four quadrant tap or do the ultrasound here in especially in 2018. There is an older technique called the diagnostic peritoneal lavage that exists that you can do.

That I'll just mention here because you know if you don't have an ultrasound you may need to do this and there are still some situations where I can see the fluid on the ultrasound but I can't get to it and I still have to go back and do a diagnostic lava. So it's still an important technique to just at least know exists, and it's in your arsenal of things you can do. So basically if I think it's a localised process, if I can't get it with a 4 quadrant tap or I can't get it with ultrasound, I'm gonna do a DPL or a diagnostic hernia lavage.

And so the the equipment I need is very similar to what I need for a 4 quadrant tap, except I really only need one catheter, not multiple. I need my scrub. I need my slides and tubes, and then I noticed I have fluid in a pressure bag here.

That's the big key here, fluids in the pressure bag. So what I'm gonna do with this patient is I'm gonna clip and prep the area, which you've probably already done, and I'm gonna make sure it's scrubbed. Then I'm gonna, I'm gonna go in somewhere lateral and slightly causal to the umbilicus and in a perfect world, you can go in if they're in right lateralcumy go on the right side, although to be honest, it doesn't really matter that much, but I go in in in in in the umbilical region and one of the quadrants I identified and I go ahead and put in my catheter in this case.

I don't use a needle. I put a catheter in. And so again, the, the nice thing about that about the right caudal quadrant of the four quadrants is that it's the least likely to be near the fast form ligament and the farthest away from the spleen and colon.

I insert my at least 20 gauge catheter, if not an 18 gauge catheter into the abdomen. And again, I can use any of the catheters I've listed here. I just tend to use a regular IV catheter and I insert it in and then I go ahead and I attach the fluid bag and I administer 22 mL per kilogramme of fluids as fast as I can because I need to get that fluid in an ASAP like quickly, quickly, quickly into the abdomen.

And notice I've instilled enough that I should be able to get some of it back. That's the reason for that amount. And you can use warm fluids of any type of isotonic crystalid you want.

And then what I do in order to make sure, cause you're probably saying, well, how do I know how much I gave with the pressure bag, right? If I'm like, oh, I need to give 400 mLs to this animal, I can't see once I put it in the pressure bag and pump it up. It's really hard to see how much you gave.

So the best thing to do is to take your fluid bag and empty it until just the amount you want to give is left in the bag. Then I can pump up my pressure bag and just give it till it's empty, and then I've given the correct amount that I want to give to the patient. Then, oh.

One more thing that you can do. I don't always do this, but if you're not using a catheter, some people use the number 11 blade to actually make a stab incision to put your whatever you're inserting in. Personally, I just go ahead and use a catheter and don't and can skip that step.

And then like I say, we insert the catheter into the incision, attach the fluid bag, and then I go ahead and let it rip. So here I am prepping. Here I am with my catheter in place with my, line in my bag, and I'm just giving the bag till it's empty because I have the correct amount in the bag for the dose I want to give to the patient.

All right, so then, and, and as I said, we wanna give it as fast as we can with ideally the slam bag, quote unquote, which is the pressure bag, or I can squeeze it manually. So once I've given it all the fluids I want to give, I'm gonna close the Venus set on the line, so clamp it off the line, then I'm gonna take the animal and go from whatever recumbency we're in to the other and back. So I roll them back and forth 2 or 3 times.

And you can tell people will be off the abdomen. It doesn't really matter, but I'll roll them back and forth several times. Then I will put them back in the original lateral recumbency and my fluid bag is empty because I put all the fluid into the animal.

I'll place that bag below the animal underneath me, open the venous set and allow the fluid to flow back into the line. And so your sample that you have will be inside the fluid line at this point. And if you've given 22 mL per kilogramme, if you get half a mil back, be happy.

I mean, I've never gotten back more than about 4 or 5 mLs total on one of these guys, so you wanna make sure you're not gonna get a lot back. Don't expect to have a lot of fluid back, but we don't need a lot of fluid because we're gonna collect in a certain way and get information back the way we want it here. So if I'm gonna collect my samples.

First thing I'm gonna do is I'm gonna put them on a slide so this orangey colour thing is a slide and the pink one's a different slide. I've placed a drop on the slide. I've had my second slide kind of on there, kind of in the same position I would do to make a blood smear, right?

And then I'm gonna drag this pink slide across, across the slide. And so I drag it across and then I'm gonna stop prematurely. So I'm not gonna drag it off the way I would for a blood smear.

I'm gonna drag it across, stop before I reach the end of the orange slide, lift up the pink slide so it's perpendicular to the orange slide, and then I'm going to remove it. And what you end up doing is if I start on this side here. I'm going to have my drop here and I'm gonna slide my slide across and I'm gonna have a line of cells where I removed the slide where I lift it up perpendicular and picked it up.

And so this line of cells that you get on your slide is going to be the heavy cells will all be there. So if this is the equivalent, it's called the line prep. This is the equivalent of doing a site of spin like if you sent the fluid to the lab and they spun it down and looked it on the slide.

This is the equivalent of doing that without the spinning step, so it's a kind of a poor man's site of spin and the nice thing is all the cells that you need to look at are right along this line. So when you put it in the microscope, you just look along that line and see what you got. Alright, so got my cytology because I'm gonna look at that.

I'm not gonna send that off to the lab. I'm gonna do my own cytology so I can get information right, right now, right now on the situation. Otherwise I can put stuff in a purple top, which typically, as I said before, is my second slide that I will collect and what you can do with the purple top tube is send this, tube off to the lab and you can do cytology so with cell counts, proteins and PCBs on them, and, and, and the lab will always get that basic cell count information as well as doing cytology for you.

And what I would also say is if you have enough fluid to send in one or two slides that you've made with your purple top to your reference lab, it is actually very helpful because sometimes if you just send in the tube, the cells can actually change in their, the way they look just because of being sitting in a tube for 24 or 48 hours. So if you made. A couple of slides to send in these, the pathologists who are looking at the slides can actually corroborate anything that looks weird on their slides with your slides.

So if it looks weird on their slide and not on your slide, they'll say it was just an artefact of preparation or of the fact that the sample sat around, but if it looks weird on both slides, then it's gonna be a real finding that they have. All right. And so as I said, and the reason again, the biggest thing that we use the EDTA tube in is we don't want the red cells to clot because if I am doing the fluid analysis and getting my total nucleated cell count, I don't want clotted fluid.

All right. And then typically the 3rd tube, as I said, I collected is a red top tube. And what I'm looking for a lot of times is does the fluid clot.

And so if I'm worried about a hemoabdomen, back to my original discussion topic, and I get red looking fluid that comes out of the abdomen, I'm worried it could be true blood. I actually will put some on a slide and then I'll go straight to the red top tube and see if the blood clots there because I really want to know if the clots in there or not to know if the sample that I got out of the abdomen is a hemoabdomen or just blood inside a blood sample. Which I'm talking, I'll talk about one more second.

The other thing you can do with the red top tube is you can get a hematicer tube out of it and you can spin it down and get the PCV, and I can compare the PCV of the fluid with the PCV in the periphery. And so, quick and dirty wise, how am I going to know if this is the hemoabdomen? So if I have free abdominal fluid that I get out of the abdomen, that's red in colour, that does not clot, I always compare the PCB to the peripheral.

And what I'm looking for is what is the PCV of the abdominal fluid versus the peripheral fluid. Oh, sorry. And then the reason I have anaemia right here is if I and if I take this information in concert with an anaemic patient as well.

I've got a patient that looks pale and I think is anaemic, and maybe I have their PCB and I know they're anaemic, and then I've got fluid that looks bloody, and that fluid is not clotting in a tube and the PCV of that fluid in the tube is pretty close to what the peripheral PCV in this dog is. I'm gonna, that's my, those are my kind of my criteria for a hemo abdomen. So looking at our two patients that we had before, Bogie, who was the original Labrador with a weird 3 day history of the of vermeyenrodenoide, his peripheral PCV was 27, 5.5, so he was a little bit on the anaemic side, and he did have a little bit of free abdominal fluid, but I actually didn't get a sample because there wasn't enough for me to actually get to, but I could see it with the ultrasound.

Versus the husky who had the distended abdomen. Look at his peripheral PCB. It actually wasn't anaemic.

So a real critical thing to remember with some of these hemo abdomens is they don't always have to be anaemic. A lot of them are not because they have a splenic contraction. They're actually not anaemic when they come in.

So this guy was not anaemic, but look, the abdominal fluid PCV was almost identical to his peripheral, and that's, oops, sorry, I didn't mean to hit that. That's very, very consistent with him having hemo. Sorry I didn't mean to hit that.

So if you see this kind of a pattern with the peripheral and abdominal PCVs being very, very similar, that's almost passhonemonic for a hemoabdomen in these cases, especially if that fluid is not clotting in the tube. Now, one other caveat is if the fluid you got in the tube is clotting from the abdomen, . Then actually you have to ignore it because you probably just like hit the spleen or hit the kidney or something.

Basically your needle went to an organ, collected blood from it, and then that blood clot in the tube, it's not free fluid. I don't care about it. It's not a hemo abdomen.

So remember, when you're comparing PCVs, you have to make sure the fluid is is not clotting in the tube. So the importance of the red top tube. OK, so, if I've gotten to the point where I've done these first diagnostics and I've gotten my free, free, free fluid sample, I've got my, my big 3, my PCB teller protein glucose, I run whatever diagnostics I want, other diagnostics.

I'll think about doing some secondary diagnostics as long as my patient is still stable. And so secondary diagnostics would be things like turning in blood to the lab, doing a urinalysis, and potentially doing some imaging or so all these things I have to leave the ER area to go to, right? And so.

Imaging is the one I'm gonna talk about the most here. So imaging, one of the things obviously you're gonna think about doing, especially when you're worried about blood in the abdomen is abdominal radiographs, which they're a little bit controversial because you might be like, well, it's a lot of fluid in there, I'm not gonna see anything. But a lot of times we'll still take them just to see what we can find.

If there's guts hanging out or like I know there's a penetrating wound or I know the animal had surgery, I may not do radiographs necessarily in those patients. Because I may have a strong enough suspicion that we need to go in there and do something that I don't worry about abdominal rats, but a lot of times I'll do them otherwise. I mean, there's tonnes and tonnes of fluid.

I, I'll skip them also. And if the animal's gonna die in radiology, please don't go take radiographs as well. But otherwise, you know, if I have any kind of a question or I'm just not sure or they have abdominal pain and there may or may not be any fluid I can find in the ultrasound or just a little bit of fluid in the ultrasound, I'll probably still take the radiograph.

And if there is tonnes of fluid and all you, you know, you really still want to take radiographs because it's really the only diagnostic modality you have. Don't forget about doing like standing lateral radiographs because you can at least see the things like the kidneys. You can get a rough idea of shape and size of the liver, things like that if you do a standing, standing radiograph for the patients standing and you hold the, you hold the plate against them and you have you, you basically shoot across them.

I mean you can still get some information from that because the fluid will fall eventually. All right, so here's some radiographs on . Good old, good old, the first dog bogey here.

And so if you look at the dog, it's obviously decreased abdominal detail here, so it's hard to make out a lot of things. And we had noted on the ultrasound there was some fluid, so it wasn't completely shocking to see that. But one of the things that we were looking at in this guy was this retroperitoneal area was very, very indistinct and it almost looked like the colon was ventrally displaced and kind of this whole area in the retroperitoneal area is kind of hard to see what was going on there.

And we were wondering if that perhaps was the source of some of the trouble that we were having with the dog. So, anyway, so that's one of the things we're keen on is that, other things that I would do potentially would be to think about taking thoracic radiographs, and they're really not so much of the hemoabdomen problem, but like cases that are like trauma cases where I'm worried about things like contusions, which this dog has, or I'm really strongly worried about neoplasia and I want to look for metastasis. Those would be the reason I take the thoracic grads.

They're not gonna help me directly with the hemoabdomen, but they'll give me some additional information about the patient. OK, and then if you've never seen an ultrasound, obviously, you, you know, if you or if you don't know what you're doing with ultrasound, you're having someone else do it, the thing that you would look for would be things like pockets of fluid like this. And so sometimes we'll do an ultrasound up in the ER and then we'll have our radiologist do a regular ultrasound to give us some more information.

And the nice thing about ultrasound is that we'll be able to tell you, hey, I can see the spleen. I can see a mass on the spleen for sure, or I can see cavitated lesions that maybe don't form a mass but are probably the source of the bleeding, which is kind of handy, which you may not be able to see on, on the radiographs, and so, and the fact that I can look at all the organs kind of and separate them out sometimes that's very helpful with ultrasound to give me a better idea, a better handle on where is the bleeding from and you know, is it multiple spots that are causing bleeding like multiple masses or is it just one thing. And sometimes don't forget to look at the mesenterian body wall because you could sometimes get especially metastasis of hemangiosarcoma to those areas.

And then the nice thing about ultrasound is in theory if I can see the fluid, I may, I should hopefully maybe be able to guide my needle in and get a sample of it, and also if there is fluid in the abdomen, I can see all the organs a lot better than I can with with the radiographs. All right, so I'm showing you the CT. This is neither of the dogs that I mentioned, but some of the cases nowadays we, we've moved to doing CT instead of ultrasound.

I'm not great at reading CTs, and even if you're not great at reading a CT, this is, this is a kind of a sad, a coronal view or a saggy view where I'm chopping down the dog starting he's laying internal recompancy and I'm chopping from the, the backbone down basically. And you know, the nice thing is I can see like here for example the spleen. This is part of one of the kidneys coming into view.

These are the GI tract loops and things. And the nice thing about it is in some of the really, really big dogs where it's hard to see stuff with ultrasound, CT gives you a little bit better global look, but honestly. Like I say, I'm not great at reading these.

I always have the radiologist help me, but this particular, CT was from a 4 year old male neutered mastiff that came in with free abdominal fluid, which was, which was pretty much the same. Not the abdominal fluid is pretty much the same as the peripheral. The blood was non-clotting, so he had a hemoabdomen, and we're trying to figure out what was wrong with him.

And you're probably asking me what in the world is on the CT. Basically this dog had some kind of undefinable diffuse disease that was basically this, this is disease, this is disease, this is disease, this disease. All these areas I'm circling are all disease areas, that nobody knew exactly what it was, but we knew it was bad and we suspected some kind of cancer, and he ended up going, getting euthanized and unfortunately not getting a knee crop.

So I can't tell you what it was, but, but just throwing it out, if you do refer cases, you will sometimes see a CT them and that's why. So this is the same dog in the lateral view on the CT. And again, this is pretty much all blood in the ventral area here, and then again, all this kind of indistinct stuff.

So this is spleen, this is a loop of GI tract and all this indistinct stuff in the middle is some kind of undefinable disease the dog had. So just to give you an idea of what some of these look like. OK, just to kind of be complete, if you are worried about coagulopathy, then you need to figure out, you know, do you have a primary or secondary problem?

And if I am worried about cavity bleeding like hemoabdomens, secondary coagulopathy, which is a PT or PTT elevation because my Think factors are not working or deficient would be what I would think about. And so I won't go into get into a lot of discussion about this, but genocide is your most common hemo abdomen coagulopathy we see and don't forget with that you're gonna see the PT way more prolonged than the PTT. So they'll both be long sometimes, but if, but if they're not both off the scale, the PT is always more prolonged than the PTT is, and that's because of factor 7 having the shortest half-life and PT checks factor 7 in the common pathway.

If we are dealing with the weird once in a million thrombocytopenia that's causing a, hemo abdomen, you would expect your blood smear to look like this where you're really not seeing any platelets at all in your blood smear, and that would be consistent with the obviously dramatic thrombocytopenia. OK, so I don't want to spend a lot of time on that. Let's go back to our cases that we had.

So diagnostics on our different cases here. So this is actually I lied to you before. This is actually bogey's radiograph and so his retroperitoneal area right here is very, very indistinct and very, very full of a radio opaque material of some sort, and his colon is very, very, ventrally deviated, but his abdominal detail is not too bad otherwise.

And again, there was not a lot of free fluid in this dog, but he had this weird area in the retroperitoneal retroperitoneum which we'll come back to. And here it is in the VD view as well. And so again with him, remember he's the one who had the 26% and 5.5 peripheral PCBs, so mildly anaemic with scanned abdominal fluid.

His plates were mildly decreased but not enough to cause bleeding, and his coagulation times actually were actually both prolonged. And so this is a dog who supposedly ate the bromethyl rodeoide. Well, come to think of it, when we question them a little bit further, they actually had anticoagulant adenoci in the property as well.

So this case actually was a a hemoabdomen. It was a retroperitoneal hemoabdomen. So all that area in the retroperitoneal was actually blood, and it was because he had a coagulopathy from from from getting anticoagular adenocide.

And so those are the big finding on him. So notice here that we're 10 times higher with the PT and we're only about 4 or 4.5 times higher, the high end on PTT, so way more prolonged PT than PTT, very consistent with anticoagular agentic side.

All right, so back to Lucy and the other dog who was the one with the descended abdomen. So we, he was a bigger dog, so radiology here loves CTing, so we CT'd him. And he actually this is his spleen.

His spleen is big, and he had here's a a hypo intense, another hypo intense, and a third hypo intense. So we say three masses inside his spleen that we could see on the CT. And so here's a spleen on the the lateral view and here again is a big hypo intense, I'm trying to remember what to call it, hypo intense area on the CT where basically there was a mass here as well.

So he had a splenic masses. And again, he was the one that really wasn't anaemic and his, but he did have a lot of free abdominal flu that was the same PCV. His platelet count was reasonably normal and noticed that his coagulation times were normal.

So consistent with having a hemolabin from a splenic mass masses that we could see on the CT. All right, so just to kind of finish up in the last couple of minutes here, we'll just talk really briefly about treatment. So the biggest thing with treatment on these guys is, do we treat them like, do we need surgical treatment or non-surgical treatment?

So the biggest thing is if it's a coagulopathy or it's trauma, pretty much you don't need to do surgery. Coaul. So you're gonna make it worse if you cut into them.

And then trauma cases, you know, honestly, you hit them, they bleed, they stop bleeding, they're fine, and you, they just reabsorb the blood and things are fine. So most of those cases do not need surgery either unless you've had the weird case that like fractured a spleen and won't stop bleeding, then obviously you might need to go to have surgery on a traumatic case like that. For all the ones that are non the non-traumatic, so, so the non-traumatic ones tend to need surgery more than the others.

And so that would be the case where, you know, I have the, the mass that's bleeding or something of that nature. They tend to need to go to surgery. The question is, do they need to go to surgery like right now?

Or can they go to surgery tomorrow or the next business day? And so if they're, they continue. Bleeding and their PCB keeps dropping, keeps dropping, keeps dropping, or you can't stabilise their vitals because they keep bleeding.

Those are the ones that need to go to surgery right away. And so it can be irregardless of our, you know, regardless of cause, those ones need to go to surgery. But again, like I say, a lot of the splenic mass and stuff will go to surgery eventually, just not the day they come in if they're able to be stabilised.

Real briefly, if you do have the coagulopathy and it's a secondary coagulopathy, your treatment is going to be providing the vitamin K dependent factors with plasma, either fresh frozen or frozen or whole blood, and then giving them something like vitamin K to help them activate their factors. If you're dealing with platelet issues, you, you have to give them fresh plasma or fresh blood or platelet rich plasma, because fresh items have functional platelets in it. And if they're actually bleeding, bleeding, bleeding from their platelet disorder, you have to give them platelets to stop the bleeding.

Not that they're not bleeding from the thrombocytopenia, you don't have to give them platelets, just that they're bleeding. All right, so give yourself some numbers if the owners, you know, if you're a numbers person and when you talk to clients, you want to have some kind of numbers for them. I mentioned that most trauma cases don't actually need to have surgery.

And so in, in the 22 cases in this particular study where you've got trauma cases that needed a transfusion, so they were anaemic enough to need a transfusion, 75% of them did not need surgery and survived 1622 did not need surgery and of those 3 quarters of them survived. The ones that died didn't die from their hemo abdomens either they died from other causes. 6 of 22 did have surgery and 2/3 of them did survive.

And then, like I said, 6 of them died from natural causes. So really, most of them don't need surgery and, and, and survive and do great. A very few of them needed surgery, but if they did need surgery, a lot of times you can fix them and and they're OK in the long term.

In humans, in contrast, more than 78% of humans, there's a more than 78% survival rate in humans who have things like traumatic splenic ruptures, who don't receive surgery. So again, a lot of humans don't receive surgery for their splenic disease from trauma, and they don't actually need to, they have a good, good survival rate as well. It's kind of similar to our numbers.

Now if they have uncontrollable haemorrhage, you have a much higher mortality rate, although this is obviously anecdotal, but the reason that we have such a high death rate in patients that we can't control haemorrhage is that it takes us so long to get into the OR that by the time we get in the OR, the animals past the point of being able to be saved. This is in contrast to humans where, and also a lot of the times our animal is bleeding from things like cancers that can be potentially be metastatic or things of that nature or terrible, terrible trauma. In contrast, oh, and then, and non-ruptured splenic and things like that.

So in contrast with humans, I keep trying to say, I'm just gonna say it right now. In contrast with humans, they tend to do better with these, these uncontrollable haemorrhage cases because they have trauma teams. If you go to a trauma centre and you can be, and you can get to a trauma centre in a timely fashion, there's usually people standing by ready to like get in the OR as fast as you can.

Those cases will do much better than ours. Other things to remember when you're talking about treatments are if you're dealing with non-ruptured splenic masses or nodules, which you found fairly, fairly incidentally, most of them tend to be, benign, and they have an excellent survival rate lasting years and years, you know, more than a year. If they are, and, and very few of the non-ruptured splenic masses tend to be, malignant.

If they go, but, but if you've got a case where they have ruptured. And you've got bleeding because of this splenic mass. Your, your, your outcomes are much, much, much, much, much worse than this.

And so if they, if they are ones that you believe are neoplastic and have bled spontaneously, it's almost always going to be hemangiosarcoma. And so up to a third of them get, die or get euthanized within the perioperative period because you get in there and you, you can't resect everything that needs to be resected or the patient, you know, dies on the table because they're bleeding so much. Otherwise, if they don't get chemotherapy and you're able to resect the disease, like you take the spleen out, but they don't get chemotherapy, it lasts for 2 to 3 months.

And if you give them chemotherapy, they maybe last for 6 months. So, you know, these, these ruptured splenic masses and things that are not traumatic tend to not hold a very good long-term outcome in our patients. However, if you're dealing with things like liver lobe torsions, splenic torsions, benign disease, or hepatocellular carcinomas even, they tend to have much better outcomes.

And so the, the hematomas and the torsions, you just remove that area and things are great. If you're dealing with hepatocellular carcinoma, they still last for more than a year if you can resect the disease. So, so again, reason for bleeding is a little bit important for us with outcomes, long term.

OK, so outcomes of our two cases just to finish up. So Bogie was the one with the anticoagular or adenoci intoxication. He also did get prometholone as well, but he didn't really have signs from that.

And he had that retroperitoneal haemorrhage. 24 hours later, his PT and PTT had normalised. We gave him vitamin K and plasma.

I should have probably said that. And his PCV was holding it about where he came in, so he was able to go home. And we actually 6 days later took radiographs and know his retroperitoneal area looks great.

So all the blood that was in that area reabsorbed and things were great. In contrast, the other dog with the splenic masses received a splenectomy. He unfortunately had in just our coma and he was getting metronomic chemotherapy, and he, this is, I put this, he, he came in probably 4 or 5 months ago, so presumably he's still with us, but I, I, I don't have contact currently with the owner.

Alright, and so we've made it to the end and so thank you for your attention and if you guys have any questions I will take it and take them down. Liz, that was absolutely fascinating. I, a very rapid tour through hemo abdomens, but very, very informative.

So thank you very much for that. One of the questions that I wanted to ask you was, when you're doing those, four quadrant taps, what gauge needles do you use before you go to your catheter to do the lavage? So yeah, I should have said that.

Thank you for asking. So the gauge of the catheter is personally I never do any lower than any smaller than 20 gauge because if you are dealing with something that's not blood and this is for just in general for quadrant taps, if it's something like purulent material or something, it may be very thick. So I'll do I'll do 18 or 20 gauge catheters even in cats.

I'll do 20 gauges, because the thicker fluid, I want to make sure I'm getting it out. So nothing for me is smaller than 20 gauge, and that's the same for catheters or needles. OK, excellent.

Catherine asked the question. She says, is there a real or theoretical risk of popping the clot in inverted commas with aggressive fluid therapy in bleeding patients? Hasn't human combat medicine moved away from aggressive fluid therapy in bleeding patients in the field?

Yeah, so, so, yes, there is, there is, and again, that now we don't really have any actual excuse me, like data data, but yes, definitely people say it's kind of it's one of those like things that we all say, you know, without a lot of data behind it. But yes, people do say that if you too aggressively resuscitate a patient, meaning you're going to resuscitate them to what would be a pretty normal looking blood pressure, where you you your concern is that you've increased, flow to the organs and potentially, yes, you can have them start bleeding again. So when you're resuscitating.

Patients, you don't want to get greedy with your blood pressures. So what, what we're looking for is like systolic blood pressures in like the, you know, 8090 range is actually pretty good for one of these cases as long as you've seen the heart rate come down because I really want to see because you don't really want this patient with a heart rate of 200, where you're like, oh, I'm afraid to push them any further because the heart rate of 200 is gonna be just as detrimental potentially as pushing fluids with these patients. But yeah, when I am resuscitating, and that's why I only give like a third to quarter of their of their shock fluid amount and then I stop and reassess and see how things are going.

And then I'll repeat the fluids only if I need to at that point. So yeah, so targets for us are usually 80 or 90 systolic blood pressures, getting the heart rates, like I say, less than 200, ideally for me closer to 160, and kind of stopping there. Like I don't push them to try to get their blood pressures up to 120 or anything like that.

But, but yeah, so it's called hypotensive resuscitation. So yeah, so when you do resuscitate these, you're a little less aggressive than you would be for my standard hit by car or something like that. Yes.

So yes, good point, yes. Excellent. Ian asks, what is the risk of hitting the spleen with the four quadrant tap?

OK, so good question. What's the, so, so as far as hitting the spring with the four quadrant tap, so when you go in in the quadrants, and I probably should have emphasised this more, you're going in, you basically are going in at a radius from the umbilicus of no more than about 1 to 2 centimetres max. So in the picture, and I can kind of click back, but in the picture, that we are really, really close to the umbilicus for a reason, and that's because the closer you get to the umbilicus, the less likely you are to hit any of the organs.

So I'm just getting. We can look at it again here. So, so here you'll notice that I'm, I, I, I wouldn't go any farther out than in this picture.

So I'm, I'm about 1, I'm about 1 centimeter.5 to 2 centimetres out from the umbilicus in a radius here, and that's as far out as you want to go. Sometimes I'll go even closer than that.

So some of the cases my needle hubs will actually be hitting each other, because if you go in that peri umbilical area where the al ligament attaches, naturally your organs don't sit there. Now, obviously if you have a really, really big spleen. Or there's a mass somewhere else in the abdomen pushing the spleen around, you have a risk of hitting it, but it, it's much less likely the closer you get to the umbilicus.

And one of the reasons we always check and make sure the fluid doesn't doesn't clot in the red top tube before I get panicked about what the PCV is is if I did hit the spleen, it will, it will clot in the tube in the red top tube and then it's not a, I know it's not a hemoabdomen fluid that I'm looking at. So, but yeah, so I hope that answers your question there. And a needle in a spleen is not a big deal.

Oh yeah, yeah, yeah, no, yeah, yeah, needle, as long as you're not like in there and like moving it up and down, raking the needle back and forth, it should that should seal back over and you'll be totally fine, yes. Following on to that one, we have a question that says, how do you stabilise the catheter during peritoneal lavage when you are turning the patient from side to side? Yeah, I don't really worry about it.

So when you're turning it from side to side, it doesn't matter what's happening with that catheter. It's just in there. Your stilt is out, so it's a nice soft catheter and as you roll them back and forth, you're not gonna cause any damage with the catheter.

When I get them back in the lateral recumbency, I want to make sure the hub because you know where the needle where the catheter in the hub joint is where it always likes to kink. So I always check and make sure that looks. Patent and then I unclamp my line and let the fluid run back.

So, so I really don't worry about it at all when I'm running back and forth. And that's why I use a catheter. If I had a needle in there, I'd be much more worried about trying to hold it in place and not having it, you know, you know, hit something as I roll back and forth.

But with a nice soft catheter with a tt out, you're good to go. No, you really don't need to worry at all. So you let it run back out basically like a closed urinary system.

Correct, correct, yep, just by gravity. Correct. Yep, yep.

Excellent. Well, Liz, that's been absolutely fascinating and insightful, certainly giving us lots of other options for if we don't have an ultrasound handy or if you're like me, you can't read ultrasounds, then yeah, it's it's a good, a good method. So I, it's my pleasure to thank you.

There's lots of comments coming in saying that was very informative. Thank you so much. So it's nice to see that.

And folks, thanks for joining us tonight and we look forward to seeing you again on another member's webinar. Don't forget to get that virtual congress dates, 18th to the 20th of January into your diary. To Paul, my controller in the background.

Thanks for making everything happen. And once again, Liz, thanks very much and good night.