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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
Auer, JA & Stick, JA, Equine Surgery,
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
Auer, JA & Stick, JA, Equine Surgery,
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
Hendrix, SM and Baxter, GM, VCNA-EP, 2005
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Thoracic Trauma1. Patient Stabilization
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
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999
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Thoracic Trauma1. Patient Stabilization
Tension Pneumothorax
→ Pleurocutaneous fistula
→
Rapid cardiopulmonary collapse→ Severe Hypoxemia (PaO2 22-28 mm Hg)
→ Thoracentesis (Patm = Ppleural)
→ Pneumothorax less detrimental
S. Fubini
Auer, JA & Stick, JA, Equine Surgery,
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
Laverty, S, et al, EVJ 28(3), 1996
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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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Thoracic Trauma3. Surgery
→ Explore pleural space
→ Control hemorrhage
→
Lavage pleural cavity → Repair lung lacerations
→ Repair rib fractures
→ Stabilize flail chest
N. Ducharme
Laverty, S, et al, EVJ 28(3), 1996
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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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Thoracic Trauma• Surgery
Close Bronchioles→ Stapled or sutured
Fowler, ME, 1973, JAVMA, 162(11)
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Thoracic Trauma• Surgery
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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Thoracic Trauma3. Surgery
→ External splint - flail chest
N. Ducharme
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Thoracic Trauma3. Surgery
→ Remove air from pleural cavity
→ Place thoracic drains (remove fluid and air)
→
Wound closure (muscle transposition)→ Skin closure techniques
→ Wound management
Hendrix, SM and Baxter, GM, VCNA-EP, 2005
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Thoracic Trauma• Surgery
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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Thoracic Trauma• Surgery
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
Laverty, S, et al, EVJ 28(3), 1996
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Thoracic Trauma• Surgery
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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Thoracic Trauma• Surgery
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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Thoracic Trauma• Surgery
ReconstructionPlate
+ Screws
+ Cerclage Wire
Bellezzo, F, et al, 2004, EVJ, 36(7)
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Thoracic Trauma• Surgery
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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Thoracic Trauma• Surgery
Wound Closure1. Primary closure or second intention
2. Primary muscle flap
3. Diaphragmatic advancement flap
4. Prosthetic mesh
Hendrix, SM and Baxter, GM, VCNA-EP, 2005
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Thoracic Trauma• Surgery
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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Thoracic Trauma• Surgery
Stone WC, et al, 1994, JAVMA, 205(6)
Muscle
Pedicle
Flap
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Thoracic Trauma• Surgery
Skin Closure - tension relief 1. V-Y flaps
2. Z-Plasty
3. Skin flaps (H-plasty, Rotating flaps)
4. Mesh expansion
5. Tension sutures
Auer, JA & Stick, JA, Equine Surgery,
2nd Ed, 1999
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Thoracic Trauma• Complications
→ Pleuritis (50% mortality)
→ Severe abdominal or musculoskeletal injury
→ Pleural abscesses→ Subcutaneous emphysema
→ Pnemothorax
Laverty, S, et al, EVJ 28(3), 1996
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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)
Laverty, S, et al, EVJ 28(3), 1996
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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
Laverty, S, et al, EVJ 28(3), 1996
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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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Thoracic Surgery• Thoracoscopy
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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Thoracic Surgery• Thoracoscopy
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
Peroni, JF, et al, EVJ, 32(4), 2000
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Thoracic Surgery• Thoracoscopy
Anatomy - R cranial hemithorax→ Collapsed R lung
→ Esophagus
→ Aorta→ Azygos vein
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L cranial hemithorax→ Collapsed L lung
→ Aorta
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - R cranial hemithorax→ Collapsed R lung
→ Esophagus
→ Pulmonary veins→ Vagus nerve
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L cranial hemithorax→ Collapsed L lung
→ Esophagus
→ Aorta→ Mediastinal LN
→ Vagus nerve
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L dorsal hemithorax→ Collapsed L lung
→ Aorta
→ Esophagus→ Dorsal mediastinum
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - R caudal hemithorax→ Diaphram
→ Ribs 14 and 15
→ Psoas major muscle
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L caudal hemithorax→ Collapsed L lung
→ Diaphram
→ Dorsal mediastinum→ Esophagus
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L caudal hemithorax→ Collapsed L lung
→ Diaphram
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - R caudal hemithorax→ Diaphragmatic hiatus
→ Ribs 14 and 15
→ Psoas major muscle
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
Anatomy - L caudal hemithorax→ Diaphragmatic hiatus
→ Aorta
→ Esophagus→ Psoas major muscle
Peroni, JF, et al, EVJ, 33(3), 2001
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Thoracic Surgery• Thoracoscopy
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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Thoracic Surgery• Thoracoscopy
Applications→ Diagnostic and therapeutic procedures:
1. Exploration
2. Biospy of lung, lymph node
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998
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Thoracic Surgery• Thoracoscopy
Applications→ Diagnostic and therapeutic procedures:
3. Insertion of drain for pleural effusion, abscess
4. Transection of pleural adhesions
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998
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Thoracic Surgery• Thoracoscopy
Applications→ Diagnostic and therapeutic procedures:
5. Pericardectomy
6. Diaphragmatic hernia repair
Vachon, AM and Fischer, AT, EVJ,
30(6), 1998
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Thoracic Surgery• Thoracoscopy
Applications→ Diagnostic and therapeutic procedures:
5. Partial pneumectomy
6. Plan thoracotomy approach
Vachon, AM and Fischer, AT, EVJ,
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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Thoracic Surgery• References
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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Thoracic Surgery• References
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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Thoracic Surgery• References
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?
Recommended