A = Airway

Is the airway patent? Pull the patient’s tongue forward and remove any debris obstructing the airway. Suction and a laryngoscope may be necessary. Intubate, or place a transtracheal oxygen source, if necessary. An emergency tracheostomy may be necessary if upper airway obstruction is present and cannot be resolved immediately with the foregoing measures.

B = Breathing

Is the animal breathing? If the animal is not breathing, immediately intubate the animal and start artificial ventilations with a supplemental oxygen source (see Cardiac Arrest and Cardiopulmonary Cerebral Resuscitation).

If the animal is breathing, what are the respiratory rate and pattern? Is the respiratory rate normal, increased, or decreased? Is the respiratory pattern normal, or is the breathing rapid and shallow, or slow and deep with inspiratory distress? Are the respiratory noises normal, or is there a high-pitched stridor on inspiration characteristic of an upper airway obstruction? Does the animal have its head extended and elbows abducted away from the body with orthopnea? Do the commissures of the mouth move with inhalation and exhalation? Is there evidence of expiratory distress with an abdominal push on exhalation? Note the lateral chest wall. Do the ribs move out and in with inhalation and exhalation, or is there paradoxical chest wall motion in an area that moves in during inhalation and out during exhalation, suggestive of a flail chest? Is there any subcutaneous emphysema that suggests airway injury?

Auscultate the thorax bilaterally. Are the breath sounds normal? Do they sound harsh with crackles because of pneumonia, pulmonary edema, or pulmonary contusions? Are the lung sounds muffled because of pleural effusion or pneumothorax? Are there inspiratory wheezes in a cat with bronchitis (asthma)? What is the mucous membrane color? Are the mucous membranes pink and normal, or pale or cyanotic? Palpate the neck, lateral thorax, and dorsal cervical region to check for tracheal displacement, subcutaneous emphysema, and rib fractures.

C = Circulation

What is the circulatory status? What is the status of the patient’s heart rate and rhythm? Can you hear the heart, or is it muffled because of hypovolemia, pleural or pericardial effusion, pneumothorax, or diaphragmatic hernia? Palpate the pulses. Is the pulse quality strong and regular and synchronous with each heartbeat, or are there thready, dropped pulses? What are the patient’s electrocardiogram (ECG) rhythm and blood pressure (BP)?

Is there arterial hemorrhage? Note whether there is any bleeding present. Use caution if there is any blood on the fur. Wear gloves. The blood may be from the patient, and gloves will help prevent further contamination of any wounds; or the blood may be from a good Samaritan bystander. If external wounds are present, note their character and condition. Place a pressure bandage on any arterial bleeding or external wounds to prevent further hemorrhage or contamination with nosocomial organisms.

Establish large-bore vascular or intraosseous access (see Vascular Access Techniques). If hypovolemic or hemorrhagic shock is present, institute immediate fluid resuscitation measures. Start with one fourth of a calculated shock dose of crystalloid fluids (0.25 × [90 mL/kg] for dogs; 0.25 × [44 mL/kg] for cats), and reassess perfusion parameters of heart rate, capillary refill time, and BP. If pulmonary contusions are suspected, use of a colloid such as hydroxyethyl starch at 5 mL/kg in incremental boluses can improve perfusion with a smaller volume of fluid. In cases of head trauma, hypertonic (7%) sodium chloride (saline) can be administered (4 mL/kg intravenous bolus) with hydroxyethyl starch. Acute abdominal hemorrhage caused by trauma can be tamponaded with an abdominal compression bandage.

After the immediate ABCs, proceed with the rest of the physical examination and treatment by using the mnemonic A CRASH PLAN.

A = Airway

S = Spine

Palpate the animal’s spine for symmetry. Is any pain or obvious swelling or fracture present? Perform a neurologic examination from C1 to the last caudal vertebra.

H = Head

Examine the eyes, ears, mouth, teeth, nose, and all cranial nerves. Stain the eyes with fluorescence dye to examine for corneal ulcers in any case of head trauma. Is anisocoria or Horner syndrome present?

P = Pelvis

Perform a rectal examination. Palpate for fractures or hemorrhage. Examine the perineal and rectal areas. Examine the external genitalia.

L = Limbs

Examine the pectoral and pelvic extremities. Are there any obvious open or closed fractures? Quickly splint the limbs to prevent further damage and help control pain. Examine the skin, muscles, and tendons.

A = Arteries

Palpate the peripheral arteries for pulses. Use a Doppler piezoelectric crystal to aid in finding a pulse if thromboembolic disease is present. Measure the patient’s BP.

N = Nerves

From afar, note the level of consciousness, behavior, and posture. Note respiratory rate, pattern, and effort. Is the patient conscious, or is the patient obtunded or comatose? Are the pupils symmetric and responsive to light, or is there anisocoria present? Does the patient display any abnormal postures such as Schiff-Sherrington posture (extended rigid forelimbs, flaccid paralysis of the hind limbs) that may signify severe spinal shock or a severed spinal cord? Examine the peripheral nerves for motor and sensory input and output to the limbs and tail.

Early Repair

During the early stage of repair, granulation tissue, some exudate, and minor epithelialization are observed. Place a nonadherent bandage with some antibacterial properties (petroleum- or nitrofurazone-impregnated gauze) or absorbent material (foam sponge, hydrogel, or hydrocolloid dressing) in direct contact with the wound to minimize disruption of the granulation tissue bed. Next, place an absorbent intermediate layer, followed by a porous outer layer, as previously described. Granulation tissue can grow through gauze mesh or adhere to foam sponges and can be ripped away at the time of bandage removal. Hemorrhage and disruption of the granulation tissue bed can occur.

Late Repair

Later in the repair process, granulation tissue can exude sanguineous drainage and have some epithelialization. A late nonadherent bandage is required. The contact layer should be some form of nonadherent dressing, foam sponge, hydrogel, or hydrocolloid substance. The intermediate layer and outer layers should be absorbent material and porous tape, respectively. With nonadherent dressings, wounds with viscous exudates may not be absorbed well. This may be advantageous and enhance epithelialization, provided that complications do not occur. Infection, exuberant granulation tissue, or adherence of absorbent materials to the wound may occur and delay the healing process.

Wounds with No Drainage

For closed wounds without any drainage, such as a laceration that has been repaired surgically, a simple bandage with a nonadherent contact layer (e.g., Telfa pad [Kendall]), an intermediate layer of absorbent material, and an outer porous layer (Elastikon, Vetrap) can be placed to prevent wound contamination during healing. The nonadherent pad will not stick to the wound and cause patient discomfort. Because there usually is minimal drainage from the wound, the function of the intermediate layer is more protective than absorptive. Any small amount will be absorbed into the intermediate layer of the bandage. It is important with any bandage to place the tape strips or “stirrups” on the patient’s limb and then overlap in the bandage, to prevent the bandage from slipping. Place the intermediate and tertiary layers loosely around the limb, starting distally and working proximally, with some overlap with each consecutive layer. This method prevents excessive pressure and potential impairment of venous drainage. Leave the toenails of the third and fourth digits exposed, whenever possible, to allow daily examination of the bandage to determine whether the bandage is impairing venous drainage. If the bandage is too tight and constricting or impeding vascular flow, the toes will become swollen and spread apart. When placed and maintained properly (e.g., the bandage does not get wet), there usually are relatively few complications observed with this type of bandage.

Wounds with Drainage

In some cases it is necessary to cover a wound in which a Penrose drain has been placed to allow drainage. In many cases there is a considerable amount of drainage from the drain and underlying soft tissues. The function of the bandage is to help obliterate dead space created by the wound itself, absorb the fluid that drains from the wound and that will contaminate the environment, and prevent external wicking of material from the external environment into the wound. When the bandage is removed, the clinician can examine the amount and type of material that has drained from the wound in order to determine when the drain should be removed.

When a bandage is placed over a draining wound, the contact layer should be a commercially available nonadherent dressing and several layers of absorbent wide-mesh gauze placed directly over the drain at the distal end of the incision. Overlay the layers of gauze with a thick layer of absorbent intermediate dressing to absorb fluid that drains from the wound. If the gauze and intermediate layers are not thick or absorbent enough, there is a potential for the drainage fluid to reach the outer layer of the bandage and provide a source of wicking of bacteria from the external environment into the wound, leading to infection.

Minor Hemorrhage

Some wounds such as lacerations have minor bleeding or hemorrhage that require an immediate bandage until definitive care can be provided. To create a pressure bandage, place a nonadherent dressing immediately in contact with the wound, followed by a thick layer of absorbent material, topped by a layer of elastic bandage material such as Elastikon or Vetrap. Unlike the bandage for a closed wound, the top tertiary outer layer should be wrapped with some tension and even pressure around the limb, starting from the distal extremity (toes) and working proximally. The pressure bandage serves to control hemorrhage but should not be left on for long periods. Pressure bandages that have been left on for too long can impair nerve function and lead to tissue necrosis and slough. Therefore pressure bandages should be used in the hospital only, so that the patient can be observed closely. If hemorrhage through the bandage occurs, place another bandage over the first until the wound can be repaired definitively. Removal of the first bandage will only disrupt any clot that has formed and cause additional hemorrhage to occur.

Initial Fracture Immobilization

Fractures require immediate immobilization to prevent additional patient discomfort and further trauma to the soft tissues of the affected limb. As with all bandages, a contact layer, an intermediate layer, and an outer layer should be used. Place the contact layer in accordance with any type of wound present. The intermediate layer should be thick absorbent material, followed by a top layer of elastic bandage material. An example is to place a Telfa pad over a wound in an open distal radius-ulna fracture, followed by a thick layer of cotton gauze cast padding, followed by an elastic layer of Kling (Johnson & Johnson Medical, Arlington, Texas), pulling each layer tightly over the previous layer with some overlap until the resultant bandage can be “thumped” with the clinician’s thumb and forefinger and sound like a ripe watermelon. The bandage should be smooth with consecutive layers of even pressure on the limb, starting distally and working proximally. Leave the toenails of the third and fourth digits exposed to allow monitoring for impaired venous drainage that would suggest that the bandage is too tight and needs to be replaced. Finally, place a top layer of Vetrap or Elastikon over the intermediary layer to protect it from becoming contaminated. If the bandage is used with a compound or open fracture, drainage may be impaired and actually lead to enhanced risk of wound infection. Bandages placed for initial fracture immobilization are temporary until definitive fracture repair can be performed once the patient’s cardiovascular and respiratory status is stable.

Exuberant Granulation Tissue

Wounds with exuberant granulation tissue must be handled carefully so as to not disrupt the healing process but to keep an overabundance of tissue from forming that will impair epithelialization. To bandage a wound with exuberant granulation tissue, place a corticosteroid-containing ointment on the wound, followed by a nonadherent contact layer. The corticosteroid will help control the exuberant growth of granulation tissue. Next, carefully wrap an absorbent material over the contact layer, then carefully place an overlay of elastic bandage material to apply some pressure on the wound. Leave the toenails of the third and fourth digits exposed so that circulation can be monitored several times daily. Bandages that are too tight must be removed immediately to prevent damage to neuronal tissue and impaired vascularization, tissue necrosis, and slough. Because wound drainage may be impaired, there is a risk of infection.

Obliteration of Dead Space

Gaping wounds or those that have undermined the areas between layers of subcutaneous tissue and fascia should be bandaged with a pressure bandage to help obliterate dead space and prevent seroma formation. An example of a wound that may require this type of bandage is the wound resulting from removal of an infiltrative lipoma on the lateral or ventral thorax. Use caution when placing pressure bandages around the thorax or cervical region because bandages placed too tightly may impair adequate ventilation. To place a pressure bandage and obliterate dead space, place a nonadherent contact layer over the wound. Usually a drain is placed in the wound, so place a large amount of wide-mesh gauze at the distal end of the drain to absorb any wound exudate or drainage. Place several layers of absorbent material over the site to further absorb any drainage. Place a layer of elastic cotton such as Kling carefully but firmly over the dead space to cause enough pressure to control drainage. Place at least two fingers between the animal’s thorax and the bandage to ensure that the bandage is not too tight. In many cases the bandage should be placed once the animal has recovered from surgery and is able to stand. If the bandage is placed while the animal is still anesthetized and recumbent, there is a tendency for the bandage to be too tight. Finally, the tertiary layer should be an elastic material such as Elastikon or Vetrap.

Modified Doughnut Bandage

A modified doughnut bandage should be placed over bony prominences on the limbs when there are early signs of pressure such as hyperemia, to prevent further injury. To place a modified doughnut bandage, cast padding material, thick wrapping material, and porous adhesive or loose elastic tape are required. Because this type of bandage becomes compressed after two or three bandage changes, it must be replaced frequently.

To place a modified doughnut bandage, follow this procedure (Figure 1-1):

Figure 1-1: Modified doughnut bandage. A, Several layers of cast padding are folded together. B, The pad is folded on itself, and a slit is cut in its center. C, The slit is formed into a hole. D, The hole is placed over the bony prominence.

(From Swaim SF, Henderson RA: Small animal wound management, ed 2, Media, Pa, 1997, Williams & Wilkins.)

Doughnut-Shaped Bandage

Like the modified doughnut bandage, a doughnut-shaped bandage is used over bony prominences to help prevent excessive pressure over the area. The bandage commonly is used over bony prominences on the distal limbs, such as the lateral malleolus, when more padding is indicated than is provided with a modified doughnut bandage. To make a doughnut-shaped bandage, use a hand towel or length of stockinet bandage material, tape, cotton gauze, elastic bandage material, or suture with umbilical tape. As the bandage becomes compressed or soiled, change it to prevent further damage to the underlying tissues.

To create a doughnut-shaped bandage, follow this procedure (Figures 1-2 and 1-3):

Figure 1-2: Doughnut-shaped bandage created from stockinet bandage material over the olecranon.

Figure 1-3: The tarsus.

External Pin Splints

An external pin splint is required when fractures or luxations are associated with open wounds. In some cases it may be difficult to bandage under the bars of the pin splint in such a way that the bandage is in contact with the wound. To create padding around the pins, fit foam rubber sponges to lie securely under and around the pins. Place bandages around the external fixator apparatus in layers to decrease contamination of the wound from the external environment and to absorb fluid that drains from the wound (Figures 1-4 to 1-6).

Figure 1-4: Foam rubber pads are placed under and around the pins of the external fixator, adjacent to the wound.

Figure 1-5: Cotton cast padding is placed around the external fixator to keep the foam rubber and contact layer securely in place.

Stay updated, free articles. Join our Telegram channel

Join