Saving the worst of the worst – what such cases taught me (Proceedings)

To review several cases that were "the worst of the worst" concerning their level of injury or illness. Without aggressive care they all were predicted to have died. Six of the 20 patients suffered at least one episode of cardiac ARREST. Age range was from newborn to 13 years. All were discharged with good neurological function and a good quality of life.

Case No.1: A 4 year old Male Australian Cattle Dog

Was running rapidly through a field of long grass and impaired himself on a 16" section of iron reinforcement rod. The owner pulled him off the rod, stating as he arrived with the dog, that the rod was buried in the dog at least a good foot. The dog was semiconscious, very pale and breathing rapidly and shallowly on arrival. The injury had taken place approximately 10-15 minutes prior.

Carried in Barely Breathing

The dog being carried by the owner were escorted to the ready area. Blow-by oxygen was started and followed by bag mask valve ventilation and a 16 g 2 in IV catheter was established by mini-cut down. Plasmalyte was started at a rapid rate. There was no palpable pulse and no venous distension. Examination also revealed a 2-3 cm hole in the thoracic inlet and no exit hole. With complete loss of consciousness BVM ventilation was switched to en ET tube that was placed with the dog in supine position.

Immediate Surgery

The dog was taken immediately to surgery, laid on the surgery table as hypertonic saline and hetastarch was administered. A rapid parasternotomy was performed with a Mayo scissors after a layer of TechniCare prep solution was applied. A right cranial and caudal lung lobe were found perforated and leaking air and blood. A cross "clamps" of red rubber tubes circling around the lobe bases were applied to these lobes to stop the leaks temporarily. The pericardium was torn but the heart was not punctured, only bruised. It was beating slowly and weakly.

Autotransfusion

The blood in the pleural space was estimated to be 250 ml. It was aspirated via surgical suction and the canister's contents poured into the Plasmalyte fluid bag with its corner cut off to allow the blood to be poured into that bag. The diaphragm was opened as the abdomen was opened on the ventral midline. The abdomen was filled with blood. The blood was poured out of the dog and caught in a large sterile dog food bowel (estimated to be 250- 400 ml). This blood was poured into the same Plasmalyte bag after a 170 micron blood filter line was switched from a regular fluid line. The contents of the Plasmalyte bag was then rapidly transfused into the dog as blood noted to be oozing from the right liver lobe.

Liver Lobe Pack

A pack was placed over this area and pressure applied. Torn mesentery was then noted and vessels torn were cross-clamped with hemostats. Two sections of intestine had a poor color and intestinal contents was oozing out slightly from one of these sites. These sites were covered with lap pads and the exploration continued. The pancreas was found torn away from the duodenum and was oozing blood. It was also wrapped in a lap pad.

Diaphragmatic Vein-Vena Cava

A large diaphragmatic vein was found also oozing and was cross clamped. The vena cava at this area was noted to be torn slightly but fortunately the site was not bleeding much at the time. The patient's Doppler flow and pressure were poor. The left inguinal region was bruised and a small hematoma was present on inner its surface. This area was packed with lap pads and pressure applied. Pressure was then being applied to both the right liver and left inguinal regions. This continued for approximately 5-10 minutes while the blood/fluid mixture was being administered rapidly until Doppler flow could be heard, although it was poor.

Doppler Flows Used For Monitoring

With Doppler flows and pressures beginning to improve one dose of hydromorphone (0.03 mg/kg) was administered IV with a very small amount of acepromazine (0.001 mg/kg). Cephazolin (40 mg/kg) and enrofloxacin (10 mg/kg) was then administered IV and a small amount of isoflurane dialed in. Throughout this whole resuscitative time a Hallowell 2000 ventilator was being used to provide positive pressure ventilation.

Millers Knot Partial Lobectomies

The two lung lobes were partially resected using the Miller's knot ligation technique. A chest tube was placed through the right 7th intercostals space by a gentle hemostat dissection technique as opposed to a more risk associate rapid stylet- puncture technique. The vena cava tear was suture –buttressed. The liver lobe that was tore was removed by the Miller's knot ligation technique as well.

Intestinal Resections

The two intestinal sections continued to have poor color so all of both of these sections of small intestine were removed. This involved the mesenteric vessels that had been bleeding prior. These were ligated.

Torn Pancreas Ligation and Wraping – J Tube Placement

The torn pancreas was irrigated and under magnification the vessel-duct areas were ligated. The duodenum where the pancreas was torn was irrigated and wrapped with omentum. Because of the pancreatic injury a jejunostomy tube was placed in the proximal jejunum for feeding.

Diaphragm Closed After Chest Tube Placed

The Diaphragm Was Closed Following The Placement Of A 12 Fr Chest Tube.

Abdominal – Partial Closure Only – Suction Drain Placed

The abdominal and thoracic cavities were extensively irrigated and because of contamination of intestinal content and generalized intestinal swelling the abdomen was only partially closed and a sterile dressing applied with attention made to intra-abdominal pressure via an indwelling urinary catheter. An indwelling suction catheter was also

Post Operative ICU Support

The dog was continued on positive pressure ventilation with a "lung protective strategy" for another 8 hours while further supportive care and monitoring was instituted: these included the following:

1. Placement of a nasogastric tube for decompression and administration of sucralfate.

2. Placement of a right jugular vein catheter and CVP and lab assessments (vpO2, etc.).

3. Beginning of Microenteral nutrition initially after surgery with Clinicare, glutamine.

4. The addition of PEEP (5 cmH20) and periodic coupage and postural drainage.

5. Continuous aspiratation on the chest tube with recording of amounts of fluid and air.

6. Continuous rate infusion of hydromorphone, ketamine, and lidocaine as required for pain.

7. Placement of a 50 mcg/ hr Fentanyl patch for pain control (debated about placement of epidural catheter but this was ruled out when coagulation parameters were prolonged.

8. Continued support with CRIs of hetastarch, Procalamine, b-complex w/ Plasmalyte

9. Periodic administrations of cephalexin, enrofloxacin, N-acetyl cystine, heparin

10. Placement of an arterial catheter in the right cranial tibial artery.

11. After the dog was weaned off the ventilator the dog was placed on nasopharyngeal oxygen for a few hours and finding that oxygenation continued to remain stable the dog was placed in the hyperbaric chamber with chest tube attached to a Heimlich valve and all IVs capped and heparin locked. He received two HBOTx of 60 minutes each at 1.8 ATA and with 100 % oxygen used. It was noted that his comfort level seemed to improve dramatically after these two treatments.

Back to the or Day 3 Post Injury

The dog was taken back to the operating room on the third postoperative day and the abdomen re-inspected carefully, irrigated, cultured and then closed with simple-continuous 0 polypropylene and the skin stapled. The jejunostomy tube was used for enteral feeding for 5 days.

Discharge

The dog made a gradual recovery and was discharged from the hospital 5 days after the injury occurred. The surgery had taken 5 hours to complete and was started within approximately 10 minutes of arrival. The all major hemorrhage and air leaks had been stopped within 10 minutes after the beginning of the surgery. He had received a total of approximately 1 blood volume of his own blood administered by a crude and not-the-ideal means of autotransfusion and some of the blood given was contaminated with intestinal contents. It should be pointed out that the owner had numerous visits with the dog during his ICU stay and was very appreciative that we were able to save his dog. He left town with the dog, still owning approximately $2,500 on a $8-9,000 bill. He was supposed to provide cement work to pay off the debit he owed.

Case No. 2: A 3 year old MN Boxer

History of being stuck by a car the previous day and was taken to a local emergency clinic. There the boxer was examined and found to have the following problems: open skull fracture, open fractured humerus, in shock, pulmonary contusions, and a mild pneumothorax. The dog received lactated Ringer's for shock, had the chest tapped, was placed in an oxygen cage, and given cephazolin and buprenorphine for pain. He remained at that clinic through the night and transported to us for further care the next morning.

Arrival and Initial Care

On arrival at the specialty facility he was found to be semiconscious, with effortless breathing that was slightly rapid (32 bpm), heart rate of 160, CRT >5 seconds, membranes pale, with low arterial flow and pressure by Doppler (~60 mmHg systolic, but diastolic could not be determined). Hct was 28 and TP was 5.3 before the dog had left the emergency clinic. Initially it had been 43 and 6.6 respectively. The abdomen was moderately distended. History revealed that the dog had received approximately 8 liters of LRS. Immediately a towel wrap was applied to abdomen a quick look ultrasound revealed free fluid. A second IV catheter was placed (14 g, 2 inch) in the cephalic vein using a facilitative maneuver above the one that had been placed by emergency clinic (18g) and an entry peripheral venous pressure was determined to be 0 cmH20 as no flow returned through the attached T-port on its own. Upon lowering the limb some blood was able to be aspirated for analysis: Hct was now 18% and TP 3.5, lactate was 8, and vPO2 was 28. Blow by oxygen was begun.

Colloid and Crystalloid Fluid Support

With a Doppler applied to the palmar arterial arch and monitoring flows and pressures hypertonic saline (7.5%) solution was begun to be delivered. Approximately 200 ml and 125 ml Oxyglobin was given to increase systemic pressures and help normalize flows (goal ~ Doppler flow stronger, JVD present, JVDT 5 sec., 1-2 cm peripheral venous pressure, and systolic arterial pressure of 70-80 mmHg) and a hunt for occult hemorrhage was made to confirm that most had been associated with abdominal and that associated with the humeral fracture and skull fracture that was associated with the left frontal sinus.

Rapid Work-Up

Lateral "trauma films" beginning at the tip of the nose and involved a lateral cervical, thoracic, abdominal and pelvic films were taken. He was carefully moved to get a DV thoracic and abdominal radiograph. Ultrasound examination of the thorax was then completed. Only "interstitial syndrome and some pulmonary contusions were observed and no evidence of a diaphragmatic injury or pneumothorax was observed. DPL was done to see whether the Hct of the lavage fluid was increasing. It was. Unfortunately the Hct in the DPL fluid effluent increased from 7 to 12 % over a 20 minute period. An 8 Fr red rubber feeding tube was inserted into the right jugular vein for more venous access.

Exploratory Surgery

Exploratory celiotomy surgery was then performed for continued abdominal hemorrhage. Approximately 3 L of bloody fluid was removed from the abdomen. This blood was autotransfused in a similar fashion to case number 1. The liver was found still hemorrhaging small amounts as well as the cranial pole of the right kidney. The liver was packed off and with continued bleeding the right lateral lobe was oversewed where the bleeding was coming from. A section of omentum was digitally manipulated and placed into the injured area just prior to the over-sewing. This contributed to the stoppage of the hemorrhage. The hemorrhage of the kidney responded to over-sewing and omental placing as well. As soon as the bleeding was stopped isoflurane was decreased and systemic arterial pressure allowed to return to 90-100 mmHg.

Goal Directed Therapy Continued as Surgery (12 Hrs) was Performed

Doppler flows were considered adequate prior but improved further once hemorrhage was controlled and the autotransfusioin of the 3 L of blood/fluid from the abdomen was completed. Mesenteric tearing was also present and some bleeding began that was managed with ligatures. Color of the involved bowel remained poor and a small area of leakage from the lumen note. This necessitated the removal of approx 12 inches of necrotic small intestine using a open technique (GIA, TA 55) and following thorough irrigation the abdomen was closed with simple continuous No. 1 polypropylene. A nasogastric tube, nasoenteral tube were both placed before the closure was started. A urinary catheter was inserted and attached to a closed system.

Orthopedic Internal Fixation of Fx Humerus

Following the abdominal surgery the open fracture was then repaired under the same general anesthesia (isoflurane, and a CRI of ketamine, morphine and lidocaine using a regional block of lidocaine, bupivacaine, and sodium, bicarbonate) and while throughout the surgery a Hallowell SA 2000 ventilator was used (volume cycled, pressure limited) and with the use of supplemental pancuronium bromide. The humeral fracture was comminuted and required a 12 hole broad 4.5 mm DCP plate with intrafragmentary 2.7 and 3.5 mm lag screws. A cancellous bone graft was used. The fracture site was extensively irrigated prior to that and a JP suction drain inserted. A brachial plexus regional block was repeated. Open fracture in the skull war regionally block after prepping and head elevated and placed in a support frame with the dog in sternal position. The open frontal fracture was exposed, debrided and irrigated. Since pupils were symmetrical and responsive and exposure of the frontal calivarium revealed no fractures or cracks no cranietectomy was considered necessary (If these were present a craniectomy would have been done). A small JP was then added and the area closed. Throughout the surgery cephazolin had been given Q 3 and enrofloxacin repeated once. Total surgical time had been 12 hours and anesthesia time 14 hours. Periodic blood analysis had been done (Hct, venous blood gases, glucose, TP, lactate) Lactate levels initially were 11 and at the conclusion of the surgery were 3.

Postoperative Care

Postoperatively the dog remained on a CRT of MLK and on the ventilator. Temperature was 88 degrees (core-esophageal) and peripheral temperature was 74. Over the course of the next 6 hours the dogs temperature was gently increased by bother core and surface rewarming. ETCO2s increased from 22 to 35 and core temperatures rose from 88 to 98 with peripheral temperature rising as well from 74 to 90 (delta T rising from 14 to 8 degrees F). An esophago-gastric (EG) tube was placed as well as nasal-pharyngeal oxygen catheter in the nasal passage on the uninjured side from the frontal fracture. Aspiration was done of the EG tube and trickle feeding stated at 20 ml per hour of 25% dextrose and 5 % glutamine in Plasmalyte. Pain was continued to be controlled with a CRI of MLK and a 100 mcg fentanyl patch was added. 4 units of FFP were given and he was placed on a CRI of hetastarch, Plasmalyte, and Procalamine with B complex added. Physical therapy (passive range of motion, massage) and respiratory therapy (active CPAP for 20 minutes) was done Q 4 hours and continued for the next 48 hours. The patient was weaned off the ventilator after approximately a total of 22 hours. He regained consciousness and began eating solid food the following day. The EG tube was used to supplement with glutamine and provide oral medications (cephalexin, enrofloxacin, tramadol)

Discharge

He was discharged on the 5th postoperative day, able to walk, and tube free. The dog made a good recovery and was seen periodically for follow-up of his orthopedic injuries. The fractured humerus and frontal bone area healed well and he continued to do well at last follow-up 18 months later.

Case No. 3: A 4 year old FS Boston Terrier

The owner stopped hearing her bark in the backyard; This was very unusual. She recognized very significant difficulties with breathing. Brought the dog rapidly to the hospital.

Arrival

As the patient arrived an intern took the dog to radiology for an immediate radiograph of the thoracic cavity. As the lateral radiograph was taken the dog stopped breathing. No pulses could be felt. The intern then brought the unconscious and cyanotic dog to the anesthetic – prep room area.

CPR Began

Following an attempt at BVM with a few breaths the larynx was visualized using a laryngoscope and the trachea intubated with a 6 mm ET tube. Ventilations were given but no lung sounds could be heard on auscultation with the ventilations. No gastric sounds either. The oxygen from the rebreathing bag went into the patient easily. The diagnosis of a ruptured trachea was made by deduction and and an immediate approach to the trachea was made. No prepping of the hair or skin was done. The cervical trachea was found to be fine so a mayo scissors was used to extend the incision parasternal through the costosternal junction. The mediastinum was found billowed full of air and it was opened to find the trachea pulled apart and the end of the previously placed tracheostomy tube was found exposed through the torn end of the trachea. Another endotracheal tube was through the lung-side exposed tracheal lumen and ventilations with 100 % oxygen was started and the lungs could be seen inflating. The heart was not perceptibly beating but after a few compressions it began beating strong enough to be felt. The beating continued to become stronger. As the beating of his heart continued he began moving some on so isoflurane was added and morphine was titrated in IV with a completed dose of 0.2 mg/kg gradually given. The owner was told of the finding and the dog's arrest and immediate resuscitation results and was asked what she would want us to do with no guarantees the dog would be fine even if we were able to repair the tracheal tearing. She wanted us to continue so this was accomplished. An iv catheter was placed, and Cephazolin was begun intravenously as well as lactated Ringer's solution. The trachea was able to be repaired after a torn section of 4 rings needed to be removed. Simple interrupted 3-0 polypropylene sutures were used to join the two ends of the trachea together. The parasternotomy was closed with figure of eight #1 polypropylene and continuous 2-0 polypropylene with a chest tube inserted to drain off fluids and air was needed. A nasopharyngeal oxygen catheter was placed and supplemental oxygen used for secondary but dissipating pulmonary edema that had occurred following the arrest. The treatment was successful and following a 2 day stay in the ICU he was allowed to be discharged. He made an uneventful recovery.

Case No. 4 A 5 month old F English Bulldog

The owner heard her little puppy struggling to breath. This came on very suddenly. The dog had uncontrolled urinations and defecation and the breathing difficulty worsened. She transported the dog as rapidly as possible to the hospital.

Arrival

As the patient arrived support jet blow oxygen was given. Ventilations were started with a mask and AMBU bag attached to oxygen and reservoir as an IM injection of 100 mg ketamine, 3 mg butorphanol and ¼ mg acepromazine. An IV catheter was placed with a facilitative maneuver and a small amount of ketamine was given to secure enough relaxation to allow intubation. As suction of the pharynx was done blow by oxygen was continued. The trachea was intubated and the ET tube immediately filled with saliva, thick mucus, foam. Ventilation through the tube was not possible. The tube was removed and another tube was placed. It too filled up with mucus and foam. Suctioning the tube was not effective. It too was then removed and a third tube was placed. After the tube was placed ventilation was able to be performed but a significant amount of fluid was still heard in the lungs. Radiographs of the thorax revealed a pulmonary edema and a suspicious esophageal foreign body Isoflurane was used to keep the patient anesthetized. Based on the dogs airway status (some edema and an already elongated soft palate) a tracheotomy was completed and suctioning was now able to be done more effectively. A stomach tube was attempted to be passed. It could not be passed by the FB. The FB was pushed into the stomach with some pressure. With continued respiratory support with an anesthetic ventilator the dog was taken to surgery and a gastrotomy and removal of a 2" round firm section of raw-hide was completed. The dog remained on the ventilator while a radiographic series of the chest was completed. An arterial blood gas was performed when on 100% and p02 220; A nasopharyngeal catheter was pre-placed. The dog was placed on room air and this allowed his oxygen saturation to only come to 90%. Support ventilation was further suctioning was continued. Approx 2 hours following the surgery a gradual weaning was able to be performed and recovery continued with only supportive supplemental oxygen needed via the tracheostomy tube. The tube was able to be removed the following day and he puppy made a full recovery.

Brief Synopsis of 16 Further Cases

All these cases made a complete recovery following resuscitation: Case #

5. Sara FS Golden Retriever – HBC – sustaining head injury, open frontal fractures, significant nasal/frontal hemorrhage, rupture of the left eye, pulmonary contusion, cardiac contusion. Underwent resuscitation, tracheotomy, frontal sinus and nasal surgery, removal of ruptured eye, head injury protocol, support ventilation and recovered completely.

6. Timber – 2 yo German Sheppard Dog - Run over in the caudal thoracic region by a 3/4 pickup truck, sustaining hemopneumothorax, hemoabdomen, shock, secondary vena cava obstruction caudally. Underwent resuscitation, chest tube placement, autotransfusion, DPL, exploratory celiotomy, liver packing and hemostatic agent application, continued autotransfusion, noninvasive support ventilation after extubation, CPAP with NP oxygen, enteral nutrition, and he made a complete recovery after an episode of severe ascities with the drainage of 3 L of fluid.

7. Whisky – 2 yo MN Jack Russell Terrier – HBSUV - sustaining a L2-L3 fracture, paralysis, no-deep pain sensation, severe abdominal road rash; he underwent workup, emergency myelography, hemilaminectomy, double vertebral plating and hyperbaric oxygen therapy; he then sustained a late onset diaphragmatic hernia (occurring 9 days post injury), a subsequent cardiac arrest while trying to stabilize in ICU, emergency thoracotomy and open chest CPR, laparotomy and diaphragmatic hernia repair, and further resuscitation and hyperbaric oxygen therapy. He made a full recovery, both neurologically and respiratory wise after even a third episode of diaphragmatic failure that required further muscle plasty.

8. Dalmatian – Choked on a super-ball – became fully obstructed - sustained a cardiac arrest in ca. Arrived at police station as owner could not make it to the vet hospital. John Fusco, an officer that took the canine officer emergency medical care course for the working canine the week before, removed the ball from the airway and provided CPR and rescue breathing. The dog made a full recovery with good neurologic function..

9. No-name - 2 mo old M Jack Russell – stepped on by a horse – sustaining severe pulmonary injury, shock, suspected hemoabdomen, liver injury. The dog was intubated and ventilated and placed on a mechanical ventilator. Resuscitation continued with fluid and Oxyglobin support. A blood transfusion was also given and the dog was maintained on a BIRD anesthetic ventilator for 36 hours and gradually weaned off and onto nasopharyngeal oxygen. He made a complete recovery after another day of hospitalization, discharge and continued care by the RDVM.

10. Annie – 1 year old FS Caviler King Charles Spaniel with acute respiratory difficulty following an elective tracheotomy post bilateral partial arytenoid resection for end stage laryngeal collapse. Ventilation was performed using an AMBU attached to the tracheotomy tube. Only when strong PPV was provided was adequate lung sounds and filling; it became more difficult to ventilate; radiographs confirmed a tension pneumomediastinum and pneumothorax. A chest tube was placed immediately and the aspiration of several hundred ml of air was accomplished. She recovered after spending 2 nights in the emergency clinic and then follow-up with primary care veterinarian. The dog has continued to do well with a 6 month follow-up regarding the airway.

11. Pia – 8 mo old FS Mexican Camp Dog – cardiac arrest following rollover movement in radiology post bilateral TPO 2 months prior. The dog was under anesthesia with isoflurane at the time. CPR was initiated with closed chest compressions but after 3 minutes there was no response and Doppler flow faded as compressions were continued. Open chest CPR was performed for 23 minutes and after several epinephrine and atropine doses and 4 defibrillation attempts conversion to a NSR with pulses occurred. The chest was closed in radiology. She was kept on a ventilator 2 hours post resuscitation and then recovered. Two hyperbaric oxygen treatments resolved the cerebral palsy like signs the dog was showing on recovery. She continued to well.

12. Jeff – 42 year old man that vomited and seizured then had a cardiac arrest as we were asking him questions. He had complained of chest pain and dizziness prior to the onset of the seizure. Nasal oxygen had been placed prior to his seizure. After 26 minutes of CPR, 3 defibrillator discharges, epinephrine and atropine doses, and fluids he converted to a SVT that was then cardioverted to a NSR. He made a full neurological recovery after being on a ventilator in the ICU for 5 days.

13. Louie – 10 year old MN Mixed Breed dog that been hit by a car and had sustained pulmonary and cardiac contusions, blunt renal trauma with severe hematuria, right coxofemoral luxation, severe open injury to the left hock with shearing and de-gloving. Following resuscitation the dog was taken to the OR then next day and his CF joint surgically reduced and stabilized. Then the degloving and shearing injury was irrigated , debrided, and stabilized with screws, wire and an external fixator. Postop swelling necessitated the use of leaches and hyperbaric oxygen. Grafting was completed and the leg was functional after the external fixator was removed

14. Baby - newborn F Poodle puppy – last one of 5 delivered by Caesarian section, not breathing and no heart beat detected. CPR was initiated, with rescue breathing initially done with a make shift mask and a neonatal AMBU bag. Doppler determined that arterial flow had resumed. The trachea was intubated with a 8 Fr. red rubber feeding tube and ventilation performed with an AMBU and then with an anesthetic ventilator. A bleed off system was fashioned to prevent over inflation of the lungs of the 300 G patient. Ventilation continued for approximately 3 hours and then fairly suddenly the puppy began ventilating and shortly thereafter she was extubated. The pup made a good recovery.

15. Gretchen – 5 year old German Short Hair Pointer with severe Clostridial pneumonia that was failing ventilator therapy on 100% oxygen and PEEP at 15 cm H2O. Radiographs revealed consolidated lungs on both the right and left but were limited to the caudal and middle right and the cranial left. A bilateral thoracotomy was completed and these lobes were removed. PO2 climbed from 60 to 220 and then to 400 corresponding to the removal of these ineffective lung lobes. Chest tubes were placed and recovery consisted of 3 hyperbaric dives. She made a complete recovery.

16. Felix – 4 year old MN Orange Tabby cat with aortic thromboembolism in which no deep pain sensation had been present over 36 hours with the rear limbs very cold and paralyzed. Heparin was given And then a workup was completed including an echocardiogram. No cardiac abnormalities were noted but color flow Doppler confirmed the ATE. Surgery was done with the removal of the thrombus from the aortic bifurcation. Following surgery the cat underwent two hyperbaric oxygen dives. Post operatively the following day the cat ran out of the cage. 4 month later the cat represented with repeated neurological signs suggestive of re-occurrence of the ATE. The cat was then euthanized due to high risk chance of recovery.

17. Lucky - 4 year old Doberman that had a kinked vena cava following trauma six months prior and now had severe ascities. During surgery to remove the kinked section of cava using an inserted conduit the cava tore badly resulting in massive hemorrhage and cardiac arrest. During continued efforts to completed the removal of the kinked section of vena cava and re-establish its blood flow a total of four cardiac arrests occurred. Autotransfusion was performed (approx 4 liter). He made a complete recovery after 4 plus hours of surgery. Note: all dogs were on a Hallowell SA Anesthesia Ventilator

18. Prince – 5 year old MN German Sheppard that was hit by a car and suffered a significant head injury with complete unconsciousness. He remained unconscious and cared for by outlying clinic. A decompressive craniotomy was completed and he gradually made sufficient enough recovery to become a beloved house companion.

19. Rocky – A 6 year MN Border Collie cross that ran straight into a tree and suffered a compression fracture of T12 and completed loss of function of the rear limbs with no deep pain sensation now being presented past 48 hours post injury. He received an decompressive hemilaminectomy and 4 hyperbaric oxygen treatments and gradually made a complete neurologic recovery.

20. Brandy - 12 year old SF German Sheppard that had sustained a severe gastric dilation-torsion 4 days prior and received emergency care and surgery; rupture of the stomach was discovered by exploratory surgery 2 days postoperatively when the dog became septic and had a very painful abdomen. Exploratory surgery revealed a dark area on the stomach. It was resected and the abdomen extensively irrigated. Two days postoperatively the dog deteriorated further. On admission the dog was dog was septic, febrile, could not stand and had thread pulses. Following resuscitation a partial gastrostomy, extensive irrigation, leaving the abdomen open for drainage and continuing supportive care. She made a complete recovery.

Summary of Important Points

The care of the seriously injured or ill patient is demanding and requires adequate preparation, rapid access to organized resources and equipment, and skilled personnel. Second in urgency only to stabilization of the airway and breathing is shock which requires a multiple of support procedures. In many, surgical intervention to provide improved and continued stability is required. Guidelines for care of the most severely injured are:

1. Be as prepared as possible and have drills and cadaver sessions.

2. Use basic ABCDE priority based case given as "horizontal" as possible.

3. Assist ventilate beginning with a bag-valve mask, using sedation, as needed.

4. Gain airway control early and completely ventilate with a mechanical ventilator.

5. Continue support ventilation throughout all resuscitation phases and use of positive pressure ventilation during anesthesia, including the use of non-invasive ventilation (NIV) in the post-weaning period and intermittently using CPAP in post pulmonary injury cases.

6. Use nasopharyngeal oxygen and oxygen collars but not oxygen cages for O2

7. Use ETCO2, VCO2, SpO2, venous/ arterial blood gases, and ultrasound for monitoring

8. Provide (large bore) venous, arterial, alimentary tract, urinary tract catheters as required.

9. Use Doppler flow and pressures (Doppler) and JVD and JDVT to guide resuscitation.

10. Use flow sounds by Doppler as the most important in guide in resuscitation

11. Remember blood flow is more important than blood pressure due to resistance factor.

12. Use venous lactates and blood gases, PCV, total protein, glucose to guide as well.

13. Use supplemental oxygen first and then provide hypertonic saline, Oxyglobin, whole blood, autotransfused blood, plasma, hetastarch, dextran, gelatin, pentastarch or Plasmalyte, or Normosol R; avoid LRS due to calcium ion and BAX protein effects

14. Use only enough flow and pressure to provide adequate tissue perfusion initially until hemorrhage is under control. This generally is flow that can be heard and BP of 50-70.

15. After hemorrhage is controlled should flows and pressures be brought to normal

16. Use hypothermia to help decrease reperfusion injury and decrease oxygen need initially.

17. Treat pain aggressively using local and regional blocks, epidurals, balanced anesthesia, fentanyl CRIs, fentanyl patches, morphine-lidocaine-ketamine, Photonic therapy, acupressure, cold; Treat anxiety and fear with low doses of chlorpromazine and acepromazine as part of the patients pain management. Provide quiet times for sleep.

18. Begin microenteral nutrition with glutamine, glucose and electrolytes early post injury.

19. Use enteral nutrition supplemented by partial parenteral nutrition over TPN post injury.

20. Provide stabilization surgery as early in the course as possible. Surgery may be needed immediately after admission, repairing all injuries under one anesthesia, remembering it is far better to have a longer surgery than a major postoperative complication.

21. Use vascular loops with feeding tubes around structures that are leaking air, blood or enteral contents as immediate measures to stop these leaks; repairing later in the procedure.

22. Use auto-stapling devices, vascular clips, electosurgery, headlight, magnification, polypropylene, continuous closures, stick ties, and suction drains.

23. Use hyperbaric oxygen as an important adjunct for increasing tissue oxygen levels and decreasing tissue edema. 1-1 ½ hour treatments of 40-100% O2 at 5-15 PSI should be used.

24. Use other adjunctive measures as needed: b-complex vitamin infusions, broad spectrum antibiotics, gi protectants, N-actetylcystine, saline enemas, newspaper splints, pentoxifylline.

25. Keep communications with owners/ RDVMs up to date and encourage visits, document.

26. Don't be afraid to do autotransfusion, even if the blood is contaminated.

27. Provide updates to owner; having good communications and record all as best as possible

28. Do not be afraid to try something new on cases that are looking like they are going to die.

29. Use drugs that have indications for the disease process based on good scientific literature.

30. Do not give up as some cases will really fool you, and support the owner(s) throughout.

References

Crowe, DT: Assessment and management of the severely polytraumatized small animal patient. J Vet Emerg Crit Care 16(4) 2006: 264-275.

Rogatsky, GG, Kamenir Y, Mayevsky A: Effects of hyperbaric oxygenation on intracranial pressure elevation rate in rats during the early phase of severe traumatic brain injury. Brain Res 1047; 2005:131-136.

K, Sunami, Y Takeda M, Hashimoto M , et al: Hyperbaric oxygen reduces infact folume in rats be increasing oxygen supply to the ischemic periphery. Crit Care Med 28; 2000 : 2831-2836

McNeil JD, Smith DL, Jenkins DH, et al. Hypotensive resuscitation using a polymerized bovine hemoglobin-based oxygen carrying solution (HBOC-201) leads to reversal of anaerobic metabolism.

J Trauma 2001; 50(6):1063–1075.

A Hjelde, M Hjelstuen, Haraldseth O, et al: Hyperbaric oxygen and neutrophil accumulation/tissue damage during permanent focal cerebral ischarmia in rats. Eur J Appl Physiol 86; 2002 : 401-405.

Dubick MA, Atkins JL. Small-volume fluid resuscitation for the far-forward combat environment: current concepts. J Trauma 2003;54(Suppl. 5):S43–S45.

Bruttig SP, O'Benar JD, Wade CE, et al. Benefit of slow infusion of hypertonic saline/dextran in swine with uncontrolled aortotomy hemorrhage. Shock 2005; 24(1):92–96.

Product Information

Care-Tech Laboratories, O-T-C Pharmaceuticals, Saint Louis, MO 63139

1-800-325-9681 Makers of Techni-Care Surgical Scrub – A Broad Spectrum Topical Antiseptic Microbicide for Degerming 99.99% Bacterial Reduction in 30 seconds of contact. Approved for use in open wounds and on mucus membranes. Clinical Care, a Dermal Wound Cleaner preferred over saline or LRS for irrigation of wounds. Humatrix Microclysmic Gel for Treatment of Tissue Trauma. Berri-Care - a barrier for IV and ostomy sites. I recommend Techni-Care in emergency and surgical preps. Is also a great prep ultrasound gel for biopsies and acts as a good electrode paste like material for ECG electrodes.