Dr. Z was contacted to evaluate a 25-year-old miniature
horse gelding due to an owner concern of labored breathing and possible “choke”
of unknown duration. Upon arrival, Dr. Z found the gelding with tachypnea
(increased RR) and marked dyspnea (increased respiratory effort). Also noted was the presence of opaque green-brown nasal discharge, consistent with feed
material. In discussion with the owner,
it was determined that the patient had last been offered a pelleted grain meal
approximately 8 hours earlier. The
client then left for work and arrived home to find the patient in the current
condition.
Dr. Z moved forward with a physical examination and sedated the patient with authorization from the owner. After sedating, Dr. Z performed repeated esophageal lavage via a nasogastric (NG) tube with warm water in an effort to resolve the suspected obstruction. After several minutes of lavage, the NG tube was able to be passed into the stomach. Dr. Z administered a water bolus via the NG tube and then removed the tube. Next, Dr. Z proceeded to administer flunixin meglumine (a non-steroidal anti-inflammatory drug) via the left jugular vein. Upon completion of the injection, the patient began to seize and Dr. Z became concerned that all or a portion of the dose may have entered the carotid artery in error.
Dr. Z attempted to pass an NG tube into the trachea to facilitate a clear airway. Upon doing so, a large volume of blood drained from the nose bilaterally. Dr. Z recommended transfer of the patient to a referral center or possible euthanasia due to volume of blood loss and concern for unknown source of blood. The client transported the patient to a secondary veterinary care facility, where an endoscopy revealed that bleeding was originating from the pharynx due to trauma associated with intubation. No pulmonary hemorrhage was evident and the patient was monitored and discharged without further incident.
Dr. Z Blamed for Unnecessary Referral
The client alleged that Dr. Z had coerced them into a referral by providing euthanasia as the only alternative and that the referral was not necessary for a successful outcome in the case. The client demanded compensation for the cost of the care at the referral center and a refund of fees for Dr. Z’s care. Dr. Z submitted the demand to their insurance carrier.
After consideration, Dr. Z felt that the complications started most likely from an inadvertent carotid administration and also that the amount of blood visualized during the seizure was consistent with upper airway trauma from repeated tube placement. Dr. Z agreed that the client would have been reasonable to monitor the patient for a period of time in place of the emergency referral or euthanasia. Dr. Z consented and the claim was settled for the cost of the referral center care. Dr. Z also agreed to refund charges for their services.
A Closer Look at the Case
Esophageal obstruction is a common concern in equine
emergency. A 2010 retrospective study by
Chiavaccini and Hassel examined the findings associated with 109 cases
presented for choke over the period 1992-2009.
In these cases, it was noted that male equids over the age of fifteen showed
an increased risk of this condition. The
study also noted that increased respiratory rate was often seen in patients
who progressed to develop aspiration pneumonia, a severe sequela, in some
cases. In the case described above, the patient developed complications related to the treatment
due to an inadvertent carotid injection.
Intra-carotid injections occur most commonly during attempts
to give jugular vein injections. In a
2022 retrospective study, Gonzalez-Medina, et al. found that inadvertent
carotid injections were most likely to be performed by veterinarians when the
injection location was in the middle jugular furlough. While short-term complications of seizure activity were
common among the patients, only one
patient suffered long-term complications and was subsequently euthanized.
References:
L. Chiavaccini and D. M. Hassel, Clinical Features and
Prognostic Variables in 109 Horses with Esophageal Obstruction (1992–2009),
Journal of Veterinary Internal Medicine accessed via Wiley online library
3.28.25 https://onlinelibrary.wiley.com/doi/full/10.1111/j.1939-1676.2010.0573.x
S. Gonzalez-Medina, Y. Nout-Lomas, and G. Landolt, Unintentional
intracarotid injections in the horse-15 cases (2010-2020), British Equine
Veterinary Association accessed via Wiley online library 3.28.2025 https://beva.onlinelibrary.wiley.com/doi/full/10.1111/eve.13706