Appropriate Protective Measures for the Prevention of Animal-related Goring Injuries

Abstract

The most common cause of morbidity and mortality worldwide in the age group of 10–49 years is road traffic accidents. Other than road traffic accidents multiple other factors add to the burden of injuries which include self-harm, occupational hazards, animal attack injuries and industrial accidents. Animal attack injuries are seen all over the world. Other than a few case reports and case series, this mode of injury is highly under-reported. Hence, the global burden of this disease is unknown. Due to the rapid deforestation, the number of animal attack injuries is increasing. These injuries can be caused by wild as well as domesticated animals. The attack can be due to a direct encounter with an animal or due to road traffic accident. Bulls are ferocious animals that are used for sporting events. They are also used for farming and livestock rearing. Injuries caused by bulls can be due to direct attacks by an unprovoked animal, road traffic accidents, or sporting events. The penetrating injury caused by the bull horn has its characteristic pattern. Treatment of bull horn injuries requires a multidisciplinary team. Creating awareness and enforcing laws can help in preventing such injuries.

1. Introduction

Injury is the leading cause of morbidity and mortality all over the world. The most common cause responsible for global DALYs is road traffic accidents. Road traffic accidents were responsible for 6.6% and 5.9% of global DALY’s in the age group of 10–24 years and 25–49 years respectively in 2019 [1]. Animal-related injuries are commonly seen all over the world. Attacks by wild animals as well as domesticated animals are commonly seen. These injuries are highly under-reported with only a few case series and case reports being published. They add a significant number to global mortality and morbidity and are a cause of concern in today’s world. These animals cause injuries by directly attacking humans or by causing road traffic accidents.

Bull horn injuries are common in different parts of the world where farming and livestock rearing is practised as well as in places where bulls are used for sports events. Bull horns can cause blunt, penetrating or mixed injuries. The injuries are most commonly seen over the abdomen and perineal region though injuries can be present anywhere from the head to toe. In low- or middle-income countries (LMIC), stray cattle, as well as domesticated cattle, are seen on the streets which can lead to road traffic accidents causing multiple injuries.

The injuries caused by penetrating bull horns have their characteristics such as multiple paths of injuries, a large area of tissue damage, creation of cavities, twists and inoculation of anaerobic and aerobic bacteria. There are four types of bull horn wounds. They are (i) sideway thrust caused due to tangential injury causing contusions, (ii) jab wounds where the tip of the horn causes injury, (iii) misleading injury where the entry point is away from the site of deep injury and (iv) goring injury in which there is a deep wound that penetrates the fascia and muscle [2].

Prevention of injuries due to bull horns can help in decreasing morbidity and mortality. Appropriate laws need to be enforced regarding bullfighting. In India, stray cattle and bulls need to be taken off the highways and kept in appropriate infrastructure where they can be taken care of (Figure 1).

Figure 1.

A and B. Image showing Indian bulls on the street which are a potential cause of road traffic accidents.

2. Mechanism and patterns of injury

Injury caused by bull goring is complex and hence it is necessary to know the mechanism behind these injuries. The bull initially lowers his head by neck flexion while charging toward the subject. After engaging, it extends its neck driving one or both horns into the subject. The weight along with the acceleration of the bull causes the generation of a tremendous force at the site of entry. The bull then tosses his head in a circular motion causing a shearing injury. Due to the flexion of the neck during charging, the most common primary site of injury is the abdomen, perineum and upper thigh. During bullfighting the individual faces the bull, hence the injuries are situated anteriorly while during running the injuries are found posteriorly [3].

Secondary injuries are caused due throwing, stomping or trampling and secondary penetrating injuries. Throwing can result in blunt trauma due to impact on the ground or the surroundings. This can cause intra-cranial injuries, spinal injuries, thoracoabdominal injuries and fractures. Stomping can cause acute life-threatening injuries. Factors determining the severity of the injury depend on the velocity and weight of the bull. Trampling occurs while running causing additional injury by multiple bulls. Secondary penetrating injuries occur if an individual attempts to stand after being thrown and the bull focuses on him as a target. The bull charges toward the individual causing secondary goring injuries. These injuries are located on the upper body as the individual is usually in a kneeling down position [3]. This causes penetrating injuries to the head, face, neck or thorax.

Injuries by bulls can also occur due to motor vehicular accidents. In LMIC like in India, cattle wander in the streets which can lead to motor vehicle crashes causing a wide spectrum of injuries. In areas where bulls are used for farming and livestock rearing, unprovoked injuries occur while handling and taking care of the livestock, this can lead to penetrating or blunt injuries.

3. Organ specific injuries

Injuries due to bull horns can affect any part of the human body. A retrospective study from January 2002 to March 2016 of penetrating bull horn injuries published from Maharashtra, India reported 67 cases. The most common site of injury was the abdomen. This was followed by the perineum, back and lower limbs. The least commonly affected site was the head and neck. The lower part of the abdomen was more commonly affected as compared to the rest of the abdomen [2]. Another retrospective study carried out from January 1978 to December 2019 in Spain reported a total of 572 cases of bull horn injury. The most frequent site of injury was the lower extremity, perineum and abdomen. The most commonly injured intra-abdominal organ was the intestine and liver. Their study reported an overall mortality of 0.87% [4]. A prospective study from June 2017 to March 2019 conducted in Tamil Nadu, India reported 42 cases. The most common site of injury was the trunk (55%) followed by the perineum (19%). The most common mechanism was penetrating injury (59.5%). Blunt injuries were seen in 31% of the patients while 9.5% of patients had both blunt and penetrating injuries. In abdominal injuries, liver injury was seen in three patients, splenic injury in one patient, renal injury in one patient and three patients had bowel perforation [5].

3.1 Head, face and neck

The incidence of head injuries as reported in a study in India was 1.6% [5]. Injuries due to bull can cause blunt or penetrating head injuries. Blunt injuries can cause fractures of the scalp bones as well as intracranial hematomas such as extradural hematoma, subdural hematoma, subarachnoid hematoma and intraparenchymal hematoma. A case of penetrating head injury with retained horn within the brain in a 3-year-old child was reported in India [6]. Individuals present with a history of loss of consciousness and/or with a low GCS.

Face can be involved due to penetrating or blunt injuries. Blunt injuries can result in fractures of facial bones and contusions over the face. Penetrating neck injury is defined as any injury that extends deep to the platysma. It can cause injury to major vessels, esophagus and the trachea. Patients can present with an unsecured airway and in shock. Injuries involving zone 1 and 2 of the neck require immediate exploration. A case of traumatic tooth intrusion in a six-year-old boy was reported in India. It was managed by extraction of intruded teeth to prevent interference with the eruption of permanent teeth [7]. A case of cervical esophageal perforation following a penetrating bull gore injury to the neck was reported from India. The patient was managed surgically with a primary repair over a T-tube and a feeding jejunostomy [8]. A case of complete tracheal transection following penetrating bull horn injury was reported from India. The patient was managed by emergency surgery. Since the distal tracheal end had retracted into the mediastinum, the patient was induced for surgery using percutaneous femoro-femoral cardiopulmonary bypass [9]. A case of penetrating bull horn injury to the neck causing mandible fracture and injury to the branches of facial vessels was reported from Mexico. The patient underwent emergency surgery during which the mandible fracture was fixed using plates and screws and the branches of facial vessels were ligated [10].

3.2 Torso injuries

Penetrating injury to the abdomen is commonly seen as injury to the lower abdomen. It can cause injuries to the bowel, urinary bladder, major vessels of the abdomen and solid organs like the liver, spleen, and kidneys. It can also cause evisceration of the bowel or omentum. Penetrating abdominal injuries can also extend to the thorax after injuring the diaphragm. Diaphragmatic injuries can have delayed presentation. Abdominal injuries can also occur due to blunt trauma due to secondary mechanisms. Blunt injury can cause solid organ injuries, abdominal wall hernias, mesenteric injuries and bowel injuries. A case of traumatic abdominal wall hernia following blunt abdominal trauma due to bull horn which was repaired by open mesh hernioplasty using a 15 × 15 cm polypropylene mesh was reported from India [11]. Another case of traumatic direct inguinal hernia following blunt bull horn injuries was reported from India [12]. A delayed presentation of intercostodiaphragmatic hernia following a forgotten penetrating injury was reported from India [13]. A case of penetrating abdominal injury causing terminal ileal perforation was reported from India. The patient was managed surgically by resection of the involved segment and ileoascending anastomosis [2].

Injuries to the thorax can be due to blunt or penetrating trauma. Penetrating trauma can cause open pneumothorax. The horn can penetrate the thorax and cause injuries to the lungs, bronchus, heart, and major vessels. Blunt trauma can cause rib fractures which can result in hemothorax, pneumothorax, and lung contusions. Injuries to major vessels can cause massive hemothorax which can be life-threatening. Penetrating injuries to the heart can be life-threatening. A case of blunt thoracic injury due to being hit by a domestic bull resulting in right-sided rib fractures with flail segment and hemothorax was reported in India. The patient was managed with an intercostal tube drainage system and epidural anesthesia (see Figure 2) [14].

Figure 2.

A and B. Image showing penetrating bull horn injury to the right hemithorax.

3.3 Perineal injuries

The perineum is one of the common sites of injury due to a penetrating bull horn. The perineal wound may be superficial or extend deeper to involve the pelvic organs. Perineal trauma can involve the anal canal, perineal body, urethra, vagina in females, scrotum and testis in males and pelvic organs like urinary bladder, reproductive organs and the rectum. Injuries can also involve the intra-abdominal organs. Patients with a perineal injury can present with bleeding per vagina, bleeding per-rectum, prolapse of pelvic organs, bowel injury, and injury to major vessels causing hypotensive shock. The delayed presentation can be in the form of a recto-vaginal fistula or a recto-urethral fistula. A case of traumatic urethrorectal fistula due to bull horn injury was reported from India. It was initially managed by diversion sigmoid colostomy and suprapubic cystostomy [15]. Two cases of goring injury to the vagina were reported from India. Both cases were managed operatively after initial resuscitation [16]. A case of penetrating bull gore injury to the perineum with urinary bladder perforation and pneumoperitoneum which was managed surgically was reported from India (Figure 3) [17].

Figure 3.

Image showing bull horn perineal injury in a (A) female, (B) male.

3.4 Extremities

Lower extremities are more commonly involved than upper extremities. Bull goring can result in lacerations which can be simple or there can be extensive tissue loss, fractures involving long bones and injuries to major vessels of the limb. These wounds are highly contaminated with vegetative matter, pieces of clothing, soil and micro-organisms such as anaerobes, gram-positive, gram-negative bacteria and fungi. They also have a high risk of transmitting tetanus.

3.5 Vascular injuries

Vascular injuries are seen during penetrating injury to the extremities, head and neck region, abdomen, thorax, perineum, back and lumbar region. A case of external iliac artery thrombosis which was repaired using the endovascular technique was reported from Spain [18].

4. Management

Patients usually present with multiple injuries following an attack by bulls. Management of an individual with bull goring injuries requires teamwork. Adequate pre-hospital care should be provided during the transportation of the patient to the hospital. Following ATLS protocols, the patient is managed primarily by maintaining Airway and stabilization of the cervical spine, breathing, circulation, neurological evaluation and control of exposure and environment. Continuous monitoring is done using an ECG, pulse oximeter and blood pressure monitors. Urinary and gastric catheters can be placed in patients with multiple injuries. A chest X-ray, pelvic X-ray and an eFAST are done as adjuncts to the primary survey. Patients with open wounds need to be vaccinated against tetanus. Once the patient is stabilized, a secondary survey is done to look for the extent of injuries. Based on the injuries a computed tomography (CT) of the head, chest, abdomen, contrast urography or angiography can be done. Penetrating injuries will require exploration under anesthesia after initial stabilization and evaluation of the patient. These individuals have to be started on triple antibiotics due to the dirty nature of the wound. Careful exploration and evaluation of the entire trajectory of the wound and removal of foreign material are necessary.

Individuals presenting with unstable vitals need to be resuscitated initially with intravenous fluids, tranexamic acid 1gm and a requisition for blood for crossmatching should be sent. If the patients are non-responders to initial resuscitation, they have to be shifted to the operating room. The source of bleeding in these patients needs to be identified and controlled. Such patients require damage control surgery as prolonged surgery in them can be fatal. The goals of damage control surgery are to stop any active bleeding and control of contamination. The minimal required amount of surgery required to stabilize the patient is done so that the patient physiological status can be corrected. Further resuscitation is then continued in the intensive care unit. Definitive surgery is carried out within 24–72 h after stabilization of the patient in the intensive care unit.

Penetrating injuries to the abdomen may present with hemodynamic instability, herniation of intraabdominal contents or with hemodynamically stable vitals. Patients with evisceration require exploration in the operating room after initial resuscitation. Unstable patients may require a laparotomy. In stable patients with penetrating injury who require exploration, a diagnostic laparoscopy can be considered. This can prevent the morbidity of an exploratory laparotomy. On exploration, patients may have an injury to the bowel, urinary bladder or solid organs. Bowel injuries may require primary repair, resection of the involved segment with anastomosis or creation of a stoma in patients requiring damage control surgery. Colonic injuries may require a protective diversion ileostomy after primary repair of the injury site. Urinary bladder injury can be repaired primarily by taking care not to injure the ureteric openings in the bladder. Suprapubic cystostomy can be done for drainage of urine and to allow healing of the urinary bladder. Injury to the liver can be managed by packing, pressure or Pringle maneuver. Grade four or five splenic injury or splenic injury with active bleeding may require splenectomy. Injury to major intra-abdominal vessels should be repaired primarily or with a graft. Blunt injuries to the abdomen with hemodynamically stable vitals can be managed conservatively with continuous monitoring in an intensive care unit and the presence of a twenty-four-hour availability of an operating room. Blunt injuries with features of peritonitis may require exploration. The presence of diaphragmatic injuries needs to be evaluated during exploration. If any diaphragmatic injury is identified, it can be primarily repaired. A randomized controlled study published in India on the management of penetrating injuries concluded that patients with penetrating injury to the anterior abdominal wall with hemodynamically stable vitals can be managed by serial observation after obtaining a CECT and in the absence of injuries requiring immediate surgery as compared to diagnostic laparoscopy in a centre that has 24-hour availability of operating room facilities, radiology facilities and an intensive care unit. This reduced the rate of non-therapeutic surgeries [19]. The presence of retroperitoneal injuries need to be identified during laparotomy. Injuries involving zone 1 of the retroperitoneum need to be explored after obtaining proximal and distal vascular control. Hematomas in zone 2 and 3 need to be explored only if they are pulsatile or expanding. If the tract of penetrating injury is extending to the retroperitoneum then the area has to be explored to look for injuries [20].

Penetrating injuries to the perineum require exploration after initial resuscitation. The wound needs to be evaluated for the extent of injury and organs involved. Patients with perineal penetrating bull horn injury may present with features of peritonitis and may require exploratory laparotomy along with local wound exploration. The perineal wound needs to be evaluated for communication with the urinary bladder, urethra, rectum and anal canal, vagina in females and scrotum and testis in males. The superficial injury needs to be closed in layers. Injuries involving the rectum and anal canal need to be repaired. A diversion sigmoid colostomy may be created to allow for healing of the wound. Injuries involving the vagina need to be repaired in layers. Precaution has to be taken while repairing the posterior wall of the vagina and anterior wall of rectum to avoid the formation of rectovaginal fistula and between anterior wall of vagina and urethra or urinary bladder to prevent the formation of fistula in females. In males, precaution needs to be taken to avoid the formation of the recto-urethral fistula or a fistula between the rectum and urinary bladder. Large perineal wounds involving the anal sphincter may require the creation of diversion sigmoid colostomy to prevent soiling of wounds. Concomitant intra-abdominal injuries need to be evaluated and appropriately managed. Perineal wounds with loss of tissue require initial debridement and wound management followed by delayed closure primarily with a reconstruction.

Patients with immediate life-threatening thoracic injuries should be identified and managed during the primary survey. These include airway obstruction, tension pneumothorax, pericardial tamponade, open pneumothorax, massive hemothorax and flail chest. The potentially life-threatening thoracic injuries are aortic injuries, tracheobronchial injuries, myocardial contusion, pulmonary contusion, diaphragmatic injuries and esophageal injuries. These injuries need to be identified during a secondary survey as these injuries have subtle signs and can be easily missed if a high index of suspicion is not maintained to look for these injuries. Emergency room thoracotomy is indicated in individuals who have a penetrating cardiac injury and have received cardio-pulmonary resuscitation for less than 15 minutes. The aim of an emergency room thoracotomy is control of hemorrhage, open cardiac massage, cardiac tamponade release, cross-clamping of descending thoracic aorta to cut off arterial supply to the distal body and preserve blood supply to the heart and brain in major penetrating injury to the abdomen, repair of cardiac or pulmonary injury and prevention of air embolism. Emergency thoracotomy is indicated in massive hemothorax which is defined as more than 1500 ml of blood in one hemithorax or when 150–200 ml of blood drains per hour for the next 2–4 h in an ICD bag and persistent hemodynamic instability in the presence of ongoing transfusion. In an open pneumothorax injury, an ICD needs to be placed after creating a flap valve over the wound. After the initial stabilization of the patient, the wound needs to be explored in an operation theater. The margins are debrided as they are heavily contaminated and the wound is closed in layers. The majority of thoracic injuries can be managed by placement of an intercostal tube drain. The ICD can be removed within 2–3 days after obtaining full lung expansion and minimal output from the drain. Patients with residual hemothorax that does not drain with an intercostal tube drain can be considered for VATS drainage. Patients with flail chest with respiratory compromise may require ventilatory support or rib fixation. Esophageal injuries presenting within 24 h can be managed surgically by primary repair. A feeding jejunostomy may be created to allow for postoperative enteral feeding. Delayed presentation of esophageal injury needs to be evaluated. In case of mediastinitis with septic shock, the patient needs surgical management. In cases of contained perforation, conservative management can be tried, if the patient deteriorates on conservative management, then the patient can be taken for surgery. Adequate analgesic support should be provided in the form of epidural analgesia or erector spinae blocks and intravenous analgesics. Chest physiotherapy and respirometry are necessary to prevent post-traumatic pneumonia and for early recovery.

Penetrating wounds to the extremity need to be explored after initial resuscitation. A CT angiography may be needed to evaluate for the presence of vascular injury. Superficial wounds may be closed primarily after debridement of devitalized tissue. Wounds with tissue loss may require serial debridement, regular dressing, and use of a vacuum-assisted closure dressing followed by delayed closure. Delayed closure may require tissue reconstruction using skin grafts, rotational flaps or free flaps. Vascular injuries need to be repaired if presented within 6 h of injury. Primary repair of the injured vessel may be done. In case of tissue loss, a reverse saphenous graft may be placed. Delayed presentation of more than 6 h may cause ischemia of the limb which may require amputation.

Penetrating neck injuries need to be evaluated in the operating room. Injuries involving the trachea need an emergency tracheostomy done in the emergency room to maintain the airway. A CT angiography needs to be done if the patient is hemodynamically stable to look for the extent of injury and presence of any vascular injury. Hemodynamically unstable patients need to be taken to the operating room after maintaining the airway. The wound needs to be evaluated to identify injuries to major structures. Tracheal injuries need to be repaired. A tracheostomy may be needed in injuries with tissue loss. Injury to major vessels can be primarily repaired. Cervical esophageal injury may be repaired primarily or an esophagostomy can be created. A feeding jejunostomy may be required to allow for enteral feeding in the postoperative period. Injury to soft tissue can be debrided to remove the devitalized tissue and closed in layers. Injuries involving the thyroid gland or salivary glands may require partial or complete excision depending on the extent of the injury.

Majority of injuries to the head can be managed conservatively in the intensive care unit. Penetrating injury to the head requires surgery after initial resuscitation. Blunt injuries causing intracranial bleed requiring surgery are hemorrhage causing midline shift, raised intracranial pressure, extradural hemorrhage, infratentorial bleed, and open depressed fracture of the cranial vault. A decompressive craniotomy is done. Depressed fracture is treated by elevation of fracture segment and debridement of the wound. Since bull horn penetrating injuries are contaminated wounds, a prosthesis is avoided during primary surgery.

Management of bull horn injuries requires a multidisciplinary team. A holistic approach toward patient care is necessary for a positive outcome for the patients. Patients with polytrauma need to be referred to a higher centre with acute care facilities or a trauma centre as soon as possible for a better outcome of the patient.

5. Conclusion

Bull horn injuries are commonly seen in rural India as they are used for domestic and farming purposes. It is also commonly seen in Spain where traditional bullfighting is a sport. Bull horn injuries have special features that make them unique as compared to other modes of injuries. Injuries due to bull horns can vary from penetrating injury to blunt injury to both. Management of bull horn injury requires a holistic approach by a multidisciplinary team. Early referral to a tertiary care centre is necessary for the survival of the patient. Injuries caused due to bulls are a preventable mechanism. The three E’s of trauma prevention should be followed which are engineering, education and enforcement. Creating awareness among the people in places where bullfighting is a sport such as Spain, Latin America and certain parts of India about the severity of injuries caused due to bullfighting can help in preventing injuries during these sports events. Appropriate protective measures should be undertaken and rules regarding the same should be enforced by the government to prevent injuries caused during these sporting events. Any individual not following such rules and regulations should be penalized. Building infrastructure to take care of stray animals, appropriate fighting grounds to prevent injuries during sporting events, use of protective equipment, and availability of a medical team on-site to attend to the individuals and take care of life-threatening conditions should be enforced by the government. Appropriate rules and regulations should be enforced by the government to prevent the presence of stray cattle and bulls on the Indian streets. This can prevent a significant number of road traffic accidents caused by bulls thus decreasing the burden of disease.

Conflict of interest

The authors declare no conflict of interest.

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