DEALING WITH SICK PARROTS: PART FOUR – EMERGENCY CONDITIONS

There is little point in diagnosing by trial treatment in avian medicine. The majority of birds undergo a full diagnostic workup on the same day they are presented, often before any supportive care or emergency treatment have been provided, resulting in a specific diagnosis with appropriate therapy and supportive care instigated.

Diagnostics should only be avoided in the critically ill – for example, those that will die under general anaesthetic (GA). These cases should be stabilised for 24 to 48 hours only, then diagnostics should be performed. If the patient is still not stable enough for a GA then it is likely to die anyway as the supportive care has not stabilised the patient. In these circumstances pursuing a diagnosis will assist the case in reaching its ultimate conclusion. It may be that euthanasia is recommended on the basis of severity of pathology identified during the workup, or the bird may decide for us.

Antibiotic therapy is rarely indicated unless the bird is presenting with wounds or lesions likely to be contaminated with secondary opportunistic bacteria. In birds, commonly found pathogens include gram negatives and Mycoplasma or Chlamydophila, but gram positives are not unusual. The first-line antibiotic to consider in the UK is enrofloxacin as it is licensed. A dose of 10mg/kg bid is suggested.

Emergency drugs used in mammals are appropriate for birds and atropine has been used to treat organophosphate poisoning, at a dose of 0.1mg/ kg every three to four hours. Dexamethasone has been used at 2mg/kg as a one-off dose to treat shock as birds are highly sensitive to steroidal therapy. I would only consider the use of steroids when, in acute respiratory distress cases, an allergic response is the main differential. Doxapram has been used as a respiratory stimulant at 10mg/ kg IV in cases of cardiovascular arrest, respiratory support and IV fluid therapy. Adrenaline and atropine can be given at 0.1mg/kg.

Fitting

Fitting can occur for a number of reasons, such as trauma, hypoglycaemia, hypocalcaemia, toxicity, or viral infections. For many birds heavy metal toxicity, hypocalcaemia and hypoglycaemia are the main three differentials, so if therapy is required prior to a diagnosis then presumptive treatment for these can be given.

Glucose saline can be provided, along with crop tubing, for hypoglycaemic patients, while supportive nutrition is important to reduce the risk of this becoming a complication in an anorexic bird.

Hypocalcaemia is typically found in birds on a poor diet and those not exposed to UVB light. African grey parrots (Psittacus erithacus) are particularly prone. Early clinical signs include weakness, falling off perches, and “stargazing” which, if allowed to progress, will lead to fitting and potentially death.

Calcium gluconate can either be via the IV route or IM route at 100mg/kg every six hours. Ideally, measurement of ionised calcium should be performed and used to tailor therapy. Exposure to UVB lighting would be considered part of emergency therapy, and dietary improvement considered long-term. Oral calcium supplementation can follow.

Heavy metal toxicity can result in fitting. Often cages and toys are galvanised with zinc and as the bird uses its beak to move around the cage or play with toys, ingested metal will build up over time. Lead is sometimes found in the house, typically from flaking old paint. Clinical signs include weight loss, difficulty digesting food, green droppings with faecal staining around the vent, blood in droppings, lethargy, fitting and death.

The diagnosis can be made radiographically or based on blood levels. Treatment with calcium EDTA at a dose of 35mg/ kg bid can be given IM or slow IV for five days. This chelates heavy metal in the blood, and so treatment is intermittent (five days on, five days off) to allow the metal to diffuse out of the tissues. If convulsions cannot be controlled then diazepam is a useful agent in birds. This can be given IM or IV at a dose of 0.5mg/kg as required.

Respiratory distress

Birds in respiratory distress are often presented. The importance of pre-oxygenation and nebulisation for birds in this condition cannot be overemphasised. Obtaining a definitive diagnosis is vital and it’s important to distinguish between a syringeal blockage and lower respiratory pathology or compression. However, in cases of upper respiratory disease, placement of an air sac tube may be required as an emergency procedure.

Often, syringeal blockages present as a change in voice. This is fatal if left untreated. In these cases, placement of an air sac tube is required. These patients should be seen quickly and the time frame calculated depending on the severity of the dyspnoea. Inhalation of a foreign body may present similarly, but typically is severe and many birds die long before they reach the surgery. The owners should be instructed to bring in the bird immediately. If they make it to the surgery, an air sac tube should be placed as a matter of urgency with mechanical ventilation. Doxapram can be used at 5mg/kg to 10 mg/kg by any parenteral route should respiratory arrest occur.

The air sac tube can be inserted to buy time before any obstruction is alleviated, however, air sac tubes will not assist conditions where the respiratory disease is below the level of the syrinx (pneumonia) and is contraindicated in birds with lower respiratory disease (affecting the air sacs). This is a relatively common emergency procedure.

For entry into the coelomic cavity, minimal instrumentation is required – ophthalmic instruments are best. The skin is incised and the muscles penetrated by either a pair of roundended scissors or fine, curved artery forceps.

The entry site can be between the last two ribs or behind the last rib, usually at the midpoint on the left side. From a practical point of view, the ideal entry point is the caudal thoracic air sac as this has direct communication with the lung fields. In order to increase the chances of entering the caudal thoracic air sac, I suggest an entry point between the last two ribs. Positioning is the same as for diagnostic coelioscopy.

An air sac tube can be made out of a shortened endotracheal tube (usually a 4mm portex tube for most birds) with lateral holes towards the end to help prevent blockage. This can be inserted and sutured to the skin and muscle of the body wall. In many cases, placement of the air sac tube leads to immediate relief, as oxygenation or anaesthetising the bird via the air sac tube is now the preferred option.

It may be that some diagnostics could be performed at the same time and tracheal endoscopy with a 1.9mm endoscope should be carried out. Coelioscopy through the air sac tube is also indicated and the air sac tube should be removed when the pathology has been identified and dealt with successfully. Air sac tubes can remain in place for up to a week, but closure of the surgical wound is not required. Severe dyspnoea due to lower respiratory pathology requires a different approach.

Respiratory disease

Many birds suffer from chronic respiratory disease; however, this may be an acute presentation due to severe pathology. These patients should be seen urgently and assessed – the bird might be able to wait for a work-up the following day, but this can only be judged by clinical examination. Again, radiography and endoscopic examination is required.

Some species of parrot, such as macaws, are prone to acute inhaled inflammatory responses (asthma), and in other birds, reactions to polytetrafluoroethylene (PTFE) from frying pans, deodorants and other items can lead to acute air sac inflammation and lung haemorrhage (typically around the ostia). Other common toxins are found in aerosols, plug-in air fresheners and smoke.

The symptoms seen with toxicity are an acute dyspnoea and, occasionally, collapse. In these cases a client should be advised to take the bird outside or to increase the ventilation in the room. Once the acute signs have settled, the bird should be brought to the surgery. The patient may benefit from a low dose of steroids and nebulisation.

Dyspnoea will also be displayed in cases where the air sac system is being compromised – a tumour, fluid or an overactive gonad could literally take up the space in the body cavity.

Crop burns typically result from overheated food sources in juvenile parrots or birds sipping a hot drink, while microwaved rearing food is a typical history given by the client. Fluid therapy, analgesia, antibiotics and proventricular feeding (even via the wound) should be performed prior to surgery. Burns create large areas of necrotic tissue, but also a large area of inflamed tissue that is thermally damaged.

It is not possible to determine the full extent of a crop burn on initial presentation, so supportive care is indicated for four to five days until the full extent of lesionsis identified. In many cases, a fistula with the skin will have been created and this should be bluntly dissected and any non-viable tissue excised prior to closure.

Birds may present after the owner has witnessed a foreign body being ingested or after he or she has “lost” something. Foreign bodies can be identified by radiography – this will detect radiodense foreign bodies, but it will not identify how long they have been present.

Some may have become adhered to the lining of the gizzard with granulation tissue and any surgical attempt at removal would be foolish. It is also possible for the material to cause a focal coelomitis or penetration of the tract – surgery is indicated as a matter of urgency. Evaluate the serosal surface of the gastrointestinal tract by coelioscopic examination.

It is far easier to manipulate a foreign body per os as opposed to a surgical procedure, especially in young handreared parrots. These may be relieved under anaesthesia by digital manipulation or using fine haemostats, but it is a good idea to hang on to the foreign body to prevent it going into the proventriculus. A proventriculotomy is possible by both a left lateral approach and a ventral midline approach. Preference varies depending on the surgeon and the species involved.

Prolapse

Cloacal prolapses are often seen in breeding females. Prolapses can be of the cloacal mucosa and can be due to papillomas, but these are less urgent unless the bird is severely traumatised. However, colon or oviduct prolapses are emergency cases and careful questioning is required to define the nature of the prolapse. Surgery will usually be indicated after a work-up, including coelioscopy and cloacal endoscopy. Organs that can prolapse through the cloaca include the cloaca itself, cloaca papillomas or granulomas, the oviduct or the colon. Differentiation of tissues and assessment of the size and anatomy of the prolapse is important. Cloacal endoscopy can also be used to differentiate masses.

In some cases birds can present in severe shock. Fluids, analgesics, antibiotics and supportive care are mandatory to stabilise the patient and a ventral midline surgical approach is required to invert the tissue and either perform a salpingotomy or an intestinal resection. A cloacopexy is required for oversexed psittacines.

Egg binding is also a common emergency. If truly egg-bound, the bird will have become ill within the past 24 to 48 hours. However, many egg-bound birds sit on the floor of the cage (due to other illnesses) and these are not as urgent. Such cases can end up with egg peritonitis due to excessive reproductive activity.

Egg laying difficulty with subsequent egg binding occurs particularly in cockatiels and budgerigars, but any species can present. Classically, these birds have a poor diet and no exposure to UVB light, resulting in eggs that are malformed, oversized or malpositioned, preventing oviposition.

Birds will lay eggs on the perch if not provided with a nesting site – many adapt the cage floor or feeding receptacles. Cockatiels can become persistent egg layers and sequentially deplete energy and calcium reserves leading to egg stasis. Clinical signs include depression, general lethargy, anorexia, swollen abdomen, straining to defecate, sitting on the bottom of the cage, and weakness. In these cases the egg can be palpated in the abdomen.

Radiography should be performed along with a blood profile to evaluate the ionised calcium levels. These patients will require heat, fluid therapy and parenteral calcium. Oxytocin has been used to assist uterine contraction, but anaesthesia will be required if the egg is not passed.

Eggs can be manipulated towards the cloaca and the oviductal opening – lubrication with gentle manipulation can open the sphincter and the egg can be removed. A large gauge needle can be used to aspirate egg contents while the shell can be removed with fine dressing forceps to prevent uterine infection. In some cases the bird will pass the shell subsequently with no assistance required.

Trauma to soft tissues can occur commonly in psittacines, often from cage mates or the environment. These cases should be seen early on, depending on the clinical signs presenting. Orthopaedic injuries can present concurrently and wounds can become infected. Birds will require analgesia, antibiotics, fluids and, possibly, antifungal therapy.

Once the patient is stabilised, examine the wounds under anaesthesia – caution is advised as many wounds can penetrate the coelomic cavity and the respiratory tract. If this is the case then endoscopic examination to evaluate internal pathology is required and radiography is mandatory to assess for orthopaedic injuries. There is little soft tissue underlying the skin in birds and the skin is fragile, so any tension on wounds will lead to dehiscence.

Debridement

Thorough debridement should be performed before closure is considered. Horizontal mattress sutures are commonly employed to provide some support to healing wounds, and selfadhesive polyurethane dressingscan be sutured over wounds to provide additional support. Fine monofilament material, such as a polydioxanone suture, should be used for wound closure.

Feather pluckers are not urgent cases unless self-trauma to the skin has occurred or there is significant blood loss from quill feathers. In these cases the bird should be collared to prevent self harm while making a diagnosis.

Bleeding feather quills can have cornflour applied at home to stem the bleeding before being brought to the clinic and provided with analgesia. Anaesthesia is indicated to remove any damaged quill feathers as the flight feathers and tail feathers are attached to the periosteum of the bone – these are removed using artery forceps. If it is a blood quill then digital pressure over the follicle is required to minimise further haemorrhage from the site and bruising. Feather regrowth typically takes eight weeks.

Orthopaedic injuries may present as a lameness or a wing droop and fractures of the thoracic girdle may lead to an elevation in the wing. Birds should be stabilised first as other major soft tissue or coelomic organ trauma may be evident and neurological signs should be assessed. Psittacines tolerate dressings poorly, so quietly sit the bird in a dark cage prior to further assessment. If dressings are used they should not be unduly heavy or they will act as a pendulum leading to increased soft tissue damage.

Radiography is the next step in the assessment of orthopaedic injuries. Two orthogonal views are required to assess fractures – avian bones are brittle with a wide medulla. Pathological fractures can be seen in egg-laying females and juvenile birds suffering from nutritional secondary hyperparathyroidism. Fixation techniques typically require a combination of external fixation with intramedullary (IM) pinning.

Commercially available mini ESF clamps are available and can be used on birds as small as 300g, while in smaller birds, down to 100g, IM pinning alone is possible.