Just as with dogs and cats, there are many different types of emergency presentations that you might see during an avian veterinary visit. To learn about the avian physical exam and gaining a thorough history, check out Part One of this article.
Common Avian Emergencies
Unfortunately, cardiac arrest carries a poor prognosis in birds. Direct compression of the heart is not possible due to the presence of the keel, but sternal compressions are still recommended to help move air through the air sacs. To perform sternal compressions, place the bird in dorsal recumbency and perform compressions at a rate of approximately 80 compressions per minute by placing a hand or finger on either side of the sternum and pushing down gently. An uncuffed ET tube should always be used due to the presence of complete tracheal rings. If only a cuffed tube is available, it must not be inflated. Intubation is very easy in birds, due to their trachea being located directly caudal to their tongue. Intravenous catheters may be placed by experienced avian veterinarians, but an intraosseous catheter (IO) is typically easier to place and easier to maintain and may be placed in the ulnar or tibiotarsal crest.
All birds should be weighed, and drug doses are extrapolated from those used in feline and canine medicine. Medications can either be given via an endotracheal tube, intravenously or via an intraosseous catheter. Additionally, hypoglycemia and hypothermia are important considerations in birds due to their small size. If needed, 0.25 ml/kg of 50% dextrose diluted in an equal volume of saline can be administered IO. Active warming should be initiated and all fluids administered should be pre-warmed. Many species start responding to catecholamines and fluid therapy once cloacal temperature reaches 98 degrees Fahrenheit.
If a bird presents in respiratory distress, immediate treatment and stabilization should be performed. Transfer the bird to a warm incubator (85-90 degrees Fahrenheit) and provide oxygen support. The bird may benefit from an anti-anxiolytic, such as butorphanol or midazolam, and in the case of inhaled toxins, terbutaline may be of benefit as a bronchodilator. Palpate the coelom to determine if coelomic fluid is contributing to the bird’s distress, and if so, perform a coelomocenteis with the bird in an upright position. A thorough history and physical examination can help determine if the dyspnea is due to upper airway disease, such as tracheal obstruction or sinusitis, or lower airway disease, such as toxin inhalation, a hypersensitivity reaction or bacterial or fungal disease. It is important to remember that constant evaluation of a patient in respiratory distress is essential. The added stress of being handled may cause any debilitated or unstable avian patient to spontaneously arrest, and frequent rests from examination and treatment may be lifesaving.
All avian species are commonly presented to the emergency room for traumatic injuries. In pet birds or psittacines, trauma can be due to a variety of causes – attacks from other birds or pets in the household and getting injured by or stuck in inappropriate toys are two common complaints. Additionally, flighted birds are exposed to many other dangers within the household. They may fly into windows, get stuck in or behind household objects, fly into moving objects such as ceiling fans, or sustain burns after landing on stoves, radiators or hot cookware. As reviewed previously, it is essential to stabilize a bird that is hemorrhaging or in respiratory distress prior to addressing orthopedic injuries. Broken or bleeding blood feathers should be removed, even if they have stopped actively hemorrhaging. The broken feather may still be irritating and painful to the bird, and the bird may respond to its presence by self-mutilating and causing itself further injury. Administering an analgesic, such as butorphanol or meloxicam, beforehand is advised. The blood feather can be removed by pulling it from the base with a pair of hemostats, and any resulting hemorrhage is usually well-controlled with the application of gentle pressure on the follicle for 30 seconds to one minute. Hemorrhage from the beak or nails may be controlled with cautery or hemostatic agents. General anesthesia is necessary prior to utilizing cautery.
Splints and bandages can be applied to stabilize fractures in the emergency setting. However, it is important to remember that, as with cats and dogs, splints and bandages are rarely appropriate for long-term stabilization and surgical repair is indicated for most wing fractures. The exceptions would be very small birds where surgery is not an option, pelvic fractures, non-displaced radial or ulnar fractures in a small patient, carpal and metacarpal fractures, and some tibiotarsal fractures. Antibiotics are indicated when treating open fractures, and clindamycin and TMS are two common empiric choices.
Bandaging: A figure-eight bandage is placed to stabilize radial and ulnar fractures, and humeral fractures are stabilized with a figure-eight bandage and a body wrap. The patient should be anesthetized during placement of the bandage, and care must be taken that the patagium is not overly compressed. If placed too tightly, a figure-eight bandage can lead to contraction and dysfunction of the wing. In cases where surgery is not indicated, the bandage should still be removed and replaced every two to three days. Physical therapy of the patagium and passive range of motion of the wing should be performed as able. As with the initial bandage placement, bandage changes and PROM should be performed under general anesthesia.
Image 1. This seagull was placed in a figure-eight bandage to stabilize a suspected fracture of the distal wing. It was discharged to a wildlife rehabilitation facility within 24 hours of presentation.
Psittacines are known to chew on their bandages, and an avian Elizabethan collar or a distraction technique must be used to prevent bandage destruction. If an E-collar is not available or not tolerated, “distraction tabs” made with porous tape are commonly placed on the external surface of bandages to direct chewing away from the bandage itself. A “chew layer” of porous tape may also be placed on top of the outer bandage layer.
Splinting: Femoral fractures typically override with external coaptation and require surgery in all but the smallest patients. Tibiotarsal fractures, however, may be addressed with splinting. A lateral splint may be fashioned out of a tongue depressor, the wooden component of a cotton swab, a syringe case, or lightweight moldable plastic. Additionally, tape splints may provide sufficient support in birds weighing less than 150 grams.
Egg binding, or dystocia, can be the result of a variety of causes. Small birds such as budgerigars, lovebirds and cockatiels often present with dystocia due to chronic egg production, but other known causes of dystocia are large or malformed eggs, obesity, very young or old layers, calcium or vitamin E deficiency, oviductal disease (infection or trauma), or masses associated with the reproductive tract. By the time an egg-bound bird is presented to a veterinarian for assessment, it has typically been trying to lay the egg for 24 to 48 hours. Subsequently, many birds who present as egg bound are also dehydrated, painful and metabolically depleted, and will benefit from stabilizing treatments, such as fluid therapy, parenteral calcium, dextrose, analgesia, and vitamins A, D, and E. Radiographs are useful to help determine the size, shape and number of eggs, and if fluid in the coelom is suspected, a coelomocentesis should be performed prior to radiographic evaluation.
Image 2. This adult laying hen was presented for an unknown trauma resulting in an almost complete traumatic removal of her comb. She was placed under deep sedation using injectable medication, and the rest of her comb was removed routinely. She recovered routinely in oxygen, and laid an egg prior to discharge!
Medical management is preferred over ovocentesis, due to the possible complication of egg yolk peritonitis. Affected birds are given between 50 to 100 mg/kg of calcium gluconate either SQ or IM, diluted with an equal volume of saline. Some practitioners prefer to divide this amount into three injections given 30 minutes apart. A small amount of a PGE2 analogue, such as misoprostol, is also instilled into the cloaca plus or minus some sterile lubricant to help promote passage of the egg. In most cases, the egg will pass within an hour or two with medical management alone. After the egg has been laid, antibiotics are typically not indicated unless metritis or salpingitis is thought to be the cause of the dystocia.
If medical management is ineffective, an ovocentesis may be performed as an emergency procedure. This should be done by an avian veterinarian if one is available. In this procedure, the bird is anesthetized, the shell is pierced with a needle, and the contents are aspirated. The shell is then gently collapsed and manually removed from the cloaca.
Another commonly seen reproductive emergency is a prolapsed cloaca. Some causes for a cloacal prolapse can be chronic egg laying, dystocia, chronic masturbatory behavior, masses or neoplasia, and papillomatous lesions. To replace the prolapse, the patient is stabilized as discussed previously and placed under general anesthesia. If immediate replacement is not possible, lubricate the prolapsed tissue with sterile lubricant until the procedure is performed. Once the bird is anesthetized, clean the prolapsed tissue well with sterile saline and gently replace it into the cloaca. Additional sterile lubricant should be used as necessary. One or two simple interrupted stay sutures may be placed to ensure that the tissue does not re-prolapse, but the coelom should be thoroughly palpated first to ensure that no egg is present within the reproductive tract. After suture placement, there should be enough space for a cotton swab to pass into the cloaca. Simple interrupted sutures are used instead of a purse string, as purse string sutures may permanently damage the cloacal sphincter.
If a patient is having seizure activity on presentation, the seizures must be immediately addressed. Administer 0.5 mg/kg midazolam intranasally via the cloaca or IM as an emergency anti-epileptic. Make sure to check the patient’s blood glucose and administer dextrose if indicated. If intravenous access has been obtained and cerebral edema is suspected, mannitol may be administered (0.5 mg/kg IV over 20 minutes). If adequate seizure control is not achieved with two to three doses of midazolam or diazepam, phenobarbital can be bolused IV or IO at 4.5 to 6 mg/kg.
There are many possible causes for seizure activity. In African grey parrots, hypocalcemia is the most common cause and is also seen in laying hens and in pigeons and doves that are not fed an appropriate diet. Hypoglycemia is most common in fledglings, but is not routinely seen in adults unless they have been without food for 24 hours or more. A seizing avian patient should receive dextrose if its blood glucose is less than 150 mg/dL and can receive 1 ml/kg of 50% dextrose slowly IO or IV diluted at least 1:1. Laying hens can also present acutely seizing due to hyperlipemic syndrome, in which abnormally high intravascular lipid levels significantly increase blood viscosity and cause sludging and lipid emboli. Psittacosis can occasionally cause seizures, as can atherosclerosis and lead toxicity. Lead toxicity can result in dull mentation, ataxia, wing droop or generalized weakness, and occasionally seizures; though any system to which lead is distributed to can be affected. If lead toxicity is suspected, radiographs can be taken to evaluate the patient for a metallic foreign body, blood samples can be collected to test for lead levels, and chelation is initiated with calcium EDTA.
Pet birds may be exposed to multiple infectious organisms, but psittacosis – an infectious disease caused by Chlamydophila psittaci – is arguably the best known. It is a zoonotic disease that is shed in infected feces and oculonasal discharge, and an average of 250 cases are reported in people per year. Month- to year-long latent infections with intermittent active shedding may occur. In these cases, the birds may appear healthy but can start shedding the organism secondary to stress. Clinical signs seen in psittacines include lethargy, anorexia, ruffled feathers, oculonasal discharge, diarrhea, yellow-green urates, emaciation and death. Antigens can be detected via ELISA, PCR or immunofluorescence, and definitive diagnosis is made via culture, identification of the organism using stained smears or a greater than four-fold increase in titer. Psittacosis is treated with doxycycline, typically for 45 days. Any humans exposed to birds with psittacosis should seek medical attention if they develop flu-like symptoms or respiratory disease. Mortality is less than one percent in people if treatment is pursued; however, it can approach 20 percent without antimicrobial intervention.
Most raptors are presented to the emergency room due to traumatic injuries, but infectious etiologies, lead toxicity and unthrifty juveniles are also seen. Stabilization is performed as above, and a thorough physical exam is conducted to attempt to determine the nature of presentation and to identify all treatable injuries and disorders. If trauma is suspected, it is especially important to perform a through ocular, oral and aural exam. Oral and aural hemorrhage, in addition to anisocoria and retinal hemorrhage, can all be evidence of head injury. Thoroughly palpate both wings and legs for signs of crepitus or laxity. A prominent keel and juvenile feathering may help identify an unthrifty fledgling, and papillomatous lesions or diarrhea staining may point towards infectious disease. During the exam, make sure that restraint is performed by an experienced handler and that the bird’s head and talons are well-controlled. Covering the head with a hood or soft cloth when examining the rest of the bird is also recommended to reduce stress. Treat any suspected pain, dehydration and identifiable orthopedic injuries as discussed previously, and contact your local wildlife rehabilitator to schedule transfer to a long-term rehabilitation facility.
The popularity of backyard poultry is steadily increasing, and chickens, geese, ducks and turkeys are becoming more frequent emergency room patients. As with raptors, the most common presenting complaint is trauma, typically due to attacks from mammalian or avian predators. Perform emergency triage and stabilization procedures as above, and address any identifiable wounds or fractures. Chickens are remarkable healers and have been known to survive significant traumas. When antibiotics are used, it is essential to determine whether the bird or her eggs will be used for food. If so, make sure to communicate the withdrawal times for all medications to the owner, and determine whether any potential consumers have allergies to the prescribed medications.
Infectious disease is another common cause for emergency presentation. E. coli (colibacillosis) is commonly seen in chicks less than a week old and leads to edema, lethargy and respiratory distress. Pasteurella multocida (Fowl cholera) causes death in older flocks though younger birds are typically more resistant. It can also cause fatalities in rabbits and mice. Affected birds show signs of fever, anorexia, depression, respiratory distress/cyanosis, oral discharge and diarrhea. The disease course usually lasts a few days, and can be treated with antibiotics that have gram-negative specificity. Mycoplasma can cause chronic respiratory disease and is not uncommon in backyard flocks.
- Confirm intracoelomic fluid via a coelomic ultrasound if available. While many cases of intracoelomic fluid can be diagnosed via palpation, it is possible to confuse coelomic fluid with organomegaly.
- Restrain the bird in a vertical position. Placing the bird in dorsal recumbency has been known to cause fluid to enter the air sacs and lungs, and may cause respiratory arrest.
- Anesthesia is often not necessary and may further compromise the birds respiratory stability.
- Sterilely prepare the area.
- Use a 25 or 27 gauge needle inserted at midline. Direct the needle to the right side of the bird’s coelom to prevent damage to the ventriculus.
- A larger needle may be necessary if ascites is secondary to egg yolk peritonitis, due to the increased viscosity of the coelomic fluid.
- A small amount of skin glue may be applied after the procedure if coelomic fluid continues to drip from the centesis site after the procedure is completed.
- Intravenous catheters are typically only placed by experienced avian veterinarians, and intraosseous catheters are preferred in emergency situations.
- General anesthesia is required, unless the bird is already very weak.
- The jugular vein, medial metatarsal vein or basilic (cutaneous ulnar vein) may be utilized.
- If attempting placement of a jugular catheter, the right side is often preferred as it is frequently larger than the left. Additionally, placing the catheter as close as possible to the thoracic inlet minimizes kinking.
- The medial metatarsal vein is typically only used in medium to larger birds, and the basilic vein is used in large birds.
- Stabilization of the catheter may be achieved with tissue glue between the catheter hub and skin, utilization of a tape “butterfly” and suture, and a soft neck wrap for jugular catheters or a figure-eight bandage for basilar catheters.
- General anesthesia is required, unless the bird is already very weak.
- Placement is in the distal ulna or tibiotarsal crest. The distal ulna is the preferred site. Do not place an IO catheter in the femur or humerus, as these are pneumatic bones and fluids could be deposited directly into the air sacs.
- Pluck the feathers and sterilely prepare the site. One of the major, more common complications of IO catheters is osteomyelitis.
- Flex the carpus to identify the dorsal condyle of the distal ulna. The tibial plateau is directly ventral to the condyle and will be the site of insertion.
- A 2% lidocaine block should be used: 0.2 mg lidocaine may be used for a 100 gram bird and can be diluted with saline. The needle insertion site should be identified prior to performing the block, as it may not be palpable after the block.
- In larger birds, the catheter may be placed with a 20-22 gauge, 1.5 inch to 2.5 inch spinal needle.
- In smaller birds, a 25 gauge hypodermic needle may be used, and stainless suture can be used as a stylette.
- Seat the needle by pushing into the periosteum, and then insert it with gentle, constant rotation.
- Confirm successful placement by grasping the needle hub and attempting to move the limb. The entire limb should move with the needle.
- Flush the needle with a small amount of heparinized saline. Very little to no resistance should be appreciated. If there is blockage secondary to a bone plug that cannot be removed via a stylette, remove the original needle and pass a new needle of the same size or one gauge size larger.
- The catheter is secured with a tape butterfly and stay sutures, and the wing is immobilized with a figure-eight wrap.
- An initial administration of 30 ml/kg of warm fluids may be given subcutaneously, intravenously or intraosseously.
- Subcutaneous fluids can be given in the inguinal or axillary regions, or dorsally. The inguinal area is preferred, and dorsal administration carries a higher risk of penetrating into the air sacs or lungs.
- Restrain the patient upright, or in dorsal recumbency if no coelomic fluid is present.
- Create a skin tent, and insert the needle gently into the tent. Make sure that a visible fluid bubble forms as fluids are administered. Absence of a bubble usually means that the needle is too deep and that fluids are being administered IM or into an air sac.
- Multiple sites may be used if the full 30 ml/kg volume is being administered.
- The bird can be held upright (if conscious) or placed in dorsal or lateral recumbency (if anesthetized).
- Identify the following: axilla, carpus, elbow and primary feathers.
- Make sure the bandage, typically made from vet wrap or another self-adherent material, is cut to an appropriate size. Many rolls will need to be cut to half their width.
- Hold the free edge of the roll under the leading edge of the primaries, and bring the bandage material through the axillary space to the top of the wing.
- Bring the bandage material over the top of the wing and down again over the dorsal surface.
- Rolling the material from the inside to the outside of the wing will roll the wing inward and encourage it to lie flat against the body wall.
- Be sure that the bandage is placed high on the wing and does not cover the elbow. Covering the elbow can put pressure on the patagial tendon, damaging it and leading to wing contracture.
- When bringing the bandage up underneath the wing for the second pass, direct it toward the top of the wing and pass it just over the shoulder, instead of under the axilla, to loosely place a loop of material around the carpus.
- For the next pass, loop the bandage through the carpus again to establish the figure-eight pattern.
- Complete the figure-eight pattern for two to three passes until the required support has been achieved.
Reviewing basic techniques and procedures should help make avian emergency medicine more approachable for the general and small animal practitioner. Any practice that treats avian and exotic species should have, at minimum, an exotics formulary and a gram scale available to weigh their smaller patients. An incubator with an oxygen input is also highly recommended. Add a thirst for information and a feathered patient, and you’re ready to go!
Special thanks are given to Dr. Katherine Quesenberry and Dr. Scott Ford for their time and contributions to this article.
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