KEY TO COSTS$ indicates relative costs of any diagnostic and treatment
regimens listed.$ costs under $250
$$ costs between $250 and $500$$$ costs between $500 and $1,000
$$$$ costs over $1,000
W ild turtles and tortoises are widely distrib-uted in North America, and both wildand exotic species continue to be popu-
lar pets. Unfortunately, chelonian interactions withthe world of humans are a frequent source of trauma,including both orthopedic (shell, limb, and maxillofa-cial fractures) and various forms of soft tissue trauma.General practitioners should be equipped to deal withthese emergencies when they are presented. Notmuch specialized equipment is needed, and chelon-ian patients, although challenging, are also veryrewarding to treat. This article outlines the essentialsof trauma management in chelonian patients basedon the current literature and the authors’ practiceexperience, which includes a regular flow of chelon-ian trauma cases each spring and summer.
DIAGNOSTIC CRITERIA
Historical Information• Patients are presented as injured wildlife or pets.• Exposure (known or surmised) to motor vehicle,
dog, lawnmower, or the like.• Wildlife cases often peak in mid-spring when turtles
and tortoises are most active and likely to crossroads.
Physical ExaminationPrinciples• Slow, gentle traction so as not to frighten or stress
the patient. Forceful traction can result in rhab-domyolysis.
• Do not flip the patient over on its back to examineand/or treat—this is highly stressful.
• Grasp the head behind the mandibles to controland/or examine the head and neck—you have onlyone chance to secure the head.
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7
Sedatives and Anesthetics for Examination and Treatment• Chemical restraint is often necessary to facilitate
examination or treatment, but remember that verysick or debilitated chelonians are often at substan-tial risk for mortality when sedatives or anestheticsare used.
• Use good judgment to determine whether the risk ishigher from the stress of handling a fully awakepatient or from sedating or anesthetizing a debili-tated animal.
• Guidelines to indicate that a patient may be atexcessive risk from sedation or anesthesia include:
— Very low heart rate (<15 beats per minute) withthe patient at optimal temperature (Dopplerflow monitor is useful but expensive). $$$
— Very low packed cell volume (PCV; <10%) ortotal plasma (TP) solids (<2.0 g/dl).
— Sepsis (see below).
— Severe starvation or dehydration (a very “light”turtle that feels like a hollow shell with almostnothing inside).
• Suggested drug protocols for chemical restraint:
— Ketamine (5–8 mg/kg IV) with medetomidine(50–100 µg/kg IV). The authors have also usedthis protocol IM with good results.
— Ketamine (40 mg/kg IM) with midazolam (2mg/kg).
— Tiletamine–zolezapam (Telazol, Fort DodgeAnimal Health, Fort Dodge, IA; 10–20 mg/kgIM).
— Propofol (5–15 mg/kg IV to effect; re-dose ap-proximately q5min).
Deep Soft Tissue Trauma• Most serious, yet most easily overlooked.• Vehicular trauma most likely to cause serious deep
trauma.• Can have trauma in one or more of the following:
— Pulmonary organs (lung lacerations).— Parenchymatous organ (liver fracture).
TRAUMA MANAGEMENT IN
TURTLES AND TORTOISESMark W. Bohling, DVMDouglass K. MacIntire, DVM, MS, DACVIM, DACVECCDepartment of Clinical SciencesAuburn University College of Veterinary MedicineAuburn University, Alabama
g acute weight loss roughly equals 10 ml fluid loss)and can be used to help guide fluid therapy.
• Thick, viscous oral secretions—Note that normaloral secretions of chelonians are somewhat thickerand more viscous than in dogs and cats; familiaritywith chelonians gained through repeated physicalexaminations can enable veterinarians to differenti-ate the normal from the abnormal.
• Lack of urination—Although not a pathognomonicindication of dehydration, lack of urination, espe-cially in patients that normally urinate frequently(e.g., water turtles) and have previously been seenpassing urine, may be an indication of dehydrationand should be part of the overall hydration assess-ment when applicable.
Infections and Parasitism• Necrotic odor.• Exudates.• Plaques of fungal hyphae.• Indications of sepsis:
— Petechial hemorrhages of the skin, oral mucousmembranes, or scutes (especially the plastralscutes).
— Hyperemic oral mucous membranes (dark red-purple).
External Parasitism• Myiasis (fly strike):
— Two types are frequently seen in wild turtles:maggot infestation of wounds (e.g., blowflies[Phaenicia spp, Lucilia spp]) and bot fly infesta-tion (flesh flies [Sarcophaga spp]).
— Fly maggots may be seen in wounds as recentas 24 to 48 hours old. Maggots may actually bebeneficial for debridement of wounds if a largeamount of necrotic tissue is present. Applica-tion of pesticides is contraindicated, so gentleremoval by flushing with sterile saline is best.
— Bot fly infestation is the infestation of healthytissue by parasitic fly larvae, which form nod-ules under the skin from which the pupae lateremerge. A small, dark “breathing hole” is usu-ally evident in the middle of the nodule. Bot flyinfestation is treated by making a small incisionover the nodule and removing the maggots orpupae with forceps.
• Ticks may also be found on wild chelonians and area potential cause of significant blood loss and stress.Remove gently with forceps.
Internal Parasitism• External signs may vary from ill thrift and diarrhea
to inappetence. • Diagnosed via fecal examination.
J U N E 2 0 0 4 V O L U M E 6 . 58
— Hollow viscus (intestinal or bladder rupture).• Often is the underlying cause of patient mortality.
Superficial Soft Tissue Trauma• Ocular trauma.• Skin lacerations or maceration.
Orthopedic Trauma• Shell trauma.• Limb trauma.• Maxillofacial or skull fractures.
Neurologic Trauma• Close apposition of spinal cord to carapace makes
spinal cord trauma common in patients with mid-dorsal carapacial fractures.
• Chelonian neurologic examination:
— Look for hindlimb paralysis.
— Chelonians respond to noxious stimuli by with-drawing limb(s) or attempting to escape or bite(except tortoises often do not attempt to bite).
— Gait, placing, and righting can also be evalu-ated, although righting is often not appropriateto test in a chelonian with shell fracture.
— Jaw and muscle tone can be evaluated whenperforming an oral examination.
• Neurologic trauma is a negative—but not hope-less—prognostic indicator. Some chelonians withdisplaced dorsal carapacial fractures and hindlimbparalysis have regained neurologic function intime.
• Ruptured colon with subsequent coelomitis is apotential fatal complication of spinal trauma; it maytake weeks to manifest. Chelonians with spinaltrauma should be monitored for defecation whileawaiting return of ambulation, and owners shouldbe warned of this potential.
Secondary Consequences of TraumaDehydration• May occur fairly rapidly because of blood and fluid
loss at the time of trauma and afterward, and an ani-mal that presents in a dehydrated condition may bein a state of hypovolemic shock, a common andlife-threatening sequela.
• Eye position (sunken) and skin turgor (tented).• PCV and TP increased from previous samples or
species norms.• Weight loss—Hospitalized chelonians should be
weighed daily. Weight loss is much more likely tobe from dehydration than loss of tissue mass. Dailyweight changes correlate directly with fluid loss (10
ShockOn presentation, a chelonian in shock may be weak(normal chelonians are incredibly strong for their size),have an abnormally rapid or slow heart rate, or beunresponsive to stimuli (e.g., toe pinch, attempts toexamine the mouth or place an intravenous catheter)that would normally evoke an escape response.
Laboratory Findings• PCV—Normal range for most tortoises is 20% to
40%. A wide range of normal values is reported forchelonians; because of this, it is best to use normalvalues for the species being treated.
• TP—Again, normal range (3.0 to 6.0 g/dl) is high.Use normal values for the species being treated.
• Fecal examination—Flotation and direct smear toevaluate for internal parasitism.
— Nematode and protozoan parasites can be fairlycommon in both wild and captive chelonians.
— Use references to aid in identification.— Treatment of all internal parasitism is usually
recommended to reduce stress.
Other Diagnostic FindingsRadiography• Lateral and craniocaudal views—Use horizontal
beam (preferred because tissues and fluid do notshift position) or vertical beam (place patient in anappropriately sized cardboard box and wedge inplace with foam).
• Useful for assessment of:— Limb fractures and depressed (intracoelomic)
shell fragments.— Pulmonary abnormalities, including trauma
and pneumonia—Look for increased radiopac-ity and asymmetry in lung fields.
EndoscopyMay be a useful, minimally invasive way to assessintracoelomic trauma, which may allow a more accu-rate prognosis. Major intracoelomic trauma is oftenotherwise difficult to diagnose and may be a signifi-cant cause of mortality. A sterile or disinfected oto-scope cone may suffice in smaller chelonians for this.
Summary of Diagnostic Criteria• Known or suspected history of trauma.• Presence of external wounds.• Internal wounds may also be present and be more
severe than the external ones.
Diagnostic Differentials• Limb fractures—In captive chelonians, pathologic
fracture from nutritional secondary hyperparathy-
roidism can occur; such animals nearly always arejuveniles and have a soft or deformed shell.
• Pneumonia—May be secondary to trauma or a signof respiratory disease from other etiologies (primarypathogens or secondary pathogens with immunesuppression).
• Weight loss—May be secondary to trauma or fromother etiologies (e.g., infection, parasitism, poornutrition).
TREATMENTRECOMMENDATIONS
Initial TreatmentInitial treatment consists of four steps: Treat for shock,decontaminate open wounds and prevent recontami-nation, initiate appropriate antimicrobial treatment, andrewarm the patient.
Treat for Shock—Fluid Therapy• Intracoelomic (ICe) route:
— Least stressful for patient and easiest for clini-cian; this is the preferred route for initial stabi-lization of most patients.
— Contraindicated when lungs or air sacs are notintact.
— Insert 28- to 25-gauge × 5⁄8-inch needle throughthe soft skin just cranial to the hindlimb.
• Intravenous (IV) route (via the jugular vein):— Preferred route of fluid resuscitation when
patient presents in a very shocky, weakened(unresponsive) state.
— Access via cut down; incision should be madein the rostrocaudal direction rather than thedorsoventral.
— Jugular veins are located superficially and dor-sal to the dorsoventral midline of the neck, inline with the dorsal edge of the tympanum.Right jugular is often larger than left.
— Ordinary IV catheters (24 to 22 gauge) workfine; patency is maintained even when thehead and neck are withdrawn into the shell.
• Intraosseous (IO) route:— Bridge between carapace and plastron.— Tiny K-wire (0.035 to 0.045 inch) or 1.0-mm
drill bit to gain access.— Short (5⁄8-inch) needle (25 gauge [for small tur-
tles] up to 20 gauge [for large turtles]) is gluedin place with cyanoacrylate.
— Spinal needle not necessary; if hypodermicneedle becomes plugged on insertion, simplyreplace it with another one.
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• Subcutaneous route:— Use when ICe route is contraindicated and IV
or IO route is not needed or is inaccessible.— Inject fluids into flank fold using a small needle
(same sizes as for ICe administration).• Suggested fluid rates for chelonians:
— IV or IO routes: 0.5–1.0 ml/100 g/hr for resus-citation or surgery.
— ICe route: 1.0–2.0 ml/100 g/injection; usuallyrepeat q8–24 hr.
Decontaminate Open Wounds and Prevent Recontamination• Gentle, thorough lavage with isotonic fluids, ±1:40
chlorhexidine gluconate (do not use chlorhexidinein cases of spinal trauma with exposed cord).
• Major challenge is preventing contamination frombeing washed deeper into the turtle’s body. Thismay be one time when tilting the patient to put theshell defect down (briefly!) is desirable. If there isalready deep contamination of the coelom, lungs,or air sacs, it may be best not to lavage.
• Standard open wound care techniques are appro-priate. Wet-to-dry gauze bandaging is usually effec-tive and is easily performed; broad-spectrum(antibacterial/antifungal) topical agents (e.g., silversulfadiazine) may also be used.
Initiate Appropriate Antimicrobial Treatment• Traumatic wounds are usually contaminated with
mixed microbial flora, including fungi and gram-positive and gram-negative bacteria.
• Broad-spectrum antimicrobial treatment is indi-cated because any isolate may potentially be patho-genic in devitalized tissues or immunocompro-mised patients.
• Most drug doses are still empirical in reptiles;research recent literature for most current dosingrecommendations.
• Antibacterials:
— Enrofloxacin (5–10 mg/kg IV or ICe, diluted to10 mg/ml in 0.9% NaCl, q48h).
— Ceftazidime (20–30 mg/kg IV, ICe, or IM q48h).
— Ceftiofur (5 mg/kg IV, ICe, or IM q24h).
— Metronidazole (20 mg/kg IV, ICe, or PO q48h).• Antifungals—Prophylactic use is recommended with
any wound requiring long-term antibiotic therapy(more than 2 weeks) and especially if coelomic cav-ity or organs are exposed to environmental contam-ination (fungal pneumonia is a major threat).
— Fluconazole (20 mg/kg ICe q7d).— Ketoconazole (15–25 mg/kg PO q24h).
Rewarm Patient to Physiologic Range • Preferred optimum temperature zone (POTZ) for
most North American species is approximately 78to 88˚F; species variation exists, however, and agood herpetologic library is helpful.
• Tortoises—A common misconception is that che-lonians from arid climates need a very hot, dryenvironment. This is not true; these animals areusually underground, where the microenviron-ment is considerably cooler and more humid thanon the surface during the hot periods of the day (oryear).
• Increases in temperature (above normal room tem-perature) must be made gradually (over 1 to 2 days)and only after initial stabilization, decontamination,and initiation of antimicrobial treatment have beenaccomplished. Rapid rewarming of an unstablechelonian can be fatal.
Definitive TreatmentSoft Tissue TraumaOcular Trauma• Manage as you would ocular trauma in other small
animals:— Topical ocular anesthetics may facilitate exam-
ination and treatment.— Removal of foreign material via saline flush or
gentle manual removal.— Appropriate topical treatment for conjunctivitis
or corneal injuries.— Temporary tarsorrhaphy may be indicated to
protect the injured eye.• Because chelonians have remarkable healing capac-
ity and may eventually recover from severe oculartrauma, even apparent blindness, do not enucleateunless necessary to treat an orbital infection.
Lacerations• Managed the same as any other contaminated
wound.• Closure—Reptile skin is naturally inverting, result-
ing in scale–scale contact. Use an everting pattern(e.g., horizontal or vertical mattress sutures).
Orthopedic TraumaFracture Repair $$–$$$• Long bone fractures are relatively uncommon.• External coaptation (taping limb into shell) is unsat-
isfactory (delayed union or nonunion).• Plating with a 1.5- to 2-mm veterinary cuttable
plate, finger plate, or maxillofacial plate seems towork best.
• Amputation is also an option.
J U N E 2 0 0 4 V O L U M E 6 . 510
Amputation• Indicated for irreparable soft tissue, nervous system,
or orthopedic trauma.• Well tolerated, particularly single hindlimb amputa-
tions.• Distal amputation:
— Permissible and even advisable on chelonianswith trauma limited to distal limb.
— Stump trauma is usually not a problem if a flapof thick, scaled skin is used to cover the ampu-tation site.
— Allows near-normal ambulation if most of thelimb can be preserved.
• High amputation (proximal trauma):
— A rounded, smooth object may be glued to theplastron at the corner with the amputated limb.This serves as a skid, protecting the plastronfrom abrasion and allowing a more normal gait.
Shell FracturesEpoxy and/or Fiberglass Patches $• In recent years, there has been a move away from
the use of epoxy and/or fiberglass patching. Othertechniques (interfragmentary wiring, shell plating)have become the standard for shell repair.
• Contraindicated in water turtles.
— These species shed the skin over their scutes.
— Fiberglass covering the shell causes shell necro-sis and sepsis.
• Patching is contraindicated with open, contami-nated shell fractures, or when pieces are missing.
— Fiberglass patching seals in contamination andprevents normal drainage.
— Open wound management is indicated untilgranulation tissue fills in the defect.
• Daily bandage changes are required to keep thewound from drying out.
• Risk of patient dehydration from fluid loss throughthe wound.
Interfragmentary Wiring $• Can be performed under sedation (see Suggested
drug protocols for chemical restraint, page 7).
• Tiny holes can be drilled in the shell fragments witha small bit (1.1–1.5 mm) or K-wire (0.045 or 0.062inch).
• Orthopedic wire (24 gauge in patients weighing200 g or less; up to 20 gauge in patients weighing 5kg or more).
• Holes placed about 3 mm from fragment edge, usu-ally two holes per side of each fragment.
• Freer periosteal elevator and needle holders areuseful for manipulating fragments and wires.
• Drill holes and place all wires before tightening anyof the wires.
• Tighten wires beginning at the most central fractureand work outward toward the marginal scutes—thismay allow a broken wire to be replaced.
Shell Plating $$–$$$• Mini plates (finger, maxillofacial, reconstruction)
can be used.
• Requires plating instrumentation and inventory.
• Stable, anatomic reduction is achievable.
• After reduction with wire and/or plates, a narrow (4-to 6-mm) bead of 1-minute epoxy can be used toseal the shell if the wound is completely free of con-tamination or if granulation tissue is visible deeperand no exudate is present.
— Care must be taken to keep epoxy on top of thecracks and not to get any into the cracks.
— Sterile lube, hydrogel, or hydrolyzed collagendressing may be placed in small cracks andvoids to keep out the epoxy.
— The epoxy seal reduces ongoing fluid losses,protects against environmental contamination,and speeds return of water turtles to an aquaticenvironment.
— The authors have not noted deleterious shelleffects with this practice.
Postoperative Pain Management• Chelonians respond appropriately to noxious stim-
uli; therefore, we must assume they feel pain.
• Very limited and largely anecdotal informationexists about reptile pain management (e.g., opioidreceptors are known to exist, but their role is uncer-tain).
• Butorphanol tartrate (0.4–0.8 mg/kg) has been rec-ommended for analgesia in chelonians. Efficacy isuncertain, but this drug may be useful and is notknown to be harmful.
Supportive TreatmentEnvironmental ControlsHighly important in all reptiles. Especially critical forinjured reptiles because they are already stressed andhave reduced adaptive capacity.
Temperature• Maintain in the upper end of the POTZ:
— Improves immune function.
— Allows more rapid wound healing.
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— Higher metabolic rate improves drug pharma-codynamics and pharmaco*kinetics.
• Cannot rely on patient behavioral thermoregula-tion; therefore, temperature gradients are inappro-priate. Patient must have uniform temperature.
HumidityHumidity control may become an issue if a water tur-tle is being kept landlocked for an extended period forwound healing. If the environment is too dry, thepatient may become dehydrated.
Nutritional Supplementation• Most turtles or tortoises with major trauma will
probably require an esophagostomy tube. It can beplaced (with the patient under sedation) at the sametime as catheterization or shell repair.
• Feeding should never be initiated until after thepatient has been stabilized and temperature hasbeen restored to the POTZ.
• Recommended feeding supplements for esophagos-tomy tube feeding:
— Tortoises: Mixed vegetable or vegetable andfruit baby food; strained mashed alfalfa pelletsare also good if the feeding tube is large enoughto prevent the pellets from plugging the tube.
— Box turtles: Same as for tortoises with the addi-tion of turkey baby food or mashed strainedearthworms (25% to 50% of diet).
— Water turtles: Mixture of strained mashedearthworms and turkey baby food (75% to 80%of diet) and mixed fruits and vegetables.
• A line of powdered dehydrated diets, formulated bya veterinary nutritionist specifically for reptiles, isalso available (see Resources, page 13).
Antiparasite Therapy• Suggested drugs and doses:
— Fenbendazole (50–100 mg/kg PO q48h forthree doses; repeat in 3 weeks) for anthelmintictreatment.
— Iodoquinol (10–50 mg/kg PO q24h) for entam-oebiasis.
— Praziquantel (8 mg/kg IM once; repeat in 3weeks) for cestodes and trematodes.
— Sulfadimethoxine (90 mg/kg once; then 45mg/kg PO q24h) for coccidians.
• Ivermectin is toxic to some chelonians and shouldnever be used in box turtles or tortoises.
Patient Monitoring• Activity level.
• Appetite (may be slow to return).• Wound appearance:
— Exudation.
— Odor.
• Hydration status—Very important, especially inpatients with an open shell wound being managedfor second-intention healing.
— Sequential PCV and TP.
— Weigh patient daily on a gram scale.
Home Management• Owners or wildlife caretakers must be extremely
attentive to all aspects of husbandry during therecovery period.
• The convalescent care requirements often create asubstantial time burden on owners or caretakersand may continue for months. This aspect of the“cost” of treatment should be thoroughly explainedbefore veterinary care is instituted.
• Owners must provide optimum environment (tem-perature, humidity, isolation from other chelonians,“dry-docking” of nonsealed water turtles).
• Nutritional support:
— Resumption of normal feeding is a high priority.
— Daily or every other day feeding via esophagos-tomy tube may be required, sometimes for aprolonged period.
— Availability of water, even placing the turtle ortortoise into a shallow pan of water, does notnecessarily ensure adequate hydration.
— If the patient is not observed to be voluntarilyeating on a regular basis and/or exhibits anysigns of dehydration, water or a hypotonic bal-anced electrolyte solution (e.g., half-strengthlactated Ringer’s solution) must be adminis-tered orally or via a feeding tube.
• A sick or injured chelonian must not be allowed tohibernate—It will die. Provision must be made foroverwinter care.
Milestones/RecoveryTime Frames• Return of normal appetite and activity level are two
reliable early indicators that recovery is progressingwell.
• Soft tissue healing takes place fairly rapidly: Skinsutures are usually removed 30 days postopera-tively.
• Bone healing is much slower: 2 to 6 months forlimb fractures and 6 to 24 months for shell fractureshave been reported.
J U N E 2 0 0 4 V O L U M E 6 . 512
PROGNOSIS
Favorable CriteriaPretreatment• Active patient with no apparent locomotor deficits.• Shell trauma limited to marginal scutes; no pieces
missing, minimal to no displacement.• No contamination of coelom.
Posttreatment• Rapid return to normal activity and appetite.• For open or second-intention wounds, rapid resolu-
tion of wound drainage and formation of granula-tion tissue.
Unfavorable CriteriaPretreatment• Massive shell trauma with missing pieces or heavy
contamination.• Major dorsocranial shell trauma (lung involvement).• Spinal trauma.• Extremely weak, unresponsive patient at admission.
Posttreatment• Slow return to normal activity level; unusually slow
recovery from sedation or anesthesia.• Prolonged anorexia.• Development of secondary problems (e.g., pneu-
monia).• Wound indicators:
—Lack of granulation tissue formation.—Secondary wound infections (bacterial or fun-
gal; may see mycelial plaques).—Necrotic odor from wound.
RECOMMENDED READING
Bennett RA, Lock BA: Nonreproductive surgery in reptiles. VetClin North Am Exotic Anim Pract 3(3):715–732, 2000.
Bonner BB: Chelonian therapeutics. Vet Clin North Am ExoticAnim Pract 3(1):257–332, 2000.
Heard DJ: Shell repair in turtles and tortoises: An hereticalapproach. Proc NAVC 13:770, 1999.
Mader DR: Reptile Medicine and Surgery. Philadelphia, WBSaunders, 1996.
Mitchell MA, Diaz-Figueroa O: Wound management in reptiles.Vet Clin North Am Exotic Anim Pract 7(1):123–140, 2004.
Paul-Murphy J, Benson K: Intraosseous fluid administration in thechelonian shell. Proc NAVC 15:820, 2001.
Schumacher J: Fluid therapy in reptiles, in Bonagura JD (ed):Current Veterinary Therapy XIII: Small Animal Practice.Philadelphia, WB Saunders, 2000, pp 1170–1173.
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RESOURCES
• Ultrasonic Doppler flow detector—Model 811-B,Parks Medical Electronics, Inc., 19460 S.W. Shaw,Aloha, OR 97007. $$$
• Powdered dehydrated turtle and tortoise diets—Quantum Series diets by Walkabout Farms;www.herpnutrition.com.
 T MANAGEMENT IN TURTLES AND TORTOISESd1uhp0uy75me04.cloudfront.net/mmah/c4/ea7dce6d514f55a...Initial treatment consists of four steps: Treat for shock, decontaminate open wounds and - DOKUMEN.TIPS (2024))
