Tackling common trauma cases

Trauma patients can come in for a wide range of reasons, from embedded objects to brain injuries, but Steven T. Berkowitz, DVM, DACVECC, stressed the importance of trauma care since 11-13% of presenting patients at a tertiary hospital are trauma patients. He was sure to remind veterinary professionals that trauma is the second leading cause of death in dogs, both under 1 year old and over 1 year old. Berkowitz discussed best practices in improving patient outcome in the session, “Trauma: The Do’s and Don’ts,”¹ at the 2022 Atlantic Coast Veterinary Conference in Atlantic City, New Jersey.

Steven Berkowitz, DVM, DACVECC, attended St. George’s University and did his clinical year of training at the University of Illinois. He completed a 3-year residency in emergency and critical care medicine at Oradell Animal Hospital in Paramus, New Jersey. Berkowitz then joined NorthStar VETS after serving as chief of emergency and critical care at another specialty hospital.

Starting with triage, Berkowitz explained that it can help sort out which patients need care first. He stated, “The purpose [of triage] is to rapidly assess your patients see who needs care first, and sort of tier out who can wait a little bit longer.” It’s important to maintain a standard when using a triage, as well. Berkowitz explained that without a set protocol, communication can become confused across different team members and specialists.

Once the triage is standardized, it will be easier to treat patients who need care immediately. Berkowitz went through various trauma cases that are seen in veterinary practice and discussed the best practices for embedded objects. He first stated to leave the object in place until the patient is stabilized and ready for surgery. Removing the object too soon can cause an increased loss of blood and further complications. He stated, “You want to push [the object] out, if you can. Obviously, if it's not going through the other side, please don't push it through the other side because you don't know what that's up against. But don't pull it back out the same way.” Instead, first stabilize the patient and ready them for surgery, then wrap the object gently and avoid any further contamination to prevent infection.

Berkowitz also emphasized that going into surgery too soon is a common pitfall. He said, “The reason that's a pitfall is that second hit principle. We now just took a patient that has poor perfusion, poor blood flow, and poor blood pressure, and we just put them under anesthesia. So, we could be inducing worsening acute kidney injury.”

To prepare for surgery, the patient cannot be in pain. “There is no way you are going to stabilize a patient in pain…it worsens prognosis [and] it causes major changes in your cardiovascular system,” Berkowitz stressed. He explains that you cannot stabilize a painful patient, meaning that you need to treat for pain management in order to stabilize. He recommended using pure mu opioids as the ideal choice, and mixed opioids as the second option. N-methyl-D-aspartate (NMDA) receptors, like ketamine or amantadine, are also a good consideration. However, according to Berkowitz, steroids and Nonsteroidal anti-inflammatory drugs (NSAIDs) should not be used. Those drugs can cause major acute kidney injury.

Reference

Berkowitz, S. Trauma: the do’s and don’ts. Presented at Atlantic Coast Veterinary Conference; Atlantic City, New Jersey. October 10-12, 2022.