Tiger Bite - Now becoming common in Malabar area 

16 FEB 2013

 

Case of the week-Tiger bite

Authors    - Dr Harshad P T -PGY 2

Moderators -Dr Shibu T V -Faculty

HOD -Dr Venu Gopal P P -HOD

65 yrs old male, was brought into ED with alleged history of tiger bite to his right forearm.

General impression-Conscious oriented

Primary survey-

Airway-Patent

Breathing-No external wounds Air entry b/L equal ,no added sounds

Circulation-Arterial pulsations not obtained on right upper limb distal to wound, CRT<2 secs

Disability-Alert, PEARL

Exposure-Multiple puncture wounds with exposed tissues on rt forearm

Vitals-

Pulse-110/min

BP-120/70mm of Hg

Spo2-99% in room air

RR-20/min

Temp-normal

GRBS-117

Detailed examination-

Symptoms-wound on rt forearm,numbness rt hand.

Allergy-nil specific

Medications-none

Past medical history-nil specific

Last meal-Lunch

Events-Right handed farmer was grazing his cow that evening was attacked by a tiger. He was bitten on his right hand. He shouted and attacked the tiger with his left hand. Tiger fled when people gathered.

On examination-

HEENT-no pallor/dehydration/open wounds

Neck-trachea central, no JVD/open wounds

Chest- No open wounds. Air entry equal B/L. Normal heart sounds

Abdomen and genitals-No open wounds/WNL

Extremities- Right forehand deformed with multiple puncture wounds with nonviable muscles protruding the wound. No radial and ulnar pulsations felt on rt upper limb. Decreased motor function of right fingers. Decreased sensations on right hand.

Saturation on right hand not recordable.

 

Labs

Hb-11.9Mg/dl

ESR-34

TC-14,500

Platelet-2.5Lakhs

S Urea-28

S creatine-2.3

S Na-140

S K-4.5

Ionised Ca-1.10

Xrays-Right hand arm Ap/Lateral

Xray shows open fracture of right radius.

Initial management

Patient was triaged into priority 1.

Limb splinting was given.

IV line attained and maintenance fluid NS started.

Pain managed with IV analgesics.

Neurological function assessed and axillary block given.

Wound wash given with NS.

Tetanus toxoid given

Anti-rabies vaccination and anti-rabies immunoglobulin given maximum dose around wound.

Empirical IV antibiotics started.

Xray of right hand taken.

Ortho consultation done.

Patient was taken to OT immediately.

Operative notes-Completely devitalised flexor muscles, crushed and torn ulnar nerve.

Ulnar artery cut.

Radial artery continuous but thrombosed.

Medial nerve intact.

Fractured rt radius.

Treated initially with wound debridement and external fixator.

Requires further surgeries.

Discussion

Animal bites are a common problem .Proper care requires wound inspection for injuries to deeper structures, meticulous wound care, care at initial encounter and decision regarding primary closure, the provision for antibiotics and prophylaxis for tetanus and rabies as indicated.

Majority of animal bites which we have to deal with is dog bite. Occasionally we will have to deal with bite by a wild animal. Wild animal bites are common in forest areas of Kerala like Waynadu which has got a Tiger reserve.

The management of animal bite should start immediately after the bite has occurred. Wound should be immediately washed with plenty of tap water and soap. Wound should be covered and immediate medical help should be sought.

Management in ED:

Stabilisation-Direct pressure if needed to control bleeding. Neurovascular assessment should be made distal to the wound. Deep wounds to vital organs should be considered as serious penetrating trauma.

Wound preparation-Meticulous wound care constitutes one of the most important step. Appropriate local anaesthesia helps wound cleansing.1% povidone iodine or 1% benzalkonium chloride can be used. Deeper wounds should be irrigated with saline using pressure irrigation. Removal of devitalised tissues is important.

Assessment of deeper structures-should be done under anaesthesia. Wounds near to joints should be assessed carefully

Primary wound closure-approach to wound closure varies with type of bite. In order to undergo primary closure a wound should be

1) Clinically uninfected

2) Less than 12hrs old (24hrs on face)

3) Not located on hand or foot.

Wounds that should not be closed include

1) Crush injuries

2) Puncture wounds

3) Bites involving hands and feets

4) Wounds more than 12 hrs old (24hrs on face)

5) Bite wounds in immunocompromised patients.

These wounds should be irrigated well left open and examined daily.

Studies have shown increased infection rates after primary closure of wounds.

Delayed primary closure-some physicians choose to leave bite wounds for drainage and possible delayed closure for 72 hrs after injury. Wound after primary care should be dressed with wet saline dressing twice daily until closure is performed.

Surgical consultation- Necessary for following wounds

1) Deep wounds penetrating bone, tendons, joints or other major structures

2) Complex facial lacerations

3) Wounds with neurovascular compromise

4) Wounds with complex infections

Antibiotic prophylaxis-Although routine antibiotics prophylaxis is not recommended, prophylaxis is warranted in

  1. Deep puncture wounds
  2. Associated crush injury
  3. Associated with venous/lymphatic compromise
  4. Wounds on hands
  5. Wounds near to joints
  6. Wounds requiring closure
  7. In immunocompromised patients

 

Antibiotic prophylaxis and empiric therapy for infected wounds typically involves broad spectrum coverage of gram positive, gram negative and anaerobic bacteria. In infected cases wound cultures should help to choose the antibiotics.

If patients are to receive antimicrobial prophylaxis, the first dose should be given as soon as possible. It is advisable to give first dose parenterally to obtain effective tissue levels and *-8then continue further doses orally.

Tetanus prophylaxis- Tetanus toxoid and tetanus immunoglobulin should be given as per wound extent and patients immunisation status.

Rabies prophylaxis- Rabies is frequent concern with animal bites, especially with wild animal bite .Bites, scratches, abrasions, contact with animal saliva with mucus membrane can transmit rabies. Early wound cleaning is an important prophylactic measure in addition to timely antirabies vaccine and immunoglobulin.

Follow up care-patients discharged after initial care should follow up with primary care provider within 24 to 48 hrs to assess wound status.

Complications-the most important complication include trauma to deep structures and infections. Another major complication seen especially in children include post-traumatic stress disorder (PTSD).

Summary-

  • The care for animal bite should start immediately after attaining the injury.
  • Wound should be washed immediately with ample water.
  • In ED serious injuries to underlying structures should be assessed.
  • Wound should be washed thoroughly with antiseptics and saline
  • Debridement of wound
  • Delayed closure
  • Prophylactic antibiotics
  • Rabies and tetanus prophylaxis
  • Surgical consultation if needed.

 

References

 

Up-to-date-animal and human bites

Tintinalli book of emergency medicine (7th edition)

Rosens book of emergency medicine (7th edition)