Equine Emergency Medicine Update

It’s not a matter of if you’ll receive a panicked phone call from a client with a sick or injured horse; it’s a matter of how often—and how you’ll handle it.
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While human urgent care centers are popping up two and three at a time in some communities across the country, the general equine veterinarian is still the primary responder in equine emergency situations.

Advances in equine medical care often spring out of developments in human medicine. While human urgent care centers are popping up two and three at a time in some communities across the country, the general equine veterinarian is still the primary responder in equine emergency situations.

There are some equine emergency/referral clinics, but they are far less common and often are attached to veterinary schools. That means most veterinarians and their staffs must be prepared to diagnose and treat emergency situations at the horse’s home barn at any time of the day or night.

“The key to providing quality emergency care in many cases is the willingness and the ability to be available when the need arises,” said Leslie Easterwood, DVM, a clinical associate professor of equine community practice at Texas A&M University’s College of Veterinary Medicine. “This could be counseling a client that the best available care is in the hands of a specialist and helping to get the horse into the best condition for transportation, or it could be actually providing the care that the horse needs to get through the crisis.”

Equine emergency care is different from that of small animals. On-call and overnight small animal practices are more readily available to the public. A dog or cat isn’t likely to see its regular doctor in the middle of the night, over a weekend or on a holiday. But for horses, the regular veterinarian or staff from the practice are the ones who respond.

Transporting a horse that is critically ill or injured isn’t always a viable option. Therefore, the client relies on his or her veterinarian to visit the barn when the horse needs help. That means emergency services are a necessity for every equine practice, and providing emergency services comes with the territory of the job.

Getting out of bed after midnight in the middle of winter is likely the least favorite part of any veterinarian’s job. However, advancements in diagnostic and treatment techniques have enhanced a veterinarian’s ability to assess and respond to situations faster—and with better outcomes—on the farm.

In the article that follows, Easterwood and Kentucky-based veterinarian Peggy S. Marsh, DVM, ACVIM, ACVECC, of Equine Medical Associates, PSC, highlight several advancements that have already changed the way veterinarians respond to emergencies. They also point out ongoing research efforts that should radically improve outcomes for horses and their owners in the future.

Enhanced Imaging Technology

Ultrasound isn’t just for reproductive or “from-the-hock-down” musculoskeletal diagnostics in racehorses anymore. As the technology has evolved and image resolution has increased, ultrasound has become an invaluable tool for everything from lameness exams to tumor exploration, guided joint injections and much more. And ultrasound has become an important tool for ambulatory care. One example is a focused ultrasound examination of the abdomen that aids in diagnosing the cause of a colic episode.

Besides ultrasound imaging developments, you can add the major advancements in the field of radiographs, especially digital radiographs in the field. “With digital radiographs, an image is seen stall-side at the time of the exam,” Easterwood said.

The image quality obtained today is light years ahead of where it was when digital radiographs were first introduced. Portability and image quality will only continue to improve as time goes on. High-quality images were the first major step for this technology. Now with the reliability and availability of wireless technology, it’s even possible to view results in the palm of your hand on a tablet or smartphone.

“The technology is getting better and better all the time,” she said.

Expanded Specialties

Compared to just a few years ago, there are an increasing number of veterinarians who specialize in large animal emergency and critical care. There are just under 50 of these specialists worldwide, and while many are at universities, some are in private practices, according to Marsh.

“They are an excellent source of information, along with the experienced equine practitioner,” Marsh said. “Discussion groups, especially those on social media, have allowed veterinarians to share information and get advice quickly.”

In the not-so-distant past, there were few specialists a veterinarian could contact and ask for advice on complicated medical situations. Now, even if the specialist is across the country, it’s much easier to find one and receive feedback on a case in a timely manner.

For example, board-certified internists can now use advanced communication technologies to view ultrasound results or digital radiographs that are being done real time in the field.

“Being able to have a specialist ‘along for the ride’ allows for another set of eyes on a case,” said Easterwood. “These consultations will become more common in the near future, and we are already seeing great success in human emergency medicine situations using this type of technology. Our veterinarians know that a specialist is only a phone call or teleconference away from being able to help on a case.”

IV Fluids

In Marsh’s opinion, some of the most exciting developments for equine emergency care are related to physiology and the scientific world’s enhanced understanding of the functions and mechanisms that take place within a living organism. She explained that over the last five years, there have been significant advancements in learning about equine physiology that are changing the protocols for treating certain conditions.

One example is the administration of intravenous (IV) fluids and the impact that saline-based solutions have on restoring the body after injury. As the understanding of physiology increases, especially regarding methods to restore normal function after injury, it is becoming clear that what is in IV fluids is important and will vary based on the situation.

The book “Equine Fluid Therapy,” edited by C. Langdon Fielding, DVM, DACVECC, and K. Gary Magdesian, DVM, DACVIM, DACVECC, DACVCP (2014), is a good resource, she said.

While saline is the most widely accepted IV solution of choice and is viewed as a “replacement fluid,” new studies are indicating that current practices are not necessarily what practitioners want to be striving for. A better understanding of the amount of—and concentration of—fluids enables greater flexibility in treating a horse that doesn’t seem to be responding to treatment. Changing the type of fluids administered means the horse gets back to normal more quickly.

Neonatal Care

Critically ill foals are routinely saved with intensive care that has evolved and is readily accessible. Advances in monitoring equipment that is modified for use on foals has allowed equine neonatal medicine to approach the level of intensive care that is available in human neonatal intensive care units. Often the research in one species leads to advances in treatments for another.

Easterwood pointed to the work of John Madigan, DVM, MS, DACVIM, at the UC Davis College of Veterinary Medicine. Madigan has worked in the area of maladjusted neonatal foals and has posed two important questions:

  • What keeps a foal quiet in the womb, so that he doesn't move around? 
  • What changes happen at the time of birth that allow a foal to rise and walk within a few hours and be able to move with the mare to avoid predators very quickly after birth?

“His work to find new ways to understand and intervene in this process will not only help equine neonates, it could potentially lead to significant breakthroughs in human neonatal medicine,” Easterwood said. “Advances in monitoring and intervening in blood pressure, oxygenation, electrolyte balances, etc., has led to many more foals saved when compared to a few decades ago.”

Blood Substitutes

When a horse needs a blood transfusion, finding a matching donor can be challenging, especially when a lot of blood is needed. If veterinarians had a synthetic substitute that was available in a bag, treatment could be delivered more quickly. Sound otherworldly? While it’s not quite viable now, Marsh predicts it’s not too far off.

“Research has shown that using synthetic blood replacements have consequences. It’s not working as well as researchers hoped, but I have no doubt that it will come to fruition in the future,” she said.

Researchers believe artificial blood substitutes might pave the way to a new era in transfusion medicine. The 2016 study "Artificial Blood Substitutes: First Steps on the Long Route to Clinical Utility," published in Clinical Medical Insights: Blood Disorders, highlighted the progress in artificial blood substitutes, focusing on red blood cell substitutes and their potential in humans.

While artificial blood technology is still at the preliminary stages of development, and a greater understanding of how this will work in patients is needed, it has the potential to streamline the blood matching process. Ultimately, once it’s proven effective in one species, it can become available in others. This means that in emergency situations, horses might be able to get blood transfusions much faster.

Orthopedic Injuries

Regardless of the horse’s discipline, there is an inherent risk for an orthopedic injury. Whether a horse is barreling down the homestretch, performing a sliding stop or completing a jumper course, there’s always the chance that fractures or soft tissue damage can occur.

This is one area that has experienced significant changes, according to Easterwood. When it comes to treating an infected synovial structure, many more horses are surviving what would have been fatal infections in the past.

When a horse sustains a potentially catastrophic injury, getting the horse to a referral hospital with a fracture that is still repairable is the first step to having a positive outcome, she noted. In recent decades, the development of new surgical techniques and external support devices, such as the Kimzey splint, has increased survival rates.

When discussing orthopedic advances in horses, Easterwood pointed to Texas A&M colleague Jeff Watkins, DVM, MS, who is working on developing orthopedic implants such as the femoral nail, which has led to advances in repairing previously fatal fractures.

“We have a long way to go before these repairs are as commonplace and affordable as we would like, but through the work of many orthopedic surgeons across the country, we are getting closer,” she said.

Similarly, there are many research studies that date back to the mid-1990s regarding regional limb perfusion, which offers local treatment to damaged structures. Variables such as the optimal volume of fluid, choice and dilution of antibiotic, length of time for the procedure, etc., have all been studied.

Optimal techniques have been developed for a variety of infection types and areas of the horse's body. More frequent regional limb perfusions, higher levels of antibiotics and advanced flushing techniques are a few of the advances that have led to increased survival in horses with severe injuries.

Stall-Side Diagnostics

When a horse spikes a fever at a show, the first question often seeks to determine whether the horse is neurologic. That leads to the question of whether the horse has equine herpesvirus, and if so, how it can be contained.

This is an unfortunate disease reality that is faced at many of today’s competitive events. Diagnosing which illness the horse has expedites a veterinarian’s response and lets him or her determine what happens next.

Real-time polymerase chain reaction (PCR) testing is so quick that the cause of an illness can be identified within hours instead of the days it might have taken in the past.

The test is so sensitive that even the DNA of dead bacteria can be identified. The technology amplifies even the smallest tissue sample and offers results, often in the same day.

“It’s nice to know right away,” said Marsh. “We’re not yet real-time like Dr. McCoy on Star Trek, but this type of diagnostic technique is faster in helping us know what to look for, and it helps limit the number of horses that will get sick.”

Owner Education

Today’s horse owners are knowledgeable about the clinical signs associated with illness and injury. The internet, veterinarian-hosted seminars and discussions during routine vet visits have helped educate owners about basic and acute care.

“Owners who know that early intervention increases survivability will experience fewer situations with their horses that result in a catastrophic outcome,” Easterwood said.

Veterinarians can compile a list of trusted online resources for clients. A clinic can plan an educational workshop to teach clients more about how to react in specific situations, which can save precious time in an emergency.

Take-Home Message

It’s not a matter of if you’ll receive a panicked phone call from a client with a sick or injured horse; it’s a matter of how often—and how you’ll handle it. While providing emergency services is part of the job for most veterinarians, it is important to consider what services you can offer with the staff and equipment you have available.

“It’s important for veterinarians to remember that the majority of emergency cases they will be called to see are something they are more than capable of handling,” Marsh said.

Exploring referral hospitals in the area and forming working relationships with other veterinarians is key for any practice. Establishing relationships with specialists, referral hospitals and other veterinarians in advance of an emergency situation is ideal. That gives both parties time to ask questions and understand how they can best work together and help one another.

“Attend or host a meet-and-greet to open the lines of communication before you’re in the middle of treating an emergency,” Marsh said. “That way you can provide the client with as much information as possible to help make decisions and provide the best care possible to the horse.” 

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