Page 972 - Cote clinical veterinary advisor dogs and cats 4th

478 Hit by Car

pneumothorax, pulmonary contusions, ventricu- a pulse oximeter, blood pressure, electrocardio- ○ Blood gas analysis can identify respiratory
and metabolic disturbances.
lar arrhythmias, uroabdomen, hemoabdomen gram (ECG), lactate, and focused assessment of • Thoracic radiographs
VetBooks.ir Clinical Presentation and thoracic) is advised. After major systems ○ Common findings include pulmonary
sonography for trauma (FAST) scan (abdominal
HISTORY, CHIEF COMPLAINT
contusions, pneumothorax, diaphragmatic
are adequately assessed and addressed, more
rupture, rib fractures, and pleural effusion.
May be witnessed or inferred based on physical
investigation of possible fractures).
exam. Chief complaints can include difficulty comprehensive diagnostics may be pursued (e.g., • Abdominal radiographs
breathing, bleeding, collapse, lameness, ocular ○ Common findings include peritoneal
or head injury, altered mentation, paresis, Differential Diagnosis effusion, retroperitoneal effusion, and
paralysis, abrasions, and degloving injuries. • Other forms of blunt trauma indistinct bladder. Free peritoneal gas may
○ Acceleration/deceleration (e.g., falls, being indicate a ruptured viscus or penetrating
PHYSICAL EXAM FINDINGS inside a car that was in an accident) abdominal wound.
Findings depend on injuries and may include ○ Crush/compression • CBC
the following: ○ Anemia secondary to hemorrhage
• Cardiovascular: tachycardia, poor pulse Initial Database ○ Leukocytosis due to inflammation, physi-
quality, arrhythmia, cool extremities, pale • Neurologic exam (p. 1136) ologic stress, or infection
mucous membranes, prolonged capillary ○ Altered mentation or cranial nerve deficits ○ Platelets may be decreased due to
refill time (CRT) increase suspicion for cerebral hemorrhage consumption
• Respiratory: quiet or absent breath sounds or edema. Skull fractures may be palpable. • Serum biochemistry
(auscultation), pulmonary crackles (aus- ○ Loss of proprioception, ataxia, paresis, or ○ Hypoalbuminemia due to inflammation
cultation), tachypnea, dyspnea, flail chest paralysis increase suspicion for spinal cord or hemorrhage
(p. 340), decreased chest wall/diaphragm injury secondary to traumatic disc hernia- ○ Increased liver enzyme activities due to
excursions with neck injuries, paradoxical tion, vertebral fracture, spinal luxation, hypoperfusion or liver trauma
breathing (chest and abdominal walls move hemorrhage causing cord compression, ○ Azotemia from hypovolemia, acute kidney
oppositely) with diaphragmatic hernia, or or spinal cord contusion. injury, or uroabdomen
severe respiratory distress • Orthopedic exam (p. 1143) • Orthopedic radiographs: if abnormalities
• Neurologic: altered/abnormal mentation (dull, ○ Careful palpation of all bones for crepitus, detected on physical exam
obtunded, stuporous, comatose, dysphoric), pain, and range of motion • Abdominocentesis (p. 1056)
cranial nerve deficits, neck/back pain, paresis/ ○ Palpation of the pelvic floor per rectum ○ Hemorrhage: confirm with PCV/TP
paralysis, fecal/urinary incontinence may identify pelvic fractures. ○ Urine: confirm by comparing effusion
• Musculoskeletal: nonambulatory, pain or • Blood pressure (p. 1065) potassium and creatinine with serum
crepitus on bone palpation or joint manipula- ○ Hypotension often represents hypovolemia values (p. 1343)
tion, lameness, obvious fracture or dislocation and requires immediate attention. It may ○ Bile: compare total bilirubin of the effu-
• Integument: abrasions/lacerations, degloving also result from inappropriate vasodilation sion to serum total bilirubin
injuries, subcutaneous emphysema, bruising from SIRS. ○ Septic effusion (ruptured viscus): identify
• Ocular: proptosis, episcleral hemorrhage, ○ Hypertension is commonly due to pain intracellular bacteria; compare blood
detached retina, blindness, corneal ulcer, or increased intracranial pressure. glucose and lactate concentrations to
hyphema • Pulse oximetry (SpO 2 ) those of effusion (p. 779)
○ Estimates arterial hemoglobin oxygen
Etiology and Pathophysiology saturation (SaO 2 ). A value < 95% requires Advanced or Confirmatory Testing
• The body’s response to physical trauma is oxygen therapy and investigation of cause. • Full-body CT scan is the gold standard
complex and individual. The acute inflam- • ECG (p. 1096) imaging modality for trauma patients.
matory response is initally protective but ○ Ventricular arrhythmias (p. 1033) occur in • Radiographic contrast studies to evaluate
can result in SIRS if excessive. 20%-25% of trauma patients. Treatment integrity of the urinary tract
• Tissue factor exposed by endothelial damage is recommended if there is hemodynamic • MRI (p. 1132) to assess extent of brain or
activates coagulation. A hypercoagulable state compromise, sustained ventricular spinal cord damage
may result and progress to disseminated tachycardia with a rate > 180 beats/min,
intravascular coagulation (DIC [p. 269]). R-on-T phenomenon or polymorphic TREATMENT
• Coagulopathy was initially hypothesized to be a ventricular tachycardia. Arrhythmias may
result of consumption, hemodilution, acidosis, not occur until 12-24 hours after trauma. Treatment Overview
and hypothermia; however, the acute hypo- ○ Most trauma-associated ventricular Treatment must be prioritized to address life-
coagulable and hyperfibrinolytic state (acute arrhythmias resolve without specific threatening problems first, with an initial goal
traumatic coagulopathy) in trauma patients therapy within 4 days (p. 1033). of maximizing delivery of oxygen to tissues.
may occur solely due to hypoperfusion. • FAST scans (p. 1102) Stabilization of cardiovascular, respiratory,
• Tissue hypoxia can result from hypovolemia ○ Abbreviated ultrasound can identify free and neurologic function should be performed
and microvascular thrombosis. thoracic or peritoneal fluid, pneumotho- immediately. In all cases, an intravenous
• Multiple organ failure can ensue (p. 665). rax, or pulmonary contusions. catheter is useful, and blood can be obtained
• Head trauma can result in bleeding, cerebral • Point-of-care blood tests for point-of-care testing at the same time. If
edema, and brain herniation. Sympathetic ○ Packed cell volume (PCV) and total hypovolemia is suspected, a fluid bolus should
stimulation can cause neurogenic pulmonary protein (TP) can identify the presence of be administered. Oxygen supplementation
edema. hemorrhage. PCV may be low, normal, or should be provided until it is proven that it is
high (due to splenic contraction in dogs) not needed. After initial triage assessment, pain
DIAGNOSIS after hemorrhage; however, TP is always medication should be administered.
decreased and is a more sensitive early
Diagnostic Overview indicator of hemorrhage. Serial monitoring Acute General Treatment
Diagnostics should complement exam findings is recommended. • Oxygen supplementation (oxygen cage, flow
and be used initially to rule out life-threatening ○ Elevated blood lactate concentrations can by/mask, nasal prongs or cannulas [p. 1146]);
derangements in major body systems. The use of indicate poor perfusion (p. 1356) avoid nasal prongs with head trauma

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