Apostila - Emergency.pdf

8/17/2019 Apostila - Emergency.pdf

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Rolfe M. Radcliffe, DVM,Diplomate ACVS

Emergency conditions of

the equine thorax

Rolfe M. RadcliffeDVM, Diplomate ACVS

Cornell University


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Thoracic Surgery• Summary

1. Sequellae2. Patient Stabilization

3. Diagnosis

4. Treatment

5. Surgical Considerations

6. Complications and Prognosis

7. Thoracoscopy


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Thoracic Trauma• Sequellae

1. SQ emphysema2. Pneumothorax

3. Pneumomediastinum

4. Hemothorax

5. Pleuritis

6. Diaphragmatic hernia

7. Lung, heart, vessels, abdomenAuer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999


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Thoracic Trauma• Clinical Signs

→ Pain 10/15 horses

(5 sustained rib fractures)

→

Abnormal respiration - 10(tachypnea, shallow, labored or distressed)

→ Decreased lung sounds - 8

→ Fluid lines (radiographs) - 6→ SQ emphysema - 12

Laverty, S, et al, EVJ 28(3), 1996


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Thoracic Trauma• Diagnosis

→ Deformed chest wall

→ Palpation (rib fractures)

→ Flail chest→ Radiographs and ultrasound

→ Thoracic or abdominal paracentesis

→ Thoracoscopy Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999


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Thoracic Trauma• Radiology/ Ultrasound

→ Diaphragmatic hernia

→ Pneumothorax

→ Pleural fluid (hemorrhage)

→ Atelectatic lung

→ Rib fractures

→ Foreign bodies

T. Divers

Hendrix, SM and Baxter, GM, VCNA-EP, 2005


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Thoracic Trauma• Diaphragmatic Hernia

→ Colic and dyspena

→ Acquired from blunt trauma

→ Radiology, ultrasound, thoracentesis

→ Treatment: Primary closure via midline

ceiliotomy, rib resection, thoracoscopy or

laparoscopy

T. Divers

Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999


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Thoracic Trauma• Pneumothorax

1. Open: open chest wound - air enters

pleural space during inspiration

2. Closed: lung laceration - air enters pleuralspace from lung

3. Tension: chest wound - one way valve creates

severe tension in pleural space

T. Divers


2nd Ed, 1999


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Thoracic Trauma• Pneumothorax

→ Causes: Pleuropneumonia (17/40), open

thoracic wounds (9), closed thoracic trauma (7),

surgery of the respiratory tract (4)→ Pneumothorax: bilateral 47.5%

unilateral 42.5%

→ Prognosis: worse if pleuropneumonia

T. Divers

Boy, MG, et al, JAVMA 216(12), 2000


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Thoracic Trauma• Treatment

1. Patient stabilization2. Conservative management

3. Surgical exploration

→ Wound debridement/ lavage

→ Thoracotomy

→ Thoracoscopy


2nd Ed, 1999


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Thoracic Trauma1. Patient Stabilization

Emergency Treatment → Remove pleural air

→ Close or bandage thoracic wounds quickly

→ Prevent tension pneumothorax→ Control hemorrhage if possible

→ Fluid therapy, blood transfusions, antibiotics,

oxygen supplementation



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Emergency Thoracentesis

→ Teat cannula or catheter

→

High in 12-15th intercostal space→ Extension set + 3-way stopcock

→ 60 ml syringe or suction pump

T. Divers


2nd Ed, 1999


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Tension Pneumothorax

→ Pleurocutaneous fistula

→

Rapid cardiopulmonary collapse→ Severe Hypoxemia (PaO2 22-28 mm Hg)

→ Thoracentesis (Patm = Ppleural)

→ Pneumothorax less detrimental

S. Fubini


2nd Ed, 1999


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Thoracic Trauma2. Conservative

→ Patient stabilization

→ Prevent tension pneumothorax

→

Simple rib fractures→ Wounds without severe lung lacerations,

continued hemorrhage, deep penetration,

abdominal cavity

N. Ducharme



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Thoracic Trauma3. Surgery

→ Patient stabilization

→ Deep penetrating wounds

→

Lung lacerations→ Complicated rib fractures (flail chest)

→ General Anesthesia with positive pressure

ventilationColahan, PT, et al, Equine Medicine

and Surgery, 5th Ed, 1999


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→ Explore pleural space

→ Control hemorrhage

→

Lavage pleural cavity → Repair lung lacerations

→ Repair rib fractures

→ Stabilize flail chest

N. Ducharme



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Thoracic Trauma• Surgery

Lung Lacerations→ Rib fractures lacerate lung parenchyma

→ Warm saline to detect bronchial damage

→ Close bronchioles

→ Appose lung margins

→ Mattress pattern with atraumatic needles

Fowler, ME, 1973, JAVMA, 162(11)


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Close Bronchioles→ Stapled or sutured

Fowler, ME, 1973, JAVMA, 162(11)


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Rib Fractures→ Control pain!

→ Remove rib fragments

→ Round sharp rib edges

→ Rib stabilization: Quill sutures, wires, plates

→ Adults heal without fixation

(Caution: closed pneumothorax)Auer, JA & Stick, JA, Equine Surgery,

2nd Ed, 1999


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→ External splint - flail chest

N. Ducharme


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→ Remove air from pleural cavity

→ Place thoracic drains (remove fluid and air)

→

Wound closure (muscle transposition)→ Skin closure techniques

→ Wound management



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Standing vs. GA→ GA required in most complicated cases

→ Risk tension pneumothorax (standing)

→ Thin, fenestrated caudal mediastinum

→ Bilateral pneumothorax fatal

→ Ultrasound and radiography

Colahan, PT, et al, Equine Medicine

and Surgery, 5th Ed, 1999


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Penetrating Wounds→ Trauma (fence posts, gates, pipes,

trees, wheelbarrows)

→ Access both thoracic and abdominal cavities→ Diaphragm extends to 6th rib on expiration

→ Explore: foreign bodies

→ Standing surgery

S. Fubini



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Thoracic Trauma - Foals→ 20% incidence of thoracic asymmetry

9 foals with rib fractures

→ No clinical signs→ History of dystocia

→ Primiparous mares

→ Fillies > colts

Jean D, et al, 1999, EVJ, 31(2)

T. Divers


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Rib Fractures - Foals→ 760 necropsy specimens

→ 19 of 76 (28%) foals died from rib fractures

→ Internal fixation (2.7mm reconstruction plates,cortical screws, cerclage wire, Steinmann pins)

12/14 (86%) survived

→ Steinmann pins: cyclic failure, implantmigration Schambourg, MA, et al, 2003, EVJ, 35

Bellezzo, F, et al, 2004, EVJ, 36(7)


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ReconstructionPlate

+ Screws

+ Cerclage Wire

Bellezzo, F, et al, 2004, EVJ, 36(7)


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Rib Fractures - Foals→ Multiple rib fx repair (ribs 2-9)

→ Life threatening when >3-5 ribs involved

→ Securos - cranial cruciate ligament repair

→ Holes drilled through outer cortex only

→ Decreased damage to parietal pleura

Kraus, BM, et al, 2005, Vet Sx, 34


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Wound Closure1. Primary closure or second intention

2. Primary muscle flap

3. Diaphragmatic advancement flap

4. Prosthetic mesh



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Muscle Pedicle Flap1. Longissimus - rotate ventral

2. External abdominal oblique - rotate dorsal

3. Z-plasty

4. Dogs: Polypropylene mesh, muscle flaps,

mesh & omental pedicle, mesh & PMMA,

diaphragmatic advancement flaps

Stone WC, et al, 1994, JAVMA, 205(6)


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Stone WC, et al, 1994, JAVMA, 205(6)

Muscle

Pedicle

Flap


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Skin Closure - tension relief 1. V-Y flaps

2. Z-Plasty

3. Skin flaps (H-plasty, Rotating flaps)

4. Mesh expansion

5. Tension sutures


2nd Ed, 1999


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Thoracic Trauma• Complications

→ Pleuritis (50% mortality)

→ Severe abdominal or musculoskeletal injury

→ Pleural abscesses→ Subcutaneous emphysema

→ Pnemothorax



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Thoracic Trauma• Prognosis

73% survival

→ 15 horses: SQ emphysema (12),

pneumothorax (12), pneumomediastinum (6),hemothorax (5)

→ Foreign body removal (2), suture wounds (6),

packed wounds (7)



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Thoracic Trauma• Conclusions

→ Favorable prognosis

→ Thoracic empyema uncommon

→ Euthanasia from extrathoracic trauma(colon perforation, renal trauma, luxated spine)

→ Foreign bodies rare

→ SQ emphysema with axillary wounds



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Thoracic Surgery• Thoracoscopy

Summary 1. Equipment

2. Technique

3. Anatomy

4. Applications

Peroni, JF, et al, EVJ, 33(3), 2001

Vachon, AM and Fischer, AT, EVJ,30(6), 1998


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Equipment→ 57cm L, 10mm D, 30º Telescope

→ Sharp Tocar/cannula 15cm L, 11mm D

→ Camera, monitor, 300 W xenon light source,CO2 insufflator

→ Biospy forceps, scissors, electrosurgery

→ Teat cannula, suction unitVachon, AM and Fischer, AT, EVJ,

30(6), 1998


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Technique→ Standing technique (stocks)

→ 8th, 10th and 12th intercostal spaces

→ Sedation - CRI detomidine→ Good view of dorsal, lateral structures

→ GA - ventral, cranial thoraxVachon, AM and Fischer, AT, EVJ,

30(6), 1998



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Anatomy - R cranial hemithorax→ Collapsed R lung

→ Esophagus

→ Aorta→ Azygos vein



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Anatomy - L cranial hemithorax→ Collapsed L lung

→ Aorta



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Anatomy - R cranial hemithorax→ Collapsed R lung

→ Esophagus

→ Pulmonary veins→ Vagus nerve



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Anatomy - L cranial hemithorax→ Collapsed L lung

→ Esophagus

→ Aorta→ Mediastinal LN

→ Vagus nerve



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Anatomy - L dorsal hemithorax→ Collapsed L lung

→ Aorta

→ Esophagus→ Dorsal mediastinum



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Anatomy - R caudal hemithorax→ Diaphram

→ Ribs 14 and 15

→ Psoas major muscle



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Anatomy - L caudal hemithorax→ Collapsed L lung

→ Diaphram

→ Dorsal mediastinum→ Esophagus



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Anatomy - L caudal hemithorax→ Collapsed L lung

→ Diaphram



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Anatomy - R caudal hemithorax→ Diaphragmatic hiatus

→ Ribs 14 and 15

→ Psoas major muscle



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Anatomy - L caudal hemithorax→ Diaphragmatic hiatus

→ Aorta

→ Esophagus→ Psoas major muscle



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Retrospective study → 32 thoracoscopies in 28 horses

→ Age 4 months - 25 years

→ 16 pleuropneumonia, 12 other→ 26 standing, 6 under GA

→ Conclusion: safe and useful tool

Vachon, AM and Fischer, AT, EVJ,

30(6), 1998


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Applications→ Diagnostic and therapeutic procedures:

1. Exploration

2. Biospy of lung, lymph node


30(6), 1998


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3. Insertion of drain for pleural effusion, abscess

4. Transection of pleural adhesions


30(6), 1998


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5. Pericardectomy

6. Diaphragmatic hernia repair


30(6), 1998


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5. Partial pneumectomy

6. Plan thoracotomy approach


30(6), 1998

Malone, ED, et al, Vet Surg, 30(2), 2001


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Thoracic Surgery• References

1. Auer, JA and Stick, JA, Thoracic trauma. Equine

Surgery, 2nd Ed., WB Saunders, 1999

2. Bellezzo, F, et al, Surgical repair of rib fractures in 14

neonatal foals: case selection, surgical technique andresults. EVJ, 36(7), 2004

3. Boy, MG and Sweeney, CR, Pneumothorax in horses:

40 cases (1980-1997). JAVMA, 216(12), 2000


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4. Colahan, PT, Mayhew, IG, Merritt, AM and Moore,

JN (eds), Diseases with physical causes. Equine

Medicine and Surgery, 5th Ed., Mosby, 1999

5. Fischer, AT and Vachon, AM, Thoracoscopy. Equinediagnostic & surgical laparoscopy, WB Saunders, 2002

6. Fowler, ME, Intrathoracic surgery in large animals.

JAVMA, 162(11), 1973

7. Hendrix, SM and Baxter, GM, Management of

complicated wounds. VCNA-EP, 21, 2005


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8. Kraus, BM, et al, Multiple rib fracture in a neonatalfoal using a nylon strand suture repair technique. VetSurg, 34, 2005

9. Laverty, S, et al, Penetrating wounds of the thorax in

15 horses. EVJ 28(3), 199610. Malone, EM, et al, Thoracoscopic-assisted

diaphragmatic hernia repair using a thoracic-ribresection. Vet Surg, 30(2), 2001

11. Peroni, JF, et al, Pleuropulmonary and cardiovascularconsequences of thoracoscopy performed in healthy standing horses. EVJ, 32(4), 2000


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12. Peroni, JF, et al, Equine thoracoscopy: normal

anatomy and surgical technique. EVJ, 33(3), 2001

13. Schambourg, MA, et al, Thoracic trauma in foals:

post-mortem findings. EVJ, 35, 200314. Stone, WC, et al, Use of a primary muscle pedicle flap

to repair a caudal thoracic wound in a horse. JAVMA,

205(6), 1994

15. Vachon, AM and Fischer, AT, Thoracoscopy in thehorse: diagnostic and therapeutic indications in 28

cases. EVJ, 30(6), 1998


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Thoracic Surgery• Acknowledgements

→ Drs. Ducharme and Fubini

→ Dr. Divers

QUESTIONS?

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