The VETgirl beat is a quarterly publication available to all subscribed members of VETgirl. The digital emagazine features highlighted webinars (small animal, large animal, veterinary technician, leadership), tech tips, provider spotlights, and recent happenings.
BEAT ISSUE 30 VETERINARY eMAGAZINE
04 THE PROFESSION
WE BUILD TOGETHER
16 KRATOM TOXICITY IN DOGS AND CATS: A GROWING POISONING TO KNOW ABOUT 08 FOCUSED CARDIAC ULTRASOUND (FCU) EXAMINATION 24 TECH TIPS 26 UPCOMING WEBINARS 06 DISCHARGE IS THE LAST WORD: FIVE WORKFLOW FIXES YOUR HOSPITAL WILL ACTUALLY FEEL 19 MIND MASSAGE 14 MYASTHENIA GRAVIS
OCTOBER 2026
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ISSUE 29 –JULY 2026
04
KRATOM TOXICITY IN DOGS AND CATS: A GROWING POISONING TO KNOW ABOUT BLOG HIGHLIGHTS 16
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THE PROFESSION WE BUILD TOGETHER
DISCHARGE IS THE LAST WORD: FIVE WORKFLOW FIXES YOUR HOSPITAL WILL ACTUALLY FEEL BLOG HIGHLIGHTS 06
19 MIND MASSAGE 24 TECH TIPS 26 UPCOMING WEBINARS
08
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MYASTHENIA GRAVIS 14 FOCUSED CARDIAC ULTRASOUND (FCU) EXAMINATION
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EARLY BIRD PRICING ENDS 123126. CE YOU THERE!
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Some technicians engage on a national—or even global—stage. Others make a tremendous impact within their own hospitals. Both matter.
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Professional engagement isn't measured by the size of your audience—it is measured by your willingness to contribute.
National Veterinary Technician Week: Your Profession Needs More Than Your Skills - It Needs Your Voice Every National Veterinary Technician Week, we celebrate the incredible impact credentialed veterinary technicians have on patient care. We recognize the countless lives you touch, the expertise you bring to every case, and the compassion you show every day. But this week is about more than celebrating what veterinary technicians do. It's also about recognizing what veterinary technicians can become. The future of our profession isn't determined solely in exam rooms, treatment areas, or operating suites. It is shaped by the technicians who choose to get involved—those who mentor, advocate, volunteer, educate, lead, and inspire others to do the same. In this VETgirl feature article, Amy Johnson, BS, LVT, LATG, CVJ, celebrates National Veterinary Technician Week by exploring how veterinary technicians help shape the future of their own profession through professional engagement. Read on to learn how you can get involved and how professional engagement can strengthen veterinary technician utilization, recognition, career development, workplace culture, and retention, while helping build a profession that future generations of veterinary technicians want to join and stay in. THE PROFESSION WE BUILD TOGETHER Amy Johnson , BS, LVT, LATG, CVJ Senior CE Manager, VETgirl
Taking Back Ownership of Our Profession Veterinary technicians are incredibly good at caring for everyone else.
We care for patients. We support veterinarians. We comfort clients. We mentor coworkers.
Too often, however, we forget to care for our own profession. When we wait for someone else to solve issues like technician utilization, career advancement, workplace culture, compensation, or recognition, progress happens slowly. Real change begins when technicians recognize that the profession belongs to all of us.
Every technician who mentors a student raises the next generation.
Every technician who advocates for appropriate utilization elevates the role of credentialed technicians.
Every technician who volunteers strengthens the organizations working on behalf of the profession.
Every technician who shares knowledge raises the standard of patient care.
Professional engagement isn't someone else's responsibility. It's ours!
Professional Engagement Builds Careers One of the greatest misconceptions about professional engagement is that it only benefits the profession. The truth is that it also benefits the individual technician. Engaged technicians develop skills that aren't always taught in clinical practice: • Leadership
That is professional engagement.
• Public speaking • Communication
Professional Engagement Is More Than Volunteering
• Project management • Team collaboration • Networking • Strategic thinking • Advocacy • Confidence
When people hear "professional engagement," they often picture serving on a committee or joining a professional organization. While those are certainly valuable, professional engagement is much broader than that. Professional engagement is making the decision to invest in something larger than your individual job. It might mean: • Joining your state or national veterinary technician association • Mentoring a new technician or veterinary assistant • Becoming involved in your local technician program • Attending conferences to network and learn • Speaking, writing, or sharing your knowledge with others
These experiences often open doors that technicians never imagined. Many leaders in veterinary medicine did not begin their careers planning to become educators, speakers, managers, specialists, executives, researchers, or industry professionals. They simply said "yes" to opportunities: • A committee meeting • A volunteer project
• A conference • A presentation • One opportunity led to another
• Advocating for credentialed technician utilization • Participating in legislative efforts that strengthen the profession • Volunteering your expertise in your community • Supporting fellow technicians through mentorship and encouragement
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You Don't Have to Change the World
Professional engagement doesn't require having all the answers. It simply requires being willing to participate.
Professional engagement doesn't require becoming president of an association or speaking at a national conference. It can begin with something much smaller:
We Need More Role Models Every veterinary technician remembers someone who helped shape their career: • The instructor who believed in them • The technician who took the time to teach • The supervisor who encouraged them to try something new • The mentor who reminded them they belonged Now, many of us have become those people for someone else. Whether you realize it or not, someone is watching how you practice. They're watching how you advocate for patients. How you communicate. How you treat your teammates. How you represent the profession. Professional engagement allows us to intentionally become the role models our profession needs. That influence extends far beyond our own hospitals. Recognition Comes From Visibility Veterinary technicians often say they want greater recognition. Recognition is important. Our education, skills, and expertise deserve to be understood and respected. But recognition doesn't happen by accident. It grows when technicians become visible:
• Attend one conference • Join one organization • Volunteer for one committee • Mentor one student • Write one article • Encourage one coworker • Share one idea • Support one colleague
Small actions have a remarkable way of becoming lifelong contributions. Every experienced leader in veterinary medicine started somewhere.
A Celebration—and an Invitation This National Veterinary Technician Week, take a moment to celebrate everything you have accomplished.
Celebrate the patients you've helped. Celebrate the families you've supported. Celebrate the knowledge you've gained. Celebrate the difference you make every single day.
• When we write • When we teach
• When we present • When we volunteer • When we participate in professional organizations • When we mentor students • When we share our expertise with the veterinary community Every engaged technician helps demonstrate the value of credentialed veterinary technicians—not only to clients and veterinarians, but to students, administrators, industry partners, and future employers. Building a Profession People Want to Stay In One of the greatest challenges facing veterinary medicine today is retaining talented veterinary technicians. Compensation and utilization certainly matter. Healthy workplace culture matters. Career pathways matter. Professional engagement supports all of these. Engaged technicians help create workplaces where people feel connected. They mentor new professionals before burnout takes hold. They advocate for better technician utilization. They develop educational opportunities. They strengthen professional organizations. They contribute ideas that improve patient care and team culture. In short, they help build a profession worth staying in.
Then ask yourself one simple question:
How Will I Help Shape the Future of My Profession?
Professional engagement isn't about adding another responsibility to your schedule. It's about recognizing that your voice matters. Your experience matters. Your ideas matter. Your leadership matters. The veterinary technician profession has never needed engaged professionals more than it does today. The future of veterinary technology won't be built by a handful of leaders. It will be built by thousands of veterinary technicians who choose to take one small step beyond their daily responsibilities and invest in the profession they love.
And that future begins with each of us..
No single volunteer or organization can solve every challenge facing veterinary technicians. But thousands of engaged technicians, each
making small contributions, absolutely can.
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a small space at the bottom for the clinician's personalized notes. The bones stay consistent. The voice stays human.
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The AAHA 2023 Technician Utilization Guidelines lay this out in Table 5.2 , "Standardized Workflow for Optimal Utilization," which identifies where protocols can systematize repetitive, high-volume work: triage calls, follow-up calls for surgical cases and recent hospitalizations, nutritional and behavioral consults, and preapproved diagnostics. The same logic applies directly to discharge. A 2025 study by Rohlf, et al. at La Trobe University found that transparent, client-centered communication was one of the strongest predictors of client satisfaction in veterinary practice, even after accounting for the seriousness of the presenting issue (Rohlf et al., Vet Sci. 2025). Standardized discharge instructions are transparency in action. Try this week: Pick your three highest-volume procedures. Write a standardized discharge template for each. Load them into your PIMS and assign one person to own updates. 2. Pre-Prepare Your Discharge Materials In human medicine, discharge includes a packet. Medication schedule. Activity restrictions. Red-flag signs. A clear phone number for "call us if." In veterinary medicine, discharge often comes with whatever the technician can pull together while the client is already at the front desk asking about parking validation. The bottleneck is almost never the conversation. It is the prep. Prescriptions are not filled. Invoices are not finalized. Go-home kits are not assembled. Handouts are not printed. Every one of those gaps is paid for in client waiting time and team stress. The 2023 "State of Emergency and Specialty Veterinary Care" report from Instinct Science found meaningful adoption of supportive technology in ER and specialty hospitals: 38% added digital treatment sheets, 36% moved to cloud-based PIMS/EMR, and 32% adopted client communication platforms in the prior year, with 75% of staff reporting positive improvements from the new tech. In a 2024 Journal of Veterinary Internal Medicine study, Flegel, et al. tested how well clients of a neurological referral center could recall the information given to them at discharge. The answer was: only partially. Clients consistently could not reproduce key portions of what they were told. The authors recommended that important instructions be specifically emphasized, which is exactly what pre-prepared, pre-tested materials make possible. Try this week: Build a discharge kit checklist for each common procedure. Include prescriptions, invoices, supplies, handouts, and QR codes linking to short recovery videos. Pre-load everything so the final 10 minutes are "review and hand off," not "assemble from scratch."
DISCHARGE IS THE LAST WORD:
The first time I really understood discharge, I was not wearing scrubs. I sat in a vinyl chair next to my mom's hospital bed, watching a nurse rip through a stack of papers and a medication list at warp speed while my mom nodded politely and remembered almost none of it. She had been admitted three times in quick succession. By the third discharge, I had a notebook, a color-coded pill chart, and a running list of every instruction that contradicted the previous one. I also had a humbling new appreciation for what our clients face every day in our hospitals. Discharge is the final word. It is the moment that determines whether a patient recovers as planned, whether a client trusts us enough to return, and whether our team has a peaceful evening or a phone tree full of "quick questions." Done well, it improves compliance, reduces callbacks, and leaves clients feeling cared for even when outcomes are difficult. Done poorly, it undermines much of the excellent medicine we provide. What if one of the most important workflow improvements in your hospital happens at the very end of the visit? In this VETgirl article, Dr. Natalie Marks, CVJ, takes a practical look at the discharge process and five ways veterinary teams can make it clearer, more consistent, and less stressful for both clients and staff. FIVE WORKFLOW FIXES YOUR HOSPITAL WILL ACTUALLY FEEL Natalie L. Marks , DVM, CVJ Marks DVM Consulting
The good news is that discharge is one of the most fixable parts of our day. Here are five workflow shifts, grounded in recent research, that any practice can begin testing this month.
1. Standardize Your Discharge Protocols
Most discharge inconsistencies do not stem from bad clinicians. They stem from the fact that every clinician writes instructions from scratch, in real time, at the end of a long day. That is a recipe for missed details, mixed messaging among doctors, and exhausted technicians trying to translate five different communication styles into one client conversation. Standardization is the solution. Build a core template for each common procedure (spay/neuter, dental, GI workup, chronic disease starts, orthopedic recovery) and leave
3. Assign Someone (or Some Time) to Own Discharge
Discharge falls apart when it is everyone's job and no one's job. When it gets squeezed in between appointments, dropped on whichever technician happens to be free, or rushed because a doctor needs the exam room back, it stops being a care moment and becomes a transaction. The Instinct Science 2023 report points in a related direction: hospitals that invested in workflow tools and clearer team structures saw better retention and morale, and technology adoption alone was linked to 10 to
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15% higher employee retention. Role clarity is part of that same picture. Defining who owns discharge during which hours is one of the simplest structural decisions a practice can make.
your staff their evenings back. The team satisfaction win is real, and so is the reduction in preventable ER visits.
Try this week: Write your post-discharge protocol on one page. Recheck the booked-at-discharge status, automated 24- to 48-hour check-in, the "when to call" section in every handout, and the named contact path for after-hours questions. Where to Start Tomorrow Morning Optimizing discharge is not about adding more work. It is about removing friction from the work you are already doing, so the last thing your client experiences is clarity rather than confusion. If you want a practical place to begin: 1. Audit your current discharge process. Map each step, time each step, and gather feedback from the team and clients. 2. Select one or two of the five fixes above. Standardized instructions and a named discharge owner are usually the highest-leverage starting points. 3. Pilot the change for two to four weeks. Gather feedback. Refine. 4. Then scale. Bake it into your software, formalize the roles, and train every new hire. Sitting in that vinyl chair next to my mom, I did not want more information. I wanted clarity, consistency, and the feeling that someone had thought this through before I arrived at the worst moment of my week. Our clients want the same thing for their pets. Discharge is where we either give it to them or we do not.
This does not require a new hire. It requires a small structural decision: who owns discharge during your busiest blocks and when does it happen? Try this week: Pick one or two technicians to be "on discharge duty" during your peak hours or carve out specific 15-minute discharge slots in your surgery and hospitalization schedule. Communicate it to the whole team so no one gets double-booked or interrupted. 4. Let Technology Carry the Repetitive Load Our industry has been slow to adopt tools, and I understand why. Change is hard, budgets are tight, and we have all been burned by software that promised the moon and delivered a slightly worse version of paper. But the data is now clear: integrated technology meaningfully reduces the burden of repetitive, documentation-heavy work, especially during discharge. Two-way communication tools, veterinary copilot platforms, templated digital workflows, e-signature for consents, automated text reminders, and shareable care plans all do the same thing. They take low-value tasks off your team's plate and give clients the consistent, accessible information they need to follow through at home. The Rohlf et al. 2025 study reinforces this from a different angle. The authors found that trauma-informed care principles, which they broke into five components (transparent and client-centered communication, client supports and strengths, emotional safety and empowerment, physical safety and comfort, and informed consent), significantly predicted both client satisfaction and reduced client disappointment. Integrated technology is one of the most practical ways to operationalize those principles at scale. Try this month: Audit your current PIMS or EMR for these features: templated discharge workflows, digital treatment sheets, a client communication portal, e-signature for consents, and automated post-visit messaging. If you are missing two or more, it is time to put an upgrade on the agenda.
It is worth the work.
RESOURCES: • Rohlf VI, Manfrenuzzi N, Rehman N, et al. Exploration of Client Experiences of Veterinary Care for Companion Animals (Dogs and Cats) and the Impact of Trauma-Informed Care on Client Outcomes. VetSci. 2025;12(8): 709. https://www.mdpi.com/2306- 7381/12/8/709 • American Animal Hospital Association. 2023 AAHA Technician Utilization Guidelines. See especially Table 5.2: Standardized Workflow for Optimal Utilization. https://www.aaha.org/ resources/2023-aaha-technician-utilization-guidelines/ • Instinct Science. The State of Emergency and Specialty Veterinary Care in 2023. Summary coverage: dvm360 and BusinessWire. • Flegel T, Dobersek K, Bayer S, et al. Client's understanding of instructions for small animals in a veterinary neurological referral center. J Vet Int Med. 2024;38(3):1639-50. DOI: 10.1111/jvim.17085. https://onlinelibrary.wiley.com/doi/10.1111/jvim.17085
5. Build a Post-Discharge Communication Protocol
Discharge is not the end of recovery. It is the beginning of recovery at home, where the doctor cannot see what is happening, and the client is doing their best with a notebook and a Google search. Follow-up is where you protect your medicine. The fix is a protocol, not a vibe. Schedule recheck appointments before the client leaves the building, then confirm them by text. Automate a 24- to 48-hour check-in for every medical and surgical discharge. Include a clear "when to call us" section in every discharge document. Give clients a consistent, low-friction way to reach you, whether that is a phone line, a secure chat, or a triage partner. Speaking of triage partners, if your hospital is not yet using one, now is the time to look. Several reputable veterinary triage services now serve as an extension of your team, handling pet parent questions 24/7 and giving
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FOCUSED CARDIAC ULTRASOUND (FCU) EXAMINATION
What is Focused Cardiac Ultrasound? Focused Cardiac Ultrasound (FCU) is ultrasound of the heart and major vessels, and can be very helpful in identifying the pericardium, pericardial sac and the right and left heart. There is no formal definition: we use it as cardiac ultrasound performed in non-cardiology settings to answer specific questions about cardiac structure and sometimes function. It is not a complete echocardiogram; it typically involves only 2D and M-mode cardiac imaging; Doppler echocardiography is part of critical care echocardiography (CCE), which is more advanced. What are the goals of FCU? 1. To visualize the pericardium/pericardial space, the right and the left heart from several angles. What can a focused cardiac ultrasound tell you at the bedside, and just as importantly, what can it miss? In this VETgirl article, Dr. Christopher Kennedy, DACVECC, DECVECC, walks through the core views of focused cardiac ultrasound (FCU), how to orient yourself to the image, and a systematic approach to evaluating the pericardium, right heart, and left heart. Read on to learn how to use FCU to identify overt cardiac abnormalities, avoid tunnel vision, and integrate your ultrasound findings with the rest of the clinical picture. Dr. Christopher Kennedy , DACVECC, DECVECC Clinical Assistant Professor, University of Illinois College of Veterinary Medicine
Video 1: PLAX4
Figure 1: PLAX4 view. LA, left atrium, RA, right atrium, LV, left ventricle, RV, right ventricle, IVS, interventricular septum. The pericardium is seen as a hyper-echoic, bright white line distal to the LV free wall. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC)
2. Parasternal short-axis view at the level of the papillary muscles (PSAX-pap).
2. To identify overt abnormalities.
Often called the “mushroom view,” this view is useful; however, it should not be obtained first, as it does not provide the same overview of the heart as the PLAX4, which means you might hyperfocus and miss something important! (See Video 2).
3. To integrate this information with history and clinical examination.
FCU is not the same as a formal echocardiogram performed by a cardiologist. Like other point of care ultrasound categories, it is designed to be quickly implemented and answer targeted questions. As such, we are often looking for obvious, as opposed to subtle, abnormalities. A clever FCU practitioner uses it to complement their clinical examination and not as their only diagnostic tool. The views We teach FCU exclusively from the right side. It can be performed in lateral or sternal recumbency or standing. Cardiologists use phased-array probes; Microconvex (curvilinear) probes can also be used. 1. Parasternal long-axis 4 chamber view (PLAX4). This view is your landing view; always start your examination here. It captures most of the heart—four chambers, right and left, and the pericardium—in one view. It can provide bountiful information, so work on obtaining this view first. (See Video 1).
Video 2: PSAX-pap
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Video 3: SX-CVC
Figure 2. PSAX-pap view. LV, left ventricle, RV, right ventricle, IVS, interventricular septum. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC) 3. Parasternal short-axis view at the level of the heart base (PSAX-base). This is the “LA:Ao view.” We prefer other measures to the LA:Ao, which are discussed in follow-on VETgirl blogs! This view considers more than just the left atrium, so we don’t call it that.
Figure 4: SX-CVC view. CVC, caudal vena cava. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC)
Figure 3: PSAX-base view. LA, left atrium, LAu, left auricle, Ao, aorta at the level of the aortic valve, RVOT, right ventricular outflow tract, PV, pulmonic valve, vein, pulmonary vein. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC) 4. Subxiphoid view (SX), which has two variations (SX-CVC and SX-heart). Sometimes called “transdiaphragmatic,” this view is an icing-on-the cake view for any FCU practitioner who wants to up their FCU’ing skills to become the crème de la crème. (See Video 3).
Video 4: SX-heart. This video starts off visualizing the right heart and moves to the left heart.
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Figure 6b: PSAX-pap, in M-mode, we use “anterior” and “posterior.” The left ventricular free wall is then termed “LV posterior wall” (LVPW), which we can see moving anteriorly in systole and posteriorly in diastole. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC)
Figure 5: SX-heart view. AV, aortic valve, LV, left ventricle, MV, mitral valve. This view is useful for confirming pericardial effusion. It can also be used for subjective assessment of LV systolic function and in critical care echocardiography for trans-aortic velocity-time integrals via Doppler echocardiography. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC) Anatomy of the image The probe emits and receives ultrasounds. It processes the ultrasounds it receives, resulting in the image that is displayed on the screen. This is the “sector.” (See Figure 6).
An orientation marker is visible on the probe and the screen (See Figures 7a and 7b).
Figure 6a: PLAX4, in 2d or B-mode, we use “near field” or “proximal” and “far field” or “distal.” (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC)
Figure 7a: Different probes have different orientation marker designs. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC)
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This is what we call the “systematic approach to FCU.”
These three questions are an excellent starting place. As we journey through the world of FCU, these questions will become more focused and, when integrated into clinical context, will become more meaningful.
Isn’t it more logical to start with the left heart and then move on to the right?
I am glad you asked! In short, no.
Here is an example.
Figure 7b: The orientation marker on the screen corresponds with that on the probe; different manufacturers use different on-screen marker symbols. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC) Sometimes structures in the sector can be muddled by the processing of the ultrasounds. Resolution is the ability to differentiate between two points in proximity. (See Figure 8) • Lateral resolution: the ability to differentiate between two things lying linearly side-by-side at the same depth. • Axial resolution: the ability to differentiate between two things along the same linear path as the ultrasound beam.
Video 5: Focusing on the left heart, the left ventricle is underloaded. This might prompt you to consider hypovolemia and fluid administration.
Video 6: When we consider first the right heart, it is clearly enlarged. This explains the underfilling of the left heart and identifies this patient as probably fluid intolerant—intravenous fluids will likely worsen this patient. Cases like this should be discussed with a cardiologist. Clinical integration The systematic approach to FCU is more developed than a quick peek at the heart. It involves several views, three general questions (see above) and encourages appraisal of all four heart chambers, their walls, the valves and the pericardium. Remember, we are not cardiologists, so we are not performing a formal echocardiogram. Goal #3 of FCU is to integrate this information into our clinical examination. What clinical questions were you asking? Sometimes these questions are simple—in my collapsed patient with poor pulses, is there pericardial effusion? Sometimes these questions are more complex— in my patient with respiratory distress, could there be a cardiac cause?
Figure 8: The blue dots are at the same depth and sufficient lateral resolution is required to resolve them. The pink dots are at different depths but lie along the same linear path as the ultrasound beam: sufficient axial resolution is required to resolve them. If the resolution is insufficient, these dots would blur into one blue and one pink structure. (Image courtesy of Dr. Christopher Kennedy, DACVECC, DECVECC) Three questions In each view, there are three questions to ask yourself and in this specific order: 1. Is there pericardial effusion?
2. How is the right heart?
3. How is the left heart?
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An easy way to integrate your FCU findings is to ask yourself, “do these findings fit with my clinical examination?” In other words, did something seem off—was there a tiny left heart in your patient with suspected left congestive heart failure? CAUTION: To do this effectively, you need to consider the whole heart. If we hyper-focus on one thing—say, a small left ventricle—we may miss other important information. And that is why we go from pericardium-to-right-to-left, in multiple views. Acknowledging error Every test we do, every measurement we perform, has a margin of error— we accept that our measurement could be off by a few points. Precision is how close we are to the true value. Cardiologists by training have greater precision (lower error) than non-cardiologists.† When we report a value, we must accept that it might not be precise. Error is acceptable, providing that we a) acknowledge it exists and b) accept that it exists. Acknowledging error allows us to practice medicine. Accepting error allows us to forgive ourselves for not being perfect. Practice your FCU to improve your precision and clinical integration. If you have a friendly neighborhood cardiologist, don’t be afraid to ask for help!
RESOURCES: • Ng A, Swanevelder J. Resolution in ultrasound imaging. BJA Education. 2011;11(5):186-192. doi: 10.1093/bjaceaccp/mkr030. • DeFrancesco T. POCUS: Heart – Introduction and Image Acquisition. In Lisciandro GR editor. Point-of-care ultrasound techniques for the small animal practitioner, 2nd ed. Hoboken: Wiley Blackwell; 2021:403-416. • Ward JL, DeFrancesco TC. The Role of Point-of-Care Ultrasound in Managing Cardiac Emergencies. Vet Clin North Am Small Anim Pract. 2023 Jul 7:S0195-5616(23)00090-6. doi: 10.1016/j.cvsm.2023.05.017. • †This is a topic within my PhD (in progress), where we have seen non-cardiologists tend to have greater error.
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WEBINAR HIGHLIGHTS
MYASTHENIA GRAVIS
Missy Carpentier, DVM, DACVIM (Neurology) Minnesota Veterinary Neurology, Columbus, MN
What do you do when weakness, regurgitation, or megaesophagus has you wondering whether myasthenia gravis could be the culprit? In this VETgirl article Dr. Missy Carpentier, DACVIM (Neurology), expands on myasthenia gravis, an important differential diagnosis covered in her October 15, 2025 VETgirl webinar, The Acute Lower Motor Neuron Canine . Read on for practical guidance on recognizing clinical presentations in dogs and cats, confirming the diagnosis, selecting treatment options, and managing complications like aspiration pneumonia to help support these patients through treatment and recovery. Want to learn more? Check out the on-demand webinar HERE !
Myasthenia Gravis (MG) can be both congenital and, more commonly, acquired with the dominating clinical sign being weakness. Dogs with the congenital form of the disease present at less than a couple months of age and have abnormal development of the acetylcholine receptors. The congenital form is rare. We are going to focus on the acquired form of the disease in this article, but if you have a juvenile patient who you suspect has MG, remember that there is a congenital form and they will not test positive on the acetylcholine receptor-antibody (AChR-Ab) test because they do not have autoantibodies against the receptor. ACQUIRED MG Acquired MG is a disease in which autoantibodies are directed against acetylcholine (Ach) receptors on the postsynaptic membrane on the neuromuscular junction. S
FELINE PRESENTATIONS In cats, the most common clinical presentation is generalized weakness, reported as the main clinical sign in 54.3% of cases. 2 They can also present with megaesophagus or dysphagia, in addition to generalized weakness. Cats are much less likely to present with focal MG, where clinical signs are localized to the esophagus or pharynx only, mainly due to the fact that the feline esophagus is a combination of skeletal and smooth muscle versus the canine esophagus that is entirely skeletal muscle. Unlike in dogs, in which only 3.4% present with a mediastinal mass, 25.7-52% of cats will present with a mediastinal mass that is most often a thymoma. 2-4 MG presents with a greater incidence in Abyssinian and Somali cats. 2, 4 An adverse drug reaction to methimazole is another cause of acquired MG in cats.
CANINE PRESENTATIONS
DIAGNOSIS
There are three classic forms for acquired MG in canines and they include: • Focal MG: Predominant pathology is megaesophagus and, therefore, the classic clinical sign is regurgitation. This form is seen in approximately 36-43% of cases. • Generalized MG: Clinical signs include regurgitation secondary to the megaesophagus and exercise induced weakness. This form is seen in approximately 57-64% of cases. • Fulminating MG: Clinical signs include profound weakness to the degree of non-ambulatory tetraparesis/plegia. This form is seen in <5% of cases. 1
A presumptive diagnosis of MG is made based on clinical signs. Previously we had a fun test, the tensilon test, to strongly support the diagnosis. However, edrophonium, the ACh blocker used in this test, is no longer available so this test is no longer performed. To confirm the diagnosis, acetylcholine receptor-antibody (AChR-Ab) tests can be performed in both dogs and cats. Ninety-eight percent of dogs that have acquired MG will demonstrate antibodies, however, 2% will be seronegative. 5 There is no correlation between a higher AChR-Ab level and prognosis in dogs, however, in cats, there is a significant correlation between a higher AChR-Ab titer and a decreased survival time.
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It is very important once MG has been diagnosed that a thorough work up is performed to rule out an underlying cause, such as a mediastinal mass mentioned above or other possible neoplastic processes. This is often performed with radiographs of the chest and an abdominal ultrasound, or if available, a whole-body CT.
Some owners have found it helpful to have their pets sleep with an inflatable cone (donut cone) around their neck to keep their neck in slight extension.
On average, approximately 88% of dogs will go into spontaneous remission approximately 6–18 months after diagnosis and will no longer require medication if the cause for MG is not neoplasia. 6 Want to hear more...tune in to hear a podcast with Dr. Carpentier on myasthenia gravis in dogs and cats HERE ! Of course, you might want to hear more about the long-term outcome of acquired MG in cats specifically...check out this podcast where we review the findings of Mignan, et al. in a study published in the Journal of Veterinary Internal Medicine, entitled: Long- term outcome of cats with acquired myasthenia gravis without evidence of a cranial mediastinal mass .
TREATMENT AND PROGNOSIS
Treatment consists of oral immunosuppressive medications, pyridostigmine, and intense supportive care. Common immunosuppressive medications that are used include prednisone, mycophenolate, cyclosporine, azathioprine, or leflunomide. Normally treatment will be initiated using one immunosuppressive medication and a second immunosuppressive medication will be added if necessary. Pyridostigmine is an anticholinesterase medication that is used to allow the ACh to be present longer at the synapse to hopefully allow it to bind to an available receptor. Possible side effects of pyridostigmine are related to a cholinergic crisis or toxicity. You can use the mnemonic “SLUDGE” to warn your owners about what side effects to watch for, including: salivation, lacrimation, urination, defecation/diarrhea, gastrointestinal signs, and emesis. These signs can also be consistent with MG, so once pyridostigmine is started it is important to evaluate these patients and get a thorough history if the owners are noticing these clinical signs to try and decipher if the clinical signs are secondary to the pyridostigmine or progressive MG (but sometimes this can be difficult). Most commonly, cats will be treated with prednisolone and pyridostigmine. It is important to educate owners that even in cats that have a mediastinal mass that is surgically removed, almost all cases of cats with MG-associated thymoma require postsurgical medical management to control the signs of MG. This is different than in dogs, where most cases will go into remission when the neoplastic mass is removed. It is important to know the significant risks that are associated with these surgeries. Most recently, therapeutic plasma exchange (TPE) has become more readily available for patients with MG and is a wonderful treatment option. The use of TPE in dogs with MG appears to be well tolerated, is safe, and can be considered as a first line therapy in addition to the medications listed above, or it can be considered in patients that are not responding to medical management alone. Overall, one of the most important aspects of treatment for these patients is supportive care. This can be drastically different in each patient based on their level of weakness, but it is aimed at providing appropriate nursing care, nutritional support, and physical therapy to try and keep them as comfortable and safe as possible. One of the leading complications of MG is aspiration pneumonia due to the megaesophagus. Diligent feeding practices of these animals with a Bailey-chair (Fig. 1) or something similar is of utmost importance. Any signs of aspiration pneumonia in these patients should be addressed promptly. I have also found that some of my patients tend to have regurgitation when they are sleeping at night.
Figure 1: Dog with megaesophagus in a Bailey chair. Photo courtesy of Kimberly Perkovick, LVT.
RESOURCES
1. Khorzad R, Whelan M, Sisson A, et al. Myasthenia gravis in dogs with an emphasis on treatment and critical care management. J Vet Emerg Crit Care. 2011;21(3):193-208. 2. Shelton GD, Ho M, Kass PH. Risk factors for acquired myasthenia gravis in cats: 105 cases (1986–1998). JAVMA. 2000;216(1):55-7. 3. Shelton GD, Schule A, Kass PH. Risk factors for acquired myasthenia gravis in dogs: 1,154 cases (1991–1995). JAMVA. 1997;211(11):1428-31. 4. Hague DW, Humphries HD, Mitchell MA, et al. Risk factors and outcomes in cats with acquired myasthenia gravis (2001–2012). J Vet Internal Med. 2015;29(5):1307-12. 5. Shelton GD. Myasthenia gravis and disorders of neuromuscular transmission. Veterinary Clinics: Small Anim Pract. 2002;32(1):189-206. 6. Shelton GD, Lindstrom JM. Spontaneous remission in canine myasthenia gravis: implications for assessing human MG therapies. Neurology. 2001;57(11):2139-41.
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product remains in pet households, veterinarians will continue to see these cases… especially when it comes in “edible” forms that dogs are drawn to (like chocolate, gummies, etc.). Mechanism of Action of Kratom So, what clinical signs do we see with kratom toxicity in dogs and cats? Kratom contains two main alkaloids: mitragynine and 7-hydroxymitragynine. Mitragynine is the most abundant alkaloid in the plant (according to ASPCA APCC, comprising approximately 12–66% of the plant’s total alkaloid content.) It is metabolized hepatically into 7-hydroxymitragynine, which is also present in the plant at low concentrations. These alkaloids result in most of the signs seen when ingested by dogs and cats. These alkaloids also have an affinity for the mu-opioid receptor agonists and can result in a dose-dependent opioid-like sedation. The alkaloids are also thought to potentially affect other receptors such as the alpha-2 adrenergic receptors, along with serotonin, dopamine and adenosine receptors in the CNS. In humans, lower doses are associated with stimulant properties, while higher doses produce sedation and euphoria. However, in veterinary patients, clinical signs can be variable – either sedative-like or paradoxical. ence—it is measured Toxic Dose, Onset, and Duration Unfortunately, as with a lot of veterinary toxicants, the exact amount of ingestion is often unknown (e.g., think THC amount in brownies – it’s difficult if not impossible to calculate how much was in the product, how much ingested, how much was removed by decontamination, etc.). As a result, an exact mg/kg is often difficult to determine. Add to that, there’s variability in product concentration, formulation (especially extracts), individual metabolism, and incomplete exposure histories. Likewise, with kratom toxicity, there is a known wide variability in reported dose-response relationships (at least in humans). According to the ASPCA Animal Poison Control Center (APCC) database, clinical signs have been reported at doses as low as 0.15 mg/kg. Conversely, exposures up to 5878 mg/ kg have been documented without reported fatalities . Clinical Signs of Kratom Toxicity So, what should we expect with a kratom poisoning case in our veterinary patients? Clinical signs typically develop within a few hours of ingestion. In most cases, signs resolve within 24–48 hours with appropriate supportive care. Kratom exposure may produce a combination of sedative and stimulatory effects. The most commonly reported clinical signs in dogs and cats include: • Miscellaneous signs (e.g., lethargy/sedation) • Gastrointestinal signs (e.g., hypersalivation, vomiting) • CNS signs (e.g., depression, vocalization, agitation, hyperactivity, hyperesthesia, progressing to tremors, etc.) • Cardiac signs (e.g., tachycardia, bradycardia, hypertension)
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KRATOM TOXICITY IN DOGS AND CATS: A GROWING POISONING
TO KNOW ABOUT Dr. Justine Lee , DACVECC, DABT Co-founder, VETgirl
Never heard of kratom? You’re probably not alone, but this “natural supplement” may be more accessible than you realize and is one that veterinary teams should have on their radar. In this VETgirl article, we break down kratom toxicosis in dogs and cats, from its opioid-like and stimulatory effects to the wide range of neurologic, gastrointestinal, and cardiovascular signs it can cause.
You’re working an ER shift when a 4-year-old, MN, Labrador retriever presents for acute agitation, hypersalivation, tachycardiac, and vomiting. The pet owner reports the dog got into a “natural supplement” that the pet owner uses for chronic back pain. You’re sitting there racking your brain, and the pet owner identifies the “gummy” that she purchased on Google… turns out the supplement contains kratom. You pause for a second — WTH is that? Never heard of it? Sounds vaguely familiar? Not quite an opioid, not quite a stimulant, and definitely not something we learned about extensively in veterinary school! Welcome to the up-and-coming world of kratom toxicosis in dogs (and less commonly, cats). Kratom ( Mitragyna speciosa ), a plant indigenous to Southeast Asia, is a member of the coffee family (Rubiaceae). In some countries, the leaves have been chewed, smoked or even brewed (as a tea). More recently in the United States, it has been “advocated” for recreational use, chronic pain, and for opioid withdrawal. As a result, its use has surged in the United States for the past decade. Kratom comes in various forms: from edibles like gummies and chocolates to powders, liquids, capsules, and even more concentrated extract formulations (which may be more potent). Note that since this is a “supplement,” there’s no regulation (e.g., not regulated by the FDA, etc.), quality control, or monitoring of this over-the-counter product in the United States. That said, in over a dozen countries, kratom is considered a controlled substance. Thankfully, some states are now banning its use (including in alphabetical order at the time of writing this blog Alabama, Arkansas, Indiana, Louisiana, Rhode Island, Vermont, and Wisconsin). Although kratom exposures still represent a small percentage of total toxicology calls, the ASPCA Animal Poison Control Center (APCC) based out of Urbana, Illinois recently documented nearly a 400% increase in reported veterinary cases in 2025 compared to 2024. As long as this
While many patients exhibit mild sedation, others may present with more concerning neurologic or cardiovascular abnormalities. Because of kratom’s mixed receptor activity, clinical presentation can vary widely.
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Differential Diagnoses Given its pharmacologic profile, kratom toxicosis can resemble several other toxicologic exposures (THC, anyone?). Depending on the clinical signs, your top differentials should also include opioid intoxication, alpha-2 agonist exposure, stimulant toxicosis, serotonergic agents, cannabis intoxication, or other CNS depressants (NOTE: This list is not all inclusive – there are a lot of toxicants that show these signs!). When in doubt, get a good history – this is imperative, as if you don’t ask about “supplement” ingestion, the owner is unlikely to remember or admit to this. When in doubt, consult with the ASPCA APCC, as this can be invaluable when presentation is atypical. Decontamination As with many oral toxicants, early decontamination may be appropriate in select patients. Emesis induction should ONLY be considered with recent ingestion in asymptomatic patients who are presenting shortly after ingestion (provided there are no contraindications such as laryngeal paralysis, BOAS, megaesophagus, etc.). Those patients with profound clinical signs, excessive sedation or neurologic impairment should NOT have emesis induction due to high risk for aspiration secondary to a decreased gag reflex. Likewise, activated charcoal may be considered after emesis IF appropriate, particularly in cases involving concentrated extracts or uncertain dose exposure. While ASPCA APCC often doesn’t advocate for the use of charcoal, this VETgirl is still old school and will consider one dose of charcoal, if appropriate. As always, the decision to pursue decontamination should consider time since ingestion, product formulation, and the patient’s neurologic status. Treatment for Kratom Toxicity In general, the determination on whether to hospitalize or treat on an outpatient basis will depend on several factors, including severity of clinical signs, amount ingested, success of decontamination (if performed), owner compliance/finances, etc. Hospitalization is warranted for patients with moderate to severe CNS depression, persistent agitation or tremors, cardiovascular instability, or inability to maintain hydration (e.g., persistent vomiting, etc.). When in doubt, patients should be carefully monitored, particularly during the first 12–24 hours. Cardiovascular parameters should be closely observed, including heart rate, rhythm, and blood pressure. ECG monitoring is reasonable in patients with bradycardia, tachycardia, or other rhythm abnormalities. If hyperactivity, tachycardia and hypertension are noted, the use of acepromazine can be considered. If bradycardia is detected, a stat blood pressure and ECG should ideally be performed. Neurologic status should be reassessed serially to detect progression from mild sedation to more profound CNS depression or escalating agitation. Body temperature should also be monitored, particularly in patients
As with most toxicants, kratom toxicity does not have a specific antidote. Management is primarily symptomatic supportive care and directed at controlling clinical signs. This may include: • Intravenous crystalloid fluid therapy
for hydration and cardiovascular support • Benzodiazepines for agitation or tremors (e.g., diazepam 0.2–0.5 mg/kg IV or midazolam 0.1–0.3 mg/kg IV) • Methocarbamol for tremor control (typically 55-100 mg/kg IV to effect) • Acepromazine for agitation when appropriate (0.01–0.05 mg/kg IV/IM) • Atropine for clinically significant bradycardia (0.02–0.04 mg/kg IV), if normotensive • Propranolol for tachycardia, when indicated (0.02–0.06 mg/kg IV slowly) • Cyproheptadine in cases where serotonergic signs are suspected • Naloxone (0.01-0.04 mg/kg, IV) can be considered in patients with significant CNS or respiratory depression, but veterinarians should be aware that response can be inconsistent*
*Because kratom alkaloids act as partial mu-opioid receptor agonists, reversal may be incomplete or transient, and repeat dosing may be required.
Prognosis for Kratom Poisoning Thankfully, the prognosis for kratom toxicosis in dogs and cats is generally excellent with appropriate supportive care. Most patients recover fully within 24–48 hours. When in doubt, early recognition, supportive care, and appropriate monitoring remain the cornerstones of successful management. When in doubt, contact the ASPCA Animal Poison Control Center at (888) 426-4435 for expert consultation and life-saving care.
As kratom continues to gain popularity among pet owners, we veterinarians and veterinary technicians need to be aware of this ever-so-common toxicity in our canine and (less commonly) feline patients!
with tremors or hyperactivity. Intravenous fluid therapy may be indicated to maintain hydration and support perfusion, if indicated.
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