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• W3092257050 abstract "Bear attacks, although rare, can inflict life-threatening injuries. We present the case of a 50-y-old woman from rural Pennsylvania who was attacked by a North American black bear, Ursus americanus. She sustained multiple complex injuries including near-complete scalp avulsion, bilateral ear avulsions, and fractures of the face, ribs, and pelvis. These injuries are similar to those sustained in other bear maulings reported in the literature and required both acute intervention and a multidisciplinary approach to recovery. Bear attacks, although rare, can inflict life-threatening injuries. We present the case of a 50-y-old woman from rural Pennsylvania who was attacked by a North American black bear, Ursus americanus. She sustained multiple complex injuries including near-complete scalp avulsion, bilateral ear avulsions, and fractures of the face, ribs, and pelvis. These injuries are similar to those sustained in other bear maulings reported in the literature and required both acute intervention and a multidisciplinary approach to recovery. The black bear, Ursus americanus, has both the largest population and largest range of North American bears. They are found across the United States and in all Canadian provinces and territories. Black bears are the smallest of North American bears, with weights typically ranging from 64 to 295 kg. They are omnivores, and approximately 5% of their diet consists of live prey.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar North American black bears are considered less aggressive toward humans compared to other bear species, such as the brown bear (Ursus arctos, including its subspecies the grizzly bear, Ursus arctos horribilis), the polar bear (Ursus maritimus), or the Asian black bear (Ursus thibetanus).1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar, 2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar, 3Rasool A. Wani A. Darzi M. Zaroo M. Iqbal S. Bashir S. et al.Incidence and pattern of bear maul injuries in Kashmir.Injury. 2010; 41: 116-119Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Encounters with black bears do not usually result in attacks or injuries, and most end with a defensive retreat by the bear.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,4Soulsbury C. White Piran C.L. Human-wildlife interactions in urban areas: a review of conflicts, benefits and opportunities.Wildlife Research. 2015; 42: 541-553Crossref Scopus (164) Google Scholar However, given the proximity of their habitat to populated areas, human–bear encounters are becoming increasingly common.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,4Soulsbury C. White Piran C.L. Human-wildlife interactions in urban areas: a review of conflicts, benefits and opportunities.Wildlife Research. 2015; 42: 541-553Crossref Scopus (164) Google Scholar Although reporting remains inexact, a review of data from all North American state and national parks between 1960 and 1980 reveals that 500 people were injured by black bears.5Middaugh J.P. Human injury from bear attacks in Alaska, 1900–1985.Alaska Med. 1987; 29: 121-126PubMed Google Scholar Ninety percent of these encounters resulted in only minor injuries.5Middaugh J.P. Human injury from bear attacks in Alaska, 1900–1985.Alaska Med. 1987; 29: 121-126PubMed Google Scholar This is lower than both the attack and injury rates from North American brown bears.6Tough S.C. Butt J.C. A review of fatal bear maulings in Alberta, Canada.Am J Forensic Med Pathol. 1993; 14: 22-27Crossref PubMed Scopus (26) Google Scholar,7Townes D.A. Laughlin M.K. Rubio-Derhammer D. The black bears of Yosemite National Park: bear-induced injuries—the role of improper food storage.Wilderness Environ Med. 2000; 11: 67-68Abstract Full Text PDF PubMed Scopus (6) Google Scholar When a black bear feels threatened, it may paw at the ground, make blowing noises, or make mock charges.8Herrero S. Higgins A. Cardoza J.E. Hajduk L.I. Fatal attacks by American black bear on people: 1900-2009.J Wild Manage. 2011; 75: 596-603Crossref Scopus (49) Google Scholar Attacks are generally classified into 1 of 3 categories: sudden (93% of reported cases), human provoked (7%), or predation (<1%).1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar Most bear attacks across species are associated with a sudden encounter with a female bear and her cubs.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar Although more frequent, these attacks are less often fatal compared to provoked or predatory attacks, which are usually committed by solitary males.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar The expansion of urban and suburban communities into black bear habitats has been an important variable in the increasing frequency of human-bear encounters.4Soulsbury C. White Piran C.L. Human-wildlife interactions in urban areas: a review of conflicts, benefits and opportunities.Wildlife Research. 2015; 42: 541-553Crossref Scopus (164) Google Scholar Habituation to human food and the presence of domestic dogs have been factors in many bear attacks.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,7Townes D.A. Laughlin M.K. Rubio-Derhammer D. The black bears of Yosemite National Park: bear-induced injuries—the role of improper food storage.Wilderness Environ Med. 2000; 11: 67-68Abstract Full Text PDF PubMed Scopus (6) Google Scholar, 8Herrero S. Higgins A. Cardoza J.E. Hajduk L.I. Fatal attacks by American black bear on people: 1900-2009.J Wild Manage. 2011; 75: 596-603Crossref Scopus (49) Google Scholar, 9Bombieri G. Delgado M.D.M. Russo L.F. Garrote P.J. Lopez-Bao J.V. Fedriani J.M. et al.Patterns of wild carnivore attacks on humans in urban areas.Sci Rep. 2018; 8: 17728Crossref PubMed Scopus (11) Google Scholar, 10Wilton C. Belant J.L. Beringer J. Distribution of American black bear occurrence and human-bear incidents in Missouri.Ursus. 2014; 25: 53-60Crossref Scopus (18) Google Scholar Fatalities are infrequent; from 1900 to 2009, 63 deaths from North American black bears were reported, the majority of which were the result of predation by adult males.8Herrero S. Higgins A. Cardoza J.E. Hajduk L.I. Fatal attacks by American black bear on people: 1900-2009.J Wild Manage. 2011; 75: 596-603Crossref Scopus (49) Google Scholar According to Pennsylvania game commission records, there have been no known fatalities from wild black bear attacks in Pennsylvania and only 3 other nonlethal attacks since 2011.11Pennsylvania Game CommissionBlack Bear.www.pgc.pa/govDate accessed: September 9, 2019Google Scholar A 50-y-old woman presented to the emergency department of a rural, quaternary care hospital via ambulance approximately 2 h after being attacked by a black bear. The patient had left her rural home to check on her dog in her backyard when she noticed it had been barking at an adult black bear. While attempting to fight off the bear, the 55 kg patient was dragged an estimated 60 m into the woods. The bear left her alone for several minutes, and despite her injuries the patient was able to return to her home and call emergency medical services. The prehospital team bandaged her nearly avulsed scalp, placed her in a cervical collar, established intravenous access, and transported her to the hospital. On arrival to the emergency department, the primary survey revealed significant craniofacial injuries, although there was no active bleeding or respiratory distress. The patient was alert, awake, and speaking in full sentences. She had normal oxygen saturation without supplemental oxygen. The secondary survey revealed a large anterior scalp avulsion with exposed cranium, bilateral ear avulsions, a complex lip laceration involving the vermillion border, and many lacerations and puncture wounds of various lengths and depths over the torso and extremities. The scalp wound was grossly contaminated with dirt. The periosteum was exposed, and there were multiple puncture and scratch wounds to the skull without associated fractures. Computed tomography imaging of her head, cervical spine, chest, abdomen, and pelvis and angiography of her neck vasculature revealed additional injuries (Table 1). The patient was given broad-spectrum antibiotics, tetanus vaccine, rabies vaccine, and immunoglobulin and was taken to the operating room that night. She was intubated fiber optically in the operating room, given the extent of her facial injuries. She underwent washout of her many wounds and initial closure of the scalp avulsion (Figure 1A and B).Table 1Injury complex of patient•Near-complete anterior avulsion injury of scalp with exposed periosteum•Complex avulsion injury of bilateral ears•Complex lip laceration involving the vermillion border•Left zygomatic arch fracture, impacted•Right anterolateral maxillary sinus fracture•Right lamina papyracea fracture•Right condylar process fracture through the coronoid of the right mandible•Right clavicle fracture, middle third•Right 10th rib fracture•Left fifth rib fracture•Right acetabular fracture•Right pubis, ischium, and sacral ala pelvic fractures•Left thumb avulsion injury and tuft fracture•Multiple puncture wounds and abrasions to the torso and extremities Open table in a new tab During the course of her hospitalization, she required 8 operations, including repair of complex lacerations to the lip, eyebrows, and ears, along with serial scalp debridements and skin grafting. Washout and closure of a thumb avulsion and operative reduction of a displaced clavicle fracture were also performed. The patient’s mandible, rib, and pelvic fractures were managed non-operatively. She was treated with 6 wk of intravenous vancomycin and cefepime for suspected cranial osteomyelitis secondary to the puncture wounds. Intraoperative and subsequent wound cultures were not collected. She also received the rabies vaccine series. The patient received evaluation and treatment from a critical care psychologist owing to concerns for acute stress disorder. She required extensive rehabilitation, including speech therapy, occupational therapy, and physical therapy. She was discharged home after being hospitalized for 55 d. At 3-mo follow-up, the scalp graft and other facial injuries were healing well (Figure 2). The patient reported persistent lower extremity neuropathies that limited walking long distances, but otherwise she was back to her functional baseline. She did not report symptoms of posttraumatic stress disorder. The patient’s dog survived the attack after sustaining several rib fractures and superficial wounds. Local wildlife agents suspected the bear was an adult female that had been seen in the area with several cubs; attempts to locate and trap the offending bear with tracking dogs and traps were unsuccessful. Victims of bear attacks can present with multiple severe and complicated injuries requiring prolonged hospitalizations and multidisciplinary care. As with any major trauma, patients presenting after a bear attack should be assessed for their ability to protect their airway and for major sources of hemorrhage or vascular injury. A retrospective study of attacks by Ursus thibetanus indicated that of 21 patients, over half required some form of emergency airway management including intubation or surgical airway.12Mize C.H. Dorji L. Zafren K. Emergency airways after Himalayan black bear attacks in Bhutan.Wilderness Environ Med. 2019; 30: 421-424Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Hemorrhage control is critical during initial resuscitation.13Akiyama G. Kuwahara H. Asahi R. Tosa R. Yokota H. Prompt procedures have great impact on the consequence of Asiatic black bear mauling.J Nippon Med Sch. 2017; 84: 294-300Crossref PubMed Scopus (1) Google Scholar,14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar Although fatalities from bear attacks after presentation to the hospital are rare (2% in 1 retrospective review of 417 cases),3Rasool A. Wani A. Darzi M. Zaroo M. Iqbal S. Bashir S. et al.Incidence and pattern of bear maul injuries in Kashmir.Injury. 2010; 41: 116-119Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar exsanguination is the most common cause of death.7Townes D.A. Laughlin M.K. Rubio-Derhammer D. The black bears of Yosemite National Park: bear-induced injuries—the role of improper food storage.Wilderness Environ Med. 2000; 11: 67-68Abstract Full Text PDF PubMed Scopus (6) Google Scholar In 1 case series, major vascular trauma occurred in 7% of Ursus thibetanus attacks, with injuries including femoral, popliteal, brachial, and carotid arteries. All of those injuries required surgical intervention.15Wani M.L. Ahangar A.G. Lone G.N. Lone R.A. Ashraf H.Z. Dar A.M. et al.Vascular injuries after bear attacks: incidence, surgical challenges and outcome.J Emerg Trauma Shock. 2001; 4: 20-22Crossref Scopus (9) Google Scholar Cervical spine injuries have only been reported in 2 cases14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar,16Thakur J.S. Mohan C. Sharma D.R. Himalayan black bear mauling: offense or defense?.Am J Otolaryngol. 2007; 28: 247-250Crossref PubMed Scopus (9) Google Scholar and rates of cervical spine injuries in bear attacks are noted to be lower than in attacks by other large carnivores.17Nabi D.G. Tak S.R. Kangoo K.A. Halwai M.A. Comparison of injury pattern in victims of bear (Ursus thibetanus) and Leopard (Panthera padus) attacks.Eur J Trauma Emerg Surg. 2009; 35: 153-158Crossref PubMed Scopus (2) Google Scholar Bear attack victims presenting with multiple or complex traumatic injuries should be transferred to a trauma facility once they are stabilized.2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar Other injuries from bear attacks may include a combination of puncture, avulsion, and crush injuries from powerful jaws, sharp teeth, and long claws.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar,18Herrero S. Fleck S. Injury to people inflicted by black, grizzly or polar bears: recent trends and new insights.Int Conf Bear Res Manage. 1990; 8: 25-32Google Scholar Craniofacial injuries may include skull fractures and associated intracerebral hemorrhage, many of which are fatal.19Bashir S.A. Rasool A. Zaroo M.I. Wani A.H. Zargar H.R. Darzi M.A. et al.Bear maul craniocerebral trauma in Kashmir Valley.J Craniofac Surg. 2013; 24: e2-e5Crossref PubMed Scopus (3) Google Scholar Maxillofacial and scalp injuries are common, as seen in this case, and include damage to the ears, nose, mandible, and eyes.14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar, 15Wani M.L. Ahangar A.G. Lone G.N. Lone R.A. Ashraf H.Z. Dar A.M. et al.Vascular injuries after bear attacks: incidence, surgical challenges and outcome.J Emerg Trauma Shock. 2001; 4: 20-22Crossref Scopus (9) Google Scholar, 16Thakur J.S. Mohan C. Sharma D.R. Himalayan black bear mauling: offense or defense?.Am J Otolaryngol. 2007; 28: 247-250Crossref PubMed Scopus (9) Google Scholar,19Bashir S.A. Rasool A. Zaroo M.I. Wani A.H. Zargar H.R. Darzi M.A. et al.Bear maul craniocerebral trauma in Kashmir Valley.J Craniofac Surg. 2013; 24: e2-e5Crossref PubMed Scopus (3) Google Scholar, 20Atreya A. Kanchan T. Nepal S. Acharya J. Brown bear attacks in Nepalese scenario: a brief review.Wilderness Environ Med. 2015; 26: 587-588Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 21Geetha N.T. Shivakumar H.R. Amarnath P.U. Rajesh Kumar B.P. Kirthikumar R. Bear maul injuries in maxillofacial region.J Maxillofac Oral Surg. 2012; 11: 420-424Crossref PubMed Scopus (8) Google Scholar, 22Ghezta N.K. Bhardwaj Y. Ram R. Ahsan R. Arya S. Incidence pattern of bear-inflicted injuries to the maxillofacial region-soft and hard tissues injuries, their management, and sequelae.J Oral Maxillofac Surg. 2019; 77: 1043Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar, 23Kar I.B. Chopda P.D. Mishra N. Sethi A.K. Mahavoi B.R. Management of maxillofacial injuries in bear mauling cases: a review of 20 cases.J Korean Assoc Oral Maxillofac Surg. 2016; 42: 13-19Crossref PubMed Google Scholar, 24Patil S.B. Mody N.B. Kale S.M. Ingole S.D. A review of 48 patient after bear attacks in Central India: demographics, management, and outcomes.Indian J Plast Surg. 2015; 48: 60-65Crossref PubMed Scopus (6) Google Scholar, 25Shah A.A. Mir B.A. Ahmad I. Latoo S. Ali A. Shah B.A. Pattern of bear maul maxillofacial injuries in Kashmir.Natl J Maxillofac Surg. 2010; 1: 96-101Crossref PubMed Google Scholar, 26Tak S.R. Dar G.N. Halwai M.A. Mir B.A. Injuries from bear (Ursus thibetanus) attacks in Kashmir.Ulus Travma Acil Cerrahi Derg. 2009; 15: 130-134PubMed Google Scholar Injuries to the face and jaw occurred in 81% of cases and injuries to the scalp in 55% of cases in 1 retrospective review.3Rasool A. Wani A. Darzi M. Zaroo M. Iqbal S. Bashir S. et al.Incidence and pattern of bear maul injuries in Kashmir.Injury. 2010; 41: 116-119Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Complex surgical repairs, including reconstruction with skin flaps or skin grafts, are required in 25% of patients presenting with craniofacial injuries.23Kar I.B. Chopda P.D. Mishra N. Sethi A.K. Mahavoi B.R. Management of maxillofacial injuries in bear mauling cases: a review of 20 cases.J Korean Assoc Oral Maxillofac Surg. 2016; 42: 13-19Crossref PubMed Google Scholar Bear attack victims may present with extremity fractures as well. Upper extremity injuries (notably humerus, clavicle, and forearm fractures) are more common than lower extremity injuries,27Dhar S.A. Butt M.F. Farooq M. Mir M.R. Wani Z.A. Afzal S. et al.Pattern of orthopaedic injuries in bear attacks: reports from tertiary care centre in Kashmir.Injury. 2008; 39: 249-255Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar particularly when victims protect their face with their arms.28Bhat T.A. Gulzar A. Bhat A.A. Bhat T.A. Ali Z. A review of upper limb injuries in bear maul victims: consistent pattern and inverse relation in severity with facial and scalp injuries.Chin J Traumatol. 2018; 21: 38-41Crossref PubMed Scopus (1) Google Scholar In 2 cases comparing attacks by North American black bears (Ursus americanus) and brown bears (Ursus arctos), there was a slightly higher incidence of lower extremity injuries in black bear attacks compared with attacks by Ursus arctos.6Tough S.C. Butt J.C. A review of fatal bear maulings in Alberta, Canada.Am J Forensic Med Pathol. 1993; 14: 22-27Crossref PubMed Scopus (26) Google Scholar,29Frank R.C. Mahabir R.C. Magi E. Lindsay R.L. de Haas W. Bear maulings treated in Calgary, Alberta: their management and sequelae.Can J Plast Surg. 2006; 14: 158-162Crossref PubMed Google Scholar Asian black bears (Ursus thibetanus) and Ursus arctos have longer claws, are more facile at walking on 2 feet, and are noted to be more aggressive, with a higher incidence of reported attacks compared to Ursus americanus.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,3Rasool A. Wani A. Darzi M. Zaroo M. Iqbal S. Bashir S. et al.Incidence and pattern of bear maul injuries in Kashmir.Injury. 2010; 41: 116-119Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,26Tak S.R. Dar G.N. Halwai M.A. Mir B.A. Injuries from bear (Ursus thibetanus) attacks in Kashmir.Ulus Travma Acil Cerrahi Derg. 2009; 15: 130-134PubMed Google Scholar,27Dhar S.A. Butt M.F. Farooq M. Mir M.R. Wani Z.A. Afzal S. et al.Pattern of orthopaedic injuries in bear attacks: reports from tertiary care centre in Kashmir.Injury. 2008; 39: 249-255Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Despite these differences, the overall injury complex across all species appears to be similar, and further studies are needed to delineate any other possible differences due to each species’ behaviors or anatomy. Wounds from bear attacks are considered contaminated at a minimum and dirty if an infection develops.30Centers for Disease Control and PreventionGuideline for Prevention of Surgical Wound Infections. Centers for Disease Control, Atlanta, GA1985: 1-10Google Scholar Skin and soft tissue infections14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar,24Patil S.B. Mody N.B. Kale S.M. 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Studies of microbes associated with infected wounds from bear injuries and oral flora found in bears have found organisms common to other bite injuries (cat, dog, human) with a predominance of aerobic bacteria.32Floyd T. Manville A.M. French S.P. Normal oral flora in black bears: guidelines for antimicrobial prophylaxis following bear attacks.Wilderness Environ Med. 1990; 1: 47-49Abstract Full Text PDF Scopus (13) Google Scholar, 33Goatcher L.J. Barrett M.W. Coleman R.N. Hawley A.W. Qureshi A.A. A study of predominant aerobic microflora of black bear (Ursus americanus) and grizzly bear (Ursus artcos) in Northwestern Alberta.Can J Microbiol. 1987; 33: 949-954Crossref PubMed Scopus (17) Google Scholar, 34Liu H.C. Hsu C.C. Regeneration of a segmental bone defect after acute osteomyelitis due to animal bite.Injury. 2004; 35: 1316-1318Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar Thorough irrigation for all wounds and debridement of crushed or devitalized tissue is recommended on initial presentation.14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar,35Phillis L.L. Semple J. Bites and injuries inflicted by wild and domestic animals.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 617-645Google Scholar Wound cultures of new injuries without signs of active infection are not recommended because diagnostic yield is low.35Phillis L.L. Semple J. Bites and injuries inflicted by wild and domestic animals.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 617-645Google Scholar,36Fleisher G.R. The management of bite wounds.N Engl J Med. 1999; 340: 138-140Crossref PubMed Scopus (127) Google Scholar Injuries sustained in bear attacks are particularly prone to infection given extensive crush, puncture, and avulsion injuries and associated tissue necrosis.14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. Williamson J.S. et al.Surgical management of injuries sustained during grizzly bear maulings treated in Vancouver, British Columbia.Can J Plast Surg. 2000; 8: 193-198Crossref Google Scholar,24Patil S.B. Mody N.B. Kale S.M. Ingole S.D. A review of 48 patient after bear attacks in Central India: demographics, management, and outcomes.Indian J Plast Surg. 2015; 48: 60-65Crossref PubMed Scopus (6) Google Scholar,27Dhar S.A. Butt M.F. Farooq M. Mir M.R. Wani Z.A. 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Gorbach S.L. et al.Practice guideline for diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Disease Society of America.Clin Infect Dis. 2014; 59: e10-e52Crossref PubMed Scopus (827) Google Scholar High-risk wounds include deep puncture wounds, complex crush wounds, wounds over vital structures, wounds to the distal extremities, and wounds with exposed bone or over joints.35Phillis L.L. Semple J. Bites and injuries inflicted by wild and domestic animals.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 617-645Google Scholar Soft tissue injuries in immunocompromised patients and patients at extremes of age and wounds with delayed evaluation are also considered high risk for infection.35Phillis L.L. Semple J. Bites and injuries inflicted by wild and domestic animals.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 617-645Google Scholar These and other types of wounds may be considered poor candidates for primary closure and require surgical consultation.35Phillis L.L. Semple J. Bites and injuries inflicted by wild and domestic animals.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 617-645Google Scholar,36Fleisher G.R. The management of bite wounds.N Engl J Med. 1999; 340: 138-140Crossref PubMed Scopus (127) Google Scholar Providers should consider the possibility of underlying osteomyelitis when choosing the initial antibiotic regimen; however, data on treatment of osteomyelitis from animal bite wounds are limited.31Kunimoto D. Rennie R. Citron D.M. Goldstein E.J. Bacteriology of a bear bite wound to a human: case report.J Clin Microbiol. 2004; 42: 3374-3376Crossref PubMed Scopus (38) Google Scholar,39Lim J.S. Byun J.H. Min K.H. Lee H.K. Choi Y.S. Osteomyelitis following domestic animal bites to hand: two case reports and practical guidelines.Arch Plast Surg. 2016; 43: 590-594Crossref PubMed Scopus (5) Google Scholar,40Lee R. Lee H.Y. Kim J.H. Han Y.S. Kim D.C. Tark K.C. Acute osteomyelitis in hand due to dog bite injury: a report of three cases.Arch Plast Surg. 2017; 44: 444-448Crossref PubMed Scopus (3) Google Scholar Although black bears are not the most common vector of rabies, cases have been reported in several US states and Canada.41Chavez K. Bear found dead of rabies is first case in NC history, wildlife officials say.The Citizen-Times. January 3, 2019; Google Scholar, 42Strong T. Rabid bear attacks in Albemarle: Shot dead by victim.The Daily Progress. April 19, 2012; Google Scholar, 43Walroth R. Brown N. Wandeler A. Casey A. MacInnes C. Rabid black bears in Ontario.Can Vet J. 1996; 37: 492PubMed Google Scholar The US Centers for Disease Control and Prevention (CDC) recommend rabies immunization for victims of wild carnivore attacks.44Center for Disease ControlRabies exposures.https://www.cdc.gov/rabies/exposure/animals/other.htmlDate accessed: June 9, 2019Google Scholar The CDC also recommend tetanus vaccination for wounds if the patient is unvaccinated, is unsure about vaccination status, or has not completed the tetanus vaccination series; if the most recent tetanus immunization or booster was more than 5 y prior to the injury, another booster is indicated.45Mootrey G. Tiwari T. Weinbarum C. Tetanus.in: Hamborsky J. Kroger A. Wolfe S. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Public Health Foundation, Washington, DC2015: 341-352Google Scholar Tetanus immunoglobulin is reserved for those who have not completed the 3-vaccine series or are unvaccinated.45Mootrey G. Tiwari T. Weinbarum C. Tetanus.in: Hamborsky J. Kroger A. Wolfe S. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Public Health Foundation, Washington, DC2015: 341-352Google Scholar After initial stabilization and treatment of acute injuries, many bear attack victims face prolonged hospitalizations3Rasool A. Wani A. Darzi M. Zaroo M. Iqbal S. Bashir S. et al.Incidence and pattern of bear maul injuries in Kashmir.Injury. 2010; 41: 116-119Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,14Mahabir R.C. Olesen P.R. Cannon W.G. Barre N.M. Snelling C.F. 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Lopez-Bao J.V. Fedriani J.M. et al.Patterns of wild carnivore attacks on humans in urban areas.Sci Rep. 2018; 8: 17728Crossref PubMed Scopus (11) Google Scholar Many resources highlight specific practices to avoid bear encounters in the backcountry.1Herrero S. Bear Attacks: Their Causes and Avoidance.3rd ed. Globe Pequot, Guilford, CT2018Google Scholar,2Freer L. Bear behavior and attacks.in: Auerbach P.S. Wilderness Medicine. 7th ed. Elsevier, Philadelphia, PA2017: 674-686Google Scholar,46Smith D. Backcountry bear basics: The definitive guide to avoiding unpleasant encounters. Mountaineers, Seattle, WA1997Google Scholar Several retrospective field studies have shown that capsaicin spray is an effective deterrent in attacks.47Herrero S. Higgins A. Field use of capsicum spray as a bear deterrent.Ursus. 1998; 10: 533-537Google Scholar,48Smith T.S. Herrero S. Debruyn T.D. Wilder J.M. Efficacy of bear deterrent spray in Alaska.J Wildlife Manage. 2008; 72: 640-645Crossref Scopus (31) Google Scholar If the offending animal is captured, relocation and monitoring are common practices employed by many wildlife agencies, with variable success.49Spencer R.D. Beausoleil R.A. Martorello D.A. How agencies respond to human-black bear conflicts: a survey of wildlife agencies in North America.Ursus. 2007; 18: 217-229Crossref Scopus (83) Google Scholar Our case highlights the life-threatening and complex injuries of an attack by Ursus americanus as consistent with those by other bear species reported in the literature. Bear attack victims may require early and aggressive resuscitation and stabilization as well as significant resources in both the acute and long-term care of their injuries. Further studies on these injuries will be key to improving the care of these patients and providing a better understanding of bear behavior and prevention of future attacks." @default.
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