Monday, June 13, 2011

A great save!! I love these ones!

I had a very busy weekend in the ER, complete with trauma, run of-the-mill bite wounds, lacerations, and plenty of vomiting and diarrhea.

The best save of the weekend was a 4 month old, adorable pit-bull puppy who had just been hit by a car.  On presentation, her mucous membranes were gray and muddy, and a capillary refill time was not detectable (as in, the color never returned as it was incredibly poor to start).  Her pulses were poor, and she was having difficulty breathing.  Lung sounds were ausculted over her entire chest, but crackles were noted, likely due to bruising.

We immediately provided her with oxygen, placed an IV catheter, and started bloodwork.  She began to breathe easier, but her blood pressure was 58mmHg.  Way too low (normal systolic being at least 90-100mmHg).  At a BP of <60, vital organs were being starved of oxygen, and the longer she spent at this level of hypotension, the more likelihood of irreparable damage.  We had to act fast.

Her owners, a very nice young couple, authorized any and all care provided.  The young man, probably in his early 20's, begged me to save his dog.  He had just lost his sister at a young and unexpected age, and couldn't bear to lose his best friend, "Lucy."  He requested the best care we could provide, regardless of the cost, including CPR, surgery, or anything else that would potentially become necessary.  "Save my dog!" He cried.  "Please! You have to save my dog!"  I assured him that we would do everything in our power, but sometimes, we lose them anyway.   Unfortunately, there's no guarantee in medicine, but I'd do my absolute best (as I always try to do).

We started with crystalloid fluid boluses, careful to mind her injured lungs, however at this point, hypotension was her primary danger.  Her BP improved to 70 after two boluses, but this was still unacceptable for her organ function.  I moved to a hetastarch bolus (a colloid fluid, which remains within the vessels longer and can provide additional BP support), which bumped the BP up to 80, and then finally, after ~45 minutes of fluid resuscitation, her BP was 110 mmHg.

Chest radiographs revealed significant intrathoracic trauma; a mild amount of free air which had escaped from her damaged lung (this is called a pneumothorax), contusions and collapse of about 1/4 of her lung lobes.  The amount of air in her chest was not a sufficient volume to require thoracocentesis, as long as this air did not continue to accumulate, it would resolve with time and supportive care.  Also, her diaphragm appeared to be ruptured, with a portion of her liver moving into her chest.  Fortunately, no orthopedic injuries (fractures or luxations) were noted, and her urinary bladder, gall bladder and GI appeared intact.  Only a scant amount of fluid was present within her abdomen (likely a mild amount of bleeding from blunt trauma, and very common with this type of injury).

The puppy was on the road to recovery.  She spent the evening with the overnight veterinarian, who would provide the same expert level of care.  If she became unable to breathe, emergency surgery might become necessary to repair her diaphragm.  Lucy was still at risk of declining in the over night period -- I had difficulty sleeping when I arrived home, anxious to find out how my little Lucy's night would turn out.

When I returned to work the next day, I was happy to see Lucy off of oxygen.  She was breathing well on room air, no longer requiring the additional supplementation of bottled oxygen.  Over the course of the day, she became playful, ate vigorously, and started to act like a real puppy again.  In even better news, a recheck of her radiographs revealed that the previous collapsed lung and bruising was already on the mend, and her diaphragm may not require surgery!

"Lucy" went home to her family the following day, almost as good as new. They plan to recheck the radiographs in several days to determine if a true rupture of her diaphgram is present, or if the radiographic changes were due to thoracic trauma alone.

 I'm proud of this save, I'm happy that despite the severity of Lucy's injuries and her near-death experience, we were able to return her home to her family, and that for this young man, the trip to my ER was a happy one.

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