Occult Boerhaave's syndrome without vomiting prior to presentation. Report of a case

PURPOSE: Cougar attacks on humans appear to be on the rise. A review of all attacks on children was performed to determine the method of attack and injury patterns so that a treatment regimen as well as possible preventative measures could be determined. METHODS: A review of all attacks, including attacks on children, was performed, including three recent attacks treated at our institution. Situation, adult supervision, patient age, injuries recorded, survival, and mode of attack, if known, were reviewed. RESULTS: There were 50 documented attacks on children with a 25% fatality rate. Most children were not alone at the time of the attack (92%), and in many instances adult supervision was present or nearby. Severe head and neck lacerations along with puncture wounds were the most common injury. Examples of typical cervical injuries include a nonfatal vertebral artery injury, phrenic nerve injury, a fatal internal carotid artery injury, and a fatal cervical spine injury. The cougar was rabid in two cases. Pasteurella resulted in late infections in two patients. CONCLUSIONS: Based on the pattern of injuries, the authors recommend aggressive evaluation for occult cervical injuries as well as surgical debridement. Antibiotics should cover oropharyngeal flora including Pasteurella multocida. Rabies prophylaxis is indicated. Adult supervision in wilderness areas is not necessarily protective.