Journal of Pediatric Surgery VOL. XVIII, NO. 5 OCTOBER 1983

Major Dog Attack Injuries in Children

By Nathan E. Wiseman, Harvey Chochinov, and Virginia Fraser Winnipeg, Manitoba, Canada

�9 Children are frequently admitted to a hospital with injuries sustained as a result of being attacked by a dog. Over a 5-year period (1977 to 1981), 57 such patients have been treated at the Winnipeg Children's Hospital. Half of the dog attack victims were 5 years or younger with injuries occurring more ofte~ in boys (55%). The majority of patients (95%) sustained puncture wounds and lacerations to the face (77%) and extremities (23%). In three of the cases, the dog attack victims presented with peri- tonitis secondary to bowel perforation and were treated successfully. A fourth child died as a result of his injuries prior to reaching the hospital. In the past, much attention has been focused on soft tissue injuries and their cosmetic repair. It is also important to recognize that the small child is particularly vul- nerable to dog maulings from which the injuries sustained may be life threatening or lethal. Preven- tion seems to be the only rational approach to solving this problem.

INDEX WORDS: Trauma; dog mauling.

I T IS the nature of human beings to keep the dog as pet, and for this they and their chil-

dren must pay the price. It has been reported in North America that annually one person out of 275 will sustain a dog bite injury, which trans- lates into 100,000 such injuries in Canada. ~ The largest number of patients are children. The child usually sustains a soft tissue injury to the face, scalp, or extremities, and often major plas- tic surgical repair is required. 2 Severe life-threat- ening and lethal injuries are fortunately rare; 3 however, over a 5-year period four such injuries have been seen at the Children's Hospital in Winnipeg.

Hospital Experience

Over a 5-year period (1977 to 1981), 57 children were admitted to the Winnipeg Chil- dren's Hospital with injuries sustained as a result of being attacked by a dog. The median age was 5

years, and 31 of the patients were male. Soft tissue injuries occurred alone in 51 patients and were associated with fractures in three patients. There were a total of 78 sites of soft tissue injury with 60 being in the head and face region and 18 in the extremities. Fracture sites in three patients were to the skull, nasal bone, and zygoma. All patients were treated successfully. In three patients, a life threatening visceral injury resulted from the dog attack, and a fourth patient expired prior to arrival at the hospital.

CASE REPORTS

Case 1 - - B B

A 28-month-old girl (13.5 kg)sustained a bite wound to the abdomen while playing with her pet St Bernard dog (84 kg). Following the injury, the child developed hematemesis and severe abdominal pain. On admission to hospital, she was febrile (38 *C), tachycardiac (132/min), and had signs of generalized peritonitis. A pattern of puncture wounds coin- ciding with the dog's incisor teeth was noted on the abdomi- nal wall with omentum protruding through one of the wounds (Fig. 1). An upright abdominal radiogram demonstrated free air within the peritoneal cavity and confirmed the presence of a perforated viscus. Following the administration of tetanus toxoid and broad spectrum antibiotics, a laparotomy was performed. At surgery, lacerations to the left lobe of the liver and a puncture wound to the anterior wall of the stomach were repaired. The child experienced an uncomplicated post- operative recovery and was discharged on the fifth postopera- tive day. The dog had been a family pet since the child was a small infant and had exhibited no aggressive behavior prior to

From the Section of Pediatric Surgery, the Children's Hospital of Winnipeg.

Presented at the 14th Annual Meeting of the Canadian Association of Paediatric Surgeons, Quebec City, Canada, September 13-15, 1982.

Address reprint requests to Dr N. E. Wiseman, the Chil- dren's Hospital of Winnipeg, Winnipeg, Manitoba, R3E OWl, Canada.

�9 1983 by Grune & Stratton, Inc. 0022/3468/83/1805~001 $01.00/0

Journal of Pediatric Surgery, Vol. 18, No. 5 (October), 1983 533

534 WlSEMAN, CHOCHINOV, AND FRASER

Fig. 1. Case 1. Imprint of St Bernard teeth on abdomi- nal wall showing protruding omentum (arrow) and incisor teeth puncture wounds (triangles).

the incident. The attack was thought to have been provoked as a result of pestering play by the child. The animal was not destroyed.

Case 2 - - A L

This 5-year-old child had gone into the bush to have a bowel movement when he was sexually assaulted by a neigh- bor's large dog. The attack was witnessed by the child's mother and an aunt who pulled the dog off the child. Following the attack, the child complained of abdominal pain and was noted to pass blood per rectum. On admission to the Children's Hospital 24 hours after the injury, the child was noted to be febrile (38.8 ~ and had signs of generalized peritonitis. The WBC was 18,500, and an upright x-ray of the abdomen revealed free air beneath the diaphragm. After the administration of gentamicin and clindamycin, the child was taken to surgery with a preoperative diagnosis of rectal perforation. Operation disclosed a discrete anterior rectal wall perforation located just above the peritoneal reflection. In addition, there was a fecal pelvic peritonitis. The perfora- tion site was closed in layers, and a defunctioning sigmoid colostomy was performed. Following a 1-week course of antibiotics, the child's postoperative recovery was complete. At 1 month, the colostomy was closed, and this was followed by the resumption of normal rectal function. A police investi- gation including a lie detector test confirmed the validity of the bizarre event which led to the child's injury. The dog (Alsatian) was destroyed.

Case 3 - - G O

A 22-month-old boy was at play when he was attacked and mauled by a large chained mongrel dog. Initial resuscitation in a rural hospital consisted of administration of Ringer's lactate, blood, tetanus toxoid, and penicillin. An open chest wound had been treated with an occlusion dressing and drainage tube. On admission to the hospital, the child was

found to be pale and alert with a temperature of 40.3 ~ a pulse rate of 144/min, and BP 110/70. Examination revealed an open wound over the right lateral chest and a large eviscerating wound in the right upper quadrant of the abdo- men through which small bowel was protruding. Following further resuscitation, the child was taken to surgery. Lapa- rotomy disclosed three sites of gastric perforation, a serosal tear to the duodenum, perforations of the ileum and descend- ing colon, and absence of the right and transverse colon. Surgical treatment consisted of debridement and closure of the gastric wounds, suture of the duodenal laceration, cre- ation of a right lower quadrant end ileostomy and a left lower quadrant mucous fistula (Fig. 2). On exploration of the chest wound there was noted to be fractures to the right 9th, 10th, and l lth ribs. The chest wall was reconstructed primarily, and chest tubes were inserted. The postoperative course was complicated by hemorrhage, respiratory failure, gram-nega- tive septicemia, and wound dehiscence. On the second postop- erative day, reexploration of the peritoneal cavity was neces- sary in order to control secondary hemorrhage which arose from the proximal end of the avulsed middle colic artery. Respiratory failure was managed with assisted ventilation from which the patient was weaned over a period of 12 days. On the ninth postoperative day, wound sepsis and dehiscence necessitated secondary suture to the laparotomy incision. By the end of the fourth postoperative week, the thoracic and abdominal wounds had healed, the ileostomy was functioning normally, and a full oral diet was tolerated. Two months postoperatively, the patient was discharged from the hospital, and at 4 months he was readmitted for ileostomy closure. An ileo-descending colic anastomosis was carried out, and the postoperative recovery was uneventful. The child returned home 4t/4 months after the injury tolerating a normal diet and having normal bowel function.

Case 4 - - C M

A 3'/2-year-old boy (15 kg) crawled unwitnessed under a fence into an enclosure occupied by four 10-month-old Husky sled dogs and was savaged to death. Postmortem examination revealed a total of 12 deep anterior and posterior cervical lacerations measuring from 3 to 6 cm in length (Fig. 3). The

Fig. 2. Case 3. Postoperative photograph showing mul- tiple puncture wounds and eviscerating abdominal and thoracic wounds (arrows) after creation of ileostomy and mucous fistula.

DOG MAULING 535

Fig. 3. Case 4. Postmortem photo showing deep cervi- cal lacerations.

lacerations were noted to extend down to the bony cervical vertebrae, and there was extensive deep cervical and peritra- cheal hemorrhage secondary to a tear of the right internal jugular vein. There were also lacerations present in the lumbosacral region, buttock, and thigh. The abdominal and thoracic cavities were intact. Death was attributed to acute exsanguination. The dogs were destroyed.

DISCUSSION

Children are frequently the victims of an attack by a dog, and the problem appears to be worldwide as attested to by reports from Canada, 4 the United States, 2 South Africa, 5 Ire- land, 6 India, 3 and Hawaii. 7 In the majority of cases, the injury occurs in a domestic setting and involves a friendly dog that is known to the victim ~ (cases 1,3). In two reports in which the breed of dog was noted, 2'5 it was found that the Alsatian (German shepherd) was most fre- quently responsible (31%, 44%), however, no breed appears safe. The most frequent anatomic site of injury is to the head, face, and neck 4 (75%) with fewer injuries involving the extremities and trunk. The mechanisms of injury include biting,

clawing, and crushing forces resulting in wounds with a characteristic pattern consisting of punc- tures, lacerations, and avulsions to both skin and soft tissue. 4 Common serious injuries include avulsions of lip, 8 nose, 5 and ear, which require major plastic reconstructive surgical repair. 2 In one patient reported herein, the force of the injury resulted in a depressed skull fracture and dural tear. A similar injury was observed by Watson, 7 and such injuries are not surprising in view of biting forces in sentry dogs which have been measured at 150 to 200 psi. 9 In each of the four reported cases of major injury, the combina- tion of a small child and large dog no doubt contributed to the severity of the injury. In case 1, the biting force of the St Bernard dog com- bined with the dagger-like configuration of the incisor teeth resulted in a penetrating wound through the abdominal wall, liver, and stomach. In case 3, similar forces penetrated the abdomi- nal and chest walls with locking of the jaw upon the viscera resulting in a tearing avulsion of the colon and chest wall. The mechanism of injury reported in case 2 was viewed with scepticism; however, the police investigation of the case found the account of the incident from witnesses, including the patient's mother, to be valid. Simi- lar cases have not been reported; however, there are accounts of women prisoners being subjected to rape by dogs as a form of torture. ]~

Deaths resulting from attack by dogs have been reported in both adults and children. 3'1~'12 Out of 15 cases (including case 4), I 1 involved children under 7 years of age. In only three of the deaths was more than one dog involved. In all patients, death resulted from exsanguinating hemorrhage as a result of multiple lacerations that may number as many as 300. Forensic pathologists 12 in examining such cases have noted a characteristic pattern of multiple tear or split wounds with adjacent puncture wounds ("a hole and a tear") and conclude that this pattern reflects the primitive gaming tactic used by the dog in stalking and savaging its prey (human). It is well known that deaths may occur as a result of contracting rabies as a complication of a dog bite; 2 however, it has not been appreciated that acute hemorrhagic death is more common.

Dogs will continue to be kept as pets, and dog attack injuries will continue to occur. Many of the most severe injuries and deaths would seem

536 WISEMAN, CHOCHINOV, AND FRASER

to be preventab le if large dogs and smal l chi ldren could be kept apar t . Keeping a dog chained or within an enclosure does not prevent a child f rom enter ing an an imal ' s t e r r i to ry (cases 3,4) and test ing its t e r r i to r ia l dominence . Ve te r ina ry prac t i t ioners recognize aggressive behavior of dogs toward chi ldren as a t r ea t ab le ent i ty . 13 The t r ea tmen t involves behavior modif icat ion tech- niques 14 (counter condit ioning, desensi t iza t ion) and in some dogs proves to be successful in a l leviat ing the aggressive behavior . Unfor tuna te - ly, the first demons t ra t ion of aggressive behavior by a dog m a y result in a devas ta t ing in jury (case 1), a fact tha t is refuted by an imal behavior is ts

who c la im tha t a careful his tory will reveal previous 'evidence of s imi lar behavior. A no the r approach to the p rob lem which could prevent many injur ies involves behavior modif icat ion of humans. ~ W e mus t learn to follow the 10 rules which are: Do not (1) hold your face close to a dog, (2) al low dogs to roam unleashed, (3) pet a s t range dog, (4) tease a dog, (5) s ta r t le a dog, (6) touch a s leeping dog, (7) leave a smal l child and dog alone, (8) omi t vaccinat ion of a dog, (9) leave a dog alone with s t rangers , and (10) ignore the warning signals of aggress ive behavior. I f the dog is to r emain man ' s best fr iend, man mus t learn how to live with his fr iend.

REFERENCES

1~ Klein D: Friendly dog syndrome. NY State J Med 66:2306--2309, 1966

2. Schultz RC, McMaster WC: The treatment of dog bite injuries, especially those of the face. Plast Reconstr Surg 49:494-500, 1972

3. Sharif SM: Dog bite death. Forens Sci 9:151-153, 1977

4. Thomson HG, Svitek V: Small animal bites: The role of primary closure. J Trauma 13:20-23, 1973

5. Chait LA, Spitz L: Dogbite injuries in children. S Afr Med J 49:718-720, 1975

6. Lawlor DL: Dog bites in children in Dublin. J Ir Med Assoc 70:120-t21, 1977

7. Watson DW: Severe head injury from dog bites. Ann Emerg Med 9:28-30, 1980

8. Musgrave RH, Williams SG: Dog bite avulsions of the lip. Plast Reconstr Surg 49:294-296, 1972

9~ Chambers G, Payne J." Treatment of dog bite wounds: Minn Med 52:427430, 1969

10. Torture as policy: The network of evil. Time Aug 16:21-24, 1976

11. Winkler WG: Human deaths induced by dog bites, United States, 1974-75. Public Health Rep 92:425~129, 1977

12. Tong GTF, Pang TC: Unusual injuries: Savaged to death by dogs. Med Sci Law 5:158-160, 1965

13. Voith VL: Prognosis of treatment for aggressive behavior of dogs toward children. Mod Vet Pract 61:939- 942, 1980

14. Voith VL: An approach to ameliorating aggressive behavior of dogs toward children. Mod Vet Pract 62:67-70, 1981