All right. Trauma. I love trauma. I love treating trauma. It's one of my favorite things. This beautiful little Pomeranian had severe bite wounds. Shame. Total, total sad thing. Another was in a boarding facility. A big dog jumped over the enclosure and went after this poor little patient. And as you can see, this left hind leg is a hot mess. There's an I.V. catheter back here. Poor guy has his cone on because despite being very sick, he really wanted to remove all of his tubes. And this pet, ultimately that leg became septic and we had to do an amputation. But look at how happy he is out there. He was, he was kicking butt, taking names. And that kiddo ended up going home. 

All right. We're going to start with Harry. Harry is a two year old male, in tact, lab cross. Broke through the fence after eating dinner and escaped. The owners did find him 3 hours later, fortunately. He didn't want to walk. He had some blood on him. He didn't look good, so they brought him on in. This is Harry. He, by this point, you know, he was starting to exhibit some remorse. He realized that his choices were pretty poor ones. On presentation, he was a bit shocky. So he was chilly at 98.3 degrees. He was tachycardic at 190 beats per minute. His respiratory rate was high, 70 breaths per minute. He short of breath, he had crackles that were louder on the right than the left. His mucous membranes were pale. He could stand, but he had a non weight bearing lameness of the right pelvic limb with significant swelling of the proximal aspect of the limb. 

All right. Trauma patients. Any breed, age, sex, intact males like Harry are overrepresented. They're out there. They're doing their thing. Their hormones are raging. They are they're roaming. They're on the lookout. They're doing dog stuff. And so they are highly motivated to get out of that fence and run around the neighborhood, explore and explain exactly who they are to everyone else in the hood. They're often in shock. They could have tachycardia, poor pulses, abnormal looking mucous membranes. They can be pale, cyanotic, injected, muddy, but they're not going to have normal, nice pink, beautiful, moist mucous membranes. They can have pain, respiratory distress, altered mental status, wounds. And the way that I think about these patients is that I go through this mnemonic of a crash plan: airway, circulation, respiration, abdomen, spine, head, pelvis, limbs, arteries, nerves. And this kind of takes me through the things that I have to worry about most to least. This little patient over here had severe bite wounds to his chest, abdomen and limbs. On lots of different drips. On fluids, has a drain here. This patient actually also went home. So these patients can really look really rough when they come in, but you can get them better. We'll talk about prognosis a little bit later as we move on. 

So, again, these patients, they've come in the door. Airway. Is their crush injury to the airway? Sometimes these little dogs get grabbed by the neck. Is there a tracheal tear or tracheal avulsion? What's happening in the upper airway? Circulation. I'm thinking about shock, arrhythmias. Could these patients have myocardial contusions which were recognizing more and more. The heart is a muscle, it can get bruised like anything else, and then they can develop arrhythmias. Those are your myocardial contusion patients. Respiration. Do they have a sucking or penetrating chest wound because of bite wounds or or a stabbing injury? Do they have a pleural space injury like a pneumothorax, a hemothorax? Do they have fractured ribs, a flail chest, pulmonary contusions or diaphragmatic hernia? Abdomen. I'm thinking about hemorrhage. Could they have a splenic fracture or a hepatic fracture causing hemorrhage into the belly? Uroabdomen. Did their bladder rupture? Did their kidney avulse? Septic abdomen. If these are bite wound patients and they have bite wounds to the abdominal cavity, you have to worry about the integrity of the GI tract. And is there leakage of intestinal contents? Are there penetrating wounds, body wall hernias. That can happen in the abdomen. The spine. You're looking for fractures or a traumatic disk extrusion or signs of that. Head. Could the patient have traumatic brain injury, an ocular injury, or a jaw injury? Pelvis. I'm thinking about fractures and if there's pelvic fractures present, I'm kind of worried about a bladder rupture as well. Limbs. I'm looking for fractures, luxations, wounds, avulsions. Look at this. Oh, this is a terrible, terrible wound and avulsion. But also, look, this pet is clearly in shock. This is someone that is placing an ECG to this patient. So we're all staring at this. And this smart person said, I'm going to think about the rest of these things first before I start worried about this big dramatic wound. Arteries. Could these patients have hemorrhage? It's kind of amazing how much they can bleed when they cut one of their carpal arteries, perhaps on glass or a bit of wire or a fence. And those patients need to have those bandaged and then taken care of. Nerves. Do they have paresis, palegia, pain. There is avulsion of the nerves that this distal limb, this little bit of the limb is not feeling anything. But I expect that all of this part of the limb certainly is. 

So where does trauma come from? Most of the patients that have blunt force trauma, so they get smacked with something, motor vehicle accidents is a cause in over 90% in some studies that we've done. Falls from a height. We see that, too. Penetrating trauma bite wounds are most common and then projectile wounds from gunshots, arrows, knives. This is a radiograph of a patient that severe bite wounds to the to the chest. This is just a big hole in the chest right here. And you can see all of this dark substance here. This is air underneath the skin where the skin got ripped away from this major wounding. 

The initial treatment for these patients. We're going to place an I.V. catheter right away. We're going to start to manage shock with some I.V. fluids, maybe some hypertonic saline. Oxygen if they are in respiratory distress or if they have traumatic brain injury oxygen is quite helpful, but make sure you're not placing nasal lines if traumatic brain injury is president, present. Reason is nasal lines can make you sneeze, sneezing increases your brain pressure. We don't want that. I'm going to give them some analgesia after a really quick neuro assessment. I just want to make sure they can move all of their limbs, that their mentation is okay and their cranial nerves are intact. If that's present, then I can go ahead and give some analgesia. So I'm not getting this patient up and necessarily testing, you know, their placement or their hop or things like that. I'm really just making sure they can move their legs they're, they know who the president is, so to speak, so their mentation is okay and that their cranial nerves are intact. I'm going to be reaching for opioids, and if you're in a practice with ketamine, you can give a dose of ketamine as well, like one or a half mg per kg IV once. If you're lucky enough to have syringe pumps, you can set all these things up on CRIs, and that's kind of cool. But for the moment when they come in, I do want to give them an opioid. And if they're really in pain, a single dose of ketamine. Avoid NSAIDs in these patients. Shocky patients do not have reliable perfusion to their kidneys, and they don't have reliable perfusion to their gut. The kidneys and the gut need prostaglandins to maintain normal blood flow. Guess what NSAIDs do? They block the synthesis of prostaglandins. So we don't want that to happen. We don't want to potentiate and worsen kidney injury or gut injury. If they have traumatic brain injury, I'm going to give a hyper osmotic agent, either hypertonic saline or mannitol. Studies have shown, they're about equivalent in reducing brain pressure, and that's going to reduce your cerebral intercranial pressure and cerebral edema. If there's wounds, especially bite wounds, start some antimicrobials. I might be starting with a cephalosporin or with a nice cillin, like unison. 

Diagnostics. I'm going to get an ECG on these kiddos. Ventricular arrhythmias are most common. Ventricles, big, meaty part of the heart, a lot muscle. That's where the bruises tend to happen most. So bruising to the ventricle can potentiate ventricular arrhythmias. The other things that are going to make your ventricular arrhythmias or any arrhythmias worse are things like hypoperfusion, hypoxemia. Blood pressure. They could be hypotensive or normotensive they're not usually hypertensive, but I am going to recheck this a number of times. Blood work wise, I'm going to at least get a PCV solids lactate at a minimum. If the total solids is low, and by that I mean less than 0.6 before you started fluids, think about hemorrhage. Reason being, remember that the spleen in dogs is made out of lots of contractile fibers. When a patient that's a dog gets hit by a car, that spleen is going to contract, release a lot of red blood cells to try to compensate for what's going on. So the red cell count might look normal, but the body can't make albumin nearly as fast as the spleen can squeeze out red cells. So those total solids are going to drop and drop first. I'm going to recheck the PCV total solids and lactate pretty often in these patients. I'll do blood gas, Chem, CBC, PT/PTT. I'm certainly putting the probe on these patients. I'm looking at the chest. I'm looking at the belly. If there's fluid in the belly, I'm going to sample it. I don't necessarily need to drain it all out, but I am going to get a sample. If there's fluids in the chest, I'm going to either get a sample or I might drain it to relieve any dyspnea. And then we're going to do radiographs of the chest and any areas with concern for fracture. This patient had a had been shot in the chest. So this is a a bullet and those are bullet fragments. And then this yellow line is encircling the areas of lung lobe retraction, which tell me that pleural effusion is present. This patient ended up having a hemothorax. 

All right, back to Harry. So what did we do? For shock, we gave him some I.V. fluids. I chose lactated ringers because it was what I had on the shelf. For analgesia, a nice dose of hydromorphone. For nausea, he got some Cerenia. I gave him some Cerenia for two reasons. One, the shock organ of the dog is the gut. A lot of patients with trauma or shock might be nauseated, so I'm going to give him some Cerenia. And then the other thing that's a little bit hard about opioids is that they can cause nausea as well. So I don't want this poor patient puking after he's just been hit by a car. He does not need that. What diagnostics? I'm going to do that AFAST. He had some abdominal effusion. We tapped it. Got about six mils of blood out of it. We did some chest radiographs. He had pulmonary contusions. That's why he was breathing hard and had those crackles. We did pelvic and hind limb radiographs because he wasn't standing appropriately on his leg. He had that swelling of the proximal limb and he had this nasty femoral fracture. He had a CBC, chem, PCV solids and lactate. He had anemia from the hemoperitoneum and he had hyperlactatemia from shock and hypoperfusion. 

What else are we going to do for these trauma patients? I might need to give them some blood products, some packed red cells, some plasma, or some fresh whole blood. If they have evidence of hemorrhage into the belly cavity or into the chest. I'm going to give them aminocaproic acid. Aminocaproic acid is a substance that helps stabilize clots. It's an antifibrinolytic. So remember, fibrinolysis is the part of the clotting cascade that sometimes we forget because we're real focused on the other parts of the clotting cascade, of platelets and the clotting factors, and all that stuff. That's very cool. But remember, once we make a clot, we ultimately have to break it down. That's fibrinolysis. I don't want these clots getting broken down, so I'm going to give some aminocaproic acid if they have hemorrhage. You might hear things like acute traumatic coagulopathy. That's the pathway that we're thinking about when we're worried about these patients breaking their clots down too fast. I give antiarrhythmics if they have arrhythmias. I give vasopressors if shock is ongoing or they're not responding to fluids or blood products. I stabilize fractures and you can stabilize tibial fractures, fibial fractures and radius ulna fractures. You can't stabilize humeral fractures or femoral fractures because in order to stabilize the fracture, need to immobilize the joint above and the joint below. When you have a humeral fracture or femoral fracture, you cannot stabilize the shoulder or the hip joint. So really, I just try to keep those patients still until we have a surgical intervention. And then I like to bandage wounds. This patient was recovering from his thoracotomy after his gunshot trauma. He's still intubated. This is a warming device over here. These are drips that he's getting. And then this is oxygen going into his nasal passages as well. 

Surgery might be indicated with trauma patients. So an exploratory laparotomy should be done when there's bite wounds. Always. If there's bite wounds to the abdomen, you need to get in there. You need to look. You need to see what's going on. Is there compromise to the GI tract? Is there a splenic fracture? You have to go in and fix those things. Uroabdomen in dogs, always, you want to go in. You want to fix that bladder. It's not just going to heal on its own. Cats are a little different of a story. Dogs, on the other hand, you do want to go in and fix that bladder. If you have evidence of sepsis, if you tap that belly, and you get fluid out, you look at it under the microscope. There are bacteria. You absolutely want to get into that belly. Diaphragmatic hernia. You do do surgery for these patients, but maybe not right off the bat. You want to try to stabilize them in some other ways first. Hemorrhage if it's severe or can't be controlled by other means. If a patient has trauma and they just have a hemoabdomen and there's no bacteria present, I usually give those patients blood products, fluids, aminocaproic acid and time. Sometimes, though, that doesn't work and you do need to go in and perhaps you need to do a splenectomy or a liver lobectomy. I tend to send patients to a surgeon for exploratory thoracotomy. So if they have sucking chest wounds, absolutely. You need to get into that chest. You need to see what's going on. Sew it up. Bite wounds, almost always. Hemorrhage, if it's severe or cannot be controlled by other means, but I will tell you that if you are hemorrhaging profusely into your chest and you go to surgery, that's a that's going to be a patient that's going to be a lot harder to stabilize. This patient got attacked by like four other dogs and he had severe wounding wounds, wounds, wounds, more wounds, ECG pads, urinary catheter, more ECG pads. And check out all of this bruising. 

Surgery might also be indicated for bite wounds that don't penetrate body cavities. For those patients, it's going to be a little easier, you flush, explore, bandage, close, place a drain. Fractures. They're going to need to be repaired or stabilized. Prioritize the spine over the limbs. Enucleation might be needed if there's proptosis and the eye doesn't have any function. There's optic nerve dysfunction, tearing of the extraocular muscles, hemorrhage within the globe. This poor Frenchy was in a car accident. His mom had to stop the car short and the little Frenchy went flying forward and bonked his head on the dashboard and proptosed his eye. Jaw fractures might need to be repaired as well. 

The prognosis for trauma is generally good. It depends on severity, but for things that are negative prognostic indicators are things like skull fractures, head trauma. We're coming to the admission the patient is not moving when they walk in the door. They don't walk in the door. They're laying on a gurney. That's a patient that's not going to do as well. Hematochezia. That's a negative prognostic indicator. The development of acute respiratory distress syndrome or ARDS, those patients don't tend to recover well. Disseminated intravascular coagulation. That's where your body starts to clot all of its blood and then bleed out. Those are patients that are not going to do well. Developing pneumonia, needing a ventilator, pressers or having cardiopulmonary arrest, all negative prognostic indicators. This is a patient that had chest tubes placed after he got bit by another dog. This is his oxygen line as well, this is a blood pressure cuff. This patient did quite well. He was a nice little Catahoula. 

All right, back to Harry. So what else are we going to do for Harry? So his hemoperitoneum and we're going to kind of go by body area that's affected, so his hemoperitoneum. He got a packed red cell transfusion and aminocaproic acid. We did not have to go into his abdomen for surgical repair of anything. He had his pulmonary contusions that we saw on his X-rays, he got oxygen in time for that. There used to be a thought that patients that had pulmonary contusions needed antibiotics because blood is a nice place for bacteria to grow. In fact, we've shown that that is not necessary. So you do not need to give antibiotics to patients that have pulmonary contusions. Once he was more stable, we repaired the femoral fractures surgically. So then the question becomes, what does stable actually mean? So in these cases, I want a static red cell count, PCV, for 24 hours or more, and no cardiovascular transfusion triggers, like tachycardia, pale mucous membranes. I want to see a subjective decrease in the volume of his abdominal effusion. So I'm going to be checking that belly fluid every 12 to 24 hours with the ultrasound to see how much is there. I want this kiddo breathing normally without extra oxygen support for at least 24 hours because if we take this patient and anesthetize him and give him breaths with a bag or a ventilator, that can make lung injury worse. So I want to see evidence of improvement in that lung injury, both clinically and so far as how the patient's breathing and then also on the X-rays as well. This patient was discharged four days after admission once his fracture was repair, repaired. He went home once in cage rest, and he had some analgesics, gabapentin, fentanyl patch and carprofen. And this was his surgical repair. I don't do surgery. I just know that this is a plate and some wires and a big pin. It looks very nicely aligned. But wait a minute. I said no NSAIDs, right? Well in these patients, by the time they're at the point that they're going home, they're eating, they're drinking, they've had normal kidney values, they are no longer in shock. Sending them home on NSAIDs is going to be perfectly fine and honestly, actually really, really helpful for helping the the soft tissue trauma from this fracture start to feel better.