The Punch Technique for Aural (Ear) Hematomas in Dogs and Cats: Simple, effective, and cosmetic!

Auricular hematomas occur from hemorrhage that develops between the 2 leaves of cartilage of the pinna. The hemorrhage can occur due to trauma to the pinna from head shaking or scratching.  Inflammatory conditions of the ear canal, such as ear mites, foreign bodies, or bacterial otitis may be the inciting cause.

Diagnosis

Aural hematomas are characteristic in appearance.(Fig.1,2) 

Fig. 1: Aural hematoma in a cat

Fig. 2: Aural hematoma in a young white tiger

The pinna is enlarged and fluctuant. Differential diagnoses include acute allergic response causing severe swelling of the pinna, and neoplasia of the pinna. Aspiration of the mass reveals blood or serum. Rule out underlying ear canal problems by a thorough palpation of the ear canal and otoscopic exam. Also, thoroughly examine the animal for evidence of skin disease such as allergies, seborrhea, fleas, or pyoderma. 

Treatment

Many methods have been described for treatment of aural hematomas. Incision and drainage, drain tubes, and laser techniques have all been described.(1-3) Medical management by simple drainage combined with either systemic or local corticosteroid therapy has also been advocated. The advantage of medical therapy or simple needle drainage is excellent cosmetic result. However, incidence of recurrence with these treatments is high. The advantage of incision and suture is a low rate of recurrence, but the scaring of the pinna can cause poor cosmetic results.

The punch technique described here (Fig. 3) allows effective drainage and very low incidence of recurrence.(4) The cosmetic results are also very good since little scar tissue develops in the small incisions.

Fig. 3: Depiction of punch technique for aural hematomas in dogs and cats.
(from: Smeak DD. Surgery of the ear canal and pinna. Saunders Manual of Small Animal Practice, 3rd ed.,
Birchard and Sherding editors, Figure 60-1, Elsevier, 2006, pg. 583)

Surgical Technique

• Clip and prepare both sides of the pinna for aseptic surgery. Place a surgical sponge in the ear canal to prevent accumulation of blood.
• Use a skin biopsy punch (size 4-6 depending on the size of the dog) to remove small plugs of skin and cartilage on the medial side of the pinna.(Fig. 4) 

  

  Creating punch incisions on the medial aspect of the pinna for  drainage of aural hematoma.

• Attempt to penetrate only the skin and 1 layer of the cartilage with the punch; however inadvertent removal a small section of both of the cartilage layers is not problematic.
• Make incisions about 0.5 – 1 cm apart and perform as many punches as necessary to drain the entire hematoma. 
• Tack the skin edge of each incision with monofilament nylon, polypropylene, or Monocryl in a simple interrupted pattern.(Fig. 5) The size of suture can be 3-0 or 4-0 depending on the size of the animal. It is not necessary for the suture to penetrate full thickness through all layers of the pinna including the skin on both sides but the suture should incorporate both layers of cartilage and the skin on the medial surface.

Fig. 5: Suturing the edge of each punch incision with monofilament suture.

Postoperative Care

Postoperatively, place a stockinette on the dog’s head to protect the pinna and reduce bleeding. I prefer not to send dogs home with a full bandage on the ear or head. Keep the dog from scratching the ear with an Elizabethan collar. Remove sutures at 14 days.(Fig. 6)

Fig. 6: Pinna of a dog 2 weeks after the punch technique
for aural hematoma (Photo courtesy of Dr. Daniel Smeak)

If otitis externa or other skin disorder is present, treat appropriately.

References

1. Pavletic MM Use of laterally placed vacuum drains for management of aural hematomas in five dogs. J Am Vet Med Assoc. 2015 Jan 1;246(1):112-7.

2. Dye TL, Teague HD, Ostwald DA Jr, Ferreira SD. Evaluation of a technique using the carbon dioxide laser for the treatment of aural hematomas. J Am Anim Hosp Assoc. 2002 Jul-Aug;38(4):385-90.

3. Kagan KG Treatment of canine aural hematoma with an indwelling drain. J Am Vet Med Assoc. 1983 Nov 1;183(9):972-

4. Smeak DD. Surgery of the ear canal and pinna. Saunders Manual of Small Animal Practice, 3rd ed., Birchard and Sherding editors, Elsevier, 2006, pg. 582)

Blog Update: Dr. Birchard has published a new book: "Their Tails Kept Wagging", a collection of moving stories about pets with serious illness who survived. Click here for more information. 

Scrotal Hematoma in Dogs After Castration: Why does it happen and how to prevent it.

Scrotal hematoma, the accumulation of blood in the scrotal sac, is a common postoperative complication of castration in dogs. (Fig. 1) 

Fig. 1: Scrotal hematoma that developed after castration in this golden retriever

Postoperative bleeding from one or both testicular arteries or veins is the most likely cause. Bleeding from these vessels can also accumulate in the abdominal cavity and be unrecognized until the dog becomes hypovolemic and develops shock. Bleeding from subcutaneous tissues could also result in a scrotal hematoma but is less likely, particularly in cases where bleeding is severe and the scrotal hematoma is large.

Etiology

Insecure ligatures are probably the cause of bleeding from testicular vessels. Ligature failure during castration may be due to a number of technical problems, such as loose ligature, improper suture material, or ligature slippage. Improper location of the suture ligature can also predispose to failure. If the spermatic cord is not adequately exteriorized the ligatures will be placed too close to the testicle. (Fig. 2) 

Fig. 2: The red dotted line indicates ligation of the spermatic cord too close to the testicle (T)
The ligatures in the figure are placed in the proper location.
(Modified from: Boothe, HW. Surgery of the testicles and scrotum. Saunders Manual of Small Animal Practice, Birchard and Sherding editors,  Figure 87-1, Elesevier, 2006, pg. 970.)

This causes excessive tissue to be incorporated in the ligatures. Insufficient stripping of the adipose tissue from the cord also predisposes the ligature to slippage.

Treatment

Scrotal hematomas can be managed medically with compresses (ice packs for the first 24 hours postoperatively, followed by warm compresses), Elizabethan collar, restricted exercise, analgesics such as NSAIDS, and antibiotics. In severe cases or those not responding to medical therapy, scrotal ablation is necessary to remove the entire scrotum and its contents.

Prevention

To prevent scrotal hematoma when performing castration, adhere to the following technical principles:

- After incising over the testicle and exposing it, break down the gubernaculum testis and place traction on the testicle to allow several centimeters of the spermatic cord to be exposed. (Fig. 3)

Fig. 3: Proper exposure and clamping of the spermatic cord during routine canine castration.

- Carefully and thoroughly strip the adipose tissue from the spermatic cord with a moistened surgical sponge.

- Triple clamp the cord with Carmalt clamps, cut between the 2 clamps closest to the testicle and perform routine ligatures with Monocryl or PDS suture (transfixing and full ligatures). The full ligature is placed in the crush area of the most proximal clamp after it is removed, the transfixing ligature is placed just distal to the full ligature. (Fig. 4)

Fig. 4: Proper ligature technique in a closed canine castration. (T=testicle)
(Modified from: Boothe, HW. Surgery of the testicles and scrotum. Saunders Manual of Small Animal Practice, Birchard and Sherding editors, Elesevier, 2006, Figure 87-1, pg. 970.)

- Check the vascular stump for bleeding prior to replacing it into the incision. Repeat the same procedure on the opposite side.  

I prefer closed castration, even on large dogs, because it allows excision of the testicular tunics along with the testicle. (Fig. 5)

Fig. 5: Closed castration allows removal of the parietal vaginal tunic with the testicle

Close the subcutaneous tissue routinely (3-0 or 4-0 absorbable suture in a simple continuous pattern). Although skin sutures can be used on the skin incision, I prefer do an intradermal closure in lieu of skin sutures. Fewer complications occur with an intradermal closure of castration incisions. In an unpublished study performed at Ohio State several years ago, dogs with intradermal skin closure had fewer incisional problems and even fewer scrotal hematomas postoperatively. Less self-trauma to the incision and scrotum were thought to be the reason for this finding.

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When seriously ill pets are surrounded with love, they are more likely to survive. Read about this in Dr. Birchard's new book: "Their Tails Kept Wagging". Click here for more information.

Introducing the Air Plasma Surgical Device (Guest Blogger Dr. William T. N. Culp)

William T. N. Culp, DVM, Diplomate, ACVS

Surgery & Oncology Department 
Veterinary Teaching Hospital
UC Davis School of Veterinary Medicine
Davis, California

AirPlasma is a recently developed technique in which air is ionized to generate energy. This process is conducted without the use of gases such as argon and helium and utilizes only air as a conductor. The energy that is created is visible in the form of a glow and tissue can be vaporized with simultaneous capillary hemostasis. (Lacitignola 2020)

AirPlasma has several advantages over other forms of similar devices. The AirPlasma device works at a much lower temperature than other plasma devices, and the local thermal damage at the point of contact can be minimized with significantly less tissue necrosis. AirPlasma does not require a return plate on the patient which avoids burns on the patient’s skin encountered with some electrosurgical devices. There also is evidence that AirPlasma has a low carcinogenic potential which is particularly important as other devices can generate fumes that result in exposure to certain carcinogens. Lastly, as stated above, AirPlasma devices are able to generate energy without the need for external gases.

There are currently 3 major areas where AirPlasma is utilized in veterinary patients: ablation of tumors, cutting, dissection, and micro-coagulation. Small masses can be ablated with the device utilizing several available tip options. The device is particularly useful for cutting and dissecting tissues as the generated plasma can be highly focused on the targeted area. Because of this advantage, cutting and dissection during procedures such as total ear canal ablation, staphylectomy, and tumor removal can be very precise with minimal trauma to surrounding tissues. Finally, this device is particularly useful in assisting with microcoagulation at surgical sites after biopsies or resections. Commonly, after liver lobectomy or other partial organ resection, a small amount of bleeding can occur. Using the AirPlasma on those sites can often control minor oozing and prevent continued blood loss.

AirPlasma technology is an exciting new modality that is demonstrating promise. Proficiency is achievable in a short period of time, and safety appears to be high. Further studies will continue to elucidate outcomes with this technology, and the applications in veterinary patients are likely to increase. For more information about the AirPlasma device, and Onemytis see http://www.medviatech.com/.

Reference

Lacitignola L, Desantis S, Izzo G, et al. Comparative morphological effects of cold-blade, electrosurgical, and plasma scalpels on dog skin. Vet Sci 2020;7,8; doi:10.3390/vetsci7010008 

Torsion of a Cryptorchid Testicle

Tank is a 5-month-old male intact boxer who presented to the Emergency Service for acute vomiting and abdominal pain. The vomiting began about 12 hours before presentation. The referring veterinarian had obtained abdominal radiographs and was suspicious of a gastric foreign body. There was no other history of medical problems with Tank.

 

On physical examination, Tank was quiet but responsive, ambulatory, and mildly dehydrated. He was painful on abdominal palpation, especially in the mid to caudal abdomen. Only one testicle was palpable in his scrotum, which was determined to be the right testicle. The left testicle was not palpable in the inguinal area.

 

A complete blood count and serum chemistry profile revealed no significant abnormalities. On review of the referring veterinarian's abdominal radiographs, we did not find evidence of a gastric foreign body or other abnormality. 

 

Abdominal ultrasound revealed a structure that appeared to be a testicle. (Fig 1)

Fig 1: Abdominal ultrasound showing a cryptorchid testicle (arrow)

Placement of the ultrasound probe on the structure elicited severe pain. We were concerned that Tank had torsion of the abdominal cryptorchid testicle. 

 

A left paramedian abdominal exploratory was performed. Torsion of the left retained testicle was confirmed, and the testicle was removed.

Fig. 2: Surgical removal of the abdominal testicle

 

The descended testicle was also removed. 

Fig. 3: Both testicles removed from Tank, normal on the right, testicular torsion on the left

Tank made an unremarkable recovery from anesthesia and surgery and was discharged from the hospital the following day. 

 

Cryptorchidism is a common congenital anomaly in male dogs. One or both testicles can be retained in the inguinal region, inguinal canal, or abdomen. For more details on surgery for this disorder, see https://drstephenbirchard.blogspot.com/2014/07/cryptorchidism-in-dogs-5-ways-to-make.html, and scan the QR code for a complete discussion of cryptorchidism in dogs and cats.

 

Adaptic Touch: The Ideal Dressing For Open Skin Wounds in Dogs and Cats

When managing open skin wounds in dogs and cats, bandaging materials and techniques are critical elements of the treatment strategy. The interior of the bandage in contact with the wound is called the primary layer and is the most important of the dressing for creating a suitable environment for healing. Many options for the primary bandage layer are available, including wet saline sponges, dry sponges, silicone dressings, medical-grade honey gauze, petroleum-impregnated gauze, and Telfa pads. The ideal first layer of the bandage should encourage granulation tissue formation. It should not inhibit healing cells and not promote infection. The primary layer should allow absorption of wound exudate into the second layer of the bandage to prevent accumulation at the wound surface.  

 

Telfa pads have historically been used for open wounds in animals, but newer materials that allow better absorption of exudate from the wound are available. Wet saline sponges are commonly used as the initial primary bandage layer in acute traumatic wounds because they are highly absorptive, allow gentle debridement of dead tissue, and are inexpensive. However, when saline sponges become dry, they are adherent, making bandage changes painful. Patient sedation is frequently necessary to prevent discomfort during removal. Lavage of the dried sponges with sterile saline during bandage change will allow them to be peeled off the wound more easily and with less pain. Although wet saline sponges are very effective in initially managing severe wounds, such as bite wounds in dogs and cats, a primary bandage layer is needed for the next healing phase. Ideally, this material should allow absorption of wound exudate and be non-adherent to reduce patient discomfort. 

 

Vitalitymedical.com

The Adaptic Touch is an excellent choice for the primary bandage layer on open wounds in dogs and cats. It is a soft and pliable silicone-coated mesh material that readily conforms to the wound surface. The pore size in the mesh is small enough to prevent the ingrowth of granulation tissue into the material. The Adaptic Touch mesh allows the passage of wound exudate into the secondary bandage layer and is non-adherent, minimizing patient discomfort during bandage changes. It has been used extensively for various human wounds and is gaining favor with veterinarians. Cotton is a good choice for the secondary layer of the Adaptic Touch bandage allowing for the transmission of fluid through the pores of the mesh. Use only one layer of the Adaptic to ensure adequate absorption into the cotton.

 

The original Adaptic mesh is a petroleum-impregnated gauze that allows absorption and is non-adherent. However, petroleum may have some detrimental effects on wound healing, and it is only partially non-adherent. These characteristics make them less ideal than their counterpart, the Adaptic Touch.

 

See the above video for a demonstration of the non-adherent nature of the Adaptic Touch dressing. 

In summary, the ideal bandages for open skin wounds in dogs and cats have primary layers that allow absorption of wound exudate, are non-adherent, and do not inhibit wound healing. For wounds that are highly contaminated and filled with dirt and debris that cannot be entirely removed by surgical debridement and flushing, moist saline sponges are indicated as the initial bandage. Since these bandages are adherent and painful to remove, transition to non-adherent dressings such as the Adaptic Touch is recommended for the next phase of wound treatment.

 

References

International case series: Using ADAPTIC TOUCH® Non-Adhering Silicone Dressing: Case Studies. London: Wounds International, 2013. 

Wounds International case studies evaluation. ADAPTIC TOUCHTM Non-Adhering Silicone Dressing in skin tear management. Wounds International, 2018 (Suppl). Cooper 

Janice Bianchi*, Simon Barrett, Fania Pagnamenta, Fiona Russell, Sandra Stringfellow, Pam
Cooper. Consensus guidance for the use of Adaptic Touch non-adherent dressing. Wounds UK, 2011, Vol 7, No 3  

When surrounded with love, seriously ill pets are more likely to survive. Read about this in Dr. Birchard's new book. Click here for more information.

 

 

 

Dr. Homer Dale: Arbitrary, Strict, Stubborn, and the Best Teacher I've Ever Had

It was a dull and lifeless classroom. Cinderblock walls were painted pale yellow, the floor was faded linoleum. There was a small wooden lectern in the front of the room, and a large blackboard with a shelf for chalk and erasers. Wooden seats with metal legs and attached desks were arranged in neat rows with an aisle down the middle. All seats faced the blackboard. Cold, bluish fluorescent lights illuminated everything. The classroom was in a small, one story building that originally was an airplane hangar, later converted to teaching and research space. Clearly the re-purposing budget was slim. 

 

 I walked into the classroom and sat down in my usual spot. Funny how, even when seats are not assigned, we still sit in the same one every time. The room could barely hold the 72 members of my class. There was a murmur of quiet conversation between early arriving students, and some of them kept nervously looking back to the room’s entrance to see if the professor was coming.  “Who is today’s scout?” I asked Jim my classmate sitting next to me. “Don”, he said. “He’s standing in the hall by the classroom door now.” Don was today’s “sentry”, who would watch for the professor walking down the hall toward the classroom to begin the session. If he appeared to be holding a stack of papers, Don’s job was to run into the room and sound the alarm “He has a quiz!”

 

I pulled my spiral notebook and pen out of my backpack in preparation for the possible quiz and then the frenetic notetaking that would occupy the next 50 minutes. No handouts were supplied in this class. One was to obey the old-school preferences of the professor: attend the class and experience his lecture in person where he taught with all he needed: a stick of chalk, and a blackboard. 

 

This was Veterinary Physiology 101. Part of the so-called Core Curriculum, it was a required course offered in the second year of veterinary school. The professor was Dr. Homer E. Dale. An imposing man, he was tall, slim, middle-aged, and had closely cropped gray hair. He wore an impeccably clean, wrinkle-free, white lab coat with his full name embroidered over the top pocket. His posture was erect, his head held high. His appearance and demeanor were almost military in nature. He spoke clearly, deliberately. There was an air of confidence about him. When asked a difficult question, he would respond: “Nobody knows the answer, even I don’t know.”

 

Dr. Dale was the most organized lecturer I had ever seen. He delivered his facts from memory, without notes. The principles of physiology flowed from him to the chalk, then to the blackboard, and then to our notebooks by hastily scribbled notes. Every statement was important. He was teaching us how the body works. 

 

In most college courses, one’s grade is determined by the time-honored tradition of two tests, a midterm exam, and a final exam. Your scores on the two tests are combined to determine your final grade. Dr. Dale did not conform to this standard evaluation protocol. He had a unique system that he liked, but we hated. 

 

The grade in Professor Dale’s class was determined entirely by surprise quizzes – no midterm or final exam, just numerous short unannounced tests administered during the first 10 minutes of class. We didn’t know until he walked into the classroom if there was a quiz, so we had to be ready for an exam every day. Each quiz was comprehensive, it covered all material that had been taught up to that day. At first glance, this appeared to be a cruel and unusual punishment for students, but it was pure genius. It forced us to come to class every day and study our notes every night. As a result, his class had priority over all our other courses. I was one of the few who didn’t despise him for these methods. In fact, I liked it. After all, we are in training to be doctors, and knowledge of physiology was essential.

 

Dr. Dale’s system also guaranteed that we came to class early, to be sure we started the dreaded quizzes on time. After he quickly handed out the 1-page tests at the beginning of class, we had precisely 10 minutes to answer the questions. If anyone took too long, there were repercussions. When he said, “Times up!” everyone had to drop their pencil and immediately pass their test down the row to be collected by the person sitting adjacent to the aisle. If anyone continued writing past the deadline, the entire row of students failed the test. 

 

If you think Dr. Dale’s methods were unfair, well, it gets worse. The physiology class consisted of two semesters, the first in Spring and the second in the Fall with summer break between the two. Remember that each quiz covered all the material that came before it. On the first day of the Fall semester, Dr. Dale gave us a quiz on the information from the entire Spring Semester. Many of us were not surprised by this perverse action. 

 

Despite his authoritarian style and unorthodox methods, I admired Dr. Dale. He was passionate about teaching and understood how important it was for us to learn the material. Yes, he was intimidating and strict, but he was brilliant, articulate, and methodical. He recognized how draconian his policies were but had no intention of changing them. After years of experience, he knew what worked.

 

The class met three times a week, and we all quickly became accustomed to Dr. Dale’s lecturing style and mannerisms. He spoke slowly, emphasizing key points and explaining the relevance of the subject matter. He had a habit of swiping one side of his face with his index figure in between sentences, and he would clear his throat in an odd way. It was more of a forced expiration than a cough, and he did it a lot. He also had a characteristic body posture while talking; hands on hips, head cocked to one side, sweeping motions with his arms, and animated facial expressions. 

 

I started to imitate him, the arm motions, the throat sounds, and his voice inflections, first to myself and then to my classmates while we were chatting between classes. They loved watching me pretend to be Dr. Dale and kept encouraging me to do it more. I also learned how to write on the blackboard like him, to shape the letters exactly the way he did. It’s easy to learn the idiosyncrasies of someone you want to emulate. 

 

As the second semester of the course ended, several members of the class wanted to organize an event to celebrate our “survival” of Dr. Dale’s physiology course. After some discussion, we decided to do a skit that depicted a typical class session. I was chosen to play the role of the esteemed Professor. It was a chance to display my admiration of this amazing man through imitation of his teaching style. But I didn’t know how he would feel about it. We approached him about the idea, and he liked it. He even asked if he could bring his teenage daughter to the event. I breathed a sign of relief. Now I could focus on how to capture his essence in an entertaining but respectful manner. 

 

We reserved a room on campus and scheduled it as an evening session. The room was arranged just like his classroom, rows of seats for the students facing front at a blackboard, with an aisle in the center. We placed 2 seats and a small table in the front of the room, to one side, for Dr. Dale and his daughter to sit and watch the proceedings. The scene was set, and it was perfect.

 

I wore a clean, white, long lab coat just like his, and wrote his name on the front. I dusted my hair with baby powder to make it look gray and donned black horned rimmed glasses like the ones he used. Once everyone was settled in the room, I made my entrance from the back of the room as he would, and . . . I had a quiz.

 

I passed out the quizes to the students and gave one to Dr. Dale and his daughter. I don’t remember what questions I asked but they were intended to be like his, only funny. As I handed Dr. Dale the quiz he facetiously picked up his grade book and shook it in my face to warn me that my behavior this evening could affect my grade. He was being a good sport which helped me relax and enjoy the moment. I couldn’t wait to start the lecture. 

 

I stood by the blackboard, picked up the chalk, and launched my best Homer Dale impersonation. As I started one of my classmates in the front row whispered, “This is excellent!” I did the voice, the mannerisms, the hands on the hips, and even the frequent swipe of the cheek and throat clearing cough. In the corner of my eye, I could see him and his daughter smiling. 

 

A few of my classmates assisted with some other elements of the skit that depicted typical class activities, and then the festivities drew to a close. The audience, and the professor and his daughter, enjoyed the show. I was so grateful that Dr. Dale allowed us to have a little fun at his expense. I think he understood that underneath all the jokes and imitations, we had tremendous respect for him and his commitment to our education. The best part of the evening for me was to see the professor reveal a little of what lies beneath that crusty exterior. We saw a tiny bit of his soul, and it was beautiful.

 

The following summer I worked for Dr. Dale as an assistant in his research laboratory and helped reorganize some of his teaching materials. I felt honored to work for him. During my breaks from work, I would sometimes sit in his office and just chat with him about vet school and other subjects. We shared a love of the outdoors and exchanged stories about some of our canoeing and camping exploits. I got to know him as a person, and my admiration of him grew. One day I mustered enough courage to tell him he was the best teacher I’d ever had. His usual stern face softened, he looked at me with kind eyes and said a simple thank you, and we went back to work. It was a moment of intimacy that I will never forget.

 

Homer Dale passed away several years ago. He was 95 years old. I regret that I didn’t keep in touch with him after graduation from veterinary school. I would have told him how much he influenced me, how much I valued his advice, mentorship, and friendship. I would have told him that he had a profound effect on my career, and that I still think about him 50 years after taking his class in that old airplane hangar. I would have told him that I still have my notes from his class, and when I read them I can hear his voice delivering each sentence.

 

Medical and Surgical Treatment of Severe Thermal Burns in a Cat

Signalment and Presentation

Maximus, a healthy 6-month-old mixed breed neutered male cat, was presented for severe thermal burns over large areas of his body after jumping into a bathtub filled with scalding hot water.  The injury occurred just a few hours before presentation.

 

On admission, Maximus was tachycardic and severely painful. All four paws were red, swollen, and bleeding. The skin on his ventral abdomen and thorax was bright red and bruised. It appeared that the injury affected about 50% of his body. There was no other previous history of medical problems.

 

Initial Treatment

Maximus was initially administered intravenous fluids, antibiotics, and buprenorphine for pain. Continuous intravenous infusion of fentanyl was added to the treatment regimen soon after admission. Blood tests showed evidence of dehydration and elevated serum potassium. Silver sulfadiazine was used as the topical cream medication on the burned areas.

 

Maximus was non-ambulatory because the skin of his footpads was peeling off, leaving subcutaneous tissue exposed. Over the next several hours, the burned areas on his legs, chest, and belly gradually became purple in color. Some of the burned skin on his chest was becoming hard and leathery. (Fig. 1a,b) On a pain scale from 1-24 (1 being little or no pain, 24 being the worst pain possible), the attending clinician listed Maximus as 24. Intravenous lidocaine and ketamine were added to the fentanyl infusion to provide more analgesia. The dosage of fentanyl was also increased.

Fig. 1a: Maximus several hours after admission to the hospital

Fig. 1b

After sedating him with intravenous propofol, all of Maximus’ burned areas were carefully clipped and cleaned. With the hair removed, the burned regions were more clearly visible; the total surface area of his burned body appeared to be closer to 60%. 

 

More blood tests showed that Maximus’ albumin was already below normal. Albumin was being depleted because of the severe inflammation of the damaged skin and loss of albumin-rich fluid that oozed from his wounds. A nasogastric tube was placed to augment his dietary intake. 

 

Wound Management

On day two after admission, Manuka honey (Medihoney) was begun as the topical medication on the wounds, and standard bandaging was continued. The burned areas were gradually declaring themselves, and on day 4, some were starting to turn yellowish-brown and becoming hard and crusty. Escars were developing, indicating full-thickness skin injury. (Fig. 2)

Fig. 2: Escar development over mid abdomen and rear legs

To simplify the bandage changes that were time-consuming and painful, the attending clinician Dr. Becky Ball began covering Maximus with infant onesies, little pajama outfits that completely covered the entire body, legs, and feet. (Fig. 3) Each day the onesie was removed, the wounds gently cleaned, Medihoney ointment applied, and a clean onesie replaced. 

Fig. 3: Onesie pajama bandage applied.

Maximus was discharged 12 days after admission. The owner, a physician, assumed the nursing care at home. Rechecks with Dr. Ball were scheduled every 4-5 days for wound assessment. The escars gradually peeled away from the healthy skin, exposing new granulation tissue underneath. No evidence of infection was seen, and Maximus' appetite was good. 

 

Maximus continued to be re-examined about every two weeks. The eschars completely sloughed off, and the skin defects were contracting and closing well. But, as the skin tightened in his inguinal region, scar tissue pulled his rear legs medially, severely restricting his mobility. (Fig. 4) Surgery would be necessary to alleviate the contracture and allow Maximus to use the hind legs better. 

Fig. 4: Wound contraction of inguinal skin.

Skin Reconstruction

 

Seven months after Maximus’ injury, a caudal superficial epigastric axial pattern skin flap was performed to alleviate the inguinal wound contracture. (Fig. 5a-b) Click here for a detailed description of the skin flap procedure. The surgery went well, and he was discharged from the hospital the following day.

Fig. 5a: Axial pattern skin flap design. Arrow indicates the direction of rotation of the flap after it is dissected out.

Fig. 5b: Completed skin flap procedure.

Seven days postoperatively, suture removal was performed. The skin flap was viable and had healed well to adjacent skin. Maximus was much more mobile and less painful. Seven months postoperatively, he was examined again and was doing well with all wounds healed and his function back to normal. (Fig. 6, 7)

Fig. 6: Appearance of inguinal area seven months after skin flap reconstruction.

Fig. 7: Maximus and his owner 15 months after his injury.

Discussion

 

Maximus overcame a severe injury with burns over a large portion of his body. He exemplifies the remarkable wound healing process, particularly when supported with good nursing care. Manuka honey was effective in preventing infection and encouraging wound healing. Dietary support was instrumental in avoiding hypoproteinemia and malnutrition. Excessive wound contracture necessitated skin flap reconstruction, improving mobility and relieving chronic pain. 

Maximus' owner, a neonatologist, was instrumental in his recovery. She assumed the challenging nursing care at home and was diligent in the tedious work of medicating, bandaging, and maintaining good hygiene.

 

Maximus’ complete story is told in Dr. Birchard’s book: Their Tails Kept Wagging: Pets Show Us How Hope, Forgiveness, and Love Prevail, a collection of inspirational stories of severely ill pets who survived due to modern medicine and compassionate caregivers. For more information, click here.