Apprentice Parvo Curriculum

Day 1 - Basics 

Please watch the Intro Video and read all the Day 1 information including the links before your first shift 

Introduction

The first day of parvo training presents a lot of information very quickly. You are not expected to know everything after one read-through, but you will be expected to answer some questions during training by using critical thinking. Reading the curriculum beforehand should make remembering easier and make the first day less overwhelming. Here’s what you should expect to do on your first day:

• Learn how to enter the Parvo ICU correctly (Do not enter the Parvo ICU past the clean side without being shown how to enter!)

• Tour the Parvo ICU so you will have a basic idea of where everything is

• Review the causes of death from parvo and how a shelter can address those causes of death in our parvo treatment protocols

• Learn how to use the Patient's Medical Chart

• Learn how to perform a basic physical assessment

• Discuss SQ treatment

• Learn feeding guidelines

• Learn to monitor and note puppies’ food intake, defecation, and vomiting

• Fold laundry

• Learn how to leave the Parvo ICU correctly so you avoid spreading the virus to your own pets or other dogs in the facility

Hand Washing

• Medical hand-washing, more thorough than typical hand-washing, is the most important method to prevent spread of disease and should therefore be done frequently and thoroughly.

• You must wash hands between each and every patient. Many of our patients have diseases in addition to parvo such as upper respiratory infections, mange, or even distemper. Washing hands in between patients is essential to prevent these diseases from spreading, which is important since any extra medical condition can reduce a patient’s chance of survival.

• Please read the following protocol for Medical Hand-Washing.

Entering & Exiting the ICU

• Before entering the Parvo ICU, we change out of street clothes and into the parvo-designated scrubs following a specific protocol. It is very important to follow the protocol exactly to avoid spreading the virus to the clean side of the changing area, other dogs in the shelter, or your own home.

• You will not wear you own clothes while in the Parvo ICU , we provide scrubs that stay in the Parvo ICU because they are considered contaminated with parvo. Your clothes will be left in a locker on the clean side.

• Please read the protocol for entering and exiting the Parvo ICU here.

Attention to Detail

It is very important that all volunteers pay attention to detail. Volunteers spend much more time with the patients than the doctors do, just as nurses do. You are the doctors’ eyes and the patient's voice. Let the doctor know if you notice pain, sneezing, congestion, nasal discharge, hair loss, or any other new or changing symptoms.

Parvo Disease Basics

Parvo is a virus. This means that we cannot cure the virus itself, because antibiotics do not kill viruses. We can only offer supportive care until the dog's own immune system is able to fight off the virus. Parvo is transmitted via "fecal-oral" route, meaning the virus is shed from the feces, which can also infect the environment. Another patient can then ingest virus from the environment, or directly from infected feces. Parvo is an incredibly hardy virus and the only household disinfectant that will kill the virus is Bleach at a 1:32 dilution (or stronger). To contain the virus from sick patients, we have a designated Isolation Unit and follow quarantine protocols.  Please review the page What is Canine Parvo Virus? for more detail.

Symptoms

• Inappetence (also called anorexia in vet medicine)

• Lethargy/depression

• Nausea

• Vomiting

• Diarrhea

• The diarrhea is often extremely liquid may consist almost entirely of blood

Incubation Period

            98% of the time we see dogs and puppies break within 3-5 days from time of exposure. There                 are outliers that will break later but the vast majority of puppies break by day 5. 

Causes of Death

1. Dehydration

   1. • The virus is attacking and killing the layer of cells that line the puppy’s GI tract which causes profound fluid loss through vomiting and diarrhea in addition to lack of food/fluid intake. This rapidly leads to severe and life-threatening dehydration.

      • Dehydration is treated with fluids to rehydrate the patient and antiemetics (medications that prevent nausea and vomiting).

      • Fluids can be administered in several different ways:

        • Subcutaneous (SQ) Administration: Fluids can be administered under the skin(SQ) with a needle, as demonstrated below.

• • 1. ** Sometimes donations will have LRS + Other Drugs. Pay attention!

• • • • • Intravenous (IV) Administration: fluids can be administered directly into a vein through an intravenous catheter. IV fluids can be administered

          • As a bolus- a large amount of fluid given quickly

          • As a CRI (Constant Rate Infusion) using an IV pump. This allows us to give a dog a certain number of milliliters per hour, 24 hours a day.

1. Secondary Bacterial Infection

   • Parvovirus also kills rapidly-growing White Blood Cells which normally fight off infection. As the puppy is fighting off parvo with a depressed and overburdened immune system, the patient becomes more susceptible to bacterial infections they would normally be able to fight off.

   • In addition, the puppy’s compromised intestinal tract may begin to allow normal gut bacteria into the bloodstream, where they can wreak havoc.

   • Once infection penetrates the bloodstream—a condition called sepsis—it spreads to the entire body and causes the patient's system to go into shock.

     • Optional: For a more thorough definition of sepsis, skim through the Sepsis Wikipedia Page.

     • Optional: For a more thorough definition of shock, skim through the Septic Shock Wikipedia Page.

     • Shock can also occur with severe loss of blood volume, called Hypovolemic Shock. Optional: Hypovolemic Shock Wikipedia Page.

   • We use antibiotics to combat these infections and prevent them from causing shock.

   • We also use sterile technique to prevent secondary bacterial infection from arising.

Parvo Medications

• We administer medications through several routes:

  • Orally (PO)

  • Subcutaneously (SQ)

  • Intravenously (IV)

• We use several types of medications:

  • Antibiotics - to prevent and treat sepsis

    • Enrofloxacin (known as Baytril) 100mg/ml - must be diluted 1:20 in fluids SQ

    • Polyflex - SQ ampicillin, NOT for IV use!

    • Cefazolin or IV Ampicillin - IV only, in place of Polyflex when on IV's

  • Antiemetics - to reduce and prevent nausea and vomiting

    • Cerenia - stings, most often SQ SID, can be IV BID

    • Metoclopromide (known as Reglan) - SQ or IV

    • Ondansetron - SQ or IV

  • Fluids - to prevent and treat dehydration

    • Lactated Ringers - preferred choice

    • Sodium Chloride - to dilute vitamin c

  • Antiparasitics/dewormers- to kill intestinal parasites

    • Panacur - hooks, rounds, whips

    • Marquis Paste - coccidia

    • Praziquantel - tapeworms

  • Antacids - to reduce damage to the stomach and esophagus from vomiting stomach acid

    • Famotidine (Pepcid) - SQ, IV, or oral

    • Omeprazole - oral

  • Pain medications

    • Bup SR

    • Tramadol

    • Gabapentin

• Treatment Order

  • Triaging - determine which patient is the most critical and treat that dog first (unless otherwise indicated)

  • Treat dogs with URIs, mange, distemper, or ringworm last because these conditions are contagious to other dogs. See Intake and Grouping information. 

Patient's Medical Chart  

Day 2 - SQ

Previous Day Review

The following official Protocol Pages will provide more thorough detail to the overviews given in Day 1 of the curriculum. Please read through all provided links.

• Scrubbing in and out

• Physical Assessment  (you can skip the "Crashing Puppy Protocol". This will be addressed later in training).

  • What is the purpose of checking gum color? Paw temperature? Fluid absorption?

• Medical Treatments

• What are the two causes of death in puppies with parvo, and how do we treat/prevent?

• Feeding Guidelines 

• Cage Cleaning

• Sterile Practice - The following items must be kept sterile:

  • Needles

  • Catheters

  • Fluid lines

  • Fluid bags (lines must be capped)

  • Medication vials

• SQ treatment basics

Subcutaneous Treatment Practice

• By Day 2, you should be familiar with Baytril, Polyflex, Reglan, Cerenia, LRS. Know the type of drug, routes and special notes. Go to the Drug Chart page to review these. You should begin studying other medications on the chart as you use new drugs.

• When a is a puppy on SQ vs PO or IV meds?  Dogs larger than ~5 lbs will initially start on SQ medications given under the skin if they are not showing severe symptoms (lots of vomiting, bloody diarrhea). SQ medications can be effective for dogs that are absorbing the medications effectively.

  • Three reasons to switch from SQ to IV:

    • When the puppy is lethargic

    • If the puppy is not absorbing SQ fluids

    • If the puppy has excessive excretion (bloody diarrhea, vomiting excessively)

  • Two main reasons to switch from SQ to PO:

    • If the dog is eating half of a meal or more

    • If the dog is squirming excessively when giving fluids - must also be eating some

• Review standard SQ treatment

  • Baytril, Polyflex, Reglan, Cerenia, and Fluids are the main SQ treatment medications you must be familiar with.

    • Doses for each dog can be found on the Drug Charts and Terminology.

    • What is the purpose of each of these common SQ medications?

    • Know all of the special notes and routes for these medications. What do you think may happen if a SQ only medication is given IV?

      • Answer: The dog is likely to have seizures and/or die from being given a SQ medication that is not meant to be given directly in the blood steam.

Medication Review

• Review/skim through the following information to begin familiarization with medications using the Drug Chart.

  • Types of fluids to be used SQ vs IV 

  • Types of anti-emetics and their strengths 

End of Shift Responsibilities

See End of Shift Responsibilities.

End of Day 2 Quiz

Day 3 - IVs

Previous Days Review 

Be able to answer the following questions. Review protocols if unable to give succinct answers.

• What is the importance of scrubbing in and out properly?

• When do you switch a puppy off SQ treatment to PO meds? SQ to IV?

• Why do SQ fluids not absorb completely in some patients? How can you tell?

• What are the drug types, routes, and dangers of the following drugs?

  • Baytril - What is the drug name? How is it administered?

  • Polyflex - How must this drug be stored?

  • Reglan - What is the drug name? How must this drug be stored?

• Why is a dog switched from SQ to IV medications?

Review the following protocols 

• Sterile Guidelines Review

• Feeding Guidelines 

• Cage Cleaning 

  • Only change blankets if they're sufficiently soiled

  • Always dispose of feces/solid materials before placing in laundry bin.

Introduction to IVs

When patients become more critical (lethargy, pale gums, increased vomiting, and/or bloody diarrhea), they are placed on IV medications and IV fluids as a constant rate infusion (CRI) continuously throughout the day. This is accomplished by placing an IV catheter. The IV catheter must be maintained properly.

See http://veterinaryteam.dvm360.com/step-step-photo-gallery-how-place-cephalic-catheter for images of IV catheter placements.

• Important checks prior to treatment include the following:

  • Swelling above or below the catheter

    • Paw swelling below the catheter indicates the tape or vet wrap is too tight

    • Arm swelling above the catheter indicates the the vein may have ruptured, or blown, and the patient needs a new catheter

      • A blown vein will leak blood and fluid in the surrounding area, causing swelling 

      • Swelling from a blown vein is generally above the catheter site due to direction of blood and IV fluid flow

      • A blown vein will clot on its own when its able to "rest" after the IV fluids and catheter have been removed.

      • A different vein/arm must be used for a new catheter.

      • The swelling is often painful depending on severity. A special bandage may be needed to prevent infection.

  • Flushing the catheter

    • Plain LRS or NaCl fluids can be injected into the catheter to check for patency, meaning there are no blood clots clogging the catheter and that the vein has not blown. A patent catheter will have minimal resistance when pushing/administering the flush. 

      • If its a blood clot: There will be moderate to high resistance. Remove the clot by pushing the flush through it, or carefully remove any visible clots with a sterile needle. 

      • If the catheter is blown: There will be low to moderate resistance and swelling above the catheter site.

    • Flush before, between and after medications. Only use however much is needed - as little as 0.2-0.5mL.

    • The drug Heparin, and anticoagulant, is often added to the flush to help prevent blood clots forming inside the catheter

      • Review the dangers of Heparin on the medical chart.

• Catheters should be changed every 72 hours. In the ICU we may leave them in longer if possible because puppies may become critical and may need extended IV treatment ie we go through all their veins including jugulars. 

• The IV Catheter port (orange/yellow parts in the picture above) is where medications are injected, and should be cleaned with an alcohol swab prior to administering medications when visibly contaminated. 

IV Medications

As a general rule, most IV medication are clear in color and nothing colorful should be injected IV.  The most common result of injecting a drug not meant for IV use is seizures and/or death. Never inject something into a dog without knowing what it is and what route is safe.

• Cefazolin OR Ampicillin - used interchangeably depending on cost, same dose. If given too fast will cause vomiting. 

• Famotidine (pepcid) - when there is a concern for ulcers or stomach acid imbalance

• Cerenia - can be given IV. When given IV prescribed BID 

• Ondansetron - IV or SQ

• IV CRI - Patients are typically on an IV CRI for several days until they start eating again

  • Lactated Ringers Solution is the most common and affordable crystalloid fluid solution given IV.

  • Additional medications are added to the fluid bag depending on need

    • 50% Dextrose - sugar

    • Reglan - anti nausea

    • KCL (Potassium Chloride) - electrolytes

**Review the following common IV medications on the medical chart page.

**Don't forget to flush before administering any medications via the catheter

Intro to Hetastarch

• • Hetastarch is a colloid fluid that contains proteins, unlike crystalloid fluids (LRS). Protein helps draw fluid from outside cells into the blood vessels, this increasing blood volume and pressure. Increased pressure helps improve circulation to all internal organs.

  • This drug is typically used on critical, and/or crashing dogs, especially when their gums are pale/grey/white. It is most commonly given as a bolus in the AM and PM shifts. It will be prescribed, for example, as "Hetastarch 50mL over 20 minutes". You must be able to calculate what fluid rate (mL/hr) to set an IV pump to.

  • Some dogs may be on a Hetastarch CRI to replenish and maintain protein levels

  • Dangers - this drug must be given slowly, and can only be given a certain amount (depending on weight) a day. Overdosing can cause severe fluid overload, fluid in the lungs, and/or internal bleeding. Use caution with this drug and triple check dosage and time.

  • The most critical patients will be on Hetastarch, especially with severe bloody diarrhea, pale to grey/white gums, and/or severe lethargy. 

Making a basic IV CRI fluid bag:

•     per 1000ml bag (new bag) add the following:

  • 3ml Reglan

  • 20 meq KCL 

  • to make a 5% bag (baseline) add 100ml 50% dextrose. Vets may request more dextrose if the patient is very small and/or not maintaining BG on 5%. 

Crashing Puppy Protocol

• Crashing Puppy Protocol - Its imperative to be familiar with this information so you'll be prepared in an emergency situation. A few minutes can be the difference between life and death for a crashing puppy!

IV Pumps

An IV Pump is used to administer a CRI (constant rate infusion) of fluids throughout the day. They are generally simple to use, but small mistakes can result in severe medical consequences. Carefully check that the IV Pump has the proper settings with every use.

See http://apexx-equipment.com/veterinary-mfg/leading-edge/Conntrol-V-935i-IV-Pump-from-Leading-Edge for an image of a common pump.

• The two setting you are responsible for setting every shift include the 'Volume To Be Infused', or VTBI, and the Rate

  • VTBI

    • The VTBI, also called 'Preset' on some pumps, is the total volume of fluid that will be administered to the patient.

    • For Hetastarch, set the VTBI/Preset to the dose prescribed by the doctor (i.e. 50mL)

    • For a CRI, set the VTBI to 9999mL, as we are unsure how many days the patient will continue to be on IV fluids and we don't want it to stop. 

  • Rate

    • The rate is always prescribed in mL/hr and NOT drops/mL

    • The doctor will prescribe the fluid rate in mL/hr (i.e. 12mL/hr) based on the patients body weight

    • The Hetastarch rate must be calculated. If the doctor prescribes 50mL over 20 minutes, set the rate to 150mL/hr and the VTBI/Preset to 50mL. The IV Pump will administer Hetastarch at a rate of 150mL/hr until it has given 50mL

End of Day 3 Quiz

• • What are the symptoms of a crashing puppy?

  • How frequently should catheters should be changed? Why?

  • How much Heparin is used to make up a flush?

  • What unit should the pump rate be set to? What will happen if it is set to the incorrect unit (drops/min)

  • Ampicillin and Cefazolin will cause nausea and vomiting if given too ______. 

  • The SQ version of Ampicillin is called _______?

  • Which drug, occasionally used in fluid bags for CRI, will stop the heart if directly injected into the patient?

  • We cover the patients fluid bags because one of the drugs is light sensitive. Which one?

Day 4 - IV and SQ Practice

Other Diseases

Many of our puppy patients have other diseases which will be treated concurrently. Volunteers and staff must take care to not spread diseases between patients. Some of these diseases are also contagious to humans. See Isolation Protocols for proper protocols to prevent spread of other diseases within the Parvo ICU. See the following pages for common diseases found in shelter dogs:

• Distemper - deadly contagious!

• URI

• Ringworm

• Mange (two types)

• Intestinal Parasites (Worms)

• Ticks

• Fleas

While under treatment in the Parvo ICU puppies are not treated for ringworm and mange. These conditions will be treated once the puppy leaves the ICU and the clinic can provide routine diagnostics. In severe cases of mange puppies may start treatment once they are 100% symptom free from parvo. 

Review/Practice

• Sterile Guidelines Practice/Review - at this point with continued review, you should be realizing how crucial it is to always be thinking about sterile technique in storing and administering drugs.

• IV Treatment Page - review important information, study the less common drugs used and  learn about IV treatment structure

• SQ Treatment - review only if needed

For your next training shift, you will be practicing more IV patients as well as SQ patients. Let your trainer know where you need the most practice still. Expect to be quizzed on the drugs being used on your patients. You should be familiar with all primary drugs in the ICU by now (Baytril, Polyflex, Reglan, Ampicillin, Cerenia). Reference the Drug Chart when needed. 

Shift Structure

1. Enter the ICU following proper quarantine protocols

2. Start of Shift Responsibilities

   1.  Do a quick walk-through the entire ICU to look at all patients and determine who is the most critical. Some patients may need emergency treatment if unresponsive during the walk-through

   2. Start the laundry - every volunteer and staff member is needed to keep the ICU clean and organized

3. Pick 2-3 medical charts at a time, starting with the critical patients, and start drawing up meds for multiple patients

4. Treat patients

• • Check gums, paws, and for edema (fluid that hasn't been absorbed from last SQ treatment)

  • Check catheter for patency and swelling

  • Administer medications

  • Offer a meatball size amount of food to patients. If showing signs of nausea, remove food from cage. Replace water bowl

  • Remove any solid materials from blankets with toilet paper. Check blankets for urine/fluids and change only if necessary

  • Force feed patients after anti-emetic medications have had time to take effect (30 minutes if SQ, 15 if IV)

  • Flush catheter with Heparin flush. Check IV bag to ensure there is enough fluids until the next shift. Check fluid rate and VTBI.

  • Fill out the medical chart for the correct shift!

  • Wash hands between patients

5. Check/continue laundry throughout shift

6. Double check all charts to ensure all patients have been treated fully

7. Carefully restore medications, ensuring that refrigerated meds are stored properly 

8. Double check all patients have enough fluids in their IV bags, all pumps are set to mL/hr, sufficiently set VTBIs/Preset (reset the amount accumulated)

9. Fill and send the End Of Shift Parvo Report 

10. Clean the ICU - dishes, wipe down counters, fold laundry, sweep 

11. Turn off the drier (this is a fire hazard)

12. Wash hands and exit ICU following proper quarantine protocols 

End of Day 4 Quiz

1. Why is washing hands between patients so important?

2. URI,ringworm, suspect distemper. In what order do you treat?

3. When does a bag of LRS with 5% Dextrose expire?

4. An LRS bag used for SQ fluids is stored, but the last volunteer forgot to put a cap on the needle. Are the fluids sterile anymore? Why/why not?

5. What are the two causes of death from parvovirus?

6. What route is Polyflex given?

7. You have a very sick puppy, his IV catheter is 4 days old and dirty but patent. Do you pull it and replace? 

Day 5 - Specific and Additional Protocols

At this point, you should be able to verbally explain the importance of all primary drugs administered as well as all the details of their administration to your trainer. You should be capable of performing 90% of treatments on your own. . We still want you to be comfortable with asking questions to your co-volunteers and doctors if you're ever not sure of something. Remember, you should never inject anything into a patient if you don't know what it is and what adverse side effects could result if used improperly.

New Protocols

• SNAP Parvo test - The IDEXX SNAP test is used to determine if a recovered patient is no longer spreading the disease and is therefore safe to come out of Isolation

Efficiency Goals

During peak parvo season in the spring and early summer, (depending on geographical location), the Parvo ICU can have 30+ patients. All volunteers must go into "triage mode" to treat all dogs in a timely manner such that shifts do not last longer than 4 hours. One efficient volunteer is often more valuable than two or three slower volunteers. The following are triaging/efficiency goals for when we have 15+ dogs.

Review these tips for efficiency on the Triage Mode page!

Shift Structure

Quiz yourself! Walk through the main shift tasks and compare them to the following example:

1. Enter the ICU following proper quarantine protocols

2. Start of Shift Responsibilities

   1.  Do a quick walk-through the entire ICU to look at all patients and determine who is the most critical. Some patients may need emergency treatment if unresponsive during the walk-through

   2. Start the laundry - every volunteer and staff member is needed to keep the ICU clean and organized

3. Pick 2-3 medical charts at a time, starting with the critical patients, and start drawing up meds for multiple patients

4. Treat patients

• • Check gums, paws, and for edema (fluid that hasn't been absorbed from last SQ treatment)

  • Check catheter for patency and swelling

  • Administer medications

  • Offer a meatball size amount of food to patients. If showing signs of nausea, remove food from cage. Replace water bowl

  • Remove any solid materials from blankets with toilet paper. Check blankets for urine/fluids and change only if necessary

  • Force feed patients after anti-emetic medications have had time to take effect (30 minutes if SQ, 15 if IV)

  • Flush catheter with Heparin flush. Check IV bag to ensure there is enough fluids until the next shift. Check fluid rate and VTBI.

  • Fill out the medical chart for the correct shift!

  • Wash hands between patients

5. Check/continue laundry throughout shift

6. Double check all charts to ensure all patients have been treated fully

7. Carefully restore medications, ensuring that refrigerated meds are stored properly 

8. Double check all patients have enough fluids in their IV bags, all pumps are set to mL/hr, sufficiently set VTBIs/Preset (reset the amount accumulated)

9. Fill and send the End Of Shift Parvo Report

10. Clean the ICU - dishes, wipe down counters, fold laundry, sweep 

11. Turn off the drier (this is a fire hazard)

12. Wash hands and exit ICU following proper quarantine protocols 

End of Day 5 Quiz

Name 3 strategies you'll use when there are 10+ dogs in the ICU

What are the signs/symptoms that indicate a puppy is crashing?

Day 6 - Wrapping It Up

Efficiency Goals

Continue to work on your efficiency for the next several weeks!

Review these tips for efficiency on the Triage Mode page!

Team Guidelines

• Signing up for shifts is a serious commitment and should be treated as such. The integrity of the Parvo Program depends on reliable volunteers. Be aware of the rules and consequences for Missing a Shift that you're scheduled for. Cancelling a shift should not be a common occurence, and cancelling a shift last minute is unacceptable unless its an emergency.

• Be aware of the requirements to Stay Active as a volunteer

• If a puppy seems to be in any amount pain, call/text the doctor. They are likely to prescribe pain medications.

• Consult the Medicine Chart posted in the Parvo ICU if you are unfamiliar with a medication. Do not be afraid to ask your co-volunteer questions as well!

• Have the veterinarians' and manager's phone number stored in your phone.

• Keep the ICU Clean!

Other Protocols

The following protocols where not covered in the previous days' material. You do not need to read through the all, just be aware that you can reference these protocols while in the ICU when needed:

• Intake Protocol

• Vaccine Protocol

• Deceased Puppy Protocol

• Blood Tests

• Discharge and Bathing Protocol

• Kittens with Panleuk

End of Training Test

Please email the parvo manager at and let them know the test has been completed so they can check your answers. Feel free to use the wiki, but most of these answers you should already know.