Page 481 - Clinical Small Animal Internal Medicine

46 Medical Management of Trauma and Burns 449

Evaluation of the abdomen consists of visual inspec- supplanted the older classification scheme of grading
VetBooks.ir tion and palpation. Small puncture wounds over the burns by degree and provides a better description of
burn severity. It is important to remember that the depth
abdomen, especially puncture wounds associated with
animal bites, may belie severe trauma to the abdominal
wall or abdominal viscera. Abdominal distension with or of the burn may vary across the affected area. Superficial
wounds are erythematous and may have a dry, flaky
without a palpable fluid wave may occur with traumatic appearance. Superficial partial‐thickness burns are
hemoabdomen. Palpation of the urinary bladder should erythematous and moist. They blanch and blisters may
be attempted although the presence of a palpable urinary be present. Deep partial‐thickness burns are character-
bladder does not exclude the possibility of uroabdomen. ized by an absence of blisters and they appear waxy with
A rectal exam should be performed in any animal that reduced pain sensation. Full‐thickness burns are white
suffered blunt trauma to the caudal half of the body. and may have eschar formation. Hair is easily plucked
Palpation of the pelvic ring for fractures and evaluation from the burn site.
of anal tone are important components of a complete Special attention should be paid to the airways of
physical exam. patients that have suffered burns in fires. The orophar-
Assessment of the abdomen with ultrasound is becom- ynx should be evaluated for the presence of soot and the
ing commonplace and has been shown to be a more sen- thorax should be carefully auscultated for evidence of
sitive indicator of free abdominal fluid than blind airway or pulmonary parenchymal injury. If the animal
four‐quadrant abdominocentesis or diagnostic perito- smells of smoke then there is a high likelihood that
neal lavage. To perform an abdominal focused assess- some degree of inhalation injury is present. Notation of
ment with sonography for trauma (FAST) exam, the respiratory rate and effort should be made immediately
patient is placed in either left or right lateral recumbency. and respiratory patterns and oxygenation status should
The ultrasound probe is placed at the first location on be reevaluated regularly.
midline just caudal to the xyphoid process (diaphragma-
tico‐hepatic position). The probe is then rotated crani-
ally, caudally, and laterally in both directions. If no free Therapy
fluid is observed then the probe is moved to the second
site. The process is repeated, targeting the four points of The treatment of trauma patients can be divided into two
investigation: diaphragmatico‐hepatic, spleno‐renal (left distinct phases. The primary or acute phase of trauma
body wall over the left kidney), cysto‐colic (midline over management is focused on restoration of systemic and
the urinary bladder), and hepato‐renal (right body wall local oxygen delivery to preinjury levels to minimize sec-
over the right kidney). If free fluid is found, the test is ondary ischemic injury. The second phase of trauma
considered positive and an attempt should be made to management lasts until the patient is discharged and
obtain a sample for evaluation. centers on maintaining oxygen delivery, definitive treat-
In most cases, orthopedic and cutaneous wounds are ment of wounds or fractures, provision of nutritional
not immediately life threatening and their evaluation support, and pain management.
should complete the physical examination when the
patient is deemed stable. The patient should be fully Primary Phase
evaluated for the presence of lacerations, puncture
wounds, abrasions or bruising. Gross deformity of Successful resuscitation begins with recognition of its
limbs is assessed followed by a detailed orthopedic need. Resuscitation should be directed at reexpansion
exam targeting long bones and joints of the appendicu- of effective circulating volume and re-establishment of
lar skeleton. If not already done, the animal should be systemic and local blood flow. The exact method of
observed ambulating, if able. Radiographs of any areas resuscitation is less important than the goals that are
of pain or instability should be obtained to determine targeted. Classic resuscitation endpoints have focused
the extent of the injuries. Wounds should be gently on macrocirculatory findings such as heart rate, pulse
clipped to facilitate assessment. quality, and blood pressure. Recent developments in
shock treatment have identified microcirculatory mark-
ers that may be better for determining when resuscita-
Burn‐Specific Considerations
tion is complete (i.e., adequate oxygen delivery and
When evaluating patients that have been burned, it is usage has been restored).
important to assess both the depth of the burn and the Beyond the traditional resuscitation endpoints, the
TBSA affected. Burn depth is classified as follows: super- evaluation of biochemical markers such as base deficit,
ficial burns, superficial partial thickness, deep partial lactate, and central venous oxygen saturation has been
thickness, and full thickness. This terminology has advocated for use in veterinary medicine. The rationale