Page 482 - Clinical Small Animal Internal Medicine

450 Section 5 Critical Care Medicine

for using biochemical markers depends on the fact that analgesia from head trauma patients is no longer advo-
VetBooks.ir cellular hypoxia may continue despite normalization cated. Adequate analgesia improves patient comfort,
facilitates examination, and improves healing.
of traditional resuscitation endpoints and the selected
markers can detect this ongoing oxygen debt. If unde-
tected, occult shock can be prolonged and can lead to Primary Wound Management
further secondary injury. The best approach for deter- The goal of wound management during the primary
mining when resuscitation is complete is one that incor- phase of treatment is to prevent further contamination
porates both traditional and goal‐directed endpoints. of the wounds and prevent additional tissue injury
Volume expansion should be achieved using replace- from occurring. Wounds should be clipped, cleaned
ment crystalloid fluids, hypertonic crystalloid fluids, with an antiseptic solution (chlorhexidine or betadine)
synthetic colloids or blood products (packed red blood and lavaged with saline. Following lavage, the wounds
cells, fresh frozen plasma, fresh whole blood) as needed, should be gently probed for depth and extent and then
although low‐volume resuscitation (hypertonic saline covered with a nonadherent sterile dressing until the
and synthetic colloid) should be considered as the best patient has been stabilized and definitive treatment is
choice for patients suffering head trauma or pulmonary possible. Very recent thermal burn wounds should be
contusions to minimize the likelihood of overresusci- lavaged with cool saline to arrest ongoing thermal
tation and exacerbation of vascular leak. There is no evi- injury and should then be covered with silver sulfadia-
dence that achieving supraphysiologic values for any of zine and a nonadherent bandage. Most chemical burns
the macrocirculatory variables confers a benefit; on the can be immediately lavaged with tap water for 30 min-
contrary, overresuscitation may lead to increased mor- utes although some alkaline agents may take longer to
bidity (wound edema, fluid overload, dilutional coagu- remove. Elemental metals, including solid sodium, can
lopathy) and should be avoided. Once normalization of ignite when they come in contact with water and
macrocirculatory variables occurs then biochemical should instead be covered with mineral oil. Wounds
analysis should be performed to determine if oxygen should never be allowed to go unaddressed for longer
debt is ongoing. than 2–4 hours.
The provision of supplemental oxygen should be con- Any gross deformities suggesting luxation or fracture
sidered in any patient that has suffered trauma to the should be identified. If fractures are present distal to the
thorax or head, any patient in shock, or any patient that stifle or elbow, the limb should be immobilized with a
may have suffered inhalation injury. The ideal method to soft bandage, ensuring that the joints above and below
provide supplemental oxygen would allow the animal to the affected area are incorporated. Attempts to reduce
move freely without restraint and would not contribute fractures are not necessary in the acute phase of manage-
to stress. Oxygen cages or chambers approach this ideal. ment. Fractures of the humerus, femur, pelvis or scapula
Flow‐by oxygen or oxygen provided by facemask may are not bandaged due to muscular coverage and inability
prove useful during the initial evaluation period when to achieve adequate immobilization. Patients with sus-
it is imperative that the animal be handled. Nasal can- pected cervical or spinal fracture or luxation should
nulation using purposemade nasal oxygen prongs is be sedated, treated for pain, and immobilized using a
well tolerated by some patients and may allow for provi- backboard to prevent further injury to the spinal cord. If
sion of supplemental oxygen without significant restraint. sedation or analgesia is inadequate, these patients
In rare circumstances, it may be necessary to secure often struggle and can exacerbate their injuries.
an airway via orotracheal intubation or tracheostomy. Luxations are treated in a similar fashion to fractures
In these cases, 100% oxygen is provided via an anesthetic and attempts at reduction should be delayed until the
circuit or self‐inflating rescue bag. patient’s condition has stabilized.
Early analgesic management is an important part of
the resuscitation phase of trauma management. Once it Secondary Phase
is determined that the patient’s life is not in immediate
danger, analgesia should be administered. In general, The secondary phase of treatment begins when the
veterinary patients are less sensitive to the respiratory endpoints of resuscitation have been met and the patient
depressant effects of opioid medications and due to the is either admitted to the hospital or moved to surgery.
minimal impact on cardiac indices and their reversibility, As stated previously, the focus of the secondary treat-
pure opioid agonists (morphine, hydromorphone, oxy- ment phase is ensuring adequate oxygen delivery is
morphone or fentanyl) should be considered the analge- maintained and establishing definitive treatment for sur-
sic of choice in the acute setting. Head trauma patients gical wounds. Additionally, at this stage supportive care
should be treated for pain once it is determined that their including nutritional support, analgesia, and preventive
neurologic status is stable. Completely withholding nursing care is considered.