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Pediatric dog bite with peritoneal violation
Journal of Pediatric Surgery Case Reports 40 (2019) 53–55
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Pediatric dog bite with peritoneal violation a,∗
a
T b
Jason Martinez , Dane Scantling , Teerin Meckmongkol , Rajeev Prasad a b
b
Drexel University College of Medicine/Hahnemann University Hospital, Department of General Surgery, 231 N. Broad St Philadelphia, PA 19102, USA St. Christopher's Hospital for Children, Department of Pediatric Surgery, 160 East Erie Avenue, Philadelphia, PA 19134, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Trauma Bites and stings
While dog bites are common in pediatric trauma centers, peritoneal violation from a dog bite is an uncommon finding given the significant bite force required to traverse the abdominal wall musculature. A very high incidence of clinical suspicion is necessary in order to avoid missing this rare, potentially life-threatening injury. In this instance, we report a case of peritoneal violation, retroperitoneal hematoma, colonic contusion, and mesenteric injury in a four year old male suffering from a dog attack in which computed axial tomography (CT) scanning was key in identifying the injuries. We also review the natural history (and injury patterns) of canine attacks in the United States.
Dog bites are a significant cause of injury amongst the pediatric population. Nearly 80 million dogs reside in U.S. households and this number has been increasing annually [1]. About 1000 Americans seek treatment for a dog related injury daily and this number is believed to be heavily under-reported [2,3]. The majority of injured children suffer bites to the extremities, head or neck as these tend to be eye level with the animal [4]. Bites to the torso are less common and represent only about 10% of injuries [4]. Intra-abdominal injury with peritoneal violation is rare with very few cases having been reported in the literature [5–8]. However, this type of injury can be life-threatening. Providers must maintain a high index of suspicion for such injuries to avoid significant morbidity and mortality. We report the case of a 4 year old male with peritoneal violation from the bite of a pit bull terrier. 1. Case report A 4-year-old male sustained an attack by the family pitbull terrier and was bitten multiple times before eventually being freed by bystanders. The child was transported to our Pediatric Level 1 Trauma Center by emergency medical services. Primary survey was intact, with a heart rate of 124, respiratory rate of 24, blood pressure of 128/ 59 mmHg, and SpO 2 of 99% on room air. His Glasgow Coma Score (GCS) upon arrival was 15, despite being anxious. Secondary survey was significant for several puncture wounds to his posterior flanks bilaterally, and to the region of his right trapezius muscle and right upper and lower abdomen. He was tender at the bite sites, but did not exhibit signs of peritoneal irritation. Additional injuries included a significant
∗
avulsion of his left ear at the level of the superior helix with approximately 1 cm of cartilage detached from the temporal region of his head. A single superficial skin laceration was also appreciated over the inferior portion of the right ear. Due to the nature of the posterior flank wounds, as well as the slender body habitus of the child, a CT scan of the abdomen and pelvis was obtained to rule out intra-abdominal injury. The results were significant for colonic wall thickening at the hepatic flexure, as well as the presence of intra-abdominal free fluid and pneumoperitoneum. There was also noted to be superficial subcutaneous emphysema along the right abdominal oblique muscle, bilateral paraspinal muscles, and inferior right chest wall musculature corresponding to the location of the injuries. In addition to imaging, a CBC was obtained during the trauma evaluation of this patient, which was significant for a WBC of 18.5 103 cells/mcL, Hgb of 11.4 g/dL, and Platelets 479 103 cells/mcL. A urinalysis was also obtained, which was significant for microscopic hematuria, with RBC's too numerous to count. The decision was made to immediately proceed to the Operating Room for a diagnostic laparoscopy. The patient was immediately brought to the operating room. Visual inspection immediately revealed peritoneal violation and multiple small defects in the abdominal wall in the right upper quadrant (Figs. 1–3). Although there was no gross spillage of intestinal contents, there was a contusion of the colon at the hepatic flexure (Fig. 4), as well as defect in the colonic mesentery (Fig. 5). There was also a small, non-expanding retroperitoneal zone 2 hematoma. The bowel was examined from the ileocecal valve to the ligament of Treitz,
Corresponding author. E-mail address: [email protected] (J. Martinez).
https://doi.org/10.1016/j.epsc.2018.10.011 Received 8 October 2018; Accepted 22 October 2018 Available online 24 October 2018 2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 40 (2019) 53–55
J. Martinez et al.
Fig. 1. Explanation: Peritoneal violation as a result of canine attack, visualized on diagnostic laparoscopy.
Fig. 5. Explanation: Mesenteric defect that was visualized intraoperatively.
and no signs of perforation or spillage were encountered. The remainder of the colon and other viscera were also uninjured. After irrigation of the abdomen, the port sites were closed and attention was turned to repair of the avulsion injury of the ear by our plastic surgery colleagues. The patient remained stable on the medical-surgical floor for the duration of his hospital stay. He was treated with intravenous ampicillin-sulbactam for bite prophylaxis. This was transitioned to oral amoxicillin-clavulanate upon discharge on hospital day four.
2. Discussion With increasing populations of both canines and humans, bites will continue to be largely inevitable [1]. In nearly 80% of attacks, the offending animal is a family dog or animal otherwise known to the victim [3]. Children are three times more likely to require medical attention for injuries related to canine bites compared to adults [9]. Children under 10 years of age represent 56% of all bite injuries with children aged 4–7 at most risk from attacks [3,9]. This may be due to the combination of their small stature and their newfound ability to engage and grab animals, sometimes provoking a bite response. Death is increasingly likely with decreasing age and on average, 18 Americans will die of their injuries each year [3]. While bites to the head, neck and extremities are by far the most common, a full one-tenth of injuries involve the torso [4]. Thus far, there have been only four other case reports detailing intra-abdominal injuries from a dog bite in the literature, with three of the four detailing gastric injuries [5–8]. In the first three cases, anterior gastric injuries were identified and primarily repaired [5–7]. Ages ranged from age 26 months to 6 years in age [5–7]. In the fourth case, a 19-month-old was eviscerated by stray dogs and required resection of 100 cm of avulsed small intestine and ascending colon. He too recovered after a prolonged recovery [8]. Our case is the first reported use of laparoscopy to evaluate for suspected intra-abdominal injuries due to a dog bite in a child. Therefore, laparoscopy can serve as a useful adjunct in the evaluation of children in whom peritoneal violation is suspected, just as it can in adults [10]. As evidenced by our case and the few before it, a high index of clinical suspicion for intra-abdominal or potentially intra-thoracic injury should be maintained when evaluating small children who have been significantly bitten in the torso by a canine.
Fig. 2. In this photo, a 1 cm wound is seen, accompanied by 4 1 – 2 mm punctures in close proximity to the inferior margin of the right lobe of the liver.
Fig. 3. Explanation: An Additional peritoneal defect visualized during diagnostic laparoscopy.
Conflict of interest Fig. 4. Explanation: A retroperitoneal hematoma is seen posteriorly during laparoscopy.
All authors certify that there are no conflicts of interest of any kind to disclose.
54
Journal of Pediatric Surgery Case Reports 40 (2019) 53–55
J. Martinez et al.
Consent
[2] Kaye AE, Belz JM, Kirschner RE. Pediatric dog bite injuries: a 5-year review of the experience at the Children's Hospital of Philadelphia. Plast Reconstr Surg 2009;124:551–8. [3] Langley Ricky L. Human fatalities resulting from dog attacks in the United States, 1979–2005. Wilderness Environ Med 2009;20(1):19–25. [4] Ramgopal S, Brungo LB, Bykowski MR, Pitetti RD, Hickey RW. Dog bites in a U.S. county: age, body part and breed in paediatric dog bites. Acta Paediatr 2018;107:893–9. [5] Mitul AR, Mahmud K. Gastric perforation following dog bite in a child. APSP J Case Rep 2015;6:29. [6] Baeza-Herrera C, Martinez-Leo BA, Tonathiu S. Drilling gastric dog bite. Acta Pediátrica México 2012;33:109–11. [7] Diau YG, Chu CC, Lee TS. Severe dog-bite with disrupted bowel in a 19 month old boy. Pediatr Surg Int 1995;10:171–2. [8] Sing SP, Verma S, Singh P, Pandey A. Gastric perforation following dog bite in a child. J Child Sci 2018;8(1):e18–20. [9] Sacks JJ, Kresnow M, Houston B. Dog bites: how big a problem? Inj Prev 1996;2:52–4. [10] Kindel T, Latchana N, Swaroop M, et al. Laparoscopy in trauma: an overview of complications and related topics. Int J Crit Illness Inj Sci 2015;5:196.
Consent was not obtained as the patient is not identifiable. A waiver of consent was granted by our IRB. Authorship All authors attest that they meet ICMJE criteria for authorship. Funding No funding was obtained for completion of this study. References [1] American Society for the Protection and Care of Animals. U.S. Pet Statistics. Available at: https://www.aspca.org/. Accessed 8/5/2018.
55
Contents lists available at ScienceDirect
Journal of Pediatric Surgery Case Reports journal homepage: www.elsevier.com/locate/epsc
Pediatric dog bite with peritoneal violation a,∗
a
T b
Jason Martinez , Dane Scantling , Teerin Meckmongkol , Rajeev Prasad a b
b
Drexel University College of Medicine/Hahnemann University Hospital, Department of General Surgery, 231 N. Broad St Philadelphia, PA 19102, USA St. Christopher's Hospital for Children, Department of Pediatric Surgery, 160 East Erie Avenue, Philadelphia, PA 19134, USA
A R T I C LE I N FO
A B S T R A C T
Keywords: Pediatric Trauma Bites and stings
While dog bites are common in pediatric trauma centers, peritoneal violation from a dog bite is an uncommon finding given the significant bite force required to traverse the abdominal wall musculature. A very high incidence of clinical suspicion is necessary in order to avoid missing this rare, potentially life-threatening injury. In this instance, we report a case of peritoneal violation, retroperitoneal hematoma, colonic contusion, and mesenteric injury in a four year old male suffering from a dog attack in which computed axial tomography (CT) scanning was key in identifying the injuries. We also review the natural history (and injury patterns) of canine attacks in the United States.
Dog bites are a significant cause of injury amongst the pediatric population. Nearly 80 million dogs reside in U.S. households and this number has been increasing annually [1]. About 1000 Americans seek treatment for a dog related injury daily and this number is believed to be heavily under-reported [2,3]. The majority of injured children suffer bites to the extremities, head or neck as these tend to be eye level with the animal [4]. Bites to the torso are less common and represent only about 10% of injuries [4]. Intra-abdominal injury with peritoneal violation is rare with very few cases having been reported in the literature [5–8]. However, this type of injury can be life-threatening. Providers must maintain a high index of suspicion for such injuries to avoid significant morbidity and mortality. We report the case of a 4 year old male with peritoneal violation from the bite of a pit bull terrier. 1. Case report A 4-year-old male sustained an attack by the family pitbull terrier and was bitten multiple times before eventually being freed by bystanders. The child was transported to our Pediatric Level 1 Trauma Center by emergency medical services. Primary survey was intact, with a heart rate of 124, respiratory rate of 24, blood pressure of 128/ 59 mmHg, and SpO 2 of 99% on room air. His Glasgow Coma Score (GCS) upon arrival was 15, despite being anxious. Secondary survey was significant for several puncture wounds to his posterior flanks bilaterally, and to the region of his right trapezius muscle and right upper and lower abdomen. He was tender at the bite sites, but did not exhibit signs of peritoneal irritation. Additional injuries included a significant
∗
avulsion of his left ear at the level of the superior helix with approximately 1 cm of cartilage detached from the temporal region of his head. A single superficial skin laceration was also appreciated over the inferior portion of the right ear. Due to the nature of the posterior flank wounds, as well as the slender body habitus of the child, a CT scan of the abdomen and pelvis was obtained to rule out intra-abdominal injury. The results were significant for colonic wall thickening at the hepatic flexure, as well as the presence of intra-abdominal free fluid and pneumoperitoneum. There was also noted to be superficial subcutaneous emphysema along the right abdominal oblique muscle, bilateral paraspinal muscles, and inferior right chest wall musculature corresponding to the location of the injuries. In addition to imaging, a CBC was obtained during the trauma evaluation of this patient, which was significant for a WBC of 18.5 103 cells/mcL, Hgb of 11.4 g/dL, and Platelets 479 103 cells/mcL. A urinalysis was also obtained, which was significant for microscopic hematuria, with RBC's too numerous to count. The decision was made to immediately proceed to the Operating Room for a diagnostic laparoscopy. The patient was immediately brought to the operating room. Visual inspection immediately revealed peritoneal violation and multiple small defects in the abdominal wall in the right upper quadrant (Figs. 1–3). Although there was no gross spillage of intestinal contents, there was a contusion of the colon at the hepatic flexure (Fig. 4), as well as defect in the colonic mesentery (Fig. 5). There was also a small, non-expanding retroperitoneal zone 2 hematoma. The bowel was examined from the ileocecal valve to the ligament of Treitz,
Corresponding author. E-mail address: [email protected] (J. Martinez).
https://doi.org/10.1016/j.epsc.2018.10.011 Received 8 October 2018; Accepted 22 October 2018 Available online 24 October 2018 2213-5766/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/BY-NC-ND/4.0/).
Journal of Pediatric Surgery Case Reports 40 (2019) 53–55
J. Martinez et al.
Fig. 1. Explanation: Peritoneal violation as a result of canine attack, visualized on diagnostic laparoscopy.
Fig. 5. Explanation: Mesenteric defect that was visualized intraoperatively.
and no signs of perforation or spillage were encountered. The remainder of the colon and other viscera were also uninjured. After irrigation of the abdomen, the port sites were closed and attention was turned to repair of the avulsion injury of the ear by our plastic surgery colleagues. The patient remained stable on the medical-surgical floor for the duration of his hospital stay. He was treated with intravenous ampicillin-sulbactam for bite prophylaxis. This was transitioned to oral amoxicillin-clavulanate upon discharge on hospital day four.
2. Discussion With increasing populations of both canines and humans, bites will continue to be largely inevitable [1]. In nearly 80% of attacks, the offending animal is a family dog or animal otherwise known to the victim [3]. Children are three times more likely to require medical attention for injuries related to canine bites compared to adults [9]. Children under 10 years of age represent 56% of all bite injuries with children aged 4–7 at most risk from attacks [3,9]. This may be due to the combination of their small stature and their newfound ability to engage and grab animals, sometimes provoking a bite response. Death is increasingly likely with decreasing age and on average, 18 Americans will die of their injuries each year [3]. While bites to the head, neck and extremities are by far the most common, a full one-tenth of injuries involve the torso [4]. Thus far, there have been only four other case reports detailing intra-abdominal injuries from a dog bite in the literature, with three of the four detailing gastric injuries [5–8]. In the first three cases, anterior gastric injuries were identified and primarily repaired [5–7]. Ages ranged from age 26 months to 6 years in age [5–7]. In the fourth case, a 19-month-old was eviscerated by stray dogs and required resection of 100 cm of avulsed small intestine and ascending colon. He too recovered after a prolonged recovery [8]. Our case is the first reported use of laparoscopy to evaluate for suspected intra-abdominal injuries due to a dog bite in a child. Therefore, laparoscopy can serve as a useful adjunct in the evaluation of children in whom peritoneal violation is suspected, just as it can in adults [10]. As evidenced by our case and the few before it, a high index of clinical suspicion for intra-abdominal or potentially intra-thoracic injury should be maintained when evaluating small children who have been significantly bitten in the torso by a canine.
Fig. 2. In this photo, a 1 cm wound is seen, accompanied by 4 1 – 2 mm punctures in close proximity to the inferior margin of the right lobe of the liver.
Fig. 3. Explanation: An Additional peritoneal defect visualized during diagnostic laparoscopy.
Conflict of interest Fig. 4. Explanation: A retroperitoneal hematoma is seen posteriorly during laparoscopy.
All authors certify that there are no conflicts of interest of any kind to disclose.
54
Journal of Pediatric Surgery Case Reports 40 (2019) 53–55
J. Martinez et al.
Consent
[2] Kaye AE, Belz JM, Kirschner RE. Pediatric dog bite injuries: a 5-year review of the experience at the Children's Hospital of Philadelphia. Plast Reconstr Surg 2009;124:551–8. [3] Langley Ricky L. Human fatalities resulting from dog attacks in the United States, 1979–2005. Wilderness Environ Med 2009;20(1):19–25. [4] Ramgopal S, Brungo LB, Bykowski MR, Pitetti RD, Hickey RW. Dog bites in a U.S. county: age, body part and breed in paediatric dog bites. Acta Paediatr 2018;107:893–9. [5] Mitul AR, Mahmud K. Gastric perforation following dog bite in a child. APSP J Case Rep 2015;6:29. [6] Baeza-Herrera C, Martinez-Leo BA, Tonathiu S. Drilling gastric dog bite. Acta Pediátrica México 2012;33:109–11. [7] Diau YG, Chu CC, Lee TS. Severe dog-bite with disrupted bowel in a 19 month old boy. Pediatr Surg Int 1995;10:171–2. [8] Sing SP, Verma S, Singh P, Pandey A. Gastric perforation following dog bite in a child. J Child Sci 2018;8(1):e18–20. [9] Sacks JJ, Kresnow M, Houston B. Dog bites: how big a problem? Inj Prev 1996;2:52–4. [10] Kindel T, Latchana N, Swaroop M, et al. Laparoscopy in trauma: an overview of complications and related topics. Int J Crit Illness Inj Sci 2015;5:196.
Consent was not obtained as the patient is not identifiable. A waiver of consent was granted by our IRB. Authorship All authors attest that they meet ICMJE criteria for authorship. Funding No funding was obtained for completion of this study. References [1] American Society for the Protection and Care of Animals. U.S. Pet Statistics. Available at: https://www.aspca.org/. Accessed 8/5/2018.
55