DOWNER COW SYNDROME-TREATMENT & MANAGEMENT

DOWNER COW SYNDROME-TREATMENT & MANAGEMENT

One of the most challenging problem for veterinarians is management of recumbent/downer animals. Prolonged recumbency due to inadequately treated and unresponsive hypocalcaemia is one of the common causes of downers syndrome. Cox (1982) proposed that downer cow was any cow which was down in sternal recumbency for more than 24 hours without evidence of a systemic involvement. Blood et al. (1983) defined the downer cow syndrome is a condition occurring following parturient paresis, characterised clinically by prolonged recumbency even after 2 successive infusions with calcium. Ninety four per cent downer cows were average to high producers. About 30 % of cows treated for milk fever will not stand for up to 24 hours after treatment and turn to downer animals (Radostitset al., 2000). Allen and Davies (1981) suggested that downer syndrome occurred as a result of one of combination of the factors like milk fever, hypophosphataemia, fat cow syndrome, excessive protein intake, Vitamin E & Selenium deficiency, recumbency due to trauma and malnutrition. Jonsson (1983) suggested that downer syndrome occurred as a result of one of combination of the factors like muscular injuries, nerve injuries, persistent hypocalcaemia, persistent hypophosphataemia, myocardosis, hepatosis, septic mastitis and other factors.Jonsson (1983) also observed that 65% cases of injuries of muscles, nerves and hind limbs terminate as downers. Downer cows as a syndrome was first reported in the 1950ies and have been a challenge for veterinarians ever since. A cow that is recumbent for too long may develop soft and nerve tissue lesions because of her recumbency. The pathophysiology and blood biochemistry related to downer cows have been studied by others. An important step in the treatment of a recumbent cow is to help her stand.
Occurence of downer cow syndrome—-
58% of cases occur in first 24 hours of lactation
97% of cases occur in first 100 days of lactation
May become recumbent for any number of primary medical
reasons: e.g. A common complication of milk fever: 20-28% of milk fever cows become “downers”
Non-medical risk factors:
Season (winter): lack of exercise, footing on ice
Management: housing, footing, trauma, stockmanship Sanitation: infectious disease
Nutritional management: metabolic disease

Metabolic disease causing primary recumbency—-

• hypocalcemia
  hypophosphatemia
  hypokalemia
  hypomagnesemia
  advanced fatty liver disease
  starvation
  Trauma causing primary recumbency——–
  • During calving or when struggling to get up
  • Fractured pelvis, long bones, dislocated hip
  • Rupture of Gastrocnemius tendon
  • Nerve damage: Sciatic &/or Obturator nerve paralysis

What else is a cause of primary recumbency?——

Septic/Toxic shock: eg. Mastitis, metritis, peritonitis, RDA/RTA, etc
• Other: eg. Lymphosarcoma in vertebral canal, BSE

Progression to secondary recumbency——–
Prolonged recumbency causes pressure damage:

• Ischemic necrosis of muscles of ‘down’ hind limb
  • edema & swelling, congestion, cellulitis, venous thrombosis
  • Primarily Gastrocnemius & Semitendinosus muscles
• Nerve damage:
  • Common Peronial branch of Sciatic nerve.
  • Loss of function of digital extensors => knuckle over at fetlock

Progression to tertiary recumbency——–

Cow struggling to get up may cause musculoskeletal damage that results in long-term recumbency:

• Fractures
• Rupture of muscle, ligaments

Clinical signs——
Usually in sternal recumbency but unable to rise
• Often bright and alert (“alert downers”)
• Eating, drinking, urinating, defecating
Hindlimbs: under body or stretched out behind (‘frog-legged’)
• Forelimbs functional: “creepers”
• Sensation often present in hindlimbs (withdrawal reflex)
• +/-attempts to rise (part way up “sitting” or roll to other hip)

Recumbency and CK (Creatine kinase activity ) testing——-

• Maximum CK activity occurs approx. 48 hrs. recumbency
• > 48 hrs., CK activity declined rapidly, even in downer animals
• a low CK value after being down for 5 days is meaningless
CK => limited usefulness as prognostic indicator
• Clinical observation is a better predictor of prognosis than CK levels.

Diagnosis: history——

Recumbent > 24 hrs.

• Often high producer, early lactation – +/- history of primary disease
  • e.g. If Hx of milk fever, ask treatment given, route of administration, serum biochemistry results, response to therapy?
• Trauma?
• Dystocia?
• Infectious disease?

Physical exam——-

• Alert, but unable to rise
• If can partly stand may observe muscle swelling, stiffness or nerve deficits
• Thorough exam to look for other primary disease
  • TPR, rectal/vaginal exam: udder, pelvis, uterus, vagina, legs, etc.

Differential diagnoses for primary disease——-

Metabolic Disease: Blood chemistry: Hypo – Ca, Phos, Mg, K; fat cow syndrome

• Musculoskeltal injury (pelvis, hip, long bones, stifle, hock, ruptured tendons)
• Nerve injury (spinal cord lesions, calving paralysis)
• Toxic conditions: mastitis, metritis, uterine torsion, peritonitis, RDA/RTA, etc.
  Blood profile——-
  Elevated CK, AST (aspartate aminotransferase activity):
• depends on duration of recumbency
• CK values peak after 36-48 hrs. then fall again
• Grave prognosis is >10 times above normal and recumbent > 2-3 days. However, best prognostic indicator is clinical observation.
  • +/- hypocalcemia, hypo-Phos, hypo-Mg, hypo-K
  • +/- elevated serum urea & creatinine (shock, poor renal perfusion, renal failure)
• Evidence of sepsis?
  Urinalysis results—— Proteinuria:
  • within 48 hrs of onset of recumbency
  • due to skeletal muscle damage – Myoglobinuria:
  • skeletal muscle damage – +/- ketonuria

Treatment:
Treatment of downer cows
Supportive care for a downer cow is essential. It will not only prevent further pressure damage and secondary lesions but will also be an important step towards having a standing cow. However one must stress that obvious reasons for recumbency must be treated before assisted standing is performed. Often the primary diagnose and the secondary lesions need to be treated simultaneously. Green et al. (2008) concluded in their study that recumbency for less than 24 hours, treatment with calcium, potassium or phosphorus and cases that not received treatment by a veterinarian before recumbency were more likely to recover. A surprising finding in their study was that repositioning did not increase the likelihood to recover; the authors assumed that the lack of benefit is because the repositioning was initiated too late, or that repositioning was only performed on the most severe cases. Thus their negative results of repositioning should not be interpreted as a negative effect.Generally at field level in India,Treatment is done by medicine along with physiotherapy to correct the etiological factor. Injection Oxytetracycline at the dose rate 10 mg/ kg body weight and Meloxicam at the dose rate of 0.5 mg/kg body weight are administered intramuscularly for five and three days respectively. Injection Calcium magnesium borogluconate (Mifex) 450ml (300ml slow i/v and 150ml s/c and Injection 5% DNS 2000ml i/v once were administered. Injection Tribivet (Vit. B1, Vit. B6, Vit. B12) 10 ml i/m. and injection Tonophospan 10ml i/m for 3 days are administered. Injection Triamcinolone (Vetalog) 5 ml i/m for 3 alternate days. Powder chelated Agrimin Forte 50 gm bid for 10 days orally given. Powder Potassium chloride 30 gm orally for 5 days is given. Physiotherapy comprised of soft bedding (paddy straw and sandy soil) and supportive slings. Sand is used as bedding material because cow is easily rolled from one side to other and for the regular removal of excreta. The cow is rolled from one side to the other for every 3 hours to prevent bed sores. Cow is assisted to stand for 30 minutes four to six times a day using supportive slings. The sling is designed in such way that the weight of the animals is equally distributed . Massage of hind limbs with vegetable oil to increase muscular activities is carried out and hot water fomentation is performed. Cow is responded well with treatment and physiotherapy. Cow is able to stand up without help of slings after complete recovery ( The line of treatment may vary from case to case and also from vets to vets, This is the general procedure which we follow in our area)
analgesics/anti-inflammatories——

• Steroidals:
  • Dexamethasone
  • Predef
• Non-steroidals
  • ASA
  • Banamine
  • Ketoprofen
  Treatment: supportive care—————
  good footing/traction
• Lots of bedding/cushion
• Shelter
• Access to water/feed
• Roll frequently (q 4-6 hrs.)
• Massage hind limbs
• Treat decubital sores & provide excellent bedding

Treatment: lifting devices—-
LIFTING TECHNIQUES AND DEVICES
There are various techniques and devices used to assist a dower cow to stand; hip lifters, inflatable balloons, different types of slings and flotation therapy
Sling– Supportive slings for cows come in various different shapes and sizes. The principle behind it is a mesh or a net that together with straps can be placed under the whole ventral part of the animal, supporting not just the abdomen but also the cranial and caudal part of the body. The sling is then attached to a front end loader or an overhead attachment; there are models that attach to a movable freestanding structure. An advantage is that it gives a better support for the animal and the weight is spread out over a larger surface. A negative aspect of the sling is that it is difficult to install on the animal. There are a lot of straps to fit.

• Hip lifters/clamp– The hip lifter or hip clamp consists of a straight extendable bar and have two metallic rings attached to each end of it. The rings are placed over the tuber coxae of the recumbent cow and then tightened. The hip lifter is then lifted together with the cow
  Air bag– Inflatable air bag, inflatable balloon or a Cow Jack are all different names for lifting devises working with the same principle. It consists of a large cylinder shaped inflatable devise that is being placed under the cow and then inflated. As the pressure in the bag increases the cow rises. An advantage of the air bag is that it is much softer on the animal and not causing any muscle damage. The negative effect of the airbag is that they support the comparatively soft abdomen of the animal leading to compression of the internal organs and the diaphragm, having a negative effect on the respiration (Cox 1988).
• Inflatable cushions
  • Only useful if animal can stand once supported
  • Only allow short-term lifting
• Aquatank:
  • Float in warm water for 6-8 hour periods
  Flotation- Flotation as a technique to help downer cows was developed in the late 1970ies by the Dane Johan Lastein after that he himself had undergone a treatment based on the same principles (Down-Cow) (Figure 2 and 3). To get the recumbent cow in to the flotation tank she is rolled up on a mat that is dragged in to a tank with removable front and rear doors, the doors are then sealed and water is put into the tank (Down-Cow; Smith et al. 1997). Even though the technique is fairly new, first reported by a veterinarian in 1982 there have been several publications made (Smith et al. 1997; Burton et al. 2009; Giudice and Gianesella 2010) reporting 37- 46% positive result. Negative aspects of the technique is the difficulty to get the cow in to the tank, the large amount of warm water that is needed and the risk of creating hyperthermia or hypothermia in the animal. The advantage is that the cow can stand comfortably for a long period and the flotation force created by the water is evenly spread.

Prognosis——
Prognosis frequently guarded & depends on:

• Cause of recumbency
• Duration of recumbency
  • Mortality 20-67%
  • Many die within 7-10 days due to sepsis or shock
  • 33 % recover between 3-30 days
  • May continue treatment if no obvious physical abnormalities, bright, eating, and continued attempts to rise
  Prevention—–
  excellent nutritional management
• Adequate bedding in calving area, stalls
• prompt treatment of milk fever to avoid prolonged recumbency
• Monitor treated cows closely for 24-48 hrs. post-treatment
  • Prevent trauma:
• Non-slippery floor
• Good design for chutes, etc. for moving cows
• Stockmanship: Move cows calmly, quietly and slowly
• Supervise parturition & provide appropriate assistance to avoid prolonged calving
• Market ‘high risk’ cows early
  Humane handling of downer cows—-
  Transport of downer cows:
• Can be transported, but must be done humanely (e.g. send to hospital pen)
• Cannot go to slaughter, cannot enter the food chain
  • If poor prognosis and/or failure to improve, humanely euthanize:
• Captive bolt pistol
• Light caliber pistol or rifle
• Barbiturate overdose
  (concerns: $, controlled substance, harmful residues: scavengers)
  • Options for disposal of deadstock:
• Off-farm: Rendering truck: animal will be condemned
  => rendered => dog food (farmer pays)
• On-farm: bury or compost
  Helping the cow rise
  On every day of the recumbency, an attempt should be made to bring the cow to its feet. Several simple but effective techniques can be tried.

In one method, the clinician stands with feet pressed under the cow at a point below the scapulohumeral joint. A sharp blow is delivered by driving the knees into the muscle mass below and caudal to the scapula. This method must not be used on the thoracic wall unprotected by the muscle mass to avoid fracturing the ribs. If the animal struggles to rise, an assistant should grasp the root of the tailhead with both hands and lift. Lifting on any other part of the tail may cause damage.

The value of hip clamps is controversial. Their proper use requires experience, skill, and a delicate touch. Continual use causes trauma and pain that is counterproductive. The forelimbs support 60 per cent of a cow’s weight and, therefore, the use of a canvas sling under the sternum is almost mandatory for consistent success.

Even if the cow does not stand, the lifted position provides an opportunity to manipulate the limbs, auscultate for crepitation, and perform vaginal and rectal examinations.
Supporting the downer cow
It is vital that recumbent cows be provided with clean water at all times. A shallow rubber feed bowl prevents spillage. If the cow does not drink, she must be given fluid therapy either by drench or parenterally. Every effort must be made to roll the cow from one side onto the other every 3 hr. If this is not done, the weight of the cow results in ischemia in the muscles of the hindlimb. This pathology precedes various myopathies and may precipitate the compartment syndrome.

Protection from the elements is essential. Rain and wind can reduce body temperature considerably and worsen shock if present. A windbreak of straw bales is vital. Straw bedding should be provided to help insulate the cow from the ground. A recumbent cow does not require a warm environment; however, in a cold environment, an inactive animal can gradually succumb to hypothermia.

The downer cows most difficult to treat are those that do not try to eat. A cow that salivates on its feed will not eat it later. Rather than being offered large amounts of feed, the cow should be tempted with sweet hay. This should be cleared away every 30 min if not accepted. Placing bitter-tasting weeds such as ivy or dandelion in the mouth may provoke salivation and an interest in eating. Lettuce and cabbage leaves are accepted by some cows. In extreme cases, the cow can be drenched with rumen contents. Sometimes drenching with a thin gruel to which powdered ginger and/or gentian has been added can be helpful.
Homeopathic treatment-
Homeopathic medicines comprising of Rhus tox, Bryonia, Pulsatilla and Guaiacum are given, dispensed in drinking water for 7 days. Cows responded to treatment within 72 hours with significant reduction in hind quarter weakness. Maintenance doses were given to the animals for another 21 days.

Compiled  & Shared by- Team, LITD (Livestock Institute of Training & Development)

Image-Courtesy-Google

Reference-On Request.

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