Princess, a 10 year old female spayed poodle, presented to the Atlantic Street Veterinary Hospital Pet Emergency Center (PEC) two hours after being attacked by another dog.
Princess, a very friendly dog, had approached a Labrador retriever who bit Princess multiple times over the chest and neck.
Princess’ owners had driven to one veterinary hospital that did not have emergency services and had been referred to PEC. Princess’ owners reported that a bulge developed on Princess’ left side during the ride.
At PEC Princess was taken immediately to the treatment area for assessment and stabilization. Princess was very painful with multiple 1-2cm punctures with dried blood over her thorax and ventral cervical region. She was able to stand but was weak. She had a large 10cm subcutaneous swelling over her left thorax. Her mucous membranes were pale pink, her heart rate was elevated, and her pulses were thready. She was having mild difficulty breathing.
Oxygen was administered, an IV catheter was placed, and pre-treatment blood samples were drawn. Princess was rapidly treated with IV fluids for shock, IV butorphanol for pain, and IV antibiotics.
Whole body radiographs (x-rays) revealed multiple rib fractures, spread ribs, pulmonary contusions and an air filled subcutaneous pocket on the left side of Princess’ chest. No pneumothorax was seen.
NOTE: A pneumothorax is present when air is present in the chest cavity but outside of the lungs and airways. A pneumothorax occurs when the chest wall was been penetrated allowing outside air to rush into the chest cavity or when a lung or airway in penetrated allowing air from within the respiratory tract to leak out into the chest cavity. Depending on the amount of air within the chest, a pneumothorax prevents the lungs from inflating properly or at all. The location of Princess’s bite wounds and the size of her attacker relative to her size made a pneumothorax expected; yet it was not found.
Princess’ bloodwork showed an elevated lactate level consistent with shock and mildly elevated liver enzymes (ALT and ALKP).
After further assessment, oxygen, IV fluids, IV pain medications and IV antibiotics, Princess was taken to exploratory surgery.
Recheck thoracic radiographs just prior to surgery showed pulmonary contusions in the left caudal lung fields.
Princess’ thoracic puncture wounds were explored. One puncture wound tracked to the large subcutaneous swelling over her left thorax. This swelling was found to be Princess’s stomach which had herniated through a rent in her diaphragm and out through a rent in her chest wall into the subcutaneous space. The stomach, moderately filled with air, like a partially deflated balloon, was serving to plug these defects, preventing a pneumothorax from occurring. Princess’ stomach was replaced into the abdomen while Princess was ventilated. The diaphragmatic rent and 3 large thoracic wall rents were repaired. A small flail chest or mobile segment of broken ribs was stabilized.
After Princess’ chest wounds were repaired her abdomen was explored via a separate midline abdominal incision to allow for full inspection of her abdomen for further injuries. Her stomach was carefully examined and found to have been avulsed from its blood supply on the lesser curvature. Yet the stomach appeared viable, and no trauma to other abdominal organs was found.
NOTE: Princess is a classic example of the externally visible bite wounds being only the tip of the iceberg in terms of the traumatic injuries rendered by dog bites.
Dogs and cats have relatively loose or mobile skin that can move with the tooth after the tooth penetrates the skin. Thus, the puncture in the skin can remain relatively small while the attacker’s tooth tears through the underlying tissues; which in Princess’s case, were the chest wall and diaphragm.
During post-anesthesia recovery, Princess’ respiratory effort and rate were elevated. PulseOximetry readings showed she was inadequately oxygenating and bilateral nasal cannulas were placed and oxygen administration initiated.
Princess’ PulseOximetry readings significantly improved, showing she was receiving adequate oxygen, yet her breathing pattern remained abnormal. To rule out pain as an additional cause for Princess’ rapid breathing, Princess was started on a constant IV infusion of morphine, ketamine and lidocaine.
Princess’ rapid breathing persisted despite the increased levels of analgesics. Recheck thoracic radiographs showed worsening of the pulmonary infiltrates. Princess was treated with the diuretic drug Lasix and her breathing steadily improved.
Princess spent the next 4 days in hospital on IV fluids, IV pain medications and IV antibiotics. Her monitoring included blood pressure measurements, ECG, PulseOximetry, respiratory rates, temperature readings, and bloodwork. She was gradually weaned off oxygen and pain medications, and discharged after she was eating a small amount. She was sent home on oral antibiotics and oral pain medications.
Two weeks later at home, Princess was still recovering but eating well and taking walks around the block.
NOTE: While the herniation of Princess’ stomach that plugged the rent in her chest wall and saved her life is unusual, the severity of the injuries she suffered is unfortunately common in little dogs and cats bit by large dogs.
