“The world’s most dangerous bird,”1 the cassowary, is known to have killed two people in the last hundred years – an Australian boy in 1926 and a Florida man in 2019. Like their cousins the ostrich and emu, cassowaries cannot fly, but they can jump up to two meters off the ground and can run up to 50 kilometers an hour.1 Their feet have three toes with sharp claws on them, and the claws are 10 cm long.1 (Figure 1) The southern cassowary, weighing up to 85 kg is the second largest bird in the world after the ostrich, and is the largest bird in Australia.2
Cassowaries attack humans for only a few reasons. Cassowaries that expect or solicit food constitute 73% of attacks. Like most animals, they will defend themselves (15 percent of attacks) and their offspring. Females lay four eggs, which the male incubates for two months and then cares for the chicks nine more months.2 In the 2019 case, police speculated that the male cassowary was protecting the nest.
Case Report
On April 12, 2019, a 75-year-old male went into the enclosure where two southern cassowaries were kept to collect an egg, when the bird attacked.3 At some point the male fell, and the bird inflicted multiple puncture wounds. The victim was able to climb out of the pen. A 911 call was made.4 According to one report, the victim said on the call, “I’m bleeding to death.”5 He was also able to call his daughter who was at his side when the ambulance arrived, and a second call to emergency services.4 This attack wasn’t witnessed, and there is no available documentation that the victim explained what happened.
Emergency medical services (EMS) arrived and placed a tourniquet above the brachial artery injury on his right arm. The patient was not responding and had a Glascow Coma Score of three, so they placed a supraglottic airway. Due to concern for pneumothorax from puncture wounds and lacerations to his right chest, needle decompression was performed. The patient had a pulse. Due to significant blood loss, they started crystalloid resuscitation fluids.
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He had multiple irregular, linear, and curvilinear abrasions and lacerations on his face, neck, trunk, and extremities that were bandaged in route. The patient remained in critical condition in the emergency department where he received mass transfusion protocol. Due to the extensive thoracic injuries, an exploratory thoracotomy and laparotomy were performed. He was then whisked to the operating room for further interventions. While in the OR, he went into traumatic arrest, was resuscitated, but ultimately succumbed to his injuries within a few hours.
In four of the seven previously documented attacks resulting in serious injury, the cassowary jumped on top of the victim.2 This likely occurred in this case based on the number of lacerations and abrasions on the body. We can only speculate about which injury caused the victim’s death. Based on the number and severity of the wounds, many of which alone could have been fatal, this man likely died due to the systemic effects of mass trauma, rather than any single reparable injury.
Discussion
Emergency services providers never know what they will see when they arrive on scene. In this case, the EMS providers took the right steps to maintain cardiovascular stability enabling the patient to survive to the hospital. Using the Massive hemorrhage, Airway, Respirations, Circulation, Head injury/Hypothermia (MARCH) mnemonic, we will discuss evaluation and treatment of specific injuries caused by animal attacks including punctures, lacerations, and fractures, that require intervention prior to the arrival of medical transport.
Massive Hemorrhage
The patient should be evaluated first for massive bleeding. Tourniquet application performed emergently on an extremity must be done for significant arterial bleeding but is rarely needed for venous bleeding unless it is a large proximal vessel. Commercially designed tourniquets are most effective.6 If commercial tourniquets are not available, a blood pressure cuff can be inflated in place of a tourniquet until the blood flow stops. Another option is to take a piece of cloth folded to a wide band (4 cm or 1.5 in), using a strong cylinder as a windlass, and tying it in place.7
If the carotid artery or jugular veins are injured, there is little that can be done in an austere environment other than applying a hemostatic dressing if one is available and evacuating the victim as soon as possible.7
Airway
Puncture wounds and lacerations can affect the airway. Facial trauma can cause bleeding that compromises the airway. Patients with bleeding into their airway should be placed on their side, to prevent aspiration of blood or secretions. Every attempt should be made to maintain cervical spine stability, but in a single rescuer situation airway is the priority.
Neck trauma can cause swelling that will compress the airway. In the austere setting, there is rarely the equipment to provide a definitive airway, however if the swelling was life threatening and above the cricothyroid membrane, an emergency cricothyrotomy could be done if equipment and an experienced provider are available.
Respiratory System
Puncture wounds of the thorax can cause significant and emergent problems with the respiratory system. A puncture wound into the chest cavity can cause a pneumothorax, the collapse of a lung. In the average person with no health problems, a single collapsed lung isn’t fatal. Place the patient in the recovery position (on their side) with the injured side down. The unaffected lung has increased ability to function without the pressure of the heart and blood vessels weighing on it. It is important to monitor for respiratory or circulatory system decline due to other internal injuries such as a tension pneumothorax or hemothorax.
A “sucking chest wound” often leads to a more serious type of pneumothorax, a tension pneumothorax, in which the air goes into the lung and gets trapped. Many times, the opening in the thorax causes a sucking noise when the patient breathes. If there is any concern that a puncture wound enters the lung, it should be covered with an airtight patch taped on three sides to prevent air trapping. This patch prevents air from entering the wound but allows trapped air to escape on exhalation.
If the patient develops a tension pneumothorax, increased air volume shifts the heart and major blood vessels away from the collapsed lung, placing pressure on the remaining good lung, and can lead to death. Initial signs of tension pneumothorax include tachycardia, narrowing pulse pressure, diminished or absent breath sounds, severe dyspnea, hypotension and hypoxia. A tension pneumothorax may cause a shifting of the trachea away from the middle of the neck to one side, however this is a late sign, as is jugular venous distension. Treat suspected tension pneumothorax with immediate needle decompression (>6 cm long angiocath) in the fourth intercostal space mid-axillary line (preferred in the ATLS 2019 update) or 2nd intercostal space mid-clavicular line.8 If no angiocath is available, a finger thoracostomy can be done in the fourth intercostal space mid-axillary line to relieve pressure as a life-saving maneuver.8
Massive hemothorax can cause similar symptoms to a tension pneumothorax. If the patient has no jugular venous distension, dullness on lung percussion, and no tracheal deviation, it is less likely to be a pneumothorax.8
Circulatory System
Significant blood loss causes decreased tissue oxygenation, which leads to hypothermia, causing decreased coagulation and increased blood loss. Check the patient’s front and back for additional injuries. Wounds should be visualized, cleaned, and dressings placed. Fractures should be splinted to prevent additional blood loss, especially if they include the pelvis or femur. Use a tourniquet on extremities if the bleeding doesn’t stop with pressure. Every person in the wilderness should have a tourniquet in their first aid kit as well as the ability to jury-rig at least one more. With a limb injury, if the first tourniquet doesn’t work, place another one more proximal to the body to prevent compartment syndrome. If you have Tranexamic acid available, use it within the first three hours after injury.
Hypothermia/Hyperthermia
Hypothermia, one leg of the lethal trauma triad along with coagulopathy and acidosis, is the most likely temperature concern after an animal attack due to exposure and hemorrhagic shock. Hypothermia is directly due to blood loss and exposure. After ensuring that blood loss is stopped, use clothing and blankets to prevent the patient from getting too chilled. Core temperatures cannot be replaced by less invasive options. Peripheral temperatures read lower than core temperatures by one-to-two degrees, and 20 percent of fevers in the emergency department are initially missed when only peripheral temperatures are utilized.9
Conclusion
No matter how rare a traumatic event causing significant bodily injury, following the MARCH mnemonic, and looking for specific physiologic problems, will save lives.
Financial/Material Support: None
Conflicts of Interest: None
References
- Alliance SDZW. Cassowary. San Diego Zoo website. https://animals.sandiegozoo.org/animals/cassowary. Published 2021. Accessed March 11, 2021.
- Kofron CP. Attacks to humans and domestic animals by the southern cassowary (Casuarius casuarius johnsonii) in Queensland, Australia. J Zool. 1999;249(4):375-81.
- Le T. Man killed by cassowary may have tried to get the bird’s egg. Alligator. https://www.alligator.org/article/2019/04/man-killed-by-cassowary-may-have-tried-to-get-the-bird-s-egg. Published 2019.
- McDonald L. Breeder killed by his large Australian pet bird that attacked him with its four inch ‘dagger-like’ claws. Daily Mail. https://www.dailymail.co.uk/news/article-6927831/Florida-man-75-killed-worlds-dangerous-bird-did-not-permit-animal.html. Published 2019. Accessed March 21, 2021.
- P A. After man calls 911 and dies, experts say he made a fatal mistake near the world’s most dangerous bird. LittleThings.com. https://littlethings.com/lifestyle/cassowary-dangerous-bird. Published 2019.
- Bulger EM, Snyder D, Schoelles K, et al. An evidence-based prehospital guideline for external hemorrhage control: American college of surgeons committee on trauma. Prehospital Emerg Care. 2014;18(2):163-73. doi:10.109/10903127.2014.896962
- Quinn RH, Wedmore I, Johnson EL, et al. Wilderness medicine society practice guidelines for basic wound management in the austere environment: 2014 update. Wilderness Environ Med. 2014;25(4):S118-33. doi:10.1016/j.wem.2014.08.015
- Galvagno SM, Nahmias JT, Young DA. Advanced Trauma Life Support Update 2019: Management and Applications for Adults and Special Populations. Anesthesiol Clin. 2019;37(1):13-32. doi:10.1016/j.anclin.2018.09.009
- Hernandez JM, Upadhye S. Do peripheral thermometers accurately correlate to core body temperature? Annals of Emergency Medicine. 2016;68(5):562-63.
