Journal of Pediatric Surgery xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center☆ Erin M. Garvey a, Denice K. Twitchell b, Rebecca Ragar b, John C. Egan b, Ramin Jamshidi b,⁎ a b
Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ 85255, USA Pediatric Surgery, Phoenix Children's Hospital, 1920 E Cambridge Ave., Phoenix, AZ 85006, USA
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 9 September 2014 Available online xxxx Key words: Pediatric trauma Dog bite Pit bull Injury prevention Pet safety
a b s t r a c t Background: Pediatric dog bite injuries are common and vary in severity. We sought to characterize predisposing factors, required interventions, and morbidity. Methods: A prospective clinical database at a level one pediatric trauma center was reviewed for dog bite injuries over 74 consecutive months ending December 2013. This included all patients brought in by ambulance and/or seen by the trauma team. Results: Of 650 dog bite incidents, 282 met the criteria for inclusion in the trauma database. Median age was 5 years (range, 2 months to 17 years) and 55% (154/282) of patients were male. Pit bulls were most frequently responsible, accounting for 39% (83/213) of incidents in which dog breed was documented. Fifty-three percent (150/282) of dogs belonged to the patient's immediate or extended family. Sixty-nine percent (194/282) of patients required operative intervention: 76% laceration repairs, 14% tissue transfers, and 2% neurosurgical interventions. The most severe injuries were depressed skull fractures, intracranial hemorrhage, laryngotracheal transection, and bilateral orchiectomy. Median length of stay was 1 day (range, 0 to 25 days). There were no mortalities. Conclusions: Pediatric dog bites span a wide range of ages, frequently require operative intervention, and can cause severe morbidity. Dog familiarity did not confer safety, and in this series, Pit bulls were most frequently responsible. These findings have great relevance for child safety. Summary Statement: Pediatric dog bites are common and can vary in severity from superficial wounds to lifethreatening injuries. Dog familiarity may confer a false sense of safety. A national dog bite prevention and education campaign should be developed with the goal of decreasing the incidence of pediatric dog bites. © 2014 Elsevier Inc. All rights reserved.
Dog bites are common in the United States and internationally, and can result in significant morbidity in pediatric patients [1–4]. Injuries can range from superficial wounds to life-threatening head and neck injuries, and fatalities have been reported [3,5–7]. The psychological insult can result in fear and nightmares and can have an adverse effect on quality of life for both the victim and their family [4,8]. Approximately 4.5 million dog bites occur each year in the US, and children account for half of the cases [9,10]. One study commenting on the unreported rates of dog bites noted a 45% incidence of dog bites in surveyed children [11]. Prior retrospective studies from the northeast and midwest have shown a predilection for male victims in the five to 12 year age range, with injuries frequently occurring during summer months by dogs that are familiar to the child (most commonly Pit bulls) [1,2]. Studies from Austria and Canada also show injuries in a similar age range, during summer months with dogs familiar to the child, though there
☆ Presented at Western Pediatric Trauma Conference July 9–11th, 2014. ⁎ Corresponding author at: Phoenix Children's Hospital, 1920 E Cambridge Ave., Phoenix, AZ 85006, USA. Tel.: + 1 602 254 5561; fax: + 1 602 254 2185. E-mail addresses: [email protected] (E.M. Garvey), [email protected] (R. Jamshidi).
were no gender predispositions, and the most common breeds involved were Rottweilers, German shepherds and Dobermans [3,4]. No such study has been reported in the southwestern United States. The purpose of this study was to characterize the demographics, relevant injuries, and resultant morbidity of dog bites at our institution and to compare our results to the existing literature.
2. Methods Institutional review board approval was obtained. Discharge diagnosis codes were used to determine the total number of dog bite patients evaluated at Phoenix Children's Hospital – a level one pediatric trauma center – between October 1st 2007 and December 31st 2013. Dog bite patients are included in the trauma database if they are evaluated by the trauma team or arrive to the emergency department (ED) via ambulance. A retrospective chart review was performed on patients in the trauma database. Patient age, gender, race, dog breed and relationship of dog to patient were recorded along with the injury sustained, operative intervention, length of hospital stay (LOS), and complications. Abbreviated Injury Scale (AIS) was assigned based on standard definition [12]. Descriptive statistical analysis was performed.
http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
2
E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
Table 1 Patient characteristics.
Table 3 Body region with most severe injury by AIS.
Variable
N = 282 (%)
Region
N = 282 (%)
Median age [range] Gender Male Female Race Caucasian Hispanic Native American African American Asian Unknown
5 years [2 months to 17 years]
External (skin) Face Extremities/Pelvis Head/neck Abdomen Chest
231 (81.9) 16 (5.65) 16 (5.65) 13 (4.6) 5 (1.8) 1 (0.4)
154 (54.6) 128 (45.4) 135 (47.9) 102 (36.2) 18 (6.4) 17 (6) 2 (0.7) 8 (2.8)
AIS: Abbreviated Injury Scale.
of cases, followed by mixed breeds in 18.2% (2/11) of cases. Pit bulls were also responsible for 38% (11/29) of all head, neck or face bites. The median LOS was one day (range, 0 to 25 days). Seventy-five of 282 (26.6%) patients were discharged from the ED. Five percent (14/282) had complications. The most common complication was infection requiring readmission (n = 6). There were no mortalities.
During the 74 month study period, 650 dog bite incidents were evaluated at our institution, of which 282 met the inclusion criteria. The median age was 5 years (range, 2 months to 17 years). The majority of patients were male and Caucasian, 54.6% and 47.9% respectively (Table 1). The most common months of injury were July and November, during which 24% (67/282) of injuries occurred. The next most common months were August and December, during which 20% (57/282) of injuries occurred. The highest AIS was documented for all patients (Table 2). The anatomical location associated with the highest AIS for each patient is displayed in Table 3. Genitalia were involved in four patients, all of whom were male. Skin injuries were most common and varied: punctures, avulsions, and simple or complex lacerations. Twenty-five patients (8.9%) had fractures associated with their dog bites (Fig. 1). Three of the five skull fractures were depressed, and three of the four forearm fractures were open. Other associated injuries included canilicular or canthal injuries (n = 10), amputations (n = 4, three digits and one ear), intracranial hemorrhage (n = 2), venous injury (n = 2), bilateral orchiectomy (n = 1) and laryngotracheal transection (n = 1). Select cases of severe injuries are summarized below. The majority of patients, 259/282 (91.8%) required intervention for their injuries: 193/282 (68.4%) required an operation and 66 patients (23.4%) were able to undergo suture repair in the emergency department. The remaining 22 patients (7.8%) did not require intervention. Primary laceration repair was the most common operative procedure (184 patients) (Fig. 2). The majority of operative procedures were performed by plastic surgeons 129/193 (66.8%) followed by pediatric surgeons (17.6%), ophthalmologists (10.4%) and hand surgeons (6.2%). Other operating specialists included orthopedics, neurosurgery, otolarngyology and urology. Over half of the dogs belonged to the patients' families or extended families (53%, 150/282). Breakdown of relationships between child and dog is displayed in Fig. 3. There were twenty-eight different dog breeds identified (Table 4). The most common breed was Pit bull at 29.4% (83/282), followed by mixed breeds at 14.2% (40/282). The dog breed was unknown in 24.5% (69/282) of cases. Each of the remaining breeds was responsible for b 4% of incidents. Among the 11 patients with the highest AIS (3–5), Pit bulls were responsible in 45.5% (5/11) Table 2 Highest AIS. Score
Severity
N = 282 (%)
1 2 3 4 5 6
Minor Moderate Serious Severe Critical Unsurvivable
198 (70.2) 73 (25.9) 6 (2.1) 4 (1.4) 1 (0.4) 0 (0)
AIS: Abbreviated Injury Scale.
3.1. Select cases A two month old Hispanic male was in an infant swing on the floor when a Pit bull puppy bit him, resulting in bilateral traumatic orchiectomy. He underwent ligation of the bilateral spermatic cords and debridement and closure of the scrotum. Endocrinology consultation was obtained, and LOS was three days. A nine month old Caucasian female was crawling across the floor when she was bitten by a mixed breed dog. She sustained a scalp laceration with a depressed skull fracture and intracranial hemorrhage. Craniotomy and operative laceration repair were required. LOS was six days. A one year old Caucasian male was playing with a female dog who was in heat. The child was bitten by a male mixed breed dog and sustained the following injuries: complex lacerations to the scalp, face, ear and eyelid; depressed skull fracture; orbital floor fracture; pneumocephaly; CSF leak; subdural hemorrhage; and transverse sinus thrombosis. He underwent a decompressive craniotomy with skull elevation, open reduction and internal fixation of the orbital floor, full thickness eyelid repair and complex facial laceration repair. LOS was 13 days, and the child experienced dysphagia, developmental regression and seizures. A five year old Hispanic male was playing outside when he was bitten by a Pit bull. He suffered from multiple complex facial, neck, back and extremity lacerations as well as laryngotracheal transection. He underwent laryngobronchoscopy, tracheostomy, and repair of the laryngotracheal transection. He also required complex triceps, biceps, and brachialis muscle repair. This involved collaboration between pediatric, plastic, and otolaryngology surgeons. LOS was 25 days, as his course was prolonged by vocal cord paralysis, laryngotracheal stenosis, and dysphagia requiring gastrostomy. 7
6
5
No. of Fractures
3. Results
4
3
2
1
0 Finger
Skull
Forearm
Nasal
Mastoid
Humerus
Metacarpal
Orbital floor
Mandibular
Fig. 1. Fractures associated with dog bites.
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx Elevation of Skull Fracture Skin Grafting 1% 2%
Craniotomy 1%
3
Table 4 Dog breeds.
Other 2%
ORIF 4%
Tissue Transfer 14%
Laceration Repair 76%
Fig. 2. Frequency and type of operative procedures (other: fasciotomy, internal jugular vein repair, tendon repair, facial nerve repair, finger amputation, laryngotracheal repair; ORIF: open reduction internal fixation).
4. Discussion Prior studies in other regions have sought to characterize pediatric dog bite injuries. Some of the largest series have been from Indianapolis and Philadelphia with international contributions from Canada and Austria [1–4]. There were also large series published from Denver and Los Angeles, but these were restricted to facial injuries [13,14]. This report is the first addressing the characteristics of all types of pediatric dog bites in the southwestern US. Results in this series are consistent with prior publications, but do demonstrate some differences in injury patterns and intensity of care required. Demographics were relatively similar between series, with most studies reporting typical age ranges between 5 and 10 years old (though a bit younger average age of 3.9 years in Denver). Most series have demonstrated a greater proportion of male patients, though females were more common in the Denver series and the Canadian and Austrian reports describe equal gender distribution. In all of these large series, the most common locations of injury were extremities or head/face. Since more than one area may be injured, we described our results by listing the body area with the highest AIS.
Unknown/Other 6% Stray 8%
Family Friend 12%
Family 53%
Neighbor 21%
Fig. 3. Relationship of patient to dog (family: immediate and/or extended; Other: one pet store dog, one police dog).
Dog breed
N = 282 (%)
Pit bull Unknown Mixed breed Labrador German shepherd Rottweiler Chow Husky Akita Great dane Chihuahua Australian shepherd Doberman Terrier Boxer Bulldog Basset hound Golden retriever Belgian malinios Shiba inu Weimaraner Rhodesian ridgeback Catahoula hound Alaskan malamute St. Bernard Mastiff Border collie Dalmatian Daschund
83 (29.4) 69 (24.5) 40 (14.2) 10 (3.5) 9 (3.2) 9 (3.2) 9 (3.2) 8 (2.8) 5 (1.8) 5 (1.8) 4 (1.4) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 2 (0.7) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4)
The overall fracture rate in our study was 8.9%, notably higher than other series. Fractures were noted in 1.4% of patients in the series from University of Alberta. In the University of Colorado series of facial dog bites, the incidence was also 1.4%. Of these, nasal bone fractures were the most common at 29%. Even when selecting only for facial injuries, our observed fracture incidence was higher at 4.6%, and we had a slightly higher proportion of skull fractures than nasal fractures. In this series, dogs causing the injury were overwhelmingly familiar with the patient: 53% of dogs belonged to the family, and 33% belonged to neighbors or family friends. This is a theme common to the large series previously published and has critical implications for injury prevention. In our series (as in Philadelphia), Pit bulls were most commonly responsible. Morbidity of these injuries is notable, with over 90% of patients requiring intervention and over two thirds requiring operation. This differs considerably from the other large series, where hospitalization rates ranged from 6% to 27% and need for operation ranged from 4% to 26%. This higher incidence of operative intervention is the most notable difference in our series when compared with the others. This is likely caused by selection bias since our study was limited to the more severe dog bite cases that warranted ambulance transport and/or trauma surgery evaluation. While the number of patients in this series was less than some of the referenced studies, this is the largest series of injuries selected by severity, which allowed a closer examination of the morbidity that can be caused by dog bites and the operative care required. Dog bite injuries at our institution occurred most commonly in July, August, November, and December which differs from all other studies that have the highest rates of injury solely in the summer months. Given the year-round warm climate in the Phoenix area, the increased incidence of dog bites during November and December may be attributable to a combination of weather and winter school breaks [15]. However, the temporal relationship is easily confounded by multiple factors and should not be over-interpreted. In our series, there were four injuries to the genitalia, all in male patients. There are fewer than 30 cases of dog bites to the external genitalia reported in the literature, almost all of which are in male
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
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E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
patients [16]. The high incidence of operation, fractures, and external genitalia wounds raise the possibility of increased severity of injury in our region compared to others. It may also relate to the high percentage of Pit bull involvement in this cohort. In 2008, there were 122,017 licensed dogs in Maricopa County, the most populous county in Arizona [17]. Pit bulls accounted for 6.25% (7,632/122,017) of the licensed dog population, only the seventh most popular breed [17]. Labrador retrievers were the most popular breed accounting for 25.7% (31,377/122,017) followed by German shepherds at 13.8% (16,881/122,017) [17]. It again warrants comment that our patients were selected by severity based on ambulance transport and/or evaluation by the trauma team. There are limitations to this retrospective review, perhaps most notably the selection bias for severe dog bite injuries given the inclusion criteria of patients brought in via ambulance or necessitating trauma team evaluation. In addition, uncertainty in identification of dog breed (unknown in 24.5% of cases) must be considered. Given the recent media coverage of Pit bull attacks in our region, patients and their families may have been more prone to label a culprit dog a “Pit bull.” For these reasons, and the region-specific nature of this study, these findings may not be generalizable to other regions. Pediatric dog bites cause significant morbidity and warrant public education and prevention efforts at the national level, although region specific strategies may be warranted. A 2009 Cochrane review sought to determine the effectiveness of educational interventions targeting pediatric patients with respect to reducing dog bite injuries. There were only two randomized controlled trials included in the review, and neither evaluated the crucial outcome of rates of dog bites [18]. A 2012 study from Johns Hopkins provided dog bite education in the form of an ED kiosk for parents of 901 children. By phone follow-up in two to four weeks, they found the parents did retain some of the information that had been provided [19]. A 2012 study from the University of Cincinnati performed a survey of five to 15 year old patients and their parents in the ED and determined 70% of children had never received dog bite education and 88% of parents wished their child would receive such education [20]. A follow up study in 2013 provided video-based education for five to nine-year olds in the ED and noted a passing score for a dog safety test in 53% of participants prior to the videobased education versus a passing score in 90% after. The majority of parents (93%) supported the education opportunity in the ED [21]. It seems wise for all pediatric institutions to review their dog bite experience so as to tailor education and prevention efforts accordingly. Currently in Maricopa County, all dogs over three months are required to be registered and licensed, and dogs are to be leashed when outside the confines of their property [22]. Safety education opportunities exist for dog owners at the time of registration, for school-aged children and for parents of small children. The American Academy of Pediatrics, the Centers for Disease Control and Prevention and the American Veterinary Medical Association have dog bite prevention recommendations, but the effective dissemination of this educational information is suboptimal [23–25].
5. Conclusion Pediatric dog bites are common and can vary in severity from superficial wounds to life-threatening injuries. A critical implication of our findings is that dog familiarity may confer a false sense of safety. A national dog bite prevention and education campaign that could be adapted at the regional level may have some impact in decreasing the incidence of pediatric dog bites. References [1] 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(2):551–8. [2] Daniels DM, Ritzi RBS, O'Neil J, et al. Analysis of nonfatal dog bites in children. J Trauma Inj Infect Crit Care 2009;66:S17–22. [3] Lang ME, Klassen T. Dog bites in Canadian children: a five-year review of severity and emergency department management. CJEM 2005;5:309–14. [4] Schalamon J, Aionedhofer H, Singer G, et al. Analysis of dog bites in children who are younger than 17 years. Pediatrics 2006;117:374–9. [5] Sacks JJ, Lockwood R, Hornereich J, et al. Fatal dog attacks, 1989–1994. Pediatrics 1996;97:891–5. [6] Reuhl J, Bratzke H, Feddersen-Petersen DU, et al. Death caused by “attack dog” bites. A contribution to current discussion. Arch Kriminol 1998;202:140–51. [7] Marsh L, Langley J, Gauld B. Dog bite injuries. N Z Med J 2004;117:U1043. [8] Kahn A, Bauche P, Lamoureux J. Dog Bites Research Team. Child victims of dog bites treated in emergency departments: a prospective study. Eur J Pediatr 2003;162: 254–8. [9] Gilchrist J, Sacks JJ, White D, et al. Dog bites: still a problem. Inj Prev 2008;14: 296–301. [10] Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51–3. [11] Beck AM, Jones BA. Unreported dog bites in children. Public Health Rep 1985;100: 315–21. [12] Gennarelli TA, Wodzin E, editors. The Abbreviated Injury Scale 2005—update 2008. Barrington, IL: Association for the Advancement of Automotive Medicine; 2008. [13] Wei LA, Chen HH, Hink EM, et al. Pediatric facial fractures from dog bites. Ophthal Plast Reconstr Surg 2013;29:179–82. [14] Chen HH, Neumeier AT, Davies BW, et al. Analysis of pediatric facial dog bites. Craniomaxillofac Trauma Reconstr 2013;6:225–32. [15] Avner JR, Baker DM. Dog bites in urban children. Pediatrics 1991;88:55–7. [16] Bertozzi M, Appignani A. The management of dog bite injuries of genitalia in paediatric age. Afr J Paediatr Surg 2013;10:205–10. [17] Dog Registration in Maricopa County. Dog Licenses by Zip Code. AZ Central, 2012. Web 06 July 2014 http://archive.azcentral.com/pets/datacenter/breeds08.html. [18] Duperrex O, Blackhall K, Mafalda B, et al. Education of children and adolescents for the prevention of dog bite injuries. Cochrane Database Syst Rev 2009;2:CD004726. [19] Shields WC, McDonald EM, Stepnitz R, et al. Dog bites: an opportunity for parent education in the pediatric emergency department. Pediatr Emerg Care 2012;28: 966–70. [20] Dixon CA, Pomerantz WJ, Hart KW, et al. An evaluation of a dog bite prevention intervention in the pediatric emergency department. J Trauma Acute Care Surg 2013;75:S208–12. [21] Dixon CA, Mahabee-gittens EM, Hart KW, et al. Dog bite prevention: a new screening tool. J Pediatr 2012;160:337–41. [22] Control Animal Care. Maricopa County Laws. Maricopa County, n.d. Web. 06 July 2014 http://www.maricopa.gov/pets/laws.aspx. [23] American Academy of Pediatrics. Dog Safety Tips. Available at www.aap.org/en-us/ …/Documents/Dog_Safety_Tips_2010.pdf. [Accessed May 17, 2014]. [24] Centers for Disease Control Prevention. Dog Bite. Available at http://www.cdc.gov/ homeandrecreationalsafety/dog-bites/index.html. [Accessed May 17, 2014]. [25] American Veterinary Medical Association. Dog Bite Prevention. Available at https:// www.avma.org/public/Pages/Dog-Bite-Prevention.aspx. [Accessed May 17, 2014].
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
Contents lists available at ScienceDirect
Journal of Pediatric Surgery journal homepage: www.elsevier.com/locate/jpedsurg
Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center☆ Erin M. Garvey a, Denice K. Twitchell b, Rebecca Ragar b, John C. Egan b, Ramin Jamshidi b,⁎ a b
Division of General Surgery, The Mayo Clinic, 5777 E Mayo Blvd., Phoenix, AZ 85255, USA Pediatric Surgery, Phoenix Children's Hospital, 1920 E Cambridge Ave., Phoenix, AZ 85006, USA
a r t i c l e
i n f o
Article history: Received 8 September 2014 Accepted 9 September 2014 Available online xxxx Key words: Pediatric trauma Dog bite Pit bull Injury prevention Pet safety
a b s t r a c t Background: Pediatric dog bite injuries are common and vary in severity. We sought to characterize predisposing factors, required interventions, and morbidity. Methods: A prospective clinical database at a level one pediatric trauma center was reviewed for dog bite injuries over 74 consecutive months ending December 2013. This included all patients brought in by ambulance and/or seen by the trauma team. Results: Of 650 dog bite incidents, 282 met the criteria for inclusion in the trauma database. Median age was 5 years (range, 2 months to 17 years) and 55% (154/282) of patients were male. Pit bulls were most frequently responsible, accounting for 39% (83/213) of incidents in which dog breed was documented. Fifty-three percent (150/282) of dogs belonged to the patient's immediate or extended family. Sixty-nine percent (194/282) of patients required operative intervention: 76% laceration repairs, 14% tissue transfers, and 2% neurosurgical interventions. The most severe injuries were depressed skull fractures, intracranial hemorrhage, laryngotracheal transection, and bilateral orchiectomy. Median length of stay was 1 day (range, 0 to 25 days). There were no mortalities. Conclusions: Pediatric dog bites span a wide range of ages, frequently require operative intervention, and can cause severe morbidity. Dog familiarity did not confer safety, and in this series, Pit bulls were most frequently responsible. These findings have great relevance for child safety. Summary Statement: Pediatric dog bites are common and can vary in severity from superficial wounds to lifethreatening injuries. Dog familiarity may confer a false sense of safety. A national dog bite prevention and education campaign should be developed with the goal of decreasing the incidence of pediatric dog bites. © 2014 Elsevier Inc. All rights reserved.
Dog bites are common in the United States and internationally, and can result in significant morbidity in pediatric patients [1–4]. Injuries can range from superficial wounds to life-threatening head and neck injuries, and fatalities have been reported [3,5–7]. The psychological insult can result in fear and nightmares and can have an adverse effect on quality of life for both the victim and their family [4,8]. Approximately 4.5 million dog bites occur each year in the US, and children account for half of the cases [9,10]. One study commenting on the unreported rates of dog bites noted a 45% incidence of dog bites in surveyed children [11]. Prior retrospective studies from the northeast and midwest have shown a predilection for male victims in the five to 12 year age range, with injuries frequently occurring during summer months by dogs that are familiar to the child (most commonly Pit bulls) [1,2]. Studies from Austria and Canada also show injuries in a similar age range, during summer months with dogs familiar to the child, though there
☆ Presented at Western Pediatric Trauma Conference July 9–11th, 2014. ⁎ Corresponding author at: Phoenix Children's Hospital, 1920 E Cambridge Ave., Phoenix, AZ 85006, USA. Tel.: + 1 602 254 5561; fax: + 1 602 254 2185. E-mail addresses: [email protected] (E.M. Garvey), [email protected] (R. Jamshidi).
were no gender predispositions, and the most common breeds involved were Rottweilers, German shepherds and Dobermans [3,4]. No such study has been reported in the southwestern United States. The purpose of this study was to characterize the demographics, relevant injuries, and resultant morbidity of dog bites at our institution and to compare our results to the existing literature.
2. Methods Institutional review board approval was obtained. Discharge diagnosis codes were used to determine the total number of dog bite patients evaluated at Phoenix Children's Hospital – a level one pediatric trauma center – between October 1st 2007 and December 31st 2013. Dog bite patients are included in the trauma database if they are evaluated by the trauma team or arrive to the emergency department (ED) via ambulance. A retrospective chart review was performed on patients in the trauma database. Patient age, gender, race, dog breed and relationship of dog to patient were recorded along with the injury sustained, operative intervention, length of hospital stay (LOS), and complications. Abbreviated Injury Scale (AIS) was assigned based on standard definition [12]. Descriptive statistical analysis was performed.
http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051 0022-3468/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
2
E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
Table 1 Patient characteristics.
Table 3 Body region with most severe injury by AIS.
Variable
N = 282 (%)
Region
N = 282 (%)
Median age [range] Gender Male Female Race Caucasian Hispanic Native American African American Asian Unknown
5 years [2 months to 17 years]
External (skin) Face Extremities/Pelvis Head/neck Abdomen Chest
231 (81.9) 16 (5.65) 16 (5.65) 13 (4.6) 5 (1.8) 1 (0.4)
154 (54.6) 128 (45.4) 135 (47.9) 102 (36.2) 18 (6.4) 17 (6) 2 (0.7) 8 (2.8)
AIS: Abbreviated Injury Scale.
of cases, followed by mixed breeds in 18.2% (2/11) of cases. Pit bulls were also responsible for 38% (11/29) of all head, neck or face bites. The median LOS was one day (range, 0 to 25 days). Seventy-five of 282 (26.6%) patients were discharged from the ED. Five percent (14/282) had complications. The most common complication was infection requiring readmission (n = 6). There were no mortalities.
During the 74 month study period, 650 dog bite incidents were evaluated at our institution, of which 282 met the inclusion criteria. The median age was 5 years (range, 2 months to 17 years). The majority of patients were male and Caucasian, 54.6% and 47.9% respectively (Table 1). The most common months of injury were July and November, during which 24% (67/282) of injuries occurred. The next most common months were August and December, during which 20% (57/282) of injuries occurred. The highest AIS was documented for all patients (Table 2). The anatomical location associated with the highest AIS for each patient is displayed in Table 3. Genitalia were involved in four patients, all of whom were male. Skin injuries were most common and varied: punctures, avulsions, and simple or complex lacerations. Twenty-five patients (8.9%) had fractures associated with their dog bites (Fig. 1). Three of the five skull fractures were depressed, and three of the four forearm fractures were open. Other associated injuries included canilicular or canthal injuries (n = 10), amputations (n = 4, three digits and one ear), intracranial hemorrhage (n = 2), venous injury (n = 2), bilateral orchiectomy (n = 1) and laryngotracheal transection (n = 1). Select cases of severe injuries are summarized below. The majority of patients, 259/282 (91.8%) required intervention for their injuries: 193/282 (68.4%) required an operation and 66 patients (23.4%) were able to undergo suture repair in the emergency department. The remaining 22 patients (7.8%) did not require intervention. Primary laceration repair was the most common operative procedure (184 patients) (Fig. 2). The majority of operative procedures were performed by plastic surgeons 129/193 (66.8%) followed by pediatric surgeons (17.6%), ophthalmologists (10.4%) and hand surgeons (6.2%). Other operating specialists included orthopedics, neurosurgery, otolarngyology and urology. Over half of the dogs belonged to the patients' families or extended families (53%, 150/282). Breakdown of relationships between child and dog is displayed in Fig. 3. There were twenty-eight different dog breeds identified (Table 4). The most common breed was Pit bull at 29.4% (83/282), followed by mixed breeds at 14.2% (40/282). The dog breed was unknown in 24.5% (69/282) of cases. Each of the remaining breeds was responsible for b 4% of incidents. Among the 11 patients with the highest AIS (3–5), Pit bulls were responsible in 45.5% (5/11) Table 2 Highest AIS. Score
Severity
N = 282 (%)
1 2 3 4 5 6
Minor Moderate Serious Severe Critical Unsurvivable
198 (70.2) 73 (25.9) 6 (2.1) 4 (1.4) 1 (0.4) 0 (0)
AIS: Abbreviated Injury Scale.
3.1. Select cases A two month old Hispanic male was in an infant swing on the floor when a Pit bull puppy bit him, resulting in bilateral traumatic orchiectomy. He underwent ligation of the bilateral spermatic cords and debridement and closure of the scrotum. Endocrinology consultation was obtained, and LOS was three days. A nine month old Caucasian female was crawling across the floor when she was bitten by a mixed breed dog. She sustained a scalp laceration with a depressed skull fracture and intracranial hemorrhage. Craniotomy and operative laceration repair were required. LOS was six days. A one year old Caucasian male was playing with a female dog who was in heat. The child was bitten by a male mixed breed dog and sustained the following injuries: complex lacerations to the scalp, face, ear and eyelid; depressed skull fracture; orbital floor fracture; pneumocephaly; CSF leak; subdural hemorrhage; and transverse sinus thrombosis. He underwent a decompressive craniotomy with skull elevation, open reduction and internal fixation of the orbital floor, full thickness eyelid repair and complex facial laceration repair. LOS was 13 days, and the child experienced dysphagia, developmental regression and seizures. A five year old Hispanic male was playing outside when he was bitten by a Pit bull. He suffered from multiple complex facial, neck, back and extremity lacerations as well as laryngotracheal transection. He underwent laryngobronchoscopy, tracheostomy, and repair of the laryngotracheal transection. He also required complex triceps, biceps, and brachialis muscle repair. This involved collaboration between pediatric, plastic, and otolaryngology surgeons. LOS was 25 days, as his course was prolonged by vocal cord paralysis, laryngotracheal stenosis, and dysphagia requiring gastrostomy. 7
6
5
No. of Fractures
3. Results
4
3
2
1
0 Finger
Skull
Forearm
Nasal
Mastoid
Humerus
Metacarpal
Orbital floor
Mandibular
Fig. 1. Fractures associated with dog bites.
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx Elevation of Skull Fracture Skin Grafting 1% 2%
Craniotomy 1%
3
Table 4 Dog breeds.
Other 2%
ORIF 4%
Tissue Transfer 14%
Laceration Repair 76%
Fig. 2. Frequency and type of operative procedures (other: fasciotomy, internal jugular vein repair, tendon repair, facial nerve repair, finger amputation, laryngotracheal repair; ORIF: open reduction internal fixation).
4. Discussion Prior studies in other regions have sought to characterize pediatric dog bite injuries. Some of the largest series have been from Indianapolis and Philadelphia with international contributions from Canada and Austria [1–4]. There were also large series published from Denver and Los Angeles, but these were restricted to facial injuries [13,14]. This report is the first addressing the characteristics of all types of pediatric dog bites in the southwestern US. Results in this series are consistent with prior publications, but do demonstrate some differences in injury patterns and intensity of care required. Demographics were relatively similar between series, with most studies reporting typical age ranges between 5 and 10 years old (though a bit younger average age of 3.9 years in Denver). Most series have demonstrated a greater proportion of male patients, though females were more common in the Denver series and the Canadian and Austrian reports describe equal gender distribution. In all of these large series, the most common locations of injury were extremities or head/face. Since more than one area may be injured, we described our results by listing the body area with the highest AIS.
Unknown/Other 6% Stray 8%
Family Friend 12%
Family 53%
Neighbor 21%
Fig. 3. Relationship of patient to dog (family: immediate and/or extended; Other: one pet store dog, one police dog).
Dog breed
N = 282 (%)
Pit bull Unknown Mixed breed Labrador German shepherd Rottweiler Chow Husky Akita Great dane Chihuahua Australian shepherd Doberman Terrier Boxer Bulldog Basset hound Golden retriever Belgian malinios Shiba inu Weimaraner Rhodesian ridgeback Catahoula hound Alaskan malamute St. Bernard Mastiff Border collie Dalmatian Daschund
83 (29.4) 69 (24.5) 40 (14.2) 10 (3.5) 9 (3.2) 9 (3.2) 9 (3.2) 8 (2.8) 5 (1.8) 5 (1.8) 4 (1.4) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 3 (1.1) 2 (0.7) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4) 1 (~0.4)
The overall fracture rate in our study was 8.9%, notably higher than other series. Fractures were noted in 1.4% of patients in the series from University of Alberta. In the University of Colorado series of facial dog bites, the incidence was also 1.4%. Of these, nasal bone fractures were the most common at 29%. Even when selecting only for facial injuries, our observed fracture incidence was higher at 4.6%, and we had a slightly higher proportion of skull fractures than nasal fractures. In this series, dogs causing the injury were overwhelmingly familiar with the patient: 53% of dogs belonged to the family, and 33% belonged to neighbors or family friends. This is a theme common to the large series previously published and has critical implications for injury prevention. In our series (as in Philadelphia), Pit bulls were most commonly responsible. Morbidity of these injuries is notable, with over 90% of patients requiring intervention and over two thirds requiring operation. This differs considerably from the other large series, where hospitalization rates ranged from 6% to 27% and need for operation ranged from 4% to 26%. This higher incidence of operative intervention is the most notable difference in our series when compared with the others. This is likely caused by selection bias since our study was limited to the more severe dog bite cases that warranted ambulance transport and/or trauma surgery evaluation. While the number of patients in this series was less than some of the referenced studies, this is the largest series of injuries selected by severity, which allowed a closer examination of the morbidity that can be caused by dog bites and the operative care required. Dog bite injuries at our institution occurred most commonly in July, August, November, and December which differs from all other studies that have the highest rates of injury solely in the summer months. Given the year-round warm climate in the Phoenix area, the increased incidence of dog bites during November and December may be attributable to a combination of weather and winter school breaks [15]. However, the temporal relationship is easily confounded by multiple factors and should not be over-interpreted. In our series, there were four injuries to the genitalia, all in male patients. There are fewer than 30 cases of dog bites to the external genitalia reported in the literature, almost all of which are in male
Please cite this article as: Garvey EM, et al, Morbidity of pediatric dog bites: A case series at a level one pediatric trauma center, J Pediatr Surg (2014), http://dx.doi.org/10.1016/j.jpedsurg.2014.09.051
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E.M. Garvey et al. / Journal of Pediatric Surgery xxx (2014) xxx–xxx
patients [16]. The high incidence of operation, fractures, and external genitalia wounds raise the possibility of increased severity of injury in our region compared to others. It may also relate to the high percentage of Pit bull involvement in this cohort. In 2008, there were 122,017 licensed dogs in Maricopa County, the most populous county in Arizona [17]. Pit bulls accounted for 6.25% (7,632/122,017) of the licensed dog population, only the seventh most popular breed [17]. Labrador retrievers were the most popular breed accounting for 25.7% (31,377/122,017) followed by German shepherds at 13.8% (16,881/122,017) [17]. It again warrants comment that our patients were selected by severity based on ambulance transport and/or evaluation by the trauma team. There are limitations to this retrospective review, perhaps most notably the selection bias for severe dog bite injuries given the inclusion criteria of patients brought in via ambulance or necessitating trauma team evaluation. In addition, uncertainty in identification of dog breed (unknown in 24.5% of cases) must be considered. Given the recent media coverage of Pit bull attacks in our region, patients and their families may have been more prone to label a culprit dog a “Pit bull.” For these reasons, and the region-specific nature of this study, these findings may not be generalizable to other regions. Pediatric dog bites cause significant morbidity and warrant public education and prevention efforts at the national level, although region specific strategies may be warranted. A 2009 Cochrane review sought to determine the effectiveness of educational interventions targeting pediatric patients with respect to reducing dog bite injuries. There were only two randomized controlled trials included in the review, and neither evaluated the crucial outcome of rates of dog bites [18]. A 2012 study from Johns Hopkins provided dog bite education in the form of an ED kiosk for parents of 901 children. By phone follow-up in two to four weeks, they found the parents did retain some of the information that had been provided [19]. A 2012 study from the University of Cincinnati performed a survey of five to 15 year old patients and their parents in the ED and determined 70% of children had never received dog bite education and 88% of parents wished their child would receive such education [20]. A follow up study in 2013 provided video-based education for five to nine-year olds in the ED and noted a passing score for a dog safety test in 53% of participants prior to the videobased education versus a passing score in 90% after. The majority of parents (93%) supported the education opportunity in the ED [21]. It seems wise for all pediatric institutions to review their dog bite experience so as to tailor education and prevention efforts accordingly. Currently in Maricopa County, all dogs over three months are required to be registered and licensed, and dogs are to be leashed when outside the confines of their property [22]. Safety education opportunities exist for dog owners at the time of registration, for school-aged children and for parents of small children. The American Academy of Pediatrics, the Centers for Disease Control and Prevention and the American Veterinary Medical Association have dog bite prevention recommendations, but the effective dissemination of this educational information is suboptimal [23–25].
5. Conclusion Pediatric dog bites are common and can vary in severity from superficial wounds to life-threatening injuries. A critical implication of our findings is that dog familiarity may confer a false sense of safety. A national dog bite prevention and education campaign that could be adapted at the regional level may have some impact in decreasing the incidence of pediatric dog bites. References [1] 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(2):551–8. [2] Daniels DM, Ritzi RBS, O'Neil J, et al. Analysis of nonfatal dog bites in children. J Trauma Inj Infect Crit Care 2009;66:S17–22. [3] Lang ME, Klassen T. Dog bites in Canadian children: a five-year review of severity and emergency department management. CJEM 2005;5:309–14. [4] Schalamon J, Aionedhofer H, Singer G, et al. Analysis of dog bites in children who are younger than 17 years. Pediatrics 2006;117:374–9. [5] Sacks JJ, Lockwood R, Hornereich J, et al. Fatal dog attacks, 1989–1994. Pediatrics 1996;97:891–5. [6] Reuhl J, Bratzke H, Feddersen-Petersen DU, et al. Death caused by “attack dog” bites. A contribution to current discussion. Arch Kriminol 1998;202:140–51. [7] Marsh L, Langley J, Gauld B. Dog bite injuries. N Z Med J 2004;117:U1043. [8] Kahn A, Bauche P, Lamoureux J. Dog Bites Research Team. Child victims of dog bites treated in emergency departments: a prospective study. Eur J Pediatr 2003;162: 254–8. [9] Gilchrist J, Sacks JJ, White D, et al. Dog bites: still a problem. Inj Prev 2008;14: 296–301. [10] Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51–3. [11] Beck AM, Jones BA. Unreported dog bites in children. Public Health Rep 1985;100: 315–21. [12] Gennarelli TA, Wodzin E, editors. The Abbreviated Injury Scale 2005—update 2008. Barrington, IL: Association for the Advancement of Automotive Medicine; 2008. [13] Wei LA, Chen HH, Hink EM, et al. Pediatric facial fractures from dog bites. Ophthal Plast Reconstr Surg 2013;29:179–82. [14] Chen HH, Neumeier AT, Davies BW, et al. Analysis of pediatric facial dog bites. Craniomaxillofac Trauma Reconstr 2013;6:225–32. [15] Avner JR, Baker DM. Dog bites in urban children. Pediatrics 1991;88:55–7. [16] Bertozzi M, Appignani A. The management of dog bite injuries of genitalia in paediatric age. Afr J Paediatr Surg 2013;10:205–10. [17] Dog Registration in Maricopa County. Dog Licenses by Zip Code. AZ Central, 2012. Web 06 July 2014 http://archive.azcentral.com/pets/datacenter/breeds08.html. [18] Duperrex O, Blackhall K, Mafalda B, et al. Education of children and adolescents for the prevention of dog bite injuries. Cochrane Database Syst Rev 2009;2:CD004726. [19] Shields WC, McDonald EM, Stepnitz R, et al. Dog bites: an opportunity for parent education in the pediatric emergency department. Pediatr Emerg Care 2012;28: 966–70. [20] Dixon CA, Pomerantz WJ, Hart KW, et al. An evaluation of a dog bite prevention intervention in the pediatric emergency department. J Trauma Acute Care Surg 2013;75:S208–12. [21] Dixon CA, Mahabee-gittens EM, Hart KW, et al. Dog bite prevention: a new screening tool. J Pediatr 2012;160:337–41. [22] Control Animal Care. Maricopa County Laws. Maricopa County, n.d. Web. 06 July 2014 http://www.maricopa.gov/pets/laws.aspx. [23] American Academy of Pediatrics. Dog Safety Tips. Available at www.aap.org/en-us/ …/Documents/Dog_Safety_Tips_2010.pdf. [Accessed May 17, 2014]. [24] Centers for Disease Control Prevention. Dog Bite. Available at http://www.cdc.gov/ homeandrecreationalsafety/dog-bites/index.html. [Accessed May 17, 2014]. [25] American Veterinary Medical Association. Dog Bite Prevention. Available at https:// www.avma.org/public/Pages/Dog-Bite-Prevention.aspx. [Accessed May 17, 2014].
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