Chelonian Emergency and Critical Care

Topics in Medicine and Surgery Chelonian Emergency and Critical Care Terry M. Norton, DVM, Dip. ACZM Abstract There are numerous chelonian species that arise from a diverse array of habitats. Chelonians are long lived and slow to reach sexual maturity, making them extremely vulnerable to human impacts on their habitat and populations. Unusual anatomic and physiological features, such as the shell and being ectothermic, make chelonians medically challenging for the veterinarian. This article presents information on the medical evaluation and stabilization of critically ill and injured chelonian patients presented to the emergency clinician. History taking, performing a physical examination, recommended diagnostic testing, fluid and transfusion therapy, cardiopulmonary resuscitation principles, nutritional support, hospital environment, and therapeutic agents recommended for the emergency and critical care of chelonians are reviewed. Differential diagnoses are presented for a variety of conditions encountered by the emergency clinician for marine turtles, tortoises, freshwater aquatic turtles, and terrapins. There are significant differences in the disease problems encountered by captive and free-ranging specimens. This review will be useful for the veterinarian working in private practice, zoological or aquarium medicine, and wildlife rehabilitation. Copyright 2005 Elsevier Inc. All rights reserved. Key words: Chelonian; critical care; emergency; terrapin; tortoise; turtle T he order Chelonia1 or Testudines2 includes tortoises, turtles, and terrapins and is comprised of approximately 270 species,1 one quarter of which reside in North America.2 Chelonians reside in a wide range of ecosystems. Aquatic species occur in marine, brackish, and freshwater habitats, while terrestrial species reside in desert to tropical environments. All reptiles, including Chelonia, are ectothermic and depend on environmental heat and behavior to attain their preferred body temperature (PBT). The preferred optimal temperature zone (POTZ) is a temperature range that allows reptiles to thermoregulate to maintain their PBT. The POTZ varies among the different species of chelonians. Chelonians have long lifespans, often surpassing humans, and are slow to reach reproductive maturity. For example, the loggerhead sea turtle reaches sexual maturity at approximately 25 to 35 years of age.3 The slow sexual maturity rates of chelonians tend to make them 106 more susceptible than other vertebrates to human pressure. These pressures include habitat degradation and destruction, collection for commercial traffic such as the pet trade, and exploitation for food and medicinal purposes. Chelonians are extremely hardy animals and can have normal activity despite being critically anemic (hematocrit ⬍5%) and hypoproteinemic (total protein ⬍1 g/dL). They can also survive months without food and tolerate extreme levels of dehydration. From the St. Catherines Island, Wildlife Survival Center, 182 Camellia Road, Midway, GA 31320. Address correspondence to: Terry M. Norton, DVM, Dip. ACZM, St. Catherines Island, Wildlife Survival Center, 182 Camellia Road, Midway, GA 31320. E-mail: tnmynahvet@ aol.com © 2005 Elsevier Inc. All rights reserved. 1055-937X/05/1402-$30.00 doi:10.1053/j.saep.2005.04.005 Seminars in Avian and Exotic Pet Medicine, Vol 14, No 2 (April), 2005: pp 106 –130 107 Chelonian Emergency and Critical Care Triage Principles In Chelonians Presented For Emergency Ideally, the emergency chelonian patient should be medically evaluated and then stabilized. However, initial emergency treatment may need to take precedence over a diagnostic work-up in a critically ill turtle. When possible, a minimum database should be established before starting emergency therapy. The keys to success in medically managing chelonians are patience, minimizing the stress throughout the course of treatment, minimizing the handling time by being prepared, treating dehydration and maintaining an adequate hydration status, providing appropriate nutritional support, and lastly, maintaining the turtle at its POTZ. History The medical history is an important step in assessing the critically ill chelonian.4,5 Captive specimens have a high incidence of medical problems related to husbandry issues. A questionnaire given to the client or caretaker can save time and request the following essential information:4 1. Reference data: date, client and animal identification, common and scientific names, captive or free-ranging specimen, presumed sex and age, duration of ownership, details of previous ownership, time in captivity, reason for presentation. 2. Information on the client’s animal collection: animals in direct and indirect contact with the presenting turtle. 3. Free-ranging specimens: GPS coordinates, specific location of where the turtle was found, time and date found, housing and transport conditions since that time, details on any treatment provided. 4. Housing: indoors, outdoors, both; enclosure description. 5. Environment: temperature range, heat source, humidity, lighting, photoperiod, recent changes, filtration and water quality in aquatic specimens. 6. Nutrition: describe diet in detail, seasonal variation in diet, vitamin or mineral supplementation, food preparation and storage, how is water provided and frequency of water changes. 7. Observations: description of activity level, appetite, fecal and urate/urine output and qual- ity and quantity, clinical signs and behavior, and duration of presenting signs. 8. Reproductive data: breeding and egg-laying details. 9. Disease control: methods of disease control, quarantine program details, disinfectants used, information on all humans in contact with the turtle, historical health problems in the collection, recent acquisitions. 10. Hibernation: details of management. Diagnostic Testing The initial diagnostic workup may include a physical examination, including body weight and morphometric measurements, clinical pathology, radiography, fecal examination, and possibly other specialized diagnostics. The emergency chelonian patient should be maintained within its POTZ during the diagnostic work-up. When working with these patients, the veterinarian should also minimize the likelihood of transmitting contagious diseases by wearing gloves, hand-washing between patients, and disinfecting equipment during the examination and hospitalization. Chelonians are challenging to evaluate medically and treat due to their highly evolved and effective structural and behavioral defenses. The shell is an anatomical feature unique to chelonians, and the primary reason they are such a medical challenge. The box turtle (Terrapene spp.) is the most extreme example of this adaptation and may retreat into its hinged shell so that it is difficult to safely assess without sedation. Depending on the patient’s physical condition and the species of chelonian, various levels of restraint will be needed for the initial evaluation. A detailed physical examination may require sedation or anesthesia; however, chemical immobilization should be delayed until the patient has been stabilized. A systematic approach should be followed when performing a physical examination on a chelonian. An observational examination of the turtle before handling can provide important information. General body condition, including overall musculature and fat, degree of alertness and strength, head and body symmetry, aural swellings, ocular abnormalities (eg, discharge, squinting, and sunken eyes from dehydration), nasal discharge, asymmetric nares, respiratory difficulty, open mouth breathing, cervical swelling, carapacial abnormalities (eg, fractures and other injuries or deformities), lameness or abnormal flipper use, abnormal skin (eg, dry, flaky or ulcerated), an inability to dive or floating asymmetrically 108 are all abnormalities that can be observed without handling the animal. A physical examination form that includes a turtle diagram is recommended for recording biological data and external abnormalities such as shell fractures, missing flippers or limbs, and lacerations. Digital images can be used to document specific lesions or injuries for long-term case monitoring. The gender,6,7 morphometrics, and age should be determined. A rough age estimate may be made by counting scute growth rings; however, these are not necessarily a sensitive method for age determination. Body weight should be recorded before therapy, and then measured serially during treatment. Weight trends can be a good indicator of hydration status. Deep cloacal temperature may be representative of the chelonian’s recent environmental temperature, and is an important parameter to obtain and monitor in hypo- and hyperthermic patients. A digital, distant laser, thermal monitoring device (Raynger St, Raytek Corporation, 1201 Shaffer Road, P.O. Box 1820, Santa Cruz, CA USA) can be used to detect surface body temperature, and when directed at the prefemoral or prescapular areas correlates well with core body temperature.4 Heart rate and rhythm can be assessed with an esophageal stethoscope, a pulse oximeter cloacal probe, or a doppler probe placed in the region of the thoracic inlet between the distal cervical region and the proximal front leg.8-10 Evaluate the limbs for swollen joints and fractures. The plastron and carapace should be evaluated for scute quality, abnormal keratinization, hardness and pliability, pyramiding, fractures, ulceration, malodor, and external parasites or epibionts. Hemorrhage within the scute keratin may be indicative of trauma if localized or septicemia if more generalized. Shell fissures usually occur at the plastron/ carapace junction and may indicate septicemia, vasculitis, or hypoproteinemia.11 Examine the skin for sloughing, abnormal shedding, swellings, edema, abscesses, ulceration, exudate, malodor, and epibiota and external parasites. Digital palpation of the caudal coelomic cavity through the inguinal fossa can be used to confirm the presence of eggs, cystic calculi, organ enlargement, masses, or fluid. The cloacal region should be examined for swelling, trauma, abnormal discharge, infection, and myiasis. In larger chelonians, digital palpation of the cloaca can be used to assess gravidity, colonic and cloacal tone, cystic calculi or space occupying lesions.4 Exteriorizing the head of the chelonian from the shell and performing an oral examination can be Terry M. Norton difficult for the veterinarian and stressful for the chelonian. This examination may need to be delayed until the turtle is stabilized.4 Once the head is exteriorized, inspect the oral cavity including the tongue, glottis, choana, and outlets of the eustachian tubes. Particular attention should be given to mucous membrane color, the quantity of mucus, petechiation, plaques, ulceration and caseous material. Be prepared to obtain any diagnostic specimens and administer any medications or nutritional support via a stomach tube if indicated. Perform a complete ophthalmic examination of the cornea, anterior and posterior chambers, and menace and papillary visual reflexes. A periocular examination and evaluation of the beak, mandible, tympanic membranes and nares should also be performed while the head is restrained. An emergency chelonian minimum database should consist of a hematocrit, total solids, glucose, and subsequently, a complete blood count and plasma biochemical panel. Bacterial blood cultures should be collected before initiating antimicrobial therapy. While the size and patient condition will dictate the amount of blood that can be safely collected, the author generally recommends 0.5 to 0.8 mL/100 g body weight for healthy patients and a reduced sample volume for diseased patients. Lithium or sodium heparin are the anticoagulants of choice, because EDTA can cause red blood cell lysis in chelonians.12 A wide range of venipucture sites can be used in chelonians,4,13-17 and the choice of site should be based on the species, size and condition of patient. Lymph contamination of the blood sample is a common problem in chelonians and will alter many clinical pathology parameters.13,16,18-20 Collection of blood from the jugular vein is preferred based on the low incidence of lymph dilution from this site,13 but may be stressful and not always feasible due to the difficulties in accessing the vein. Alternative sites used by the author include the brachial and subcarapacial veins in tortoises, the dorsal tail vein in aquatic species, and the cervical sinus in sea turtles. Radiography is an important diagnostic tool used to assess chelonian emergencies. Useful reviews of chelonian radiography are available.21-26 Radiopaque materials such as barnacles should be removed from the shell before performing a radiographic study. Three radiographic views should be routinely performed in chelonians presented for emergency care: anterior-posterior and lateral projections using a horizontal x-ray beam and a dorsoventral view.22,23 Additional views such as lateral, dorsoventral and oblique, may be needed for specific problems such 109 Chelonian Emergency and Critical Care as fractures of the limbs or skull. An anterior-posterior horizontal beam radiograph should be taken in chelonians with fractures of the carapace to assess lung involvement.26 Digestive tract radiographic contrast procedures are often necessary to document intestinal obstruction and foreign bodies.22 Determining Hydration Status and Fluid Therapy On completion of the initial evaluation, the patient should be stabilized. Most chelonians presented for emergency care are dehydrated, thus rehydration is often the first step in treatment. Physical examination findings indicative of dehydration in chelonians include sunken eyes, changes in skin turgor, skin tenting, loss of skin suppleness, dry mouth with ropey, thick oral secretions, depression, a slow and difficult to find heart beat, and minimal to no urination. Venipuncture and tube feeding are more challenging in the dehydrated patient.1 Weight loss found over 1 to 14 days is likely caused by dehydration, thus serial body weights should be performed during hospitalization.1 Elevation of the packed cell volume (PCV) and total solids or total protein (TP) can be helpful in determining the extent of dehydration. However, ill chelonians are often anemic and hypoproteinemic, which may mask the extent of dehydration. Serial PCV and plasma TP determinations help assess the status of the patient and target the most appropriate therapeutic regimen. Hypoglycemia or hyperglycemia is often present in sick chelonians. Blood glucose determination is easy, quick, inexpensive and essential in choosing the appropriate fluid therapy in chelonians. Fluid Types Selecting the route, rate and type of fluids to administer depends on the species of chelonian and condition of the patient. Fluid choice is frequently dictated by clinician preference, the patient’s presenting problem, and clinical pathology and acid-base abnormalities. Many ill tortoises have isotonic or hypotonic dehydration.27 Lactic acidosis is common in stressed chelonians. Most debilitated chelonians benefit from rehydration therapy and glucose supplementation. Mammalian crystalloid fluid preparations are suitable for chelonians. Fluids commonly used in chelonians include “reptile ringers solution” (one part Lactated Ringers Solution ⫹ 2 parts 2.5% dextrose and 0.45% sodium chloride),27-29 Normasol-R1, and lactated ringers solution. Use of lactated ringers solution is controversial in chelonians based on the common finding of lactic acidosis.27,28 It is critical to correct hydration status of the ill chelonian before starting oral nutritional support. Whole blood transfusions are indicated in cases of acute hemorrhage and life-threatening anemia.30 Sea turtles with a PCV ⱕ5% may benefit from a whole blood transfusion from a healthy captive sea turtle donor (Manire, C, pers comm., 2005). Those chelonia with a PCV ⬎5% can often be successfully managed with fluid therapy, iron supplementation, and other supportive measures. The donor and recipient should be the same species, because cross matching has not been perfected in reptiles. Acidcitrate-dextrose solutions are the preferred anticoagulants for storing blood for transfusions. Hetastarch, diluted 1:2 or 1:3 with 0.9% saline, can be given at a rate of 0.1 mL/kg every 10 to 15 minutes in chelonians with severe shock from massive blood loss.1 A purified bovine hemoglobin (Oxyglobin, Biopure Corp., Cambridge MA 02141) has had limited clinical use in sea turtles,29 desert tortoises,30 and a terrapin31 without adverse affects. In healthy desert tortoises (Gopherus agassizi) this product was administered at dose of 20 mL/kg IV without adverse effect.30 A Hispaniolan slider, Trachemys decorata, was resuscitated after near exsanguinations with the use of Oxyglobin and a single blood transfusion from another individual of the same species. Discolored mucous membranes are normally observed after using this product.30 Route of Fluid Therapy Intravascular. In severely compromised chelonians, intravenous (IV) or intraosseous (IO) routes of fluid administration allow for rapid rehydration and emergency therapy. However, placement and maintenance of catheters in these sites can be technically challenging, especially in aquatic species, and should be reserved for patients that are unconscious or minimally responsive.1 The jugular vein is the preferred site for IV catheter placement in most chelonians. A small skin incision allows direct visualization of the vessel. After catheter placement, secure the catheter to the skin with tape and or suture.1,32 Maintaining patency of the jugular catheter may be difficult, especially in active turtles.33 Intravenous or IO routes are necessary for administration of whole and artificial blood, colloidal fluids, and fluids containing greater than 5% dextrose.1,30,34-36 Intraosseous catheters may be placed in the distal humerus, distal femur or plastron-carapacial bridge.33,37 An appropriately sized spinal needle can be inserted into the distal one fourth of the medial aspect of the humerus at an angle of approximately 30 to 45° from 110 parallel. The needle should be inserted as distally as possible without entering the joint capsule. Confirm the spinal needle position radiographically. The catheterized limb should then be reduced into the fossae and secured with tape to the carapace.33 The primary disadvantages associated with IO catheters are that the fluid flow rate is limited due to the small bone marrow space, fluid and drug administration may be painful, and the metal of the spinal needle may fatigue and break.38 Bolus IV fluid therapy can be used to stabilize some patients before pursuing other routes of administration. The subcarapacial vein is used for most chelonians and the cervical sinus for sea turtles. Advantages to the bolus IV method include easy vessel accessibility, minimal stress to the patient, and repeated vascular access. The epicoelomic fluid administration site is useful in chelonians that are completely retracted into their shell and difficult to coerce out. McArthur (2004) describes this as the preferred site for fluid administration to critically dehydrated chelonians.27 The needle should be inserted into the potential space located dorsal to the plastron and ventral to the pectoral muscles, coelom, and the scapulohumeral joint, and directed caudally toward the opposite hind leg.32 The intracoelomic (IC) route is commonly used for maintenance fluid therapy in sea turtles. Fluids may be injected into the coelomic cavity through the inguinal fossa. An IC catheter has been described for use in sea turtles for up to 5 days.27,39 This route is technically easy and allows administration of crystalloid fluids with up to 5% dextrose, however, fluids may not be absorbed rapidly when given by this route. Disadvantages of coelomic administration include the potential of compromising the lung space or perforating the lungs, the urinary bladder,32 or an ovarian follicle in mature females. Hypoproteinemic patients may have fluid in the coelomic cavity (ascites/anasarca), which will further complicate absorption. Subcutaneous fluid administration is technically easy. Fluids can be given into any accessible fold of skin, but are typically placed into the inguinal fossa, front limb fossa, or ventral neck fold. Administering the fluids in multiple sites may improve absorption and rehydrate the chelonian faster. Disadvantages to this route include poor absorption in severely debilitated chelonians and that only ⱕ2.5% dextrose solutions can be administered. The oral route of fluid administration should be reserved for use in patients with functional gastrointestinal tracts that are mildly to moderately dehydrated and for maintenance fluid therapy. Severely Terry M. Norton dehydrated and weak turtles tend to regurgitate orally administered fluids. Fluids can be administered directly into the stomach using an appropriately sized, well-lubricated red rubber or metal feeding tube. An equine stomach tube may be used for large chelonians. For long-term oral medication, fluid therapy and nutritional support, an esophagostomy tube should be considered. The stomach volume in most chelonian patients is about 2% of the body weight or 20 mL/kg.1,32 Anatomically, the stomach is located in the anterior one third to midcoelomic cavity. The distance to the anterior portion of the stomach should be marked on the tube selected for feeding. In species prone to regurgitate after tube feeding, such as sea turtles, the patient should be placed at a slight incline on a padded board to avoid regurgitation and to assist in passing the feeding tube into the stomach. The head and neck should be extended to straighten the esophagus for tube passage. The head should be secured by grasping the turtle on either side behind the mandible. Steady downward pressure will cause the lower jaw to fatigue and open. A padded speculum or polyvinyl chloride tube can be used to keep the mouth open. The turtle should be held in a vertical position after the tube is removed and its head and neck extended until it swallows to prevent leakage or regurgitation. Finally, soaking mildly dehydrated patients in shallow luke warm water (75-80° F), which reaches to just below the chin when the head is retracted, will assist in rehydration.32 Mildly dehydrated marine and estuarine turtles will benefit from placement in fresh water for 24 hours. Not only will this help to rehydrate these animals, but exposure to fresh water will also reduce the epibota load. Fluids, various drugs, elemental diets, and dewormers may be administered by the intracloacal route.1,40 Absorption may be improved if the caudal aspect of the turtle is elevated higher than the cranial aspect for 10 to 20 minute after fluid administration. Volume of Fluids to Administer. The volume of fluids to administer depends on the degree of dehydration and if hypoproteinemia and anemia are present. Fluid volume should not exceed 2 to 3% total body weight (TBW) in chelonians.41 Generally recommended maintenance fluid rates range from 15 mL/ kg/d in species greater than 1 kg to 25 mL/kg/d in species less than one kilogram. A severely dehydrated patient may tolerate up to 40 mL/kg/d. However, over hydration is a concern because of the slow metabolism in chelonians.32 Infusion or syringe pumps can be used to accurately control the flow rate. 111 Chelonian Emergency and Critical Care Table 1. Emergency Drugs Used to Treat Chelonians Drug Dosage Comments Doxapram Prednisolone sodium succinate 5 mg/kg IM, IV1 5 to 10 mg/kg IV1 Dexamethosone sodium phosphate Methylprednisolone Glycopyrrolate Atropine Epinephrine (1:1000, 1 mg/ml) Midazolam Diazepam Activated charcoal, kaolin 0.1-0.25 mg/kg IV/IM1 Calcium EDTA 10-40 mg/kg IM q12 h79 Vitamin K1 Iron dextran Calcium gluconate Calcium lactate/Calcium glycerophosphate Potassium chloride 50% dextrose 0.2-2.5 mg/kg PO or IM176, as needed 12 mg/kg IM 1-2 times/wk176 100 mg/kg IM or IC q 8 h176 10 mg/kg SC, IM176 Mineral oil Cisapride 6-10 mg/kg PO79 0.5-2.0 mg/kg PO q 24 h176 Respiratory stimulant Short-acting steroid, used in shock therapy Same as above 20 mg/kg IV1 0.01 mg/kg or 0.05 ml/kg IV, IM, SC1 0.01-0.02 mg/kg IV, IM, SC1 0.1 mg/kg IV, intracardiac177 1.0 to 2 mg/kg IM or IV67 0.5 mg/kg IV79 2-8 gm/kg oral via stomach tube93 15-30 mEq/L of fluid29 1 mL/kg IV CPR Principles in Chelonians The following protocol is recommended for chelonians presented in respiratory or cardiovascular arrest. First, determine if the animal has a heartbeat with a Doppler probe, electrocardiogram, and/or ultrasound. Proceed only if cardiac electrical activity is present. Second, extend the head and neck, swab the mouth to remove any materials blocking the glottis, and intubate the patient with an uncuffed endotracheal (ET) tube. Use suction and or gravity to remove any material from the ET. Ventilate the patient with oxygen. An ambubag can be used for field emergencies. Lubricate the eyes if they are open. In the author’s experience, resuscitation is futile if there is pungent odor on exhalation or suction, reduced global pressure that gives the eyes a dented appearance, and increased jaw tone. These findings dictate euthanasia even if there is a heart beat.1 Place an IV or IO catheter, obtain blood for a minimum database, and then bolus fluids and emergency medications. If the heart rate remains below 20 bpm with ventilation and bolus fluids, glycopyr- Short-acting steroid, CNS trauma Treat bradycardia Treat bradycardia Cardiac stimulant Control seizures Control seizures Absorbs and neutralizes some poisons Heavy metal chelator, zinc and lead toxicity Coagulopathies, hepatic disease Iron-deficiency anemia Hypocalcemia Hypocalcemia Hypokalemia Recommend administering at 5-10% in fluids slow bolus for hypoglycemia Gastrointestinal stasis rolate (IV) or atropine (IV) should be administered.1 Epinephrine can be given IV, IO, IP, intratracheally or intracardiac.33 Therapeutic Agents Used in Chelonian Emergency and Critical Care Although several pharmacokinetic studies have recently been conducted on chelonians,42-53 limited information is available on accurate dosing for the numerous species presented to the emergency clinician (Refer to Tables 1, 2, and 3 for dosages). Drugs with available pharmacokinetic data should be selected when possible. Although there are limitations to metabolic scaling, it can be a useful tool when no pharmacokinetic data are available.1 Because sick chelonians do not necessarily absorb drugs well, it is important to correct hypothermia, dehydration, hypoglycemia, acid-base and electrolyte imbalances before or in conjunction with starting other therapeutic agents. This is especially important when using nephrotoxic or hepatotoxic drugs and anesthetics. Drug pharmacokinetics are temperature dependent 112 Terry M. Norton Table 2. Antimicrobials Used to Manage Critical Care Chelonian Patients Drug Dosage and frequency Comments Ceftazidime *5 mg/kg IM q 48 h (gopher tortoises)42, 2.53.0 mg/kg IM q 72 h (sea turtles), 50 mg/ 10 ml saline ⫻ 30 min nebulization q 12 h *20 mg/kg SC, IM, IV q 72 h44,45 Chloramphenicol 30-50 mg/kg IM q24h, 50 mg/kg PO q24h79 Clarithromycin Clindamycin *15 mg/kg PO q 48-72 h47 5 mg/kg PO/IM q 24 h Enrofloxacin *5 mg/kg SC/IM q 24-48 h,49,50 *10 mg/kg PO q 24 h53 *20 mg/kg PO q 48 h (anaerobes) (yellow rat snakes and iguanas)48 Amikacin Metronidazole Fluconazole Itraconazole Acyclovir Targets primarily Gram-negative bacteria, potentially nephrotoxic Targets primarily Gram-negative bacteria, less nephrotoxic than amikacin Bacteriostatic, aerobic, and anaerobic antibacterial spectrum Used to treat Mycoplasma URTD Good anaerobic spectrum, use in combination with amikacin, ceftazidime, or enrofloxacin Irritating to tissue, recommend diluting and giving SQ Excellent efficacy against anaerobic bacteria, very bitter, potential for toxicity *21 mg/kg loading dose, then 10 mg/kg q 5 d SQ, IV51 *5 mg/kg PO SID or 15 mg/kg PO q 72 h (sea turtles)46 80 mg/kg PO SID1 to TID30; Topical (5% ointment) q 12 h30 *indicates the dose is based on pharmacokinetics, duration of therapy will depend on the clinical problem and response, but most antimicrobial regimens in critically ill chelonians are administered for a minimum of 2-3 weeks. in reptiles, and it is best to maintain the chelonian patient at its POTZ during therapy.32 Many medications are unpalatable when administered orally, but can be followed by something palatable (eg, a/d diet, tuna juice, fruit or sweet vegetable baby food) to lessen the negative effect.1 Antimicrobial Therapy in the Critically Ill Chelonian Sick and injured turtles are usually given broadspectrum antibiotics as a treatment for established bacterial infections or as a preventive measure (Refer to Table 2 for dosages). Diagnostic samples should be obtained for culture and antimicrobial sensitivity testing before starting antibiotic therapy whenever possible. Although controversial, the front half of body, including the soft tissues of the forelimbs and neck, should be used for injections,1,54,55 especially when using nephrotoxic drugs. Enrofloxacin is a commonly used antibiotic in chelonians and has good efficacy against aerobic Gram-negative bacteria. Unfortunately, it can cause tissue necrosis when injected multiple times IM or SQ and is painful on administration. The irritating effect of the drug can be reduced significantly by diluting it in fluids or sterile water and using the subcutaneous route for injection. Once the patient is stabilized, it can be administered orally.53 Anaerobic bacteria can also cause significant morbidity in chelonians and should be considered when deciding on a therapeutic plan. Analgesic in the Critically Ill Chelonian Many critically ill chelonians are painful and benefit from analgesics. Chelonians are relatively stoic and challenging to assess for pain (refer to Table 3 for dosages). Pain may be exhibited in chelonians by a decreased appetite, depression, or alteration in normal behavior. The nonsteroidal antiinflammatory drugs (NSAID) are long acting and decrease endotoxin production in septic patients.1,56,57 Meloxicam, carprofen, ketoprofen, and flunixin megalimine have all been used in chelonians.1,56,57 Although NSAID efficacy has not been evaluated extensively by controlled studies, anorexic and depressed cheloni- 113 Chelonian Emergency and Critical Care Table 3. Analgesics and Anesthetics Used to Manage Critically Ill Chelonian Drug Butorphanol Dosage Comments 0.2-2 mg/kg IM, 0.2-0.5 mg/kg IV, IO67 Premedication, analgesia, lower dose if debilitated, 4h duration Buprenorphine 0.1-1 mg/kg IM67 Same as above Meloxicam *0.2 mg/kg SC, IM, IV; 0.4 mg/kg PO q24-48 Rehydrate patient prior to hrs56 administration Carprofen 1-4 mg/kg PO, SC, IM, IV q24h175 Same as above Medetomidine/ketamine M/K Tortoises- M: 0.075 to 0.15 mg/kg K:5 Reverse M with atipamazole at 5 mg/kg58,59,60,65,66; Aldabra tortoises- M:0.025 to times the Medetomidine dose in 0.08 mg/kg, K:5 mg/kg59, Freshwater aquatic mg (same volume) turtles- M:0.3 mg/kg, K:5 mg/kg67, can add 0.4 mg/kg butorphanol to this regimen67; Propofol 10-15 mg/kg IV67; desert tortoises: low dose 2-4 Administer slowly to effect over 1-2 mg/kg IV, moderate dose 5-8 mg/kg IV, high minutes, dilute 1:2 with saline67 dose 12 mg/kg IV67 ans often develop normal feeding behavior and activity after NSAID administration. Adequate hydration and renal function should be assured before NSAID administration and duration of administration should not exceed 3 to 5 days.57,10 The opioids, butorphanol and buprenorphine, are commonly used in chelonians to manage pain. The disadvantages associated with opioid administration are that they are relatively short acting and may cause sedation in debilitated patients. Butorphanol is contraindicated in patients with head trauma.1 Anesthesia in the Critically Ill Chelonian While anesthesia or sedation is necessary in some emergency situations, it should be used with caution in dehydrated or debilitated patients (refer to Table 3 for dosages).1,32 A thorough diagnostic workup should occur before anesthesia and should be delayed if the heart rate less is ⬍15 bpm when the patient is maintained at its POTZ, if blood work reveals a PCV ⬍10% or a plasma TP ⬍2.0 g/dL, or if there is evidence of sepsis or severe respiratory compromise.1 Several excellent reviews and controlled studies on injectable and inhalant anesthestic regimens have been recently conducted in chelonians.57-67 It is important for the emergency clinician to be comfortable with a few anesthetic regimens that can be applied to a wide range of chelonian species under a variety of circumstances. The author’s preference for injectable anesthetics include the combination of medetomidine and ketamine58,59,66 or propofol IV67 for short, relatively noninvasive procedures or for induction of general anesthesia. The advantages of the medetamidine and ketamine combination are that it may be given IM or IV, the medetomidine is reversible with atipamezole, and very low doses of ketamine may be used because of the synergism with medetomidine. The low ketamine dose does make a significant difference in the level of sedation and muscle relaxation. Butorphanol may be added to the medetomidine and ketamine cocktail for additional analgesia and sedation.67 Disadvantages of the medetomidine and ketamine anesthetic regimen include significant species variations in anesthesia and sedation in response to the drug combination and induction of significant bradycardia, hypotension, hypercapnia, and hypoxemia. Furthermore, these drugs may be contraindicated in debilitated or dehydrated chelonians, especially those with hepatic or renal dysfunction. The lower end of the dose range should be used in debilitated chelonians. Propofol is a hypnotic sedative that provides rapid induction. While intravenous injection is preferred, the drug does not cause irritation if it is administered extravascularly.57 If propofol is given by rapid infusion, it can cause a marked respiratory depression.67 Propofol dosages for chelonians range from 2 to 15 mg/kg, and recovery rates are dose dependent. Use the lower end of the dose range in debilitated chelonians to allow intubation. Local anesthesics, such as lidocaine, may be used alone or in combination with injectable or inhalation anesthesia.68 Inhalant anesthetics should be used for invasive or prolonged procedures. In critical chelonian pa- 114 tients, it may be advisable to use inhalation anesthetics without an injectable induction agent. Ventilation and thermoregulatory support should be maintained during the procedure and throughout the recovery period. Monitor heart rate via a Doppler, pulse oximeter, or ECG. Intraoperative fluid therapy and vascular access for emergency support should be maintained. Although isoflurane is useful in reptiles, sevoflurane provides significant reduction in recovery times and may be more appropriate for critically ill patients.64 Sea turtles are notorious for prolonged recoveries with a variety of anesthetic regimens and have much faster recoveries when using the reversible combination of medetomidine and ketamine for induction and sevoflurane for maintenance anesthesia.69 Nutrition Needs of this Species in the Emergency Setting Nutritional support is an important component of chelonian critical care.1 Patients respond more quickly to therapy if their nutritional status is positive.1 The critically ill chelonian is often immunosuppressed secondary to starvation.1 Regurgitation and aspiration may occur in dehydrated and debilitated chelonians. These turtles may not be able to digest solid food and the material may remain in the stomach as a result of decreased gastrointestinal (GI) motility. Thus GI nutritional support should not be instituted until the patient has been rehydrated and attains normal blood glucose and GI motility. The volume of formula fed by stomach tube is approximately 7% of the turtle’s body weight in grams daily. Begin with smaller volumes and more dilute solutions and steadily increase the volume and concentration to meet the turtle’s nutritional requirements. The turtle should be weighed daily during the convalescent period, and the measurement of weight gain or loss can be used as a guide for dietary management. Esophagostomy tubes (E-tubes) are integral in managing the critically ill chelonian. The stress associated with tube placement is short, and usually far outweighs the stress associated with daily head restraint to administer oral medications, fluid therapy, and nutritional support. An E-tube may be left in place for months, is usually well tolerated by the turtle, and most clients can manage the turtle with an E-tube at home. The tube should be left in until the animal is eating normally. An E-tube may be stressful to patients where the tube prevents them from withdrawing into the shell, and therefore may be contraindicated in such patients. Possible complications of E-tube placement include cellulitis or ab- Terry M. Norton scess formation at the stoma site and ulceration or erosion with or without perforation of the gastric wall at the point where the tube contacts the stomach. Smaller patients are at greater risk of developing problems from the E-tube. Smaller tube size and the propensity to clog with thick solutions may limit the ability to meet the patient’s nutritional needs. The technique for placing an E-tube has been described.1,27 Sedation is recommended for tube placement. Test the formula to be used before tube placement to assure it will pass through the tube without clogging. The tube should enter at the mid to lower esophagus rather that the upper esophagus or pharyngeal region. Premeasure the tube and obtain radiographs after E-tube placement to confirm tube positioning. A purse string suture and Chinese finger lock suture will secure the tube. Flexible tubing should be used that allows for flexion and extension of the neck. After feeding, the tube should be flushed with water or saline to remove any gruel. Enteral tube feeding formulas that have been used in various species of chelonians can be found in Table 4. Hospitalization A dedicated room or facility designed to accommodate the various levels of medical care required for chelonians is ideal, however, this is usually not practical. The veterinarian and hospital care staff should have access to literature on the natural history and husbandry needs of the various chelonian species presented to the facility for medical care2,70-75 (www. chelonia.org, world chelonian trust web site). Hospital personnel should be trained in chelonian husbandry and medicine. The importance of infectious disease control during the physical examination, diagnostic work up, and hospitalization cannot be overemphasized. Chelonians with suspected infectious disease should be hospitalized in isolation. In aquatic settings, separate filtration systems should be used for turtles with suspected infectious diseases. Captive specimens should not be exposed to wild specimens and visa versa. The clinician should avoid mixing species and separate animals from different sources. Enclosures should be simple in design and made out of easy to disinfect, nonporous, nonabrasive materials such as plastic, glass, painted or sealed wood, stainless steel, or fiberglass. Plastic storage tubs, plastic swimming pools, and modified plastic dog kennels can be used to house hospitalized chelonians. Intensive care units used for avian species can be used for smaller critically ill chelonians. The best substrate for use in a critical care setting should pose minimal fire risk, if ingested should not cause 115 Chelonian Emergency and Critical Care Table 4. Enteral Feeding Formulas and Diets for Anorexic and Critically Ill Chelonians Enteral diet information Herbivores Comments Critical Care diet (Oxbow Pet Products, 29012 Mill Road, Murdock, NE 68407, 800-249-0366) 1 part alfalfa pellets blended for several minutes with 2-4 parts water Alfalfa Powder78 (NOW foods, Glendale Heights, IL 60108), comprised of alfalfa that has been harvested, dried and powdered, can mix with fruit baby foods for frugivorous species Green Powder78 (NOW foods, Glendale Heights, IL 60108), comprised of barley grass that has been harvested, dried and powdered. Omnivores/ Carnivores Elemental diets easily absorbable Emeraid II (Lafeber Co., Cornell, IL 61319) Walkabout Farms enteral feeding diets Canine/feline a/d diet® (Hill’s Pet Nutrition, Inc., Topeka, KS 66601) (mixed with 4 jars of vegetable baby food) Critical Care diet (Oxbow Pet Products) Ensure ®(Abbott Laboratories, Abbott Park, IL 60064) alone or mixed with fish blenderized (sea turtles), add mixed green vegetables for green sea turtles (Chelonia mydas) Walkabout Farms enteral feeding diets 1) Peptamen (elemental diet for children) (Nestle USA Inc., Deerfield, IL 60015) 2) Vivonex Novartis, (Novartis, Minneapolis, MN 55416) an impaction, and should allow for proper wound and waste management.76,77 Compressed, baled hemp chippings, shredded paper, newspaper, and rabbit pellets may be used.76,77 Hide areas within the enclosure should be used to make the patient more comfortable and assist in thermoregulation. Hides can be made out of disposable materials such as cardboard boxes and margarine containers with holes cut in them. Appropriate containers for food and water should also be provided. Hospital personnel should become familiar with the POTZ for the species presented for emergency evaluation and potential hospitalization. In general, reptiles are hospitalized at the mid- to high end of their POTZ, but should still be provided with a thermogradient. Basking lights, infrared ceramic heat bulbs, or thermostatically controlled radiant heating panels can be mounted to walls of the enclosure or Alfalfa based product, may clog smaller tubes, www.oxbowhay.com Very thick and may clog tube Health or natural food stores, 1 part volume powder to 5 parts of water, only short term by itself, add extra calcium, Vit D, psyllium (methylcellulose)-motility disorders Same as above, more crude fiber, lower crude protein, lower levels of Ca and Ph so better for gout and renal failure http:www.herpnutrition.com Add vitamin/mineral supplementation http:www.herpnutrition.com the cage front. The heat source should always be placed outside of the enclosure. Under tank/enclosure heating elements are not recommended. Diurnal heat cycles (lowering the temperature at night) are beneficial to recovering chelonians.76 Infrared or ceramic heat emitters can be used as nighttime heat sources without affecting photoperiod. Timers can be set for light and heat source activation. The environmental temperature for a hospitalized patient should be monitored daily with maximum and minimum thermometers or digital thermometers. Sick chelonians that are too weak to move from a heat source should be monitored closely. Basking chelonians require exposure to full spectrum lighting.78 Several weaker UVA and UVB-emitting fluorescent tubes are commercially available.78 However, artificial lights cannot replace the benefits of natural sunlight, thus moving the patient out- 116 doors when weather permits is probably best. Containers that facilitate moving the patient inside and outside are helpful and efficient.76 Humidity should be measured and monitored in all enclosures. As a general rule, desert chelonians need to be kept at humidity levels ⬍40%, while tropical species need humidity levels of ⬎ 60%.77 The humidity can be increased if necessary by providing heated water in bathing areas, regular misting and dampening of substrate, using damp soil or peat/sand base substrate, and keeping lids on holding areas. Open top enclosures will provide better ventilation and are preferred for most chelonians.76 Initially, debilitated aquatic and semiaquatic species should be dry docked on a padded surface, such as a shower box or plastic draining board mats.79 These turtles can be kept moist by regular misting and placing Vaseline or another water soluble (K-Y) jelly on the skin and shell. Once stabilized, these animals require specialized facilities. Marine turtles should be provided specially designed circular fiberglass tanks with a filtration system and continuous flow, temperature controlled salt water. You must adjust water levels to accommodate turtles with varying degrees of debilitation. Water quality issues need to be addressed for all aquatic species. Semiaquatic species need haul out areas with a basking heat source. Turtles should not have direct access to electrical outlets, cords or filtration systems. Differential Diagnosis and Medical Principles of Emergency Care in Chelonians The general medical, surgical, and emergency care principles used in various chelonian species are similar. Medical problems differ significantly between chelonians coming from a captive or free-ranging environment. The majority of problems encountered in captive chelonians can be traced back to improper husbandry. It is not uncommon for a captive chelonian with a chronic medical problem to present as an emergency. The environment (marine, freshwater, estuarine, terrestrial) of free-ranging chelonians will dictate the types of problems that are encountered. Traumatic Injuries Trauma is a common reason for chelonians to be presented for emergency care. Chelonians that experience a traumatic injury may present with uncontrolled hemorrhage, lacerations, head trauma, and fracture of the limbs, skull, mandible, or shell. Prob- Terry M. Norton lems encountered in free-ranging marine turtles may include boat related injuries secondary to propeller or direct impact, encounters with predators such as sharks, entrapment in dredging equipment, dropping on a boat deck after incidental capture, and wounds created from fishing gear entanglement such as nets, fishing line, crab and fish traps and plastic rings from beverage containers. Captive marine turtles are predisposed to traumatic bite wounds from interspecific (eg, shark in same aquarium) or intraspecific aggression. Sea turtles should not be housed together if space is limited. Freshwater and estuarine species, such as the diamond back terrapin (Malaclemys terrapin), encounter similar traumatic injuries as marine specimens. Aquatic and terrestrial chelonians are commonly hit by automobiles or trucks when crossing roads. Predators, primarily carnivores, commonly cause severe damage to freshwater and terrestrial chelonians by gnawing on the limbs and shell.32 Traumatic injuries in chelonians often involve the central nervous system (CNS) and require immediate attention. Short-acting corticosteroids such as methylprednisolone, dexamethasone sodium phosphate, or prednisolone sodium succinate should be administered IV and then repeated in 12 to 24 hours.1 Supportive care, wound care, broad-spectrum antibiotics, and analgesics are indicated depending on the type of injury. Warm the patient to ambient indoor temperatures (68 - 75 F; 20 - 30° C) only after hemostasis is achieved, antibiotics are on board, and vital signs are stable.1 Warmed animals have higher O2 demands, increased potential for hemorrhage, and increased bacterial growth in contaminated wounds. Once the turtle is stabilized, radiographs can be taken to determine the extent of the injuries, prognosis and plan for further therapy. In cases of hind limb paresis, it is important to rule out a spinal or pelvic fracture. Pelvic fractures may predispose female turtles to dystocia; therefore, these animals should not be released into the wild. Uncontrolled hemorrhage should be addressed immediately. This can be accomplished by digital pressure, a pressure bandage, vessel ligation with suture, or by surgical electrocautery. Carapace and plastron fractures are common in chelonians. After radiographic evaluation, the fracture site and surrounding tissue should be cleaned with dilute chlorhexidine, betadine, or saline. A wet-to-dry bandage may be placed over the injury to further decontaminate the wound. Foreign debris should be carefully removed from the fracture site. If the coelomic cavity is open, minimize contamination. Fractures of the carapace over the lungs or of the bridge may put the 117 Chelonian Emergency and Critical Care patient at risk for bacterial and fungal pneumonia. After cleansing, the shell fracture should be reduced. If realignment is difficult or a spinal injury is suspected, then fracture alignment should be approached with caution or delayed. After cleansing and drying the fracture, the wound should be dressed. Silver sulfadiazine (SSD) cream or triple antibiotic ointment are applied to open shell fractures and wounds. The author recommends covering open wounds and shell fractures with a silvercoated mesh (Acticoat with silcryst nanocrystals, Smith & Nephew, Inc., Largo, FL USA). This product provides 72 hours of antibacterial and antifungal activity; however, it must be kept moist with sterile water while being used. DuoDerm or tegaderm can be used to cover various dressing materials and keep the wound clean and dry. For a more waterproof bandage, tissue glue can be applied to the edges of the adherent bandages. Vet wrap (3-M Corp., St. Paul, MN USA) can be used to keep the dressing in place and stabilize the fracture. Aquatic species should be kept in shallow water or may need to be dry docked until a waterproof bandage is placed over the wound or fracture or until final repair. Shell fracture repair methods have been described previously.1,26 All skin wounds should be cleaned and debrided as described for shell injuries. Primary closure should be reserved for noncontaminated wounds. Contaminated wounds should be left open to heal by second intention or closed using a delayed technique once the wound has been decontaminated. Reptiles produce thick caseous abscesses. Because these abscesses do not drain well, penrose drains are generally not used for wound care. In areas that are difficult to bandage, suture loops can be placed around the wound, the preferred topical treatment and dressing applied, and umbilical tape placed through the suture loops and tied together like a shoelace to hold the dressing in place. This method allows for regular wound cleaning and bandaging. Fractured limbs in chelonians may result as a consequence to a variety of traumatic insults, such as being hit by a car or boat, being dropped, or having excessive force applied to the limbs when extricating them for tube feeding. Chelonians suspected to have metabolic bone disease should be handled with caution, as they are predisposed to pathological fractures. Patient stabilization takes priority over permanent fracture repair. Various methods or combinations of methods may be used to repair a long bone fracture in a chelonian. Several excellent reviews are available on chelonian and reptile orthopedic procedures.26 Vomiting, Ileus, Obstruction Vomiting or regurgitation in chelonians is usually indicative of a poor prognosis.32 A thorough diagnostic work up should be performed to make a definitive diagnosis. Some causes of vomiting include foreign body or other gastrointestinal obstruction, noxious tasting materials, dehydration and debilitation, gastric stasis, gastrointestinal yeast, and parasitism. Vomiting is more common in anorectic and debilitated turtles than tortoises.1 Turtles should be rehydrated and stabilized first, and then tube fed with an easily digestible elemental diet such as Peptamen (Nestle USA, Inc., Deerfield, IL USA). The neck should be extended and the turtle held in a vertical position after the tube is removed to prevent regurgitation. Higher caloric diets should be introduced gradually. Heavily parasitized turtles and tortoises may become partially or completely obstructed with nematodes after being dewormed with relatively low doses of fenbendazole (30 mg/kg PO once).11 These patients should be rehydrated and stabilized to ensure that they regain their normal gastrointestinal motility. To prevent this complication, always start debilitated chelonians with lower doses of anthelminthics (fenbendazole) and gradually increase the dose to the recommended levels of 50 mg/kg over several weeks. The gradual increase in dosage reduces the chance of obstruction by reducing the number of parasites affected per treatment. Fenbendazole, although effective in chelonian species, should be used with caution based on recently described bone marrow suppression effects avian species.80 Pyrantel pamoate may be a safer alternative anthelminthic to use in debilitated chelonians. Gastrointestinal stasis or ileus is a common cause of morbidity in debilitated chelonians and must be differentiated from obstruction. Gastrointestinal stasis is precipitated by dehydration, systemic disease, dietary indiscretion, decreased dietary fiber, malnutrition, suboptimal management practices, and seasonal motility changes.81 Diagnosis is challenging because of difficulties in palpating the chelonian coelomic cavity and the normally slow GI transit time of these animals. Without appropriate treatment, the condition may progress to impaction and obstruction require intensive medical or surgical therapy.82 Debilitated marine turtles often develop a secondary gastrointestinal stasis and become obstructed with nondigestible prey materials. Radiopaque material and gas in the gastrointestinal tract are visible radiographically. This condition can be resolved with fluid therapy, mineral oil, enemas, and gastrointestinal motility modifiers. The obstruction should be resolved 118 before offering the animal food. In other chelonians, elucidating the cause of the ileus, correcting the medical problem, and providing supportive care will usually resolve the ileus. Motility modifying drugs, such as metoclopramide and cisapride, are clinically effective in chelonians.82,83 Foreign body ingestion is a common emergency presentation in chelonians.83-87 Occasionally foreign bodies are found incidentally on whole body radiographs. In aquatic species, fishhooks with attached fishing line may become anchored in the oral cavity, esophagus, or other parts of the gastrointestinal tract. These foreign bodies frequently lead to intestinal plication or coelomitis secondary to penetration of the serosal surface of the gastrointestinal tract. A variety of foreign materials, such as plastic bags, metal, and glass, have been found in marine turtle gastrointestinal tracts and may be an incidental finding or lead to an enteritis or obstruction. Ingestion of substrates such as corncob, wood chips, gravel, sand, kitty litter, or walnut shell by captive terrestrial chelonians may cause GI obstruction.32 The radiographic hallmark sign for intestinal obstruction is the accumulation of radiopaque material in a dilated segment of intestine. A prominent obstructive gas pattern is not always observed. Conservative medical treatment consisting of enemas, parenteral fluids, petroleum laxatives and water given via a stomach tube (15 mL/kg) may be all that is necessary for clinical resolution.88 However, surgical removal of the foreign body or material may be required in some cases.83,89,90 Hypothermia Hypothermia, or cold stunning, in sea turtles is a wintertime phenomenon where the water temperature suddenly drops below 50°F (10°C).29 The turtles lose their ability to swim and dive, become buoyant and float to the surface. It is most common in juvenile sea turtles, and has been documented to occur from the Gulf of Mexico to New England and Western Europe. Hypothermia is also a common problem in other chelonian species. Common causes of hypothermia may include escape from a heated enclosure, airline transport, power or heating element failure, and an unexpected drop in nighttime temperatures.32 Hypothermia has been investigated more thoroughly in sea turtles; however, similar medical management can be applied to other chelonians. Secondary infections, especially bacterial pneumonias, are not uncommon and may not be apparent until several weeks after the initial hypothermic event.32 Terry M. Norton A classification system has been developed for hypothermic sea turtles based on a series of reflex responses, including head lift, cloacal or tail touch reflex, eye touch reflex, and nose touch reflex.91 The degree of responsiveness can be used to dictate the best approach to be taken and approximate a prognosis. The severity of secondary problems often depends on the length of time the animal has been debilitated and the temperature extremes the turtle was exposed to. Traumatic wounds, dehydration, corneal ulcerations, dermal, carapacial and plastron lesions, flipper tip necrosis consistent with frostbite, and buoyancy disorders are frequent findings in severe cases.29 Other chelonian species often present with similar clinical signs, including lethargy, poor response to external stimuli, and in extreme cases evidence of frostbite of digits and tail tips.29 Common abnormal clinical pathology findings in cases of hypothermia include an initial heterophilic leukocytosis with subsequent development of leukopenia and monocytosis, both regenerative and nonregenerative anemias, hypoglycemia or hyperglycemia, increased creatine phosphokinase (CPK), decreased blood urea nitrogen (BUN), hypocalcemia, hypoproteinemia, hypokalemia, hypernatremia, hyperchloremia, and metabolic acidosis.29 Electrolyte disturbances may be secondary to malfunctioning salt glands. Cultures of blood and other fluids often reveal localized and systemic bacterial and fungal infections. Radiographs often reveal changes consistent with pneumonia. Coelomic fluid evaluation may reveal evidence of inflammation or infection.29 The therapeutic plan for hypothermic sea turtles should include a slow increase in body temperature, gradual reintroduction to sea water from fresh and brackish water over a 2 week period, prophylactic antibiotic and antifungal therapy, nutritional support, and close monitoring of clinical pathology and acid-base abnormalities.29 Many turtles can have positive clinical outcomes with proper medical attention. Body temperature and heart rate are important parameters to obtain at the time of presentation, and to monitor until the rewarming process is complete. Less severe cases are placed in shallow water, while more severe cases are dry-docked and placed on foam pads. The water or room temperature should initially be only 4-6°F (2-4°C) warmer than the ambient water temperature where the turtle was found. Body temperature should be increased by 5°F (3°C) per day until reaching 75°F (24°C). Broad-spectrum systemic antibacterial and antifungal therapy should be initiated when the turtle reaches 60 to 65°F (1619°C). The skin and shell should be kept moist with bacteriostatic water and soluble lubricating jelly. 119 Chelonian Emergency and Critical Care Hyperthermia Reptiles are less able to compensate for elevated temperatures than mammals or birds. Temperatures over 100°F (38°C) are usually lethal for most chelonians.32 Hyperthermia in chelonians can occur as a result of placing a turtle in a glass or plastic tank outdoors in the sun, a closed car during the day, or accidental overheating in an enclosure. Ill or injured chelonians stranded on a beach or road also may become overheated. Early clinical signs of hyperthermia include increased activity, retreating to the water, seeking cool areas, and hyperemic skin. Eventually, the turtle develops open mouth breathing, rapid respirations, and may become comatose.32 Treatment should include cooling the animal, administering fluids and possibly, in severe cases, a short acting steroid to reduce brain swelling.32 The chelonian should be placed into a shallow pan of cool water (not cold) for a brief period to reduce the core body temperature. Body temperature should be monitored carefully. Subsequently, the turtle should be placed in a small enclosure at the lower end of its POTZ.32 Drowning Despite the chelonian’s ability to survive extended periods without breathing and having significant anaerobic respiration adaptations,32 drowning is a common problem in the aquatic and terrestrial chelonian. A common cause of drowning in marine turtles occurs when the animals are incidentally captured or entangled in shrimp nets or various fishing gear and subsequently trapped underwater for extended periods of time. Diamondback terrapins (M. terrapin) are attracted to crab traps and often are unable free themselves once trapped. Terrestrial chelonians may be found at the bottom swimming pools. Live turtles that have been submerged under water for extended periods of time may present in a comatose state without corneal or deep pain reflexes. The cardiopulmonary resuscitation protocol described previously should be used in cases where there is cardiac and respiratory arrest. Trawl-captured loggerhead sea turtles exhibit a marked acidemia and lactic acidosis when first brought on board.92 Blood gas and lactate levels should be monitored during the recovery process. Once intubated, the turtle should be placed with its head down to drain fluid from the lungs. Suctioning fluid from the endotracheal tube may be of some benefit. Limb and head pumping, intermittent positive-pressure ventilation (2-6 times per min), and doxapram administration (5-10 mg/kg IV) may assist in reviving the turtle. Aggressive therapy to correct acidosis, electro- lyte imbalances, dehydration, and hypothermia may be necessary. Broad-spectrum antimicrobial therapy is usually indicated. Toxicosis Chelonians can be exposed to a variety of toxins and contaminants in captivity and the wild. Unfortunately, many of the toxicities that have been documented in captive chelonians are iatrogenic and induced by the veterinary clinician.93 Ivermectin has been used successfully and safely in a variety of reptiles; however, it is toxic to many species of chelonians.94 Although there are species differences in susceptibility to the toxic effects of ivermectin, the drug should be avoided in all chelonians. Clinical signs associated with ivermectin intoxication are primarily related to general neuromuscular weakness, and death usually occurs because of respiratory paralysis.94 Metronidazole is used to treat anaerobic bacterial infections and amoebiasis in reptiles.1,48 Tortoises are prone to developing side effects from this drug, and may not tolerate the relatively high doses or duration of therapy necessary to treat amoebiasis effectively.1 Metronidazole treatment regimens in chelonians need to be tailored to the individual with close monitoring for clinical signs of toxicity. Clinical signs of metronidazole toxicity include anorexia, head tilt, circling, dysequilibrium and signs of hepatotoxicity.95 Metronidazole toxicity can be fatal in chelonians. Two red-belled short-necked turtles (Emydura subglobosa) with shell lesions were soaked for 45 minutes in a dilute (0.024%) chlorhexidine solution and subsequently developed partial flaccid paralysis and died.96 Cholecalciferol toxicity has been reported in a leopard tortoise (Geochelone pardalis)secondary to ingesting rodent bait.97 While numerous plant species are suspected to be potentially toxic in chelonians, few published reports have been made on actual toxicosis.98 Oak toxicity was recently reported as the suspected cause of death in an African spurred tortoise, Geochelone sulcata.99 Lead poisoning has been documented in a wild common snapping turtle (Chelydra serpentina) after swallowing a fishing sinker100 and a tortoise after ingesting lead paint chips.101 Central nervous system disease predominated in these cases. Sea turtles may encounter waters that contain chemical pollutants, such as petroleum products from oil spills, and present with oil or tar on their skin and shell or systemic signs of toxicity due to ingestion.79 An increased stranding rate of sea turtles in Florida has been associated with red tide blooms of the dinoflagellate Karenia brevis. Affected 120 animals often present with central nervous system deficits.102 A diagnosis of toxicity in a chelonian is usually based on a thorough history, clinical signs, physical examination, and various diagnostic tests. The diagnostic tests generally used to confirm a toxic exposure include contaminant analysis of blood, plasma, stomach contents or tissue, and radiographs. Fluid therapy, wound care, and other supportive measures described previously may be used to treat intoxication. In addition, activated charcoal or psyllium may be used to bind and decrease the absorption of orally ingested toxins,79 calcium EDTA to treat lead toxicity,103 midazolam or diazepam93 to control seizures, and atropine to treat organophosphate toxicity. Nutritional Diseases and the Critically Ill Chelonian Some of the more common nutritional diseases that occur in captive chelonians include generalized cachexia/starvation, metabolic bone disease or secondary nutritional hyperparathyroidism, vitamin A deficiency, and iodine deficiency/goiter.104-106 These patients are often immunnocompromised and predisposed to secondary infections. Nutritional hyperparathyroidism or metabolic bone disease is most common in young growing chelonians and is caused by deficiencies in calcium, vitamin D, an improper calcium/phosphorous ratio, lack of exposure to UV light, or a combination of these factors. Clinical signs may include a soft deformed shell, limb fractures, and a malformed overgrown rhampthotheca.106 Radiographs can aid in the diagnosis of advanced cases. Starvation or cachectic myopathy may occur in captive and free-ranging chelonians.107,108 In captive specimens, primary malnutrition and poor husbandry (eg, suboptimal environmental temperatures) are often responsible. Confiscated Southeast Asian turtles are routinely presented with severe emaciation after being maintained at suboptimal conditions for extended periods of time.1 Emaciated free-ranging chelonians usually have an underlying problem.108 The underlying cause of the emaciation may be masked by numerous secondary medical problems such as bacterial or fungal pneumonia, septicemia, and severe endoparasitism.108 These turtles may be critically anemic, hypoproteinemic, and hypoglycemic. They often have severe ascites, serous atrophy of fat, lymphoid depletion, and bone marrow suppression. Severely malnourished chelonians may present in a moribund state and require emergency care. Treatment for energy deficiency in chelonians should Terry M. Norton involve fluid and electrolyte replacement initially and then small but increasing levels of calories. In addition, iron dextran, whole blood or artificial hemoglobin, broad- spectrum antimicrobial drugs, and antiparasitics may be necessary. Specific nutritional problems such as vitamin A deficiency, metabolic bone disease and hypothyroidism should be treated once the turtle has been stabilized. Dystocia Most dystocias in chelonians do not present as a medical emergency unless there is an obstructive process involved. It may be difficult to determine when a gravid patient is overdue or when one should intervene. Common causes of dystocia in chelonians include inadequate nesting sites, inadequate thermal environment, malnutrition, dehydration, poor muscle tone, endocrine abnormalities, and metabolic abnormalities such as hypocalcemia. A dystocia is more likely to be a medical emergency when it occurs secondary to reproductive tract or cloaca prolapses, systemic infections, abnormal egg shape and size, stricture or torsion of the oviducts, impingement of the pelvic canal from misaligned healed fractures, uroliths, soft tissue masses, or broken eggs.109 The dystocia patient may be asymptomatic or may have one or more of the following clinical signs: decreased appetite or anorexia, decreased activity level, excessive basking, restlessness, constant digging behavior, raising the hindquarters accompanied by cloacal aversion, and eventual weakness and lethargy.109 The diagnostic workup should include a thorough history, physical examination, and radiographs. Radiographs should be evaluated for the presence of eggs, the size, shape, and position of eggs, eggs in the bladder,110 any broken eggs, bone density, pathological fractures and pelvic fractures, evidence of constipation, and cystic calculi. Ultrasound, hematology, and a serum chemistry profile may provide additional important information in some cases. Debilitated chelonians suffering from dystocia should be stabilized before oxytocin therapy or surgery. Dehydration, hypothermia, and hypocalcemia should be corrected. Antibiotic therapy and nutritional support may be indicated in some cases. It is important to provide adequate nesting areas, water, and an appropriate thermogradient during the treatment period.109 In nonobstructive dystocias, the patient may be pretreated with calcium followed by oxytocin. Eggs should pass within 30 to 60 minute.109 Obstructive dystocias will require surgery in most cases. If the egg can be visualized through the cloaca, ovicentesis and collapsing the egg may be attempted. 121 Chelonian Emergency and Critical Care If surgery is deemed necessary, an inguinal approach is less invasive and preferred over entering the coelom via a plastron osteotomy. A salpingotomy, salpingectomy, or gonadectomy may be performed depending on the cause of the dystocia and condition of the oviductal tissue.109 The ovary should always be removed with the oviduct to prevent ovulation into the coelomic cavity during the next reproductive season. A unilateral salpingectomy can be performed to maintain future reproduction.111 irritation or desiccation from substrates while attempting to breed, constipation, or neurologic defects.32 The phallus can be reduced using the same techniques described for the cloaca. If the phallus is necrotic, the base of the penis can be double ligated with two vertical mattress sutures and then amputated.32 Penile amputation will not affect urination but the turtle will not be able to copulate or reproduce.32 Urolithiasis Ectoparasites, such as maggots,116 ticks,116 sarcophagid fly larvae,117,118 leeches,119 and various epibiota found on sea turtles,108,119 may contribute to the overall poor condition of a critically ill chelonian and should be manually removed or treated appropriately. Placing marine turtles in freshwater for 24 hours will significantly reduce the parasite load and aid in rehydration. Endoparasites may be a contributing factor to disease in an already compromised chelonian, and in some cases they may be the primary cause of debilitation.11,120-129 Stress, overcrowding, poor husbandry, infectious diseases, and immunocompromising conditions may lead to heavy endoparasite infestations. Clinical disease associated with Entamoeba spp. is much more prevalent in chelonians than previously recognized.1,120,121 It is a difficult parasite to identify and treatment may need to be started before a specific diagnosis is made.1 There are multiple species of amoeba with varying degrees of pathogenicity.1 The most common clinical signs are diarrhea, often with intermittent blood and mucous, anorexia, depression, and severe dehydration. Treatment consists of aggressive fluid therapy and supportive care. Bonner recommends a prolonged course and high doses of metronidazole (100 to 150 mg/kg sid PO for 5 days, skip 7 days, and then repeat another 5 day course) due to the difficulties in eradicating this parasite.1 This regimen may be toxic to tortoises. Recent pharmacokinetic studies in the yellow rat snake and green iguana suggest that a dose of 20 mg/kg every 48 hours reaches therapeutic levels for treating anaerobic bacterial infections.48,130 Metronidazole eliminates the trophozoites stages, while iodoquinol can be used to treat the amoebic cyst stages. Broad-spectrum antimicrobial therapy is often indicated.1 Digenetic trematodes of the family Spirorchidae are commonly found in the cardiovascular system of freshwater and marine turtles, and have been implicated as a cause of significant morbidity and mortality in some cases.18,126,127,129 The eggs are released into the circulatory system, and eventually become trapped within the terminal arterioles of the visceral Cystic calculi have been documented in a variety of captive and wild turtle species.112 The condition is relatively common in California desert tortoises. Most cases result from water deprivation or excess amounts or inappropriate types of dietary protein.113,114 Emergency care should be sought if the chelonian is straining excessively or develops a prolapse of the uterus or bladder. Treatment should include rehydrating and stabilizing the patient for a surgical cystotomy.113 Cloacal and Phallus Prolapses A cloacal prolapse should be attended to quickly so that the prolapsed organ remains viable. Cloacal prolapses usually occur from excessive straining secondary to an inciting cause, which may include constipation, bacterial enteritis, parasitic enteritis, cystic calculi, egg binding, and other conditions causing straining.115 In addition to determining the cause of the prolapse, it is important to determine what structure is protruding and its viability.115 The colon has a lumen with feces inside and a smooth surface. The urinary bladder is thin walled, translucent, and urine may be aspirated from it. The uterus and oviduct have a lumen, no feces, and longitudinal striations on the surface. Treatment for a cloacal prolapse should include cleaning, lubricating, and replacing the viable tissue back through the vent. Soaking the prolapse in 50% dextrose will reduce the edema to facilitate replacement. A purse string or transverse suture should be used to maintain the reduction. The vent can be surgically enlarged to assist in replacing the prolapsed tissue. In cases of chronic prolapse when the tissue is edematous and friable, it may be difficult to impossible to reduce the tissue and instead require a coeliotomy or amputation. If the colon is prolapsed, a colopexy can be used to prevent recurrence.115 Chelonians have a large phallus, which is solid tissue and has no lumen. Phallus prolapses are not uncommon in chelonians, and may occur secondary to an infection, forced separation during copulation, Parasites 122 organs, extremities and shell. A granulomatous response is produced by the eggs in various tissues, including the gastrointestinal tract, liver, spleen, lungs and CNS.18,126,127 Clinical signs are related to the pathology caused by the eggs and may include generalized debilitation, severe ulcerative colitis, pitted ulcerations (due to ischemic necrosis) of the carapace and plastron, edematous limbs due to vascular obstruction, and buoyancy problems secondary to pneumonia. A major loggerhead sea turtle stranding event occurred in south Florida in 2001.129 Most turtles presented with partial paralysis and many had secondary problems. Postmortem results revealed adult trematodes in the brain and spinal cord. No other primary agent has been identified in these turtles. These turtles often respond to supportive care and treatment for the trematodes. Treatment with high dose of praziquantel may be effective in decreasing the severity of clinical signs but will not affect the eggs already in the tissues.131,132 Infectious Disease Several excellent reviews of infectious diseases in chelonians have been published.128,133,134 Clinical signs associated with infectious disease agents may be severe, present acutely, and warrant emergency care. Upper respiratory tract disease (URTDS) complex is a relatively common reason for chelonians to be presented and provides a good example of dealing with an infectious disease in an emergency setting.134-141 Herpesvirus, iridovirus and Mycoplasma agassizii are important infectious diseases of terrestrial chelonians.134-141 Infected chelonians often present with an acute onset of clinical signs, including anorexia, depression, and nasal and ocular dicharge.134-142 Herpesvirus and iridovirus infected chelonians frequently present with stomatitis and glossitis,137,143 whereas this is never observed with M. agassizii alone.138,140,141 Mixed infections of Herpesvirus and M. agassizii have been reported, further complicating the diagnosis.144 Herpesviruses have been documented to affect many chelonian taxa, and all chelonians should be considered susceptible.134,135,142-148 These infections are believed to lie dormant in various tissues following the primary infection, and during times of stress, such as hibernation and illegal importation, recrudesce.134 Herpesvirus infections have been implicated as the causative agent in several diseases of captive and free-ranging sea turtles.145,147-149 Fibropapilloma disease syndrome (FP) is the most well studied disease affecting sea turtle populations. A herpesvirus has been implicated as the causative agent of the disease syndrome,147-152 however, envi- Terry M. Norton ronmental pollutants or other unknown immunosuppressive factors are most likely a contributing factor in the disease process.153 Turtles may have multiple cutaneous FPs found on all soft integumentary tissue, but especially in the axillary and inguinal regions.147 The FPs can develop on the eyelids, conjunctiva, and cornea and may be so extensive as to impair the turtle’s vision.147 This visual impairment hinders feeding and leads to emaciation. Furthermore, FPs may be found internally in various organs.152,153 A diagnosis is made by observing typical skin lesions and histopathology.150 Radiography and laparascopy are used to identify internal FP. Euthanasia is recommended in turtles with internal lesions. Initial treatment consists of correcting dehydration, hypoglycemia, and malnutrition. Antimicrobial therapy is usually indicated before and after surgery. Laser surgery can be used to remove the FPs in stages. In these cases, the skin is often left open to heal by second intention (Pers. comm. Mader D, 2003). Iridovirus is an important emerging disease in chelonians137,154 Until recently, it had only been recognized sporadically.136,155 Frogs are implicated as a reservoir host capable of infecting captive and freeranging chelonian populations.137 Viral infections in chelonians are often complicated by secondary bacterial, fungal, and parasitic infections, and should be considered in the diagnostic and therapeutic approach. Diagnostic samples (eg, serology, cytology, histopathology, electron microscopy, culture and PCR) should be collected before initiating treatment.133,137,156 Initial emergency therapy should focus on stabilizing the patient with emergency drugs and rehydration. Critical care may consist of broad-spectrum antimicrobial therapy for aerobic and anaerobic bacteria, antifungals, antiviral drugs, fluid therapy, and nutritional support. Acyclovir administered orally and topically has been shown to be clinically effective against both chelonian herpesvirus and iridovirus infections.137,157 Bacterial and Fungal Infections Debilitated and injured chelonians often present with bacterial or fungal infections. These may include infected traumatic injuries, abscesses, stomatitis, shell infections, osteomyelitis, and respiratory disease. Poor husbandry, malnutrition, and a lack of sanitary procedures are predisposing factors for infection in captive specimens. Bacterial abscesses are the most common inflammatory condition in reptiles, and can occur anywhere on the body. Reptile abscesses are most often well encapsulated by fibrous 123 Chelonian Emergency and Critical Care connective tissue. Gram-negative bacteria cause the highest morbidity in chelonians, however, anaerobic bacteria (eg. Bacteroides spp., Fusobacterium spp., Clostridium spp., and Peptostreptococcus spp.) can cause serious disease and should be considered in the therapeutic plan.158 Bacteroides spp. and Fusobacterium spp. produce potent tissue toxins, which can cause tissue necrosis and increase the severity of mixed aerobic and anaerobic bacterial infections.158 Clostridium spp. have systemically active toxins that cause hemolysis and renal tubular necrosis.158 Salmonella spp. can cause disease in chelonians and are a potential zoonosis.159 Atypical mycobacterial infections can cause abscesses, cutaneous and subcutaneous nodules, osteomyelitis, osteoarthritis, and other problems in chelonians.160 Predisposing factors include debilitation, injury, malnutrition, and other disease processes. This is also a potentially zoonotic disease. Dermatophilus chelonae is a newly discovered species of bacteria that grows at lower temperatures than D. congolensis.161,162 Several tortoise and turtle species have been reported to develop skin abscess, dermal nodules, ulcerative stomatitis, septic arthritis, and a granulomatous coelomitis. Middle and inner ear abscesses are commonly seen in captive and wild box turtles and other chelonians.163,164 Lesions may be unilateral or bilateral. A variety of Gram-negative bacteria have been isolated from most cases, however, anaerobic bacteria, fungal organisms and parasites may be involved.163,164,165 The route of infection may be via the eustachian tube. Organochlorine toxicity and vitamin A deficiency are predisposing factors.163 Shell infections can involve the superficial keratin or may extend into the osteoderms of the carapace and plastron. Aerobic and anaerobic bacteria and mycotic agents are commonly isolated. Mucormycosis has been associated with ulcerative epidermitis in soft-shelled turtles (Trionyx ferox). This is a very serious condition in this group of chelonians because of the importance of the integument and shell as a site of oxygen transport and osmotic balance.166 Culture, cytology, histopathology, and molecular diagnostics are routinely used to diagnose bacterial and fungal infections. Special stains, such as acid-fast stains for Mycobacteria spp., also may be needed to make a diagnosis. Treatment for bacterial infections should include antibiotic therapy based on culture and antimicrobial sensitivity. Anaerobic bacteria should be treated with metronidazole, penicillin, chloramphenicol, or clindamycin.158 Because of the caseous nature of reptile abscesses, complete surgical excision of the abscess and removal of the accumulated caseous material are required for effective treatment. Antibiotic-impregnated polymethylmethacrylate beads have been used to treat osteomyelitis in reptiles.167 The silver mesh described previously can be used to pack wounds and provides 72 hrs of antibacterial and antifungal activity. Pharmacokinetic studies involving fluconazole and itraconazole in sea turtles have advanced the treatment capabilities for fungal infections.46,51 Pneumonia Pneumonia is a common problem in critically ill chelonians.1,168 Suboptimal temperatures, increased humidity, malnutrition, and overcrowding are predisposing factors for pneumonia.1,168 Because reptiles tolerate an anaerobic environment, they can conceal clinical signs of pneumonia until the condition is severe.168 Pneumonia can be caused by a wide array of infectious diseases. Gram-negative bacteria are recovered from a large percentage of the cases. These are often opportunistic infections with the same bacteria being considered normal flora in the healthy chelonian.168 Anaerobic bacteria are more difficult to culture, but do represent an important cause of pneumonia.158 Although less commonly isolated, atypical bacteria such as Mycoplasma spp., Chlamydiophila spp., and Mycobacterium spp. are also important pathogens to consider.168,169 Herpesviruses have been implicated as a cause of respiratory disease in several chelonian species,134,145 and may predispose the patient to secondary bacterial and fungal infections. Chelonians appear to be more susceptible to fungal pneumonia than other reptile orders.1,128,170,171 Over exposure to fungal spores, immunosuppression, or overuse of antibiotics are predisposing factors. Aspergillosis spp., Candida spp., Mucor spp., Geotrichum spp., Penicillium spp., Cladosporium spp., Rhizopus spp., Beauveria spp., Sporotrichum spp., Basidiobolus ranarum and Paecilomyces spp. have all been isolated from chelonians with pneumonia.128,170-172 Migrating nematode parasites and digenetic spirorchid trematodes may predispose the chelonian to bacterial or fungal pneumonia.127,129 Aspiration pneumonia may occur in debilitated chelonians.168 Clinical signs may include anorexia, lethargy, increased or abnormal respiratory sounds, increased respiratory rate (especially at rest), and asymmetric floating in aquatic species.168 Abnormal posture may also be noted in cases of inspiratory and/or expiratory dyspnea, which may manifest itself as labored breathing with the neck extended and mouth open.168 124 Diagnosis of pneumonia is based on history, physical examination, and horizontal beam anterior-posterior and lateral radiographic views.168 A tracheal wash should be performed before starting therapy if the patient can tolerate the procedure.168 Sedation may be necessary. A sterile red rubber catheter or bronchoscope is placed through the glottis, down the trachea, through a bronchus and into the lung. If the pneumonia is determined to be unilateral based on the radiographic findings, then treatment can be targeted to that lung. Sterile saline solution should be flushed through the catheter and then aspirated back. Bronchoscopy is limited to larger patients, but will allow visualization of the respiratory tract and collection of appropriate samples. Cytology and culture should be performed on samples obtained from the pulmonic lavage. Fungal pneumonias often produce localized or diffuse granulomatous nodules, which makes recovery of the organism difficult without a biopsy. Nodules noted on radiographs may be suggestive of fungal involvement.168,172,173 Treatment for a fungal pneumonia should include minimizing stress, providing a positive nutritional balance, and maintaining hydration.1 Patients in extreme respiratory distress from pneumonia should be positioned on a slight incline with their head and forelimbs extended.1 The animal can be intubated to facilitate suction of debris from the lower respiratory tract. Coupage may be helpful in bringing up debris to be suctioned. Supplemental oxygen may inhibit respiration and compromise the chelonian’s limited ability to eliminate inflammatory debris.1 Oxygen supplementation should be humidified to avoid irritation of the respiratory system.168 Bacterial pneumonia should be managed with broad-spectrum antibiotics. Nebulization therapy can be used to increase the humidity of the respiratory epithelial microenvironment, improve pulmonary hydration, and increase the mucociliary transport mechanism.1,168 Furthermore, it assists in breaking up necrotic and inflammatory debris and delivers antimicrobials directly to the site. Treatment of fungal pneumonia in chelonia is difficult and often unsuccessful. Some authors advocate prophylactic antifungal therapy in susceptible species.1 Medical management generally consists of oral or subcutaneous fluconazole51 or itraconazole.46 Amphotercin B may also be used, and can be delivered directly into an affected lung via a catheter placed through a carapacial osteotomy.171,174 Granulomatous nodules may require surgical excision.168 Terry M. Norton Acyclovir therapy is indicated when herpesvirus is diagnosed or suspected. Buoyancy Disorders Aquatic turtles, especially sea turtles, are often presented with buoyancy disorders, where they are unable to float normally at the surface or submerge.79 Any condition leading to gas or air accumulation in a body organ or in the coelomic cavity may cause abnormal buoyancy. Common causes of this condition include 1) pneumonia, 2) gastrointestinal disease (eg, motility disorders, spinal cord injury, foreign body and other obstructive processes leading to gas accumulation), and 3) free air in the coelomic cavity (respiratory or intestinal leakage or microbial fermentation). Efforts should be directed toward diagnosing the primary problem, which may include blood work, radiology, endoscopy and laparoscopy. Initially the turtle should be stabilized and then attempts should be made to treat the primary disease. Laparoscopic surgery has been used to repair a lung tear in a sea turtle (Pers comm, Dover S, 2004). Intracoelomic administration of large volumes of sterile fluids has been used as an ancillary treatment for this condition in loggerhead sea turtles (Pers comm, Sheridan, T, 2005). Some turtles, especially those with spinal injuries, may remain abnormally buoyant for life. Septicemia Bacterial septicemia is a relatively common sequellae to more localized infections. Multiple Gramnegative bacteria are commonly cultured; however, anaerobic bacteria and fungal organisms may also be isolated.1,175 Clinical signs may include anorexia, lethargy, weakness, red-purple oral mucous membranes, and general malodor of the turtle.1 Petechial hemorrhages occur initially along marginal scutes and then develop into larger areas of hemorrhage.1 Hemorrhage across the bridge is a serious clinical sign and can progress to a disseminated intravascular coagulation (DIC)-like syndrome.1 Successful treatment of sepsis is more likely if clinical signs are recognized early and treatment is begun before diagnosis on predisposed turtles. 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