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Below we outline a systematic approach to diagnosing and treating trauma, emphasizing that many internal injuries may not be apparent for 12–48 hours after the initial event.
Below we outline a systematic approach to diagnosing and treating trauma, emphasizing that many internal injuries may not be apparent for 12–48 hours after the initial event.
Initial Assessment & Stabilization:
Initial Assessment & Stabilization:
• Primary Priorities: Immediate resuscitation of airway, breathing, and circulation (ABCs), control of hemorrhage, and pain relief.
• Primary Priorities: Immediate resuscitation of airway, breathing, and circulation (ABCs), control of hemorrhage, and pain relief.
• Stabilization Measures:
• Stabilization Measures:
◦ Immobilize the neck and spine until fractures or luxations are ruled out.
◦ Immobilize the neck and spine until fractures or luxations are ruled out.
◦ Support extremity fractures with bandages or splints to prevent further injury.
◦ Support extremity fractures with bandages or splints to prevent further injury.
• Minimum Initial Database: Point-of-care tests including PCV, total solids (TS), BUN test strip, and blood glucose.
• Minimum Initial Database: Point-of-care tests including PCV, total solids (TS), BUN test strip, and blood glucose.
• Extended Database: Arterial or venous blood gases, electrolytes, blood lactate, and coagulation assessment.
• Extended Database: Arterial or venous blood gases, electrolytes, blood lactate, and coagulation assessment.
Monitoring & Scoring Systems:
Monitoring & Scoring Systems:
• Objective Scoring:
• Objective Scoring:
◦ Animal Trauma Triage (ATT) Score: Rates perfusion, cardiac, respiratory, skeletal, and neurologic status (higher scores correlate with higher mortality).
◦ Animal Trauma Triage (ATT) Score: Rates perfusion, cardiac, respiratory, skeletal, and neurologic status (higher scores correlate with higher mortality).
◦ Modified Glasgow Coma Score: Used specifically for neurologic monitoring.
◦ Modified Glasgow Coma Score: Used specifically for neurologic monitoring.
◦ Composite Glasgow Pain Scale: For objective pain assessment.
◦ Composite Glasgow Pain Scale: For objective pain assessment.
• Continuous Evaluation: Monitoring vital signs (temp, pulse, respiration, BP) and clinical pathology data like serial PCV/TS, which will decrease as hemorrhage and fluid resuscitation progress.
• Continuous Evaluation: Monitoring vital signs (temp, pulse, respiration, BP) and clinical pathology data like serial PCV/TS, which will decrease as hemorrhage and fluid resuscitation progress.
Thoracic Trauma
Thoracic Trauma
• Potentially Life-Threatening Issues: Pulmonary contusions, pneumothorax, flail chest, diaphragmatic hernia, and cardiac arrhythmias.
• Potentially Life-Threatening Issues: Pulmonary contusions, pneumothorax, flail chest, diaphragmatic hernia, and cardiac arrhythmias.
• Diagnostic Findings:
• Diagnostic Findings:
◦ Dull/quiet lung sounds: Consistent with pleural air or fluid.
◦ Dull/quiet lung sounds: Consistent with pleural air or fluid.
◦ Crackles/rales: Indicative of severe pulmonary contusions.
◦ Crackles/rales: Indicative of severe pulmonary contusions.
• Interventions:
• Interventions:
◦ Thoracocentesis: Should be performed before radiographs if the animal is in respiratory distress.
◦ Thoracocentesis: Should be performed before radiographs if the animal is in respiratory distress.
◦ Oxygen & Ventilation: Supplemental oxygen is standard; positive-pressure ventilation is needed if no improvement is seen.
◦ Oxygen & Ventilation: Supplemental oxygen is standard; positive-pressure ventilation is needed if no improvement is seen.
◦ Cardiac Support: Antiarrhythmics (e.g., lidocaine) are warranted if heart rate is >180 bpm in dogs or if perfusion is impaired.
◦ Cardiac Support: Antiarrhythmics (e.g., lidocaine) are warranted if heart rate is >180 bpm in dogs or if perfusion is impaired.
Abdominal Trauma
Abdominal Trauma
• Major Sources of Bleeding: Rupture of the spleen or liver are most common; other sources include mesenteric vessels or kidneys.
• Major Sources of Bleeding: Rupture of the spleen or liver are most common; other sources include mesenteric vessels or kidneys.
• Detection of Fluid:
• Detection of Fluid:
◦ AFAST (Abdominal Focused Assessment with Sonography for Trauma): Identifies even small amounts of free fluid.
◦ AFAST (Abdominal Focused Assessment with Sonography for Trauma): Identifies even small amounts of free fluid.
◦ Diagnostic Peritoneal Lavage (DPL): Infusing saline into the abdomen to evaluate for hemorrhage or sepsis.
◦ Diagnostic Peritoneal Lavage (DPL): Infusing saline into the abdomen to evaluate for hemorrhage or sepsis.
• Resuscitation Strategy: Use small-volume fluid resuscitation to achieve low-normal blood pressure (90 mmHg systolic) to avoid dislodging clots.
• Resuscitation Strategy: Use small-volume fluid resuscitation to achieve low-normal blood pressure (90 mmHg systolic) to avoid dislodging clots.
• Surgical Indications: Emergency surgery (laparotomy) is required for ongoing hemorrhage, organ rotation/ischemia, or diaphragmatic hernia.
• Surgical Indications: Emergency surgery (laparotomy) is required for ongoing hemorrhage, organ rotation/ischemia, or diaphragmatic hernia.
Advanced Resuscitation & Surgery:
Advanced Resuscitation & Surgery:
• Damage Control Resuscitation: Early use of blood products to hypotensive endpoints to avoid the "Lethal Triad": acidosis, coagulopathy, and hypothermia.
• Damage Control Resuscitation: Early use of blood products to hypotensive endpoints to avoid the "Lethal Triad": acidosis, coagulopathy, and hypothermia.
• Damage Control Surgery: A limited laparotomy intended only to control bleeding and contamination, delaying definitive repair until the patient is stable.
• Damage Control Surgery: A limited laparotomy intended only to control bleeding and contamination, delaying definitive repair until the patient is stable.
• Acute Traumatic Coagulopathy: Diagnosed via thromboelastogram; treated with blood products and antifibrinolytic agents (e.g., tranexamic acid).
• Acute Traumatic Coagulopathy: Diagnosed via thromboelastogram; treated with blood products and antifibrinolytic agents (e.g., tranexamic acid).
6. Prognostic Factors (Poorer Outcomes)
6. Prognostic Factors (Poorer Outcomes)
• Biochemical Markers: Hyperlactatemia, hyperkalemia, elevated BUN, and ionized hypercalcemia.
• Biochemical Markers: Hyperlactatemia, hyperkalemia, elevated BUN, and ionized hypercalcemia.
• Physical Markers: High ATT score, low Glasgow coma score, low SpO2, and head trauma.
• Physical Markers: High ATT score, low Glasgow coma score, low SpO2, and head trauma.
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