Page 480 - Clinical Small Animal Internal Medicine

448 Section 5 Critical Care Medicine

suffering blunt trauma should be reevaluated fre- and any lacerations, puncture wounds, abrasions or
VetBooks.ir quently for new clinical signs or progression of existing bruising should be noted. The patient should be observed
while breathing prior to auscultation. Careful attention
clinical signs.
Penetrating trauma is much less difficult to diagnose,
ing. Paradoxical movement of the thoracic wall inward
as these patients will have visible external wounds should be paid to the rate, depth, and pattern of breath-
consistent with sharp or ballistic injuries. Very often in during inspiration (flail chest) is indicative of segmental
penetrating trauma, the amount of apparent external fracture of contiguous ribs. Thoracic auscultation should
blood loss is small and animals with thick coats should be performed in a quiet environment. The presence of
be closely inspected for small penetrating wounds. breath sounds should be evaluated. Decreased breath
sounds ventrally may indicate the presence of pleural
fluid whereas decreased or absent breath sounds dorsally
Diagnosis may indicate the presence of pneumothorax. In addition
to ventral and dorsal differences, the breath sounds in
Trauma is not often a diagnostic challenge. However, each hemithorax should be compared to determine if
elucidating the extent of injuries can be. In all cases of unilateral pleural space disease (e.g., tension pneumo-
suspected trauma, a complete medical history and a thorax) is present.
detailed description of the traumatic event, if possible, Once the presence of breath sounds is confirmed, the
are essential. Owners should be asked about the patient’s quality of the sounds should be evaluated. Increases
behavior immediately following the traumatic event. in bronchovesicular sounds or the presence of focal or
Specifically, the owner should be questioned about loss diffuse crackles may indicate pulmonary contusion or
of consciousness, ambulation status, and whether the pet hemorrhage. Detection of borborygmi within the tho-
has urinated since the event. The owner should be asked racic cavity indicates herniation of abdominal contents
to estimate the speed of the vehicle, height of the fall, and through the diaphragm. Auscultation of the trachea
size of attacking animal, as applicable. Additionally, should also be performed. Tracheal injury may result in
the owner should be asked to describe where on the pet loud guttural sounds while laryngeal injury may result in
they believe most of the trauma occurred. If a car hit the higher pitched wheezes (stridor).
pet, the owner should be asked if the pet was seen trave- The oral mucous membranes should be evaluated for
ling under the car or tire. If the pet was attacked by an color and capillary refill time (CRT). Pale mucous mem-
animal, it should be determined if the pet was bitten and branes can be present from anemia or peripheral vaso-
released or clenched and shaken. Finally, if a patient fell constriction and decreased cardiac output, as seen with
from height, the type of substrate upon which they shock. Cyanosis may be observed if severe pulmonary or
landed should be ascertained. pleural space disease is present. Normal CRT is 1–2 sec-
A complete physical examination should be performed, onds. Prolongation of CRT is consistent with decreased
with special attention paid to the neurologic system and cardiac output and early to late decompensated shock.
thoracic and abdominal cavities. When evaluating the Patients in compensated shock may have a brisker than
neurologic system in a trauma patient, a stepwise normal CRT and mucous membrane color may be bright
approach targeting life‐threatening injuries first is utilized. pink to red.
The patient’s mentation and level of consciousness The presence of cardiac sounds should be confirmed
(LOC) should be evaluated and their motor activity and the rate and regularity of the rhythm should be noted.
should be noted. Decerebrate rigidity (extension of all Tachycardia can occur secondary to shock, pain or anxi-
four limbs and opisthotonus) is associated with brainstem ety. Bradycardia may occur during shock in cats, but its
compression and altered LOC. Decerebellate rigidity presence in dogs is a harbinger of circulatory collapse and
(extension of forelimbs with hindlimb flexion) indicates cardiopulmonary arrest. The absence of heart sounds
cerebellar herniation and may be associated with normal may indicate pleural space disease (hemothorax), pericar-
or altered LOC. Motor function should be noted, taking dial effusion or cardiac arrest. Pulses should be palpated
care to discriminate between spinal reflexes and volun- during cardiac auscultation and should be evaluated for
tary movement. Finally, brainstem reflexes are assessed. strength and synchrony with the heart. Heart sounds that
Pupil size, symmetry, and responsiveness are evaluated. do not generate a palpable pulse or pulses of varying
Attempts should be made to elicit an occulocephalic strength are abnormal and electrocardiography should be
reflex, taking care to avoid exacerbating possible cervical considered. Severe peripheral vasoconstriction as seen in
injuries. shock states results in the distal limbs being cooler to the
Following evaluation of the neurologic system, the touch than the trunk. A rectal temperature below normal
thorax should be evaluated for evidence of trauma. is consistent with decompensated shock and should be
A visual inspection of the thorax should be performed considered a negative prognostic indicator.