Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Thursday, February 27, 2014

Final Outcome on Hershey: Look how good she looks!

This is the continuing story of Hershey: the 3 year female spayed Labrador attacked by 2 pitbulls.


Hershey's tail wound immediate before reconstruction
Under general anesthesia, Hershey's tail wound was prepared for aseptic surgery. A wide area of skin was clipped and prepared to allow a large skin flap to be created.
Diagrammatic representation of the planned advancement skin flap
A large local advancement skin flap was constructed by making incisions as shown in the above picture (dotted lines). The flap was deeply undermined to preserve blood supply and advanced caudally to cover most of the granulated wound.
Appearance of the tail base after advancement flap completion
We will discuss the various types of skin flaps that can be done in dogs and cats in later blogs. Hershey's abundant loose skin in the area adjacent to the wound made this type of flap a reasonable choice.

Hershey did very well postoperatively and was discharged the day after surgery with strict instructions to limit her activity for the next 4 weeks. Skin staples were removed at 14 days.

Several months after surgery the owners sent me pictures to show how well she healed.
Several months after wound treatment Hershey was doing very well and had good cosmetic and functional
results (i.e. her tail still works!)

I hope you enjoyed the story of Hershey. She was an amazing, sweet dog who went through an incredible ordeal. She was a great teaching case for the OSU students because of the combination of supportive care, prevention of sepsis, intense open wound management, and final reconstruction that was required.

Please post any comments or questions about this clinical case either on the blog site or on facebook.

Wednesday, February 26, 2014

Hershey Makes Great Progress But How Do We Close Her Final Open Wound?

This is the continuing story of Hershey: the 3 year female spayed Labrador attacked by 2 pit bulls.

Hershey continued to do well. She tolerated her daily wound care procedures very well and quickly recovered each day after sedation. After several days we were able to do her bandage changes without sedation. Throughout the entire process Hershey ate very well. Large open wounds increase caloric and protein needs, so her good appetite was a significant factor in her healing and overall recovery.


Thigh wound closure

Hershey's wounds filled with granulation tissue, and after 14 days I felt that her caudal thigh wound could be closed. It appeared healthy and was not infected.


Hershey caudal thigh wound after 14 days of wound management
The caudal thigh wound was closed with simple interrupted subcutaneous sutures
of Monocryl and cruciate mattress sutures of Novafil in the skin.

The thigh wound was closed by simply dissecting the skin edges to free them from the granulation tissue along the periphery of the wound and doing a side to side closure. Very little dead space was present so a closed suction drain was not necessary. 

Hershey seemed much more comfortable after the thigh wound was closed. She was less lame on the leg and more mobile and energetic. The tail base wound continued to be managed with a tie-over bandage but now using Adaptic sponges as the primary layer.
Adaptic sponge on Hershey's tail base wound as the first layer of the tie-over bandage
Hershey's closed thigh wound and tie-over bandage

Tail base wound closure

At 21 days after admission, Hershey's tail base wound was ready for closure. But, how could this be accomplished? Look at the wound in the following picture.

Hershey's tail base wound after 21 days of wound management
Question:
How would you close this wound?

In the next blog I'll show what we did and how it turned out.

Tuesday, February 25, 2014

Initial Treatment of Hershey: Supportive care and aggressive wound management

This is the continuing story of Hershey: the 3 year female spayed Labrador attacked by 2 pitbulls.

The emergency service at Ohio State began supportive care on Hershey immediately after admission consisting of intravenous fluids, broad spectrum antibiotics, and analgesics. 

Once she appeared more clinically stable, Hershey was placed under anesthesia for her initial wound assessment. The wounds were probed to determine the extent of undermining, and lavaged with sterile saline. A rectal exam was performed to confirm there was no injury to the rectum.
Hershey's wounds were initially probed and flushed with sterile saline
Some debridement of necrotic tissue was initially done and areas of obvious infection opened up to establish drainage.

My surgical service began treating Hershey soon after admission. Our biggest concern was sepsis; wounds of this magnitude with obvious severe infection can quickly result in septicemia and lead to a downward spiral of organ failure and death. Hershey was not showing signs of that yet. 

We began a daily routine of general anesthesia, serial debridement of necrotic and infected tissue, lavage, and wet to dry tie-over bandages. 
Each day meticulous surgical debridement of the wounds was preformed.
The most important principle with severe infected wounds like this is to surgically open all areas where the skin is undermined. Aggressive debridement of infected and necrotic tissue can then be done. 
After debridement, lavage with copious amounts of sterile saline was done.
Packing the wounds with sterile saline moistened sponges for the wet to dry tie-over bandages.
Tie-over bandages on the rump, tail base, and left caudal thigh.
You will frequently hear surgeons say that they are waiting for the wounds to “declare themselves”. This simple phrase refers to the daily assessment of the tissues to determine what is viable and what is sloughing out and in need of debridement. Wound closure is not even considered until the tissues appear healthy and granulation tissue is well established. Depending on the wounds, this can take several days or even weeks to develop.

After several days of wet to dry dressings, we transitioned to sugar bandages. This allowed us to change Hershey's bandages with only mild sedation, and ultimately with no sedation at all.
Granulated sugar tie-over bandages were used as the second phase of wound treatment


In the next blog we’ll look at how the wounds progressed and what the next phase of management would entail.

Monday, February 24, 2014

This Is What Happens When A Labrador Retriever Is Attacked By 2 Pitbulls (Viewer discretion is advised)

Hershey on admission to the Veterinary Hospital at The Ohio State University
Presentation

This is the story of Hershey, a 3 year old female spayed Labrador Retriever who was attacked by 2 pitbulls 3-4 days ago. On presentation she was depressed but alert, ambulatory, and had an elevated temperature but otherwise normal vital signs. On physical examination she had extensive traumatic, infected wounds over her rump, left caudal thigh, perineum, tail base, and perianal areas. The wounds around the anus did not communicate with the rectum.


Other than an inflammatory leukogram, her blood work did not show significant abnormalities.

Questions:


  • What are your primary concerns with Hershey's overall condition and potential risks in the short term?
  • What prognosis should be given to the owners?
  • What supportive care measures should begin immediately?
  • What techniques do you use to assess the wounds, i.e., how do you determine how extensive they are?
  • Once Hershey is stable enough for anesthesia, what do you do with these wounds now, and what is your plan for her care over the next several days?
Please feel free to post any questions or comments either on the blog site or on facebook.

To be continued . . . .

Sunday, February 23, 2014

Adaptic Gauze for Open Wounds: Effective, absorptive, non-painful, and cheap!

Adaptic petroleum impregnated sponge. (from: Amazon.com)
Petroleum impregnated gauze sponges (e.g., Adaptic sponges) are  non-adherent gauze sheets that can be used on open wounds in dogs and cats. They are considered semi-occlusive; they allow absorption of fluid without adhering to the wound surface. These sponges provide moisture and protect the delicate cells on the wound surface.
from: Amazon.com
Clinical Use
Adaptic sponges are a good choice for wounds that have already established a healthy granulation bed and do not require any further debridement. Since they allow some absorption of fluid be sure to apply cast padding as the second layer of the bandage.  They can be left on 2-3 days, giving owners a more convenient schedule for outpatient visits. They are less painful to remove than wet to dry dressings and thus the patient may not require sedation for bandage changes.
 
A fully granulated wound in a dog that would be a good candidate for an Adaptic dressing.
One study found that petroleum impregnated sponges were superior to other non-adherent dressings in encouraging wound contraction.(1) However, they inhibited epitheliazation of wounds to a greater degree than the other materials investigated. Although this is considered a disadvantage of the sponges, I have seen wounds in many clinical cases epithelialize completely while using them.
 
Adaptic dressings being applied to an extensive open wound on a dog.  Standard bandage material
(cast padding, Kling, and Vetwrap) were applied over the Adaptics to complete the bandage.
Cost
Petroleum sponges cost a fraction of some other non-adherent wound coverings.  A 3 X 3 inch sterile Adaptic sponge costs roughly 50 cents per sheet compared to hydrocolloid dressings that can cost several times that amount. Another advantage is that the Adaptic sponge can be trimmed to match the size and shape of the wound.

Comparison to Telfa Pads
Over the years I have found that many veterinarians and vet students are unaware of the advantages of these types of sponges. Telfa pads seem to be more recognized and used as non-adherent primary layer of bandages. I find that Telfa pads are much too occlusive; they trap exudate next to the wound surface rather than absorbing it into the bandage. Petroleum sponges are much more absorptive than Telfa pads and are a option better for open wounds.

Conclusion
Petroleum gauze sponges provide a good option for the management of the final stage of wound healing of non-infected granulating wounds. Surgical reconstruction of the wound can then be considered if feasible.

References

1. Lee AH, Swaim SF, McGuire JA, Hughes KS. Effects of nonadherent dressing materials on the healing of open wounds in dogs. J Am Vet Med Assoc. 1987 Feb 15;190(4):416-22.

Sunday, February 16, 2014

Sugar For Wounds in Dogs and Cats? Sweet!


Why put sugar in an open wound in a dog or cat? Granulated sugar is a time-honored technique of debridement and fluid absorption from open wounds in humans and animals.(1) It is absorbent, soaking up contaminated fluid and debris from the wound surface, and is anti-bacterial. The hyperosmolarity of sugar or honey in a wound prevents bacterial proliferation and even resolves existing infection. Besides all that, it is very inexpensive.  A 5-pound bag of sugar costs roughly 4 or 5 dollars. Compare that to hydrogels or biological wound dressings.


I have been using sugar for wounds routinely for the past several years and the results are impressive. Sugar is very good for open, traumatic, and even infected wounds. I especially like it in wounds containing large areas of dead space. Caution: do not pour sugar into a wound and then immediately close it. It is very important to flush the material out of the wound with sterile saline no more than 24 hours after using it.
Applying sugar to extensive infected open wounds originally caused by dog bites
Don’t be bashful with the quantity of sugar used. Pack the wound with a liberal amount of sugar, then change the bandage daily and perform copious lavage to remove the fluid and debris from the wound surface.

Medical grade honey has also been found to be an effective topical agent for open wound management. Gauze sponges soaked in honey can be placed on open wounds and have similar benefits to sugar. One human study found honey to be preferable to sugar for wound healing and associated with less pain during bandage changes.(2)

Technique

After initially treating traumatic wounds with wet saline dressings (or wet to dry dressing), sugar provides an excellent transitional strategy for wound management. The sugar bandage allows for continued absorption and debridement of a wound but is non-adherent making the bandage less painful to remove. Sugar can be poured directly on the wound or sprinkled on a saline moistened sponge and then placed on the wound.  A standard or tie-over bandage can then be placed. (See previous blog on tie-over bandages.) Once a healthy bed of granulation tissue has been established, the wound can either be closed or petroleum impregnated gauze used as the primary layer of the bandage until it heals. Look for more on these topics in upcoming blogs.
Medial elbow area open wound in a dog
Application of sugar prior to placing a tie-over bandage
Appearance of wound after several days of sugar therapy.


Wound almost completely healed a few weeks later
References

1. Emergency Medicine and Critical Care: Wound Management:
Initial Wound Management. The Merck Veterinary Manual
http://www.merckmanuals.com/vet/emergency_medicine_and_critical_care/wound_management/initial_wound_management.html


2. Mphande ANKillowe CPhalira SJones HWHarrison WJEffects of honey and sugar dressings on wound healing. J Wound Care. 2007 Jul;16(7):317-9.


Monday, February 10, 2014

Tie-Over Bandage: The greatest thing for open wounds since the wet to dry dressing


Have a dog or cat with an open skin wound in a difficult area to bandage? This situation is screaming out for a tie-over bandage.  They can be placed virtually anywhere and they are practical, effective, and inexpensive. They can be constructed as a wet saline dressing, a sugar bandage, or even a petroleum impregnated gauze dressing.

As with any bandage sedation may be necessary, such as dexdomitor or acepromazine combined with hydromorphone. Consider general anesthesia for severe wounds that will require extensive debridement.

Equipment needed:

  • Suture (2-0 polpropylene or nylon is best. Be sure to use a monofilament suture)
  • Sterile sponges (2 x 2’s, 4 x 4’s, or laparotomy sponges depending on size of the wound)
  • Sterile paper drape or other thin impervious material
  • Umbilical tape


Technique:

Fig. 1: From left to right the steps for constructing a tie-over bandage
(from: Knapp DW. Management of the open wound. In: Saunders Manual of Small Animal Practice,
Birchard and Sherding, editors, Elsevier, 2006, pg. 549)
  1. Debride and flush the wound with sterile saline.
  2. Place several loops of suture through the skin, around the wound. (Fig 1)
  3. Pack the wound with sterile moistened sponges or sugar.
  4. Cover the sponges with sterile paper drape material.
  5. Lace umbilical tape back and forth through the suture loops to secure the bandage in place. (There is no prescribed method for this step; just make it look pretty.)
  6. Change the bandage daily.
Video of the tie-over technique


Examples:

Extensive bite wounds in this Labrador resulted in a large open wound
from the lumbar area to the base of the tail.
After debridement and flushing, a wet saline tie-over bandage was placed.
Extensive burn wounds in a pit bull with areas of full and partial thickness
skin necrosis.
After debridement and flushing the entire injured area was covered by a
wet saline tie over bandage.

I will show the results of wound management in both of the above dogs in future blogs. 
Post any questions or comments.