Chelonian Emergency and Critical Care

Topics in Medicine and SurgeryTopics in Medicine and Surgery

Chelonian Emergency and Critical CareTerry 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 extremelyvulnerable to human impacts on their habitat and populations. Unusual anatomic andphysiological features, such as the shell and being ectothermic, make cheloniansmedically challenging for the veterinarian. This article presents information on themedical evaluation and stabilization of critically ill and injured chelonian patientspresented to the emergency clinician. History taking, performing a physical examina-tion, recommended diagnostic testing, fluid and transfusion therapy, cardiopulmonaryresuscitation principles, nutritional support, hospital environment, and therapeuticagents recommended for the emergency and critical care of chelonians are reviewed.Differential diagnoses are presented for a variety of conditions encountered by theemergency clinician for marine turtles, tortoises, freshwater aquatic turtles, and terra-pins. There are significant differences in the disease problems encountered by captiveand free-ranging specimens. This review will be useful for the veterinarian working inprivate practice, zoological or aquarium medicine, and wildlife rehabilitation. Copy-right 2005 Elsevier Inc. All rights reserved.

Key words: Chelonian; critical care; emergency; terrapin; tortoise; turtle

The order Chelonia1 or Testudines2 includestortoises, turtles, and terrapins and is com-prised of approximately 270 species,1 onequarter of which reside in North America.2 Cheloni-ans reside in a wide range of ecosystems. Aquaticspecies occur in marine, brackish, and freshwaterhabitats, while terrestrial species reside in desert totropical environments. All reptiles, including Chelo-nia, are ectothermic and depend on environmentalheat and behavior to attain their preferred bodytemperature (PBT). The preferred optimal temper-ature zone (POTZ) is a temperature range that al-lows reptiles to thermoregulate to maintain theirPBT. The POTZ varies among the different speciesof chelonians.

Chelonians have long lifespans, often surpassing hu-mans, and are slow to reach reproductive maturity. Forexample, the loggerhead sea turtle reaches sexual ma-turity at approximately 25 to 35 years of age.3 The slowsexual maturity rates of chelonians tend to make them

more susceptible than other vertebrates to humanpressure. These pressures include habitat degradationand destruction, collection for commercial traffic suchas the pet trade, and exploitation for food and medic-inal purposes. Chelonians are extremely hardy animalsand can have normal activity despite being criticallyanemic (hematocrit 5%) and hypoproteinemic (to-tal protein 1 g/dL). They can also survive monthswithout food and tolerate extreme levels of dehydra-tion.

From the St. Catherines Island, Wildlife Survival Center, 182Camellia Road, Midway, GA 31320.

Address correspondence to: Terry M. Norton, DVM, Dip.ACZM, St. Catherines Island, Wildlife Survival Center, 182Camellia Road, Midway, GA 31320. E-mail: [email protected]

2005 Elsevier Inc. All rights reserved.1055-937X/05/1402-$30.00doi:10.1053/j.saep.2005.04.005

106 Seminars in Avian and Exotic Pet Medicine, Vol 14, No 2 (April), 2005: pp 106130

Triage Principles In CheloniansPresented For Emergency

Ideally, the emergency chelonian patient should bemedically evaluated and then stabilized. However,initial emergency treatment may need to take prece-dence over a diagnostic work-up in a critically illturtle. When possible, a minimum database shouldbe established before starting emergency therapy.The keys to success in medically managing cheloni-ans are patience, minimizing the stress throughoutthe course of treatment, minimizing the handlingtime by being prepared, treating dehydration andmaintaining an adequate hydration status, providingappropriate nutritional support, and lastly, maintain-ing the turtle at its POTZ.

HistoryThe medical history is an important step in assessingthe critically ill chelonian.4,5 Captive specimens havea high incidence of medical problems related tohusbandry issues. A questionnaire given to the clientor caretaker can save time and request the followingessential information:4

1. Reference data: date, client and animal iden-tification, common and scientific names, cap-tive or free-ranging specimen, presumed sexand age, duration of ownership, details of pre-vious ownership, time in captivity, reason forpresentation.

2. Information on the clients animal collection:animals in direct and indirect contact with thepresenting turtle.

3. Free-ranging specimens: GPS coordinates, spe-cific location of where the turtle was found,time and date found, housing and transportconditions since that time, details on any treat-ment provided.

4. Housing: indoors, outdoors, both; enclosuredescription.

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 vari-ation in diet, vitamin or mineral supplementa-tion, food preparation and storage, how is wa-ter provided and frequency of water changes.

7. Observations: description of activity level, ap-petite, 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-layingdetails.

9. Disease control: methods of disease control,quarantine program details, disinfectants used,information on all humans in contact with theturtle, historical health problems in the collec-tion, recent acquisitions.

10. Hibernation: details of management.

Diagnostic TestingThe initial diagnostic workup may include a physicalexamination, including body weight and morpho-metric measurements, clinical pathology, radiogra-phy, fecal examination, and possibly other special-ized diagnostics. The emergency chelonian patientshould be maintained within its POTZ during thediagnostic work-up. When working with these pa-tients, the veterinarian should also minimize thelikelihood of transmitting contagious diseases bywearing gloves, hand-washing between patients, anddisinfecting equipment during the examination andhospitalization. Chelonians are challenging to eval-uate medically and treat due to their highly evolvedand effective structural and behavioral defenses. Theshell is an anatomical feature unique to chelonians,and the primary reason they are such a medicalchallenge. The box turtle (Terrapene spp.) is the mostextreme example of this adaptation and may retreatinto its hinged shell so that it is difficult to safelyassess without sedation. Depending on the patientsphysical condition and the species of chelonian, var-ious levels of restraint will be needed for the initialevaluation. A detailed physical examination may re-quire sedation or anesthesia; however, chemical im-mobilization should be delayed until the patient hasbeen stabilized.

A systematic approach should be followed whenperforming a physical examination on a chelonian.An observational examination of the turtle beforehandling can provide important information. Gen-eral body condition, including overall musculatureand fat, degree of alertness and strength, head andbody symmetry, aural swellings, ocular abnormalities(eg, discharge, squinting, and sunken eyes from de-hydration), nasal discharge, asymmetric nares, respi-ratory difficulty, open mouth breathing, cervicalswelling, carapacial abnormalities (eg, fractures andother injuries or deformities), lameness or abnormalflipper use, abnormal skin (eg, dry, flaky or ulcer-ated), an inability to dive or floating asymmetrically

Chelonian Emergency and Critical Care 107

are all abnormalities that can be observed withouthandling the animal.

A physical examination form that includes a turtlediagram is recommended for recording biologicaldata and external abnormalities such as shell frac-tures, missing flippers or limbs, and lacerations. Dig-ital images can be used to document specific lesionsor injuries for long-term case monitoring. The gen-der,6,7 morphometrics, and age should be deter-mined. A rough age estimate may be made by count-ing scute growth rings; however, these are not nec-essarily a sensitive method for age determination.Body weight should be recorded before therapy, andthen measured serially during treatment. Weighttrends can be a good indicator of hydration status.

Deep cloacal temperature may be representativeof the chelonians recent environmental tempera-ture, and is an important parameter to obtain andmonitor in hypo- and hyperthermic patients. A dig-ital, distant laser, thermal monitoring device (Rayn-ger St, Raytek Corporation, 1201 Shaffer Road, P.O.Box 1820, Santa Cruz, CA USA) can be used todetect surface body temperature, and when directedat the prefemoral or prescapular areas correlateswell with core body temperature.4 Heart rate andrhythm can be assessed with an esophageal stetho-scope, a pulse oximeter cloacal probe, or a dopplerprobe placed in the region of the thoracic inletbetween the distal cervical region and the proximalfront leg.8-10

Evaluate the limbs for swollen joints and fractures.The plastron and carapace should be evaluated forscute quality, abnormal keratinization, hardness andpliability, pyramiding, fractures, ulceration, mal-odor, and external parasites or epibionts. Hemor-rhage within the scute keratin may be indicative oftrauma if localized or septicemia if more general-ized. Shell fissures usually occur at the plastron/carapace junction and may indicate septicemia, vas-culitis, or hypoproteinemia.11 Examine the skin forsloughing, abnormal shedding, swellings, edema, ab-scesses, ulceration, exudate, malodor, and epibiotaand external parasites.

Digital palpation of the caudal coelomic cavitythrough the inguinal fossa can be used to confirmthe presence of eggs, cystic calculi, organ enlarge-ment, masses, or fluid. The cloacal region should beexamined for swelling, trauma, abnormal discharge,infection, and myiasis. In larger chelonians, digitalpalpation of the cloaca can be used to assess gravid-ity, colonic and cloacal tone, cystic calculi or spaceoccupying lesions.4

Exteriorizing the head of the chelonian from theshell and performing an oral examination can be

difficult for the veterinarian and stressful for thechelonian. This examination may need to be delayeduntil the turtle is stabilized.4 Once the head is exte-riorized, inspect the oral cavity including the tongue,glottis, choana, and outlets of the eustachian tubes.Particular attention should be given to mucousmembrane color, the quantity of mucus, petechia-tion, plaques, ulceration and caseous material. Beprepared to obtain any diagnostic specimens andadminister any medications or nutritional supportvia a stomach tube if indicated. Perform a completeophthalmic examination of the cornea, anterior andposterior chambers, and menace and papillary visualreflexes. A periocular examination and evaluation ofthe beak, mandible, tympanic membranes and naresshould also be performed while the head is re-strained.

An emergency chelonian minimum databaseshould consist of a hematocrit, total solids, glucose,and subsequently, a complete blood count andplasma biochemical panel. Bacterial blood culturesshould be collected before initiating antimicrobialtherapy. While the size and patient condition willdictate the amount of blood that can be safely col-lected, the author generally recommends 0.5 to 0.8mL/100 g body weight for healthy patients and areduced sample volume for diseased patients. Lith-ium or sodium heparin are the anticoagulants ofchoice, because EDTA can cause red blood cell lysisin chelonians.12

A wide range of venipucture sites can be used inchelonians,4,13-17 and the choice of site should bebased on the species, size and condition of patient.Lymph contamination of the blood sample is a com-mon problem in chelonians and will alter many clin-ical pathology parameters.13,16,18-20 Collection ofblood from the jugular vein is preferred based onthe low incidence of lymph dilution from this site,13

but may be stressful and not always feasible due tothe difficulties in accessing the vein. Alternative sitesused by the author include the brachial and subcara-pacial veins in tortoises, the dorsal tail vein in aquaticspecies, and the cervical sinus in sea turtles.

Radiography is an important diagnostic tool usedto assess chelonian emergencies. Useful reviews ofchelonian radiography are available.21-26 Radiopaquematerials such as barnacles should be removed fromthe shell before performing a radiographic study.Three radiographic views should be routinely per-formed in chelonians presented for emergency care:anterior-posterior and lateral projections using ahorizontal x-ray beam and a dorsoventral view.22,23

Additional views such as lateral, dorsoventral andoblique, may be needed for specific problems such

108 Terry M. Norton

as fractures of the limbs or skull. An anterior-poste-rior horizontal beam radiograph should be taken inchelonians with fractures of the carapace to assesslung involvement.26 Digestive tract radiographic con-trast procedures are often necessary to documentintestinal obstruction and foreign bodies.22

Determining Hydration Status andFluid TherapyOn completion of the initial evaluation, the patientshould be stabilized. Most chelonians presented foremergency care are dehydrated, thus rehydration isoften the first step in treatment. Physical examina-tion findings indicative of dehydration in cheloniansinclude sunken eyes, changes in skin turgor, skintenting, loss of skin suppleness, dry mouth withropey, thick oral secretions, depression, a slow anddifficult to find heart beat, and minimal to no uri-nation. Venipuncture and tube feeding are morechallenging in the dehydrated patient.1 Weight lossfound over 1 to 14 days is likely caused by dehydra-tion, thus serial body weights should be performedduring hospitalization.1 Elevation of the packed cellvolume (PCV) and total solids or total protein (TP)can be helpful in determining the extent of dehy-dration. However, ill chelonians are often anemicand hypoproteinemic, which may mask the extent ofdehydration. Serial PCV and plasma TP determina-tions help assess the status of the patient and targetthe most appropriate therapeutic regimen. Hypogly-cemia or hyperglycemia is often present in sick che-lonians. Blood glucose determination is easy, quick,inexpensive and essential in choosing the appropri-ate fluid therapy in chelonians.

Fluid TypesSelecting the route, rate and type of fluids to admin-ister depends on the species of chelonian and con-dition of the patient. Fluid choice is frequently dic-tated by clinician preference, the patients present-ing problem, and clinical pathology and acid-baseabnormalities. Many ill tortoises have isotonic orhypotonic dehydration.27 Lactic acidosis is commonin stressed chelonians. Most debilitated cheloniansbenefit from rehydration therapy and glucose sup-plementation. Mammalian crystalloid fluid prepara-tions are suitable for chelonians. Fluids commonlyused in chelonians include reptile ringers solution(one part Lactated Ringers Solution 2 parts 2.5%dextrose and 0.45% sodium chloride),27-29 Norma-sol-R1, and lactated ringers solution. Use of lactatedringers solution is controversial in chelonians basedon the common finding of lactic acidosis.27,28 It is

critical to correct hydration status of the ill chelo-nian before starting oral nutritional support.

Whole blood transfusions are indicated in cases ofacute hemorrhage and life-threatening anemia.30

Sea turtles with a PCV 5% may benefit from awhole blood transfusion from a healthy captive seaturtle donor (Manire, C, pers comm., 2005). Thosechelonia with a PCV 5% can often be successfullymanaged with fluid therapy, iron supplementation,and other supportive measures. The donor and re-cipient should be the same species, because crossmatching has not been perfected in reptiles. Acid-citrate-dextrose solutions are the preferred antico-agulants 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 15minutes in chelonians with severe shock from mas-sive blood loss.1 A purified bovine hemoglobin (Oxy-globin, Biopure Corp., Cambridge MA 02141) hashad limited clinical use in sea turtles,29 desert tor-toises,30 and a terrapin31 without adverse affects. Inhealthy desert tortoises (Gopherus agassizi) this prod-uct was administered at dose of 20 mL/kg IV withoutadverse effect.30 A Hispaniolan slider, Trachemys deco-rata, was resuscitated after near exsanguinations withthe use of Oxyglobin and a single blood transfusionfrom another individual of the same species. Discol-ored mucous membranes are normally observed af-ter using this product.30

Route of Fluid Therapy

Intravascular. In severely compromised cheloni-ans, intravenous (IV) or intraosseous (IO) routes offluid administration allow for rapid rehydration andemergency therapy. However, placement and main-tenance of catheters in these sites can be technicallychallenging, especially in aquatic species, and shouldbe reserved for patients that are unconscious orminimally responsive.1 The jugular vein is the pre-ferred site for IV catheter placement in most chelo-nians. A small skin incision allows direct visualizationof the vessel. After catheter placement, secure thecatheter to the skin with tape and or suture.1,32 Main-taining patency of the jugular catheter may be diffi-cult, especially in active turtles.33 Intravenous or IOroutes are necessary for administration of whole andartificial blood, colloidal fluids, and fluids contain-ing greater than 5% dextrose.1,30,34-36 Intraosseouscatheters may be placed in the distal humerus, distalfemur or plastron-carapacial bridge.33,37 An appro-priately sized spinal needle can be inserted into thedistal one fourth of the medial aspect of the hu-merus at an angle of approximately 30 to 45 from


parallel. The needle should be inserted as distally aspossible without entering the joint capsule. Confirmthe spinal needle position radiographically. Thecatheterized limb should then be reduced into thefossae and secured with tape to the carapace.33 Theprimary disadvantages associated with IO cathetersare that the fluid flow rate is limited due to the smallbone marrow space, fluid and drug administrationmay be painful, and the metal of the spinal needlemay fatigue and break.38

Bolus IV fluid therapy can be used to stabilizesome patients before pursuing other routes of ad-ministration. The subcarapacial vein is used for mostchelonians and the cervical sinus for sea turtles.Advantages to the bolus IV method include easyvessel accessibility, minimal stress to the patient, andrepeated vascular access.

The epicoelomic fluid administration site is usefulin chelonians that are completely retracted intotheir shell and difficult to coerce out. McArthur(2004) describes this as the preferred site for fluidadministration to critically dehydrated chelonians.27

The needle should be inserted into the potentialspace located dorsal to the plastron and ventral tothe pectoral muscles, coelom, and the scapulo-humeral joint, and directed caudally toward the op-posite hind leg.32

The intracoelomic (IC) route is commonly usedfor maintenance fluid therapy in sea turtles. Fluidsmay be injected into the coelomic cavity through theinguinal fossa. An IC catheter has been described foruse in sea turtles for up to 5 days.27,39 This route istechnically easy and allows administration of crystal-loid fluids with up to 5% dextrose, however, fluidsmay not be absorbed rapidly when given by this route.Disadvantages of coelomic administration include thepotential of compromising the lung space or perforat-ing the lungs, the urinary bladder,32 or an ovarianfollicle in mature females. Hypoproteinemic patientsmay have fluid in the coelomic cavity (ascites/ana-sarca), which will further complicate absorption.

Subcutaneous fluid administration is technicallyeasy. Fluids can be given into any accessible fold ofskin, but are typically placed into the inguinal fossa,front limb fossa, or ventral neck fold. Administeringthe fluids in multiple sites may improve absorptionand rehydrate the chelonian faster. Disadvantages tothis route include poor absorption in severely debil-itated chelonians and that only 2.5% dextrose so-lutions can be administered.

The oral route of fluid administration should bereserved for use in patients with functional gastroin-testinal tracts that are mildly to moderately dehy-drated and for maintenance fluid therapy. Severely

dehydrated and weak turtles tend to regurgitateorally administered fluids. Fluids can be adminis-tered directly into the stomach using an appropri-ately sized, well-lubricated red rubber or metal feed-ing tube. An equine stomach tube may be used forlarge chelonians. For long-term oral medication,fluid therapy and nutritional support, an esophagos-tomy tube should be considered. The stomach vol-ume in most chelonian patients is about 2% of thebody weight or 20 mL/kg.1,32 Anatomically, the stom-ach is located in the anterior one third to mid-coelomic cavity. The distance to the anterior portionof the stomach should be marked on the tube se-lected for feeding. In species prone to regurgitateafter tube feeding, such as sea turtles, the patientshould be placed at a slight incline on a paddedboard to avoid regurgitation and to assist in passingthe feeding tube into the stomach. The head andneck should be extended to straighten the esopha-gus for tube passage. The head should be secured bygrasping the turtle on either side behind the man-dible. Steady downward pressure will cause the lowerjaw to fatigue and open. A padded speculum orpolyvinyl chloride tube can be used to keep themouth open. The turtle should be held in a verticalposition after the tube is removed and its head andneck extended until it swallows to prevent leakage orregurgitation.

Finally, soaking mildly dehydrated patients inshallow luke warm water (75-80 F), which reaches tojust below the chin when the head is retracted, willassist in rehydration.32 Mildly dehydrated marineand estuarine turtles will benefit from placement infresh water for 24 hours. Not only will this help torehydrate these animals, but exposure to fresh waterwill also reduce the epibota load. Fluids, variousdrugs, elemental diets, and dewormers may be ad-ministered by the intracloacal route.1,40 Absorptionmay be improved if the caudal aspect of the turtle iselevated higher than the cranial aspect for 10 to 20minute after fluid administration.

Volume of Fluids to Administer. The volume offluids to administer depends on the degree of dehy-dration and if hypoproteinemia and anemia arepresent. Fluid volume should not exceed 2 to 3% totalbody weight (TBW) in chelonians.41 Generally recom-mended maintenance fluid rates range from 15 mL/kg/d in species greater than 1 kg to 25 mL/kg/d inspecies less than one kilogram. A severely dehydratedpatient may tolerate up to 40 mL/kg/d. However, overhydration is a concern because of the slow metabolismin chelonians.32 Infusion or syringe pumps can be usedto accurately control the flow rate.

110 Terry M. Norton

CPR Principles in CheloniansThe following protocol is recommended for chelo-nians presented in respiratory or cardiovascular ar-rest. First, determine if the animal has a heartbeatwith a Doppler probe, electrocardiogram, and/orultrasound. Proceed only if cardiac electrical activityis present. Second, extend the head and neck, swabthe mouth to remove any materials blocking theglottis, and intubate the patient with an uncuffedendotracheal (ET) tube. Use suction and or gravityto remove any material from the ET. Ventilate thepatient with oxygen. An ambubag can be used forfield emergencies. Lubricate the eyes if they areopen. In the authors experience, resuscitation isfutile if there is pungent odor on exhalation orsuction, reduced global pressure that gives the eyes adented appearance, and increased jaw tone. Thesefindings dictate euthanasia even if there is a heartbeat.1 Place an IV or IO catheter, obtain blood for aminimum database, and then bolus fluids and emer-gency medications. If the heart rate remains below20 bpm with ventilation and bolus fluids, glycopyr-

rolate (IV) or atropine (IV) should be adminis-tered.1 Epinephrine can be given IV, IO, IP, intra-tracheally or intracardiac.33

Therapeutic Agents Used in ChelonianEmergency and Critical CareAlthough several pharmacokinetic studies have re-cently been conducted on chelonians,42-53 limitedinformation is available on accurate dosing for thenumerous species presented to the emergency clini-cian (Refer to Tables 1, 2, and 3 for dosages). Drugswith available pharmacokinetic data should be se-lected when possible. Although there are limitationsto metabolic scaling, it can be a useful tool when nopharmacokinetic data are available.1 Because sickchelonians do not necessarily absorb drugs well, it isimportant to correct hypothermia, dehydration, hy-poglycemia, acid-base and electrolyte imbalances be-fore or in conjunction with starting other therapeu-tic agents. This is especially important when usingnephrotoxic or hepatotoxic drugs and anesthetics.Drug pharmacokinetics are temperature dependent

Table 1. Emergency Drugs Used to Treat CheloniansDrug Dosage Comments

Doxapram 5 mg/kg IM, IV1 Respiratory stimulantPrednisolone sodium succinate 5 to 10 mg/kg IV1 Short-acting steroid, used in shock

therapyDexamethosone sodiumphosphate

0.1-0.25 mg/kg IV/IM1 Same as above

Methylprednisolone 20 mg/kg IV1 Short-acting steroid, CNS traumaGlycopyrrolate 0.01 mg/kg or 0.05 ml/kg IV, IM, SC1 Treat bradycardiaAtropine 0.01-0.02 mg/kg IV, IM, SC1 Treat bradycardiaEpinephrine (1:1000, 1 mg/ml) 0.1 mg/kg IV, intracardiac177 Cardiac stimulantMidazolam 1.0 to 2 mg/kg IM or IV67 Control seizuresDiazepam 0.5 mg/kg IV79 Control seizuresActivated charcoal, kaolin 2-8 gm/kg oral via stomach tube93 Absorbs and neutralizes some

poisonsCalcium EDTA 10-40 mg/kg IM q12 h79 Heavy metal chelator, zinc and lead

toxicityVitamin K1 0.2-2.5 mg/kg PO or IM176, as needed Coagulopathies, hepatic diseaseIron dextran 12 mg/kg IM 1-2 times/wk176 Iron-deficiency anemiaCalcium gluconate 100 mg/kg IM or IC q 8 h176 HypocalcemiaCalcium lactate/Calciumglycerophosphate

10 mg/kg SC, IM176 Hypocalcemia

Potassium chloride 15-30 mEq/L of fluid29 Hypokalemia50% dextrose 1 mL/kg IV Recommend administering at 5-10%

in fluids slow bolus forhypoglycemia

Mineral oil 6-10 mg/kg PO79

Cisapride 0.5-2.0 mg/kg PO q 24 h176 Gastrointestinal stasis


in reptiles, and it is best to maintain the chelonianpatient at its POTZ during therapy.32 Many medica-tions are unpalatable when administered orally, butcan be followed by something palatable (eg, a/ddiet, tuna juice, fruit or sweet vegetable baby food)to lessen the negative effect.1

Antimicrobial Therapy in the CriticallyIll ChelonianSick and injured turtles are usually given broad-spectrum antibiotics as a treatment for establishedbacterial infections or as a preventive measure (Re-fer to Table 2 for dosages). Diagnostic samplesshould be obtained for culture and antimicrobialsensitivity testing before starting antibiotic therapywhenever possible. Although controversial, the fronthalf of body, including the soft tissues of the fore-limbs and neck, should be used for injections,1,54,55

especially when using nephrotoxic drugs. Enrofloxa-cin is a commonly used antibiotic in chelonians andhas good efficacy against aerobic Gram-negative bac-teria. Unfortunately, it can cause tissue necrosis

when injected multiple times IM or SQ and is painfulon administration. The irritating effect of the drugcan be reduced significantly by diluting it in fluids orsterile water and using the subcutaneous route forinjection. Once the patient is stabilized, it can beadministered orally.53 Anaerobic bacteria can alsocause significant morbidity in chelonians and shouldbe considered when deciding on a therapeutic plan.

Analgesic in the Critically Ill ChelonianMany critically ill chelonians are painful and benefitfrom analgesics. Chelonians are relatively stoic andchallenging to assess for pain (refer to Table 3 fordosages). Pain may be exhibited in chelonians by adecreased appetite, depression, or alteration in nor-mal behavior. The nonsteroidal antiinflammatorydrugs (NSAID) are long acting and decrease endo-toxin production in septic patients.1,56,57 Meloxicam,carprofen, ketoprofen, and flunixin megaliminehave all been used in chelonians.1,56,57 AlthoughNSAID efficacy has not been evaluated extensively bycontrolled studies, anorexic and depressed cheloni-

Table 2. Antimicrobials Used to Manage Critical Care Chelonian PatientsDrug Dosage and frequency Comments

Amikacin *5 mg/kg IM q 48 h (gopher tortoises)42, 2.5-3.0 mg/kg IM q 72 h (sea turtles), 50 mg/10 ml saline 30 min nebulization q 12 h

Targets primarily Gram-negativebacteria, potentially nephrotoxic

Ceftazidime *20 mg/kg SC, IM, IV q 72 h44,45 Targets primarily Gram-negativebacteria, less nephrotoxic thanamikacin

Chloramphenicol 30-50 mg/kg IM q24h, 50 mg/kg PO q24h79 Bacteriostatic, aerobic, andanaerobic antibacterial spectrum

Clarithromycin *15 mg/kg PO q 48-72 h47 Used to treat Mycoplasma URTDClindamycin 5 mg/kg PO/IM q 24 h Good anaerobic spectrum, use in

combination with amikacin,ceftazidime, or enrofloxacin

Enrofloxacin *5 mg/kg SC/IM q 24-48 h,49,50 *10 mg/kg POq 24 h53

Irritating to tissue, recommenddiluting and giving SQ

Metronidazole *20 mg/kg PO q 48 h (anaerobes) (yellow ratsnakes and iguanas)48

Excellent efficacy against anaerobicbacteria, very bitter, potential fortoxicity

Fluconazole *21 mg/kg loading dose, then 10 mg/kg q 5 dSQ, IV51

Itraconazole *5 mg/kg PO SID or 15 mg/kg PO q 72 h (seaturtles)46

Acyclovir 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 regimensin critically ill chelonians are administered for a minimum of 2-3 weeks.

112 Terry M. Norton

ans often develop normal feeding behavior and ac-tivity after NSAID administration. Adequate hydra-tion and renal function should be assured beforeNSAID administration and duration of administra-tion 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 adminis-tration are that they are relatively short acting andmay cause sedation in debilitated patients. Butor-phanol is contraindicated in patients with headtrauma.1

Anesthesia in the Critically Ill ChelonianWhile anesthesia or sedation is necessary in someemergency situations, it should be used with cautionin dehydrated or debilitated patients (refer to Table3 for dosages).1,32 A thorough diagnostic workupshould occur before anesthesia and should be de-layed if the heart rate less is 15 bpm when thepatient is maintained at its POTZ, if blood workreveals a PCV10% or a plasma TP2.0 g/dL, or ifthere is evidence of sepsis or severe respiratory com-promise.1

Several excellent reviews and controlled studieson injectable and inhalant anesthestic regimenshave been recently conducted in chelonians.57-67 It isimportant for the emergency clinician to be comfort-able with a few anesthetic regimens that can beapplied to a wide range of chelonian species under avariety of circumstances. The authors preference forinjectable anesthetics include the combination ofmedetomidine and ketamine58,59,66 or propofol IV67

for short, relatively noninvasive procedures or forinduction of general anesthesia. The advantages ofthe medetamidine and ketamine combination arethat it may be given IM or IV, the medetomidine isreversible with atipamezole, and very low doses ofketamine may be used because of the synergism withmedetomidine. The low ketamine dose does make asignificant difference in the level of sedation andmuscle relaxation. Butorphanol may be added to themedetomidine and ketamine cocktail for additionalanalgesia and sedation.67 Disadvantages of the me-detomidine and ketamine anesthetic regimen in-clude significant species variations in anesthesia andsedation in response to the drug combination andinduction of significant bradycardia, hypotension,hypercapnia, and hypoxemia. Furthermore, thesedrugs may be contraindicated in debilitated or de-hydrated chelonians, especially those with hepatic orrenal dysfunction. The lower end of the dose rangeshould be used in debilitated chelonians. Propofol isa hypnotic sedative that provides rapid induction.While intravenous injection is preferred, the drugdoes not cause irritation if it is administered ex-travascularly.57 If propofol is given by rapid infusion,it can cause a marked respiratory depression.67

Propofol dosages for chelonians range from 2 to 15mg/kg, and recovery rates are dose dependent. Usethe lower end of the dose range in debilitated che-lonians to allow intubation. Local anesthesics, suchas lidocaine, may be used alone or in combinationwith injectable or inhalation anesthesia.68

Inhalant anesthetics should be used for invasiveor prolonged procedures. In critical chelonian pa-

Table 3. Analgesics and Anesthetics Used to Manage Critically Ill ChelonianDrug Dosage Comments

Butorphanol 0.2-2 mg/kg IM, 0.2-0.5 mg/kg IV, IO67 Premedication, analgesia, lowerdose if debilitated, 4h duration

Buprenorphine 0.1-1 mg/kg IM67 Same as aboveMeloxicam *0.2 mg/kg SC, IM, IV; 0.4 mg/kg PO q24-48

hrs56Rehydrate patient prior toadministration

Carprofen 1-4 mg/kg PO, SC, IM, IV q24h175 Same as aboveMedetomidine/ketamine M/K Tortoises- M: 0.075 to 0.15 mg/kg K:5

mg/kg58,59,60,65,66; Aldabra tortoises- M:0.025 to0.08 mg/kg, K:5 mg/kg59, Freshwater aquaticturtles- M:0.3 mg/kg, K:5 mg/kg67, can add0.4 mg/kg butorphanol to this regimen67;

Reverse M with atipamazole at 5times the Medetomidine dose inmg (same volume)

Propofol 10-15 mg/kg IV67; desert tortoises: low dose 2-4mg/kg IV, moderate dose 5-8 mg/kg IV, highdose 12 mg/kg IV67

Administer slowly to effect over 1-2minutes, dilute 1:2 with saline67


tients, it may be advisable to use inhalation anesthet-ics without an injectable induction agent. Ventila-tion and thermoregulatory support should be main-tained during the procedure and throughout therecovery period. Monitor heart rate via a Doppler,pulse oximeter, or ECG. Intraoperative fluid therapyand vascular access for emergency support should bemaintained. Although isoflurane is useful in reptiles,sevoflurane provides significant reduction in recov-ery times and may be more appropriate for criticallyill patients.64 Sea turtles are notorious for prolongedrecoveries with a variety of anesthetic regimens andhave much faster recoveries when using the revers-ible combination of medetomidine and ketamine forinduction and sevoflurane for maintenance anesthe-sia.69

Nutrition Needs of this Species in theEmergency SettingNutritional support is an important component ofchelonian critical care.1 Patients respond morequickly to therapy if their nutritional status is posi-tive.1 The critically ill chelonian is often immunosup-pressed secondary to starvation.1 Regurgitation andaspiration may occur in dehydrated and debilitatedchelonians. These turtles may not be able to digestsolid food and the material may remain in the stom-ach as a result of decreased gastrointestinal (GI)motility. Thus GI nutritional support should not beinstituted until the patient has been rehydrated andattains normal blood glucose and GI motility. Thevolume of formula fed by stomach tube is approxi-mately 7% of the turtles body weight in grams daily.Begin with smaller volumes and more dilute solu-tions and steadily increase the volume and concen-tration to meet the turtles nutritional requirements.The turtle should be weighed daily during the con-valescent period, and the measurement of weightgain or loss can be used as a guide for dietary man-agement.

Esophagostomy tubes (E-tubes) are integral inmanaging the critically ill chelonian. The stress as-sociated with tube placement is short, and usually faroutweighs the stress associated with daily head re-straint to administer oral medications, fluid therapy,and nutritional support. An E-tube may be left inplace for months, is usually well tolerated by theturtle, and most clients can manage the turtle withan E-tube at home. The tube should be left in untilthe animal is eating normally. An E-tube may bestressful to patients where the tube prevents themfrom withdrawing into the shell, and therefore maybe contraindicated in such patients. Possible compli-cations of E-tube placement include cellulitis or ab-

scess formation at the stoma site and ulceration orerosion with or without perforation of the gastricwall at the point where the tube contacts the stom-ach. Smaller patients are at greater risk of develop-ing problems from the E-tube. Smaller tube size andthe propensity to clog with thick solutions may limitthe ability to meet the patients nutritional needs.The technique for placing an E-tube has been de-scribed.1,27 Sedation is recommended for tube place-ment. Test the formula to be used before tube place-ment to assure it will pass through the tube withoutclogging. The tube should enter at the mid to loweresophagus rather that the upper esophagus or pha-ryngeal region. Premeasure the tube and obtain ra-diographs after E-tube placement to confirm tubepositioning. A purse string suture and Chinese fin-ger lock suture will secure the tube. Flexible tubingshould be used that allows for flexion and extensionof the neck. After feeding, the tube should beflushed with water or saline to remove any gruel.Enteral tube feeding formulas that have been usedin various species of chelonians can be found inTable 4.

HospitalizationA dedicated room or facility designed to accommo-date the various levels of medical care required forchelonians is ideal, however, this is usually not prac-tical. The veterinarian and hospital care staff shouldhave access to literature on the natural history andhusbandry needs of the various chelonian speciespresented to the facility for medical care2,70-75 (www.chelonia.org, world chelonian trust web site). Hos-pital personnel should be trained in chelonian hus-bandry and medicine. The importance of infectiousdisease control during the physical examination, di-agnostic work up, and hospitalization cannot beoveremphasized. Chelonians with suspected infec-tious disease should be hospitalized in isolation. Inaquatic settings, separate filtration systems should beused for turtles with suspected infectious diseases.Captive specimens should not be exposed to wildspecimens and visa versa. The clinician should avoidmixing species and separate animals from differentsources. Enclosures should be simple in design andmade out of easy to disinfect, nonporous, nonabra-sive materials such as plastic, glass, painted or sealedwood, stainless steel, or fiberglass. Plastic storagetubs, plastic swimming pools, and modified plasticdog kennels can be used to house hospitalized che-lonians. Intensive care units used for avian speciescan be used for smaller critically ill chelonians. Thebest substrate for use in a critical care setting shouldpose minimal fire risk, if ingested should not cause

114 Terry M. Norton

an impaction, and should allow for proper woundand waste management.76,77 Compressed, baledhemp chippings, shredded paper, newspaper, andrabbit pellets may be used.76,77 Hide areas within theenclosure should be used to make the patient morecomfortable and assist in thermoregulation. Hidescan be made out of disposable materials such ascardboard boxes and margarine containers withholes cut in them. Appropriate containers for foodand water should also be provided.

Hospital personnel should become familiar withthe POTZ for the species presented for emergencyevaluation and potential hospitalization. In general,reptiles are hospitalized at the mid- to high end oftheir POTZ, but should still be provided with a ther-mogradient. Basking lights, infrared ceramic heatbulbs, or thermostatically controlled radiant heatingpanels can be mounted to walls of the enclosure or

the cage front. The heat source should always beplaced outside of the enclosure. Under tank/enclo-sure heating elements are not recommended. Diur-nal heat cycles (lowering the temperature at night)are beneficial to recovering chelonians.76 Infrared orceramic heat emitters can be used as nighttime heatsources without affecting photoperiod. Timers canbe set for light and heat source activation. The en-vironmental temperature for a hospitalized patientshould be monitored daily with maximum and min-imum thermometers or digital thermometers. Sickchelonians that are too weak to move from a heatsource should be monitored closely.

Basking chelonians require exposure to full spec-trum lighting.78 Several weaker UVA and UVB-emit-ting fluorescent tubes are commercially available.78

However, artificial lights cannot replace the benefitsof natural sunlight, thus moving the patient out-

Table 4. Enteral Feeding Formulas and Diets for Anorexic and Critically Ill CheloniansEnteral diet information Comments

Herbivores Critical Care diet (Oxbow Pet Products, 29012 MillRoad, Murdock, NE 68407, 800-249-0366)

Alfalfa based product, may clogsmaller tubes,www.oxbowhay.com

1 part alfalfa pellets blended for several minuteswith 2-4 parts water

Very thick and may clog tube

Alfalfa Powder78 (NOW foods, Glendale Heights, IL60108), comprised of alfalfa that has beenharvested, dried and powdered, can mix withfruit baby foods for frugivorous species

Health or natural food stores,1 part volume powder to 5 partsof water, only short term byitself, add extra calcium, Vit D,psyllium (methylcellulose)-motilitydisorders

Green Powder78 (NOW foods, Glendale Heights, IL60108), comprised of barley grass that has beenharvested, dried and powdered.

Same as above, more crude fiber,lower crude protein, lower levelsof Ca and Ph so better for goutand renal failure

Emeraid II (Lafeber Co., Cornell, IL 61319)Walkabout Farms enteral feeding diets http:www.herpnutrition.com

Omnivores/Carnivores

Canine/feline a/d diet (Hills Pet Nutrition, Inc.,Topeka, KS 66601) (mixed with 4 jars ofvegetable baby food)

Critical Care diet (Oxbow Pet Products)Ensure (Abbott Laboratories, Abbott Park, IL60064) alone or mixed with fish blenderized (seaturtles), add mixed green vegetables for greensea turtles (Chelonia mydas)

Add vitamin/mineralsupplementation

Walkabout Farms enteral feeding diets http:www.herpnutrition.comElemental

diets easilyabsorbable

1) Peptamen (elemental diet for children) (NestleUSA Inc., Deerfield, IL 60015)

2) Vivonex Novartis, (Novartis, Minneapolis, MN55416)


doors when weather permits is probably best. Con-tainers that facilitate moving the patient inside andoutside are helpful and efficient.76

Humidity should be measured and monitored inall enclosures. As a general rule, desert cheloniansneed to be kept at humidity levels 40%, whiletropical species need humidity levels of 60%.77

The humidity can be increased if necessary by pro-viding heated water in bathing areas, regular mistingand dampening of substrate, using damp soil orpeat/sand base substrate, and keeping lids on hold-ing areas. Open top enclosures will provide betterventilation and are preferred for most chelonians.76

Initially, debilitated aquatic and semiaquatic spe-cies should be dry docked on a padded surface, suchas a shower box or plastic draining board mats.79

These turtles can be kept moist by regular mistingand placing Vaseline or another water soluble (K-Y)jelly on the skin and shell. Once stabilized, theseanimals require specialized facilities. Marine turtlesshould be provided specially designed circular fiber-glass tanks with a filtration system and continuousflow, temperature controlled salt water. You mustadjust water levels to accommodate turtles with vary-ing degrees of debilitation. Water quality issues needto be addressed for all aquatic species. Semiaquaticspecies need haul out areas with a basking heatsource. Turtles should not have direct access to elec-trical outlets, cords or filtration systems.

Differential Diagnosis and MedicalPrinciples of Emergency Carein Chelonians

The general medical, surgical, and emergency careprinciples used in various chelonian species are sim-ilar. Medical problems differ significantly betweenchelonians coming from a captive or free-rangingenvironment. The majority of problems encoun-tered in captive chelonians can be traced back toimproper husbandry. It is not uncommon for a cap-tive chelonian with a chronic medical problem topresent as an emergency. The environment (marine,freshwater, estuarine, terrestrial) of free-rangingchelonians will dictate the types of problems that areencountered.

Traumatic InjuriesTrauma is a common reason for chelonians to bepresented for emergency care. Chelonians that ex-perience a traumatic injury may present with uncon-trolled hemorrhage, lacerations, head trauma, andfracture of the limbs, skull, mandible, or shell. Prob-

lems encountered in free-ranging marine turtles mayinclude boat related injuries secondary to propelleror direct impact, encounters with predators such assharks, entrapment in dredging equipment, drop-ping on a boat deck after incidental capture, andwounds created from fishing gear entanglementsuch as nets, fishing line, crab and fish traps andplastic rings from beverage containers. Captive ma-rine turtles are predisposed to traumatic bite woundsfrom interspecific (eg, shark in same aquarium) orintraspecific aggression. Sea turtles should not behoused together if space is limited. Freshwater andestuarine species, such as the diamond back terrapin(Malaclemys terrapin), encounter similar traumatic in-juries as marine specimens. Aquatic and terrestrialchelonians are commonly hit by automobiles ortrucks when crossing roads. Predators, primarily car-nivores, commonly cause severe damage to freshwa-ter and terrestrial chelonians by gnawing on thelimbs and shell.32

Traumatic injuries in chelonians often involve thecentral nervous system (CNS) and require immedi-ate attention. Short-acting corticosteroids such asmethylprednisolone, dexamethasone sodium phos-phate, or prednisolone sodium succinate should beadministered IV and then repeated in 12 to 24hours.1 Supportive care, wound care, broad-spec-trum antibiotics, and analgesics are indicated de-pending on the type of injury. Warm the patient toambient indoor temperatures (68 - 75 F; 20 - 30 C)only after hemostasis is achieved, antibiotics are onboard, and vital signs are stable.1 Warmed animalshave higher O2 demands, increased potential forhemorrhage, and increased bacterial growth in con-taminated wounds. Once the turtle is stabilized, ra-diographs can be taken to determine the extent ofthe injuries, prognosis and plan for further therapy.In cases of hind limb paresis, it is important to ruleout a spinal or pelvic fracture. Pelvic fractures maypredispose female turtles to dystocia; therefore,these animals should not be released into the wild.

Uncontrolled hemorrhage should be addressedimmediately. This can be accomplished by digitalpressure, a pressure bandage, vessel ligation withsuture, or by surgical electrocautery. Carapace andplastron fractures are common in chelonians. Afterradiographic evaluation, the fracture site and sur-rounding tissue should be cleaned with dilute chlo-rhexidine, betadine, or saline. A wet-to-dry bandagemay be placed over the injury to further decontam-inate the wound. Foreign debris should be carefullyremoved from the fracture site. If the coelomic cavityis open, minimize contamination. Fractures of thecarapace over the lungs or of the bridge may put the

116 Terry M. Norton

patient at risk for bacterial and fungal pneumonia.After cleansing, the shell fracture should be re-duced. If realignment is difficult or a spinal injury issuspected, then fracture alignment should be ap-proached with caution or delayed. After cleansingand drying the fracture, the wound should bedressed. Silver sulfadiazine (SSD) cream or tripleantibiotic ointment are applied to open shell frac-tures and wounds. The author recommends cover-ing open wounds and shell fractures with a silver-coated mesh (Acticoat with silcryst nanocrystals,Smith & Nephew, Inc., Largo, FL USA). This prod-uct provides 72 hours of antibacterial and antifungalactivity; however, it must be kept moist with sterilewater while being used. DuoDerm or tegaderm canbe used to cover various dressing materials and keepthe wound clean and dry. For a more waterproofbandage, tissue glue can be applied to the edges ofthe adherent bandages. Vet wrap (3-M Corp., St.Paul, MN USA) can be used to keep the dressing inplace and stabilize the fracture. Aquatic speciesshould be kept in shallow water or may need to bedry docked until a waterproof bandage is placed overthe wound or fracture or until final repair. Shellfracture repair methods have been described previ-ously.1,26

All skin wounds should be cleaned and debridedas described for shell injuries. Primary closureshould be reserved for noncontaminated wounds.Contaminated wounds should be left open to heal bysecond intention or closed using a delayed tech-nique once the wound has been decontaminated.Reptiles produce thick caseous abscesses. Becausethese abscesses do not drain well, penrose drains aregenerally not used for wound care. In areas that aredifficult to bandage, suture loops can be placedaround the wound, the preferred topical treatmentand dressing applied, and umbilical tape placedthrough the suture loops and tied together like ashoelace to hold the dressing in place. This methodallows for regular wound cleaning and bandaging.

Fractured limbs in chelonians may result as aconsequence to a variety of traumatic insults, such asbeing hit by a car or boat, being dropped, or havingexcessive force applied to the limbs when extricatingthem for tube feeding. Chelonians suspected to havemetabolic bone disease should be handled with cau-tion, as they are predisposed to pathological frac-tures. Patient stabilization takes priority over perma-nent fracture repair. Various methods or combina-tions of methods may be used to repair a long bonefracture in a chelonian. Several excellent reviews areavailable on chelonian and reptile orthopedic pro-cedures.26

Vomiting, Ileus, ObstructionVomiting or regurgitation in chelonians is usuallyindicative of a poor prognosis.32 A thorough diag-nostic work up should be performed to make adefinitive diagnosis. Some causes of vomiting in-clude foreign body or other gastrointestinal obstruc-tion, noxious tasting materials, dehydration and de-bilitation, gastric stasis, gastrointestinal yeast, andparasitism. Vomiting is more common in anorecticand debilitated turtles than tortoises.1 Turtles shouldbe rehydrated and stabilized first, and then tube fedwith an easily digestible elemental diet such as Pep-tamen (Nestle USA, Inc., Deerfield, IL USA). Theneck should be extended and the turtle held in avertical position after the tube is removed to preventregurgitation. Higher caloric diets should be intro-duced gradually.

Heavily parasitized turtles and tortoises may be-come partially or completely obstructed with nema-todes after being dewormed with relatively low dosesof fenbendazole (30 mg/kg PO once).11 These pa-tients should be rehydrated and stabilized to ensurethat they regain their normal gastrointestinal motil-ity. To prevent this complication, always start debil-itated chelonians with lower doses of anthelminthics(fenbendazole) and gradually increase the dose tothe recommended levels of 50 mg/kg over severalweeks. The gradual increase in dosage reduces thechance of obstruction by reducing the number ofparasites affected per treatment. Fenbendazole, al-though effective in chelonian species, should beused with caution based on recently described bonemarrow suppression effects avian species.80 Pyrantelpamoate may be a safer alternative anthelminthic touse in debilitated chelonians.

Gastrointestinal stasis or ileus is a common causeof morbidity in debilitated chelonians and must bedifferentiated from obstruction. Gastrointestinal sta-sis is precipitated by dehydration, systemic disease,dietary indiscretion, decreased dietary fiber, malnu-trition, suboptimal management practices, and sea-sonal motility changes.81 Diagnosis is challengingbecause of difficulties in palpating the cheloniancoelomic cavity and the normally slow GI transit timeof these animals. Without appropriate treatment, thecondition may progress to impaction and obstructionrequire intensive medical or surgical therapy.82 Debili-tated marine turtles often develop a secondary gastro-intestinal stasis and become obstructed with nondi-gestible prey materials. Radiopaque material and gasin the gastrointestinal tract are visible radiographi-cally. This condition can be resolved with fluid ther-apy, mineral oil, enemas, and gastrointestinal motil-ity modifiers. The obstruction should be resolved


before offering the animal food. In other cheloni-ans, elucidating the cause of the ileus, correcting themedical problem, and providing supportive care willusually resolve the ileus. Motility modifying drugs,such as metoclopramide and cisapride, are clinicallyeffective in chelonians.82,83

Foreign body ingestion is a common emergencypresentation in chelonians.83-87 Occasionally foreignbodies are found incidentally on whole body radio-graphs. In aquatic species, fishhooks with attachedfishing line may become anchored in the oral cavity,esophagus, or other parts of the gastrointestinaltract. These foreign bodies frequently lead to intes-tinal plication or coelomitis secondary to penetra-tion of the serosal surface of the gastrointestinaltract. A variety of foreign materials, such as plasticbags, metal, and glass, have been found in marineturtle gastrointestinal tracts and may be an inciden-tal finding or lead to an enteritis or obstruction.Ingestion of substrates such as corncob, wood chips,gravel, sand, kitty litter, or walnut shell by captiveterrestrial chelonians may cause GI obstruction.32

The radiographic hallmark sign for intestinal ob-struction is the accumulation of radiopaque materialin a dilated segment of intestine. A prominent ob-structive gas pattern is not always observed. Conser-vative medical treatment consisting of enemas, par-enteral fluids, petroleum laxatives and water givenvia a stomach tube (15 mL/kg) may be all that isnecessary for clinical resolution.88 However, surgicalremoval of the foreign body or material may berequired in some cases.83,89,90

HypothermiaHypothermia, or cold stunning, in sea turtles is awintertime phenomenon where the water tempera-ture suddenly drops below 50F (10C).29 The turtleslose their ability to swim and dive, become buoyantand float to the surface. It is most common in juve-nile sea turtles, and has been documented to occurfrom the Gulf of Mexico to New England and West-ern Europe. Hypothermia is also a common problemin other chelonian species. Common causes of hy-pothermia may include escape from a heated enclo-sure, airline transport, power or heating elementfailure, and an unexpected drop in nighttime tem-peratures.32 Hypothermia has been investigatedmore thoroughly in sea turtles; however, similarmedical management can be applied to other che-lonians. Secondary infections, especially bacterialpneumonias, are not uncommon and may not beapparent until several weeks after the initial hypo-thermic event.32

A classification system has been developed forhypothermic sea turtles based on a series of reflexresponses, including head lift, cloacal or tail touchreflex, eye touch reflex, and nose touch reflex.91 Thedegree of responsiveness can be used to dictate thebest approach to be taken and approximate a prog-nosis. The severity of secondary problems often de-pends on the length of time the animal has beendebilitated and the temperature extremes the turtlewas exposed to. Traumatic wounds, dehydration,corneal ulcerations, dermal, carapacial and plastronlesions, flipper tip necrosis consistent with frostbite,and buoyancy disorders are frequent findings in se-vere cases.29 Other chelonian species often presentwith similar clinical signs, including lethargy, poorresponse to external stimuli, and in extreme casesevidence of frostbite of digits and tail tips.29

Common abnormal clinical pathology findings incases of hypothermia include an initial heterophilicleukocytosis with subsequent development of leuko-penia and monocytosis, both regenerative and non-regenerative anemias, hypoglycemia or hyperglyce-mia, increased creatine phosphokinase (CPK), de-creased blood urea nitrogen (BUN), hypocalcemia,hypoproteinemia, hypokalemia, hypernatremia, hy-perchloremia, and metabolic acidosis.29 Electrolytedisturbances may be secondary to malfunctioningsalt glands. Cultures of blood and other fluids oftenreveal localized and systemic bacterial and fungalinfections. Radiographs often reveal changes consis-tent with pneumonia. Coelomic fluid evaluation mayreveal evidence of inflammation or infection.29

The therapeutic plan for hypothermic sea turtlesshould include a slow increase in body temperature,gradual reintroduction to sea water from fresh andbrackish water over a 2 week period, prophylacticantibiotic and antifungal therapy, nutritional sup-port, and close monitoring of clinical pathology andacid-base abnormalities.29 Many turtles can have pos-itive clinical outcomes with proper medical atten-tion. Body temperature and heart rate are importantparameters to obtain at the time of presentation, andto monitor until the rewarming process is complete.Less severe cases are placed in shallow water, whilemore severe cases are dry-docked and placed onfoam pads. The water or room temperature shouldinitially be only 4-6F (2-4C) warmer than the am-bient water temperature where the turtle was found.Body temperature should be increased by 5F (3C)per day until reaching 75F (24C). Broad-spectrumsystemic antibacterial and antifungal therapy shouldbe initiated when the turtle reaches 60 to 65F (16-19C). The skin and shell should be kept moist withbacteriostatic water and soluble lubricating jelly.

118 Terry M. Norton

HyperthermiaReptiles are less able to compensate for elevatedtemperatures than mammals or birds. Temperaturesover 100F (38C) are usually lethal for most chelo-nians.32 Hyperthermia in chelonians can occur as aresult of placing a turtle in a glass or plastic tankoutdoors in the sun, a closed car during the day, oraccidental overheating in an enclosure. Ill or injuredchelonians stranded on a beach or road also maybecome overheated. Early clinical signs of hyperther-mia include increased activity, retreating to the wa-ter, seeking cool areas, and hyperemic skin. Eventu-ally, the turtle develops open mouth breathing,rapid respirations, and may become comatose.32

Treatment should include cooling the animal, ad-ministering fluids and possibly, in severe cases, ashort acting steroid to reduce brain swelling.32 Thechelonian should be placed into a shallow pan ofcool water (not cold) for a brief period to reduce thecore body temperature. Body temperature should bemonitored carefully. Subsequently, the turtle shouldbe placed in a small enclosure at the lower end of itsPOTZ.32

DrowningDespite the chelonians ability to survive extendedperiods without breathing and having significant an-aerobic respiration adaptations,32 drowning is a com-mon problem in the aquatic and terrestrial chelo-nian. A common cause of drowning in marine turtlesoccurs when the animals are incidentally captured orentangled in shrimp nets or various fishing gear andsubsequently trapped underwater for extended peri-ods of time. Diamondback terrapins (M. terrapin) areattracted to crab traps and often are unable freethemselves once trapped. Terrestrial chelonians maybe found at the bottom swimming pools.

Live turtles that have been submerged under wa-ter for extended periods of time may present in acomatose state without corneal or deep pain re-flexes. The cardiopulmonary resuscitation protocoldescribed previously should be used in cases wherethere is cardiac and respiratory arrest. Trawl-cap-tured loggerhead sea turtles exhibit a marked aci-demia and lactic acidosis when first brought onboard.92 Blood gas and lactate levels should be mon-itored during the recovery process. Once intubated,the turtle should be placed with its head down todrain fluid from the lungs. Suctioning fluid from theendotracheal tube may be of some benefit. Limb andhead pumping, intermittent positive-pressure venti-lation (2-6 times per min), and doxapram adminis-tration (5-10 mg/kg IV) may assist in reviving theturtle. Aggressive therapy to correct acidosis, electro-

lyte imbalances, dehydration, and hypothermia maybe necessary. Broad-spectrum antimicrobial therapyis usually indicated.

ToxicosisChelonians can be exposed to a variety of toxins andcontaminants in captivity and the wild. Unfortu-nately, many of the toxicities that have been docu-mented in captive chelonians are iatrogenic andinduced by the veterinary clinician.93 Ivermectin hasbeen used successfully and safely in a variety of rep-tiles; however, it is toxic to many species of cheloni-ans.94 Although there are species differences in sus-ceptibility to the toxic effects of ivermectin, the drugshould be avoided in all chelonians. Clinical signsassociated with ivermectin intoxication are primarilyrelated to general neuromuscular weakness, anddeath usually occurs because of respiratory paraly-sis.94

Metronidazole is used to treat anaerobic bacterialinfections and amoebiasis in reptiles.1,48 Tortoisesare prone to developing side effects from this drug,and may not tolerate the relatively high doses orduration of therapy necessary to treat amoebiasiseffectively.1 Metronidazole treatment regimens inchelonians need to be tailored to the individual withclose monitoring for clinical signs of toxicity. Clini-cal signs of metronidazole toxicity include anorexia,head tilt, circling, dysequilibrium and signs of hep-atotoxicity.95 Metronidazole toxicity can be fatal inchelonians.

Two red-belled short-necked turtles (Emydura sub-globosa) with shell lesions were soaked for 45 minutesin a dilute (0.024%) chlorhexidine solution and sub-sequently developed partial flaccid paralysis anddied.96 Cholecalciferol toxicity has been reported ina leopard tortoise (Geochelone pardalis)secondary toingesting rodent bait.97 While numerous plant spe-cies are suspected to be potentially toxic in cheloni-ans, few published reports have been made on actualtoxicosis.98 Oak toxicity was recently reported as thesuspected cause of death in an African spurred tor-toise, Geochelone sulcata.99 Lead poisoning has beendocumented in a wild common snapping turtle (Che-lydra serpentina) after swallowing a fishing sinker100

and a tortoise after ingesting lead paint chips.101

Central nervous system disease predominated inthese cases. Sea turtles may encounter waters thatcontain chemical pollutants, such as petroleumproducts from oil spills, and present with oil or taron their skin and shell or systemic signs of toxicitydue to ingestion.79 An increased stranding rate of seaturtles in Florida has been associated with red tideblooms of the dinoflagellate Karenia brevis. Affected


animals often present with central nervous systemdeficits.102

A diagnosis of toxicity in a chelonian is usuallybased on a thorough history, clinical signs, physicalexamination, and various diagnostic tests. The diag-nostic tests generally used to confirm a toxic expo-sure include contaminant analysis of blood, plasma,stomach contents or tissue, and radiographs. Fluidtherapy, wound care, and other supportive measuresdescribed previously may be used to treat intoxica-tion. In addition, activated charcoal or psyllium maybe used to bind and decrease the absorption oforally ingested toxins,79 calcium EDTA to treat leadtoxicity,103 midazolam or diazepam93 to control sei-zures, and atropine to treat organophosphate toxic-ity.

Nutritional Diseases and the CriticallyIll ChelonianSome of the more common nutritional diseases thatoccur in captive chelonians include generalized ca-chexia/starvation, metabolic bone disease or sec-ondary nutritional hyperparathyroidism, vitamin Adeficiency, and iodine deficiency/goiter.104-106 Thesepatients are often immunnocompromised and pre-disposed to secondary infections. Nutritional hyper-parathyroidism or metabolic bone disease is mostcommon in young growing chelonians and is causedby deficiencies in calcium, vitamin D, an impropercalcium/phosphorous ratio, lack of exposure to UVlight, or a combination of these factors. Clinical signsmay include a soft deformed shell, limb fractures,and a malformed overgrown rhampthotheca.106 Ra-diographs can aid in the diagnosis of advanced cases.

Starvation or cachectic myopathy may occur incaptive and free-ranging chelonians.107,108 In captivespecimens, primary malnutrition and poor hus-bandry (eg, suboptimal environmental tempera-tures) are often responsible. Confiscated SoutheastAsian turtles are routinely presented with severeemaciation after being maintained at suboptimalconditions for extended periods of time.1 Emaciatedfree-ranging chelonians usually have an underlyingproblem.108 The underlying cause of the emaciationmay be masked by numerous secondary medicalproblems such as bacterial or fungal pneumonia,septicemia, and severe endoparasitism.108 These tur-tles may be critically anemic, hypoproteinemic, andhypoglycemic. They often have severe ascites, serousatrophy of fat, lymphoid depletion, and bone mar-row suppression.

Severely malnourished chelonians may present ina moribund state and require emergency care. Treat-ment for energy deficiency in chelonians should

involve fluid and electrolyte replacement initiallyand then small but increasing levels of calories. Inaddition, iron dextran, whole blood or artificial he-moglobin, broad- spectrum antimicrobial drugs, andantiparasitics may be necessary. Specific nutritionalproblems such as vitamin A deficiency, metabolicbone disease and hypothyroidism should be treatedonce the turtle has been stabilized.

DystociaMost dystocias in chelonians do not present as amedical emergency unless there is an obstructiveprocess involved. It may be difficult to determinewhen a gravid patient is overdue or when one shouldintervene. Common causes of dystocia in cheloniansinclude inadequate nesting sites, inadequate ther-mal environment, malnutrition, dehydration, poormuscle tone, endocrine abnormalities, and meta-bolic abnormalities such as hypocalcemia. A dystociais more likely to be a medical emergency when itoccurs secondary to reproductive tract or cloaca pro-lapses, systemic infections, abnormal egg shape andsize, stricture or torsion of the oviducts, impinge-ment of the pelvic canal from misaligned healedfractures, uroliths, soft tissue masses, or brokeneggs.109 The dystocia patient may be asymptomatic ormay have one or more of the following clinical signs:decreased appetite or anorexia, decreased activitylevel, excessive basking, restlessness, constant dig-ging behavior, raising the hindquarters accompa-nied by cloacal aversion, and eventual weakness andlethargy.109 The diagnostic workup should include athorough history, physical examination, and radio-graphs. Radiographs should be evaluated for thepresence of eggs, the size, shape, and position ofeggs, eggs in the bladder,110 any broken eggs, bonedensity, pathological fractures and pelvic fractures,evidence of constipation, and cystic calculi. Ultra-sound, hematology, and a serum chemistry profilemay provide additional important information insome cases.

Debilitated chelonians suffering from dystociashould be stabilized before oxytocin therapy or sur-gery. Dehydration, hypothermia, and hypocalcemiashould be corrected. Antibiotic therapy and nutri-tional support may be indicated in some cases. It isimportant to provide adequate nesting areas, water,and an appropriate thermogradient during the treat-ment period.109 In nonobstructive dystocias, the pa-tient may be pretreated with calcium followed byoxytocin. Eggs should pass within 30 to 60 minute.109

Obstructive dystocias will require surgery in mostcases. If the egg can be visualized through the cloaca,ovicentesis and collapsing the egg may be attempted.

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If surgery is deemed necessary, an inguinal approachis less invasive and preferred over entering the coe-lom via a plastron osteotomy. A salpingotomy, sal-pingectomy, or gonadectomy may be performed de-pending on the cause of the dystocia and conditionof the oviductal tissue.109 The ovary should always beremoved with the oviduct to prevent ovulation intothe coelomic cavity during the next reproductiveseason. A unilateral salpingectomy can be per-formed to maintain future reproduction.111

UrolithiasisCystic calculi have been documented in a variety ofcaptive and wild turtle species.112 The condition isrelatively common in California desert tortoises.Most cases result from water deprivation or excessamounts or inappropriate types of dietary pro-tein.113,114 Emergency care should be sought if thechelonian is straining excessively or develops a pro-lapse of the uterus or bladder. Treatment shouldinclude rehydrating and stabilizing the patient for asurgical cystotomy.113

Cloacal and Phallus ProlapsesA cloacal prolapse should be attended to quickly sothat the prolapsed organ remains viable. Cloacalprolapses usually occur from excessive straining sec-ondary to an inciting cause, which may include con-stipation, bacterial enteritis, parasitic enteritis, cysticcalculi, egg binding, and other conditions causingstraining.115 In addition to determining the cause ofthe prolapse, it is important to determine what struc-ture is protruding and its viability.115 The colon has alumen with feces inside and a smooth surface. Theurinary bladder is thin walled, translucent, and urinemay be aspirated from it. The uterus and oviducthave a lumen, no feces, and longitudinal striationson the surface.

Treatment for a cloacal prolapse should includecleaning, lubricating, and replacing the viable tissueback through the vent. Soaking the prolapse in 50%dextrose will reduce the edema to facilitate replace-ment. A purse string or transverse suture should beused to maintain the reduction. The vent can besurgically enlarged to assist in replacing the pro-lapsed tissue. In cases of chronic prolapse when thetissue is edematous and friable, it may be difficult toimpossible to reduce the tissue and instead require acoeliotomy or amputation. If the colon is prolapsed,a colopexy can be used to prevent recurrence.115

Chelonians have a large phallus, which is solidtissue and has no lumen. Phallus prolapses are notuncommon in chelonians, and may occur secondaryto an infection, forced separation during copulation,

irritation or desiccation from substrates while at-tempting to breed, constipation, or neurologic de-fects.32 The phallus can be reduced using the sametechniques described for the cloaca. If the phallus isnecrotic, the base of the penis can be double ligatedwith two vertical mattress sutures and then amputat-ed.32 Penile amputation will not affect urination butthe turtle will not be able to copulate or reproduce.32

ParasitesEctoparasites, such as maggots,116 ticks,116 sarcoph-agid fly larvae,117,118 leeches,119 and various epibiotafound on sea turtles,108,119 may contribute to theoverall poor condition of a critically ill chelonianand should be manually removed or treated appro-priately. Placing marine turtles in freshwater for 24hours will significantly reduce the parasite load andaid in rehydration.

Endoparasites may be a contributing factor todisease in an already compromised chelonian, andin some cases they may be the primary cause ofdebilitation.11,120-129 Stress, overcrowding, poor hus-bandry, infectious diseases, and immunocompromis-ing conditions may lead to heavy endoparasite infes-tations. Clinical disease associated with Entamoebaspp. is much more prevalent in chelonians thanpreviously recognized.1,120,121 It is a difficult parasiteto identify and treatment may need to be startedbefore a specific diagnosis is made.1 There are mul-tiple species of amoeba with varying degrees ofpathogenicity.1 The most common clinical signs arediarrhea, often with intermittent blood and mucous,anorexia, depression, and severe dehydration. Treat-ment consists of aggressive fluid therapy and sup-portive care. Bonner recommends a prolongedcourse and high doses of metronidazole (100 to 150mg/kg sid PO for 5 days, skip 7 days, and then repeatanother 5 day course) due to the difficulties in erad-icating this parasite.1 This regimen may be toxic totortoises. Recent pharmacokinetic studies in the yel-low rat snake and green iguana suggest that a dose of20 mg/kg every 48 hours reaches therapeutic levelsfor treating anaerobic bacterial infections.48,130 Met-ronidazole eliminates the trophozoites stages, whileiodoquinol can be used to treat the amoebic cyststages. Broad-spectrum antimicrobial therapy is of-ten indicated.1

Digenetic trematodes of the family Spirorchidaeare commonly found in the cardiovascular system offreshwater and marine turtles, and have been impli-cated as a cause of significant morbidity and mortal-ity in some cases.18,126,127,129 The eggs are releasedinto the circulatory system, and eventually becometrapped within the terminal arterioles of the visceral


organs, extremities and shell. A granulomatous re-sponse is produced by the eggs in various tissues,including the gastrointestinal tract, liver, spleen,lungs and CNS.18,126,127 Clinical signs are related tothe pathology caused by the eggs and may includegeneralized debilitation, severe ulcerative colitis, pit-ted ulcerations (due to ischemic necrosis) of thecarapace and plastron, edematous limbs due to vas-cular obstruction, and buoyancy problems secondaryto pneumonia. A major loggerhead sea turtle strand-ing event occurred in south Florida in 2001.129 Mostturtles presented with partial paralysis and many hadsecondary problems. Postmortem results revealedadult trematodes in the brain and spinal cord. Noother primary agent has been identified in theseturtles. These turtles often respond to supportivecare and treatment for the trematodes. Treatmentwith high dose of praziquantel may be effective indecreasing the severity of clinical signs but will notaffect the eggs already in the tissues.131,132

Infectious DiseaseSeveral excellent reviews of infectious diseases inchelonians have been published.128,133,134 Clinicalsigns associated with infectious disease agents may besevere, present acutely, and warrant emergency care.Upper respiratory tract disease (URTDS) complex isa relatively common reason for chelonians to bepresented and provides a good example of dealingwith an infectious disease in an emergency set-ting.134-141 Herpesvirus, iridovirus and Mycoplasmaagassizii are important infectious diseases of terres-trial chelonians.134-141 Infected chelonians oftenpresent with an acute onset of clinical signs, includ-ing anorexia, depression, and nasal and ocular di-charge.134-142 Herpesvirus and iridovirus infectedchelonians frequently present with stomatitis andglossitis,137,143 whereas this is never observed with M.agassizii alone.138,140,141 Mixed infections of Herpesvi-rus and M. agassizii have been reported, furthercomplicating the diagnosis.144

Herpesviruses have been documented to affectmany chelonian taxa, and all chelonians should beconsidered susceptible.134,135,142-148 These infectionsare believed to lie dormant in various tissues follow-ing the primary infection, and during times of stress,such as hibernation and illegal importation, recru-desce.134 Herpesvirus infections have been impli-cated as the causative agent in several diseases ofcaptive and free-ranging sea turtles.145,147-149 Fibro-papilloma disease syndrome (FP) is the most wellstudied disease affecting sea turtle populations. Aherpesvirus has been implicated as the causativeagent of the disease syndrome,147-152 however, envi-

ronmental pollutants or other unknown immuno-suppressive factors are most likely a contributingfactor in the disease process.153 Turtles may havemultiple cutaneous FPs found on all soft integumen-tary tissue, but especially in the axillary and inguinalregions.147 The FPs can develop on the eyelids, con-junctiva, and cornea and may be so extensive as toimpair the turtles vision.147 This visual impairmenthinders feeding and leads to emaciation. Further-more, FPs may be found internally in various or-gans.152,153 A diagnosis is made by observing typicalskin lesions and histopathology.150 Radiography andlaparascopy are used to identify internal FP. Eutha-nasia is recommended in turtles with internal le-sions. Initial treatment consists of correcting dehy-dration, hypoglycemia, and malnutrition. Antimicro-bial therapy is usually indicated before and aftersurgery. Laser surgery can be used to remove the FPsin stages. In these cases, the skin is often left open toheal by second intention (Pers. comm. Mader D,2003).

Iridovirus is an important emerging disease inchelonians137,154 Until recently, it had only been rec-ognized sporadically.136,155 Frogs are implicated as areservoir host capable of infecting captive and free-ranging chelonian populations.137 Viral infections inchelonians are often complicated by secondary bac-terial, fungal, and parasitic infections, and should beconsidered in the diagnostic and therapeutic ap-proach. Diagnostic samples (eg, serology, cytology,histopathology, electron microscopy, culture andPCR) should be collected before initiating treat-ment.133,137,156

Initial emergency therapy should focus on stabi-lizing the patient with emergency drugs and rehydra-tion. Critical care may consist of broad-spectrumantimicrobial therapy for aerobic and anaerobic bac-teria, antifungals, antiviral drugs, fluid therapy, andnutritional support. Acyclovir administered orallyand topically has been shown to be clinically effec-tive against both chelonian herpesvirus and iridovi-rus infections.137,157

Bacterial and Fungal InfectionsDebilitated and injured chelonians often presentwith bacterial or fungal infections. These may in-clude infected traumatic injuries, abscesses, stomati-tis, shell infections, osteomyelitis, and respiratorydisease. Poor husbandry, malnutrition, and a lack ofsanitary procedures are predisposing factors for in-fection in captive specimens. Bacterial abscesses arethe most common inflammatory condition in rep-tiles, and can occur anywhere on the body. Reptileabscesses are most often well encapsulated by fibrous

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connective tissue. Gram-negative bacteria cause thehighest morbidity in chelonians, however, anaerobicbacteria (eg. Bacteroides spp., Fusobacterium spp., Clos-tridium spp., and Peptostreptococcus spp.) can causeserious disease and should be considered in thetherapeutic plan.158 Bacteroides spp. and Fusobacteriumspp. produce potent tissue toxins, which can causetissue necrosis and increase the severity of mixedaerobic and anaerobic bacterial infections.158 Clos-tridium spp. have systemically active toxins that causehemolysis and renal tubular necrosis.158 Salmonellaspp. can cause disease in chelonians and are a po-tential zoonosis.159 Atypical mycobacterial infectionscan cause abscesses, cutaneous and subcutaneousnodules, osteomyelitis, osteoarthritis, and otherproblems in chelonians.160 Predisposing factors in-clude debilitation, injury, malnutrition, and otherdisease processes. This is also a potentially zoonoticdisease. Dermatophilus chelonae is a newly discoveredspecies of bacteria that grows at lower temperaturesthan D. congolensis.161,162 Several tortoise and turtlespecies have been reported to develop skin abscess,dermal nodules, ulcerative stomatitis, septic arthritis,and a granulomatous coelomitis. Middle and innerear abscesses are commonly seen in captive and wildbox turtles and other chelonians.163,164 Lesions maybe unilateral or bilateral. A variety of Gram-negativebacteria have been isolated from most cases, how-ever, anaerobic bacteria, fungal organisms and par-asites may be involved.163,164,165 The route of infec-tion may be via the eustachian tube. Organochlorinetoxicity and vitamin A deficiency are predisposingfactors.163

Shell infections can involve the superficial keratinor may extend into the osteoderms of the carapaceand plastron. Aerobic and anaerobic bacteria andmycotic agents are commonly isolated. Mucormyco-sis has been associated with ulcerative epidermitis insoft-shelled turtles (Trionyx ferox). This is a very seri-ous condition in this group of chelonians because ofthe importance of the integument and shell as a siteof oxygen transport and osmotic balance.166 Culture,cytology, histopathology, and molecular diagnosticsare routinely used to diagnose bacterial and fungalinfections. Special stains, such as acid-fast stains forMycobacteria spp., also may be needed to make adiagnosis.

Treatment for bacterial infections should includeantibiotic therapy based on culture and antimicro-bial sensitivity. Anaerobic bacteria should be treatedwith metronidazole, penicillin, chloramphenicol, orclindamycin.158 Because of the caseous nature ofreptile abscesses, complete surgical excision of theabscess and removal of the accumulated caseous

material are required for effective treatment. Antibi-otic-impregnated polymethylmethacrylate beadshave been used to treat osteomyelitis in reptiles.167

The silver mesh described previously can be used topack wounds and provides 72 hrs of antibacterialand antifungal activity. Pharmacokinetic studies in-volving fluconazole and itraconazole in sea turtleshave advanced the treatment capabilities for fungalinfections.46,51

PneumoniaPneumonia is a common problem in critically illchelonians.1,168 Suboptimal temperatures, increasedhumidity, malnutrition, and overcrowding are pre-disposing factors for pneumonia.1,168 Because rep-tiles tolerate an anaerobic environment, they canconceal clinical signs of pneumonia until the condi-tion is severe.168 Pneumonia can be caused by a widearray of infectious diseases. Gram-negative bacteriaare recovered from a large percentage of the cases.These are often opportunistic infections with thesame bacteria being considered normal flora in thehealthy chelonian.168 Anaerobic bacteria are moredifficult to culture, but do represent an importantcause of pneumonia.158 Although less commonly iso-lated, atypical bacteria such as Mycoplasma spp.,Chlamydiophila spp., and Mycobacterium spp. are alsoimportant pathogens to consider.168,169 Herpesvi-ruses have been implicated as a cause of respiratorydisease in several chelonian species,134,145 and maypredispose the patient to secondary bacterial andfungal infections.

Chelonians appear to be more susceptible to fun-gal pneumonia than other reptile orders.1,128,170,171

Over exposure to fungal spores, immunosuppres-sion, or overuse of antibiotics are predisposing fac-tors. Aspergillosis spp., Candida spp., Mucor spp.,Geotrichum spp., Penicillium spp., Cladosporium spp.,Rhizopus spp., Beauveria spp., Sporotrichum spp., Basid-iobolus ranarum and Paecilomyces spp. have all beenisolated from chelonians with pneumonia.128,170-172

Migrating nematode parasites and digenetic spi-rorchid trematodes may predispose the chelonian tobacterial or fungal pneumonia.127,129 Aspirationpneumonia may occur in debilitated chelonians.168

Clinical signs may include anorexia, lethargy, in-creased or abnormal respiratory sounds, increasedrespiratory rate (especially at rest), and asymmetricfloating in aquatic species.168 Abnormal posture mayalso be noted in cases of inspiratory and/or expira-tory dyspnea, which may manifest itself as laboredbreathing with the neck extended and mouthopen.168


Diagnosis of pneumonia is based on history, phys-ical examination, and horizontal beam anterior-pos-terior and lateral radiographic views.168 A trachealwash should be performed before starting therapy ifthe patient can tolerate the procedure.168 Sedationmay be necessary. A sterile red rubber catheter orbronchoscope is placed through the glottis, downthe trachea, through a bronchus and into the lung.If the pneumonia is determined to be unilateralbased on the radiographic findings, then treatmentcan be targeted to that lung. Sterile saline solutionshould be flushed through the catheter and thenaspirated back. Bronchoscopy is limited to largerpatients, but will allow visualization of the respiratorytract and collection of appropriate samples. Cytologyand culture should be performed on samples ob-tained from the pulmonic lavage. Fungal pneumo-nias often produce localized or diffuse granuloma-tous nodules, which makes recovery of the organismdifficult without a biopsy. Nodules noted on radio-graphs may be suggestive of fungal involve-ment.168,172,173

Treatment for a fungal pneumonia should in-clude minimizing stress, providing a positive nu-tritional balance, and maintaining hydration.1 Pa-tients in extreme respiratory distress from pneu-monia should be positioned on a slight inclinewith their head and forelimbs extended.1 The an-imal can be intubated to facilitate suction of debrisfrom the lower respiratory tract. Coupage may behelpful in bringing up debris to be suctioned.Supplemental oxygen may inhibit respiration andcompromise the chelonians limited ability toeliminate inflammatory debris.1 Oxygen supple-mentation should be humidified to avoid irritationof the respiratory system.168 Bacterial pneumoniashould be managed with broad-spectrum antibiot-ics. Nebulization therapy can be used to increasethe humidity of the respiratory epithelial microen-vironment, improve pulmonary hydration, and in-crease the mucociliary transport mechanism.1,168

Furthermore, it assists in breaking up necrotic andinflammatory debris and delivers antimicrobialsdirectly to the site.

Treatment of fungal pneumonia in chelonia isdifficult and often unsuccessful. Some authors advo-cate prophylactic antifungal therapy in susceptiblespecies.1 Medical management generally consists oforal or subcutaneous fluconazole51 or itraconazole.46

Amphotercin B may also be used, and can be deliv-ered directly into an affected lung via a catheterplaced through a carapacial osteotomy.171,174 Granu-lomatous nodules may require surgical excision.168

Acyclovir therapy is indicated when herpesvirus isdiagnosed or suspected.

Buoyancy DisordersAquatic turtles, especially sea turtles, are oftenpresented with buoyancy disorders, where they areunable to float normally at the surface or sub-merge.79 Any condition leading to gas or air accu-mulation in a body organ or in the coelomic cavitymay cause abnormal buoyancy. Common causes ofthis condition include 1) pneumonia, 2) gastroin-testinal disease (eg, motility disorders, spinal cordinjury, foreign body and other obstructive pro-cesses leading to gas accumulation), and 3) freeair in the coelomic cavity (respiratory or intestinalleakage or microbial fermentation). Efforts shouldbe directed toward diagnosing the primary prob-lem, which may include blood work, radiology,endoscopy and laparoscopy. Initially the turtleshould be stabilized and then attempts should bemade to treat the primary disease. Laparoscopicsurgery has been used to repair a lung tear in a seaturtle (Pers comm, Dover S, 2004). Intracoelomicadministration of large volumes of sterile fluidshas been used as an ancillary treatment for thiscondition in loggerhead sea turtles (Pers comm,Sheridan, T, 2005). Some turtles, especially thosewith spinal injuries, may remain abnormally buoy-ant for

Chelonian Emergency and Critical Care

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