Emergency Medicine Forum

A father rushes through the EMS ambulance entrance holding his 2 y/o son screaming, “I need some help, please, I need a doctor!”

Multiple personnel rush to see what the problem is, and then note the child is covered with blood, and so is the dad.

The father is instructed to put his son down on a gurney in the resuscitation area.  I was coming out of a patient room and saw the commotion and quickly responded to the bedside.

The father noted that he went to put some laundry in down in the basement, and when he came up stairs, his pit bull was attacking his son.  He kicked the pit bull, grabbed his son, ran to his car and came here. 

A quick visual of the child reveals a pale child, lying still, eyes shut, whimpering, blood is noted around his chest, abdomen, groin, and thigh. 

The nurses quickly respond to my usual request:  “IV (250 NS bolus), oxygen, monitor, undress him, check vital signs, and draw blood for a trauma panel and a bedside glucose.” 

Exam:

Airway: Open
Breathing:  = breath sounds with good air exchange, no subcutaneous air, lacerations to the chest wall on the right but bleeding not arterial.
Abdomen: soft but tender
Pulses faint at the groin (femoral artery)
Bleeding was only oozing at this time

Secondary Exam:

HEENT:  PERRL neck:  no obvious bleeding, laceration, or c-spine tenderness.  No bites to the face or skull
Heart: RRR, tachycardia at 160, pulses faint at femoral artery
Lungs:  =BS, lacerations without any evidence for sucking chest wound.  No subcutaneous air. Bleeding controlled
Abd: Soft, tender throughout, especially on the left where lacerations were present.  Lacerations are deep to the subcutaneous fat.  No bowl seen.
Groin:  Large laceration to the scrotum, bleeding minimal and tissue damage appears extensive. Penis in tact.  Blood noted around rectum.  After clearing off blood, digital rectal reveals no gross blood in rectal vault
Ext:  Numerous lacerations to upper thigh.  Most with extensive tissue damage, and subcutaneous fat exposed.  Capillary refill 5 seconds.
Pulses: present at the femoral area.
Neurologic:  Child is lethargic, whimpering to IV start and minimal withdraw to the needle.  He moves all 4 extremities spontaneously.
Back:  Unremarkable.

Questions:
1. What should you order?

This child is in shock from trauma/blood loss/potential internal bleeding. You don’t need the blood pressure to tell you this as you can diagnose this by clinical exam (pale, altered mental status, tachycardia, decreased pulses, and prolonged capillary refill). Shock is defined as decreased perfusion to organs and tissues. (1) It turns out the blood pressure was only 60 by palpation. In response to the identified shock, I ordered the following:
a. IV fluid resuscitation 20cc/kg (already ordered)
b. Oxygen (already ordered)
c. Initiated the transfer protocol to the local pediatric trauma center (I was in a small, adult only hospital without pediatric inpatient facilities). I do this early if I’m at a hospital that doesn’t usually manage these cases. Any delay in initiation of the transfer process can cause a substantial delay in definitive care (i.e. OR). Remember to initiate it as soon as possible. This child doesn’t need an abdominal CT at your hospital before you get the transfer going; he needs a quick transfer to a trauma center. If you have time, fine, but hopefully he will be in an ambulance shortly en route to the trauma center.
d. Second IV at maintenance rate
e. Blood for labs including type and cross was already ordered with the ‘trauma’ panel.
f. Accucheck for altered Mental status (which was likely from shock and not hypoglycemia but you still need to check) was already ordered.
g. X-ray for chest x-ray was ordered.
h. FAST exam: negative for intra-abdominal bleeding.
i. Foley for urine output
j. Consider NG tube. Depending on the situation, I will put it in or not. In this case, he improved with the fluids, so I held off on the NG tube. Many would argue I should have put it in.
k. Then get more history from Dad:
i. Allergies (based on response, start antibiotics)
ii. Other medical problems/medications/immunizations
iii. More details about the attack

2. What is normal capillary refill time?

Capillary refill can be determined faster than blood pressure, and some consider it the fastest assessment of hypoperfusion. (2) Any delay (>2 seconds) indicates hypoperfusion/shock. (2)

3. What proportion of animal bites in the US is from dogs? How often are they fatal?

It’s interesting that dog attacks account for 80-90% of bites in the US. (3) Between 5-15% are from cats, 2-5% from rodents, and other animals even less. (3) Unfortunately, dog bites can be fatal. Between 10-20 people each year die from dog bites, and most of these victims are children. (3).

4. What are the bad bugs (bacteria) for cats and dogs?

In cats, we always learn about Pasteurella Multocida (the most common pathogen contracted from cat bites). In dogs, the bad bug is Capnocytophaga Canimorsus, which can cause sepsis (especially if immunocompromised). (3)

5. Which bite wounds should you leave open?

Bites to the hands, bites to the lower extremities, and bites in immunocompromised patients should ‘generally’ be left open. (3). Facial wounds are at low risk for infection because of the excellent blood supply and usually are closed. (3).

Outcome:
This child responded very quickly to fluids (although I did need a second 20cc/kg bolus to appreciate this improvement), with an improved exam: mental status: crying consoled by dad, complaining about the IV’s and foley). Capillary refill normal, pulses easily palpable, blood pressure 100/80. His wounds were quickly dressed, and an ambulance arrived within 40 minutes to transfer him to the trauma center. CXR was negative for any pneumothorax.

Later I found out he went to the OR to repair all the substantial lacerations. He still had abdominal pain on arrival, and CT of the abdomen was negative. He almost lost one testicle, but they were able to save it. He remained in the hospital for several days.

I remember hearing the father explain to the mother who arrived quite distraught just as the ambulance arrived, ”I don’t think Harry meant to hurt him, Joey must have been bothering him.”

The child’s name was Joseph. I never understand these thought processes. I have 4 children, and would never hesitate to get a dog out of our home if he came close to biting one of my children. I love animals (we have 3 dogs), but they are still dogs, and my children’s wellbeing and safety will always trump a dog.

References:
1. Definition of Shock.  The free dictionary.  Accessed at: http://medical-dictionary.thefreedictionary.com/shock.
2. Graneto JW.  Pediatrics, Fever.  Emedicine, Aug 6, 2009.  Accessed at: http://emedicine.medscape.com/article/801598-overview
3. Garth AP, Harris NS. Bites, Animal: Emedicine June 2009.  Accessed at: http://emedicine.medscape.com/article/768875-overview