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| CASE REPORT |
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| Year : 2023 | Volume
: 4
| Issue : 1 | Page : 57-60 |
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Elephant attack survivor - A case report with review of literature
Awaneesh Katiyar, Ajay Kumar
Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| Date of Submission | 16-Apr-2021 |
| Date of Decision | 09-Jul-2022 |
| Date of Acceptance | 22-Oct-2022 |
| Date of Web Publication | 26-Apr-2023 |
Correspondence Address:
Dr. Awaneesh Katiyar
Department of Trauma Surgery and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JME.JME_36_21
How to cite this article:
Katiyar A, Kumar A. Elephant attack survivor - A case report with review of literature. J Med Evid 2023;4:57-60 |
| Introduction | |  |
An elephant is a social animal, but it can kill any animal on the land, the elephant attacks other animals for their protection. We are presenting a rare case of an elephant attack survivor. In India, elephant attacks are not rare; usually, after reviewing the literature, elephant attacks against humans are lethal.[1] Survivor after severe trauma is rare; most die at the scene, others in the hospital.
| Case Report | | |
A 75-year-old male presented to the trauma emergency department; with history of elephant attack. At the time of presentation in the emergency, the patient was breathless with respiratory rate 36 breaths / min, pulse 110 beats/min, blood pressure 96/48, SpO2 72% at room air, the Glasgow Coma Scale was E3V4M5, left lateral chest was moving paradoxically with respiration [Video 1] [Additional file 1]. Arterial blood gas analysis showed pH 7.29, partial pressure of carbon dioxide 58 mmHg, partial pressure of oxygen 90 mmHg, bicarbonate 28 base deficit 14 mmol/L and lactate 3.2 mmol/L. The patient was put on 12 L/min moist O2 inhalation with a non-rebreathing mask, but the patient could not maintain saturation above 80%. Hence, the patient was put on BiPAP non-invasive ventilation and SpO2 improved to 95%. There was no fluid in the peritoneal cavity or pleural cavity, no signs of head injury, pelvic fracture or long bone fracture on ultrasonographic evaluation. The patient did not have a history of comorbidities such as diabetes mellitus and chronic obstructive pulmonary disease. Blood investigation revealed Hb-9.6 grams/dL, total leucocyte counts 5600, S. creatinine 0.98 mg/dL and S. urea 25 mg/dL, other parameters were within normal limit. After resuscitation, patient underwent contrast enhanced computed tomography (CECT), CECT was suggestive of left-sided hemothorax with multiple displaced fractured ribs [Figure 1], the patient planned for surgery.
Arterial blood gas showed, hypoxemia and hypercarbia, the patient was intubated and put in assisted control ventilation. Cefazolin 2 g intravenous (IV), amikacin 750 mg IV and tetanus toxoid intramuscular were given for empiric coverage. The patient shifted to the operation theatre after a pre-operative assessment.
Ribs were exposed by giving two incisions on the left chest in the lateral left up position. Fractured ribs were identified, and displaced ends were reduced and fixed with reconstruction plates and stainless steel wire [Figure 2]. Chest tube was placed in the pleural cavity after the fixation of the ribs, wound was closed in a single layer of interrupted sutures. The intercostal muscles spared and wound closed with fascia and skin.
The patient was shifted to the intensive care unit and extubated after 12 h of surgery. Chest physiotherapy was started on day 1.Chest physiotherapy with incentive spirometer was started on day one of surgery. Intercostal drain (ICD) output was 300ml (serosanguinous) on day one, drain output slowly reduced to 50 ml on day five, the intercostal tube was removed on day five and the wound was healthy and discharged on a postoperative day six.
Follow-up
After the 7th day of follow-up, the patient had had a surgical site infection, and a 5-cm wound gap was noted. The rest of the wound was healthy, and the sutures were removed. The patient was re-admitted, pus was sent for culture and sensitivity, the wound was washed with warm normal saline and the plates were exposed, but there was no active air leak from the wound and screws were fixed [Figure 3]a. Pus report showed Staphylococcus aureus, sensitive to amoxicillin and clavulanic acid. The dressing was continued for 5 days, and the wound became healthy. On day 5 of the re-admission, the wound was closed with a non-absorbable monofilament suture (nylon 2-0) to provide better strength to the wound [Figure 3]b. The patient was discharged on oral antibiotics and reviewed on the 7th day, the wound was healthy and the suture was removed on the 10th day [Figure 4]. On monthly follow-up till 1 year, there were no complaints. | Figure 3: (a) Surgical site infection – wound gap, (b) wound closure under negative pressure on 5th day
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| Discussion | | |
Elephant attacks away from their niche are rare. Such accidents are common in zoos, circuses and nearby territory of forests where humans are invading their natural habitats.[2] Elephant aggressive at 15-20 years of their age; at this age, elephants become dangerous because of their behaviour change; these bull elephants are known as “musth.” Elephant attack is always considered a significant trauma; management protocol is the same as per Advanced Trauma Life Support (ATLS) protocol. Identify and treat the life-threatening injury first, then identify other associated injuries. In India, animal attacks are frequent in hilly or rural areas where healthcare facilities are deficient. Most of the victims die on the way before they receive definitive care.[3] Management of such patients requires deep clinical acumen and keeping a high index of suspicion in the emergency room for underlying dangerous life or limb-threatening injuries. Das et al. from India reported 14 deaths by elephant attacks; 12 died due to trampling over the chest and two over the head without other footmarks over the body.[4] According to a case report by Hejna et al. from the Czech Republic, none of them had a tusk injury, where a chronically ill female elephant attacked the elephant keeper.[1] Keeper tripped down under her feet, and she attacked him with tusks till death. The young man usually sustains severe trauma compared to females and elderly because of their aggressive fighting tendency.[4],[5] Elephants attack the torso more frequently than the extremities, face or head.[6]
On PubMed Advanced search using keywords-'elephant' AND 'attack' AND 'injury', we found 47 articles. Forty-two related to the incidence of wild attacks, behavior and pattern of elephant attacks, wild animal-related deaths and post mortem etc. Five research articles (7 patients) were related to elephant attacks having chest trauma with other injuries, those who were brought to the hospital [Table 1]. Out of seven patients, two patients died (polytrauma) immediately after arrival. Three patients had isolated chest injuries and two (polytrauma) patients had severe injuries but survived after multiple surgeries. Chest trauma is a common injury and is associated with multiple ribs fracture. A number of displaced ribs fractured is directly proportional to increased complications, e.g., underlying lung contusion and lacerations. Lung lacerations are usually lethal due to massive haemothorax or tension pneumothorax.[7] Flail chest with underlying contusion increases mortality of the patient. Surgical fixation of ribs is a newer treatment modality for flail chest and severely displaced ribs fracture.[8] Due to the failure of non-operative intervention, there has been growing interest in operative treatment for multiple rib fractures and flail chests. Few studies suggested that the surgical treatment of flail chest patients reduces the length of hospital stay, intensive care stay, mechanical ventilation days, mortality and rate of pneumonia.[9] Surgical site infection, implant failure, implant infection and causalgia are specific complications of surgery. Persistent pus discharge, implant failure, persistent pain, implant-related sepsis or infection are the indications of removal of implant.[10] More randomised controlled trials on methods, indications and related complications are required to adopt surgical fixation as a treatment modality in multiple rib fracture cases.[11] Early surgical fixation of the rib can be a life-saving intervention for a flail chest with non-compliant chest recoil and loss of chest integrity. Chest trauma is the 2nd leading cause of death following trauma and is mostly due to respiratory complications. These lethal complications can be avoided if anatomy and physiology are restored as early as possible. From the author's point of view, early fixation on the gross flail chest can be a life-saving intervention.
| Conclusion | | |
The patient should be managed as per ATLS guidelines, and life-threatening injuries should be managed first. Elephant attacks should always be considered a dangerous mechanism of injury and evaluated accordingly. In severe chest trauma (flail chest and intrusion of fractured ribs), surgical fixation of ribs can provide early recovery and better outcomes.
Key messages
- Elephants attacks can be avoided by teaching people in affected areas
- The patient should be managed according to ATLS protocol – threatening life injuries should be treated first
- Appropriate treatment should not be biased by distracting injuries
- Early surgical fixation of ribs can be a good modality of treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Hejna P, Zátopková L, Safr M. A fatal elephant attack. J Forensic Sci 2012;57:267-9.  |
| 2. | Fowler M, Mikota SK. Biology, medicine, and surgery of elephants. Can Vat J 2008;49:45. |
| 3. | Yadav SK, Shrestha S, Sapkota SM. Rogue-elephant-inflicted panfacial injuries: A rare case report. Case Rep Dent 2012;2012:127957. |
| 4. | Das SK, Chattopadhyay S. Human fatalities from wild elephant attacks – A study of fourteen cases. J Forensic Leg Med 2011;18:154-7. |
| 5. | Durrheim DN, Leggat PA. Risk to tourists posed by wild mammals in South Africa. J Travel Med 1999;6:172-9. |
| 6. | Perera BM. The human-elephant conflict: A review of current status and mitigation methods. Gajah 2009;30:41-52. |
| 7. | Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: The deadly dozen. Crit Care Nurs Q 2005;28:22-40. |
| 8. | de Moya M, Nirula R, Biffl W. Rib fixation: Who, what, when? Trauma Surg Acute Care Open 2017;2:e000059. |
| 9. | Swart E, Laratta J, Slobogean G, Mehta S. Operative treatment of rib fractures in flail chest injuries: A meta-analysis and cost-effectiveness analysis. J Orthop Trauma 2017;31:64-70. |
| 10. | Haseeb M, Butt MF, Altaf T, Muzaffar K, Gupta A, Jallu A. Indications of implant removal: A study of 83 cases. Int J Health Sci (Qassim) 2017;11:1-7. |
| 11. | Senekjian L, Nirula R. Rib fracture fixation: Indications and outcomes. Crit Care Clin 2017;33:153-65. |
| 12. | Singh PK, Ali SM, Sethi M, Manohar DB. Injuries in survivors of elephant attack: Report of three cases. Chinese journal of traumatology 2021;24:394-6. |
| 13. | Syahmi WM, Mafauzy MM, Baharuddin KA, Ikhwan SM, Sayuti KA. Elephant attack-A rare case of survival. The Medical Journal of Malaysia. 2021;76:741-3. |
| 14. | Heger A, Schwarz CS, Krauskopf A, Heinze S. Fatal attack on a pedestrian by an escaped circus elephant. Forensic science international 2019;300:e1-3. |
| 15. | Tsung AH, Allen BR. A 51-year-old woman crushed by an elephant trunk. Wilderness & Environmental Medicine 2015;26:54-8. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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