Hi, everybody. Thanks for joining me for this session on crunchy pies, which is what I call tortoises that have been attacked by dogs because the vast majority of times that's what I think dogs view them as they don't necessarily see them as a living object. But some of them just picked them up to play with them as if they're toys.
So the intending learning sorry from teeth and today the intended learning outcomes for the session is to learn the internal anatomy of a loa, which is what we call shield reptiles and the importance of that is so that you can assess properly the potential internal injuries from these penetrating wounds to the shell. Because it's a little bit different or more familiar species just for the internal anatomy, how to stabilise these animals, what dressings are suitable? When should surgical intervention be performed to recognise that the healing times can be prolonged in many cases months to a year.
So we need to manage your owner's expectations from the. How to place an esophagosy for ease of feeding and medicating tortoises are particularly stubborn animals and it can be sexually difficult given oral medication unless we have an esophagos placed. And recognise that these animals do feel pain and analgesia as fatal.
So for any of you that listened to me before, you may recognise this slates because for me. It's really important that we all realise the human animal bonds is not a species specific. It isn't just a dog or cat.
It literally can be any type of animal. And although we might not necessarily understand the bonds between an order and a tortoise that we should be respecting that. So terminology what's a tortoise actually it just depends on where you live because in some places they call any Chalonia a turtle.
But for the purposes of this talk, because I'm Scottish and I'm based in the UK, a tortoise equals land dwelling Chalonia and the terrain is a freshwater. So where does it start? It starts with your front house staff because that's who are going to take the phone call from the owner.
And it's really important that we train our front of his staff not to panic when they get these phone calls that their tortoises just been bitten by a dog. And what sort of questions should we be training our front of his staff to ask, when did this happen? Wouldn't be the first time we've all experienced it with dogs and cats and on our phones up complete panic that there are animals being hit by a car and then you find out it happened 3 days ago.
It's just that they've now decided it's an emergency. So it is important for us to figure out and to establish exactly when this happened. What breed of dog is it?
That's important because the bite force of the dogs can be very dramatically depending on the breed of the dog. What size of tortoises or terrain is it? And again, for the same reasons, a fully grown so a tortoises can be 80 kilogrammes and if it's getting chewed on by a German shepherd, then The injuries might not be quite as severe as a socata tortoise that's only 10 kilogrammes.
Is there any active bleeding? Get those to take photographs of enclosure. We realise that it's important to realise that these animals need to be seen as soon as possible because they will be going into shock.
The owners keep that warm, but sure they don't put it back into its enclosure and substrate. But recognise owners don't necessarily understand the word substrate. So it's important that the staff ask what's on the bottom of the enclosure for this animal.
Transporting to the clinic, it can be a cat basket, it can be a plastic tub, it can be a shoebox. It doesn't really matter. But what we should be advising is a towel to stop the animal sliding about.
And a hot water bottle to keep the individual warm, but it's going to very dramatically depending on the size of the animal because it would be the first time I've had to bring something in and wear. So we need to keep our options open. So animals arrived at your clinic, your colleagues have all managed to successfully body swear it.
So you've ended up having to deal with it. What's next? Well it's important that you realise that you shouldn't panic either.
Any vet can stabilise a tortoise with a dog bite injury. They're just an animal. So you completely transferable skills.
And recognise that for the vast majority of the state, it's not actually species specific. So we ask you, where do you keep your animal? We ask what you feed your animal.
We ask how much exercise does it get? We ask, is it still passing urine is still passing faeces is still eating these kind of things where the species specific part comes in as its preferred temperature and it's UV. And sites like the there are really good for you to be able to get quick access to accurate information as for free as to what the information or sorry, what the husbandry requirements for these species should be.
Remember that if you stop thinking species specific and start thinking more body systems. Recognise that everything has the same body systems. They're just in a different rapper.
And when you're doing your clinical exam, all the clinical exam is an assessment of body systems. And I find that that's why I perceive exotic animal medicine is actually really easy to do. And the vast majority of what I do any that could do because I don't actually approach things in a species centric manner actually approach them in a body systems manner.
Recognise that these animals hate pain, so owners are often completely unaware of how well or how painful the reptile is. And it's really important that we realise that just because it's eating doesn't mean it's not in pain. I remember as a very young vet once it just qualified being told that if I was eating it mean it wasn't sore or it wasn't too well.
And Back in the days before your mobile phones had cameras on them. I remember a tortoise coming that been chewed up by a dog and its limbs were broken. It's half a shell was missing.
It's bows were falling out and were last sated and I was still like eating on my table because it was desperately trying to pretend everything was OK. The shell is made up of carrot and skits. So that's a ski.
So the top shells called the catappa, the bottom shells called the platron. How did I remember it because it took me ages. I can't get my head initially.
How I remember it is if you put a tortoise on the plate on a plate. It's plash one touches the plate. So the PPP, that's just how I remember it.
But this shell is made up of car skis and they've got bony plates underneath that. And but they're overlapping. So the joints and the car and skis on the side do not marry up with the joints in the bow or the seams in the board underneath and that actually means that the shell is a lot more rigid.
But we have to recognise that shell punctures and fractures actually cause orthopaedic pain. That's broken bones. And we know that mammals that orthopaedic pains considered one of the worst forms of pain that you can get.
So we need to have a think about what organs lie underneath the shell. If we look at the cat on the picture in the left hand side, all the desks have a name. So one's above just the head here called the neutral scoops.
And then the skis that run down the middle here are the people skis, and that's because we've got the vertebrae underneath there and the spinal cord running down. Then we have the plural skis just laterally to the vertebral skis and underneath there's the lungs. The skis that join the catapus and the plaster on are called the bridging skits.
And then you've got the marginal skis. OK, just at the front here and again at the back. So basically over all four legs are the marginal skis.
So if we turn the tortoises onto its back, metaphorically. So that we're looking at the pla drawn. We've got the.
Heart is usually round about here. So we've got the goulash gets at the. Cranial edge of the plastron.
And then we have the humeral skis, the pectoral skis, the abdominal skis. That I've covered up here because this is roughly where your liver would set if you're tortoise, the stomach, the GI tract, the bladder, which is often by looped and tortoises and can, especially when it's filled take up quite a considerable area and the abdomen and then the kidneys and goods. So it's quite easy to see that if there's puncture wounds to the catapus, then we could, we could easily have a lung damage or spinal damage.
But if there's puncture wounds to the lash on, then we could have damage to our gastrointestinal tract or stomach or kidneys or bladder or heart. So let's have a look at the skeleton. Thelonia are the only species that actually have their thoracic girdle and their pelvic girdle inside the rib cage.
How mental is that? I think that's absolutely phenomenal. So this is the thoracic girdle here.
The exceptionally long neck. We've got our pelvic girdle, and then we have our vertebrae and essentially the canapus and the plastron are made up of modified ribs. OK, so this is This just gives you an idea, a pictorial idea of where the lungs set and internal organs sit there.
This is postmortem picture, but you can see that if there's puncture wounds to the plaster on, or organs lie underneath. What does it look like in real life? Well, here's our heart here.
This is an albeit an abnormal liver. We, we have stomach just peeking out here and we have intestines here and this is the bladder. OK.
The liver's enlarged because the animal was ill and this is an example of fatty liver and a tortoise. So we've had a look, we know roughly where the organs and sights. So we've got an idea of what potential injuries we could be looking at.
But we need to assess for co morbidities as well. So. As the tortoises shell is exceptionally flexible, for example, then that could be a sign that we've got metabolic bone disease.
I'm just going to play this video here because this wasn't a tortoise that was brought in because it's been attacked by a dog and this animal was not alive by the time I checked the video because I just finished it. A bit about half an hour previously, but it was still alive when it came into my clinic. So this animal was septic and had a septicmia, cutaneous ulcer disease and renal failure.
So but it's important we look for these comorbidities because that's going to have an impact as to what we're going to advise. The best place to look for a septic flushes on the platron and instead of This species which should have a creamy yellow plastron, you can see it's actually got a real pink tinge to it. Versus is this free fluid because we've got Scott and the easiest way to tell the difference is when I ran my finger nail down the skis here on the lash on on the right hand side picture with the free fluid as you can actually see the fluid moves in between the car to the sk and the bone.
Whereas with the septic flush, you're not going to see that. You're not going to see that movement. You might see some blanching, but you're not going to see any movement of fluid.
So should we treat them or should be euthanize them? Well, it really depends what the injuries are. If there is metabolic bone disease, if there is evidence of renal failure or sepsis, then we need to give a guarded grave prognosis depending on the severity of these things.
If we've evidence of internal organ damage like this and these puncture wounds were very, very deep. And we were really worried about internal organ damage here. Then that's got to be guarded to grave depending on what organs we think have been damaged and are the flexible.
If over 30% of the shells missing, so over a third of the shell is missing. That's reportedly grief. OK.
So those are the cases that I would be strongly recommending euthanasia, severe damage to the breading dredging skis guarded to grieve. Every case that I've treated where it's lost most of its bridging skis has ended up not doing well and either dying or needing ethanized. So I often recommend euthanizing these ones.
If it was just one site that was affected, then. It would be worthwhile given that a goal, especially if there's no sign of sepsis and there's no obvious internal organ damage, but it fits both sides like this individual, and then I do sell orders that in my experience, they don't intend to do very well. If the owner is not emotionally, financially or time invested, it's grave because it doesn't matter if it's treatable, if the owner is not willing to for whatever reason.
To engage and to be on board and to see that this is actually going to be a long term treatment plan of weeks or months to a year, then there's no point in starting because you're going to be putting the animal through a lot and then euthanizing later in the day. So the right they say I see to owners, look, you could be looking at months to year. We need to be in board and otherwise, I strongly recommend euthanasia.
Presence of maggots. Reportedly this is grave. This is we tortoises I nicknamed Maggot Mario because it came in to see me after it's been elsewhere and the tortoises lived outdoors.
And the order had been told to put new honey on the winds and put it in its enclosure. The problem was it was the middle of summer. So got fly struck and by the time it came to see me it had maggots and the wind.
So despite the fact it's reportedly grave, it actually depends on the extent and the damage because that's maggot Mario fully healed up. The maggots were. Hadn't gone deep into the lung tissue.
So we managed to successfully remove all of them underneath a general anaesthetic. But if they had successfully got into the lungs or into the abdomen, then that would be great because you're not never going to be sure you've got all of them. So it really presence of maggots.
Means that yes, there's an increased risk that it's not going to go the way that you want to, but I wouldn't automatically euthanize. Just because I've seen maggots. So in the cases that warrant euthanasia, for whatever reason, we need to remember that the term comes from the Greek word euthanas, which means easy death or painless or good death.
And just because they're reptile doesn't mean that they don't deserve the same high level of care that you would give a mammal. And owners are often highly bonded to me one day. This is a tortoise is 116 years old at this point and this was the 3rd generation of owner from the same family.
So not only is this a beloved pet and woman has grown up with this tortoise is the last living link with family members that have passed on. So if we're going to euthana molest the animal is moribund, then jugular access is going to require a premedox alone metine or ketamine. The jugular runs lateral to our dorsal lateral to the tympanic scale, which is here.
So tympanic scale is where the ear drum would be. And it's much more superficial than dogs and cats and the right one is bigger than the last one. Thank you to Ianears, who's my conference husband for providing me with this photograph.
It may be visible if the animals are well hydrated, but these animals are coming and see as are often in shock. So it might not be as obvious as as in this picture. We can use the sub kind of patient sinus.
Oops, going to go back the way that propofol because it was anaesthetizing the soca for surgery, but the techniques the same. Basically, you are aiming to the top of the catapus and soon midline and as soon as you go through the skin, you start to aspirate as you advance the needle and when you get a flash of blood, then you know you're in the right place. You can use the dorsal tail vein, which is a midline.
And this is the same individual. The picture in the left was me trying to get blood sample actually from this particular tortoise, which is a Burmese brain. And this is fluid so it can be colourless, clear, or it can be this kind of pale pink it's got some blood contamination.
So the 11 vessels and tortoises or reptiles in general are quite big and they run very close to the blood vessels because you can see in the picture on the right when I've successfully managed to get into the blood vessel. The colour is much deeper red. So just be aware that if you've had a limp vessel, then you're not going to get the same response as if you've had a vein.
So can we tell that the animals actually passed away. Well, you can use a Doppler to check for the heartbeat. And where I would normally put the Doppler is and the.
Hual fossa, so just between the front leg and the neck and I'm aiming my Doppler head down. Diagonally to the other quadrilateral hind limb so that I can pick up from the heart. This is a doppler unit from eBay.
And it's for pregnant women. And all I did was ask for the 8 megahertz probe instead of the 2 megahertz probe. And I do have the very expensive all saying all dancing and Doppler, but I really like this one because the footprint is so much smaller and it's much easier to get in between the catapus and the plaster.
But we do have to remember that just because the breathing and the heart stops and reptiles doesn't equal death because the reptile brain can actually stay alive without oxygen. For quite a long time, there has been successful resuscitation of tortoises after the heart stopped for 5 minutes with no apparent neurological deficits. That's phenomenal, really phenomenal.
Can you imagine that in a mammal, not a chance, but it does then mean that we have to realise that tortoises and reptiles in general. That euthanasia is a two-step process. So you need to induce surgical anaesthesia.
And in the past, I would wait until the heart stopped. But if I've induced surgical anaesthesia and all the reflexes are gone. Then I will pass.
OK. And I don't pass in front of the owners. I do explain to owners what I'm going to do and why I have to do it.
But I tell them that's not something that they need to see. They don't need to have that memory. And then I leave the room and bring their pet back afterwards and I've never had to own or had an issue with that.
The easiest way to pass the tortoise is up the nostrils. OK, if you use the needle and I think it was PC that showed that if you use a needle going up the nostril and it reaches the brain and it pass the brain quite nicely. So for the ones that we are going to treat what they, well, learns need to be board because it can take up to a year to heal, which means it can be expensive.
OK. So they have to be prepared for that. We also need them to be aware that the animal might need repeated surgeries because we're looking at living structures.
And we're dealing with punctures versus crushing injuries and the puncture wounds are really obvious, but the crushing injuries can take 3 to 4 days plus before the extent of the shell that damage becomes apparent. And we may very well operate, you know, +34 days later and then find that we have further die back and we have to repeat the surgery. Internal injuries may take weeks to become apparent and that includes bowel perforations.
It's amazing what these animals will tolerate before succumbing to sepsis or peritonitis. So that is something that we need to make owners aware of as well. Reptiles have the anatomical and physiological pain pathways required to feel pain.
And as I previously discussed, many will still eat despite being in quite horrific pain, pain that we would never eat if we were in. And it's often underestimated because it's not shown in human referenced ways. So we assume that because we can do things to them and they tolerate it, that it's not as painful as it would maybe be in other species.
But if we recognise that all vertebrates have the same anatomical and physiological pain pathways, then It makes a little bit easier for us to get our head train because if another species finds it painful if it's a condition or procedure, consider painful in another species, then it's going to be painful and reptiles as well. And does the patient display any abnormal behavioural responses. We know that reptiles have been proven to display and behaviorally lithograms due to pain.
Have we formed a full clinical exam and compared the contralateral sites. So when I'm looking for chronic pain, for example, in reptiles, I'll do a skeletal exam. No, I get that in tortoises, it's limited because of the shell as to what we can do and also the personality of the animal because sometimes they just pull their head and and their limbs and and it doesn't matter what you do.
You're not going to get them out. But at least try. To compare range of movements and palpation.
I stuck a bearded dragon in there to remind me to say that. They cannot metabolise drugs if they're cold, but they can't heal if they're cold either. Every everything in reptiles is to do with with temperature.
So it's important that we keep them at their preferred optimum temperature zone, which is going to vary on species. And again, that's why I would encourage you to use sources like carpenters do a table on temperatures, but also the fever. The state of drug administration is really important because there's been various studies that have shown that .
If we administer drugs subcutaneously or intramuscularly and the cale half of the animal, and they can go through the liver and kidneys first before they reach the rest of the animal because of the renal portal system and the path and portal system. Now what does that mean? That means that if it's a drug that is metabolised by the kidneys or the liver, that it might be subtherapeutic by the time it gets into the animal because it's already been metabolised.
So we need to realise that and always give these injections, these intramuscular injections or the the substains injections and the cranial half of the animal. Doses can be challenging because all the different species respond differently to drugs. And those respond differently depending on their temperature they'll also respond differently as to whether they're eating.
Are not eating because their metabolic rate varies so much. And so there's still a lot of work to be done in doses. I, my current go to for up to date doses as the carpenter's exotic animal formulary because it does all the different species and As time goes on, we might think to ourselves or look back and go, we were crazy to think that that dose was appropriate.
But once we know better, we do better. So there are some, some drugs that have been studied. And can be studied or meloxicams be studied quite a lot and some of the ops have been studied quite a lot in reptiles and certainly my advice has changed over the years depending on what the current knowledge is at the time.
So multimodal analgesia is really important regardless of species because we want to be hitting the pain pathways at different areas because then we're going to get much better overall control of our pain. So Meloxicam do 0.2 to 0.5 megs per kg every 24 to 48 hours.
We know in radio sliders that lasts for 48 hours and tortoises I often give it every 24 hours. And our nonsteroid anti inflammatory is going to give us local pain control from the inflammation point of view. But this is orthopaedic pain.
And I think if I had mushed up and to bones by a dog, I would want good drugs. I would want the good drugs. So yes, by all means, we need to have an anti-inflammatory and board, but we really need to have an opiate.
And board as well. So tramadol has less respiratory depression than morphine, for example, and Depending on what source you look at, that those could be 5 to 15 megs per kg and over 5 to 10 megs per kg there and it's been shown to our quarterly. No tramadol is one of the very few drugs that if I was given an intramuscularly, I would actually choose to give it in the cale half.
And the reason for that is that it's not actually tramadol itself that is the most potent analgesic. It's the metabolite. So I would choose to inject it in the caudal half of the animal because I wanted to go through the lever first to get a much faster onset of the pain relief.
I tend to give it every day. So I give it every 24 hours rather than every 40 hours. You can give methadone and it's reportedly 3 to 5 megs per kg subcutaneously or intramuscularly every 24 hours and I would get that in the cranial half.
Local anaesthesia, lidocaine and use them for splash blocks. I'll go into that more later. And we know that reptiles do have an MD blocker receptor, sorry.
So although there's not been much work done to show that drugs such as ketamine or manadine have any analgesic effect and reptiles is something that we should consider and certainly it's a good argument for having ketamine and our prema or G protocol just to block that receptor. In 2016 demonstrated the 70.9% of tortoises bitten by dogs were infected with recognised potential pathogens.
So I strongly recommend doing a bacteriology culture and sensitivity of these these bite ones and getting our samples before we clean the wounds. And I know that might seem obvious, but it wouldn't be the first time that I've jumped and going hell for leather, trying to irrigate these wounds and then suddenly realised I hadn't taken a bacteriology swab. So please don't take offence if I'm seeing something that sounds really simple.
It's usually because I've made that mistake at some point in my career. Sarah Pella also demonstrated that both gramme positives and gramme negative isolates were yielded. And The, the.
The islets found in the wounds where is it's commonly found in kidney siva, but we have to also recognise that some of the the islates me actually originate from the skin of the tortoise and they've been carried in by the trauma from the teeth or from the environment the tortoise lives in. And with antibiotic guardianship, we need to be careful and not just continuously reaching for petrol. OK.
We've all done it. We've all done it, and reached for the flu to quite alone, especially in the UK where betrol is licenced for use in exotic. So it's not a be always a be deficiency.
And when these culture results from the debate ones were retrospectively reviewed, actually showed that many of devices were susceptible to doxycycline. So as a first line antibiotic, we should be using Doxcyclingetically while we're waiting on our culture and results. And for doxy, we could use 10 megs per kg orderly.
And if you wait for hours or if you've got a long acting injectable version, then you could get a loading dose of 50 megs per kg and muscularly and then 25 megs per kg and muscularly every 72 hours. And again, ensuring that's in the cranial half, you can use the legs or I I quite like using the pictorial muscles, which I will show you later on in the presentation. We know from other studies that ropes are frequently isolated and saliva.
So it's as warranted to add in meronite is all at 20 to 30 makes per kg or every 24 to 48 hours while we're waiting on our culture and sensitivity to combat lose on ropes. So for venna puncture, if we want to take blood sample to check liver and kidney function for these animals. It's the same sites discussed underneath euthanasia.
I'm taking blood here for actually blood culture because this animal was septic. I'm, I'm using some kind of sinus to take blood here. Because I find it quite an easy one to get, especially in shy individuals because I don't need the head to be out.
I can just push the head back in. So I. I can do it in most animals completely conscious.
There have been some studies that have shown, damage to the spinal cord, so you do need to be a little bit careful of that. I think if you go very far cranially and it's just where the skin. Joins the catappa and you put your needle in mid lane there and you're aiming diagonally for the top of the catappa and you ask it as soon as you're through the skin so that as soon as you get into the sinus, you get blood back, then you're much less likely to have a problem.
I suspect when the people that are having problems that have gone in and damaged spinal cord and potentially have been injecting. Are placing their needle much further and to the animal rather than just where the skin meets the catapus. Use hein only.
And the reason I say that is because EDT causes lysis of the red cells and a lot of reptile species. So that make a smear at the same time for your white blood cell count. Prep the skin really well using chlorhexine 0.05% solution or a 10% betadine solution so that we're not introducing bacteria.
And remember that lymph deletion, if you go in and you get clear fluid or a really pale pinky tinge fluid, then. Come back out, get a new needle, a new syringe, try again. OK, because this is the blood from the same animals.
So ones on the left is the actual blood sample and the sample on the right was lymph that had some blood in it, but it had lymph dilution and that is really going to interfere with your results. There's reportedly less risk with lymph deletion using the jugular but I personally find jugulars quite hard to get. Some of my other exotic colleagues are much better than I am at hitting jugulars.
He's a Burmese brain mountain tortoises. There's a tympanic scale and I've highlighted in yellow the track the jugular was taking in this individual. And the safe volume to take is 0.5 to 0.8% of body weight.
But if you're using an in-house roar, for example, the Bench top analyzer I use only 0.3 mL of blood to run me avian stroke reptile profile. So diagnostic imaging it's a really good idea to try to assess the depth of some of these injuries and advanced imaging will give way more detail.
But that's not always going to be possible. It's going to be out with the reach of some owners's finances and you know, I'm a realist. I recognise that and sometimes we have to do the best with the limited resources that we have.
So if when you do radiography, I want your clean coal after a DV because I want to know. Not only, you know, potentially the depth of the injuries. I want to know as this animal carrying eggs, could I have broken eggs and inside there that's going to cause laceration to the uterus because the dog's tooth has gone through the past drawn and crushed an egg shell open.
And ideally when we're doing our lateral or cranial caudal, we'd want to use a horizontal beam for our extra unit or radiograph unit, but we don't live in an ideal world. So sometimes . We have to do things that because our X-ray machine doesn't move, doesn't have a head that moves to allow a horizon to be.
I'm fortunate mine does, but I've worked in places where it doesn't. So I did have to tape animal. This is animal is conscious and I've taped it.
On its site to the X-ray table so that I can get a lateral. And here's another to where I have taped it to a monk so that I can do a quad. OK.
So this is a lateral of a tortoise that been chewed by a dog. You can see the damage to the cranial part of the canopies here and there's some damage here and to the caudals and part of the canopies, but you also see that the cranial aspect of the plaster is missing. But this is lungs and Lungs are lungs are lungs are lungs.
So realistically it doesn't matter what species they're in, they are supposed to be filled with gas and gas should be black on a tree. So you can see that this animal has severe damage in its lungs because that's what it should look like. OK.
Here's a cranial cale of the same individual. This is a different animal, a cranial cale and you can see there's damaged lungs, but you can actually see that we've got a fracture running along this the catapus and it's gone right through to the board. It's not just that this, this kits that are fractured.
And this is what it should look like, the black areas. And thank you to my work wife, Dr. Chrissy Green for lending me this picture that's from her acupuncture course.
We also need to be aware that tortoises exhibit and the exhibit this thing called spinal walking. So any fracture that crosses the mid lane has a good chance of saving the spinal cord and the spinal cord here. Thank you again to Chrissy Green for lend me this photograph or sorry radiograph where she's drawn on it.
So the pale blue dotted lines are where the spinal cord is running. And spinal walking so tortoises and they can have a severed spinal cord and still walk, which is a real swing when you're trying to get your head right into whether this animal has an intact cord because they are still walking and it's the result of reflexes that travel from the foot to the spinal cord back. But the walk will be completely different.
So they'll often be a little bit more uncoordinated. The legs will be flopping more than striding, and their legs, their hind legs, they wouldn't be up on the soles of their hind feet. So, but that being said, a lot of tortoises that I get in that have been injured, they're not wanting to walk.
They're just wanting to hide. It might be because they're cold and might be because they're in shock. It might be because they're too sore.
It can sometimes take time for us to know whether they're they're going to do well or not. But the other significance of this is that if we are seeing spinal walking and we have a mid lane fracture and due to a crushing injury or a puncture, we need to remember that the nerve going to the internal organs function is likely to be compromised. So we really need to be monitoring the bladder and bowel function in this animal.
Because if it is if we are assess feeding it or it's still eating, but it's not passing faeces and it's not urinating, then that is a concern. OK. A lot of these animals will urinate on you through stress.
When you're handling them when you're doing your dressing changes, they will actively choose to pass faeces and urine on you just as a stress response. So as something that you will see that you can use to help monitor the bladder and bowel function. So diagnostic, what other diagnostic imaging, well, you can ultrasound and you can do that and the prefemoral fossa.
What are you looking for? Well, if this animal like this female tortoise and postmorteming on the left hand side, which has got follicles on the ovary. So we need to know if that this animal is especially if it's a female is reproductively active because it could potentially have a hold of the follicles are in there and they could have been damaged, which means we're going to get egg yolk peritonitis.
OK. And it's just a beautiful bacterial and culture soup, which is going to put even more pressure on our tortoises. So we need to be aware of this and know if it's a possibility.
Just as a little signal, if you've ever ultrasoed a tortoise terrain looking for follicles, don't look for them, expectancy on the ultra. Saying a big black circle like we would with an ovarian and a guinea pig, for example, because these follicles are yolks, which means you are full of fat and protein, which means they're soft tissue density on the. So what you tend to see is something that looks like a circle and it's like a bunch of grapes.
I caught me out as a younger vet. It took me a little bit of time to figure out what I was seeing and I like people to learn from my mistakes. So we need to address the hydration status or assess or the hydration status and it can be really difficult to address and sorry and assess and tortoises and it's really only obvious once it's quite severely dehydrated.
Here's one of my clients tortoises is nice and easy with a lovely bright pink tongue is flashy and the possession is beautiful and nice, nice and glossy. And but if I'm seeing an individual like this where the eye is sunken. I would say that the best example in the bottom left that's come up as less dehydrated than the second example and this individual here is quite severely dehydrated, but that could also be a sign of hexia because we're looking for the eye possession for sunken eyes.
But assume that any injured tortoise is going to be at least mildly to moderately dehydrated. Maintenance and reptiles is lower than in mammals. It's 10 to 30 mL per kilogramme per day.
We want to ensure that we do not exceed 40 miles per kilogramme per day to avoid fluid overload. Acute loss, the deficits can be replaced in 12 to 36 hours, chronic losses 4 to 8 to 96 hours. Oral fluids are suitable for mild dehydration only.
OK, and the rest you can be given as bolus IV we've got perfusion deficits, you can. And the literature there are things you can put atrocious needles and the bridging skis, but that's contraindicated if we have osteomyelitis, metabolic bone disease or sepsis and it's also incredibly painful. You shouldn't give in and and trailomic fluids because there's an increased risk of organ puncture.
We shouldn't be given subcutaneous fluids that's really painful. But if the gastrointestinal tract is functioning, use it. So here's, I wouldn't pass it like we are with this individual, but you can just drip water on their head and the loft and just drink it.
OK. Or you can, this is a pad crop tube I'm using with a yellow bellied slider to feed it, but you can do that with fluids. So you can give it orderly.
So we've given they've given them fluids because remember if especially if animals in shock, if it's in shock, then that's more likely to kill animal than the broken bone as the broken bone becomes secondary, but we've stabilised the animal. And they were pressing on to cleaning the wounds, . And how we clean the winds is going to very slightly where it's superficial versus sloic penetration.
So this is an animal here where you can see that the caudal part of the. Caus has been no away by a dog. Superficial, we're going to splash block with some local anaesthesia and then we're going to flush with warm de heavy or poverty be same individual this this animal had soil and this because the order I put it back in the tortoise table.
But if we've got lowic penetrations, penetration, we're still going to do our splash blocks. We do it if you can see bubbles coming out of any of these holes, that means the lungs have been penetrated. OK.
So I will not be doing, I wouldn't be pouring liquid in there because you'll drain potentially drain the animal. But if there's no bubbles coming out of there, then you know, I might see a membrane moving, but as long as I can't see any bubbles, then I am going to use their warm sterile ceiling to flush these wins copiously. I'm going to tell that to the side so that while I'm flushing the ceiling is coming straight back out again.
I will use sterile toothbrushes. I just actually go to the supermarket. I buy box standard toothbrushes and I put them to the cle.
It reduces the costs. And if it was just the cost to me, it reduces the cost of my owners and I use them to clean the wounds, not where the sums open, but for these superficial ones, it's really good after the local anaesthetic on just to get in all the nooks and crannies to get the dirt. And I'll use a 0.05% chlorhexine or 10% bet or poverty, but not where there's an open I'll just use warm sterile saline in that case.
We should use warm water when we're making up our dilute and chlorhexine or be. And then we're going to dry the area with a sterile paper towel because we're going to put some dressings on. And my preferred dressing is granny flakes.
I love granny flakes. I use tonnes of it and it's a hydroco dressing. So if you not come across it, think of it as a solid version of venture site.
She's really good at keeping the wounds moist and promoting healing of granulation formation of granulation tissue and keeping a further contamination out. It also helps with some debridement. I'll mould it into any deficits and I'll hold it on because it takes a minute or two to it here and it won't adhere to wet tissue initially.
And then I'll use my port or due to pours and cocky or elasticlast just round the edges of it and I will cover it with fat wrap. I quite like that wrap with like tortoises, not tortoises or chickens or tractors or things on owners seem to quite like it as well. And initially I'm going to be redressing every 2 days.
And I'm going to warn the owners that when the granny flakes is removed, it will be stuck to the win. So when I first take it off, it can often look easy or gloppy and that can make owners panic. But once you've put some local anaesthetic on and scrubbed and flush the area, it usually look so much better and warn the owners that we want it to be bleeding because if it's oozing blood, that means we've got a good healthy blood supply and that's normal for us, but it's not normal for owners.
So it can really freak corners. I just be aware of the owners wouldn't have the same frame of reference as we do. And then I redress it exactly the same way.
And once you get die back once it's become a pattern and it can take anywhere from days to weeks, some fragments if we've got had crushing injuries. I've still got soft tissue attachment and a good blood supply. It can actually take weeks for them to have die back, which is why they may need more than one operation.
But once we've got die back a patent, as you can see in this individual that's dead born, and we need to surgically to debate that. OK, and warn the winners the much bigger postment because that can freak some people out. So how do we anaesthetize them?
Well, there's various options and you get 10 exotic vets in a room. You're probably going to get a defin answers as to what they're going to do. But we need to ensure that we keep the theatre warm as hot as you can tolerate it because the They need the heat to metabolise the drugs, keep them asleep.
It's it's as simple as that and keep them alive. I'm going are we going to get a premed? What are we going to get the premed.
And again, I'm going to give everything in the cranial half of the animal unless it's the Unless it's tramadol. So pre-med you could use dexametine or ketamine and muscularly. There's been some lovely studies that have shown that actually meatomidine, sorry, provides really nice analgesia in these animals.
Or you could use meatomidine. So metamidine is a mic mixture so it does have some dex metaine in it. So in theory it should still provide some analgesic effect.
And then you've got your ketamine that could block your NMDA receptors, but we just don't know for how long and for how efficiently that happens in reptiles. But potentially with the NMDA receptor blocker with your ketamine and with your metamidine or your dex meatomidine, we've already got some analgesia on board because we know the IV profile doesn't have to fight any analgesia. So you could give IV propofol.
You can use the the tail veins for it because intravenous access doesn't go through the hepatic portal system or the renal system actually goes into the abdominal vein first. So that's fine. Or you can use the sub kind of sinus, but again, just where the skin meets plash drawn because there have been cases in the literature of people injecting .
Into the spinal cord. I've, I have administered IV propofol for years and the subcardiac sinus and never had an issue, thankfully. And as a site that I find quite easy, but I believe in being transparent.
Or if you don't want to get a vein for whatever reason, you can use LA. I really actually quite like it, especially in the bigger species where it's hard to get into the veins. I'll use Alfa I intramuscularly 10 to 20 makes per kg.
We need to lubricate the cornea as well, and we should be intubating these animals. The glottis is at the base of the tongue, the tongue is friable. So don't pull the tongue actually put your finger and the guar regions.
So the high up through region just by the point of the jaw and push up. She can see the glotti is here and a reptiles. Go is shot unless they're actively breathing and you can't depending on the size of the animal, you can be using anything from a sex gauge catheter IV caster without this style or if it's when you're bigger species you'd be using can eat tube to gently push open the glot test.
OK, but here's an animal with the glut is open and you can see I'm putting pressure on the throat region. But bear in mind that and tortoises and terrapins the trachea bifurcates really high up in the neck, really high up in the neck. So be very careful with your length of chip.
Otherwise you're actually only intubating one lung. So maintenance, I tend to use eyes of floating. I'm not a huge fan of floating and reptiles.
Douglas Mader and his textbook had said that some reptiles can be 8% of see floating for 24 hours and still never achieve a surgical complain of general anaesthesia. And certainly that has been my experience with some reptiles. And so I tend to use I use flu in maintenance will be 2.5%.
But you need to lower that over time. It does take quite a long time for them to reach an equilibrium. So I will start to load it depending on who the animal is, what his reflexes are, if we've got jaw tension to have a blank.
Do I have a pedal reflex? And then ideal world, you will have a ventilator, but it is completely acceptable to just manually back them and use fingertip pressure. Basically, you want to be putting enough pressure on that you see the front limbs starting to move slightly because these animals do not have a diaphragm and when they a week they breathe by moving the front, their heads and their front legs.
So if you're putting just enough pressure on to see the skin between the front leg and the neck start to move slightly and the front leg to move slightly, then you know, you're inflating the lungs. But if you do, if you're lucky enough that you do have a ventilator, that's the pressures to use and you get between 1 and 5 breaths a minute. Really strongly advise you to place esophagotomy tube.
It gives you an ease of medicating for months, but also allows you to assess feet and they're really, really easy to place honestly so easy to place. The ideal diameter diameters 30% to 50% theophageal diameter, measure the volume, the chip holds so that you know the exact volume used to flush the chip and premeasure the catheter. So we want to do the cranial rim of the lash on here the junction between the pictorial and the abdominal skis.
So that's not like here. OK, because we know that our stomach is going to be right about this region. And I prefer to make the incision in the left hand side of the neck because the right jugular tends to be larger than the left jugular.
We put curve team starts into the mouth. We tend so you can see that I've got them tend to here. I'm covering it with my index finger and then I wiggle it.
The reason I'm wiggling it back and forth is it allows the jugular and the rot artery to follow me just in case I've caught them on it. And then I use a scalpel blades to size over the heats the heat through grab my tube. I've already premarked or if you've got a tube that's numbers on, I know which number is.
And then I pull out the mice. OK. And then once I've got it to the required length, I turn it around to redirected down the throat and the stomach.
And then I use a Chinese finger trap suture to secure it. OK. I'm going, and then I curve the tube over the head onto the consulate say the catapist and that helps prevent the loop that that because they're stubborn.
They are really stubborn. And if you if you leave a loop, they can actually put their like through it and rap. OK, life isn't perfect.
So sometimes I don't get a really good lip on it. Maybe I pick to stuff a chip. So I just put some micro report on the scales of the leg on the same site.
Because that reduces the risk of them using the scales to put out. OK. So once this animal is awake, we're going to make sure it's hydration and warm before feeding it and they'll use either Emirate or critical care ox and stomach passive of tortoises and is estimated that 2 to 5% of the body weight.
OK. So when we're doing the lament, we can use our lidocaine and pica, the doses that we currently use are from a million literature. So the light the can be 2 to 4 megs per kg maximum and the pivotine 1 to 2 makes per kg and I use both because lidocaines fast on set but short acting where your perfect is longer takes longer on set, it's also longer acting.
And we sterile toothbrushes, warmed and delusions of hexine are best to scrub the wounds, not inside the ceiling. OK, because if we get sloic entry, then we want to be using sing to copiously flush these wounds I run yours really good for nibbling back those bits of bones. And granny flanks.
OK. So we want to debate it back to we've got a budgets. That seems simple, but a lot of its panic and we'll say to me, but how I know I've got it back to healthy tissue.
You're going to have, it's going to use blood. OK. So you'll know.
And you just keep going until you've got that. So we've got this tortoise here. You can see that we've got a lot of crushing injuries as well as as a puncture injuries and that's how big the win was once it finished to breathing it.
Once we're wanting them to wake up again, we need to keep them warm. If we've given alpha2s, we want to give on to Palmaso to reverse at the same volume. OK.
Yes, that will probably reverse analgesic effect just like it does mammals, but it will mean that they recover faster. We use an ambu bag again same amount pressure and because the stimulus to breathe is falling on two levels and reptiles in theory, if you put them keep them 100% oxygen, then you can keep them not necessarily asleep, but you're removing the impetus to breathe. And you want to keep them intubated until they're wanting to withdraw their head and they're breathing on their own because they'll breathe on their own.
First of all, I should have said that a lot of tortoises when they're under surgical plane of anaesthesia will stop breathing on the room, which is why you need to breathe for them. But sometimes if they start breathing on their own, but they're not at the stage they're moving, you extubate them and then they decide to stop breathing again. And I've had to reinate a few of them.
So we don't extubate until they're moving. And you can actually get adrenaline and muscularly to increase the speed of recovery and that's to do with shunting of blood in the heart. Remember that these animals healed by me is ossification.
So it's not the edges of the wind that they heal from and they'll form a membrane first of all, and that will gradually over time harden. And that animal. I think it took 5.5 months to heal that win, which I was really pleased with it worked really well.
We redressed with granny flakes to 3 times a week while there's still a lot of discharge. And then once I'm getting less or less, then once weekly, and I stopped when the hard layers formed and we can stop that at that point. Also, I warn owners that this is going to fall off keep it might be a year later.
Cause they can panic. So if we get some stable fractures, we can use local anaesthetic and cleaning, surgical tape and dressings when cleaned may be enough for these fractures. If we've got a depressed fracture like here, then we can underneath a deep sedation stroke GA we can actually use a scalpel blade, which is what I did in this animal to leave out.
Or you can glue clothing hooks onto depressed fractures, which I'll discuss under unstable fractures and dress until they're healed. So that when I did manage with bandages, and this is it going through its stages of healing. And that animal took 6 months to heal.
So if you've got unstable fractures options, I haven't found many of these with dog by injuries. It tends more to be strummers or lawn mowers. But this is a really nice, cheap and cheerful way to do it because it causes absolutely no more trauma to the shell and you can go and buy these clothing hooks at various outlet shops.
They're cheap. You just place them half a centimetre perpendicular fracture. You want to rough in the keratin at the point of placement to get the glue somewhere more to stick to.
And use super glue on fully covered the base of the hook and make sure you don't get it and the fracture, the glue and the fracture and you leave the glue set for a minimum of 12 hours. And then you use sterile stainless steel wire 34 gauge minimum to a figure of on. And it's really nice because it allows stabilisation of the fractures, but you can also visualise the fracture site.
And it's easy access if you've got fragments that have become devitalized or infected and the healing fractures reportedly as little as 6 weeks, but I found it can take a lot longer than that. And they're dead easy to remove as well. And you actually just need to grab them with a pair of pliers and twist when you've taken the wires off.
You can for complete less you can use sterile screws, but it does cause more trauma to the shell and needs to be placed under general anaesthetic. You again. Centimetre perpendicular to the fracture.
I need to make sure that you've not screwed fully through the shell, because you could be causing trauma with the sharp end of the screw to internal organs. And you want to ensure you don't screw it down tight to the shell because you need some of the screw left to be proud to hold the wire. You've got your animal eating again and it's not eating oral medication and so how do you remove the esophagostomy tube?
Well, just get a stitch cutter, cut this, cut the Chinese finger trap suture and then pull the chip out. And you can do it conscious, the skin and oesophagus he by secondary intention and hopefully that means that you will all feel a lot more confident at treating tortoise, dog bite injuries. And I'm thank you so much for listening.
Thank you so much for the webinar as well for inviting me to give this presentation. As always, I'm happy to answer any questions. I do have ADHD.
So if I don't get back to you within a week, please remind me. It's not that I don't care. It's not that I'm not interested.
It literally is just that sometimes if you fall off my first page of 50 emails, I forget to go back and check.
