A 4yr FS German short-haired pointer has a negative exploratory laparotomy (could be just as well an US-guided percutaneous needle or Tru-cut Biopsy) earlier in the day. She remains hypothermic with mild tachycardia of 144 beats per minute. On physical exam she is dull but alert and otherwise unremarkable. Incision is clean dry and intact. Her bloodwork is also unremarkable with a normal packed cell volume.
1) You continue monitoring with traditional training of vital signs, physical examination +/- lab work and +/- radiography
2) Immediately after you do your physical exam you do Global FAST and you find
AFAST: Abdominal Fluid Score (AFS = 4), and these are large pockets of free fluid, urinary bladder is medium sized, rest NSF -> abdominocentesis and fluid analysis -> hemoabdomen
TFAST: poor left ventricular filling and attenuated or flat caudal vena cava -> needs volume give crystalloids
Vet BLUE: absent B-lines all views (ABAV) -> no signs of aspiration pneumonia, no lung edema
Conclusions: has a post-op hemoabdomen that requires immediate re-exploration. Large volume AFS 3 and 4 post-interventional procedures are not going to stop bleeding on their own.
*What are you waiting for? Complications where the dog decompensates? Need blood products? Becomes unstable? Has a huge veterinary bill +/- survival? Get to surgery ASASE – As Soon As Stable Enough (ASASE)
Run Coag Times, check BMBT, and re-explore! Using the AFAST abdominal fluid scoring system is HUGELY impactful:
AFS 1 and 2 do not have enough free fluid in their abdominal cavity to cause anemia – if anemia present then (4) major considerations: 1) the patient is bleeding somewhere else, 2) has pre-existing anemia, 3) its lab error or 4) now much less commonly, hemodilution
AFS 3 and 4 have enough blood in their abdominal cavity to develop anemia, and the potential for severe anemia < 25%. In post-interventional cases as discussed here, surgery is indicated.
If the dog began as an AFS 1 or 2, then continue serial exams every 2-4 hours with a calculated AFS. As long as the patient remains AFS 1 or 2 medical therapy is indicated. If the patient becomes AFS 3 and the patient is not coaguloapthic, then the patient needs to be explored and have their bleeding surgical stopped.
Blunt trauma is NOT discussed here and is generally medically-treated. Stay tuned for Blunt Trauma.
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