3 CE

CREDITS CE Article 1

Treating Thoracic Injuries

R olfe M. Radcliffe, DVM, Abstract: The treatment of equine thoracic trauma often requires rapid emergency measures to save
DACVS horses from life-threatening sequelae. Complications of thoracic trauma include pneumothorax,
N orm G. Ducharme, DVM,
pneumomediastinum, hemothorax, pleuritis, diaphragmatic hernia, and damage to the lungs, heart,
MS, DACVS
T homas J. Divers, DVM, blood vessels, or abdomen. Patient stabilization is the primary objective before conservative or surgi-
DACVIM, DACVECC cal treatment. Deciding how to manage each case depends on many factors, such as the location,
R obin D. Gleed, BVS, type, and extent of the injury; anesthetic concerns; and response to initial treatment.
MRCVS, DACVA

T
Cornell University horacic injuries are relatively uncom- Additional extrathoracic trauma indicated
mon in horses and may follow blunt a grave prognosis, with all affected horses
At a Glance or penetrating trauma1 (Figure 1). requiring euthanasia.2 However, an overall
Because these injuries may be life threat- satisfactory outcome was reported when
Clinical Signs ening, efficient management of affected thoracic injury occurred alone.
Page 208
patients is necessary to optimize the chance
Emergency Management for survival.1 A review of penetrating tho- Clinical Signs
Page 210
racic wounds in horses identified collision Clinical signs may be attributed to damage
Thoracic Injury Evaluation with an object as the most common cause to internal or external thoracic structures.2
Page 216
of trauma.2 The many reported sequelae External injury may cause soft tissue or
Specific Thoracic Injury of thoracic injury in horses include sub- muscle damage, blood vessel laceration,
Page 217 cutaneous emphysema, pneumothorax, and rib fracture, with systemic conse-
Conservative Versus pneumomediastinum, hemothorax, pleu- quences including pain and shock. Horses
Surgical Management ritis, diaphragmatic hernia, and damage with internal thoracic trauma, such as
Page 219 to the lungs, heart, and blood vessels. pneumothorax or hemothorax, often pres-
Prognosis Abdominal and spinal injury may also ent in respiratory distress. Common clini-
Page 220 occur in association with thoracic trauma. cal signs include nostril flaring; dyspnea;

FIGURE 1
Deep penetrating injury near the cranial thoracic cavity caused by a large wooden stake.

Courtesy of Dr. Ed Earley

A thorough evaluation of the abdomen is indicated when penetrating thoracic injury occurs caudal to the sixth rib. In this case, the
stake did not enter the thoracic or abdominal cavities, and conservative treatment with antimicrobials and local wound therapy
resulted in complete healing without complications.

208 Compendium Equine: Continuing Education for Veterinarians | June 2009 | CompendiumEquine.com
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tachypnea; accentuated respiratory excursions; cyanotic or hypoxemic adult equine patients.1,4,5
and cyanotic mucous membranes.1 Horses with Intratracheal oxygen insufflation improves
abdominal trauma may develop colic associ- Pao2 compared with nasal oxygen by provid-
ated with damage to, or rupture of, abdominal ing higher inspired concentrations of oxygen;
viscera; diaphragmatic hernias; or other organ however, tracheal oxygen delivery may cause
injury. Determining the location and depth coughing, which may be counterproductive.
of trauma can guide management decisions Emergency evacuation of pleural air should
regarding thoracic or abdominal involvement; be performed after wound bandage or clo-
deep wounds and those caudal to the sixth sure. When tension pneumothorax is sus-
rib are more likely to involve the abdomen.1,2 pected, immediate opening of the thorax or
Neurologic signs arising from other extratho- placement of a cannula allows supra-atmo-
racic injury, such as spinal trauma, have also spheric pressure to return to atmospheric
been reported.2 pressure, converting tension pneumothorax to
open pneumothoraxa less life-threatening
Emergency Management complication of thoracic injury.1 Immediate
Patient stabilization through rapid evaluation removal of air from the thorax is then indi-
and treatment is the cornerstone of effective cated. Pulmonary reexpansion improves ven-
emergency management. Immediate emergenc y tilation and helps control hemorrhage from the
treatment must be administered during the low-pressure pulmonary vessels. A sterile teat
initial patient evaluation before a more thor- cannula, 14-gauge catheter, or thoracostomy
CriticalPo nt ough diagnostic evaluation. As with cardiopul- tube is inserted into the dorsal thorax at the
monary resuscitation in humans, emergency 11th to 15th intercostal space1,4 (Figure 2). A
Determining the triage treatment of equine patients should thoracostomy tube (2436 French) placed ven-
location and depth follow the ABC protocol: Airway, Breathing, trally is indicated to provide complete drain-
of trauma can guide and Circulation. Initial treatment should be age if large volumes of pleural fluid or blood
management deci- directed at restoring alveolar ventilation and clots are present. Cannula placement directly
sions regarding oxygenation as well as managing shock. In in front of a rib avoids the intercostal blood
thoracic or abdomi- small animal patients with acute thoracic vessels located caudal to the ribs. An exten-
injury, six conditions are immediately addressed: sion line and three-way stopcock are attached
nal involvement;
airway obstruction, open and tension pneu- to facilitate active suction via a 60-mL syringe
deep wounds and mothorax, flail chest, massive hemothorax, and or suction device. A Heimlich or other one-
those caudal to the cardiac tamponade.3 Pneumothorax, flail chest, way valve allows continuous exiting flow1,4 but
sixth rib are more hemothorax, hemorrhagic shock, and abdomi- must be attached firmly and monitored closely
likely to involve the nal injury are the primary complications in because pneumothorax will worsen if the
abdomen. horses, requiring immediate action. valve becomes dislodged. A continuous flow
evacuation device has also been used success-
Pneumothorax fully in cattle to treat pneumothorax second-
Chest wounds should be sealed with a ster- ary to infectious lower airway disease.6 These
ile, airtight dressing to prevent further move- authors reported continuous-flow chest evacu-
ment of air into the thorax. Temporary wound ation to be superior to traditional one-time
closure or packing, application of petrolatum air removal because it avoids the high recur-
dressings, or application of plastic wrap over rence rate common in closed pneumothorax,
sterile dressings can create an airtight mem- in which air leakage continues from ruptured
brane. Next, stent bandages or standard ban- bullae.
dage materials should be placed fully around
the thorax, except in flail chest patients, in Flail Chest
which bandaging is contraindicated.3 Severe Flail chest results when two or more adjacent
pain often accompanies trauma to the pleural ribs are fractured in multiple planes.2,3 Blunt
cavity, ribs, and intercostal nerves, leading to trauma is frequently the cause, with fractures
abnormal ventilation (i.e., shallow breathing, occurring on either side of the point of impact.
tachypnea, hypoventilation) and hypoxemia This creates a flail segment of chest wall that
(Pao2: <80 mm Hg).1,2 Nasal or tracheal insuf- exhibits paradoxical respiratory movement.
flation of oxygen (15 L/min) is indicated in Such abnormal motion prevents development

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FIGURE 2

CriticalPo nt
Patient stabiliza-
tion is the primary
goal of initial ther-
apy. Treatment is
directed at removal Diagram showing placement of a thoracostomy tube (a) with a continuous-flow evacua-
of pleural air, clo- tion system (b) and tube attachment via a Chinese locking pattern (c).
sure or bandaging (Reprinted with permission from Chevalier H, Divers TJ. Pulmonary dysfunction in adult horses in the intensive care unit. Clin
Tech Equine Pract 2003;2[2]:165-177)
of thoracic wounds,
control of hemor-
rhage, and treat- of the pressure gradient necessary for normal in decreased ventilation and further pulmo-
ment of shock. air exchange, leading to severe ventilatory nary injury. Attendant pulmonary contusion,
compromise.3 Stabilization of the flail chest which is significant with flail chest patients,
segment is required to restore ventilation. causes decreased alveolar volume, decreased
Application of an external splint is recom- compliance, and impeded diffusion at the
mended in small animals with an intact flail bloodair interface.
segment with little soft tissue damage; this
may prove useful in equine patients as well2,3 Hemothorax and Hemorrhagic Shock
(Figure 3). The splint, which is constructed of Hemorrhagic shock results from the pathologic
aluminum rods and a metal or plastic stent, loss of blood from many causes, including
is secured to the ribs with orthopedic wire, trauma, and leads to hypovolemia.7 Hemorrhagic
providing stability for fracture healing. Septic shock may occur in horses with thoracic trauma
pleuritis, possibly associated with an ortho- when damage to the heart, great vessels, and
pedic wire, was a reported complication in intercostal and pulmonary vasculature results
one repair.2 Flail chest characterized by severe in hemothorax and significant blood volume
fractures or extensive soft tissue damage usu- loss. Clinical signs associated with hemor-
ally requires surgical debridement, fracture rhagic shock include tachycardia, tachypnea,
stabilization, and reconstructive procedures pale mucous membranes, trembling, sweating,
of the chest wall.3 Bandaging of the thorax is distress, and, possibly, a systolic heart mur-
contraindicated for patients with flail chest, as mur.8,9 These signs vary with the severity of
inward stabilization of the flail segment results blood loss, acute or chronic hemorrhage, and

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the underlying lesion.9 In equine patients with fluid therapy should follow immediately. The
trauma and acute hemorrhage into the thorax use of a large amount of hetastarch is likely
or abdomen, the degree of tachycardia may contraindicated in patients with acute hem-
not correlate with the severity of pain. For orrhage because of possible coagulopathy
example, moderate to severe tachycardia (80 or coagulopathic effects. 8,11 Fresh-frozen
to 140 bpm) in a horse with mild or intermit- plasma is indicated to replace clotting factors
tent pain may indicate severe blood loss. when hemorrhage leads to abnormal clot-
Immediate treatment of equine patients ting factor loss or consumption, a problem
with thoracic hemorrhage includes fluid ther- further exacerbated by additional crystalloid
apy, stopping the hemorrhage if possible, and therapy. 8,11 Aminocaproic acid (10 to 20 mg/
whole blood transfusion when indicated.1012 kg) may help prevent fatal hemorrhage when
The goal of fluid support in treating acute surgery is not an option; it should be adminis-
CriticalPo nt circulatory failure is rapid restoration of the tered slowly, mixed in intravenous fluids.8,15
circulating vascular volume, cardiac output, Blood transfusions should be considered
The need for a
and tissue perfusion.10,13 The administration when signs of hypotension and severe bleed-
transfusion in of balanced, polyionic intravenous crystalloid ing persist despite initial fluid therapy. Horses
patients with acute fluids is indicated at a rate of 20 to 80 mL/kg can lose approximately 20% of their blood vol-
hemorrhage should over several hours, depending on the degree ume (8% to 10% of their body weight; approxi-
be based on clinical of hypovolemia and blood pressure. Normal to mately 8 to 10 L in an 1100-lb [500kg] adult
signs (i.e., heart low blood pressure (permissive hypotension) horse) without changes in their blood pressure.
rate, pulse quality, is the goal of therapy if the hemorrhage can be In peracute cases, death from hemorrhage may
mucous membrane stopped.8 Hypertonic (7.2%) sodium chloride occur without a marked decrease in the packed
solution (4 mL/kg; 1 to 2 L in an adult horse) cell volume (PCV).8,12 Therefore, the need for a
color, temperature
has also been used successfully in treating transfusion in patients with acute hemorrhage
of extremities,
hemorrhagic shock in horses and other spe- should be based on clinical signs (i.e., heart
attitude, degree of cies,13 but its use in uncontrolled hemorrhage rate, pulse quality, mucous membrane color,
weakness) and not may be detrimental because rapid increases in temperature of extremities, attitude, degree of
on the PCV. blood pressure could disrupt clot formation. weakness) and not on the PCV. Several mea-
Hypertonic saline exerts its effect via osmotic surements that may be helpful when determin-
extracellular plasma expans ion, increased ing the need to transfuse include blood lactate,
plasma volume, and increased vasopressin arterial or venous oxygen tension or satura-
levels.13,14 When hypertonic saline is used tion, and blood pressure.12 The recommended
in horses for shock management, isotonic volume of blood to transfuse is approximately

FIGURE 3
Managing rib fractures that create flail chest. Septic pleuritis is a reported complication of this
technique if the wires that stabilize the ribs enter the thoracic cavity and act as a conduit for bacteria.

Courtesy of Norm G. Ducharme

Application of orthopedic wires. An external splint.

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6 to 8 L in adult horses or 30% to 40% of the with small amounts of an anticoagulant (e.g.,
estimated or calculated blood loss8 (Box 1). approximately one part acid citrate dextrose
Autotransfusion may be attempted when a per 15 parts blood).
large volume of blood is present in the thorax
and when bleeding is unassociated with sep- Abdominal Injury
sis or bacterial contamination.8,16,17 We agree Thorough evaluation of the abdominal cavity
with the cited authors that the blood must is also important in equine patients with tho-
be collected from a sterile thorax via aseptic racic trauma.1,2 The cupula of the diaphragm
technique to avoid bacterial contamination. extends to the sixth rib during expiration,
After insertion of a thoracic teat cannula or making it essential to evaluate the abdomen of
chest tube, blood is collected in a container an equine patient with a deep, penetrating tho-
racic injury caudal to this location.1 A complete
Box 1. evaluation of the abdomen includes peritoneal
paracentesis, ultrasonography, wound explo-
A Practical Example of Transfusion ration, laparoscopy, or exploratory celiotomy.
in an Equine Patienta Diaphragmatic hernias occur infrequently
in horses but have been reported secondary
The amount of lost blood can be estimated from the following formula to trauma.18 Thoracic radiography and ultra-
(packed cell volume [PCV] can be used in this formula once blood sonography are indicated for preoperative
volume is reestablished with fluid administration or after 812 hr of diagnosis (Figure 4). In one study, although
compensation): two horses with penetrating thoracic injury
were euthanized due to abdominal perforation
Normal PCV Patient PCV and bowel rupture, only one had a diaphrag-
Liters of blood lost = 0.08 Patient weight (kg)
Normal PCV matic hernia.2 Large defects with second-
ary colon displacement into the thorax may
As a rule of thumb, if a PCV of 40% is assumed for the donor, 2.2 mL of cause pulmonary compression and dyspnea,
whole blood per kilogram of patient weight will increase the PCV by ap- whereas small defects are more likely to incar-
proximately 1% in most horses. For example, 1100 mL of whole blood
cerate bowel and cause colic.18 Successful
will raise the PCV from 15% to 16% in a 500-kg (1100-lb) horse. The
repairs of diaphragmatic hernias in horses
administration rate of blood varies with the patients clinical status. For
have been reported1820; however, the progno-
horses with severe hypotension and hemorrhage, blood can be admin-
sis is less favorable with large defects and in
istered as a rapid bolus along with (but not in place of) crystalloids and
colloids because the benefits outweigh the risks of reactions. More of- horses showing clinical signs.21
ten, crystalloids and colloids are given as boluses first and then followed
with blood administration. When possible, it is advisable to initially Thoracic Injury Evaluation
administer blood slowly (approximately 0.1 mL/kg over 1015 min) to Examination of equine patients with thoracic
ensure tolerance. After that period, rates of up to 2030 mL/kg/hr can be trauma includes thoracic auscultation and per
used. To remove fibrin and debris, plasma filtration sets should be used cussion, diagnostic thoracocentesis, chest wall
for blood administration. palpation, wound evaluation, blood gas analysis,
radiography, and ultrasonography.1,2 Auscultation
Case Example: and percussion of the chest wall in equine
patients may help identify pneumothorax or
A 450-kg (990-lb) Thoroughbred racehorse was impaled on a fence, resulting in
acute thoracic trauma and a PCV of 10%. hemothorax. In patients with pneumothorax,
lung sounds are absent, but increased reso-
Blood loss (liters) nance is percussed dorsally. Diminished lung
= (40% 10%) 40% (0.08 450 kg) sounds ventrally and percussion of a fluid line
= 30% 40% 36
= 27 L are characteristic of hemothorax. Diagnostic
thoracocentesis can be used to confirm pneu-
Typically, the goal is to replace 30% to 40% of the calculated blood loss: mothorax or hemothorax.22 A needle, catheter,
or teat cannula is placed into the thorax as
27 L 0.30 = 8.1 L of whole blood administered as a transfusion
previously described, and a fluid extension
a
Adapted from Magdesian KG. Therapeutics in practice: acute blood loss. Compend Equine line is attached. Pneumothorax is confirmed
Contin Educ Vet 2008;3(2):80-90. when fluid bubbles out of the extension; how-
ever, if the fluid is aspirated into the chest,

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Treating Thoracic Injuries CE

pneumothorax is unlikely. Chest wall and FIGURE 4

wound palpation may help identify rib frac-
tures, thoracic wall penetration, foreign bod-
ies, or other injury. Arterial blood gas analysis
provides information on lung ventilation, lung
perfusion, and acidbase status, while arterial
and venous samples together provide informa-
tion on tissue oxygenation.12 Serial samples
are indicated to help evaluate the response to
therapy. Thoracic radiography (Figure 5) and
ultrasonography are becoming more practical
in the field. These diagnostics can help detect
rib fractures, pneumothorax, pneumomedi-
astinum, hemothorax, diaphragmatic hernias,
and foreign bodies.1 Ultrasonographic evalua-
tion is also useful for determining the amount
of blood or air in the thorax, guiding pleuro-
centesis, and inserting chest tubes.

Specific Thoracic Injury

Thoracic ultrasonogram of an equine patient with diaphragmatic
Pneumothorax
hernia involving the liver and small intestine. Note the distended loops
In a review of 40 cases of pneumothorax in of small intestine (large arrow) and region of the liver (small arrow) within the
horses, the reported causes were pleuropneu- thoracic cavity.
monia, open and closed thoracic trauma, and
surgery of the upper and lower respiratory bilateral pneumothoraxa potentially fatal
tract.23 In this study, pleuropneumonia was complication. Based on radiographic exami-
the most common cause of pneumothorax; nation, nine of 15 horses with penetrating tho-
affected horses had a significantly worse prog- racic injury had pneumothorax, six cases of
nosis for survival compared with horses with which were bilateral.2
pneumothorax due to other causes. There are CriticalPo nt
three types of pneumothorax. Open pneu- Hemothorax
mothorax occurs with penetrating, open chest Hemothorax, hemorrhagic shock, and death
Progressive
wounds when air moves freely during inspi- may result from severe thoracic injury involv- subcutaneous
ration and expiration.1,2 Damage to the lung ing the heart or great vessels. Most horses with emphysema with
parenchyma by displaced rib fractures or a massive hemothorax from thoracic injury do secondary pneu-
ruptured lung bulla permits air to enter the not survive.1 However, in six of 15 horses with momediastinum
pleural space, creating a closed pneumothorax. a penetrating thoracic injury, hemothorax (pos- or, less commonly,
Tension pneumothorax occurs when intra- sibly originating from the intercostal artery or pneumothorax is
pleural pressure exceeds atmospheric pres- pulmonary laceration) was not life threatening.2 a reported compli-
sure. This life-threatening condition usually Removing blood from the thorax improves pul-
cation of axillary
follows the formation of a pleurocutaneous monary ventilation and avoids the formation of
fistula, in which air enters the pleural space septic pleural effusion, pleural adhesions, and wounds in horses.
during inspiration but is blocked from exiting constricting fibrothorax.1,2 Patient stabilization
during expiration. Thoracic pressure builds on through restoration of circulating blood volume
the affected side, forcing air across the medi- is recommended before thoracic drainage.
astinal cavity and/or decreasing compliance of
the opposite lung. Severe hypoxemia with Pao2 Rib Fractures
levels as low as 22 mm Hg has been reported Most rib fractures in equine patients occur in
in humans with tension pneumothorax.1 foals during parturition, and their management
Unilateral pneumothorax, except for ten- is described in the literature.1,2427 Rib fractures
sion pneumothorax, is well tolerated in horses. in foals are reported to be a significant cause of
However, a thin, fenestrated caudal mediasti- morbidity and mortality but may not be clini-
num in some horses may predispose them to cally apparent.2427 Ultrasonography was found

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FIGURE 5 Lung Lacerations
Lung trauma is a rare manifestation of thoracic
injury in horses. Few reports in the large animal
literature describe how to manage lacerations
involving the lung following thoracic trauma,
although one report summarizes intrathoracic
surgery in large animals.28 Partial or complete
lung lobectomy is recommended for severe lac-
erations, cysts, bullae, abscesses, or tumors.29
Conventional excision and closure by suture or
staple techniques are described in small ani-
mals and may be applied to equine patients.29,30
Bronchial involvement is identified via applica-
tion of warm saline to the site of injury and
followed by bronchial closure.28 Overlapping
horizontal mattress sutures are placed to seal
the lung stump after an amputation and to
repair lacerations to the lung margin. The edge
of the excision line is oversewn with a simple
continuous pattern to avoid leakage.30 Injury
to the central lung parenchyma may also be
Thoracic radiograph depicting bilateral pneumothorax in an equine closed via a simple continuous suture pattern
patient with thoracic trauma. Note the dorsal margin of the collapsed lungs following identification of bronchial damage
(large arrow), the fractured rib (small arrow), and the chest tubes (arrowheads). and ligation. Monofilament, absorbable suture
material with swaged-on, atraumatic needles is
to be superior to radiography for evaluating currently recommended for lung and bronchial
thoracic trauma in foals, even for identifying closure.28,30 Minor alveolar leakage does not
nondisplaced fractures.27 Surgical stabilization require closure and generally seals quickly.
may be recommended to reduce the reported
25% mortality rate associated with direct com- Axillary Wounds
plications from rib fractures.24,26,27 Axillary wounds often extend deep into the tis-
Rib fractures are also common in adult sues and function as one-way valves, producing
horses following blunt or penetrating tho- marked, progressive subcutaneous emphysema.
racic injury.1 Five of 15 horses sustained rib Most clinicians recommend packing these
fractures in a review of penetrating thoracic wounds with gauze and closing the skin or
trauma.2 Although some fractured ribs can be using stent bandages to limit further air penetra-
identified on physical or radiographic exami- tion into the tissue.22 Packing material should be
nation, many fractures may not be palpable or replaced every 24 to 48 hours until the wound
visible and may be missed. Most rib fractures bed has completely granulated. Equine patients
in adult horses are reported to heal without should be confined to a stall and cross-tied to
fixation.1 Displaced rib fractures may lacerate minimize limb movement. However, despite
the lungs, heart, blood vessels, diaphragm, or various treatments, axillary wounds in horses
other deep structures. In such cases, surgical may lead to severe subcutaneous emphysema
rib fixation is indicated to minimize continued that may progress to secondary pneumome-
thoracic injury.3 One possible complication is diastinum (and, occasionally, pneumothorax),
a closed pneumothorax, resulting from closed which may become apparent weeks after the
chest wounds in which rib fractures cause pul- initial injury. In affected patients, reports docu-
monary parenchymal damage. The reported ment respiratory distress that occurred as late
techniques for stabilizing rib fractures include as 16 days after injury, necessitating patient
the use of quill sutures, external splints, pins, confinement and observation for an extended
wires, and plate application.3,28 When severe period of time.2,31 In six of 15 horses in one
rib damage prevents realignment, the remain- study, pneumomediastinum was identified; five
ing bone and fragments should be removed. of the six horses had axillary wounds.2

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Conservative Versus Surgical Management Anesthesia and Surgical Approach

Thoracic injury may be successfully man- Selecting the appropriate type of anesthesia and
aged with conservative and surgical treatment surgical approach for treating thoracic injury
strategies.1,2,22,32 However, patient stabiliza- requires careful consideration of several factors,
tion is the primary objective before either specifically patient stability; anesthetic concerns;
method of treatment.1,22,32 Horses with simple location, type, and extent of the injury; clini-
rib fractures, small chest wounds, or modest cian experience; and response to initial treat-
degrees of pneumothorax or hemothorax and ment.28 General anesthesia should be used with
without severe lung lacerations, rib fractures, caution in thoracic trauma patients until they
deep penetration, or contamination are candi- have been initially stabilized.1,22 Anesthetic risks
dates for conservative management. Medical must be weighed against the benefits of stand-
therapy includes antimicrobials and NSAIDs, ing versus recumbent procedures. To avoid
thoracocentesis or thoracostomy tube place- further respiratory and cardiovascular compro-
ment, second-intention wound healing, ban- mise of patients, clinicians should select stand-
daging, and the supportive care measures ing wound exploration and treatment when
described in this article. Surgical therapy may possible.1,22 Intercostal perineural anesthesia is
be indicated for more severe injury.32 Surgery recommended for standing procedures to facili-
allows improved exploration and lavage of tate repair and help control postoperative pain.
the wound and pleural or abdominal cavities, Thorough wound exploration, debridement,
control of hemorrhage, complete removal and lavage are necessary to remove bacteria,
of foreign bodies, repair of lung lacerations foreign bodies, rib fragments, and other debris.1
and rib fractures, and the stabilization of flail Many of these treatments may be used in stand-
chest. ing horses. However, tension or bilateral pneu-

CompendiumEquine.com | June 2009 | Compendium Equine: Continuing Education for Veterinarians 219
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mothorax, which is difficult to manage without and treat many postoperative complications of
the ability to provide mechanical ventilation, thoracic injury, including pleuritis, pericarditis,
may develop during standing surgery, result- abscesses, pleural adhesions, and diaphrag-
ing in severe cardiopulmonary deterioration.1,2 matic hernias.3335 Currently, thoracoscopy alone
General anesthesia is indicated in horses with does not allow closure of diaphragmatic defects
severe chest wall disruption, deep penetrat- because of nonreducible omental adhesions and
ing wounds, foreign bodies, abdominal cavity the limitations of available instrumentation.33
involvement, complicated rib fractures, exten-
sive lung lacerations, or severe contamination Wound Closure
that requires aggressive thoracic lavage.32 The Primary wound closure is recommended, when
use of controlled positive-pressure ventilation possible, after thoracic injury in horses.1,2,22 For
is essential in equine patients with open pneu- small uncomplicated wounds, the thoracic
mothorax.2 In addition, patients in which hem- muscles and soft tissues are apposed over
orrhage, pneumothorax, or hypoxemia persists the defect. For large chest wounds, or those
despite conservative treatment may require otherwise unsuitable for routine closure, two
wound exploration or wound closure tech- thoracic reconstructive techniques have been
niques that necessitate mechanical ventilation described in large animals: primary muscle
and general anesthesia.2 flap and prosthetic mesh repairs.1,3,22 Rotating
Most thoracic approaches in equine patients muscle pedicle flaps of the longissimus dorsi
simply involve enlarging the existing traumatic and external abdominal oblique muscles,
wound. However, several surgical approaches transposed via a Z-plasty technique, were used
to the equine thorax have been reported, to close a caudal lateral thoracic wound in a
including lateral thoracotomy via the inter- horse.37 Polypropylene mesh, although useful
costal technique or rib resection and thora- for closing large defects in animals, should
coscopy.28,30,3335 In small animals, a median be used with caution to avoid complications
sternotomy has also been described for gain- related to infection. We recommend closing
ing access to both sides of the thorax30; this as much of the wound as possible at the ini-
approach may be useful in calves or foals.28 In tial surgery. Mesh implants should be reserved
general, the thoracotomy incision is centered for subsequent procedures, when necessary,
over the site of the thoracic injury, and in most and only after infection has resolved. Delayed
cases, the wound is simply enlarged to obtain primary closure and second-intention healing
adequate exposure of the ribs, heart, lungs, may also be selected, especially with large or
diaphragm, and pleura.1,28 Various retractors, highly contaminated wounds.1,22 Closed suc-
including the Finochietto rib retractor, are also tion drains placed into the wound can help
useful for gaining surgical exposure. prevent seroma formation and secondary inci-
Thoracoscopy provides several advantages sional infection. Mesh expansion and various
over thoracotomy for evaluating and treating tension-relieving suture patterns are most com-
thoracic injury in equine patients.3335 Thoraco monly used in horses to reduce tension dur-
scopy allows detailed exploration of the ing closure of extensive thoracic or abdominal
thoracic cavity in patients with minimal mor- wounds.1 Close postoperative monitoring is
bidity, whereas thoracotomy is more inva- essential. When infection persists, aggressive
sive and is limited by difficult exposure.3336 retreatment via debridement, drainage, lavage,
Standing thoracoscopy provides excellent access and appropriate antimicrobial selection based
to the dorsal and lateral aspects of the thorax, on culture and sensitivity is recommended to
while the cranial and ventral portions are best prevent secondary pleuritis.22
viewed with a lateral, a dorsal, or an oblique
recumbency technique.35 The specific iden- Prognosis
tification of the organ injury can help direct In a review of 15 cases, a satisfactory outcome
treatment and improve planning for thoraco- was reported following penetrating thoracic
tomy or abdominal procedures.33 With thoracos- trauma without extrathoracic injury.2 Eleven
copy, foreign bodies within accessible regions horses, representing a 73% survival rate, were
of the thorax may be identified and removed.1 discharged from the hospital. The other four
Thoracoscopy can also help effectively evaluate horses were euthanized due to complications

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Treating Thoracic Injuries CE

of extrathoracic injury, including colon perfora- especially for injuries caudal to the sixth rib.
tion, renal trauma, and spinal luxation.2 While Frequent, extended monitoring for respira-
horses that develop secondary pleuritis often tory distress in equine patients with axillary
have a guarded prognosis,38,39 it is important to wounds is advised to detect secondary pneu-
note that only one horse developed pleuritis, momediastinum and pneumothorax and to
indicating a low incidence of this complica- provide appropriate therapy. A low occurrence
tion.2 A mortality rate of approximately 50% of thoracic empyema has been reported in
has been reported in horses that develop pleu- cases of penetrating thoracic injury in horses;
ritis or acute pleuropneumonia.1,2,22,38,39 however, if septic pleuritis develops, it has a
poor prognosis and a mortality rate of approxi-
Conclusion mately 50%.1,2,22,38,39 Without extrathoracic injury
The emergency evaluation and treatment of or severe complications, as discussed in this
horses with thoracic injury primarily involves article, the prognosis for equine patients with
cardiovascular and respiratory function assess- thoracic injury should be favorable.2
ment and provision of appropriate support. An
understanding of emergency first-aid steps;
shock therapy; anesthetic concerns; standard
SHARE YOUR COMMENTS
surgical approaches to the thorax; methods of
wound treatment, reconstruction, and closure; Have something to say about this topic?
and potential complications can help clinicians Let us know:
manage these difficult cases. E-MAIL [email protected]
We recommend a thorough evaluation of FAX 800-556-3288
the abdomen in all cases of thoracic trauma,

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CE Treating Thoracic Injuries
REFERENCES
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1. Which condition does not require imme- 5. Of the following sequelae reported with a. standing surgery to stabilize the flail
diate emergency treatment in horses thoracic injury in horses, which one has chest with a thoracic bandage
with acute thoracic injury? been associated with axillary wounds? b. standing surgery to stabilize the flail
a. airway obstruction a. hemothorax chest with an external splint
b. tension pneumothorax b. pleuritis c. standing surgery to explore the wound
c. nondisplaced rib fracture c. pneumomediastinum and stabilize rib fractures
d. massive hemothorax d. rib fracture d. surgery with the patient under general
anesthesia to explore the wound; evalu-
2. In a retrospective study23 in horses, 6. A horse presents to your clinic with a his- ate the thoracic and abdominal cavities;
which problem was identified as the tory of acute thoracic injury and clinical repair the diaphragmatic hernia; sta-
most common cause of pneumothorax signs of hemorrhagic shock. On what bilize the rib fractures; remove foreign
and was associated with decreased clinical evidence should you base the bodies; place thoracic drains; and
survival? need for a whole blood transfusion? debride, lavage, and close the wound
a. open thoracic trauma a. PCV
b. closed thoracic trauma b. total plasma protein level 9. Flail chest results from
c. pleuropneumonia c. platelet count
a. the fracture of two or more adjacent ribs
d. clinical signs
d. lower respiratory surgery in one plane.
b. the fracture of two or more adjacent
7. In patients with acute hemorrhage, a large
3. Overlapping ___________ sutures are ribs in multiple planes.
amount of ___________ is contraindicated
placed to seal the lung stump after because of possible coagulopathic effects. c. two or more fractures involving a single rib.
amputation or to repair lacerations to the a. hetastarch d. rib fracture with secondary pulmonary
lung margin. b. hypertonic saline laceration.
a. horizontal mattress c. whole blood
b. vertical mattress d. plasma 10. Which statement regarding pneumothorax
c. simple interrupted is true?
d. cruciate 8. A 5-year-old Standardbred gelding suffers a. Open pneumothorax involves lung
blunt trauma during race training. On pre- perforation.
4. Following wound bandaging or closure sentation, you note the following: severe b. Closed pneumothorax does not involve
in equine patients with pneumothorax respiratory distress, an open chest wound, lung perforation.
secondary to thoracic trauma, which flail chest, tachycardia, pale mucous c. Tension pneumothorax occurs when
emergency procedure is indicated? membranes, and colic. You diagnose intrapleural pressure exceeds atmo-
a. intravenous fluid therapy pneumothorax, hemothorax, diaphrag- spheric pressure.
b. whole blood transfusion matic hernia, and multiple rib fractures. d. Tension pneumothorax occurs when
c. removal of a foreign body Following patient stabilization, which atmospheric pressure exceeds intra-
d. removal of pleural air treatment strategy do you recommend? pleural pressure.

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