Management of iatrogenic injuries and other equine emergencies Flashcards
What does a iatrogenic injury mean?
Examples?
- Injury caused by medical (veterinary) examination or treatment
E.g. - Nasal haemorrhage during nasogastric intubation / endoscopy
- Rectal tears during rectal examination
- Evisceration following castration
- Adverse drug reaction
- Anaesthetic death
What are complications of nasogastric intubation?
- Haemorrhage (common)
- Oesophageal perforation (uncommon)
- Inhalational pneumonia (uncommon)
What can be done to minimise risk of damage with nasogastric intubation?
- Use an appropriate tube
- Ensure the horse is restrained
- Pass the tube along the ventral meatus
- Never force the tube
- Ensure it is placed in the oesophagus / stomach before administering fluids
What should be done if there is a haemorrhage?
- Can be alarming to the owner = Mention possible complication
- Leave the horse quietly for 5-10 minutes
- Haemorrhage will usually stop by this time
- Do not pack the nasal passages
- Further assessment required if haemorrhage continues (uncommon)
- Endoscopy
- Clotting profiles
When would you suspect oesophageal perforation?
- If blood on tube (in absence of epistaxis)
How would you assess / treat oesophageal perforation?
- Endoscopic assessment of the oesophagus +/- radiography
- Full thickness perforations have poor prognosis
How does inhalational pneumonia occur?
- Passage of nasogastric tube into the trachea
What happens with water inhalation?
- Small quantities not usually a problem
- Large quantities can result in pulmonary oedema / inhalational pneumonia
What happens with liquid paraffin inhalation?
- Severe lipoid pneumonia
- LIFE THREATENING
What are the biggest complication of rectal examination?
What increases this risk?
- Rectal Tears
- Increased risk:
- Arabians
- Stallions / colts
- Colics
- Fractious horses
- Using an ultrasound probe
How can you reduce risk of rectal tears on rectal examination?
- Be in a safe position
- Ensure the horse is restrained
- Sedate if necessary +/- butylscopolamine
- Never push against the rectum if the horse strains
When would you suspect a rectal tear?
- Blood on rectal sleeve
What would your initial action to a rectal tear be?
- Inform the owner
- Sedation
- Butylscopolamine
- +/- epidural anaesthesia
- Evaluate rectal mucosa - Lubrication and lidocaine
- Proctoscopy
- Determine the location and grade
What are the grades of rectal tears?
- Grade 1 = Mucosa & submucosa torn
- Grade 2 = Muscularis only
- Grade 3a = Mucosa and muscularis (serosa intact)
- Grade 3b = Mucosa and muscularis (tear into mesocolon) - further caudal
- Grade 4 = All layers torn
How would you treat each grade of rectal tear?
- Grade 1 = medical management
- Grade 2 = medical management
- Grade 3+4 = Medical / surgical management (euthanasia?)
What is medical treatment of rectal tears?
- Broad spectrum antimicrobials – penicillin / gentamicin
- Flunixin meglumine
- Tetanus status
- +/- epidural anaesthetic and packing of rectum
What are surgical management of rectal tears?
- Direct suturing - single handed long needle
- Placement of a rectal liner - GA
- Temporary diverting colostomy - May require 2 GA ££
What are other iatrogenic injuries / accidents?
- Adverse drug reaction
- Anaphylaxis
- Intracarotid drug administration
- Perivascular injections
- Injection site abscess
- Iatrogenic synovial sepsis
- Broken needles
- Catheter accidents
- Anaesthesic-related complications
What are golden rules of trapped horses?
- Trapped horses can be unpredictable = Offering food and keeping a companion nearby may help
- Be aware of your own and others’ safety - Work from the spine side of the horse
- Have control of the horse’s head - Place a headcollar
- Be prepared to sedate / anaesthetise
- Never release the horse unless it has somewhere safe to go
- Always plan an exit route for you and others
What should be done after freeing a horse?
- Full clinical exam
- Assessment + Tx of -
- limb fractures
- wounds
- head / ocular injuries
- dehydration / hypothermia
- acute haemorrhage
- URT/LRT inflammation
What injuries need to be considered with stable fires?
- Smoke inhalation - black sut around nose
- Skin burns
- Corneal ulceration
- Hypovolaemia ‘burn shock
How would you assess a horse initially after a stable fire?
- Lukewarm water; remove rugs
- Sedation / anxiolytics if required
- Administer flunixin
- +/- oxygen
- IV catheter +/- tracheostomy
- Referral / euthanasia may be needed
What should be done with less severe burn cases?
- Cool skin
- Clip hair
- Lavage (0.05% chlorhexidine solution)
- Water (not oil) based antimicrobial ointment = Silver sulfadiazine
With wounds what would be your initial advice to the owners?
- Control haemorrhage: = Dressing, Pressure
- Do not move the horse if it is very lame unless in imminent danger
- Minor wounds in low-risk areas = telephone advice may be all that is needed
- More severe cases = tell owners not to apply anything to the wound
What history would you want to know with wounds?
- Tetanus status
With wounds what would you assess on clinical exam?
PRIOR TO EXAM = stop haemorrhage + stabilise limb
- Shock/ other injuries
- Assess stance / weightbearing
- Vital parameters
- Blood loss
- Other smaller wounds
What would you do with the wound?
- Sedation
- Assess - age of wound, contamination + location
- Apply sterile gel
- Clip + clean around site
What would you use to lavage the wound?
- 0.05 chlorohexidine
- 0.1 povidone iodine
-35-60ml syringe w 18/19G needle
Whilst assessing wounds what would you check?
- Sterile gloves, use finger / sterile probe
- Depth and direction
- Foreign material
- Subcutaneous pockets
- Bone / tendon exposure
- Joint / tendon sheath?
- Thoracic / abdominal organs?
- Trachea / oesophagus?
What would your considerations with injuries be?
- Time since injury
- Contamination / infection
- Tissue defects
- Tissue flaps / viability
- Patient compliance
- Is GA needed
What is ideal conditions for wound suturing?
- <8h old
- Healthy tissue
- Eyelids, nostrils, lips (full thickness)
What can be used for local anaesthesia with wounds to suture? What nerve block could you do?
- Mepivacaine
- Lignocaine
- regional nerve block
- Ring / L-block
How would you suture a horse?
- Remove necrotic tissue
- Preserve tissue flaps
- Skin staples = quick + easy - NO TENSION
- Skin suture = 2-0 - 0 USP monofilament = polypropylene
- SC suture = 2-0 USP, absorbable = poliglecaprone
- Drain
- Dress / bandage
What are other ongoing management of wounds?
- Analgesia / anti-inflammatories
- IV at first, followed by oral
- Antimicrobials - IM followed by oral
- Tetanus toxoid booster
- Box rest
- Suture / staple removal - 10-14days
- Dressing / bandage change - as often as needed (exudate)
How is secondary intention healing carried out?
- Sterile hydrogel + non-adherent, absorbent dressing
- Bandaging of distal limb
What are complications of wounds?
- Synovial sepsis / fracture (missed initially)
- Sequestrum formation - Where cortex of the bone exposed
- Dehiscence - wound bursting open
- Foreign material remains in situ - Be careful if wood involved
- Bandage sores
What must a wound bed be for a successful graft?
- Vascularised
- No necrotic tissue
- No overt infection
- No evidence of delayed wound healing
- Sequestrum
- Foreign body
What are indications for grafting?
- Traumatic injuries
- Non- / slow-healing granulating wounds
- Adjunct to management of skin neoplasia
- Extensive skin burns
- Deformity-causing scarring
How is pinch / punch grafting carried out?
- Well lit, quiet
- Sedation
- Equipment ready
- Donor site prepared =
- Neck
- +/- abdomen
- Clipped, local anaesthesia
- Skin preparation
- Grafting site prepared = Cleaned & superficial debridement already performed
Placing grafts
* Start at the lowest site (prevents haemorrhage obscuring sites)
* Make a pocket in the granulation bed - No 15 scalpel blade
* Tuck grafts into each pocket
* Non-adhesive dressing, bandage
* Box rest
* Change bandage in 5-7 days
What do you need to identify for referral horses?
- Identify cases needing -
- More intensive care
- Detailed investigations
- Surgical intervention
- Initiate honest discussion with owner / carer
- If appropriate start arranging possible transport
- If referral is declined, the client should be aware of potential outcomes
What should be done if considering referral?
- Good communication between vet, referral centre and owner
