Elle's Chest Wound Update

I'm super impressed with how Elle's chest is healing.  With a reminder that they are quite graphic as the wound was significant, here are the latest photos in chronological order:

 

 

On 21 Aug the difference between the AM and PM photos surprised me so I took an extra photo that day.  Here is the 10AM:

And here is the 3:30 PM:

 

I'm really pleased with the progress, the wound has filled in nicely and the edges are contracting.  I've continued to take detailed notes on treatment and observations each day.  

 

I did notice that Elle's forehead swelled up last week and she began dropping chewed up bits of hay, called quidding.  She also had bloody nasal discharge from her L nostril and it was the L side of her forehead that had swollen.

  

Dr. Landes came out to examine her last Saturday.  She may have injured her head at the same time as the initial chest wound, since we don't know exactly what happened.  After a dental to resolve her hooks in front and ramps in back, Dr. Landes took some head xrays to try to see what was going on in the sinuses of her skull.  He also had a radiologist look at the images to give us some more information.  The sinuses are inflamed with fluid in the L rostral sinus (closer to her nostrils) and the bloody nose may indeed have been from trauma to the head (so it's possibly not an infection in the sinus or tooth roots).  The xrays of her nasal bone were fuzzy looking (radiolucent) which might be from incomplete healing or soft tissue causing the swelling.

The recommendations for her face include endoscopic evaluation of ethmoids and sinoscopy (using a small camera in a tube to visualize what's going on inside different portions of her face).  We'll be headed into CSU on Tues for that evaluation, as long as I can get her into the trailer because her balance issues can make loading difficult for her. 

Elle's Chest Wound Healing

Here are the photos of Elle's chest as it's been attended to here.  They are accurate but graphic photos of the wound progression so proceed only if you're comfortable with these sorts of photos.

Elle's been extremely well behaved for all the cleaning, lasering, bandaging, and temperature taking!  She stands quietly while tied in the stall and occasionally nibbles on the hanging ball of hay for entertainment while I work.  Taking cookies gently at the end of each treatment is her favorite part.

These photos are going in chronological order so we can see the progression of the wound. This first photo is from 11 Aug 2021 when she first arrived.  The bald patches are where the tissue isn't getting good blood supply because of damage from the original wound, so the hair has fallen out in that area.  Because of this we knew that the suture line would break down there.

This next photo is from 13 Aug 2021, and you can see that the edges of the wound are healing, but not together.  That means the body is not going to close the wound up where it was originally opened, and it will have to heal from the inside out by building good granulation tissue inside the cavity. 

In order to encourage the cavity to grow good granulation tissue, I began packing the wound with Calcium Alginate padding.  This pad encourages the granulation tissue to grow.  I also want the cavity to remain uninfected by bacteria, so I've been soaking the pad in honey, which is an excellent natural antibacterial.  So the wound is remaining open, and I'm stuffing it with honey soaked CaAlg to get it to fill in with healthy tissue.  The red tape going around Elle's chest/shoulder is to hold the padding in place.  The tape never touches the open wound, it just gently holds the bandage over the wound.

 

This photo with the red tape is from 14 Aug 2021, and if you look closely you can see the honey soaked padding inside the cavity.  Unfortunately with these types of wounds, they often look worse before they look better.  This is because the outer tissue dies and sloughs off, while the inner tissue grows and fills in. 

 

This next photo is from today, 15 Aug 2021.  The wound is looking much better, with a big difference from yesterday to today.  The edges have healthy pink tissue coming in, and the cavity itself is continuing to heal from the inside out and produce the healthy granulation tissue we want.  The wound is also starting to constrict, getting smaller as the body is repairing the damage.  I did gently palpate inside the cavity and it is appreciably more shallow and smaller in diameter today than yesterday.

I've continued to use the laser on it twice daily, the first five minute treatment is on setting 2 to stimulate the tissue to grow, and then five minutes with setting 3 for pain relief for Elle.  I can definitely tell that the two settings must feel different to her, as she is a little fidgety with the setting 2 treatment though she tolerates it well.  When I switch to setting 3 she closes her eyes and lowers her head.

This last photo is of the new bandage placed today, 15 Aug 2021.  I have packed the cavity with honey-soaked CaAlg padding, then applied a hydrophilic foam pad.  The blue tape is going over the padding so it never touches the wound itself, and gently secures the bandage in place.  I do put a shoulder guard over the whole thing to keep it clean and in place.
 

Here is a photo of the treatment sheet from this week as I've filled it in with notes, observations, and documenting everything I've done to care for Elle over the past week.  It's really important to have these records just in case something goes sideways in the process of healing a wound like this.  That way I have notes to refer back to and the attending veterinarian (Dr. Landes in this case) can review everything that has occurred in the process.

This next photo is from 16 Aug 2021, and you can see the suture line breaking down as expected.  As sutures came out I removed them, and ones that were tearing through the skin I also removed.

On 17 Aug 2021  the last of the sutures were removed, so now I'm caring for it as a regular open wound since our biologic bandage of sorts has broken down.  It's still getting lasered twice daily, coated in honey, with some swat insect repellent ointment applied around the wound on the healthy tissue.  I have a new shoulder guard that should arrive any day now, which hopefully will work to put a plastic liner on it and then keep the wound covered with that as well.  

Wound Care

Over the weekend Elle was injured, and so there are some graphic photos in this blog post as I detail her wound care, rehab, and recovery.  She is an approximately 10 y/o chestnut warmblood mare with some underlying proprioceptive issues, who incurred a large wound over the mid to ventral aspect of her right pectoral muscle.  It required suturing to close, but will likely not heal without some sloughing of tissue.  Her owner sent her here for wound care and dressing as the injury heals.  

When I get these types of cases for PT/rehab, I do quite a bit of documentation to ensure that any veterinarians involved are kept abreast of the status of the patient as well as keeping the owners informed.  This also lets me keep detailed information on how the wound is healing, including the horse's vital signs which can indicate something may be going awry before the horse starts behaving oddly. 

Here is the treatment sheet I use for large laceration cases:

This chart has a spot for me to track all kinds of pertinent details about the horse, and the last column on the right is where I make additional notes on the horse and wound treatment.  I also take a photo at each treatment to document progress visually.

This first photo is from when the wound was found, on Sun 8/8.

 

This second photo is from today, after I brought Elle to Bit of Honey and after I lavaged the wound with saline solution.  I have a weed sprayer, which I fill with a salt water solution of 2 tsp salt /1 L water, and it does a great job rinsing the wound without debriding too much tissue.  Spraying the wound with salt water inhibits bacterial growth, as most bacteria doesn't like to live in salty environments.  I don't use disinfectant like betadine or chlorhexidine at this stage in the wound healing, because those solutions, while excellent for killing bacteria, also decrease regrowth of healthy tissue.

Once the wound was thoroughly rinsed with the saline solution I gently removed crusted material from surrounding healthy tissue.  Too much serum or exudate left on the healthy surrounding skin can irritate the skin and cause secondary issues, so I like to keep the rest of the leg clean by rinsing with water then soaking the hair with laser sheen hair polish to help any dripping to slide off the hair rather than stick.  

Once everything was clean, I applied honey to the wound.  Honey is a great natural antibacterial substance.  It's inexpensive, works well to help prevent infection, and doesn't sting when applied to the wound.  Because we are in the middle of August and despite detailed manure management and liberal use of fly predators there are some flies around.  I applied some swat fly repellent ointment to the healthy skin surrounding the wound, which helps to minimize flies on the injury.  If necessary I'll assemble a cover for the wound using a shoulder guard, but I wanted to give this a try first to minimize friction on the sutures from fabric rubbing.

Elle also had a treatment with the laser.  This works well to reduce inflammation and pain, as well as stimulate growth of new healthy granulation tissue.  She seemed to like the laser, she nuzzled it a couple times when I was moving it over the actual wound.  If the setting is incorrect the horse will almost always tell me by acting uncomfortable, either pawing or leaning away from me.  When they lean into the laser or nuzzle it with their noses it's usually because it feels good to them.

Elle was set up in the stall with fresh shavings, water buckets, and her evening grain including bute for pain management and oral antibiotics to prevent infection.  I'll continue to monitor her and treat the wound twice daily for at least two weeks, and we'll see how healing comes along!

 

More Drawings: Horses and Dogs

With the smoke so bad around here I've been spending more time in the house, which means more drawing.  It makes me so happy that I can do this!

This is Sam, done from a photo of him free jumping shortly after he arrived at Bit of Honey.  I've drawn this photo of Sam twice, once with only pencils/graphite and once with graphite and conte crayon to get the dark parts blacker.

The up-close puppy nose is Pascal when he arrived just over a year ago and was only eight weeks old.

This one is a work in progress.  A photo of Elle, a warmblood mare owned by one of my clients, with her first foal just an hour after she was born.  Such a cute little chestnut filly!  I picked up some different types of charcoal and then came across some charcoal paper, so I'm playing with those new materials.