April is an old girl, 13 years old but is still very active and playful. She is a small mixed toy dog that only weighed 11pounds. She was bitten in the head by a visiting dog in the house. She presented to a local emergency clinic and was expertly stabilized. A bite wound was identified over the right side of her head. She seemed quiet but responsive at this time. Over night and the next 24 hours her status declined. She developed seizures which were treated with diazepam and Phenobarbital. She became increasingly dull and less responsive. She began to vomit. During this time, the emergency doctors were in telephone contact with me while we tried to stabilize her. Radiographs revealed a depressed skull fracture on the right side of her skull (see radiographs). I was able to review the radiographs remotely. A consultation was scheduled which confirmed that April was in a dangerous stupor and declining rapidly due to a presumptive epidural or intradural hemorrhage. She was transferred to the Westminster Neurological Hospital. An emergency craniotomy was performed to explore the wound. At surgery, bite wounds were identified that penetrated the skin, skull, dura and even the brain parenchyma. Both the dura and brain was actively bleeding. Bone, skin and perhaps a tooth fragment were removed from the bite wound. All hemorrhage was arrested and the wound was carefully cleaned. Wounds were closed primarily. Over the next 3 days, she improved in her mental attitude with a cessation of seizures and return to normal appetite. She was still quite weak especially on the left side of her body and needed assistance in walking. She went home for further care. At the time of her suture removal 2 weeks after surgery, she was nearly 100% with just subtle left sided postural reaction deficits. She celebrated her recheck by running all over the exam room, jumping, cavorting and playing.
April will continue on a low dose of anticonvulsants for the next 6 months. If she has no further seizures, we will wean her off the Phenobarbital if she has no further seizures during this time.
April’s case demonstrates a great collaboration between the emergency clinic and the neurology consultation services that I provide. It was a case that greatly benefited from good communications and cooperation and surely saved her life.
Processing ....
April is an old girl, 13 years old but is still very active and playful. She is a small mixed toy dog that only weighed 11pounds. She was bitten in the head by a visiting dog in the house. She presented to a local emergency clinic and was expertly stabilized. A bite wound was identified over the right side of her head. She seemed quiet but responsive at this time. Over night and the next 24 hours her status declined. She developed seizures which were treated with diazepam and Phenobarbital. She became increasingly dull and less responsive. She began to vomit. During this time, the emergency doctors were in telephone contact with me while we tried to stabilize her. Radiographs revealed a depressed skull fracture on the right side of her skull (see radiographs). I was able to review the radiographs remotely. A consultation was scheduled which confirmed that April was in a dangerous stupor and declining rapidly due to a presumptive epidural or intradural hemorrhage. She was transferred to the Westminster Neurological Hospital. An emergency craniotomy was performed to explore the wound. At surgery, bite wounds were identified that penetrated the skin, skull, dura and even the brain parenchyma. Both the dura and brain was actively bleeding. Bone, skin and perhaps a tooth fragment were removed from the bite wound. All hemorrhage was arrested and the wound was carefully cleaned. Wounds were closed primarily. Over the next 3 days, she improved in her mental attitude with a cessation of seizures and return to normal appetite. She was still quite weak especially on the left side of her body and needed assistance in walking. She went home for further care. At the time of her suture removal 2 weeks after surgery, she was nearly 100% with just subtle left sided postural reaction deficits. She celebrated her recheck by running all over the exam room, jumping, cavorting and playing.