Triage and Management of Trauma Cases:

Acting Quickly and Effectively

BY MARI E HOLOWAYCHUK, DVM, DACVECC
Trauma is a leading cause of death and disability in people, and is a common reason for dogs and cats
to present as an emergency to veterinary hospitals. Animals experiencing trauma can have a wide vari-
ety of injuries, with considerable differences in prognosis depending on the type of injuries and the
body systems affected. Preparedness for trauma emergencies, knowledge of the most common
injuries, and the understanding of the emergency procedures necessary for treatment can dramatically
improve the outcomes of traumatized small animals. This issue of Small Animal Veterinary Rounds
outlines the common injuries sustained following blunt and penetrating trauma in veterinary patients,
as well as strategies for preparedness and triage. The discussion includes recommendations for emer-
gency fluid resuscitation, supportive care, and survival prognosis.
Trauma is a common reason for animals to present to veterinary hospitals on an emergency basis. Over
35 years ago, a retrospective study by Kolata et al
1
reviewing dogs and cats presenting to 2 large urban vet-
erinary hospitals found that approximately 13% of admissions were for the treatment of traumatic injuries.
Approximately 35% of these cases involved serious injuries with an overall mortality rate of 9%.
1
A more
recent prospective study by Hayes et al
2
documented that trauma was the presenting complaint in 11% of
dogs consecutively admitted to a veterinary teaching hospital (VTH) intensive care unit (ICU). Only
gastrointestinal/pancreatic disease was a more common cause of presentation than trauma. A similar
prospective study revealed that 12% of cats consecutively admitted to a VTH ICU listed trauma as the rea-
son for presentation; it was the third most common presenting complaint, after gastrointestinal/pancreatic
and renal/urinary tract disease.
3
Traumatic injuries in dogs and cats are typically categorized as blunt or penetrating. Blunt trauma is
usually caused by motor vehicle accidents (eg, hit by car, bicycle, tractor, boat, or train) or by falls from
height. Over 90% of blunt trauma cases presenting to veterinary hospitals are due to motor vehicle
accidents.
4
Penetrating trauma is primarily caused by animal altercations (eg, bite or claw wounds, big dog
little dog encounters), gunshot wounds, or accidental impalements. Approximately 75% of penetrating
trauma cases are the result of animal altercations.
5
The injuries sustained vary depending on the cause of trauma and the animal population investigated. In
dogs experiencing blunt trauma, 87% of those who sustained more than superficial abrasions had skeletal
injuries, typically of the pelvis.
6
Multiple traumatic injuries were documented in 36% of dogs, with the liver
the most frequently injured abdominal organ.
6
In another recent canine study, the primary injuries following
blunt trauma were thoracic (70%), abdominal (50%), extremity (40%), and head (30%) injuries.
4
The most
common thoracic injuries in these dogs were pulmonary contusions and pneumothorax (~50% each).
4
Other
thoracic injuries included hemothorax, rib fractures, pneumomediastinum, diaphragmatic hernia, and flail
chest. Superficial abrasions and lacerations were the primary injuries of the extremities, but fractures and lux-
ations also occurred. The most common abdominal injury was hemoabdomen, followed by abdominal her-
nias and rupture of the urinary tract.
4
Similarly, in dogs presenting after motor vehicle accidents, the most
frequent injuries included long bone fractures, pulmonary contusions, soft tissue injuries, pelvic fractures, and
hemoabdomen.
7
Few studies have been published describing blunt trauma injuries specifically in cats. In addition to
motor vehicle accidents, cats commonly sustain injuries due to falls from height, washer/dryer entrapments,
and vehicle fan belt incidents. Unfortunately, many cats do not recover from injuries suffered during such
events. A study describing 119 cats with high-rise syndrome found that almost half of the cats had frac-
tured limbs (mostly hind limbs), and thoracic trauma was diagnosed in one-third of cats.
8
Falls from the sev-
enth floor or higher were associated with more severe injuries and a greater incidence of thoracic trauma.
Very few studies have investigated penetrating trauma in dogs and cats. A recent study of penetrating
trauma in 16 animals (15 dogs and 1 cat) found that the thoracic cavity was affected in 6 patients, the
Editor
D. Allen, DVM, MSc, DACVIM
Small Animal Internal Medicine
A. Abrams Ogg, DVM, DVSc, DACVIM
M. Barry, DVM, DVSc, ACVIM
S. Blois, DVM, DVSc, DACVIM
A. Defarges, DVM, MSc, DACVIM
S. Kruth, DVM, DACVIM
D. Richardson, DVM, DACVIM
B. Rutland, BSc(VB), BVMS, DACVIM
Small Animal Surgery
S. Boston, DVM, DVSc, DACVS
B. Brisson, DMV, DVSc, DACVS
T. Gibson, DVM, DVSc, DACVS
A. Kisiel, DVM, MSc
N. Moens, DVM, DACVS, DECVS
A. Singh, DVM, DVSc, DACVS
E. Stone, DVM, MSc, MPP Dean, OVC
Ophthalmology
C. Pinard, DVM, MSc, DACVO
Dermatology
A. Yu, DVM, MSc, DACVD
Cardiology
M. OGrady, DVM, MSc, DACVIM
L. OSullivan, DVM, DVSc, DACVIM
Neurology
L. Gaitero, DVM, DECVN
F. James, DVM, MSc, DVSc, DACVIM
Critical Care
S. Bateman, DVM, DVSc, DACVECC
A. Bersenas, DVM, DVSc, DACVECC
M. Holowaychuk, DVM, DACVECC
K. Mathews, DVM, DVSc, DACVECC
Radiology
H. Chalmers, DVM, DACVR
S. Nykamp DVM, DACVR
Anesthesia
D. Dyson, DVM, DVSc, DACVA
C. Kerr, DVM, DVSc, PhD, DACVA
M. Sinclair, DVM, DVSc, DACVA
P. Steagall, MV, MSc, PhD
A. Valverde, DVM, DVSc, DACVA
Oncology
A. Mutsaers, DVM, PhD, DACVIM
M. Parsons-Doherty, BSc, DVM
V. Poirier, DVM, DACVIM, DECVIM-CA, DACVR
P. Woods, DVM, MSc, DACVIM
Ontario Veterinary College
University of Guelph
50 Stone Road, Guelph, Ontario, N1G 2W1
A Veterinarian Learning Resource authored by the Department of Clinical Studies, Ontario Veterinary College, University of Guelph
Volume 1, Issue 3
2011
Available online at www.canadianveterinarians.net/savrounds
The Canadian Veterinary
Medical Association recognizes
the educational value of this
publication and provides
support for its distribution
Veterinary Rounds
SMALLANIMAL
TABLE 1. Obtaining an abbreviated history for an
animal presenting emergently: AMPLE
A Allergies Has the animal experienced an adverse
reaction to medications or to blood
products previously given?
M Medications List all medications the animal is given,
including nutraceuticals. When were they
given last? When are the next doses due?
P Past history Are there any past medical or surgical
conditions?
L Last When were the last meal, urination, and
bowel movements? When was the animal
last observed to be healthy?
E Events What were the events that led to the animal
presenting to the clinic? Include any visits to
other veterinary clinics and any treatments
administered.
abdominal cavity in 3 patients, and both cavities in 5 patients.
5
The trachea was also injured in 2 patients. The thoracic cavity
was affected in 50% of animal altercation cases, and injuries
included rib fractures, pneumothorax, subcutaneous emphy-
sema, and body wall disruption.
5
Generally, animals sustaining trauma are young, male, and
sexually intact.
1,4-8
A recent retrospective study investigating 235
dogs injured by blunt trauma found that most were 2-3 years
old and medium-large breeds.
4
Conversely, dogs sustaining
penetrating injuries were small breed dogs (mean 7.1 kg body
weight).
5
Additionally, Jack Russell terriers and Dachshunds
were dramatically overrepresented for trauma caused by animal
altercations.
5
Preparedness
Evidence indicates that injured patients benefit from the
preparedness of the hospital and staff, as well as a team
approach to emergency cases.
9
Ideally, a veterinarian and at
least 2 technical support staff should be available in the event
of a trauma emergency. The period immediately following a
traumatic event constitutes the golden hour of emergency
medicine when rapid assessment and resuscitation are critical
and more easily achieved with appropriate preparedness and
pre-planning. A ready area for handling emergencies and
providing immediate resuscitation should be designated and
maintained in the hospital. This area requires good lighting
and a level of organization allowing most emergency supplies
to be readily accessible. Equipment such as an oxygen source,
a crash cart, monitoring equipment, and supplies for catheter
placement, fluid resuscitation, warming, and wound manage-
ment should be within reach. A backboard made of plexiglass
or plastic, or a commercially available stretcher, cart, or gur-
ney can be helpful to transport nonambulatory patients.
Every trauma patient should be assessed in an orderly and
systematic fashion. Immediately upon the animals presenta-
tion, a veterinarian or well-trained technician/assistant should
make the following assessments: level of consciousness, airway
patency (listen for increased, decreased, or absence of airway
sounds), breathing rate and effort (watch chest movements),
strength and rate of pulse (palpation) or heart sounds (ausculta-
tion), colour of mucous membranes, and capillary refill time
(CRT). Check for external abnormalities such as hemorrhage,
sucking wounds in the neck or chest, and abdominal distension.
If the animal is deemed unstable, it should be moved to the
ready area immediately. Animals should be carried or moved
on a stretcher or a trolley; avoid letting them walk in case they
collapse. Do not place a leash around the neck of animals with
head, ocular, neck, or respiratory injuries or problems. One
assistant should stay with the owner to obtain an adequate his-
tory and ensure that the owner is calm. Conversely, the owner
may accompany the pet to the ready area so that additional
information can be obtained while early interventions are being
accomplished. Almost immediately, the owner should be asked
the following questions:
Can we begin oxygen therapy and place an intravenous
(IV) catheter?
Can cardiopulmonary resuscitation be started if your pet
arrests?
Examination gloves should always be worn to avoid contamination
of open wounds with nosocomial bacteria. Additionally, animals
are often covered in blood and it may be blood from the injured
animal or from the injured person who handled the animal.
It is very important to obtain a sufficient history even dur-
ing an emergency. When time is of the essence, the acronym
AMPLE Allergies, Medications, Past history, Last, Events
is useful to ensure pertinent questions are asked (Table 1).
Triage
The term triage is derived from the French verb trier,
which means to pick or to sort. In veterinary medicine,
triage is defined as a systematic approach used to treat the most
severely injured animals first, and to define the most life-threat-
ening injury, with the hope of saving lives and decreasing mor-
bidity.
10,11
For trauma patients, many will present with multiple
injuries that must be prioritized. In general, injuries placed in
order from most to least critical include arterial bleeding (in
practice, it is rare for animals to live long enough following the
traumatic event for you to see these cases), followed by injuries
to the respiratory, cardiovascular, neurological, abdominal,
musculoskeletal, and dermatological systems. A primary survey
is performed initially to assess the injuries, followed by a sec-
ondary survey and further diagnostic tests once the patient is
considered relatively stable.
Primary survey
Every animal presenting following trauma requires an ini-
tial assessment focusing on the most life-threatening body sys-
tems. This is best remembered by addressing the ABCDEs
(Airway, Breathing, Circulation/Consciousness, Drugs, Exami-
nation/ Electrocardiogram [ECG]). If a problem is identified
during the primary survey, begin corrective therapy immedi-
ately. For the airway, first assess whether air is moving (ie,
patency of the airway) and whether there are mandibular, tra-
cheal, or laryngeal injuries that could interfere with the airway.
A nonpatent airway necessitates immediate endotracheal intu-
bation. If intubation is impossible due to excessive swelling,
bleeding, or fractures, an emergency tracheotomy is required.
Next, assess the animals ventilatory pattern (eg, normal,
tachypneic, dyspneic, hyperpneic, orthopneic). Examine the
colour of the mucous membranes and look for evidence of tho-
racic penetration or flail chest. Subsequently, evaluate for signs
of hemorrhage or hypovolemic shock, such as prolonged CRT,
weak and rapid femoral pulses, tachycardia, or cool extremities.
Note that cats presenting in severe shock typically exhibit
bradycardia, weak or absent femoral pulses, and hypothermia.
ble) during the examination and a rectal temperature should also
be taken. Incidental findings (eg, scraped nails, gravel, oil, punc-
ture wounds) should be noted because they may offer information
about what occurred. During or immediately after the examina-
tion, apply ECG leads and note the heart rate and rhythm.
Diagnostic tests
Blood obtained from the catheter hub after the stylet is
removed can provide a minimum database. Since most trauma
patients are young and otherwise healthy, extensive laboratory
tests are not usually necessary, but they can be performed later if
indicated based on history, physical examination findings, and
the results of the initial laboratory blood tests. Perform a packed
cell volume (PCV) and total solids (TS) to identify blood loss.
Lastly, evaluate for evidence of neurological impairment,
including altered mentation, recumbency, and lack of cranial
nerve or withdrawal reflexes. The letters AVPU may be used for
quick categorization of the animals neurological status: A = alert,
V = responsive to verbal stimulation, P = responds to painful
stimulation, and U = unresponsive to painful stimulation.
Seizure activity can be seen following head trauma and should
be controlled immediately with anticonvulsant therapy
(ie, diazepam 0.5 mg/kg IV or 1 mg/kg per rectum).
If at this point no abnormalities have been encountered,
consider administering pain-relieving medication (Table 2).
Butorphanol is a safe and effective sedative for all patients and
suitable for mild pain. If the pain is considered moderate to
severe, fentanyl, hydromorphone, or buprenorphine are recom-
mended. Nonsteroidal anti-inflammatory drugs (NSAIDs) are
excellent analgesics, but should not be given until the animal is
further assessed and stabilized. Steroids are not recommended
for the treatment of shock in trauma patients.
Once analgesics have been administered, perform a more
detailed examination to assess for other injuries. Investigate for
head trauma by gently palpating the face and skull for fractures or
lacerations and look for blood from the nose, mouth, ears, or eyes.
Palpate the trachea and neck for crepitus or wounds and auscul-
tate the lungs. For an animal in sternal recumbency, absent lung
sounds dorsally suggest pneumothorax and absent lung sounds
ventrally suggest pleural effusion. Perform a rapid evaluation of
the abdomen, flank, spine, limbs, anus, vulva, and pelvis. Palpate
distal limbs for temperature, pain, wounds, or fractures. Blood
pressure (oscillometric or Doppler) should be measured (if possi-
BY MICHELLE EVASON, DVM, DACVIM (SAIM)
The goal during hospitalization of a dog or cat is to maintain a
stable body weight. This is crucial since malnutrition and sub-
sequent weight loss cause elevations in catecholamines, gluco-
corticoids, and glucagon. An increase in these compounds
results in activation of the inammatory cascade, a decrease in
protein synthesis, and increased catabolism. Patients in a state
of malnutrition rely on muscle and adipose tissue as their
energy source, thus worsening catabolism. This is a vast over-
simplication of a complex process, but serves to illustrate the
importance of minimizing catabolism (especially of protein) in
hospitalized patients.
A study by Remillard et al
1
analyzed the number of hospi-
talized canine patients that were in a negative energy balance,
dened as <95% of the resting energy requirement (RER).The
daily feeding data and outcomes for 276 dogs over 821 days in
hospital was assessed and a negative energy balance was noted
on 73% of the days. This nding was attributed to: poorly writ-
ten orders (22%), orders to withhold food (34%), and dogs
that would not eat (44%). The study also found that caloric
intake had a signicant and positive effect on patient outcome.
The best method of nutritional support is enteral feeding,
unless it is unsafe to do so in light of the patients health sta-
tus and specic condition.The maximif the gut works, use it
supports our current understanding that enteral feeding main-
tains gastro-intestinal tract health and prevents bacterial
translocation. Mohr et al
2
investigated the effect of early
enteral nutrition versus NPO (nil per os) in dogs with parvo-
virus enteritis. The group that received early enteral nutrition
(within 24 hours of hospitalization) gained weight, improved
gastrointestinal barrier function, and perhaps most impor-
tantly had a shorter recovery period.
When determining the energy requirement for a hospital-
ized patient, it is imperative to calculate the patients resting
energy requirement to meet needs, maintain stable body
weight, and prevent malnutrition this means no less than
RER = 70 x (body weight in kg)
0.75
kcals/day. It is important to
note that individual patient variation can increase this require-
ment up to 30%, so monitoring body weight at least once daily
in hospital is vital.
Maximizing the diets energy content becomes essential, as
often there is a need to limit meal volumes to help prevent
vomiting and slowly regain normal intake amounts. Diets with
higher calorie content allow for greater energy density, and
increasing dietary fat achieves this goal for most hospitalized
patients. However, caution must be used in patients with fat
intolerant conditions (such as pancreatitis). Protein content
should be sufcient to maintain a positive nitrogen balance;
providing a greater number of total calories from protein
helps prevent loss of lean body mass. Thus, the recommended
in-hospital diet achieves the following goals: high energy den-
sity, protein and water content (ie. canned diet or slurry), and,
if provided orally, is highly palatable.
References:
1. Remillard RL, Darden DE, Michel KE, et al. An investigation of the caloric
intake and outcome of hospitalized dogs. Vet Ther. 2001;2(4):301-310.
2. Mohr AJ, Leisewitz AL, Jacobson LS, et al. Effect of early enteral nutrition
on intestinal permeability, intestinal protein loss, and outcomes in dogs
with severe parvoviral enteritis. J Vet Intern Med. 2003;17(6):791-798.
In-hospital Nutrition Think About It!
TABLE 2. Suggested analgesics for dogs and cats
following trauma
Analgesic Cat Dose Dog Dose
Fentanyl 1-2 g/kg IV bolus 2-3 g/kg IV bolus
followed by 2-5 g/ followed by 2-6 g/
kg/hour IV continuous kg/hour IV continuous
rate infusion rate infusion
Hydromorphone 0.02-0.05 mg/kg IV 0.05-0.1 mg/kg IV
or IM every 4 hours or IM every 4 hours
Buprenorphine 0.005-0.02 mg/kg IV or 0.005-0.02 mg/kg IV
IM every 8-12 hours or IM every 6-8 hours
Butorphanol 0.2-0.4 mg/kg IV or 0.2-0.4 mg/kg IV or
IM every 2-4 hours IM every 2-4 hours
IV = intravenous; IM = intramuscular
Initially, even with blood loss, the PCV might be normal
due to splenic contraction in dogs (this does not occur in
cats) and the length of time it takes for interstitial fluid to
move into the intravascular space. Serial measurements of
PCV and TS are often more accurate indicators of blood
loss following trauma. Other measurements should also be
taken, including blood urea nitrogen to assess for azotemia
and blood glucose (glucometer). Hyperglycemia is associ-
ated with more severe injuries in veterinary patients with
head trauma
12
and is a negative prognostic indicator in peo-
ple following trauma.
13
Blood lactate should also be mea-
sured using a handheld monitor validated for use in dogs
and cats, and repeated later to gauge the response to fluid
therapy and shock resuscitation.
14-16
Radiographs should only be performed after a complete
physical examination to identify the area in question and
only when the patient is adequately stabilized. Radiographs
of fractures are not essential in the first 12-24 hours of care.
Remember that thoracic injuries occur in almost every
trauma patient; therefore, thoracic radiographs should be
obtained on all animals suffering from trauma.
Focused assessment using sonography for trauma
(FAST) is a simple and rapid ultrasound examination that
can be performed in animals in an emergency setting to
detect intra-abdominal free fluid suggestive of hemorrhage
or organ rupture (eg, uroabdomen).
17,18
Veterinarians with
limited previous ultrasound experience can perform a
FAST examination in under 5 minutes. It can be used
with a scoring system (0-4) to evaluate for the presence of
fluid (anechoic) in 4 areas.
19
With the patient in lateral
recumbency (preferably right lateral), use the ultrasound
probe to assess for fluid: 1) just caudal to the xiphoid
process, 2) on the midline over the urinary bladder, and at
the 3) left and 4) right flank regions. During the FAST
examination, the urinary bladder and gallbladder can also
be visualized. Although an organ is visualized on radi-
ographs or ultrasound and appears intact, organ rupture
(eg, urinary bladder, urethra, gallbladder) can still be pre-
sent. FAST can be performed on initial presentation and
serially thereafter to monitor for the presence of abdomi-
nal fluid. If abdominal fluid is found, an abdominocente-
sis can be performed to obtain a sample of fluid for
analysis. If the sample appears bloody, place it in a red top
blood tube to ascertain that it does not clot. If the fluid
sample clots, it is possible that a blood vessel or organ (eg,
spleen) was inadvertently aspirated. Otherwise, perform a
PCV and TS on the fluid; a PCV >10% is suggestive of
hemorrhage.
20
If a uroabdomen is suspected, measure the
potassium or creatinine concentration of the fluid and
compare it to the peripheral blood (serum). A fluid:serum
ratio of potassium >1.4 or creatinine >2.0 is consistent
with a uroabdomen.
20
Biliary ruptures are not typically
diagnosed until days to weeks following the traumatic
event. A fluid:serum ratio of bilirubin >2.0 is consistent
with a bile peritonitis.
20
Secondary survey
Once the primary survey is complete and life-threaten-
ing problems are addressed, the secondary survey should
begin. This involves a more detailed examination for poten-
tial life threatening or complicating injuries (Table 3). After
completion of the primary and secondary surveys, a problem
list should be formulated with diagnostic and therapeutic
plans for each problem. Radiographs and other diagnostic
tests can then be performed if the animal is stable.
Tertiary survey
Approximately 12-24 hours following presentation,
the animal must be thoroughly re-evaluated. The tertiary
survey is ideally performed by a different veterinarian and
is used to evaluate the response to therapy/stabilization
and identify any previously hidden or overlooked prob-
lems. The key to successful management of trauma cases is
constant monitoring and reassessment as the patients sta-
tus can change at any time.
Management of Trauma Patients
Aside from specific repair of fractures, lacerations,
wounds, and organ ruptures, treatment for the vast major-
ity of trauma patients is supportive. Initially, this includes
emergent fluid resuscitation, oxygen therapy, and pain
management. Thereafter, monitoring and treatment for
cardiac arrhythmias, pulmonary contusions, and traumatic
brain injury (TBI) might be required.
Emergent fluid resuscitation
IV access should be obtained in all trauma cases. Short
large-bore catheters are ideal for emergency fluid resusci-
tation. Catheter size will vary depending on the size of the
animal, ease of access, and rapidity of fluid delivery.
Peripherally, 20-22 G catheters are recommended for cats,
and 16-20 G catheters are recommended for dogs. Once
the catheter is placed, if blood samples have not already
been obtained, they can be collected from the catheter for
laboratory tests.
When a patient has clinical signs of poor perfusion
(shock), the blood volume must be restored as soon as pos-
sible. Clinical signs of poor perfusion include tachycardia,
poor pulse quality, hypotension, prolonged CRT, pale
mucous membrane colour, hypothermia, and cool extrem-
ities. The volume of fluid required to treat shock is based
on the patients weight and estimated blood volume. If iso-
tonic crystalloids (eg, balanced electrolyte solutions,
sodium chloride [NaCl] 0.9%) are used, administering 1
full blood volume might be required over an hour. This
would necessitate 80-90 mL/kg in dogs, and 45-60 mL/kg
Veterinary Rounds
SMALLANIMAL
TABLE 3. Secondary survey of all potentially
injured body systems: A CRASH PLAN
A airway
C circulation, cardiovascular (bleeding)
R respiration (breathing)
A abdomen, analgesics
S spine, skin, scrotum
H head /mentation, hydration, hypothermia
P pelvis, perineum (vulva, anus, rectal exam)
L limbs (wounds, fractures, swelling, pain)
A arteries/veins
N nerves, neck, neurologic examination, nutritional status
in cats. The animals response to fluid resuscitation deter-
mines the approximate volume that is administered. The
recommended regimen for fluid resuscitation during shock
is to divide the total volume to be given over 1 hour into
smaller volumes and use frequent monitoring to assess the
response. By dividing the total fluid volume into
1
4 volumes
and monitoring every 15 minutes, it is easier to determine
when emergent fluid resuscitation is complete. Not all
patients in shock will require replacement of a full blood
volume to treat their shock. If the clinical signs of shock
resolve after the first 15 minutes, there is no need to pro-
ceed with another bolus of fluid.
Clinical and laboratory signs (Table 4) should be moni-
tored frequently during fluid resuscitation (every 5-15 min-
utes). If possible, a PCV/TS and lactate should also be
measured following 30-60 minutes of fluid resuscitation and
compared with the baseline values collected on presentation.
Be cautious about overhydration, since excessive increases in
hydrostatic pressure may worsen the status of patients with
pulmonary contusions or cerebral edema, or dislodge clots
that are providing life-saving hemostasis. Signs of over-
hydration include chemosis, serous nasal discharge, and
peripheral or pulmonary edema. The following changes are
noted with successful shock resuscitation: decreased heart
rate, increased blood pressure, improved pulse pressure,
increased temperature of the extremities, improved mucous
membrane colour, shortened CRT, and decreased lactate. If
perfusion parameters do not improve despite administration
of a complete shock volume of isotonic crystalloid fluids,
ongoing blood loss should be considered and a FAST exam-
ination performed to evaluate for a possible hemoabdomen.
A transfusion of whole blood may be required for patients
with evidence of hemorrhage, if shock cannot be stabilized
with intravenous fluid resuscitation.
Hypertonic saline (NaCl 3%-7%) is often used in the
treatment of shock and trauma to more rapidly expand the
intravascular fluid compartment. Hypertonic saline also causes
a decrease in intracranial pressure, which can be advanta-
geous for patients with TBI. Side effects of hypertonic
saline include hypernatremia, hyperchloremia, and meta-
bolic acidosis; in addition, bronchoconstriction or shallow
breathing can be seen with rapid infusions. The recom-
mended dose of hypertonic saline is 4-6 mL/kg (dogs) and
2-4 mL/kg (cats) administered as a bolus over 15 minutes.
Pulmonary contusions
Pulmonary contusions are a common consequence of
blunt thoracic trauma; they are characterized by damage
to the pulmonary vasculature and subsequent leakage of
blood and plasma into the interstitium and alveoli. The
extent of the injury ranges from mild focal bruising in 1
lung lobe to severe diffuse hemorrhage affecting the entire
lung. The severity of clinical signs is dependent upon the
extent of lung injury, ranging from mild respiratory signs
to severe respiratory impairment or failure.
21
Pulmonary
impairment from contusions can progress until 24-48
hours following the traumatic episode; therefore, animals
can present with adequate respiratory function and then
later decompensate.
21
As a result, close monitoring of ani-
mals with thoracic trauma is essential to ensure that if
signs develop, they are treated appropriately.
Radiographic evidence of pulmonary contusions might
not become evident until 12-24 hours following trauma,
and prior radiographs might appear normal.
21
A high index of suspicion for pulmonary contusions
should be present in any animal that sustains nonpenetrat-
ing chest trauma, especially those with concurrent thoracic
wall injuries. Pulmonary contusions occur in approxi-
mately 40%-50% of all animals sustaining chest injuries.
4
Care of animals with pulmonary contusions is primarily
supportive and includes oxygen therapy, pain manage-
ment, and management of shock and concurrent injuries.
Diuretics and bronchodilators are not effective for treating
pulmonary contusions. In severely affected cases, emer-
gency ventilation can be achieved manually using an anes-
thetic machine reservoir bag or an artificial manual
breathing unit (AMBU) bag; however, long-term ventila-
tion requires a mechanical ventilator, usually necessitating
referral to a specialty centre. Clinical signs generally
resolve in approximately 1 week; however, oxygen supple-
mentation is only required for 2-3 days in most cases.
22
Ventricular arrhythmias
An ECG is helpful for enabling moment-to-moment
monitoring of heart rate during emergent fluid resuscita-
tion and in assessing for arrhythmias in animals with
tachycardia or bradycardia. Ventricular arrhythmias are
the most common arrhythmias seen in injured dogs, but
are much less common in cats.
23
They can occur due to
myocardial injury (ie, traumatic myocarditis), metabolic
acidosis, electrolyte disturbances (ie, hypokalemia, hypo-
magnesemia), pain, hypovolemia, splenic disease (eg, tor-
sion), or heart disease.
24,25
Arrhythmias can occur from
12-36 hours following the traumatic event; therefore,
hospitalization and ECG/heart rate monitoring of dogs
for 24 hours after trauma is strongly recommended.
Treatment of ventricular arrhythmias is recommended if
the arrhythmia is sustained, fast (relative to the size of the
patient), appears multifocal or polymorphic, displays R on T
phenomena, causes hypotension (mean arterial pressure
<70 mmHg), or is associated with pre-existing heart disease.
Initial treatment (for dogs) is lidocaine 2 mg/kg IV repeated
up to a total dose of 8 mg/kg IV. If the dog does not
respond to lidocaine, procainamide may be given at a dose
of 6-10 mg/kg IV slowly over 15 minutes. Magnesium sul-
fate can also be effective for ventricular arrhythmias at a
dose of 0.3 mEq/kg IV diluted 1:10 in water with 5% dex-
trose (D5W) and given over 20-30 minutes. Many under-
Veterinary Rounds
SMALLANIMAL
TABLE 4. Suggested endpoint parameters for
uid resuscitation
Parameter Desired value
Heart rate Dogs: 80-140 beats/min
Cats: 160-200 beats/min
Systolic blood pressure 100-120 mm Hg
Mean arterial blood pressure 70-80 mm Hg
Urine output >1 mL/kg/hour
Lactate <1-2 mmol/L
lying issues can cause ventricular arrhythmias; therefore, it is
important to measure electrolytes, provide analgesia, and ensure
that appropriate treatment such as oxygen therapy is provided.
Prognosis
The severity of the injuries and organ systems affected
often determine the likelihood of survival following trauma; in
general, however, the prognosis is good and 80%-90% of ani-
mals survive.
4,6-8
Dogs with polytrauma, TBI, cardiac arrhyth-
mias, body wall hernias, severe soft tissue injuries, vertebral
fractures, or recumbency at admission have a higher mortality
following blunt trauma.
4,6,7
Conclusions
Many dogs and cats present to veterinary hospitals emer-
gently following trauma. Injuries can range from superficial skin
abrasions to severe life-threatening head injuries or abdominal
organ ruptures. Regardless of the underlying cause of the
trauma or the injuries sustained, the general approach and sup-
portive care for trauma cases are similar and include providing
analgesia, appropriate fluid resuscitation, and continuous mon-
itoring and management of specific injuries. With appropriate
preparedness and systematic assessment of each case, the prog-
nosis for survival is excellent.
Dr. Holowaychuk is an Assistant Professor in Emergency and Critical Care
Medicine at the Ontario Veterinary College in Guelph, Ontario. Dr. Evason
is Manager, Veterinary Professional Services, Medi-Cal/Royal Canin.
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information in this article is intended solely for the general information of the reader, is not to be used for treatment purposes, and is not intended to diagnose health problems or to take the place of professional
veterinarian care. While this article attempts to be as accurate as possible, it should not be relied upon as being comprehensive or error-free. The reader assumes all responsibility and risk for the use of this article.
Under no circumstances shall the Ontario Veterinary College, the University of Guelph, their employees and agents, or anyone else involved in creating this article be liable for any DIRECT, INDIRECT, INCI-
DENTAL, SPECIAL or CONSEQUENTIAL DAMAGES, or LOST PROFITS that result directly or indirectly from the use this article or that result directly or indirectly from mistakes, omissions, or errors in this
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Disclosure Statement: Dr. Holowaychuk has stated that she has no disclo-
sures to announce in association with the contents of this issue.