-
Topics in Medicine and SurgeryTopics in Medicine and Surgery
Chelonian Emergency and Critical CareTe
at ah seat anandThiticary tandrt, hd crvari
emergency clinician for marine turtles, tortoises, freshwater
aquatic turtles, and terra-pins. There are significant differences
in the disease problems encountered by captive
T he ortortoiprisedquarter of whans reside inspecies
occuhabitats, whitropical envinia, are ectoheat and
betemperatureature zone (lows reptilesPBT. The POTZ varies among
the different speciesof chelonians.
Chelonians have long lifespans, often surpassing hu-mans, and
are slow to reach reproductive maturity. Forexample, the loggerhead
sea turtle reaches sexual ma-tur 3
sex
humanradationffic suchmedic-animalscriticallymic
(to-monthsehydra-
nter, 182Camellia Road, Midway, GA 31320.
Address correspondence to: Terry M. Norton, DVM, Dip.ACZM, St.
Catherines Island, Wildlife Survival Center, 182Camellia Road,
Midway, GA 31320. E-mail: [email protected]
2005 Elsevier Inc. All rights reserved.
106 Seminars in Avian and Exotic Pet Medicine, Vol 14, No 2
(April), 2005: pp 106130ity at approximately 25 to 35 years of age.
The slowual maturity rates of chelonians tend to make them
1055-937X/05/1402-$30.00doi:10.1053/j.saep.2005.04.005and
free-ranging specimens. This review will be useful for the
veterinarian working inprivate practice, zoological or aquarium
medicine, and wildlife rehabilitation. Copy-right 2005 Elsevier
Inc. All rights reserved.
Key words: Chelonian; critical care; emergency; terrapin;
tortoise; turtle
der Chelonia1 or Testudines2 includesses, turtles, and terrapins
and is com- of approximately 270 species,1 oneich reside in North
America.2 Cheloni-a wide range of ecosystems. Aquatic
r in marine, brackish, and freshwaterle terrestrial species
reside in desert toronments. All reptiles, including Chelo-thermic
and depend on environmentalhavior to attain their preferred
body(PBT). The preferred optimal temper-POTZ) is a temperature
range that al-to thermoregulate to maintain their
more susceptible than other vertebrates topressure. These
pressures include habitat degand destruction, collection for
commercial traas the pet trade, and exploitation for food andinal
purposes. Chelonians are extremely hardyand can have normal
activity despite beinganemic (hematocrit 5%) and hypoproteinetal
protein 1 g/dL). They can also survivewithout food and tolerate
extreme levels of dtion.
From the St. Catherines Island, Wildlife Survival Cerry M.
Norton, DVM, Dip. ACZM
Abstract
There are numerous chelonian species thChelonians are long lived
and slow to reacvulnerable to human impacts on their
habitphysiological features, such as the shellmedically challenging
for the veterinarian.medical evaluation and stabilization of
crpresented to the emergency clinician. Histotion, recommended
diagnostic testing, fluidresuscitation principles, nutritional
suppoagents recommended for the emergency anDifferential diagnoses
are presented for arise from a diverse array of habitats.xual
maturity, making them extremelyd populations. Unusual anatomic
andbeing ectothermic, make cheloniansis article presents
information on thelly ill and injured chelonian patientsaking,
performing a physical examina-transfusion therapy,
cardiopulmonaryospital environment, and therapeuticitical care of
chelonians are reviewed.ety of conditions encountered by the
-
Triage Principles In CheloniansPr
IdmeinidetubeThanthtimmaaping
HThthahuoress
1
2
3
4
5
6
7
ity and quantity, clinical signs and behavior,
8
9
10
DThexmephizeshdiatielikwedishouaanshanchexintassphiouevqumobe
peAnhaeranbo(ehyratswothfliate
Chelonian Emergency and Critical Care 107esented For
Emergency
eally, the emergency chelonian patient should bedically
evaluated and then stabilized. However,tial emergency treatment may
need to take prece-nce over a diagnostic work-up in a critically
illrtle. When possible, a minimum database shouldestablished before
starting emergency therapy.e keys to success in medically managing
cheloni-s are patience, minimizing the stress throughoute course of
treatment, minimizing the handlinge by being prepared, treating
dehydration andintaining an adequate hydration status,
providingpropriate nutritional support, and lastly, maintain-the
turtle at its POTZ.
istorye medical history is an important step in assessinge
critically ill chelonian.4,5 Captive specimens havehigh incidence
of medical problems related tosbandry issues. A questionnaire given
to the clientcaretaker can save time and request the
followingential information:4
. Reference data: date, client and animal iden-tification,
common and scientific names, cap-tive or free-ranging specimen,
presumed sexand age, duration of ownership, details of pre-vious
ownership, time in captivity, reason forpresentation.
. Information on the clients animal collection:animals in direct
and indirect contact with thepresenting turtle.
. Free-ranging specimens: GPS coordinates, spe-cific location of
where the turtle was found,time and date found, housing and
transportconditions since that time, details on any treat-ment
provided.
. Housing: indoors, outdoors, both; enclosuredescription.
. Environment: temperature range, heat source,humidity,
lighting, photoperiod, recent changes,filtration and water quality
in aquatic specimens.
. Nutrition: describe diet in detail, seasonal vari-ation in
diet, vitamin or mineral supplementa-tion, food preparation and
storage, how is wa-ter provided and frequency of water changes.
. Observations: description of activity level, ap-petite, fecal
and urate/urine output and qual-and duration of presenting
signs.
. Reproductive data: breeding and egg-layingdetails.
. Disease control: methods of disease control,quarantine program
details, disinfectants used,information on all humans in contact
with theturtle, historical health problems in the collec-tion,
recent acquisitions.
. Hibernation: details of management.
iagnostic Testinge initial diagnostic workup may include a
physicalamination, including body weight and morpho-tric
measurements, clinical pathology, radiogra-y, fecal examination,
and possibly other special-d diagnostics. The emergency chelonian
patientould be maintained within its POTZ during thegnostic
work-up. When working with these pa-nts, the veterinarian should
also minimize theelihood of transmitting contagious diseases
byaring gloves, hand-washing between patients, andinfecting
equipment during the examination andspitalization. Chelonians are
challenging to eval-te medically and treat due to their highly
evolvedd effective structural and behavioral defenses. Theell is an
anatomical feature unique to chelonians,d the primary reason they
are such a medicalallenge. The box turtle (Terrapene spp.) is the
mosttreme example of this adaptation and may retreato its hinged
shell so that it is difficult to safelyess without sedation.
Depending on the patientsysical condition and the species of
chelonian, var-s levels of restraint will be needed for the
initial
aluation. A detailed physical examination may re-ire sedation or
anesthesia; however, chemical im-bilization should be delayed until
the patient hasen stabilized.A systematic approach should be
followed whenrforming a physical examination on a
chelonian.observational examination of the turtle before
ndling can provide important information. Gen-al body condition,
including overall musculatured fat, degree of alertness and
strength, head anddy symmetry, aural swellings, ocular
abnormalitiesg, discharge, squinting, and sunken eyes from
de-dration), nasal discharge, asymmetric nares, respi-ory
difficulty, open mouth breathing, cervicalelling, carapacial
abnormalities (eg, fractures ander injuries or deformities),
lameness or abnormal
pper use, abnormal skin (eg, dry, flaky or ulcer-d), an
inability to dive or floating asymmetrically
-
are all abnormalities that can be observed withoutha
diadatuitaordemiingessBothtre
oftumoitageBodeatwerhscoprbefro
Thscupliodrhtraizecacusloscean
ththmeexinfpaityoc
sh
difficult for the veterinarian and stressful for
thechunriogloPametiopradviaopporethshstr
shanplashthdiclecmLreiumchin
chbaLymoicablothbuthuspasp
tochmathThforanhoAdob
108 Terry M. Nortonndling the animal.A physical examination form
that includes a turtlegram is recommended for recording
biologicalta and external abnormalities such as shell frac-res,
missing flippers or limbs, and lacerations. Dig-l images can be
used to document specific lesionsinjuries for long-term case
monitoring. The gen-r,6,7 morphometrics, and age should be
deter-ned. A rough age estimate may be made by count-scute growth
rings; however, these are not nec-
arily a sensitive method for age determination.dy weight should
be recorded before therapy, anden measured serially during
treatment. Weightnds can be a good indicator of hydration
status.Deep cloacal temperature may be representativethe chelonians
recent environmental tempera-re, and is an important parameter to
obtain andnitor in hypo- and hyperthermic patients. A dig-l,
distant laser, thermal monitoring device (Rayn-r St, Raytek
Corporation, 1201 Shaffer Road, P.O.x 1820, Santa Cruz, CA USA) can
be used totect surface body temperature, and when directedthe
prefemoral or prescapular areas correlatesll with core body
temperature.4 Heart rate andythm can be assessed with an esophageal
stetho-pe, a pulse oximeter cloacal probe, or a dopplerobe placed
in the region of the thoracic inlettween the distal cervical region
and the proximalnt leg.8-10
Evaluate the limbs for swollen joints and fractures.e plastron
and carapace should be evaluated forte quality, abnormal
keratinization, hardness andability, pyramiding, fractures,
ulceration, mal-or, and external parasites or epibionts. Hemor-age
within the scute keratin may be indicative ofuma if localized or
septicemia if more general-d. Shell fissures usually occur at the
plastron/rapace junction and may indicate septicemia, vas-litis, or
hypoproteinemia.11 Examine the skin forughing, abnormal shedding,
swellings, edema, ab-sses, ulceration, exudate, malodor, and
epibiotad external parasites.Digital palpation of the caudal
coelomic cavityrough the inguinal fossa can be used to confirme
presence of eggs, cystic calculi, organ enlarge-nt, masses, or
fluid. The cloacal region should beamined for swelling, trauma,
abnormal discharge,ection, and myiasis. In larger chelonians,
digitallpation of the cloaca can be used to assess gravid-, colonic
and cloacal tone, cystic calculi or spacecupying lesions.4
Exteriorizing the head of the chelonian from theell and
performing an oral examination can beelonian. This examination may
need to be delayedtil the turtle is stabilized.4 Once the head is
exte-rized, inspect the oral cavity including the tongue,ttis,
choana, and outlets of the eustachian tubes.rticular attention
should be given to mucousmbrane color, the quantity of mucus,
petechia-n, plaques, ulceration and caseous material. Beepared to
obtain any diagnostic specimens andminister any medications or
nutritional supporta stomach tube if indicated. Perform a
completehthalmic examination of the cornea, anterior andsterior
chambers, and menace and papillary visualflexes. A periocular
examination and evaluation ofe beak, mandible, tympanic membranes
and naresould also be performed while the head is re-ained.An
emergency chelonian minimum databaseould consist of a hematocrit,
total solids, glucose,d subsequently, a complete blood count andsma
biochemical panel. Bacterial blood culturesould be collected before
initiating antimicrobialerapy. While the size and patient condition
willtate the amount of blood that can be safely col-ted, the author
generally recommends 0.5 to 0.8/100 g body weight for healthy
patients and a
duced sample volume for diseased patients. Lith-or sodium
heparin are the anticoagulants of
oice, because EDTA can cause red blood cell
lysischelonians.12
A wide range of venipucture sites can be used inelonians,4,13-17
and the choice of site should besed on the species, size and
condition of patient.mph contamination of the blood sample is a
com-n problem in chelonians and will alter many clin-l pathology
parameters.13,16,18-20 Collection ofod from the jugular vein is
preferred based one low incidence of lymph dilution from this
site,13
t may be stressful and not always feasible due toe difficulties
in accessing the vein. Alternative sitesed by the author include
the brachial and subcara-cial veins in tortoises, the dorsal tail
vein in aquaticecies, and the cervical sinus in sea
turtles.Radiography is an important diagnostic tool usedassess
chelonian emergencies. Useful reviews ofelonian radiography are
available.21-26 Radiopaqueterials such as barnacles should be
removed frome shell before performing a radiographic study.ree
radiographic views should be routinely per-med in chelonians
presented for emergency care:terior-posterior and lateral
projections using arizontal x-ray beam and a dorsoventral
view.22,23
ditional views such as lateral, dorsoventral andlique, may be
needed for specific problems such
-
as fractures of the limbs or skull. An
anterior-poste-riochluntraint
DFlOnshemofttioinctenrodifnachfoutioduvocadrandetiothcelonineate
FlSeistdittatingabhyinbepletious(odesorinon
critical to correct hydration status of the ill chelo-nia
acSewhtuchmaancipmacitag
camisivglohatoiheucadratthfroorter
Ro
Inanfluemtenchbemiferniaofcataicuroartingcafemprdisme
Chelonian Emergency and Critical Care 109r horizontal beam
radiograph should be taken inelonians with fractures of the
carapace to assessg involvement.26 Digestive tract radiographic
con-st procedures are often necessary to documentestinal
obstruction and foreign bodies.22
etermining Hydration Status anduid Therapycompletion of the
initial evaluation, the patient
ould be stabilized. Most chelonians presented forergency care
are dehydrated, thus rehydration isen the first step in treatment.
Physical examina-n findings indicative of dehydration in
chelonianslude sunken eyes, changes in skin turgor, skinting, loss
of skin suppleness, dry mouth withpey, thick oral secretions,
depression, a slow andficult to find heart beat, and minimal to no
uri-tion. Venipuncture and tube feeding are moreallenging in the
dehydrated patient.1 Weight lossnd over 1 to 14 days is likely
caused by dehydra-n, thus serial body weights should be
performedring hospitalization.1 Elevation of the packed celllume
(PCV) and total solids or total protein (TP)n be helpful in
determining the extent of dehy-ation. However, ill chelonians are
often anemicd hypoproteinemic, which may mask the extent
ofhydration. Serial PCV and plasma TP determina-ns help assess the
status of the patient and targete most appropriate therapeutic
regimen. Hypogly-mia or hyperglycemia is often present in sick
che-ians. Blood glucose determination is easy, quick,xpensive and
essential in choosing the appropri-fluid therapy in chelonians.
uid Typeslecting the route, rate and type of fluids to admin-er
depends on the species of chelonian and con-ion of the patient.
Fluid choice is frequently dic-ed by clinician preference, the
patients present-problem, and clinical pathology and acid-base
normalities. Many ill tortoises have isotonic orpotonic
dehydration.27 Lactic acidosis is commonstressed chelonians. Most
debilitated cheloniansnefit from rehydration therapy and glucose
sup-mentation. Mammalian crystalloid fluid prepara-ns are suitable
for chelonians. Fluids commonlyed in chelonians include reptile
ringers solutionne part Lactated Ringers Solution 2 parts
2.5%xtrose and 0.45% sodium chloride),27-29 Norma-l-R1, and
lactated ringers solution. Use of lactatedgers solution is
controversial in chelonians based the common finding of lactic
acidosis.27,28 It isn before starting oral nutritional
support.Whole blood transfusions are indicated in cases ofute
hemorrhage and life-threatening anemia.30
a turtles with a PCV 5% may benefit from aole blood transfusion
from a healthy captive seartle donor (Manire, C, pers comm., 2005).
Thoseelonia with a PCV 5% can often be successfullynaged with fluid
therapy, iron supplementation,d other supportive measures. The
donor and re-ient should be the same species, because crosstching
has not been perfected in reptiles. Acid-rate-dextrose solutions
are the preferred antico-ulants for storing blood for
transfusions.Hetastarch, diluted 1:2 or 1:3 with 0.9% saline,n be
given at a rate of 0.1 mL/kg every 10 to 15nutes in chelonians with
severe shock from mas-e blood loss.1 A purified bovine hemoglobin
(Oxy-bin, Biopure Corp., Cambridge MA 02141) hasd limited clinical
use in sea turtles,29 desert tor-ses,30 and a terrapin31 without
adverse affects. Inalthy desert tortoises (Gopherus agassizi) this
prod-t was administered at dose of 20 mL/kg IV withoutverse
effect.30 A Hispaniolan slider, Trachemys deco-a, was resuscitated
after near exsanguinations withe use of Oxyglobin and a single
blood transfusionm another individual of the same species.
Discol-ed mucous membranes are normally observed af- using this
product.30
ute of Fluid Therapy
travascular. In severely compromised cheloni-s, intravenous (IV)
or intraosseous (IO) routes ofid administration allow for rapid
rehydration andergency therapy. However, placement and main-ance of
catheters in these sites can be technicallyallenging, especially in
aquatic species, and should reserved for patients that are
unconscious ornimally responsive.1 The jugular vein is the pre-red
site for IV catheter placement in most chelo-ns. A small skin
incision allows direct visualizationthe vessel. After catheter
placement, secure thetheter to the skin with tape and or
suture.1,32 Main-ning patency of the jugular catheter may be
diffi-lt, especially in active turtles.33 Intravenous or IOutes are
necessary for administration of whole andificial blood, colloidal
fluids, and fluids contain- greater than 5% dextrose.1,30,34-36
Intraosseoustheters may be placed in the distal humerus, distalur
or plastron-carapacial bridge.33,37 An appro-
iately sized spinal needle can be inserted into thetal one
fourth of the medial aspect of the hu-rus at an angle of
approximately 30 to 45 from
-
parallel. The needle should be inserted as distally
aspothcafosprarebomama
somichAdvere
inth(2adThspthhupo
formaingustecloimaDipoingfolmasar
easkifrothanthitalut
retesdr
dehydrated and weak turtles tend to
regurgitateorterateinglarflutomumboaccooflecaftshbothnegugrdibjawpomoponere
shjusassanfrerewidrmimaelemi
Vofludrprbomekgsppahyin to
110 Terry M. Nortonssible without entering the joint capsule.
Confirme spinal needle position radiographically. Thetheterized
limb should then be reduced into thesae and secured with tape to
the carapace.33 Theimary disadvantages associated with IO
cathetersthat the fluid flow rate is limited due to the small
ne marrow space, fluid and drug administrationy be painful, and
the metal of the spinal needley fatigue and break.38
Bolus IV fluid therapy can be used to stabilizeme patients
before pursuing other routes of ad-nistration. The subcarapacial
vein is used for mostelonians and the cervical sinus for sea
turtles.vantages to the bolus IV method include easyssel
accessibility, minimal stress to the patient, andpeated vascular
access.The epicoelomic fluid administration site is
usefulchelonians that are completely retracted into
eir shell and difficult to coerce out. McArthur004) describes
this as the preferred site for fluidministration to critically
dehydrated chelonians.27
e needle should be inserted into the potentialace located dorsal
to the plastron and ventral toe pectoral muscles, coelom, and the
scapulo-meral joint, and directed caudally toward the op-site hind
leg.32
The intracoelomic (IC) route is commonly usedmaintenance fluid
therapy in sea turtles. Fluidsy be injected into the coelomic
cavity through theuinal fossa. An IC catheter has been described
fore in sea turtles for up to 5 days.27,39 This route ishnically
easy and allows administration of crystal-d fluids with up to 5%
dextrose, however, fluidsy not be absorbed rapidly when given by
this route.sadvantages of coelomic administration include
thetential of compromising the lung space or perforat- the lungs,
the urinary bladder,32 or an ovarianlicle in mature females.
Hypoproteinemic patientsy have fluid in the coelomic cavity
(ascites/ana-ca), which will further complicate
absorption.Subcutaneous fluid administration is technicallysy.
Fluids can be given into any accessible fold ofn, but are typically
placed into the inguinal fossa,nt limb fossa, or ventral neck fold.
Administeringe fluids in multiple sites may improve absorptiond
rehydrate the chelonian faster. Disadvantages tois route include
poor absorption in severely debil-ted chelonians and that only 2.5%
dextrose so-ions can be administered.The oral route of fluid
administration should beserved for use in patients with functional
gastroin-tinal tracts that are mildly to moderately dehy-ated and
for maintenance fluid therapy. Severelyally administered fluids.
Fluids can be adminis-ed directly into the stomach using an
appropri-ly sized, well-lubricated red rubber or metal feed-tube.
An equine stomach tube may be used for
ge chelonians. For long-term oral medication,id therapy and
nutritional support, an esophagos-y tube should be considered. The
stomach vol-e in most chelonian patients is about 2% of thedy
weight or 20 mL/kg.1,32 Anatomically, the stom-h is located in the
anterior one third to mid-elomic cavity. The distance to the
anterior portionthe stomach should be marked on the tube se-ted for
feeding. In species prone to regurgitateer tube feeding, such as
sea turtles, the patientould be placed at a slight incline on a
paddedard to avoid regurgitation and to assist in passinge feeding
tube into the stomach. The head andck should be extended to
straighten the esopha-s for tube passage. The head should be
secured byasping the turtle on either side behind the man-le.
Steady downward pressure will cause the lowerto fatigue and open. A
padded speculum or
lyvinyl chloride tube can be used to keep theuth open. The
turtle should be held in a verticalsition after the tube is removed
and its head andck extended until it swallows to prevent leakage
orgurgitation.Finally, soaking mildly dehydrated patients inallow
luke warm water (75-80 F), which reaches tot below the chin when
the head is retracted, willist in rehydration.32 Mildly dehydrated
marined estuarine turtles will benefit from placement insh water
for 24 hours. Not only will this help tohydrate these animals, but
exposure to fresh waterll also reduce the epibota load. Fluids,
variousugs, elemental diets, and dewormers may be ad-nistered by
the intracloacal route.1,40 Absorptiony be improved if the caudal
aspect of the turtle isvated higher than the cranial aspect for 10
to 20nute after fluid administration.
lume of Fluids to Administer. The volume ofids to administer
depends on the degree of dehy-ation and if hypoproteinemia and
anemia areesent. Fluid volume should not exceed 2 to 3% totaldy
weight (TBW) in chelonians.41 Generally recom-nded maintenance
fluid rates range from 15 mL//d in species greater than 1 kg to 25
mL/kg/d inecies less than one kilogram. A severely dehydratedtient
may tolerate up to 40 mL/kg/d. However, overdration is a concern
because of the slow metabolismchelonians.32 Infusion or syringe
pumps can be usedaccurately control the flow rate.
-
CPThniarewiultisthgloentopafieopfusudefinbemige20
Table 1. Emergency Drugs Used to Treat Chelonians
l/kg , SCiac17
V67
mach
79
176,s/wk8 h17
Chelonian Emergency and Critical Care 111R Principles in
Chelonianse following protocol is recommended for chelo-ns
presented in respiratory or cardiovascular ar-st. First, determine
if the animal has a heartbeatth a Doppler probe, electrocardiogram,
and/orrasound. Proceed only if cardiac electrical activitypresent.
Second, extend the head and neck, swabe mouth to remove any
materials blocking thettis, and intubate the patient with an
uncuffeddotracheal (ET) tube. Use suction and or gravityremove any
material from the ET. Ventilate thetient with oxygen. An ambubag
can be used forld emergencies. Lubricate the eyes if they areen. In
the authors experience, resuscitation istile if there is pungent
odor on exhalation orction, reduced global pressure that gives the
eyes anted appearance, and increased jaw tone. Thesedings dictate
euthanasia even if there is a heartat.1 Place an IV or IO catheter,
obtain blood for animum database, and then bolus fluids and
emer-ncy medications. If the heart rate remains belowbpm with
ventilation and bolus fluids, glycopyr-
Drug Dosage
Doxapram 5 mg/kg IM, IV1
Prednisolone sodium succinate 5 to 10 mg/kg IV1
Dexamethosone sodiumphosphate
0.1-0.25 mg/kg IV/IM1
Methylprednisolone 20 mg/kg IV1
Glycopyrrolate 0.01 mg/kg or 0.05 mAtropine 0.01-0.02 mg/kg IV,
IMEpinephrine (1:1000, 1 mg/ml) 0.1 mg/kg IV, intracardMidazolam
1.0 to 2 mg/kg IM or IDiazepam 0.5 mg/kg IV79
Activated charcoal, kaolin 2-8 gm/kg oral via sto
Calcium EDTA 10-40 mg/kg IM q12 h
Vitamin K1 0.2-2.5 mg/kg PO or IMIron dextran 12 mg/kg IM 1-2
timeCalcium gluconate 100 mg/kg IM or IC qCalcium
lactate/Calciumglycerophosphate
10 mg/kg SC, IM176
Potassium chloride 15-30 mEq/L of fluid29
50% dextrose 1 mL/kg IV
Mineral oil 6-10 mg/kg PO79
Cisapride 0.5-2.0 mg/kg PO q 24late (IV) or atropine (IV) should
be adminis-ed.1 Epinephrine can be given IV, IO, IP, intra-cheally
or intracardiac.33
erapeutic Agents Used in Chelonianergency and Critical Care
though several pharmacokinetic studies have re-ntly been
conducted on chelonians,42-53 limitedormation is available on
accurate dosing for themerous species presented to the emergency
clini-n (Refer to Tables 1, 2, and 3 for dosages). Drugsth
available pharmacokinetic data should be se-ted when possible.
Although there are limitationsmetabolic scaling, it can be a useful
tool when noarmacokinetic data are available.1 Because sickelonians
do not necessarily absorb drugs well, it isportant to correct
hypothermia, dehydration, hy-glycemia, acid-base and electrolyte
imbalances be-e or in conjunction with starting other
therapeu-agents. This is especially important when usingphrotoxic
or hepatotoxic drugs and anesthetics.ug pharmacokinetics are
temperature dependent
Comments
Respiratory stimulantShort-acting steroid, used in shock
therapySame as above
Short-acting steroid, CNS traumaIV, IM, SC1 Treat bradycardia1
Treat bradycardia7 Cardiac stimulant
Control seizuresControl seizures
tube93 Absorbs and neutralizes somepoisons
Heavy metal chelator, zinc and leadtoxicity
as needed Coagulopathies, hepatic disease176 Iron-deficiency
anemia6 Hypocalcemia
Hypocalcemia
HypokalemiaRecommend administering at 5-10%
in fluids slow bolus forhypoglycemia
6 Gastrointestinal stasisrotertra
ThEmAlceinfnuciawilectophchimpoforticneDr
h17
-
inpatiocadieto
AnIllSicspbafershsenwhhalimespcinhater
Table 2. Antimicrobials Used to Manage Critical Care Chelonian
Patientsy
ises)s), 5ation
PO
10 m
) (ye
mg/
q 7
al (5
112 Terry M. Nortonreptiles, and it is best to maintain the
cheloniantient at its POTZ during therapy.32 Many medica-ns are
unpalatable when administered orally, butn be followed by something
palatable (eg, a/dt, tuna juice, fruit or sweet vegetable baby
food)lessen the negative effect.1
timicrobial Therapy in the CriticallyCheloniank and injured
turtles are usually given broad-ectrum antibiotics as a treatment
for establishedcterial infections or as a preventive measure (Re-
to Table 2 for dosages). Diagnostic samplesould be obtained for
culture and antimicrobialsitivity testing before starting
antibiotic therapyenever possible. Although controversial, the
frontlf of body, including the soft tissues of the fore-bs and
neck, should be used for injections,1,54,55
ecially when using nephrotoxic drugs. Enrofloxa-is a commonly
used antibiotic in chelonians and
s good efficacy against aerobic Gram-negative bac-ia.
Unfortunately, it can cause tissue necrosis
Drug Dosage and frequenc
Amikacin *5 mg/kg IM q 48 h (gopher torto3.0 mg/kg IM q 72 h
(sea turtle10 ml saline 30 min nebuliz
Ceftazidime *20 mg/kg SC, IM, IV q 72 h44,45
Chloramphenicol 30-50 mg/kg IM q24h, 50 mg/kg
Clarithromycin *15 mg/kg PO q 48-72 h47
Clindamycin 5 mg/kg PO/IM q 24 h
Enrofloxacin *5 mg/kg SC/IM q 24-48 h,49,50 *q 24 h53
Metronidazole *20 mg/kg PO q 48 h (anaerobessnakes and
iguanas)48
Fluconazole *21 mg/kg loading dose, then 10SQ, IV51
Itraconazole *5 mg/kg PO SID or 15 mg/kg POturtles)46
Acyclovir 80 mg/kg PO SID1 to TID30; Topicointment) q 12 h30
*indicates the dose is based on pharmacokinetics, duration of
therapy willin critically ill chelonians are administered for a
minimum of 2-3 weeksen injected multiple times IM or SQ and is
painfuladministration. The irritating effect of the drug
n be reduced significantly by diluting it in fluids orrile water
and using the subcutaneous route forection. Once the patient is
stabilized, it can beministered orally.53 Anaerobic bacteria can
alsouse significant morbidity in chelonians and shouldconsidered
when deciding on a therapeutic plan.
algesic in the Critically Ill Chelonianny critically ill
chelonians are painful and benefitm analgesics. Chelonians are
relatively stoic andallenging to assess for pain (refer to Table 3
forsages). Pain may be exhibited in chelonians by acreased
appetite, depression, or alteration in nor-l behavior. The
nonsteroidal antiinflammatoryugs (NSAID) are long acting and
decrease endo-in production in septic patients.1,56,57
Meloxicam,rprofen, ketoprofen, and flunixin megalimineve all been
used in chelonians.1,56,57 AlthoughAID efficacy has not been
evaluated extensively byntrolled studies, anorexic and depressed
cheloni-
Comments42, 2.5-0 mg/q 12 h
Targets primarily Gram-negativebacteria, potentially
nephrotoxic
Targets primarily Gram-negativebacteria, less nephrotoxic
thanamikacin
q24h79 Bacteriostatic, aerobic, andanaerobic antibacterial
spectrum
Used to treat Mycoplasma URTDGood anaerobic spectrum, use
incombination with amikacin,ceftazidime, or enrofloxacin
g/kg PO Irritating to tissue, recommenddiluting and giving
SQ
llow rat Excellent efficacy against anaerobicbacteria, very
bitter, potential fortoxicity
kg q 5 d
2 h (sea
%
d on the clinical problem and response, but most antimicrobial
regimenswhoncasteinjadcabe
AnMafrochdodemadrtoxcahaNSco
depen.
-
antivtioNStio
arThtramaphtra
AnWemin 3 shlayparethpr
onhaimabapvainjme
forindththrekemesigmumeandeclusedindhy
Table 3. Analgesics and Anesthetics Used to Manage Critically
Ill Chelonian
/kg IV
g/kg
4h175
mg/kortoisFreshmg/kthis rtoise-8 m
Chelonian Emergency and Critical Care 113s often develop normal
feeding behavior and ac-ity after NSAID administration. Adequate
hydra-n and renal function should be assured beforeAID
administration and duration of administra-n should not exceed 3 to
5 days.57,10
The opioids, butorphanol and buprenorphine,e commonly used in
chelonians to manage pain.e disadvantages associated with opioid
adminis-tion are that they are relatively short acting andy cause
sedation in debilitated patients. Butor-anol is contraindicated in
patients with headuma.1
esthesia in the Critically Ill Chelonianhile anesthesia or
sedation is necessary in someergency situations, it should be used
with cautiondehydrated or debilitated patients (refer to Tablefor
dosages).1,32 A thorough diagnostic workupould occur before
anesthesia and should be de-ed if the heart rate less is 15 bpm
when thetient is maintained at its POTZ, if blood workveals a
PCV10% or a plasma TP2.0 g/dL, or ifere is evidence of sepsis or
severe respiratory com-omise.1
Several excellent reviews and controlled studiesinjectable and
inhalant anesthestic regimens
ve been recently conducted in chelonians.57-67 It isportant for
the emergency clinician to be comfort-le with a few anesthetic
regimens that can beplied to a wide range of chelonian species
under ariety of circumstances. The authors preference forectable
anesthetics include the combination ofdetomidine and
ketamine58,59,66 or propofol IV67
Drug Dosage
Butorphanol 0.2-2 mg/kg IM, 0.2-0.5 mg
Buprenorphine 0.1-1 mg/kg IM67
Meloxicam *0.2 mg/kg SC, IM, IV; 0.4 mhrs56
Carprofen 1-4 mg/kg PO, SC, IM, IV q2Medetomidine/ketamine M/K
Tortoises- M: 0.075 to 0.15
mg/kg58,59,60,65,66; Aldabra t0.08 mg/kg, K:5 mg/kg59, turtles-
M:0.3 mg/kg, K:5 0.4 mg/kg butorphanol to
Propofol 10-15 mg/kg IV67; desert tormg/kg IV, moderate dose
5dose 12 mg/kg IV67short, relatively noninvasive procedures or
foruction of general anesthesia. The advantages of
e medetamidine and ketamine combination areat it may be given IM
or IV, the medetomidine isversible with atipamezole, and very low
doses oftamine may be used because of the synergism withdetomidine.
The low ketamine dose does make anificant difference in the level
of sedation andscle relaxation. Butorphanol may be added to
thedetomidine and ketamine cocktail for additionalalgesia and
sedation.67 Disadvantages of the me-tomidine and ketamine
anesthetic regimen in-de significant species variations in
anesthesia andation in response to the drug combination anduction
of significant bradycardia, hypotension,percapnia, and hypoxemia.
Furthermore, theseugs may be contraindicated in debilitated or
de-drated chelonians, especially those with hepatic ornal
dysfunction. The lower end of the dose rangeould be used in
debilitated chelonians. Propofol ishypnotic sedative that provides
rapid induction.hile intravenous injection is preferred, the druges
not cause irritation if it is administered ex-vascularly.57 If
propofol is given by rapid infusion,can cause a marked respiratory
depression.67
opofol dosages for chelonians range from 2 to 15/kg, and
recovery rates are dose dependent. Usee lower end of the dose range
in debilitated che-ians to allow intubation. Local anesthesics,
suchlidocaine, may be used alone or in combinationth injectable or
inhalation anesthesia.68
Inhalant anesthetics should be used for invasiveprolonged
procedures. In critical chelonian pa-
Comments
, IO67 Premedication, analgesia, lowerdose if debilitated, 4h
duration
Same as abovePO q24-48 Rehydrate patient prior to
administration Same as aboveg K:5es- M:0.025 towater aquaticg67,
can addegimen67;
Reverse M with atipamazole at 5times the Medetomidine dose inmg
(same volume)
s: low dose 2-4g/kg IV, high
Administer slowly to effect over 1-2minutes, dilute 1:2 with
saline67drhyreshaWdotrait Prmgthlonaswi
or
-
tients, it may be advisable to use inhalation
anesthet-icstiotairepuanmaseverill rehaiblindsia
NEmNuchqutivpraspchsoacmoinsattvomaBetiotraThvagaag
masooustranplatuanthstrfrobeca
scess formation at the stoma site and ulceration
orerwaacingththThscrmemecloesoryndiopogeshoffluEninTa
HAdachtichahuprchpitbadisagovtioaqusCaspmisomasivwotudoloncabepo
114 Terry M. Nortonwithout an injectable induction agent.
Ventila-n and thermoregulatory support should be main-ned during
the procedure and throughout thecovery period. Monitor heart rate
via a Doppler,lse oximeter, or ECG. Intraoperative fluid therapyd
vascular access for emergency support should beintained. Although
isoflurane is useful in reptiles,oflurane provides significant
reduction in recov-y times and may be more appropriate for
criticallypatients.64 Sea turtles are notorious for
prolongedcoveries with a variety of anesthetic regimens andve much
faster recoveries when using the revers-e combination of
medetomidine and ketamine foruction and sevoflurane for maintenance
anesthe-.69
utrition Needs of this Species in theergency Settingtritional
support is an important component ofelonian critical care.1
Patients respond moreickly to therapy if their nutritional status
is posi-e.1 The critically ill chelonian is often immunosup-essed
secondary to starvation.1 Regurgitation andiration may occur in
dehydrated and debilitatedelonians. These turtles may not be able
to digestlid food and the material may remain in the stom-h as a
result of decreased gastrointestinal (GI)tility. Thus GI
nutritional support should not betituted until the patient has been
rehydrated andains normal blood glucose and GI motility. Thelume of
formula fed by stomach tube is approxi-tely 7% of the turtles body
weight in grams daily.gin with smaller volumes and more dilute
solu-ns and steadily increase the volume and concen-tion to meet
the turtles nutritional requirements.e turtle should be weighed
daily during the con-lescent period, and the measurement of
weightin or loss can be used as a guide for dietary
man-ement.Esophagostomy tubes (E-tubes) are integral innaging the
critically ill chelonian. The stress as-ciated with tube placement
is short, and usually fartweighs the stress associated with daily
head re-aint to administer oral medications, fluid therapy,d
nutritional support. An E-tube may be left ince for months, is
usually well tolerated by thertle, and most clients can manage the
turtle withE-tube at home. The tube should be left in untile animal
is eating normally. An E-tube may beessful to patients where the
tube prevents themm withdrawing into the shell, and therefore
maycontraindicated in such patients. Possible compli-tions of
E-tube placement include cellulitis or ab-osion with or without
perforation of the gastricll at the point where the tube contacts
the stom-h. Smaller patients are at greater risk of
develop-problems from the E-tube. Smaller tube size and
e propensity to clog with thick solutions may limite ability to
meet the patients nutritional needs.e technique for placing an
E-tube has been de-ibed.1,27 Sedation is recommended for tube
place-nt. Test the formula to be used before tube place-nt to
assure it will pass through the tube withoutgging. The tube should
enter at the mid to lowerphagus rather that the upper esophagus or
pha-geal region. Premeasure the tube and obtain ra-graphs after
E-tube placement to confirm tubesitioning. A purse string suture
and Chinese fin-r lock suture will secure the tube. Flexible
tubingould be used that allows for flexion and extensionthe neck.
After feeding, the tube should beshed with water or saline to
remove any gruel.teral tube feeding formulas that have been
usedvarious species of chelonians can be found inble 4.
ospitalizationdedicated room or facility designed to accommo-te
the various levels of medical care required forelonians is ideal,
however, this is usually not prac-al. The veterinarian and hospital
care staff shouldve access to literature on the natural history
andsbandry needs of the various chelonian speciesesented to the
facility for medical care2,70-75 (www.elonia.org, world chelonian
trust web site). Hos-al personnel should be trained in chelonian
hus-ndry and medicine. The importance of infectiousease control
during the physical examination, di-nostic work up, and
hospitalization cannot beeremphasized. Chelonians with suspected
infec-us disease should be hospitalized in isolation. Inuatic
settings, separate filtration systems should beed for turtles with
suspected infectious diseases.ptive specimens should not be exposed
to wildecimens and visa versa. The clinician should avoidxing
species and separate animals from differenturces. Enclosures should
be simple in design andde out of easy to disinfect, nonporous,
nonabra-e materials such as plastic, glass, painted or sealedod,
stainless steel, or fiberglass. Plastic storagebs, plastic swimming
pools, and modified plasticg kennels can be used to house
hospitalized che-ians. Intensive care units used for avian
species
n be used for smaller critically ill chelonians. Thest substrate
for use in a critical care setting shouldse minimal fire risk, if
ingested should not cause
-
ananherabencocacahoan
thevrethmobupa
Table 4. Enteral Feeding Formulas and Diets for Anorexic and
Critically Ill Cheloniansn
s, 299-03
ral m
le Heas bn micies
e Hethat
319tstritio
Chelonian Emergency and Critical Care 115impaction, and should
allow for proper woundd waste management.76,77 Compressed, baledmp
chippings, shredded paper, newspaper, andbit pellets may be
used.76,77 Hide areas within theclosure should be used to make the
patient moremfortable and assist in thermoregulation. Hidesn be
made out of disposable materials such asrdboard boxes and margarine
containers withles cut in them. Appropriate containers for foodd
water should also be provided.Hospital personnel should become
familiar withe POTZ for the species presented for emergencyaluation
and potential hospitalization. In general,ptiles are hospitalized
at the mid- to high end ofeir POTZ, but should still be provided
with a ther-gradient. Basking lights, infrared ceramic heatlbs, or
thermostatically controlled radiant heatingnels can be mounted to
walls of the enclosure or
Enteral diet informatio
Herbivores Critical Care diet (Oxbow Pet ProductRoad, Murdock,
NE 68407, 800-24
1 part alfalfa pellets blended for sevewith 2-4 parts water
Alfalfa Powder78 (NOW foods, Glenda60108), comprised of alfalfa
that hharvested, dried and powdered, cafruit baby foods for
frugivorous spe
Green Powder78 (NOW foods, Glendal60108), comprised of barley
grassharvested, dried and powdered.
Emeraid II (Lafeber Co., Cornell, IL 61Walkabout Farms enteral
feeding die
Omnivores/Carnivores
Canine/feline a/d diet (Hills Pet NuTopeka, KS 66601) (mixed
with 4vegetable baby food)
Critical Care diet (Oxbow Pet ProductEnsure (Abbott
Laboratories, Abbot60064) alone or mixed with fish blturtles), add
mixed green vegetablesea turtles (Chelonia mydas)
Walkabout Farms enteral feeding dieElemental
diets easilyabsorbable
1) Peptamen (elemental diet for childUSA Inc., Deerfield, IL
60015)
2) Vivonex Novartis, (Novartis, Minne55416)e cage front. The
heat source should always beced outside of the enclosure. Under
tank/enclo-re heating elements are not recommended. Diur-l heat
cycles (lowering the temperature at night) beneficial to recovering
chelonians.76 Infrared orramic heat emitters can be used as
nighttime heaturces without affecting photoperiod. Timers canset
for light and heat source activation. The en-onmental temperature
for a hospitalized patientould be monitored daily with maximum and
min-um thermometers or digital thermometers. Sickelonians that are
too weak to move from a heaturce should be monitored
closely.Basking chelonians require exposure to full spec-m
lighting.78 Several weaker UVA and UVB-emit-g fluorescent tubes are
commercially available.78
wever, artificial lights cannot replace the benefitsnatural
sunlight, thus moving the patient out-
Comments
012 Mill66)
Alfalfa based product, may clogsmaller
tubes,www.oxbowhay.com
inutes Very thick and may clog tube
ights, ILeenx with
Health or natural food stores,1 part volume powder to 5 partsof
water, only short term byitself, add extra calcium, Vit D,psyllium
(methylcellulose)-motilitydisorders
ights, ILhas been
Same as above, more crude fiber,lower crude protein, lower
levelsof Ca and Ph so better for goutand renal failure
)http:www.herpnutrition.com
n, Inc.,f
k, ILrized (sear green
Add vitamin/mineralsupplementation
http:www.herpnutrition.com(Nestle
, MNthplasunaarecesobevirshimchso
trutinHoof
jars o
s)t Parendes fo
tsren)
apolis
-
doors when weather permits is probably best. Con-taiou
allnetroThvidanpeingve
cieas Thanjelanshglafloadingtospsotri
DiPrin
Thprilachenterimtivprfrechen
TrTrprpetrofra
lems encountered in free-ranging marine turtles
mayincorshpinwosuplarinfrointhoest(Mjurchtrunivterlim
ceatemephadhotrupeamonbohahetamdiothInouprth
imprsuplaradrorhmainareisca
116 Terry M. Nortonners that facilitate moving the patient
inside andtside are helpful and efficient.76
Humidity should be measured and monitored inenclosures. As a
general rule, desert cheloniansed to be kept at humidity levels
40%, whilepical species need humidity levels of 60%.77
e humidity can be increased if necessary by pro-ing heated water
in bathing areas, regular mistingd dampening of substrate, using
damp soil orat/sand base substrate, and keeping lids on hold-areas.
Open top enclosures will provide better
ntilation and are preferred for most chelonians.76
Initially, debilitated aquatic and semiaquatic spe-s should be
dry docked on a padded surface, sucha shower box or plastic
draining board mats.79
ese turtles can be kept moist by regular mistingd placing
Vaseline or another water soluble (K-Y)ly on the skin and shell.
Once stabilized, theseimals require specialized facilities. Marine
turtlesould be provided specially designed circular fiber-ss tanks
with a filtration system and continuousw, temperature controlled
salt water. You mustjust water levels to accommodate turtles with
vary-degrees of debilitation. Water quality issues needbe addressed
for all aquatic species. Semiaquaticecies need haul out areas with
a basking heaturce. Turtles should not have direct access to
elec-cal outlets, cords or filtration systems.
fferential Diagnosis and Medicalinciples of Emergency
CareChelonians
e general medical, surgical, and emergency careinciples used in
various chelonian species are sim-r. Medical problems differ
significantly betweenelonians coming from a captive or
free-rangingvironment. The majority of problems encoun-ed in
captive chelonians can be traced back toproper husbandry. It is not
uncommon for a cap-e chelonian with a chronic medical problem
toesent as an emergency. The environment (marine,shwater,
estuarine, terrestrial) of free-rangingelonians will dictate the
types of problems that arecountered.
aumatic Injuriesauma is a common reason for chelonians to
beesented for emergency care. Chelonians that ex-rience a traumatic
injury may present with uncon-lled hemorrhage, lacerations, head
trauma, andcture of the limbs, skull, mandible, or shell. Prob-lude
boat related injuries secondary to propellerdirect impact,
encounters with predators such asarks, entrapment in dredging
equipment, drop-g on a boat deck after incidental capture, andunds
created from fishing gear entanglementch as nets, fishing line,
crab and fish traps andstic rings from beverage containers. Captive
ma-e turtles are predisposed to traumatic bite woundsm
interspecific (eg, shark in same aquarium) orraspecific aggression.
Sea turtles should not beused together if space is limited.
Freshwater anduarine species, such as the diamond back
terrapinalaclemys terrapin), encounter similar traumatic in-ies as
marine specimens. Aquatic and terrestrialelonians are commonly hit
by automobiles orcks when crossing roads. Predators, primarily
car-ores, commonly cause severe damage to freshwa-and terrestrial
chelonians by gnawing on thebs and shell.32
Traumatic injuries in chelonians often involve thentral nervous
system (CNS) and require immedi-attention. Short-acting
corticosteroids such asthylprednisolone, dexamethasone sodium
phos-ate, or prednisolone sodium succinate should beministered IV
and then repeated in 12 to 24urs.1 Supportive care, wound care,
broad-spec-m antibiotics, and analgesics are indicated de-nding on
the type of injury. Warm the patient tobient indoor temperatures
(68 - 75 F; 20 - 30 C)ly after hemostasis is achieved, antibiotics
are onard, and vital signs are stable.1 Warmed animalsve higher O2
demands, increased potential formorrhage, and increased bacterial
growth in con-inated wounds. Once the turtle is stabilized,
ra-graphs can be taken to determine the extent of
e injuries, prognosis and plan for further therapy.cases of hind
limb paresis, it is important to rulet a spinal or pelvic fracture.
Pelvic fractures mayedispose female turtles to dystocia;
therefore,ese animals should not be released into the
wild.Uncontrolled hemorrhage should be addressedmediately. This can
be accomplished by digitalessure, a pressure bandage, vessel
ligation withture, or by surgical electrocautery. Carapace andstron
fractures are common in chelonians. Afteriographic evaluation, the
fracture site and sur-
unding tissue should be cleaned with dilute chlo-exidine,
betadine, or saline. A wet-to-dry bandagey be placed over the
injury to further decontam-te the wound. Foreign debris should be
carefullymoved from the fracture site. If the coelomic cavityopen,
minimize contamination. Fractures of therapace over the lungs or of
the bridge may put the
-
patient at risk for bacterial and fungal
pneumonia.AfdusuprandrantuingcoSmucacwabethbathPaplashdrthfraou
asshCosecniqRethgedifaroanthshall
cobeexthmetiotunetiofraavce
Vomiting, Ileus,
ObstructionVoindnodeclutiobilpaanbewitamneveredu
cotodof tiethityita(fethwechpathusmapaus
ofdifsisdietrisobecoofcoreqtatintgeincaapity
Chelonian Emergency and Critical Care 117ter cleansing, the
shell fracture should be re-ced. If realignment is difficult or a
spinal injury isspected, then fracture alignment should be
ap-oached with caution or delayed. After cleansingd drying the
fracture, the wound should beessed. Silver sulfadiazine (SSD) cream
or tripletibiotic ointment are applied to open shell frac-res and
wounds. The author recommends cover-open wounds and shell fractures
with a silver-
ated mesh (Acticoat with silcryst nanocrystals,ith & Nephew,
Inc., Largo, FL USA). This prod-t provides 72 hours of
antibacterial and antifungaltivity; however, it must be kept moist
with sterileter while being used. DuoDerm or tegaderm canused to
cover various dressing materials and keepe wound clean and dry. For
a more waterproofndage, tissue glue can be applied to the edges ofe
adherent bandages. Vet wrap (3-M Corp., St.ul, MN USA) can be used
to keep the dressing ince and stabilize the fracture. Aquatic
speciesould be kept in shallow water or may need to bey docked
until a waterproof bandage is placed overe wound or fracture or
until final repair. Shellcture repair methods have been described
previ-sly.1,26
All skin wounds should be cleaned and debrideddescribed for
shell injuries. Primary closure
ould be reserved for noncontaminated wounds.ntaminated wounds
should be left open to heal byond intention or closed using a
delayed tech-ue once the wound has been decontaminated.ptiles
produce thick caseous abscesses. Becauseese abscesses do not drain
well, penrose drains arenerally not used for wound care. In areas
that areficult to bandage, suture loops can be placedund the wound,
the preferred topical treatmentd dressing applied, and umbilical
tape placedrough the suture loops and tied together like aoelace to
hold the dressing in place. This methodows for regular wound
cleaning and bandaging.Fractured limbs in chelonians may result as
ansequence to a variety of traumatic insults, such asing hit by a
car or boat, being dropped, or havingcessive force applied to the
limbs when extricatingem for tube feeding. Chelonians suspected to
havetabolic bone disease should be handled with cau-n, as they are
predisposed to pathological frac-res. Patient stabilization takes
priority over perma-nt fracture repair. Various methods or
combina-ns of methods may be used to repair a long bonecture in a
chelonian. Several excellent reviews areailable on chelonian and
reptile orthopedic pro-dures.26miting or regurgitation in
chelonians is usuallyicative of a poor prognosis.32 A thorough
diag-stic work up should be performed to make afinitive diagnosis.
Some causes of vomiting in-de foreign body or other
gastrointestinal obstruc-n, noxious tasting materials, dehydration
and de-itation, gastric stasis, gastrointestinal yeast,
andrasitism. Vomiting is more common in anorecticd debilitated
turtles than tortoises.1 Turtles shouldrehydrated and stabilized
first, and then tube fedth an easily digestible elemental diet such
as Pep-en (Nestle USA, Inc., Deerfield, IL USA). The
ck should be extended and the turtle held in artical position
after the tube is removed to preventgurgitation. Higher caloric
diets should be intro-ced gradually.Heavily parasitized turtles and
tortoises may be-me partially or completely obstructed with nema-es
after being dewormed with relatively low dosesfenbendazole (30
mg/kg PO once).11 These pa-nts should be rehydrated and stabilized
to ensureat they regain their normal gastrointestinal motil-. To
prevent this complication, always start debil-ted chelonians with
lower doses of anthelminthicsnbendazole) and gradually increase the
dose toe recommended levels of 50 mg/kg over severaleks. The
gradual increase in dosage reduces theance of obstruction by
reducing the number ofrasites affected per treatment. Fenbendazole,
al-ough effective in chelonian species, should beed with caution
based on recently described bonerrow suppression effects avian
species.80 Pyrantelmoate may be a safer alternative anthelminthic
toe in debilitated chelonians.Gastrointestinal stasis or ileus is a
common causemorbidity in debilitated chelonians and must
beferentiated from obstruction. Gastrointestinal sta-is
precipitated by dehydration, systemic disease,tary indiscretion,
decreased dietary fiber, malnu-tion, suboptimal management
practices, and sea-nal motility changes.81 Diagnosis is
challengingcause of difficulties in palpating the chelonianelomic
cavity and the normally slow GI transit timethese animals. Without
appropriate treatment, thendition may progress to impaction and
obstructionuire intensive medical or surgical therapy.82 Debili-ed
marine turtles often develop a secondary gastro-estinal stasis and
become obstructed with nondi-stible prey materials. Radiopaque
material and gasthe gastrointestinal tract are visible
radiographi-lly. This condition can be resolved with fluid ther-y,
mineral oil, enemas, and gastrointestinal motil-modifiers. The
obstruction should be resolved
-
before offering the animal food. In other
cheloni-anmeussueff
prbogrfisesotratintiotrabatutalIngrterThstrinstrvaenvianerere
HHywitulosannilfroerinposufaipemomelonpnapth
A classification system has been developed
forhyreredebenopedewacolesanvewireev
caleuperemicrehypedissalreinftenre
shgrbranpoacitivtiopatoLemofoainibieBopesysbe19ba
118 Terry M. Nortons, elucidating the cause of the ileus,
correcting thedical problem, and providing supportive care
willually resolve the ileus. Motility modifying drugs,ch as
metoclopramide and cisapride, are clinicallyective in
chelonians.82,83
Foreign body ingestion is a common emergencyesentation in
chelonians.83-87 Occasionally foreigndies are found incidentally on
whole body radio-aphs. In aquatic species, fishhooks with
attachedhing line may become anchored in the oral cavity,phagus, or
other parts of the gastrointestinalct. These foreign bodies
frequently lead to intes-al plication or coelomitis secondary to
penetra-n of the serosal surface of the gastrointestinalct. A
variety of foreign materials, such as plasticgs, metal, and glass,
have been found in marinertle gastrointestinal tracts and may be an
inciden-finding or lead to an enteritis or obstruction.
gestion of substrates such as corncob, wood chips,avel, sand,
kitty litter, or walnut shell by captiverestrial chelonians may
cause GI obstruction.32
e radiographic hallmark sign for intestinal ob-uction is the
accumulation of radiopaque materiala dilated segment of intestine.
A prominent ob-uctive gas pattern is not always observed.
Conser-tive medical treatment consisting of enemas, par-teral
fluids, petroleum laxatives and water givena stomach tube (15
mL/kg) may be all that is
cessary for clinical resolution.88 However, surgicalmoval of the
foreign body or material may bequired in some cases.83,89,90
ypothermiapothermia, or cold stunning, in sea turtles is
antertime phenomenon where the water tempera-re suddenly drops
below 50F (10C).29 The turtlese their ability to swim and dive,
become buoyantd float to the surface. It is most common in juve-e
sea turtles, and has been documented to occurm the Gulf of Mexico
to New England and West-n Europe. Hypothermia is also a common
problemother chelonian species. Common causes of hy-thermia may
include escape from a heated enclo-re, airline transport, power or
heating elementlure, and an unexpected drop in nighttime
tem-ratures.32 Hypothermia has been investigatedre thoroughly in
sea turtles; however, similardical management can be applied to
other che-ians. Secondary infections, especially bacterialeumonias,
are not uncommon and may not beparent until several weeks after the
initial hypo-ermic event.32pothermic sea turtles based on a series
of reflexsponses, including head lift, cloacal or tail touchflex,
eye touch reflex, and nose touch reflex.91 Thegree of
responsiveness can be used to dictate thest approach to be taken
and approximate a prog-sis. The severity of secondary problems
often de-nds on the length of time the animal has beenbilitated and
the temperature extremes the turtles exposed to. Traumatic wounds,
dehydration,rneal ulcerations, dermal, carapacial and plastronions,
flipper tip necrosis consistent with frostbite,d buoyancy disorders
are frequent findings in se-re cases.29 Other chelonian species
often presentth similar clinical signs, including lethargy,
poorsponse to external stimuli, and in extreme casesidence of
frostbite of digits and tail tips.29
Common abnormal clinical pathology findings inses of hypothermia
include an initial heterophilickocytosis with subsequent
development of leuko-nia and monocytosis, both regenerative and
non-generative anemias, hypoglycemia or hyperglyce-a, increased
creatine phosphokinase (CPK), de-ased blood urea nitrogen (BUN),
hypocalcemia,poproteinemia, hypokalemia, hypernatremia,
hy-rchloremia, and metabolic acidosis.29 Electrolyteturbances may
be secondary to malfunctioningt glands. Cultures of blood and other
fluids oftenveal localized and systemic bacterial and
fungalections. Radiographs often reveal changes consis-t with
pneumonia. Coelomic fluid evaluation may
veal evidence of inflammation or infection.29
The therapeutic plan for hypothermic sea turtlesould include a
slow increase in body temperature,adual reintroduction to sea water
from fresh andackish water over a 2 week period,
prophylactictibiotic and antifungal therapy, nutritional sup-rt,
and close monitoring of clinical pathology andid-base
abnormalities.29 Many turtles can have pos-e clinical outcomes with
proper medical atten-n. Body temperature and heart rate are
importantrameters to obtain at the time of presentation, andmonitor
until the rewarming process is complete.ss severe cases are placed
in shallow water, whilere severe cases are dry-docked and placed
onm pads. The water or room temperature shouldtially be only 4-6F
(2-4C) warmer than the am-nt water temperature where the turtle was
found.dy temperature should be increased by 5F (3C)r day until
reaching 75F (24C). Broad-spectrumtemic antibacterial and
antifungal therapy shouldinitiated when the turtle reaches 60 to
65F (16-C). The skin and shell should be kept moist
withcteriostatic water and soluble lubricating jelly.
-
HyperthermiaRetemovniareouacchbemiterallrapTrmishchcocomobePO
DDepeaemoniaocensuodattthbe
tercofledethtudeboitothdrenhelattratu
lyte imbalances, dehydration, and hypothermia maybeis
ToChconameindbetileanceshassredesis
infareandueffchclocaheatoch
gloinseqdieaingcieantoxsutoidolydanCethcoprondutublo
Chelonian Emergency and Critical Care 119ptiles are less able to
compensate for elevatedperatures than mammals or birds.
Temperatures
er 100F (38C) are usually lethal for most chelo-ns.32
Hyperthermia in chelonians can occur as asult of placing a turtle
in a glass or plastic tanktdoors in the sun, a closed car during
the day, orcidental overheating in an enclosure. Ill or
injuredelonians stranded on a beach or road also maycome
overheated. Early clinical signs of hyperther-a include increased
activity, retreating to the wa-, seeking cool areas, and hyperemic
skin. Eventu-y, the turtle develops open mouth breathing,id
respirations, and may become comatose.32
eatment should include cooling the animal, ad-nistering fluids
and possibly, in severe cases, aort acting steroid to reduce brain
swelling.32 Theelonian should be placed into a shallow pan ofol
water (not cold) for a brief period to reduce there body
temperature. Body temperature should benitored carefully.
Subsequently, the turtle shouldplaced in a small enclosure at the
lower end of itsTZ.32
rowningspite the chelonians ability to survive extendedriods
without breathing and having significant an-robic respiration
adaptations,32 drowning is a com-n problem in the aquatic and
terrestrial chelo-n. A common cause of drowning in marine
turtlescurs when the animals are incidentally captured ortangled in
shrimp nets or various fishing gear andbsequently trapped
underwater for extended peri-s of time. Diamondback terrapins (M.
terrapin) areracted to crab traps and often are unable freeemselves
once trapped. Terrestrial chelonians mayfound at the bottom
swimming pools.Live turtles that have been submerged under wa-for
extended periods of time may present in a
matose state without corneal or deep pain re-xes. The
cardiopulmonary resuscitation protocolscribed previously should be
used in cases whereere is cardiac and respiratory arrest.
Trawl-cap-red loggerhead sea turtles exhibit a marked aci-mia and
lactic acidosis when first brought onard.92 Blood gas and lactate
levels should be mon-red during the recovery process. Once
intubated,e turtle should be placed with its head down toain fluid
from the lungs. Suctioning fluid from thedotracheal tube may be of
some benefit. Limb andad pumping, intermittent positive-pressure
venti-ion (2-6 times per min), and doxapram adminis-tion (5-10
mg/kg IV) may assist in reviving thertle. Aggressive therapy to
correct acidosis, electro-necessary. Broad-spectrum antimicrobial
therapyusually indicated.
xicosiselonians can be exposed to a variety of toxins
andntaminants in captivity and the wild. Unfortu-tely, many of the
toxicities that have been docu-nted in captive chelonians are
iatrogenic anduced by the veterinary clinician.93 Ivermectin hasen
used successfully and safely in a variety of rep-s; however, it is
toxic to many species of cheloni-s.94 Although there are species
differences in sus-ptibility to the toxic effects of ivermectin,
the drugould be avoided in all chelonians. Clinical signsociated
with ivermectin intoxication are primarilylated to general
neuromuscular weakness, andath usually occurs because of
respiratory paraly-.94
Metronidazole is used to treat anaerobic bacterialections and
amoebiasis in reptiles.1,48 Tortoisesprone to developing side
effects from this drug,
d may not tolerate the relatively high doses orration of therapy
necessary to treat amoebiasisectively.1 Metronidazole treatment
regimens inelonians need to be tailored to the individual withse
monitoring for clinical signs of toxicity. Clini-l signs of
metronidazole toxicity include anorexia,ad tilt, circling,
dysequilibrium and signs of hep-toxicity.95 Metronidazole toxicity
can be fatal inelonians.Two red-belled short-necked turtles
(Emydura sub-bosa) with shell lesions were soaked for 45 minutesa
dilute (0.024%) chlorhexidine solution and sub-uently developed
partial flaccid paralysis andd.96 Cholecalciferol toxicity has been
reported inleopard tortoise (Geochelone pardalis)secondary toesting
rodent bait.97 While numerous plant spe-s are suspected to be
potentially toxic in cheloni-s, few published reports have been
made on actualicosis.98 Oak toxicity was recently reported as
thespected cause of death in an African spurred tor-se, Geochelone
sulcata.99 Lead poisoning has beencumented in a wild common
snapping turtle (Che-ra serpentina) after swallowing a fishing
sinker100
d a tortoise after ingesting lead paint chips.101
ntral nervous system disease predominated inese cases. Sea
turtles may encounter waters thatntain chemical pollutants, such as
petroleumoducts from oil spills, and present with oil or tartheir
skin and shell or systemic signs of toxicitye to ingestion.79 An
increased stranding rate of seartles in Florida has been associated
with red tideoms of the dinoflagellate Karenia brevis. Affected
-
animals often present with central nervous systemde 102
baexnosustothdetiobeortoxzuity
NIllSoocchondepadispacobycaligmaandio
caspbatuAsemcofreprmaprseptlehyatrro
a mme
involve fluid and electrolyte replacement
initiallyanadmoanprboon
DMomeprwhintincmamuboisoclapsizmefraegmadelevginnieletthgrpregdeevsomaso
shgeshtioimanmetieoxObcaov
120 Terry M. Nortonficits.A diagnosis of toxicity in a chelonian
is usuallysed on a thorough history, clinical signs,
physicalamination, and various diagnostic tests. The diag-stic
tests generally used to confirm a toxic expo-re include contaminant
analysis of blood, plasma,mach contents or tissue, and radiographs.
Fluiderapy, wound care, and other supportive measuresscribed
previously may be used to treat intoxica-n. In addition, activated
charcoal or psyllium mayused to bind and decrease the absorption
of
ally ingested toxins,79 calcium EDTA to treat leadicity,103
midazolam or diazepam93 to control sei-res, and atropine to treat
organophosphate toxic-.
utritional Diseases and the CriticallyChelonianme of the more
common nutritional diseases thatcur in captive chelonians include
generalized ca-exia/starvation, metabolic bone disease or sec-dary
nutritional hyperparathyroidism, vitamin Aficiency, and iodine
deficiency/goiter.104-106 Thesetients are often immunnocompromised
and pre-posed to secondary infections. Nutritional
hyper-rathyroidism or metabolic bone disease is mostmmon in young
growing chelonians and is causeddeficiencies in calcium, vitamin D,
an improperlcium/phosphorous ratio, lack of exposure to UVht, or a
combination of these factors. Clinical signsy include a soft
deformed shell, limb fractures,d a malformed overgrown
rhampthotheca.106 Ra-graphs can aid in the diagnosis of advanced
cases.Starvation or cachectic myopathy may occur inptive and
free-ranging chelonians.107,108 In captiveecimens, primary
malnutrition and poor hus-ndry (eg, suboptimal environmental
tempera-res) are often responsible. Confiscated Southeastian
turtles are routinely presented with severeaciation after being
maintained at suboptimalnditions for extended periods of time.1
Emaciatede-ranging chelonians usually have an underlyingoblem.108
The underlying cause of the emaciationy be masked by numerous
secondary medicaloblems such as bacterial or fungal
pneumonia,ticemia, and severe endoparasitism.108 These tur-s may be
critically anemic, hypoproteinemic, andpoglycemic. They often have
severe ascites, serousophy of fat, lymphoid depletion, and bone
mar-w suppression.Severely malnourished chelonians may present
inoribund state and require emergency care. Treat-nt for energy
deficiency in chelonians shouldd then small but increasing levels
of calories. Indition, iron dextran, whole blood or artificial
he-globin, broad- spectrum antimicrobial drugs, andtiparasitics may
be necessary. Specific nutritionaloblems such as vitamin A
deficiency, metabolicne disease and hypothyroidism should be
treatedce the turtle has been stabilized.
ystociast dystocias in chelonians do not present as adical
emergency unless there is an obstructiveocess involved. It may be
difficult to determineen a gravid patient is overdue or when one
shouldervene. Common causes of dystocia in chelonianslude
inadequate nesting sites, inadequate ther-l environment,
malnutrition, dehydration, poorscle tone, endocrine abnormalities,
and meta-lic abnormalities such as hypocalcemia. A dystociamore
likely to be a medical emergency when itcurs secondary to
reproductive tract or cloaca pro-ses, systemic infections, abnormal
egg shape ande, stricture or torsion of the oviducts, impinge-nt of
the pelvic canal from misaligned healedctures, uroliths, soft
tissue masses, or brokengs.109 The dystocia patient may be
asymptomatic ory have one or more of the following clinical
signs:creased appetite or anorexia, decreased activityel, excessive
basking, restlessness, constant dig-g behavior, raising the
hindquarters accompa-d by cloacal aversion, and eventual weakness
andhargy.109 The diagnostic workup should include aorough history,
physical examination, and radio-aphs. Radiographs should be
evaluated for theesence of eggs, the size, shape, and position
ofgs, eggs in the bladder,110 any broken eggs, bonensity,
pathological fractures and pelvic fractures,idence of constipation,
and cystic calculi. Ultra-und, hematology, and a serum chemistry
profiley provide additional important information inme
cases.Debilitated chelonians suffering from dystociaould be
stabilized before oxytocin therapy or sur-ry. Dehydration,
hypothermia, and hypocalcemiaould be corrected. Antibiotic therapy
and nutri-nal support may be indicated in some cases. It isportant
to provide adequate nesting areas, water,d an appropriate
thermogradient during the treat-nt period.109 In nonobstructive
dystocias, the pa-nt may be pretreated with calcium followed
byytocin. Eggs should pass within 30 to 60 minute.109
structive dystocias will require surgery in mostses. If the egg
can be visualized through the cloaca,icentesis and collapsing the
egg may be attempted.
-
If surgery is deemed necessary, an inguinal approachislompinpeof
rethseafor
UCycareMoamteichlapincsu
ClAthpronsticastrthtulumurmahaon
clebademeussulaptisimcoa c
tisunto
irritation or desiccation from substrates while
at-temfectecnewiedth
PaEcagfouovanprhoaid
disindebaingtatspprtobetippadiaanmepocomganicatorlow20forroiodstaten
arefrecaityinttra
Chelonian Emergency and Critical Care 121less invasive and
preferred over entering the coe-via a plastron osteotomy. A
salpingotomy, sal-
gectomy, or gonadectomy may be performed de-nding on the cause
of the dystocia and conditionthe oviductal tissue.109 The ovary
should always bemoved with the oviduct to prevent ovulation intoe
coelomic cavity during the next reproductiveson. A unilateral
salpingectomy can be per-med to maintain future
reproduction.111
rolithiasisstic calculi have been documented in a variety
ofptive and wild turtle species.112 The condition islatively common
in California desert tortoises.st cases result from water
deprivation or excessounts or inappropriate types of dietary
pro-n.113,114 Emergency care should be sought if theelonian is
straining excessively or develops a pro-se of the uterus or
bladder. Treatment shouldlude rehydrating and stabilizing the
patient for argical cystotomy.113
oacal and Phallus Prolapsescloacal prolapse should be attended
to quickly soat the prolapsed organ remains viable. Cloacalolapses
usually occur from excessive straining sec-dary to an inciting
cause, which may include con-pation, bacterial enteritis, parasitic
enteritis, cysticlculi, egg binding, and other conditions
causingaining.115 In addition to determining the cause ofe
prolapse, it is important to determine what struc-re is protruding
and its viability.115 The colon has aen with feces inside and a
smooth surface. The
inary bladder is thin walled, translucent, and uriney be
aspirated from it. The uterus and oviductve a lumen, no feces, and
longitudinal striationsthe surface.Treatment for a cloacal prolapse
should includeaning, lubricating, and replacing the viable tissueck
through the vent. Soaking the prolapse in 50%xtrose will reduce the
edema to facilitate replace-nt. A purse string or transverse suture
should beed to maintain the reduction. The vent can bergically
enlarged to assist in replacing the pro-sed tissue. In cases of
chronic prolapse when thesue is edematous and friable, it may be
difficult topossible to reduce the tissue and instead require
aeliotomy or amputation. If the colon is prolapsed,olopexy can be
used to prevent recurrence.115
Chelonians have a large phallus, which is solidsue and has no
lumen. Phallus prolapses are notcommon in chelonians, and may occur
secondaryan infection, forced separation during copulation,pting to
breed, constipation, or neurologic de-ts.32 The phallus can be
reduced using the samehniques described for the cloaca. If the
phallus iscrotic, the base of the penis can be double ligatedth two
vertical mattress sutures and then amputat-.32 Penile amputation
will not affect urination bute turtle will not be able to copulate
or reproduce.32
rasitestoparasites, such as maggots,116 ticks,116 sarcoph-id fly
larvae,117,118 leeches,119 and various epibiotand on sea
turtles,108,119 may contribute to theerall poor condition of a
critically ill cheloniand should be manually removed or treated
appro-iately. Placing marine turtles in freshwater for 24urs will
significantly reduce the parasite load andin
rehydration.Endoparasites may be a contributing factor toease in an
already compromised chelonian, andsome cases they may be the
primary cause ofbilitation.11,120-129 Stress, overcrowding, poor
hus-ndry, infectious diseases, and immunocompromis-conditions may
lead to heavy endoparasite infes-
ions. Clinical disease associated with Entamoebap. is much more
prevalent in chelonians thaneviously recognized.1,120,121 It is a
difficult parasiteidentify and treatment may need to be startedfore
a specific diagnosis is made.1 There are mul-le species of amoeba
with varying degrees ofthogenicity.1 The most common clinical signs
arerrhea, often with intermittent blood and mucous,orexia,
depression, and severe dehydration. Treat-nt consists of aggressive
fluid therapy and sup-rtive care. Bonner recommends a prolongedurse
and high doses of metronidazole (100 to 150/kg sid PO for 5 days,
skip 7 days, and then repeatother 5 day course) due to the
difficulties in erad-ting this parasite.1 This regimen may be toxic
totoises. Recent pharmacokinetic studies in the yel-rat snake and
green iguana suggest that a dose ofmg/kg every 48 hours reaches
therapeutic levels treating anaerobic bacterial infections.48,130
Met-nidazole eliminates the trophozoites stages, whileoquinol can
be used to treat the amoebic cystges. Broad-spectrum antimicrobial
therapy is of- indicated.1
Digenetic trematodes of the family Spirorchidaecommonly found in
the cardiovascular system ofshwater and marine turtles, and have
been impli-ted as a cause of significant morbidity and mortal- in
some cases.18,126,127,129 The eggs are releasedo the circulatory
system, and eventually becomepped within the terminal arterioles of
the visceral
-
organs, extremities and shell. A granulomatous
re-spinclunthgetedcacutoingtusecadothtucawideaff
InSechsigsevUpaprwitinagtripringchchgloagruco
macoareingsudecacapastuheag
ronmental pollutants or other unknown
immuno-sufacmutarrejunimhinmogaskilapnasiodrbiasuinhe20
chogreranchtercoprhisPCme
liztioanternuantivru
BaDewiclutisdissanfecthtileab
122 Terry M. Nortononse is produced by the eggs in various
tissues,luding the gastrointestinal tract, liver, spleen,gs and
CNS.18,126,127 Clinical signs are related to
e pathology caused by the eggs and may includeneralized
debilitation, severe ulcerative colitis, pit-ulcerations (due to
ischemic necrosis) of the
rapace and plastron, edematous limbs due to vas-lar obstruction,
and buoyancy problems secondarypneumonia. A major loggerhead sea
turtle strand- event occurred in south Florida in 2001.129 Most
rtles presented with partial paralysis and many hadondary
problems. Postmortem results revealedult trematodes in the brain
and spinal cord. Noer primary agent has been identified in
these
rtles. These turtles often respond to supportivere and treatment
for the trematodes. Treatmentth high dose of praziquantel may be
effective increasing the severity of clinical signs but will notect
the eggs already in the tissues.131,132
fectious Diseaseveral excellent reviews of infectious diseases
inelonians have been published.128,133,134 Clinicalns associated
with infectious disease agents may beere, present acutely, and
warrant emergency care.per respiratory tract disease (URTDS)
complex isrelatively common reason for chelonians to beesented and
provides a good example of dealingth an infectious disease in an
emergency set-g.134-141 Herpesvirus, iridovirus and Mycoplasma
assizii are important infectious diseases of terres-al
chelonians.134-141 Infected chelonians oftenesent with an acute
onset of clinical signs, includ-anorexia, depression, and nasal and
ocular di-
arge.134-142 Herpesvirus and iridovirus infectedelonians
frequently present with stomatitis andssitis,137,143 whereas this
is never observed with M.
assizii alone.138,140,141 Mixed infections of Herpesvi-s and M.
agassizii have been reported, furthermplicating the
diagnosis.144
Herpesviruses have been documented to affectny chelonian taxa,
and all chelonians should bensidered susceptible.134,135,142-148
These infectionsbelieved to lie dormant in various tissues
follow-the primary infection, and during times of stress,
ch as hibernation and illegal importation, recru-sce.134
Herpesvirus infections have been impli-ted as the causative agent
in several diseases ofptive and free-ranging sea
turtles.145,147-149 Fibro-pilloma disease syndrome (FP) is the most
welldied disease affecting sea turtle populations. Arpesvirus has
been implicated as the causativeent of the disease syndrome,147-152
however, envi-ppressive factors are most likely a contributingtor
in the disease process.153 Turtles may haveltiple cutaneous FPs
found on all soft integumen-y tissue, but especially in the
axillary and inguinalgions.147 The FPs can develop on the eyelids,
con-ctiva, and cornea and may be so extensive as topair the turtles
vision.147 This visual impairmentders feeding and leads to
emaciation. Further-re, FPs may be found internally in various
or-ns.152,153 A diagnosis is made by observing typicaln lesions and
histopathology.150 Radiography andarascopy are used to identify
internal FP. Eutha-sia is recommended in turtles with internal
le-ns. Initial treatment consists of correcting dehy-ation,
hypoglycemia, and malnutrition. Antimicro-l therapy is usually
indicated before and afterrgery. Laser surgery can be used to
remove the FPsstages. In these cases, the skin is often left open
toal by second intention (Pers. comm. Mader D,03).Iridovirus is an
important emerging disease inelonians137,154 Until recently, it had
only been rec-nized sporadically.136,155 Frogs are implicated as
aservoir host capable of infecting captive and free-ging chelonian
populations.137 Viral infections inelonians are often complicated
by secondary bac-ial, fungal, and parasitic infections, and should
bensidered in the diagnostic and therapeutic ap-oach. Diagnostic
samples (eg, serology, cytology,topathology, electron microscopy,
culture andR) should be collected before initiating
treat-nt.133,137,156
Initial emergency therapy should focus on stabi-ing the patient
with emergency drugs and rehydra-n. Critical care may consist of
broad-spectrumtimicrobial therapy for aerobic and anaerobic bac-ia,
antifungals, antiviral drugs, fluid therapy, andtritional support.
Acyclovir administered orallyd topically has been shown to be
clinically effec-e against both chelonian herpesvirus and iridovi-s
infections.137,157
cterial and Fungal Infectionsbilitated and injured chelonians
often presentth bacterial or fungal infections. These may in-de
infected traumatic injuries, abscesses, stomati-, shell infections,
osteomyelitis, and respiratoryease. Poor husbandry, malnutrition,
and a lack ofitary procedures are predisposing factors for in-tion
in captive specimens. Bacterial abscesses aree most common
inflammatory condition in rep-s, and can occur anywhere on the
body. Reptilescesses are most often well encapsulated by
fibrous
-
connective tissue. Gram-negative bacteria cause
thehigbatriserthsptisaetrihesptencanoprcludisdisspthspdeaneabobebaevasitiotoxfac
oranmysissoouthof cytareinfMydia
anbiawiclireab
material are required for effective treatment.
Antibi-otihaThpaanvohainf
PnPnchhudistilecotioarrareThsamhedifcalatChimrudisprfu
gaOvsiotorGeRhiobisoMirobapnClcrerefloalstorbrop
Chelonian Emergency and Critical Care 123hest morbidity in
chelonians, however, anaerobiccteria (eg. Bacteroides spp.,
Fusobacterium spp., Clos-dium spp., and Peptostreptococcus spp.)
can causeious disease and should be considered in theerapeutic
plan.158 Bacteroides spp. and Fusobacteriump. produce potent tissue
toxins, which can causesue necrosis and increase the severity of
mixedrobic and anaerobic bacterial infections.158 Clos-dium spp.
have systemically active toxins that causemolysis and renal tubular
necrosis.158 Salmonellap. can cause disease in chelonians and are a
po-tial zoonosis.159 Atypical mycobacterial infectionsn cause
abscesses, cutaneous and subcutaneousdules, osteomyelitis,
osteoarthritis, and otheroblems in chelonians.160 Predisposing
factors in-de debilitation, injury, malnutrition, and otherease
processes. This is also a potentially zoonoticease. Dermatophilus
chelonae is a newly discoveredecies of bacteria that grows at lower
temperaturesan D. congolensis.161,162 Several tortoise and
turtleecies have been reported to develop skin abscess,rmal
nodules, ulcerative stomatitis, septic arthritis,d a granulomatous
coelomitis. Middle and innerr abscesses are commonly seen in
captive and wildx turtles and other chelonians.163,164 Lesions
mayunilateral or bilateral. A variety of Gram-negativecteria have
been isolated from most cases, how-er, anaerobic bacteria, fungal
organisms and par-tes may be involved.163,164,165 The route of
infec-n may be via the eustachian tube. Organochlorineicity and
vitamin A deficiency are predisposingtors.163
Shell infections can involve the superficial keratinmay extend
into the osteoderms of the carapaced plastron. Aerobic and
anaerobic bacteria andcotic agents are commonly isolated.
Mucormyco-has been associated with ulcerative epidermitis
inft-shelled turtles (Trionyx ferox). This is a very seri-s
condition in this group of chelonians because ofe importance of the
integument and shell as a siteoxygen transport and osmotic
balance.166 Culture,ology, histopathology, and molecular
diagnosticsroutinely used to diagnose bacterial and fungal
ections. Special stains, such as acid-fast stains forcobacteria
spp., also may be needed to make agnosis.Treatment for bacterial
infections should includetibiotic therapy based on culture and
antimicro-l sensitivity. Anaerobic bacteria should be treatedth
metronidazole, penicillin, chloramphenicol, orndamycin.158 Because
of the caseous nature ofptile abscesses, complete surgical excision
of thescess and removal of the accumulated caseousc-impregnated
polymethylmethacrylate beadsve been used to treat osteomyelitis in
reptiles.167
e silver mesh described previously can be used tock wounds and
provides 72 hrs of antibacteriald antifungal activity.
Pharmacokinetic studies in-lving fluconazole and itraconazole in
sea turtlesve advanced the treatment capabilities for
fungalections.46,51
eumoniaeumonia is a common problem in critically
illelonians.1,168 Suboptimal temperatures, increasedmidity,
malnutrition, and overcrowding are pre-posing factors for
pneumonia.1,168 Because rep-s tolerate an anaerobic environment,
they cannceal clinical signs of pneumonia until the condi-n is
severe.168 Pneumonia can be caused by a wideay of infectious
diseases. Gram-negative bacteriarecovered from a large percentage
of the cases.ese are often opportunistic infections with thee
bacteria being considered normal flora in the
althy chelonian.168 Anaerobic bacteria are moreficult to
culture, but do represent an importantuse of pneumonia.158 Although
less commonly iso-ed, atypical bacteria such as Mycoplasma
spp.,lamydiophila spp., and Mycobacterium spp. are alsoportant
pathogens to consider.168,169 Herpesvi-ses have been implicated as
a cause of respiratoryease in several chelonian species,134,145 and
mayedispose the patient to secondary bacterial andngal
infections.Chelonians appear to be more susceptible to fun-l
pneumonia than other reptile orders.1,128,170,171
er exposure to fungal spores, immunosuppres-n, or overuse of
antibiotics are predisposing fac-s. Aspergillosis spp., Candida
spp., Mucor spp.,
otrichum spp., Penicillium spp., Cladosporium spp.,izopus spp.,
Beauveria spp., Sporotrichum spp., Basid-olus ranarum and
Paecilomyces spp. have all beenlated from chelonians with
pneumonia.128,170-172
grating nematode parasites and digenetic spi-rchid trematodes
may predispose the chelonian tocterial or fungal pneumonia.127,129
Aspirationeumonia may occur in debilitated chelonians.168
inical signs may include anorexia, lethargy, in-ased or abnormal
respiratory sounds, increasedspiratory rate (especially at rest),
and asymmetricating in aquatic species.168 Abnormal posture mayo be
noted in cases of inspiratory and/or expira-y dyspnea, which may
manifest itself as laboredeathing with the neck extended and
mouthen.168
-
Diagnosis of pneumonia is based on history,
phys-icaterwathmabrthIfbacashasppatraantainiatoudifgrme
clutritiemowiimfroheSucoelimeofshicsthvircrFuindi
difcasporAmerplalom
Acyclovir therapy is indicated when herpesvirus isdia
BuAqprunmemumathtesinceairleabelemenshmasutuadhacoShwian
SeBalaeneevalsormePeginheseindrliktrepopeshcapridpa
124 Terry M. Nortonl examination, and horizontal beam
anterior-pos-ior and lateral radiographic views.168 A trachealsh
should be performed before starting therapy ife patient can
tolerate the procedure.168 Sedationy be necessary. A sterile red
rubber catheter oronchoscope is placed through the glottis, downe
trachea, through a bronchus and into the lung.the pneumonia is
determined to be unilateralsed on the radiographic findings, then
treatmentn be targeted to that lung. Sterile saline solutionould be
flushed through the catheter and thenirated back. Bronchoscopy is
limited to largertients, but will allow visualization of the
respiratoryct and collection of appropriate samples. Cytologyd
culture should be performed on samples ob-ned from the pulmonic
lavage. Fungal pneumo-s often produce localized or diffuse
granuloma-s nodules, which makes recovery of the organismficult
without a biopsy. Nodules noted on radio-aphs may be suggestive of
fungal involve-nt.168,172,173
Treatment for a fungal pneumonia should in-de minimizing stress,
providing a positive nu-tional balance, and maintaining hydration.1
Pa-nts in extreme respiratory distress from pneu-nia should be
positioned on a slight incline
th their head and forelimbs extended.1 The an-al can be
intubated to facilitate suction of debrism the lower respiratory
tract. Coupage may belpful in bringing up debris to be
suctioned.pplemental oxygen may inhibit respiration andmpromise the
chelonians limited ability tominate inflammatory debris. 1 Oxygen
supple-ntation should be humidified to avoid irritation the
respiratory system.168 Bacterial pneumoniaould be managed with
broad-spectrum antibiot-. Nebulization therapy can be used to
increasee humidity of the respiratory epithelial microen-onment,
improve pulmonary hydration, and in-ease the mucociliary transport
mechanism.1,168
rthermore, it assists in breaking up necrotic andflammatory
debris and delivers antimicrobialsrectly to the site.Treatment of
fungal pneumonia in chelonia isficult and often unsuccessful. Some
authors advo-te prophylactic antifungal therapy in
susceptibleecies.1 Medical management generally consists ofal or
subcutaneous fluconazole51 or itraconazole.46
photercin B may also be used, and can be deliv-ed directly into
an affected lung via a catheterced through a carapacial
osteotomy.171
