“Scoop & Run” or “Stay & Play?”

Numerous studies in human medicine have evaluated the competing philosophies of “Scoop & Run” and “Stay & Play.” In situations where transport times are short, Scoop & Run may provide better outcomes.Reference Smith and Conn ⁷ However, these philosophies and outcomes have not been evaluated in animals, to the authors’ knowledge.

Triage

Vital signs in a human (respiratory rate, temperature, pulse, and blood pressure) are the same vital signs evaluated in a LEK9. It is feasible to teach EMS personnel how to evaluate these. Normal parameters are listed in Table 1. Monitoring equipment routinely found on an ambulance can also be used on a canine, when needed (Figures 1–4 and Table 1).

Figure 1.

Location to Auscult the LEK9’s Heart.

Abbreviation: LEK9, law enforcement canine.

Figure 2.

EKG Pads Taped to Paw Pad.

Abbreviation: EKG, electrocardiogram.

Figure 3.

Pulse Oximeter Attached to Tongue.

Figure 4.

Blood Pressure Cuff Placed on LEK9 Limb.

Abbreviation: LEK9, law enforcement canine.

Table 1.

Vital Signs and Monitoring Parameters

Abbreviation: LEK9, law enforcement canine.

Naloxone Administration for Opioid Overdose

The opioid epidemic continues to increase in the United States. ⁸ It has been documented that LEK9s are being exposed to fentanyl and potentially carfentanil-containing products in the line of duty. ⁹ This may present a serious health threat to these canine patients. At least four LEK9s have overdosed in recent years. ^{10 ,} Reference Koh ¹¹

Humans and primates are comparatively sensitive to the respiratory depressant effects of opioids compared to other mammals, such as LEK9s. However, now that fentanyl and carfentanil are commonplace on the streets, it is likely that accidental inhalation of these compounds may begin to clinically impact LEK9s because the potencies of these compounds are much greater than morphine or heroinReference Armenian, Vo, Barr-Walker and Lynch ^{12 ,} Reference Kukanich and Clark ¹³ (Table 2).

Table 2.

Relative Potencies (as Compared to Morphine)Reference Armenian, Vo, Barr-Walker and Lynch ^{12 ,} Reference Kukanich and Clark ¹³

Treatment of Opioid Overdose

Most first responders are familiar with using naloxone (Narcan; Adapt Pharma, Inc.; Radnor, Pennsylvania USA) to treat an opioid overdose in a human. Treatment in a canine is very similar. First, it is important to remember that the canine may have residual drug powder on their nose, face, paws, or body. Responders should wear gloves when attempting to resuscitate these canine patients and should never attempt mouth-to-snout ventilation (the act of a human placing their lips on a dog’s snout to give them a breath, typically utilized during cardiopulmonary resuscitation/CPR).

Naloxone can be administered intra-nasally (Figures 5a and 5b) or intramuscularly (Figure 6). To the authors’ knowledge, there are currently no published recommendations on the dose of IN naloxone to administer to a dog. However, unpublished research suggests that IN naloxone works well in dogs.Reference Palmer and Gautier ^{14 ,} Reference Otto ¹⁵ Extrapolating from human data and knowledge regarding the anatomy of a dog’s nasal mucosa, experts believe that administering naloxone IN would be beneficial. Intramuscular administration requires more technical expertise, and in the event that a first responder has not been trained in IM administration in a dog, the authors recommend they administer the naloxone IN (Table 3 shows dosing recommendations).Reference Palmer and Gautier ¹⁴

Figure 5a and 5b.

Intra-Nasal Naloxone Administration.

Figure 6.

Location for Intra-Muscular Injection.

Table 3.

Naloxone Dosing (for a 25kg Working Dog)Reference Palmer and Gautier ¹⁴

Abbreviations: IM, intramuscular; IN, intranasal; IO, intraosseous; IV, intravascular.

If the canine patient does not respond to an initial dose, the dose can be repeated in two minutes (Figure 7). If the canine patient is not breathing, a tight-fitting oxygen mask is attached to the LEK9’s snout and connected to a bag valve mask or Ambubag (Ambu Inc.; Columbia, Maryland USA). Ventilations are delivered at approximately six to ten breaths per minute. Laryngeal Mask Airways (LMAs) may also be used in LEK9s; however, EMS may find it easier to obtain a complete seal of the airway with an endotracheal tube. For the average 25kg LEK9, a Size 3 LMA can be used.Reference Wiederstein and Moens ¹⁶

Figure 7.

Naloxone Treatment Recommendations.

Many first responders are knowledgeable in how to intubate a human and provide artificial ventilation. Training on dog intubation is substantially easier than intubating a human (Figure 8). The average 25kg LEK9 would likely require a Size 9 endotracheal tube; however, smaller tubes more commonly found on an ambulance, such as a Size 7.5 or 8, could also be used.

Figure 8.

LEK9 Intubation Model.

Abbreviation: LEK9, law enforcement canine.

Oxygen Supplementation and Intubation

Oxygen supplementation is potentially life-saving and administration carries almost no risk to canine patients. It should be provided to any canine patient with a serious injury or respiratory difficulty where the law allows.

There are three potential options for increasing the canine patient’s fraction of inspired oxygen: flow-by, oxygen mask, and intubation. Flow-by oxygen can be administered by holding any type of oxygen-delivery device near the canine patient’s nose and mouth. This may be beneficial in conscious canine patients who do not tolerate a face mask. A face mask specifically designed for canine patients (Figure 9) can be used to create a tight-seal around a canine’s nose and mouth. This route of administration can increase the oxygen concentration upwards of 90% and the tight seal is essential for a dog that is hypo-ventilating or apneic to allow positive pressure ventilation. This method of ventilation (compared with endotracheal intubation) may force air into the stomach.

Figure 9.

Oxygen Mask Administration.

In an unconscious canine patient, intubation is relatively easy (compared to a human). Intubation should NEVER be attempted in a conscious canine. A Miller or MacIntosh laryngoscope blade can be used to visualize the epiglottis and the arytenoids. A Size 9 endotracheal tube will easily fit most LEK9s (average weight 25kg). Canine patients should be positioned lying prone with an assistant opening the mouth. If a laryngoscope is not available, a flashlight or smartphone light can be used to visualize the canine patient’s airway. Endotracheal tubes can be secured to the canine patient with gauze or white tape tied around the patient’s nose.

If a canine patient appears to regain consciousness after intubation, evidenced by swallowing, chewing, or movement of the limbs, the endotracheal tube should be removed immediately. It is relatively easy for a canine to bite through the endotracheal tube, lodging a foreign body in their airway.

If available, a capnograph should be placed on any intubated canine to monitor ventilation. An end-tidal CO2 concentration between 30-40mmHg is the goal.

In canines who are spontaneously breathing, yet are unconscious, it is advised to put them in the “sniffing” position, a common position for human intubation. The canine can be placed in lateral recumbency with head and neck extended. This position helps prevent the canine patient from obstructing their airway. Most canines will breathe adequately through their nose when they are not hot or exerting themselves. The canine should never be prevented from open-mouth breathing (panting), as this is their primary mechanism of heat dissipation.

Intravenous Catheter Placement

Two vessels are ideal for catheter placement in canine patients, the cephalic (front aspect of forelimb; Figure 10) and lateral saphenous (lateral aspect of hindlimb; Figure 11). Venipuncture can be facilitated by placing a tourniquet proximal to where the catheter will be inserted.

Figures 10a through 10e.

Cephalic Vein Intravenous Catheter Placement.

Figure 11.

Lateral Saphenous Vein.

Clipping (eg, shaving) a small section of skin around the vessel will facilitate visualization of the vessel, placement of the catheter, and taping of the catheter to the skin. An 18g IV catheter will be appropriate for the average size LEK9 (25kg), though 20g can also be used if there is difficulty placing an 18g. Catheters are most easily secured by taping them to the leg (Figure 10e).

Fluid Therapy

An IV fluid bolus may prove life-saving to a hypovolemic canine in the field, although the rate and amount are controversial. In canine patients with significant known or active blood loss, a quarter shock bolus (20ml/kg) of a crystalloid solution may be administered. In the average 25kg LEK9, this is equivalent to approximately 500mL. The fluid bolus can be given as rapidly as possible. Repeated boluses can be administered, depending upon the canine patient’s vitals. A veterinarian should be contacted at the earliest possible indication of an injured LEK9. The consulting veterinarian can direct fluid therapy en route via phone.

Canine patients with significant blood loss, or continued active hemorrhage, would benefit from routing to a veterinary hospital with blood transfusion and operative capabilities. At time of publication, a smartphone application is being created for first responders to use to help identify the veterinary hospital that is closest to them. Updates will be available at www.workingdogHQ.com.

Fracture Stabilization

Bone fractures are a common field injury in LEK9s. If EMS personnel suspect a fractured bone, the canine has likely experienced significant trauma. Before evaluating the fracture, an assessment of the canine patient’s vital signs for more critical injuries (such as pneumothorax or internal hemorrhage) should be performed. If no other emergent injuries are identified, an attempt may be made to stabilize the fracture for transport. This prevents further injury and may provide some analgesia. A human splint or other material can be used to stabilize the fracture for transport.

Pneumothorax

Development of a life-threatening pneumothorax is a common occurrence in humans experiencing blunt trauma; this is also true for LEK9s. Any LEK9 that has experienced blunt force trauma may develop a pneumothorax. This is a more complex procedure to teach EMS personnel without experience in canine anatomy. Auscultation for lung sounds on the dorsal aspect of the LEK9 (Figure 12) should precede any intervention. If lung sounds are not audible, the canine patient is in respiratory distress (excessive panting or short shallow breathing, respiratory rate >100bpm); if pulse oximetry is <95% and history is consistent with a possible pneumothorax (eg, blast injury or trauma to chest), a thoracocentesis may be considered if trained personnel are available.

Figure 12.

Location of the Dorsal Lung Fields (Black Rectangle).

Supplies needed would be the following: 20-gauge needle, or catheter, or butterfly catheter; a three-way stopcock; and initially, a 3cc syringe, then a larger syringe (eg, 20cc or 35cc).

Directions

This is at minimum a two-person job. Ideally, one person restrains the LEK9, one operates the syringe and stopcock, and another holds the needle/catheter in place in the chest. The canine patient should be laying sternal with the top of their head facing up (eg, they are laying on their sternum, not their back and not laying to one side) or standing if they are more comfortable. If time allows and equipment is on-hand, a small area in the top one-third of the seventh through ninth ribs (canines have 13 ribs; Figure 13) should be shaved and scrubbed. The needle is inserted into the chest at the cranial edge of the rib to avoid the neurovascular bundle at the caudal edge. Once the needle is in the chest, the stopcock is turned to the on position and gentle negative pressure applied to the syringe plunger. If positive for air, aspiration is continued until the syringe is full, then the stopcock is turned to the off position and the syringe is emptied. At this point, a larger syringe can be substituted to facilitate more rapid emptying. If negative for air, the stopcock is turned to the off position and the needle removed from the chest. The canine can be repositioned and the procedure can be repeated inserting the needle into a different site.

Figure 13a and 13b.

LEK9s Chest Location for Thoracocentesis (Shaved Square) and Thoracocentesis Equipment.

Abbreviation: LEK9, law enforcement canine.

Seizures

Seizures may develop secondary to a traumatic event (ie, head trauma), or they may be primary in origin (ie, epilepsy). For the purposes of this manuscript, seizure secondary to trauma is discussed, though treatment for both is the same in the field.

Ideally, the handler has been prescribed anti-seizure medication for any canine with a history of seizures. Depending on the legalities in each state, a veterinarian may or may not be able to prescribe anti-seizure medications via standing order to the EMS personnel in their county. If a standing order applies, canines in status epilepticus should be treated with IN, IM, or IV midazolam. Midazolam is a common benzodiazepine carried on an ambulance. New research suggests that IN midazolam may be beneficial in a seizing canine.Reference Charalambous, Bhatti and Van Ham ¹⁷ Intravenous administration of midazolam is also appropriate if an IV catheter is in place prior to seizure activity. Rectally administered midazolam is likely ineffectiveReference Schwartz, Muñana, Nettifee-Osborne, Messenger and Papich ¹⁸ (Table 4). Supplementary oxygen should be provided to the canine patient once seizure activity has stopped. Their head should never be positioned below their heart at any time.

Table 4.

Seizure Control

Abbreviation: LEK9, law enforcement canine.

Heat Stroke

According to the Officer Down Memorial Page, a website that attempts to track LEK9 deaths, one of the most common causes of LEK9 death is heat stroke. ¹⁹ This may occur after over-exertion in warm weather, or by being in a squad car when the air conditioning unit fails or the engine stalls out. Symptoms of heat stroke include: tachycardia, excessive panting, excessive tongue length, not retracting the tongue into the mouth (even during commands), and nausea; if left untreated, it will rapidly progress to shock, seizures, unconsciousness, multi-system organ failure, and death. Early recognition of symptoms is paramount to saving the canine. Body temperature, particularly in working dogs, is not an accurate measure of heatstroke. If a canine is in a hot car with no ventilation, heat stroke can ensue in as little as a few minutes.

Canines with heat stroke should be placed in a cool, shaded area, and hosed down with cool water immediately (rapid time to cooling is associated with a better prognosis). It’s important to make sure that residual water left in the hose is not initially used, as that can be hot and cause severe dermal burns. Fans can also be helpful, if available. If conscious, the canine can be offered cool water. If an IV catheter can be placed, particularly if transport to a veterinary emergency center is delayed, administration of room temperature or cooled crystalloid fluids (eg, 20mL/kg) may facilitate more rapid cooling. This can be repeated after assessment of vitals.

After initial cooling is attempted in the field, immediate transport to the nearest, appropriately equipped veterinary hospital will allow for IV fluid therapy and further monitoring for a minimum of 24 hours.

Sedation and Pain Management

Traumatic injuries can cause severe pain in working canines. Any condition that may be painful in a human should be considered painful in a LEK9. Severe pain may itself cause significant pathology, including tachy-arrhythmias, hyperventilation, and shock. Pain may also prevent first responders from providing life-saving treatment to a canine patient, due to aggression.

If providers cannot adequately treat a canine due to pain, telephonic consultation with a veterinarian should be sought for medication orders. This is, of course, dependent upon what drugs are available in the ambulance, and the medical status of the canine patient.

Ideally, veterinarians would prescribe standing orders for drugs (Table 5) for EMS providers in their county for canine care. The best option for analgesia would be a full mu agonist opioid (such as fentanyl or morphine). This can be given intravenously or intramuscularly.

Table 5.

Analgesic Agents

Abbreviations: IM, intramuscular; IV, intravascular; LEK9, law enforcement canine.

Medications outside of the opioid family may be beneficial, depending on the canine patient and situation. A veterinarian could prescribe ketamine, but should be contacted before administration since administering it as the sole sedative or analgesic is not recommended. It should also be noted that benzodiazepines (lorazepam and midazolam) often cause paradoxical excitement in dogs, and therefore are also not recommended as the sole sedative.

Smoke Inhalation

Smoke contains carbon monoxide, among other toxins. All dogs with smoke inhalation should have oxygen supplementation immediately while in transport to a veterinary facility for continued oxygen supplementation and monitoring. Dogs may appear normal or have increased respiratory rates. There may be loud respiratory noise (gurgling, snoring, whistles) on inhalation from swelling of the upper airway. They may have cherry red gums, and often have skin and/or eye burns (corneal ulcers). Swelling of the airway can progress for 24-72 hours.

Gastric Dilatation and Volvulus (GDV)

A GDV may also be referred to as a torsion or bloat and is most common in deep-chested dogs such as German Shepherds and Belgian Malinois. Clinical signs may include non-productive retching, pacing, and a bloated abdomen. In this condition, the stomach fills with gas and twists on itself, cutting off circulation, and preventing venous return to the heart (Figures 14a and 14b). As the stomach distends, it may also compress the diaphragm and lung fields, making ventilation difficult. A GDV is always a surgical emergency.

Figure 14a and 14b.

Radiograph of Gastric Dilatation Volvulus and Radiograph of Normal LEK9 Abdomen without Gastric Dilatation Volvulus.

Decompressing the air in the stomach is essential to restore circulation, facilitate breathing, and to prevent the stomach tissue from dying while the dog is stabilized for surgery. Field trocarization may be performed on a canine when the law allows, the canine patient is facing imminent death, and the veterinary facility is far away. The most significant danger is hitting the spleen.

The procedure entails inserting a needle or catheter into the area of the abdomen that likely has stomach under it. This is the area that will “ping,” or sound tympanic, if you flick it with your finger. It may be on either side of the dog and should be located between the end of the ribs and the beginning of the pelvis. The area over the spleen will not ping; it will be more of a dull sound and should not be trocharized.

Steps for Trocharization in the Field (Figure 15)

The spot with the loudest ping, or the most distended area of the flank, is identified. If possible, the area is shaved and prepped (wiped with antibacterial cleanser).

Figure 15.

Area to Trochar for Gastric Dilatation Volvulus.

The needle (18-20g) or catheter (16-18g) is carefully inserted into the gas-filled stomach. If using a catheter, the stylet is removed. A hissing sound should be audible as gas is released. When the hissing sound diminishes, gentle pressure is placed on the area to allow more gas to be released. The procedure continues until the hissing stops, then the needle or catheter are removed, and the LEK9 is transported to a veterinarian immediately.