Equine Wounds: Sorting Simple from Serious Flashcards
1
Q
what is the difference between a simple vs. serious wound
A
simple: no threat to life, will not be life changing, wont cause permanent lameness. A wound that heals within expected timeframe & not associated with significant complications (surgical wound that heals by 1st intention)
serious: life threatening or potentially life changing (healing delayed &/or associated with complications)
2
Q
what is the triage of the patient
A
initial evaluation of patient
threat to life or life changing, immediate action required to prevent serious consequences –> 1st aid
3
Q
what is the stepwise approach (6)
A
- triage: initial evaluation
- exam
- further investigation: radiography, ultrasonography, synovial fluid analysis
- diagnosis
- treatment
- monitoring & treatment of complications
4
Q
what does the initial triage of the horse include
A
5
Q
what are the red flags for the must not miss diagnoses (6)
A
- respiratory obstruction
- pneumothorax
- hemorrhage
- septic synovitis
- fracture
- tendon transection
6
Q
what can cause respiratory obstruction
A
wounds associated with swelling which obstructs the resp tract
nares, nasopharynx, larynx, trachea
7
Q
what are the signs of respiratory obstruction
A
- resp distress with loud inspiratory noise
- increased inspiratory effort, flared nostrils, cyanosis, may collapse
8
Q
how can you locate where the respiratory obstruction is occuring
A
endoscopy can confirm site of obstruction but prioritize temporary tracheostomy if obstruction is severe
9
Q
how can respiratory obstruction be treated
A
- temporary tracheostomy
- wound management
10
Q
what type of wound can cause a pneumothorax
A
penetrating thoracic wall injury
small axillary wound or tracheal perforation (air tracks along tissue planes into pleural cavity)
11
Q
what is the difference between unilateral or bilateral pneumothorax
A
it can be unilateral or bilateral depending on whether the mediastinum is incomplete or complete
12
Q
what is a tension pneumothorax
A
air enters the pleural cavity but cannot leave –> more severe signs
13
Q
what are the signs of pneumothorax (5)
A
- respiratory distress without loud resp noise
- increased resp rate, flared nostrils, cyanosis, may collapse
- subcut emphysema over thorax
- auscultation no movement of air dorsally
- confirm by radiography/ultrasonography or diagnostic aspiration of air
14
Q
how is pneumothorax treated (2)
A
- prevent air from entering the pleural cavity (cover wound with occlusive dressing)
- remove air from pleural cavity (aspirate at 13ic, indwelling drain may be necessary), nasal O2
15
Q
what is the volume of blood a horse can lose before decompensation occurs
A
~30% –> 11-12 litres
16
Q
how do you assess signs of hemorrhage
A
- signs of hypovolemic shock
- anemia
- PCV <0.2L/L (20%)
17
Q
how do you intervene with hemorrhages
A
- reduce loss - pressure bandage, tourniquet to allow vessels to be clamped/ligated
- restore circulating volume
18
Q
how many litres of blood does a horse have
A
7-8% of their body weight
ex. 500kg = 35-40 litres
19
Q
what is septic synovitis
A
infection within a a synovial structure
20
Q
what structure is prone to septic synovitis
A
digital flexor tendon sheath because distal limb and superficial location
21
Q
what are the signs of septic synovitis (2)
A
- rapidly developing severe lameness (4-5/5)
- analysis of sample, pressure test/contrast radiography to confirm penetration
22
Q
what is a tendon/ligament transection
A
may be partial or complete
23
Q
where is tendon/ligament transection most commonly
A
distal limb
24
Q
what tendon is prone to damage on the dorsal surface of the distal limb
A
extensor tendon
25
what tendon and ligament is prone to damage on the palmar/plantar surface of the distal limb
flexor tendon(s) +/- suspensory ligament (potential for concurrent digital flexor tendon sheath penetration)
26
what are the signs of tendon/ligament transection
altered posutre/function if complete transection (severe lameness and altered posture and limb function)
27
how would you confirm tendon/ligament transection
wound exploration may be more helpful than ultrasonography because of the tissue defect there will not be good contact and lots of gas
28
which tendon/ligament is damaged in each of these presentations
29
what are the signs of a fracture
sudden onset 4-5/5 lameness unless small unicortical fragment only, unless affected bone not involved in weight bearing
30
what are unstable limb fractures
crepitus, abnormal angulation/shortening of limb
31
how would you find more information regarding a fracture
1. probing/exploring wound
2. radiography (ultrasonography small fragments)
32
what would the medical history of a horse with respiratory obstruction be (3)
1. patient distressed
2. markedly increased resp effort
3. inspiratory noise (if incomplete obstruction)
33
what would the inspection, clinical exam of a horse with respiratory obstruction be (2)
1. absent or reduced airflow at nostrils
2. little or no airflow audible on auscultation of trachea and lungs
34
what would medical history be of a horse with pneumothorax (2)
1. chest wall wound
2. rapid breathing
35
what would inspection and clinical exam be of a horse with pneumothorax (4)
1. deep thoracic wound
2. increased resp rate, shallow
3. may be cyanotic
4. no airflow audible on auscultation of dorsal lung fields (one or both sounds)
36
what would medical history be of a horse with hemorrhage (2)
1. active bleeding
2. large volume of blood pooled on ground
37
what would inspection and clinical exam be of a horse with hemorrhage (2)
1. signs of shock: increased HR, weak pulse, pale MM, cold extrematies
2. increased RR
38
what would the medical history of a horse with septic synovitis be
1. rapid onset severe lameness after wound sustained
39
what would the inspection and clinical exam of a horse with septic synovitis be (2)
1. 4-5/5 lameness
2. wound in vicinity of synovial structure
40
what would the medical history of a horse with tendon/ligament transected (2)
1. sudden onset severe lameness associated with trauma
2. abnormal posture (if weight bears) or altered foot placement
41
what would the inspection and clinical exam of a horse with tendon/ligament transected (3)
1. variable lameness depending on tendon or ligament
2. may knuckle over on fetlock when walking --\> extensor tendon transection
3. wound overlying tendon or ligament
42
what would be the medical history of a horse with a limb fracture be
1. sudden onset lameness associated with trauma (but incident may not be seen)
43
what would be the clinical exam and inspection of a horse with a limb fracture be (2)
1. 4-5/5 lameness
2. may be crepitus, altered limb angulation or shortening if fracture unstable
44
how do you examine the wound
45
what are ways to physically restrain so you can examine the wound
1. halter
2. expertise of handler
3. need for head protection?
46
how can you chemically restrain the hrose if you need to examine a wound
1. a2 agonist and opioid
usually detomidine/romifidine + butorphanol IV
47
how do you prepare to examine the wound
1. clip surrounding skin
2. aseptic preparation of skin
3. flush wound with sterile saline
48
how do you probe a wound
1. sterile gloved finger
2. blunt metal probe
49
what are you looking for when you probe a wound (5)
1. depth
2. involvement of underlying structures
3. underminded skin
4. foreign bodies
5. bone fragment
50
what are you looking for when you probe a wound with a blunt metal probe
narrow tracts
can radiograph in situ
51
what are the steps to treating a wound (9)
1. clean
2. debride
3. do you need antimicrobials and/or NSAIDs?
4. suture?
5. protect wound - bandage
6. immobilization of wound?
7. give owner instructions
8. tetanus vaccine
9. complications
52
how do you clean a wound
flush with high pressure lavage
53
how do you debride a wound
if heavily contaminated or devitalized tissue
54
what do you need to debride a wound
local analgesia
sedation
55
what do you need to be careful of when debriding a wound in the distal limb
be sparing with skin
56
what do you need to consider when deciding whether or not to suture the wound
is it 1st intention or 2nd intention healing
if suturing - how will tension and dead space be managed
57
what do you need to consider when bandaging the wound
which contact layer to use
if immobilization is needed
58
what factors affect wound healing
59
what would an acute wound tissue look like in a simple wound
skin, subcut tissue, muscle (not transected)
60
what trauma would cause an acute simple wound
minimal, ex. incised wound
61
what contamination would be in an acute simple wound
minor
62
what infection would be in a chronic simple wound
absent
63
how would a simple chronic wound heal
1st inention or by 2nd intention with minimal granulation tissue
64
would there be scarring in a simple chronic wound
minimal
65
what would the tissues be in an acute serious wound
involvement of deeper structures (bone, penetration of synovial cavity, tendon/ligament transected)
66
what type of trauma would there be in a acute serious wound
1. laceration
2. major blunt trauma
3. wire wrapped around limb
tissue viability may be affected, possible distal limb ischemia
67
would there be tissue contamination in an acute serious wound
extensive foreign material within wound
may be difficult to remove
68
would there be infection in a chronic serious wound
present, organisns may be highly resistant
69
how would a chronic serious wound heal
exuberant granulation tissue
70
would there be scarring in a chronic serious wound
may result in significant scarry
may affects aesthetics and/or function (eyelid)
71
when is suturing appropriate
when you are sure the wound won't break down and you can manage dead space --\> drainage is key
72
if the wound has no/minimal contamination (after cleaning & debridement) what antibiotic would you use
1st line: potentiated sulphonamide
alternative: oxytetracycline, doxycycline
73
if the wound has contaminated, deep wound, deeper structures, questionable tissue viability what antibiotic would you use
1st line: penicilin + gentamicin
alt: oxytetracycline, doxycycline
consider local administration (IV regional perfusion, or intra-synovial for synovial sepsis)
74
what antibiotics would you use for an infected wound
1st line: culture if possible
also consider foreign body, sequestrum, necrotic soft tissue? poor drainage?
75
what are the 3 layers in a bandage and their functions
primary or contact layer: creates moisture, absorbs exudate, gas permeable
secondary layer: absorbs & protects, immobilization if multiple cotton wool layers compressed (robert jones bandage)
tertiary layer: secures & protects other layers
76
when is immobilization indicated
1. high tensions at skin margin
2. second intention healing
77
how would you bandage the proximal limb, neck, trunk
adhesive dressing materials or use suture loops and umbilical tape to tie on dressing
78
when is radiography useful
1. fracture
2. radiodense foreign object (grit)
3. in situ probe useful to visualize end of narrow tract
79
when is ultrasonography useful
1. soft tissue injury, fractures (especially small fragments)
2. all types of foreign bodies (wood, grit, metal)
3. wound tracts can be visualized
80
when is synovial fluid analysis useful
1. septic synovitis: gross appearance, lab analysis
2. bacteriology
81
what are the 3 areas of the foot that are danger areas when there is a penetration and why
1. middle 1/3 of frog
2. angle of sole
3. angle of sole
deep penetration may involve digital flexor tendon, navicular bursa or digital flexor tendon sheath
82
what can go wrong with wound healing and what shouldnt you do
horse remains very painful/lame or becomes more painful/lame --\> don't just give more NSAIDs
83
what should you consider when a wound isn't healing (4)
1. infection: foreign body, sequestrum, necrotic tissue
2. wound breakdown if closed
3. exuberant granulation tissue - 2nd intention healing
4. pressure (bandage) sores
84
why is "proud flesh" not good
inhibits epithelialization and wound contraction
85
what is proud flesh
exuberant granulation tissue
86
when is proud flesh common
common in distal limb wounds healing by second intention
87
what is exuberant granulation tissue stimulated by (3)
persistent low grade inflammation
1. infection, foreign bodies, necrotic tissue
2. inappropriate treatment
3. movement
88
how can you treat proud flesh
excise it and try to immobilize the limb
intermittent application of steroid
skin grafting --\> island grafting
