Dog Hit by Car Emergency Protocol

Alright, let's get this dog stabilized. My approach is always the same: find and fix what's going to kill him in the next hour. The history and vitals (tachycardia, pale gums, weak pulses, abdominal guarding) are classic for hypovolemic shock, likely from internal hemorrhage.

Here’s our plan, effective immediately:

ABCDE Primary Survey & Stabilization:

* A/B (Airway/Breathing): He's ambulatory, so his airway is likely patent. Auscultate the thorax now. Even if lung sounds are clear, start flow-by oxygen at 5-10 L/min. Tachypnea and distress warrant it.
* C (Circulation): This is our priority. Place two large-bore (18g or larger) cephalic IV catheters. While they're being placed, get a baseline PCV/TS, lactate, and blood gas. Start fluid resuscitation with isotonic crystalloids (LRS or Plasmalyte). Give a 15-20 mL/kg bolus over 10-15 minutes, then STOP and reassess vitals. Do not fluid-dump.
* D (Disability): A quick neuro check. Is he mentating appropriately? Any obvious head trauma or abnormal pupillary light response?
* E (Exposure): Check his temperature. Trauma patients often become hypothermic, which worsens coagulopathy. Start active warming if temp is <99°F. Examine the flank wound and cover it with a sterile dressing.

AFAST/TFAST: While fluids are running, I'm at the bedside with the ultrasound.

* TFAST: I'm looking for a pneumothorax (loss of glide sign) or pleural effusion. The presence of B-lines would suggest early pulmonary contusions.
* AFAST: This is critical. I'm looking for free fluid. Any positive site (especially with an AFS of 2 or more) in a patient with this signalment is hemoabdomen until proven otherwise. If we find significant free fluid and the PCV of the fluid is similar to peripheral blood, we need to consider permissive hypotension (targeting a MAP of 60-65 mmHg) to avoid blowing clots while we prepare for a possible exploratory laparotomy.

Pain Management: Pain is contributing to his shock. Administer a full mu-opioid now. I'd use methadone 0.2-0.3 mg/kg IV. This is part of resuscitation, not an afterthought.

Imaging Priorities: We do NOT move to radiology until he is more stable. Our POCUS exam is the first-line imaging. Once his heart rate is trending down, pulses are stronger, and lactate is clearing, we'll get full thoracic and abdominal radiographs. Sarah Lin can give us the definitive read, but my immediate concern is identifying life-threatening injuries like a major diaphragmatic hernia or severe pneumothorax that our TFAST might have missed.

Delayed Presentations (The "Watch-Outs"):

* Pulmonary Contusions: They often "blossom" 12-24 hours post-trauma. Even with clear initial rads, we need to monitor respiratory rate and effort closely.
* Uroabdomen: A ruptured bladder is common. If he doesn't urinate within a few hours, or if his azotemia/potassium starts to climb despite fluid therapy, we'll need to run a BUN/creatinine on any abdominal fluid vs. peripheral blood.
* Diaphragmatic Hernia: Can be missed initially, especially on a stressed, expiratory film. Repeat rads if any respiratory signs develop.

The next 30-60 minutes are critical. Our goals are to reverse shock, provide analgesia, and use our bedside ultrasound to decide if this is a medical or surgical abdomen. Let's move.

Colleague, this is a critical case requiring a systematic approach. While Dr. Cole manages the immediate resuscitation, my focus is on the diagnostic imaging pathway. The priority is to identify life-threatening injuries rapidly without destabilizing the patient.

Immediate Imaging Priority: POCUS

Point-of-care ultrasound (POCUS) is the first-line imaging modality here, specifically the AFAST and TFAST protocols. My Ultrasound Interpreter has provided an excellent summary of the technique, which I will frame clinically. These are not comprehensive scans; they are focused exams to answer specific yes/no questions.

* AFAST (Abdomen): The primary goal is to detect free fluid. A positive AFAST (fluid in one or more of the four quadrants) in a hypotensive trauma patient is highly suggestive of active hemorrhage until proven otherwise. The Abdominal Fluid Score (AFS) is a semi-quantitative tool; a rising AFS on serial scans is a significant indicator of ongoing bleeding and may prompt surgical intervention. We are also looking for a uroabdomen, which will appear as anechoic free fluid.

TFAST (Thorax): This is performed concurrently to rule out critical thoracic injuries. The key finding to look for is the "glide sign"—the normal sliding of the visceral on the parietal pleura. An absent* glide sign is diagnostic for pneumothorax at that location and is an emergency. We also assess for pleural and pericardial effusion.

Secondary Imaging: Radiography

Once the patient is more stable, survey radiographs are indicated. Do not attempt these until shock has been addressed.

Thoracic Radiographs (3-view): This is the priority after POCUS.

* Pulmonary Contusions: These are the most common injury. They appear as patchy, unstructured interstitial to alveolar patterns. Critically, these findings may lag behind the clinical signs by 12-24 hours, so repeat films are often necessary.
* Pneumothorax: Look for retraction of the lung lobes from the thoracic wall and elevation of the cardiac silhouette from the sternum.
* Diaphragmatic Hernia: Signs include loss of the diaphragmatic silhouette, displacement of abdominal organs into the thorax, and associated pleural effusion.

Abdominal Radiographs: Primarily to assess for loss of serosal detail (confirming effusion seen on AFAST), pneumoperitoneum (GI rupture), and obvious skeletal trauma.

Skeletal Radiographs: Focus on the pelvis and appendicular skeleton based on physical exam findings of crepitus or instability. Two orthogonal views are the minimum standard.

Uroabdomen can be a delayed presentation; if suspected based on progressive abdominal effusion and compatible bloodwork, a positive-contrast cystogram or CT excretory urogram would be the definitive diagnostic tests once the patient is stable enough for the procedure.