Survival of child after lion attack
A local newspaper wrote, “According to the owner of the circus, a lion became excited by the noise of the audience during the evening show, escaped from its unlocked cage and attacked an eight-year-old boy. The victim was dragged about twenty feet. The four-year-old lion was called ‘Bang-Bang’ and weighed about 200 kg” []. The patient was sent to a rural hospital (approximately 150 km from the capital city) and was transferred to our hospital almost 5 hours after the attack.\nUpon arrival to the emergency room, the patient was in poor condition: Extremely pale, no arterial pressure, semiobstructed airway, breathing difficulty, and unstable vital parameters (heart rate, 170 beats per minute; respiratory rate, 34 breaths per minute; Glasgow Coma Scale (GCS), 5/15 points; and hemoglobin, 5.5 g/dL). Orotracheal intubation was performed immediately.\nThe results of the clinical examination were as follows:\nHead and neck: Multiple scalp wounds, with profuse bleeding; extensive bilateral fronto-parieto-temporal injury with brain matter escaping through perforations caused by the bite; right ocular globe with hyperemia, enlarged right pupil (8 mm), and upper and lower eyelid edema; wound at level of left orbit; and bleeding neck wound Chest: Open wound on left side, measuring approximately 15 cm; fractures of the fourth, fifth, and sixth costal arches; muscle, pericardium, and mediastinum exposed; dullness upon percussion; decreased breathing sounds on left side; and collapsed left lung Abdomen: Open wound in the left infraumbilical region, measuring 9 cm, with irregular edges; reduced bowel sounds; and abdomen taut upon palpation Extremities: No injuries.\nHe received 2 L of normal saline and 2 U of whole blood through two large bore peripheral intravenous line and vitamin K, improving his vital signs. In the initial cranial computed tomography (CT) scan, severe trauma was predominantly seen to the left of the skull, including dislocated fractures. Intracranial injuries with areas of intracerebral contusion and bleeding as well as subdural air accumulation in the areas where the lion's canines penetrated the skull were found [].\nThe child was sent directly to the surgical ward, received tetanus toxoid and then postexposure rabies prophylaxis, and was assisted by the medical team (pediatric surgeon, neurosurgeon, and cardiovascular surgeon).\nThe following procedures were performed:\nHead: Surgical cleaning and detailed washing with normal saline and povidone iodine were performed throughout the extensive scalp injury, followed by the control of bleeding. Multifragment fracture of the left parietal bone, with depression and exposure of the brain matter through orifices situated at the bifrontal, biparietal, and occipital levels was found []. Small bone fragments were removed from the left parietal region, along with protruding injured extradural brain tissue. Only hemostasis was performed due to the hemodynamic instability with hypovolemic shock Chest: Surgical cleaning of thorax and thoracotomy, evidencing three rib fractures, no injuries to the lungs, pericardium, or diaphragm; chest tube left connected to water-sealed flask; left chest tube returned 400 mL of fresh red blood Abdomen: Median, supraumbilical, and infraumbilical laparotomy, revealing abundant free-moving milky fluid in abdominal cavity and swollen intestinal rings; cavity inventory performed, revealing absence of visceral injuries; laparotomy left contained with bag and compresses.\nThe patient was admitted to the intensive care unit under mechanical ventilation with sedation and analgesia (heart rate, 115 beats per minute; blood pressure, 100/70 mmHg; GCS, 4/15 points) []. Cefotaxime, cloxacillin, metronidazole, 20% mannitol, and phenytoin were initiated parenterally. The ophthalmological evaluation discarded injury to the left ocular globe.\nOn the fourth postoperative day (GCS, 6/15 points; left brachiocrural hemiparesis, 3/5), the patient progressed with fever and right basal pneumonia. New antibiotic therapy was instituted (ceftazidime, vancomycin, and metronidazole), followed by the closure of abdominal cavity.\nOn the sixth postoperative day (GCS, 10/15 points), mechanical ventilation and chest drainage were removed and 20% mannitol was suspended. Blood derivative products (packed red blood cells and fresh frozen plasma) were used because of low prothrombin time (52%) and thrombocytopenia.\nOn the ninth postoperative day (GCS, 12/15 points), Acinetobacter baumannii and Pseudomona aeruginosa were isolated from sputum/tracheal secretions. The patient was sensitive to imipenem and amikacin; hence, the consequent change of antibiotic. An occurrence of cerebrospinal fluid fistula in the left parietal region was found.\nOn the twelfth postoperative day, in the operating room, the correction of occipital depressed fracture and hermetic closure of the dura defect in the parietal region, with free autologous periosteal graft, was performed using interrupted 3-0 absorbable sutures.\nOn the fifteenth postoperative day (GCS, 14/15 points), the child was discharged from the intensive care unit. During his hospital stay, he presented behavioral disorders (obsessive–compulsive disorder and panic attacks) and was treated with clomipramine and clonazepam. Seven months later, he developed amblyopia without other neurological deficit.