(P53) A Dog Bite to Remember (Acute Limb Ischemia After a Dog Bite)

Chief Complaint : I was attacked by my dog after he got startled while my boyfriend and I were having a fight. He bit me everywhere.

History of Present Illness : Patient is a 28-year-old female with no past medical history who presents to the emergency department after sustaining multiple bite wounds one hour ago. She states that her Pitbull is easily startled, about an hour ago while she was having a fight with her boyfriend, the dog became startled and proceeded to bite her on her right arm, left abdominal region, and mid-gluteal region. Per patient the dog is not vaccinated for rabies or other shots. The patient is not up to date on her tetanus vaccine/booster. She currently endorses significant pain in her right upper extremity with associated numbness and paresthesias in her right hand. The patient currently denies any foreign body sensation but also states that she “can’t feel much” on her right upper extremity. Otherwise not on any anticoagulation, no history of diabetes or immunocompromised state. No allergies to medications.

Pertinent Physical Exam: Skin: Elliptical 6 cm laceration on the flexor surface of the distal right upper arm with fat protrusion and visible underlying muscle belly. Other multiple superficial lacerations in the right antecubital/proximal forearm region. Superficial 0.5cm laceration on the palmar aspect of the 2nd right finger. Other superficial skin abrasions in the left upper quadrant and above the gluteal cleft.
MSK/Extremities: Significantly diminished right radial pulse. Decreased sensation in the right first three digits distribution of the median nerve, with decreased range of motion and weakness in the right hand.

Pertinent Laboratory Data: CT Angiogram of the Right Upper extremity w/ and w/o contrast: Soft tissue wound of the right arm with soft tissue emphysema. Occlusion of the mid to distal Brachial Artery with reconstitution of flow at the origin of the radial and ulnar arteries.

Case Discussion: This patient presented to our emergency department after sustaining multiple dog bites, which is a somewhat common and low acuity chief complaint. This case emphasizes the importance of obtaining a good history and physical exam as well as always considering the most emergent scenarios even when it comes to chief complaints that seem lower acuity. With her complaints of severe pain and paresthesias in her upper extremity, acute limb ischemia was of high concern and the next step was to perform a neurovascular exam. When it was found that the patient had a significantly weak radial pulse and median nerve damage, vascular surgery was urgently consulted, and CT Angiogram was performed which demonstrated occlusion of the brachial artery. The patient was shortly after taken to the OR where a brachial-brachial artery bypass was successfully performed using the saphenous vein due to the extent of damage to the brachial artery. Fortunately, after intervention the patient had good neurovascular outcomes and almost complete functional recovery of her right upper extremity. This emphasizes the importance of recognizing early signs and symptoms of acute limb ischemia. Especially since odds of good functional outcomes and limb salvage significantly decrease past the 6-hour mark. Most emergency departments have lower acuity areas, it is reasonable to foresee that a dog bite or presentation such as this may be triaged to such areas where it may go unnoticed for a longer period. It is thus important to raise awareness of the pertinent 6Ps of acute limb ischemia: Pain, Paresthesias, Pallor, Poikilothermia, Pulselessness, and Paralysis among all members of the department. Since pain and paresthesias are the earliest findings and pulselessness and paralysis are later findings indicating poor prognosis, I believe more awareness of these symptoms among ED staff will lead to better patient care and outcomes.

References and Acknowledgements (Optional): Dr. Emmanuel Onyeyirim