In small animal practice, it is not uncommon to be contacted by a client for advice on their pet reptile. This will include chelonians (tortoises, terrapins and turtles) that have received a traumatic injury and may be in pain and systemically compromised. It is important that you can offer first aid advice and are able to assess these injuries on presentation.
Common injuries
Common injuries seen in chelonians include bite wounds from a conspecific, attacks from wild or domestic predators (such as dogs and foxes) and strimmer or lawnmower injuries in tortoises that are free roaming in the garden. Injuries from falls and road traffic accidents may also be seen.
Injuries can be classified into mild (prognosis good, manageable in general practice; Figure 1), moderate (guarded, protracted healing time, experience would be beneficial; Figure 2) and severe (life threatening, specialist experience required; Figure 3).
Multi-modal analgesia should be at the forefront of clinical discussions around severe cases, as should the unavoidable fluid loss through wound exudation and the potential negative systemic effects that the loss of these fluids can have in uricotelic patients.
Triage
The initial point of contact with the owner is usually a telephone call; this is where vital information on the cause and extent of the injury should be attained, as well as information on the species. Knowing what species you will be dealing with and the type of injury it has sustained will enable you to quickly research the appropriate husbandry and issue before they arrive, potentially saving vital time. If necessary, first aid advice and information on how to safely transport the patient to the clinic can be given.
If the wound is haemorrhaging, the owner should be advised to apply pressure to the area to encourage bleeding to stop; this should be done with something absorbent and lint free (for example, a sanitary towel). If shell or limb fractures are suspected, immobilisation may be appropriate. This can be done by gently wrapping a towel around the body for support and to keep movement to the minimum. If the animal is not used to being handled, however, or if the owner does not feel confident doing this, it can cause extra stress and would cause more harm than good.
These patients should be brought to the clinic as soon as possible for assessment. They should be transported by placing them in a snug fitting polystyrene, cardboard or plastic box with a heat source – a water bottle wrapped in a towel can be useful to prevent excessive movement and maintain the body temperature. The box should also have high sides to prevent the patient trying to climb out.
Initial assessment
It is important to consider stress levels, which can be very challenging in reptiles that don’t give many outward signs. Stress can be severely detrimental to health and can have a negative effect on wound healing. To limit stress, it is ideal to first assess patients without any form of restraint. You can assess the extent of the injuries, patient demeanour, activity and respiration.
History gathering
Getting a full history is very important. Finding out when and how the injury occurred is helpful – reptiles can be slow to show clinical signs, and the injury may have occurred days or weeks before the owner noticed there was a problem. Finding out if they have adequate husbandry is also very important and will be crucial for wound healing. Any underlying illnesses, conditions or current medications should be identified at this stage.
Examination
A full physical examination should be performed. While handling, it is essential to be mindful of the mental demeanour of the patient and always try to position the patient upright with the cranial end elevated to reduce pressure on the lungs and therefore minimise respiratory effort.
Structures
Reptilian skin is similar in general construction to mammalian skin, in that it is composed of an outer epidermis and an inner dermis, tightly adhered to underlying bony structures over the distal limbs and head. In chelonians, the shell is comprised of a dermal bone layer, which consists of about 60 bones formed from modified pectoral and pelvic limb girdles, trunk vertebrae, sacrum and ribs. Covering the dermal layer are the scutes, which are formed from the epidermis and are the equivalent to scales in other reptiles. The scutes, being epidermal in origin, are innervated and will bleed if damaged.
Dealing with a stable patient
If the patient is stable, wound lavage should be performed as soon as possible to reduce the chances of infection by removing contamination, debris and other foreign substances.
A solution should be used that is not going to damage tissue. Using a warm isotonic solution is ideal (Hartmann’s/ saline); the amount of solution used should ensure the contamination and bacteria present are adequately diluted. The pressure at which it is delivered needs to be enough to dislodge bacteria but not enough to push it further into the wound. A guide is to use 100ml of fluid per cm of wound, delivered with a pressure of 8 to 15psi, which can be achieved using a 20ml syringe and 19-gauge needle.
In heavily contaminated wounds it may be necessary, and less stressful, to initially place the patient in a warm bath of water (an unused cat litter tray can be useful) to remove the heavy contamination before lavage. If the wound is heavily contaminated, the use of an antiseptic solution may be appropriate. If used, these should be made up to the correct dilutions: Betadine (povidone-iodine) can be used at a 0.1 percent dilution or Hibitane (chlorhexidine) at 0.025 to 0.05 percent dilution. Chlorhexidine has the longest residual effects and won’t be denatured by protein. Antiseptic solutions should not be used in healthy granulating tissue as this may inhibit wound healing by damaging important cells. In old wounds or those you suspect are infected, a swab should be taken for culture and sensitivity.
Dealing with unstable patients
Any haemorrhage should be controlled and the patient should be stabilised. If the animal is weak, stressed or in shock, wound lavage may need to be postponed until the patient has been stabilised. The wound can be covered with a sterile dressing to prevent further contamination until a management plan is made.
Radiography should be taken for shell injures to determine the extent of the injury. This will identify if the bony portion of the shell has been affected or just the keratinised scutes. Other areas of potential damage include the spine, lung field or the coelomic cavity. Dorsoventral positioning with no restraint is possible. The radiography will also give information on the generalised bone mineralisation. For assessing the lung field, a lateral/craniocaudal view will be necessary with a horizontal beam. This view can be carried out while conscious by immobilising the patient and raising them up.
Pain relief
Reptiles do not show classic signs of pain and may be difficult to assess. However, these traumatised patients will be painful – in some cases, extremely painful. A multimodal analgesia plan must be included in your care plan.
Open wound management
Reptile wounds should be managed as open wounds and allowed to heal by second intention due to the potential for infection and the solid non-draining pus associated with reptiles. Closing these wounds could seal in the infection and cause further complications.
Primary closure should not be used unless the wound is very clean and fresh, which is unlikely due to the main causes of these wounds. If they are considered to be clean enough, ample lavage should be performed before closure.
Healing
Wound healing can be very slow in reptiles compared to mammals and birds; it may take several years for shell damage to fully heal. As reptiles are ectotherms, the wound healing process is highly dependent on the environmental temperature.
Lower temperatures will delay cell migration and thus delay wound healing. Appropriate levels of UV light should be provided to try to improve homeostasis.
Even though the healing of reptile wounds can be slower, the healing process follows a similar pattern to mammals, going through the different stages – inflammation, proliferation and maturation – and the same considerations will apply. The aim is to offer the best environment for the wound healing and to consider and deal with any factors that may cause it to be delayed.
Inflammation
In the inflammatory phase there may be signs of redness, swelling and production of exudate. To promote the wound healing process at this phase, clean the wound by lavage to remove dirt/debris and to reduce potential pathogens. This should be carried out at initial presentation and between each dressing change.
Debridement to remove any necrotic tissue (Figure 4) may also be necessary. This can be done by surgical, enzymatic, autolytic or mechanical means. Surgical debridement may need to be performed due to the caseous nature of the reptile inflammatory response.
Dressing a wound will provide protection from contamination and abrasions and offer support and comfort. These can be difficult to apply so adhesive dressings prove helpful. Exudate can be managed using foam pads and regular dressing changes depending on the amount of exudate being produced.
Infection control may be necessary depending on clinical signs; blood tests to check for systemic infection and swabs for culture and sensitivity are useful. Topical antimicrobial treatments can also be used (eg manuka honey).
Considering the factors that may delay wound healing at each assessment is crucial. Note that movement is high on the list to cause problems for wounds around the head and leg areas.
Proliferation
Granulation tissue formation (Figure 5) only occurs when the inflammatory stage is complete. To encourage healthy granulation tissue to form, a moist wound environment should be provided with the use of hydrocolloid gels/ dressings. Compeed dressings offer a moist environment and are useful for sticking to shells. Continue regular dressing changes and lavage in-between changes. With shell injuries, once there is a healthy wound bed, the shell can be repaired.
Maturation (remodelling phase)
Contraction and closure of the wound occurs in the remodelling phase (Figure 6). Extensive trauma to shells may never fully heal, so a resin patch might need to stay in place permanently in adults.
Husbandry
Any husbandry issues should be corrected for optimal wound healing and the patient should be removed from risk of repeat injury. The enclosure substrate should be removed and replaced with newspaper, and hygiene must be maintained at a high level. For aquatic species, it may be necessary for the water to be treated with an antibacterial preparation.
