Presenter: Paul Aldridge BVSc Cert SAS MRCVS
After participating in last week’s Platinum Member’s webinar discussing pharyngeal stick injury it was clear why Paul Aldridge, who led this webinar, always gives a frisbee as a parting gift to the owners of dogs who have recovered from this sometimes fatal condition. If the stress, money and heartache for both vet and owner could somehow be avoided by simply replacing a stick with a frisbee, then I can’t imagine owners ever wanting to throw a stick for their dog again. However, despite owner education, it is still not uncommon to encounter pharyngeal stick injuries, and in last week’s webinar Paul discussed how to secure the best possible outcome for the dog by providing a prompt, thorough and aggressive approach to managing these emergency situations.
Paul advises as with all emergencies, patients with pharyngeal stick injuries must at first be stabilised by performing a major body assessment and providing any necessary treatment. This could be in the form of oxygen for the dyspnoeic patient and intravenous fluid boluses for hypovolaemic patients. Once a patient is stable a general anaesthetic can be administered to allow for an urgent and thorough assessment of the oral cavity. This includes checking all aspects of the tongue, the tonsils and tonsillar crypts, the oral palatal surfaces and the pharyngeal and peri laryngeal mucosa. If a wound is found, it is important to probe this and assess how far it extends. Paul also advises always checking for further wounds as some sticks can penetrate through several structures. This is particularly important with penetrating wounds found in the soft palate which could extend back into the dorsal pharynx and oesophagus. Sticks which penetrate with this dorsal trajectory present the most risk to the dog and have the potential to cause life threatening damage.
Radiography is another diagnostic tool essential for determining the extent of the damage made by the penetrating stick. Radiography of the head, neck and pharynx may show the presence of cervical emphysema seen as gas lucencies within the neck but outside of the trachea or oesophagus. This is a clear indicator that there has been significant damage to either the pharynx and/or larynx which calls for either surgical exploration or immediate referral. Thoracic radiography may also show the presence of gas extending down the facial planes of the neck and evidence of a pneumomediastinum. There may also be improved contrast within the mediastinum with easier identification of structures such as thoracic vessels and tracheal rings. All these signs once again indicate oesophageal injury and surgical exploration must be carried out.
Paul went on to discuss the treatment for both the oral approach to injuries where surgical exploration is not warranted and also the more urgent cervical approach where dorsal pharyngeal punctures have been observed and/or where there is radiographic evidence pointing towards pharyngeal and/or oesophageal injury. Repair of oesophageal tears was also discussed with Paul advising the use of the two layered approach using single interrupted sutures. However, when placing these sutures into the mucosa and sub mucosa, the knots should be placed within the lumen of the oesophagus, the complete opposite to the technique used to place sutures within the intestinal wall. Post-operative care was also discussed including the placement of a gastrotomy tube using the limited approach through the dogs flank in order to avoid further trauma to the oesophagus. The placement of feeding tubes in patients with oesophageal tears is vital as these patients need to have nil by mouth for at least seven days in order to protect and prevent any further damage to their oesophagus.
Throughout this webinar Paul delivered some key ‘take home’ messages for managing these challenging cases. One of those messages, as stated before, is to always keep looking for further penetration points even when one wound has already been found. This is particularly important where the location of a wound indicates the dorsal trajectory of a stick. It is also imperative to never ‘wait and see’ with these cases; some dogs may come into the consulting room looking very bright and perky and it could be easy to just send these cases home with antibiotics in the hope everything will be okay.
Unfortunately, if these cases have suffered a deep penetrating wound and are left untreated, they are likely to go on to develop mediastinitis and/or pneumomediastinum which are often fatal conditions. All pharyngeal stick injuries must be treated as life threatening conditions until proved otherwise and the presence of cervical emphysema and/or pneumomediastinum are all indicators for rapid surgical exploration or referral.
Finally, the last ‘take home’ message delivered by Paul is to remember that ‘prevention is better than cure’ and owners should be advised about the dangers of sticks and encouraged to ‘buy a frisbee!’
The Stethoscope (MRCVS)