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 lavages via a nasogastric (NG) tube with warm water 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 a NG tube into the trachea several times to facilitate a clear airway. Upon doing so, a large volume of blood drained from the nose bilaterally and the patient started having signs of difficulty breathing. Dr. Z recommended transferring the patient to a referral center or euthanasia due to the volume of blood loss, concerns for the unknown source of blood, seizures, and respiratory distress. The client transported the patient to a secondary veterinary care facility, where endoscopy revealed that bleeding originated 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 Referral Costs
The client alleged that Dr. Z had coerced them into a referral by providing euthanasia as the only alternative. The client also alleged that the referral was not necessary for a successful outcome in the case and they incurred unnecessary veterinary expenses. The client demanded compensation for the cost of the care at the referral center and a refund of fees for Dr. Z’s care. Since the client was demanding money, Dr. Z submitted the demand to their professional liability insurance carrier for review.
After consideration, Dr. Z believed that the complications started with the inadvertent carotid administration and that the amount of blood visualized during the seizure was consistent with upper airway trauma from repeated tube placement .
After an internal review by the professional liability insurance carrier, Dr. Z’s recommendation to refer was considered appropriate and in the best interest of the horse, based on the patient’s current condition of seizures, profuse bleeding, and respiratory distress. The carrier found liability with Dr. Z regarding the carotid stick which resulted in the seizures and subsequent bleeding from Dr. Z’s attempt to secure an airway. Hence, the need for referral was due to the original carotid stick error. Dr. Z consented to settle the matter, and the carrier reimbursed the client for the cost of the referral center care. Dr. Z also agreed to refund charges for their services as a good-will gesture.
A Closer Look at the Case
Esophageal obstruction is a common concern in equine emergencies. 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