Article

An urban Northeastern United States alligator bite

American Journal of Emergency Medicine 32 (2014) 487.e1-487.e3

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American Journal of Emergency Medicine

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Case Report

An urban Northeastern United States alligator bite?

Abstract

Individuals who live and work in the Southeastern coastal range of the 3 US crocodilian carnivores, American alligators, American crocodiles, and caiman, understand the risks of reptile-human encounters. Individuals who live in other parts of the country may be exposed through contact with exotic pets at private homes, small menageries, or petting zoos or from escaped or abandoned animals. During these encounters, individuals may be severely injured. Emergency medical services, law enforcement, and animal welfare workers in nonhabitat areas are usually not trained in the handling and safe removal of injured individuals from the scene when the reptile is present. The emergency management of large crocodilian injuries is similar to that of other major trauma; however, providers also must take into consideration the significant crush component potentially inflicted by the tremendous bite power and shaking inflicting during attacks by these large reptiles, appropriate antibiotic coverage for less common organisms that inhabit their mouths, and management of possible psychological distress, including posttrau- matic stress disorder produced by such an unusual attack. Emergency physicians should support the development of a readily available National database of scientifically collect information on attacks to inform appropriate care and support efforts to explore responsible measures that the USDA Animal and Plant Health Inspection Service and other appropriate local, state, and federal agencies can take to ensure ethical and biologically sustainable management of our large reptiles, which also helps to ensure the safety of the public.

A 40-year-old man was evaluated in our urban Northeastern US emergency department for injuries to his hand. One hour prior, he had been swimming at a friend’s evening pool party and noted sharp pain in his thumb. He looked in the water and saw blood and an object moving, which was a 1.5- to 2-ft-long alligator. He left the water and informed his host, who removed the pet alligator. No other swimmers were bitten. The police were not notified.

He was otherwise healthy and on no medications. His examination revealed normal vital signs and several small puncture wounds, a small skin avulsion, and three 1.5- to 2.5-cm-long superficial lacerations, without obvious foreign body or active bleeding, on the thumb and thenar eminence of his dominant right hand (see Figs. 1

? Conflict of interest statement: This work has not been formally presented. This case report is not under consideration for publication elsewhere and will not be published while under consideration by the American Journal of Emergency Medicine. The authors attest that no financial assistance was received to support the writing of this case report, and no affiliations or relationships or conflict of interests exist that would influence the opinions stated in this article. All authors have made substantive contributions to the study, and all authors endorse the conclusions. No writing assistance was received.

and 2). Motor strength, sensation, temperature, capillary refill, and pulses were intact. The wounds were carefully inspected, vigorously irrigated, and cleansed and dead tissue was debrided. Radiography identified no foreign body or fracture. The wounds were not closed. His tetanus immunization was up to date. The patient received trimethoprim-sulfamethoxazole and cephalexin and was placed on a 7-day course of both. Public health and law enforcement were notified. At his 2-day recheck, the wounds were healing well, and normal hand function was present. The alligator had been removed by animal management.

Three crocodilian species inhabit the United States, with the American alligator (Alligator mississippiensis) the most common (see Figs. 3 and 4). Alligators live in most southern states, primarily in Florida and Louisiana. Because of strong recovery after dwindling populations were classified as endangered in the 1950s, in 1987, alligators were declassified. Occasional sightings in other states represent released pets or animals straying from their normal range. Alligators are not found naturally in more northern states because they are ectothermic [1,2]. The American crocodile (Crocodylus acutus) and nonnative caiman (Caiman crocodilus) inhabit southern Florida [3,4]. Alligators average 8 ft (females) to 11 ft (males); however, males can reach 19 ft and 1000 lb. These agile, stealthy carnivores exert tremendous bite power (2000 + PSI), rolling and head shaking on attack [5-9]. Worldwide, hundreds of deaths occur from crocodilian attacks [10-12]. As more individuals live or vacation

Fig. 1. Punctures, small skin avulsion, and superficial lacerations inflicted by a juvenile American alligator. Photograph courtesy of Dr Suzanne M. Shepherd, MD, DTM&H, Hospital of the University of Pennsylvania.

0735-6757/$ – see front matter (C) 2014

487.e2 S.M. Shepherd, W.H. Shoff / American Journal of Emergency Medicine 32 (2014) 487.e1487.e3

Fig. 4. Juvenile American alligators of approximately the same size as the alligator that bit this patient. Photograph courtesy of Dr Suzanne M. Shepherd, MD, DTM&H, Hospital of the University of Pennsylvania.

Fig. 2. Punctures, small skin avulsion, and superficial lacerations inflicted by a juvenile American alligator. Photograph courtesy of Dr Suzanne M. Shepherd, MD, DTM&H, Hospital of the University of Pennsylvania.

in coastal southern states, human-alligator interactions have in- creased significantly. Alligators become habituated to humans fairly quickly, especially with food present. Thousands of nuisance com- plaints and about a dozen human attacks are reported yearly [13], but reporting is not mandatory. Langley [1] examined wildlife service data from 12 states (1928-2008) and reported 567 cases of adverse encounters with wild alligators, with 529 resulting in injury, including 24 fatalities (4.5%; 22 in Florida). Injuries, largely single bites, were reported in water and on land in individuals of all ages, with whites and males most commonly injured. No crocodile or caiman cases were reported [1].

Extensive injury may occur, with reported injuries ranging from abrasions, punctures, and lacerations to fractures, crush, and tearing injuries with significant tissue loss, amputations, head and neck

Fig. 3. Adult American alligator (Alligator mississippiensis) in natural habitat in Florida. Photograph courtesy of Dr Suzanne M. Shepherd, MD, DTM&H, Hospital of the University of Pennsylvania.

injuries, internal injuries, and death [12,14-21]. Immediate manage- ment includes thorough evaluation and debridement of wounds, evaluation for potential serious underlying tissue injuries, fracture management, restoration of vascular, nerve and tendon integrity, and tetanus and prophylactic broad spectrum antibiotic use. A number of aerobic and anaerobic bacteria and fungal species have been cultured from alligator mouths and wounds. Flandry et al [22] cultured more than 38 species from A mississippiensis, including Aeromonas hydro- phila; Vibrio spp, including Vibrio vulnificus; Citrobacter freundii; Bacteroides oralis; Proteus vulgaris; Pseudomonas spp; Clostridium bifermentans; Bacteroides bivius; Fusobacterium varium; Peptococcus prevotii; and Clostridium tetani. Additionally reported are Salmonella spp, Enterobacter agglomerans, Citrobacter diversus [23-32], and Serratia spp and Burkolderia pseudomallei from Australian salt water crocodiles [10]. Infection can progress quickly and includes cellulitis, vesicle and bulla formation, tissue necrosis, pneumonia, and sepsis. If pneumonia develops, consider Pseudoallescheria boydii and add voriconazole [28,33,34]. Appropriate antibiotic therapy may include a fluoroquino- lone or third-generation or extended action cephalosporin plus clindamycin, trimethaprim-sulfamethoxazole, or carbapenems [28,29]. Public health and animal management must be notified. Close follow-up is warranted, including evaluation for possible psychological sequelae, including posttraumatic stress disorder.

Registering crocodilian ownership is not mandated, nor are their

requirements for safe housing of these potentially dangerous reptiles. Owners may experience difficulty disposing of pets when they become larger and more dangerous. Emergency services providers and law enforcement working in states outside of the natural habitat of crocodilians may not be trained to safely remove injured individuals and secure the scene. Emergency care providers in nonendemic areas are not used to evaluating crocodilian injuries. Like other large carnivorous exotic pets, the Animal and Plant Inspection Service of the United States Department of Agriculture should address responsible, sustainable, and ethical management and conservation of these large reptiles. These authors support previous suggestions that a uniform reporting system be developed to obtain appropriate information about alligator encounters and to inform optimal injury management [1,35].

Suzanne Moore Shepherd, MD, DTM&H William H. Shoff, MD, DTM&H Department of Emergency Medicine University of Pennsylvania Health System

Philadelphia, PA 19106, USA E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.11.004

S.M. Shepherd, W.H. Shoff / American Journal of Emergency Medicine 32 (2014) 487.e1487.e3 487.e3

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