|Year : 2020 | Volume
| Issue : 1 | Page : 35-38
Man versus wild: A case report of a bear attack with thoracic complications
Dyan DíSouza, Sreekar Balasundaram
Department of CTVS, St. Johns Medical College, Bengaluru, Karnataka, India
|Date of Web Publication||24-Dec-2020|
Resident, C/O Dept of CTVS, St John's Medical College Bangalore
Source of Support: None, Conflict of Interest: None
Bear attacks on humans are rare and are even more rarely reported in medical literature. Each year people have numerous accidental interactions with bears around the world. In India, bear attack incidences have been reported in and around Kashmir and in Central India. A very small fraction of these bear attacks result in human injury. Injuries due to bear attacks include skin lacerations, bites etc. The most common areas of injury are the face, legs and hands. Thoracic injuries due to a bear attack hasn't been reported earlier. We present the case of a 55 year old with bear attack, suffered among other injuries, a right Hemo-Pneumothorax. A flail segment was also noted on the right anterolateral region. The patient did not need any invasive ventilation. Right Inter-costal Drain tube inserted ICD drain was discontinued on day 4 of admission. Post drain removal a subcutaneous collection was noted on the back with suspicious pleural tear near the 12th rib detected on MRI. ICD was re-inserted and the patient, conservatively managed. Bear attacks are rare in India, and thoracic injuries causing a flail segment, pleural tear and a hemo-pneumothorax hasn't yet been reported. This case report hence, highlights the fact that bear attacks, like a blunt/penetrating trauma can provide with a challenging scenario in the emergency room. Right knowledge and stepwise management of these cases can therefore ensure complete and wholesome treatment, even in cases with thoracic injuries.
Keywords: Casualty, pleural tear, pneumothorax, trauma
|How to cite this article:|
DíSouza D, Balasundaram S. Man versus wild: A case report of a bear attack with thoracic complications. J Cardiothorac Trauma 2020;5:35-8
|How to cite this URL:|
DíSouza D, Balasundaram S. Man versus wild: A case report of a bear attack with thoracic complications. J Cardiothorac Trauma [serial online] 2020 [cited 2021 Nov 29];5:35-8. Available from: https://www.jctt.org/text.asp?2020/5/1/35/304869
| Introduction|| |
Bear attacks on humans are rare and are even more rarely reported in medical literature. Each year, people have numerous accidental interactions with bears around the world. In India, bear attack incidences have been reported in and around Kashmir and in Central India. A very small fraction of these bear attacks result in human injury. The chance of a human encountering a bear increases as the remote bear territory diminishes. A search of scientific literature reveals very few articles detailing case reports or an in-depth analysis of injuries due to bear mauling. Here, we discuss the presentation and subsequent management of a 55-year-old male who came to us with chest wall and thoracic injuries after being mauled by a bear.
| Case Report|| |
A 55-year-old male hailing from Anantapur presented with a history of being mauled by a bear in the early hours of the morning while in the fields. The patient claimed that there were three bears probably mother bear and her cubs and the attack was unprovoked. It started with the bear attacking him and causing numerous lacerations on the back and the right shoulder regions. The patient then “played dead” and the bear walked ahead; however, our patient woke up a tad bit earlier and caused the bear to come back and maul him again. The patient then had a brief loss of consciousness.
He was taken to a nearby clinic and was resuscitated with intravenous fluids. Hemopneumothorax was seen on the right side, right intercostal drain tube was inserted, and he was then referred to our center. The patient on arrival was alert, conscious, and oriented (Glasgow Coma Scale of 15/15) and with peripheral oxygen saturation of 90% at room air and 100% with 4 l/h of O2. He had multiple abrasions on the back and the right clavicular and shoulder areas with deep lacerations in the right deltoid region and another one in the right scapular area. A flail segment was noted on the right side in the anterolateral region. The patient was monitored in the intensive unit and then was shifted to the ward. The patient did not need any invasive ventilation. The wounds were thoroughly washed and secondarily sutured. Abrasions were dressed regularly, and collagen dressing was applied given the large area of abrasions spanning the entire back region. X-ray of the chest [Figure 1] revealed multiple rib fractures and an Inter-costal Drainage tube (ICD) in situ on the right side.
Computed tomography (CT) of the thorax [Figure 2] revealed multiple displaced comminuted fractures of the right posterior 10th–12th ribs and right lateral rib fractures in 8th–12th ribs. Undisplaced fracture of the right posterior 9th rib was noted. Right mild Hemopneumothorax with ICD in situ was also noted. The other findings noted were a hemangioma of D2 vertebral body and undisplaced D9–D11 fractures of the spinous process. It also detected a 2 mm air focus in the left Internal Jugular Vein (IJV) with no contrast extravasation.
|Figure 2: High-Resolution Computed Tomography of the thorax showing hemopneumothorax after ICD insertion|
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His drain was discontinued on day 4 of admission. He subsequently developed a fluctuant swelling in the back on the right para-vertebral region extending from the infrascapular to the lumbar area, post ICD removal. The collection was sero-sanguinous and was sterile on culture. Chest X-ray (CXR) (supine-anteroposterior view) [Figure 3] revealed pleural effusion on the right side.
A magnetic resonance imaging (MRI) [Figure 4] and [Figure 5] was done to rule out a cerebrospinal fluid leak given CT report of vertebral fracture and showed a suspicious area of communication of the above collection with the pleura at the site of the 12th rib. It confirmed pleural effusion. The orthopedicians suggested conservative management for the spine fractures. The ICD tube was re-inserted and 600 ml of fluid was drained which was sterile on culture. After 2 days of <30 ml output, the drain was removed. The subcutaneous swelling on the back decreased completely. The patient was on injections ceftriaxone and amikacin with regular monitoring of serum creatinine. Rabies Post-Exposure Prophylaxis (PEP) was promptly initiated at admission. The patient was discharged on stable hemodynamics after 15 days. He was asymptomatic on follow-up after 30 days.
|Figure 5: Pleural fluid tracked to the lumbar paraspinal region in the subcutaneous plane|
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| Discussion|| |
Bear attacks are relatively uncommon in India. There have been a few reported cases from Kashmir in the North India and in the Central India region.
There are eight types of bears in the world. They include the American black bear, brown bear, polar bear, giant pandas, Asiatic black bear, sloth bear, spectacled bear, and the sun bear. The sloth bears inhabit forests and tall grasslands in India, Nepal, Sri Lanka, and Bhutan. For those who frequent forests in India, sloth bears present a considerable danger – worsen than that of tigers or leopards.
Three species of bear are found in India, the Himalayan black bear, the brown bear, and the sloth bear. Nagpur, which is surrounded by a large number of forests, is a habitat only for sloth bears (Melursus ursus ursinus). They are medium-sized bears, with an average weight of 130 kg, 2–3 ft high at the shoulder, and a body length of 4.6–6.3 ft. They are primarily nocturnal in nature and hunt for the food during the night. Their ideal habitat is a forested area with rocky outcrops. They mainly eat fruits, tubers, and insects with a special liking for Mahua flowers. Sloth bears probably view humans as potential predators, as their reactions to them (roaring, followed by retreat or charging) are similar to those evoked by the presence of tigers and leopards. The female sloth bear is most dangerous when she has babies with her and can attack immediately without provocation.
A recent survey suggested that sloth bears may occupy 52% of the land area of India. Notably, though this study was based on very large sampling cells (2,800 km2 across a sampling region of nearly 3 million km2), a map of India showing sloth bear presence is shown in [Figure 6].
The risk of rabies is present with any wild animal bit and more so in a case with a sloth bear attack. The treatment of such cases usually involves three components: wound care, passive immunization (immune globulin), and active immunization (vaccine). On November 1, 1989, the first confirmed case of rabies in a polar bear (Ursus maritimus) was encountered by Inuit hunters in the vicinity of Cape Kendall, Southampton Island, and Northwest Territories (Canada). The paper concluded that the impact of rabies on the population dynamics of polar bears probably is minimal and that rabies in polar bears constitutes a potential health hazard for polar bear hunters.
Bears may carry rabies, hepatitis, distemper, Trichinella, and other organisms. In one reported case, cultures of bacteria from a deep wound in the thigh grew Streptococcus sanguis, Neisseria sicca, Bacillus spp., and Mycobacterium fortuitum. Serratia fonticola, Serratia marcescens, Aeromonas hydrophila, Bacillus cereus, and Enterococcus durans have also been isolated from bear wounds.
As the entire body is exposed, the central target area for the face includes the lips, nose, and cheeks. Bargali et al. quoted that 8% of bear attacks were fatal. Most victims were attacked on their legs, 12.4% on their hands, and 11% on other parts of their bodies. Fifty-two percent of cases of multiple injuries were reported. Victims suffered injuries such as fractures and severed body parts (eyes and scrotal sac).
In a 3-year study done in Kashmir, it was found that of 212 cases of bear maul during this period, 15 cases (7.07%) of them had vascular injury. All these patients had unprovoked bear-clawing injuries. Vascular injury by the bear attack has a very good outcome probably because of the absence of cavitation effect, provided prompt resuscitation, revascularization and proper technique of vascular repair is followed.
Thoracic injuries due to a bear maul have not been reported earlier. Hemopneumothorax reduced post-ICD tube insertion. However, a tear in the pleura was missed in the initial assessment and was picked up only on the MRI scan and on noticing the subcutaneous collection.
Thoracic CT is highly sensitive in detecting thoracic injuries after blunt chest trauma and is superior to routine CXR in visualizing lung contusions, pneumothorax, and hemothorax. Early Thoracic Computed Tomography (TCT) influences therapeutic management in a significant number of patients. However, an initial MRI indicated to diagnose minor pleural tears is still questionable.
Other injuries rare instances reported by bear attack include strangulation of the intestine due to a bear bite and evisceration of the right eye. Patil et al. who reviewed 48 bear attack patients in Central India received no patients with abdominal, chest, viscera, or brain injuries.
| Conclusion|| |
Bear attacks are rare in India, and thoracic injuries causing a flail segment, pleural tear, and a hemopneumothorax have not yet been reported. This case report hence highlights the fact that bear attacks, like a blunt/penetrating trauma, can provide with a challenging scenario in the emergency room. Right knowledge and stepwise management of these cases can, therefore, ensure complete and wholesome treatment, even in cases with thoracic injuries.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]