Stephen J. Birchard DVM, MS, Diplomate ACVS

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

This is Hershey, an 8 month old female spayed Labrador Retriever who was attacked by 2 pit-bulls just hours before presentation. On admission to the Ohio State Veterinary Teaching Hospital she was depressed but alert, ambulatory, and had an elevated temperature but otherwise normal vital signs. On physical examination she had extensive traumatic 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.

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

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
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
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 recently spoke with the owners to see how Hershey was doing. Now 12 years after the injury, she is doing quite well will no after effects from her injuries other than she is not too keen on being scratched on her rear end. She is getting old (13 years) and has some arthritis but is absolutely fine otherwise.

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