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Emergency Stabilization

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sihirlifil's version from 2018-03-16 15:10

Emergency Stabilization in the Field

Question Answer
Components of optimal emergency treatment (7)Initial wound management
Prevention/minimization of infection
Analgesia
+/- IV fluid therapy
Sedation +/- anesthesia
Stabilization of fracture
Safe transportation/rescue if necessary
Initial exam: what do you assess for degree of damage?Severe loss of soft tissue
Severe loss of bone
Type of bone(s) fracture(s)
If treatment is likely to be hopeless...Smooth & quiet euthanasia
Initial exam: if any doubt or in good condition...Soft tissues need protecting, splints applied immediately
How do you control the patient?Make sure they are in safe place
Use a twitch/restraint
Sedation/analgesia
What's this?
Twitch
Control of the patient: options for sedation/analgesia?Xylazine hydrochloride (0.2-1.1 mg/kg IV)
Butorphanol tartrate (0.02-0.04 mg/kg IV)
Acepromazine aleate (0.02-0.03 mg/kg IV)
Detomidine hydrochloride (0.005-0.02 mg/kg IV)
Romifidine (40-100 ug/kg IV)
**Something to keep in mind about sedation?Less is often more! Don't want ataxic patient!!!
Remember to stabilize BEFORE trying to diagnose
Control of the patient: common combinations (3)Xylazine & Acepromazine
Xylazine & Butorphanol
Detomidine & Butorphanol
Which drug do you avoid with thoracic limb injury?Butorphanol! Causes the horse to lean forward (increases difficulty in standing)
Priorities of emergency 1st aidPrevent damage to neural & vascular elements of the limb
Prevent fracture becoming open, protect limb from additional contamination if already open
Stabilize limb: relieve anxiety in the patient
Minimize further damage to bone/soft tissue
How does self-trauma occur?Horses try to place the limb in normal position. Lifting & placing = grinding bone ends
Self-trauma: how do we prevent?Splints encourage animal to rest the limb
Considerations with severe injury (3)Hypovolemia from severe blood loss (uncommon)
Thrombi --> loss of vascularity to distal limb
Shock (anxiety, perspiration)
**If shock occurs, how do you handle it?Place IV catheter and use a solution of electrolytes and glucose (10-20 mL/kg intially, then reassess) and administer shock rate fluids if necessary
Animals in colder climates could benefit from a blanket or aluminum emergency blanket being placed
How to control swelling & minimize pain:Pressure over fracture site
MOST IMPORTANT tissue to protect?SKIN!
What do i do with these?
An intact skin barrier greatly reduces the chance of infection. Once skin is open, then cover the wound with a water soluble antibiotic ointment and sterile dressing to reduce further contamination. If able to, remove the hair around the wound and gently clean with mild soap and water. The wound can then be cleaned thoroughly, disinfected, and covered with sterile bandage material. When bone is visible, the bone should be cleaned also before being covered with a sterile dressing. A splint can then be applied over top of the dressing.
For open fractures/large wounds, what do you want to add?Start systemic antibiotics!
Which systemic antibiotics can be used for open fractures/large wounds?Penicillin sodium/potassium (10,000-44,000 IU/kg IV, IM q 6h)
Penicillin G procaine (22,000-44,000 IU/kg IM q 12h)
Gentamicin sulfate (4-6.6 mg/kg IV, IM)
Cefazolin sodium (11-25 mg/kg IV, IM)
Tetanus toxoid immunization?
Properties for an ideal splint (5)Neutralizes damaging forces
Allows horse to move
Can be applied in difficult circumstances
Does not require GA
Economical, accessible to primary responder in the field
What materials can you use to splint?Kimzey splint, 4x4, PVC pipe... and be inventive
What CAN'T you splint?Proximal scapula
Femur
Pelvis
Axial skelton
What happens if you have an axial skeletal problem (therefore can't splint?)Still requires protection from abuse during transport! If results in paraplegia/quadriplegia, must be hauled recumbent
memorize

Forelimb injury

Question Answer
Functional divisions of the forelimb:
A = Distal to MCIII
B = Distal radius to distal MCIII
C = Elbow to distal radius
D = Distal scapula to elbow
Which division doesn't require immobilization?D (above distal scapula)
Most common location for fractures to occurRegion A
Includes P2, P1, sesamoids, distal MCIII
Region A: what forces must splinting counteract?Bending of fetlock
How do you splint region A?Initial light bandage layer 1/2 - 1 inch thick
Apply splint on dorsal surface (carpus-toe)
Align dorsal cortices of bones & splint in straight line
Apply casting material over splint
Why is only minimal padding required? why do we need padding at all?Thicker padding will compress as the bones move, which will loosen the cast & alow excessive motion of fracture ends
. No padding may cause swelling, increasing the pressure within the cast and may then lead to problems with perfusion
What are your casting materials?
How would you describe this fracture? How stable? Which joint is instable? Tx options?
(LASx)
Walk through how to apply a bandage here
(region A) Have assistant hold limb proximal to the carpus & let it hang
First layer: Cotton bandage/Combi roll
Splint dorsal aspect
Tape splint to bone column
Apply cast material over top
What's this?
Kimzey splint
How do you apply a splint to region B (midforelimb)?Use prox & distal limb to attach splint
Robert-Jones with rigid splints. Many layers required, separate layers with elastic gauze
Finished bandage should be 3x diameter of limb at fracture site
Minimum of 2 splints, caudal & lateral (90* apart)
(splints should extend from elbow to ground & be tightly secured to the bandage using non-elastic tape)
Describe the fracture: (prognosis?)
Longitudinal monocortical fracture of distal radius
What's wrong with this stabilization attempt?
Not thick enough! And there's only 1 splint
How is this splint?
Region C: what is PARAMOUNT?Prevent limb from abduction
How do you apply a bandage in region C?Apply RJ bandage with lateral splint extending to lateral chest. Should lie against the ribs. Tape splint at lvl of axilla
Why do we need a large lateral splint for region C?Due to the musculature of the antebrachium being primarily located on the lateral aspect of the limb and therefore having a tendency to abduct the limb distal to the fracture, potentially perforating skin on the medial side.
What's wrong with this picture? (region C)
Board doesn’t really look particularly mobile, and appears to be very heavy in addition
Region D = ? special about this?Proximal to elbow (humerus, ulna, neck of scapula) = well-protected by muscles!
Region D: if triceps disrupted...Horse is unable to fix elbow, can't bear weight
Region D: how do you splint it? in WHO?Splint carpus in extension, then limb can be used for balance. Simple padded bandage, splint caudal aspect of carpus, really only necessary for transport (makes walking difficult)
Not appropriate in foals
What's going on here?
(region D) Affected humerus U/S image is the topmost, normal is below. There is a fracture of the proximal humerus with disruption of the infraspinatus tendon overlying it. Note the normal appearance of the infraspinatus tendon (arrowheads) in the lower U/S image
memorize

HIndlimb injury

Question Answer
Functional divisions of the hind limb:
A = distal to distal MTIII
B = middle to proximal MTIII
C = tarsus to proximal tibia
D = femur
Distal hindlimb (region A): how do you splint?Treat like FL (bandage limb, apply splint (board or PVC) to plantar aspect and then can apply fiberglass cast material over the splint) EXCEPT splint on plantar aspect of limb. Reciprocal apparatus in action, support limb in extension to apply
LegSaver can be used to alllow more fetlock flexion
Describe the fracture
(region A) Comminuted P1 fracture with large bone fragment at proximal dorsal aspect
Fractures of middle MTIII to tarsus: how do you splint?Calcaneal tuber can be used as extension of MTIII. Splints lateral & caudal over RJ bandage (does not need to be as extensive as on FL)
Tape splints from calcaneal tuber to ground with non-elastic tape
Describe the fracture
Barbaro’s injuries: comminuted P1 fracture, medial condylar fracture of MTIII and medial sesamoid with luxated fetlock joint
Fractures of the tibia & tarsus: how do you splint?Difficult due to reciprocal apparatus, angulation of hock & stifle
LATERAL splint ONLY, can be bent to follow angulation of limb. Better if foot flexed
RJ bandage should be thick & tight. Aluminum, electrical conduit, or steel reinforcement bar OR wide board (15-20cm) from ground to lateral thigh
Femur fractures: how do you stabilize?Difficult! Vast muscle coverage, limb will not be weight-bearing
Femur fracture: treatment?Mid-diaphyseal or proximal femoral fractures only been successfully surgically treated in foals and small ponies. Distal metaphyseal fractures have been repaired in yearlings with plates and screws
Pelvic fractures: how do you splint?YOU DON'T!
Pelvic fractures: treatment?Fluid therapy if hypovolemic (occasionally large vessels lacerated)
Conservative therapy: 4-6 months stall rest + anti-inflammatories
No surgery option for adult horses, possible but difficult in foals
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Transport

Question Answer
Important for owner communicationIf unrepairable, DO NOT TRANSPORT
Financial constraints
Overall health of patient
Consult nearest surgical facility as soon as possible for estimate & prognosis of THAT SPECIFIC fracture
Common complications with repair (6)Implant failure
Contralateral limb laminitis
Cast sores
Infection of implants
Non-union or delayed union
Anesthesia risks
Moving broken horses: the BEST trailer is...Bigger! Vans and gooseneck trailers are better than small ones as they are more stable
How should FL injuries travel? hind? Why?Forelimb fractures should travel facing backwards, fractured hindlimbs should face forward. That is so when the vehicle has to brake the animal throws it’s weight on the uninjured limbs
How should the horse be confined in the trailer?Confine the animal with chest and rump bars, and squeezed with partitions so that it may lean on them for balance. If the horse is allowed to travel with it’s head free it can then use it as a counterweight for balance as well
How do you transport recumbent patients?Requires specialized equipment, you are also going to need sedation and padding for the horse, remembering to pad the halter. Can blind fold the horse as well, to keep it calmer for transport
NSAIDs: how do they help?Prevent soft tissue inflammation
Control inflammatory pain
Reduce platelet adhesion (prevent thrombi)
NSAIDs: which ones?PBZ 2.2-4.4 mg/kg IV
Banamine 1.1 mg/kg IV
Ketoprofen 2.2 mg/kg IV
Besides NSAIDs, other possibilities for analgesia?Fentanyl transdermal patches 2-3/100 ug/h per 500 kg (replace every 2-3 days)
CRIs: Butorphanol (13 ug/kg per hour IV), Lidocaine (1.3 mg/kg IV loading & 0.05 mg/kg maintenance), Ketamine (0.4-0.8 mg/kg per hour IV)
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