Species: dog
Breed: Labrador Retriever
Sex: m, not neutered
Weight: 39.8 kg
Birth date: 2020-09-24 00:00:00
Primary diagnosis: Polytrauma patient (mandibula and maxilla fractures, torn right lip, retrobulbar haemorrhage right, suspected traumatic myocarditis)
Situation: hospitalized
Medical history: The 13.10.2024 in the afternoon Max ran and jumped off a 10 metre tower while out for a walk. After the fall, Max was able to stand and walk on all fours and was conscious. The right side of his face was bleeding and swollen. The owners went to the private vet, who gave Max buprenorphine and etamsylate and referred him to our clinic. Max is otherwise healthy and has no pre-existing conditions. On the 14.10 a CT of the head and thorax was done. CT-report (14.10): Multiple open fractures of right face with a large defect affecting the right mandible and bony borders of the oral, nasal and orbital cavity with substantial bondy and dental loss and open communication between all of the aforementioned cavities; Intra-articular right temporo-mandibular fracture, mildly displaced; Regional subcutaneous emphysema and soft tissus swelling; Right exophtalmus; Moderate ventriculomegaly; Pulmonary lesion, more marked on the left side. Max also is blind on both sides. Surgery report (17.10): Ispection, removal of the 2 fractured molar teeth, courettage of the exposed bone fragments with the burr to make the surface as smooth as possible, development of a bilateral mucosal flap for closure of the defect; Closure without tension of the intraoral side, closure of the labial skin. The dog was put under Fentanyl CRI (and other medication) for a few days. Max was in a reduced general state, he had phases where he was restless, and he had a ventricular tachycardia with ventricular extrasystoles. On the 16.10 the Fentanyl CRI was reduced and stopped, and those symptoms got better. His general state then worsened again and he developed fever. On the 21.10 Max got a blood transfusion.
Medication: 15.10: Fentanyl CRI 0.005 mg/kg/h, Ondansetron 0.3 mg/kg IV TID, Ampicillin 30 mg/kg IV TID, Meloxicam 0.2mg/kg IV SID, Metoclopramid CRI, Metamizol 40 mg/kg IV TID, Oxytetracyclin eye ointment TID. 16.10: Ondansetron & Ampicillin & Metoclopramid & Oxytretracylin eye ointment same as on 15.10, Meloxicam 0.1 mg/kg IV SID, Metamizol 50 mg/kg IV TID, Ketamin 0.5 mg/kg SC TID, Fentanyl CRI reduced and stopped, after stopping Fentanyl start with Methadon 0.1 mg/kg IV q4h. 17.10: Ondansetron & Ampicillin & Metacam & Metoclopramid & Oxytretracylin eye ointment & Methadon & Ketamin same as on 16.10, Metamizol 40 mg/kg IV TID. 20.10 (not filmed): Ondansetron 0.3 mg/kg IV TID, Ampicillin 30 mg/kg IV TID, Meloxicam 0.1 mg/kg IV SID, Maropitant 1 mg/kg IV SID, Oxytetracyclin eye ointment TID, Metamizol 40mg/kg IV TID, Methadon 0.1 mg/kg IV q4h, Marbofloxacin 2 mg/kg IV SID, Gabapentin 10 mg/kg PO TID. 21.10 (only eye ointment given before observation 7): Ondansetron & Ampicillin & Meloxicam & Maropitant & Oxytetracyclin eye ointment & Metamizol & Marbofloxacin & Gabapentin same as on 20.10, Buprenorphin 0.015 mg/kg VI TID (not given at 17). 22.10 (only eye ointment given before observation 7): Ondansetron 0.3 mg/kg IV TID, Ampicillin 30 mg/kg IV TID, Meloxicam 0.1 mg/kg IV SID, Oxytetracyclin eye ointment TID, Metamizol 30 mg/kg IV TID, Buprenorphin 0.015 mg/kg IV 1x at 09, Marbofloxacin 2 mg/kg IV SID, Gabapentin 10 mg/kg PO TID, Sucralfat unclear dosis PO BID, Ranitidin 4.1 mg/kg PO/ BID. 23.10 (nothing given before observation 9): Oxytetracylcine eye ointment TID, Ondansetron 0.3 mg/kg PO, Cylanic 625 mg PO BID (Amoxicillin 12.5 mg/kg & Clavulaic acid 3.1 mg/kg), Meloxicam 0.1 mg/kg PO SID, Marbofloxacin 2 mg/kg PO SID, Sucralfat 25 mg/kg PO TID, Ranitidin 0.5 mg/kg PO BID.
Pain type: acute, inflammatory, somatic
Pain origin: head
Pain duration: 24 hours to 7 days
Estimated pain severity: 23