Triage of Horses_ Pinery Fires 2016 Dr. Lidwien Verdegaal

Horses in the Pinery bush fire Nov 2015

Lidwien Verdegaal DVM, Dipl. ECEIM, Dipl. RNVA School of Animal and Veterinary Science [email protected]

Triage of horses

Lidwien Verdegaal DVM, Dip ECEIM

•  On scene •  Triage of burned horses •  Clinical findings and treatment •  DescripGon of cases at the EHPC •  Recovery, complicaGons and challenges •  What did we learn?

Triage of horses What is the first thing to do?

•  Do horses need to move to safe zone: •  Where to move them to? •  Fire brigade?

•  Consider the human safety above all

On-‐scene consideraDons

First aid quesGons •  How many horses? •  What is the behaviour of the horse?

Advice: •  Calm (people & horses) •  Apply water lavage (hose, buckets)

On-‐scene consideraDons: telephone call

•  Always consider horses may have explosive acGon •  Flight is insGncGve

•  Find people experienced in horse handling •  Calm, quiet

•  Have the right equipment and medicine on hand •  Restraint/ rescue •  SedaGon, medicaGons & bandages

On-‐scene consideraDons: emergency handling

Under no circumstances enter an acDve fire zone

Structure fires

High fatality rate due to • radiant heat • smoke inhalaGon • contact burns

Surviving horses:

• extensive dorsal burns • smoke inhalaGon injury

• ash or noxious gases

Bush fires

High fatality due to • radiant heat • contact burns • injury limbs

Surviving horses:

• extensive limb burns • smoke inhalaGon

Heat à causes cell death à Inflammatory response &/or oedema Airways: à respiratory distress •  ParGal airway obstrucGon upper part of

respiratory tract •  Protein leakage into lungs (oedema and

hypoxia) Other organs: Injury of Gssues •  systemic shock (circulatory collapse)

Burn – thermal injuries Why?

•  Airways •  DehydraGon/ shock •  Hoofs: coronary bands and laminiGs •  Skin burns: direct and radiant heat:

•  Eyes •  Face •  Distal limbs •  Ventral body •  Perineum

Burn – thermal injuries Where?

Arrival at the hospital Triage of the burned case

Principles •  PrioriGse: cooling •  Assess % burned body surface area •  Clinical exam and problem list Treatment: •  Treatment of shock (IV fluids) •  Treatment of smoke inhalaGon •  Burn skin injury

•  ClassificaGon and prognosis •  Treatment

Triage of burned cases Priority is cooling!

Immediately cool all body areas:

Ice & cold water > for 20 minutes

Triage of the burned case

Principles •  PrioriGse: cooling þ •  Assess % burned body surface area •  Clinical exam and problem list Treatment: •  Treatment of shock (IV fluids) •  Treatment of smoke inhalaGon •  Burn skin injury


Ø  15-‐20% burned surface area requires IV fluids & intensive care

Courtesy Wendy Ducke0

Unconscious or semi-‐conscious

Down & unable to walk Respiratory difficulGes

Major swelling of the limbs

Extensive burns to bare areas

Extensive damage to underlying structures

Triage of the burned case: Humane euthanasia


Principles •  PrioriGse: cooling þ •  Assess % burned body surface area þ •  Clinical exam and problem list Treatment: •  Treatment of shock (fluids) •  Treatment of smoke inhalaGon •  Burn skin injury


•  1 horse or more horses involved? •  Appearance/ behaviour •  Vital signs •  DehydraGon/ shock? •  Respiratory distress, cough •  Skin injuries:

–  Oozing skin, oedema –  Ocular wounds, joint, tendon, coronary band

Triage of cases IniDal clinical exam


Principles •  PrioriGse: cooling þ •  Assess % burned body surface area þ •  Clinical exam and problem list þ Treatment: •  Treatment of burn shock (fluids) •  Treatment of smoke inhalaGon •  Burn skin injury

1.  ClassificaGon and prognosis 2.  Treatment

Burn shock: emergency treatment

> 15% surface area •  IV fluids •  IV plasma and/or Hetastarch® •  NSAIDs (flunixin, meloxicam) •  Pulmonary oedema

•  Humidified oxygen •  AnGbioGcs


Principles •  PrioriGse: cooling þ •  Assess % burned body surface area þ •  Clinical exam and problem list þ Treatment: •  Treatment of burn shock (IV fluids) þ •  Treatment of smoke inhalaGon •  Burn skin injury


Smoke InhalaDon Treatment

•  Maintain airway open •  Upper airway obstrucGon –

tracheotomy •  Humidified oxygen •  Broad spectrum anGmicrobials •  NebulisaGon (saline) •  Bronchodilators

Smoke InhalaDon Endoscopy and airway sampling

!

The long-‐term prognosis is uncertain


Principles •  PrioriGse: cooling þ •  Assess % burned body surface area þ •  Clinical exam and problem list þ Treatment: •  Treatment of burn shock (IV fluids) þ •  Treatment of smoke inhalaGon þ •  Burn skin injury


ClassificaDon burn wounds

!

1st degree: Superficial epidermis: painful 2nd degree: ParGal thickness and deep: minimal pain 3rd degree: Full thickness: no cutaneous sensaGon

and fluid loss

Management of 1st degree burns Treatment

•  Water lavage •  Silver sulfadiazine •  Aloe vera •  Pain relief (flunixin, meloxicam)

Management of 2nd degree burns Treatment

•  Usually not fatal •  Manage as for superficial burn •  Vesicles & blisters •  Apply anGbacterial dressing/

cream

Management of 3rd degree burns Treatment

•  PotenGally life threatening •  Manage shock •  Manage respiratory distress

•  Euthanasia? •  Clip surrounding hair •  Clean wound 2-‐3 x daily

•  Dilute chlorhexidine •  AnGbacterial topical treatment? •  Permeable dressings •  Debride necroGc Gssue


EHPC: night of 25th of November 2015 •  6 severely burned horses •  different breeds, age range 2 – 18 years old •  arrival range 2 to 6 hours post thermal injury

The second day…

1.  Swollen muzzle/ face 2.  Increased RR 3.  Low protein (blood) 4.  Assess wounds

Day 2 at hospital

Triage of the burned case Pain management

One of the most challenging issues is

the management of pain!

Days post injury treatment

Wound care

PruriDs, non-‐ healing wounds and pain

Coronary band injury and laminiDs

Weight loss, negaDve energy balance, colic, kidney problems, lung injury

Triage of the burned case: Survival!

•  Severity of burns; unpredictable unGl up to weeks later

•  During 1st 2 weeks: every day seems to be different! ComplicaGons of Pinery fires include: •  Severe coronary band injury (no laminiGs) •  Severe pain: due to coronary band and/ or skin burns

•  Respiratory effects (good recovery in our cases) •  Deep 2nd and 3rd degree burns: long term recovery •  Weight loss due to high metabolic demand but also less appeGte due to high triglycerides and pain

What have we learned..

Acknowledgement •  The team of EHPC!! •  Excellent veterinary students Michelle, JusGna, Katelyn for 2

weeks and many other students!

•  Many volunteers!!: nurses, students, daughters of staff members etc.!!

•  PharmaceuGcal companies

Triage of the burned case Team effort!!

Thank you!

Triage of the burned case The goal is survival

Triage of Horses_ Pinery Fires 2016 Dr. Lidwien Verdegaal

Education

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