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Abstract

Background

Traumatic attacks from large feline predators cause a small yet significant burden of disease in rural populations, are increasing in frequency, cause complex injuries and worsen human–wildlife conflicts. Data on the traumatic injury pattern found in victims of these animals is sparse, and this study aimed to collate and synthesise patterns of injury to inform the care and management of these patients.

Methods

A multi-ethnographic literature search (PubMed, Embase, Web of Science, Google Scholar, and other sources) was performed on 12/1/21 to capture all available data describing anatomical injury and the mechanism of injury sustained by humans from attacks by lions, leopards and tigers. Quality and bias assessment was performed using the Joanna Briggs Critical Evaluation tools.

Results

Of 5110 studies identified, 42 were included in this review totalling 84 individual patient cases. A total of 85% of fatal injuries were due to exsanguination combined with neuroaxis injury of the neck. All wounds were susceptible to tissue loss, infection and long-term neuro-vascular complications. Leopards injured anterior-midline structures of the neck more often than did lions and tigers, while the latter caused high-energy fractures. Time lag to treatment for survivors of wild attacks extended to multiple days, and occult injury was common.

Conclusion

In addition to the primary finding of complex neck injury, this study generated specific patterns of injury seen from the included species and highlighted occult injury and healthcare disparity as challenges in providing patient care.

Keywords

Trauma human–wildlife conflict big cat injury

Introduction

Injury patterns from apex predators such as felid carnivores are poorly described and understood.¹ While infrequent, attacks by Panthera species (lions, leopards and tigers) generate a significant burden of traumatic injury in communities that reside near these species. Many hundreds of attacks occur each decade in the habitat countries of lions,² leopards³ and tigers.⁴ Outside of habitat regions, large volume captivity in the global northwest,⁵ and encroaching suburbia into the wilderness of developing countries⁶ means the global number of attacks is rising.

This produces morbidity and mortality in communities that depend on agrarian occupations for subsistence,⁷ undermines conservation efforts and has become an important concern for those managing human–wildlife conflict.⁸

Available injury data from big cats is sparse and is largely confined to case reports,¹ with current management based on expert opinion and scoping trauma algorithms. Clinically the wounds inflicted are high energy, complex and require pre-hospital input and multi-disciplinary secondary care. Sequalae include polymicrobial infection,⁹ enduring neurology¹⁰ and complex bony and soft tissue neck wounds.⁵ Generating knowledge of common injuries or complications from the specific mode of injury of a big cat attack, may lead to earlier identification of occult and treatable injury at the scene, and within a hospital. Identifying these patients as victims of complex trauma may lead to earlier multi-specialty treatment. Overall, improved patient care may improve human–wildlife conflict relations, especially in the context of reduced human tolerance to living near conservation species.¹¹ This study, therefore, aims to generate both a general and species-specific injury pattern resulting from attacks by lions, leopards and tigers, so that future healthcare providers can plan for these unique types of injuries.

Methods

Registration and protocol

A structured pre-registered search protocol was registered with PROSPERO¹² (ID-CRD42020223448) and conducted according to PRISMA guidelines.¹³

The search protocol was completed with no deviation. After expert opinion suggested captive animals would attack similarly to wild animals, as they are non-domesticated, this study also included events from captive settings.

Endpoints were altered to focus on injury patterns alone due to the severe methodological heterogeneity found in studies quoting only mortality figures.

PEO and inclusion criteria

The population of this study included humans of any age, gender, sex and occupation in any geographic location worldwide, who had been exposed to traumatic injury or fatality from an attack by a lion, leopard or tiger (herein defined as ‘big cat’), whether wild or captive. Only these Panthera species were included. The primary outcome of interest was the descriptions of injuries sustained by the victims recorded alongside the species of cat. Secondary outcomes included the number of deaths and survivors of the attack, long-term complications and associated ethnographic data. The preliminary search indicated a prohibitive lack of human injury data from jaguars and they were excluded.

Only English language studies were included. There was no timeframe limitation, and all study types were eligible. Patients could only be included if the species of attacking animal was clearly stated as one of interest.

Search strategy and data collection

A multi-ethnographic search protocol was created including electronic databases PubMed, Embase, Web of Science (WoS) and Google Scholar, in addition to backwards and forwards searching of the included studies. A total of 60 organisations, field experts and government departments were contacted to supply new or supplementary data of which 11 responded (Supplementary Material: Appendix 1). The search terms for PubMed, Embase and Web of Science are found in Figure 1 and Supplementary Material: Appendix 2, while for Google Scholar, the search strategy included ‘Attack (species of big cat)’ for three searches, and ‘Bite (species of big cat)’ for three searches. The final study was included on 20/5/21 and all searches were conducted by the author JK.

Figure 1.

Pubmed search strategy.

Data screening and extraction

Reference titles and abstracts from all sources were screened manually for relevancy and reduced to a list for full-text retrieval by JK. Full texts were assessed for quality and content by two reviewers (JK and JLT) and reduced to the final list. The included studies data were extracted into Microsoft Excel^TM to comprise event demographics, wild/captive event, species of cat, injury description, complications and mortality.

Quality assessment

Risk of Bias combined with methodological quality was assessed with the Joanna Briggs Tools for Case Reports¹⁴ and Case Series¹⁵ by JK. Publication bias and selective reporting were addressed by contacting authors, governmental departments and non-governmental organisations, and the inclusion of grey literature from non-medical databases. Missing data were addressed by contacting the authors. Studies of poor descriptive quality were excluded and agreement on the final included studies was achieved by two reviewers (JK and JLT).

Meta-analysis

The descriptive nature of the endpoints and the apparent population, clinical and methodological heterogeneity prohibited a statistical meta-analysis. A narrative analysis was conducted, and key data synthesised included mechanism of injury, anatomical site most affected, wound characteristics and long-term complications. To account for the heterogeneity in the event demographics, subgroup analyses were conducted on captive versus wild exposures, adult versus paediatric injury patterns and the injury pattern inflicted by each species of big cat.

Results

Search results

A total of 5110 items from all sources were returned, of which 211 full texts were assessed for eligibility, yielding 42 included studies (Figure 2 and Table 1). Of those excluded; 103 lacked sufficient detail relating to injuries (including all author and organisational responses), five had inseparable data collated with other animals, 53 had no relevant data, six contained duplicated data and two were non-English language.

Figure 2.

PRISMA flowchart of search and study selection.

Table 1.

All included studies demographics, clinical outcomes and methodological quality.

Characteristics and outcomes of all included studies
Reference groups: Group A = Primary injury to neck, Group B = Any head injury, Group C = Isolated head and neck injury, Group D = Cervical spine fracture/dislocation
Author	Year	Location	Wild/Captive	Big Cat Species	Population characteristics	Exposure event	Main injuries	Injured/death	Reference groups	Quality scoreCase reports −/8Case series −/10
Agarwal	2020	India	Wild	Leopard	50 M	Attacked while cutting trees and dragged	Primary anterior neck wound – laryngo-pharyngeal injury	1 Injured	Group A Group B	7/8
Anderson	2008	United States	Captive Exotic Animal Farm	2 Siberian Tigers	36 F Farm Worker	Cleaning cage, attacked on leg first then neck	Neck wounds, cervical spine fracture, bilateral lower limb tissue loss	1 Injured	Group A Group D	7/8
Bahram	2004	United States	Captive Zoo	Leopard	55 F Zoo Volunteer	Feeding animals in cage	Soft tissue injury to face, neck and scalp	1 Injured	Group A Group B Group C	7/8
Bhandari	2019	Nepal	Wild, near village	Tiger	16 M	Investigating tiger sighting, a single paw swipe to face	Minor facial soft tissue Fracture mandible and zygoma	1 Injured	Group B Group C	6/8
Bock	2000	Germany	Captive Zoo	Lions	Male	Apparent suicide, entered lion cage deliberately	Primary neck wound with post-mortem scavenging	1 Death at Scene	Group A Group D	3/8
Burdge	1985	Case 1: Kenya Case 2: Canada	Case 1: Wild Case 2: Captive	Case 1: Lion Case 2: Tiger	Case 1: Young Masai Warrior Case 2: 11 F	Case 1: deliberate engagement with lion Case 2: seized from behind when helping in cage	Case 1: wounds to shoulder and thigh with infection Case 2: Neck wound with cervical spine fracture	2 Injured	Case 2: Group A Group B Group C Group D	7/8
Capitini	2002	United States	Captive Private Reserve	White Siberian Tiger	7 F Visitor	Broke through cage and picked up in jaws	Isolated chest wounds with subsequent Neisseria infection	1 Injured		7/8
Chapenoire	2001	France	Captive Animal Park	Tiger	49 M Animal Park Owner	Thrown to ground, grasped and dragged	Fatal neck wound with polytrauma	1 Death At Scene	Group AGroup D	5/8
Chowdry	1881	Unknown, Tavoy Hospital	Wild Jungle	Tiger	15 M	Attacked in jungle, returning from hills	Significant Maxillo-facial and ocular injury	1 Injured	Group B	6/8
Chum	2011	Canada	Captive Private Home	Siberian Tiger	11 M	Pounced on and mauled	Penetrating skull and neck wounds	1 Injured	Group AGroup BGroup C	7/8
Clark	1991	United States	Captive Circus	Tiger	10 M	Reached into cage and had arm attacked	Arm amputation	1 Injured		1/8
Cohle	1990	United States	Captive Family pet	Leopard	2 F	Found by mother as being attacked	Penetrating skull and neck wounds	1 Death at unclear timepoint	Group BGroup C	3/8
Daboub	2013	Bolivia	Captive Circus	Lion	8 M	Escaped from cage	Polytrauma – open wounds to head, neck, chest, and abdomen	1 Injured	Group B	6/8
Ďatko	2014	Czech Republic	Captive Zoological Garden	Lion	20 M Zoo Worker	Found lifeless in enclosure	Fatal injury to neck with head and thorax wounds	1 Death at Scene	Group AGroup BGroup D	6/8
Datta	1936	Unknown, Khobang Tea Estate	Wild	Leopard	2 cases of unknown age or gender	Unknown	Case 1 – scalp injury with rebleedCase 2 – Shoulder and scapula injury and infection	2 Injured	Case 1:Group BGroup C	1/10
Eashow	2007	Nepal	Wild	Tiger	50 M	Mauled	Isolated left arm injury	1 Injured		7/8
Emami	2012	Germany	Captive	3 Siberian Tigers	28-year-old patient Tamer	Slipped and fell, then was attacked while performing	Head injury with sub-total amputation left hand	1 Injured	Group B	7/8
Eyre	1986	Kenya	Wild	Leopard	Only one case of adequate detail out of 3	Unknown	Traumatic amputation of distal phalanx	1 Injured		6/10
Hadiza	2019	Nigeria	Captive Zoo	Lion	42 M Zookeeper	Attacked at zoo	Neck wounds, died of tetanus at day 3	1 DeathIn hospital	Group AGroup C	3/8
Hejna	2010	Czech Republic	Captive Zoo	Leopard	26 M Feline Caretaker	Found injured in cage	Neck wound, with cervical spine and vascular injury	1 DeathIn transit	Group AGroup BGroup CGroup D	3/8
Isolato	2000	Canada	Captive	Siberian Tiger	35M Trainer	Bitten once left palm	Tendon injury and tenosynovitis	1 Injured		8/8
Kanchan	2020	India	Captive Zoological Park	Tiger	35 M Caretaker	Found lying in a pool of blood in cage	Severe chest injury with additional neck injury	1 DeathIn hospital		4/8
Kelly	2020	South Africa	Captive Private Reserve	Bengal Tiger	54 F	Attacked by neck attempting to stroke animal	Neck wound, C1 fracture, left humeral fracture and transient cerebral ischaemia	1 Injured	Group AGroup D	7/8
Khanna	2004	India	Wild	Tiger	45 M	Mauled by tiger	Maxillo-facial wounds and fracture	1 Injured	Group BGroup C	5/8
Matthew	1872	Unknown, Midnapore Charitable Hospital	Wild	Leopard	Male labourer	Bitten on throat while cutting wood	Laryngo-pharyngeal injury	1 Injured	Group AGroup C	6/8
McGeachie	1958	Unknown	Unclear	Lion	Unknown	Bitten on right hand	Soft tissue injury to hand, subsequent infection	1 Injured		3/8
Murphy	2007	Ireland	Captive Zoo	Female Siberian Tiger	19 F Visitor	Hand through wire fence, bitten	Extensive isolated left arm injury	1 Injured		3/8
Nabi	2009	India	Wild	Leopard	35 patients total of 16 women, 8 girls, 9 men, 2 boys	Presenting to institution after leopard attack	Trauma concentrated to head, neck and face, fatality from great vessel injury	17 deaths at unclear timepoint, 2 delayed deaths in hospital, 16 survivors	Group AGroup D	3/10
Papadopoulos	1999	United Kingdom	Captive Safari Park	Bengal Tiger	49 M	Attacked from behind 27 years previously	Neck injury at index event, presented with tethered cord and syrinx	1 Injured	Group AGroup C	5/8
Pathak	2013	India	Wild	Bengal Tiger	35 F	Attacked collecting Tendu leaves	Fatal neck wound with cervical spine and vascular injury	1 Death at Scene	Group AGroup D	6/8
Pathak	2014	India	Wild	Tiger	34 F	Attacked collecting Tendu leaves Injuries from claws	Fatal wound to neck, penetrating thoraco-abdominal trauma	1 Death at Scene	Group AGroup B	6/8
Pawar	2018	India	Wild	Leopard	55 Farmer	Leopard attack	Maxillo-facial wounds and fracture	1 Injured	Group BGroup C	4/8
Perrone	2020	Italy	Captive Circus	4 Bengal Tigers	61 M Tamer	Stuck by paw while training, lost consciousness then attacked	Extensive head and neck injury with fractures of skull, neck and ribs, and lower limb wounds	1 Death at Scene	Group AGroup BGroup D	4/8
Pickles	1987	Southern Africa	Wild	Lion	Male	Attacked while asleep under tree	Isolated chest wound	1 Injured		2/8
Prayson	2008	Ethiopia	Wild	Lion	56 M Hunter	Attacked while hunting the animal	Soft tissue arm, open fracture leg	1 Injured		7/8
Rahman	2009	Bangladesh	Wild	Tigers – Likely Royal Bengal	6 Cases 17 M, 31 M, 42 M, 33M, 40 M, 46 M	Attacked while asleep or working	Mixed, 1 Maxillo-facial, 3 scalp injuries, 1 neck and chest injury, 1 abdominal injury	5 Injured 1 Death – Abdominal injury, in hospital	Group BGroup C	7/10
Schiller	2006	United States	Captive Private Zoo	Siberian Tiger	37 F	Cleaning cage, bitten on neck	Neck injury with cervical spine fracture, bilateral lower leg wounds with an open fracture	1 Injured	Group AGroup D	6/8
Srivastava	2013	India	Wild	Tiger	15 F	Attacked and dragged at night	Carotid dissection and right fronto-parietal infarct from blunt paw trauma	1 Injured	Group AGroup C	4/8
Szleszkowski	2017	Poland	Captive Zoo	Sumatran Tiger	58 M Zoo Employee	Jumped onto back	Fatal injury to neck including vasculature and cervical spine	1 Death at Scene	Group AGroup D	5/8
Tantius	2016	Germany	Captive Zoo's	2 Siberian Tiger, one per case at different zoos	Case 1: 43 FCase 2: 56 M	Zookeepers attacked	Case 1: Fatal neck wound with cervical spine destructionCase 2: Fatal neck wound with cervical spine injury	2 Deaths at Scene	Group AGroup BGroup D	6/8
Vogel	2000	United States	Captive Animal Sanctuary	Persian Leopard	53 F Visitor	Attacked, mauled and dragged	Fatal neck wound with polytrauma	1 Death at Scene	Group AGroup BGroup D	4/8
Wiens	1996	United States	Captive Exotic Animal Farm	Tiger	28 M	Attacked cleaning cage	Neck wounds with cervical spine injury	1 Injured	Group AGroup CGroup D	7/8

Table 2.

Summary of all infections with microbiological results.

Infections with microbiological results
Study	Species of cat	Swab/culture site	Time delay until infection or culture results	Microbiological growth
Anderson, 2008	Tiger	Anterior neck wound	Unknown	Coagulase-negative Staphylococcus
Capitini, 2002	Tiger	Thorax wounds	2 days	Neisseria weaveri Pasturella multocida – novel subspecies
Easow, 2007	Tiger	Forearm/elbow wounds	3 days	A. hydrophila, Escherichia coli
Isotalo, 2000	Tiger	Left palm wound	7.5 h	P. multocida, Bergeyella zoohelcum CDC group EF-4b Comamonas species
Burdge, 1985	Lion	Shoulder, thigh, deltoid, forearm wounds	24 h	Shoulder Wound – P. multocidaThigh, deltoid, forearm wounds – P. multocida, Staphylococcus aureus, Escherichia coli
Burdge, 1985	Tiger	Blood, cerebrospinal fluid and wound	24 h	Blood & CSF – P. multocida Wounds – P. Multcocida, E. Coli, Staphylococcus epidermidis, diphtheroids, α-hemolytic streptococci, Acinetobacter species
Nabi, 2009	Leopard	Unknown	Unknown	Rabies
Bharam, 2004	Leopard	Head and neck wound	5 days	P. multocida ‘rare’ coagulation-negative, Staphylococcus species ‘rare’ Neisseria species
Hadiza, 2019	Lion	Unknown	3 days	Tetanus
Prayson, 2007	Lion	Bone cultures	1st Bone Culture – 36 h2nd Bone Culture - growth at 2 weeks	1st Bone Culture – Bacillus cereus2nd Bone Culture – M. arginini
McGeachie, 1958	Lion	Hand wound	3 days	Pasteurella septica

Quality of included research

A total of 84 total patients’ cases were of a sufficient descriptive quality to facilitate data extraction; 38 studies were case reports and four were case series. Case reports described injuries in detail and were generally high quality with 21 studies scoring ≥ 6/8. Only five studies reported patient demographics adequately,^16–20 and detail of the clinical timeline and status on arrival to the hospital varied, including the recording of subjective observations such as ‘pale’²¹ and ‘toxic’²² rather than numerical clinical parameters. Only one case series scored highly in the domains⁹ for consecutive and complete inclusion. The largest study, numbering 35 cases, did not report consecutive or complete inclusion and pooled injury data from deceased patients and survivors.²³ A full quality assessment is found in Supplementary Material: Appendix 3.

Key characteristics of study population and exposures

Of the 84 cases from the included 42 studies, there were 31 tiger cases, 45 leopard cases and eight cases of a lion attack; 24 studies took place in captive settings and 16 in wild settings – one study included patients from both settings,²² and one study was unclear on the setting.²⁴

The captive-setting injuries mainly took place in the global northwest while attacks in the wild took place in habitat countries of continental Africa and Asia. Population demographics, activities and time of death in relation to the attack are recorded in Table 1, with a total of 50 survivors and 34 deaths, of which 10 were confirmed at the scene. There were nine^{10,21,22,25–30} paediatric cases of sufficient detail and only one paediatric fatality.²⁹

Pooled data from all cats: Anatomical injuries

Of 84 included cases, 40 sustained their primary injury to the neck (Table 1, Group A), of which 29 were fatal. The anterior and posterior triangles were equally affected, and wounds were spaced at the extremes of the neck by paired infra-auricular and supraclavicular wounds. The second most wounded was the head, including face and calvarium, with one fatal injury²⁹ and 10^{9,25,27,31–34} primary injuries in survivors. Additionally, a large proportion of all cases, no matter their primary injury, sustained at least one head wound (Table 1, Group B).

There were six^{9,18,26,35–37} primary injuries to the thorax with two fatalities,^18,35 the only case of isolated abdominal injury proved fatal,⁹ and all cases involving only limb injuries survived.^{20,22,24,28,38–41}

Pooled data from all cats: Pattern of injury themes

An attack confined solely above the clavicles was the most common injury pattern (Table 1, Group C) (Figure 3). Of the eight patients who sustained only limb injuries, four were results of captive events^28,38 or attempts to engage the animal.^22,40 Polytrauma with multi-organ involvement was frequent (n = 10)^{5,16,18,21,35,36,42–45} and lethal with only three survivors.^5,21,42 Deaths at the scene or in transit were due to combined exsanguination from carotid sheath contents and lethal neuroaxis injury. The five deaths in those surviving to hospital arose from infection in four cases – rabies²³ from a leopard, tetanus⁴⁶ from a lion and two cases of sepsis.^9,23 Only one patient died in hospital from bleeding,³⁵ while all other exsanguination deaths occurred prehospital. All species dragged their victims once clasped in their jaws with distances reaching 60 m⁴⁴ and associated wound contamination was recorded in 38 patients.^5,6,23,32 Transfixion of the neck by canines was identified in six cases,^{5,19,42,43,47,48} and was a causal agent of spinal injury^{5,19,43,47,48} and vascular injury^42,48 due to ligamentous rupture and vessel shearing.

Figure 3.

Common patterns of injury.

Pooled injury pattern of all cats: Wound morphology and fracture pattern

Wounds from bites and claws were deep, involved neurovascular structures and tracked to the cervical spine⁴⁸ and base of the skull.¹⁷ Except for six cases where paws or claws were the main inflictor,^{9,10,18,22,25,31} bites were the primary vehicle of injury. Bite wounds were paired^{17,36,43,44,48} consisting of two to four wounds separated in space generating large oval injuries at the skin with diameters of 2–3 cm,^17,35,48 and depths up to 7 cm,⁴⁴ with a surrounding soft tissue crush injury.⁴⁹

Teeth caused direct fracture to the skull²⁹ and cervical spine,⁴⁸ and deep longitudinal scalp wounds were a common source of bleeding in 16 cases.^{6,9,16,17,21,22,27,29–31,33,44,50,51}

Penetrating thoracoabdominal trauma was principally perpetrated by claws (n = 8).^{18,19,31,35,36,43,45,48} Claw wounds were lesser in diameter,¹⁸ linear rather than oval and typified by superficial grazes leading to the puncture site.^16,48 Blunt injuries such as facial fractures,²⁵ vascular shearing¹⁰ and unconsciousness³⁶ were results of single paw swipes or holds.

Ongoing bleeding was recorded in 11 cases at prolonged intervals post-trauma,^{6,9,21,27,31,34,49} ranging from 5 h⁶ to more than 2 days (n = 2).^31,34 Infection and inoculation were noted in 16 cases^{9,20,22,23,26,31,39,40,42,44,46,50} and was often polymicrobial with unusual organisms (Table 2). Long-term complications manifested in enduring hemiplegia,^10,22 single limb weakness,^5,49 pseudomeningocele,⁴² syrinx⁵² and pharyngeal and swallowing problems.^30,53 Compound cervical spine fracture or dislocation was common (Table 1, Group D) and included multilevel injury in seven patients^{16,19,36,42,43,45,48} (Figure 4). Mandibular fracture^{6,9,17,25,29,34,36} accounted for 70% of maxillofacial fractures, and the temporal and occipital bones were the most fractured of the calvarium.^{21,22,29,30,36}

Figure 4.

Frequency of cervical spine injury per level.

Unique injury patterns per species

Differences between species were found in the global fracture pattern, and bite locations of the neck. Fractures below the clavicles were more common in lions and tigers (Figure 5), the latter causing bilateral rib fractures,^35,36 a scapula fracture³⁵ and the only sternal fracture-dislocations in this review.^19,36 Cervical spine injury pattern in tigers involved the higher and lower spinal levels with only one recorded C4 fracture,³⁶ while lions fractured lower spinal levels (Figure 4).

Figure 5.

Numbers of pooled fractures from all big cats.

Neck injuries from leopards were distinct in anterior midline-structure involvement and had a higher association with pharyngeal, laryngeal and oesophageal injury (n = 12),^6,23,44,53 rarely seen in the other cats (Figure 6).

Figure 6.

Summary of wounds sustained by victims of each big cat, including survivorship.

Lion injuries included both pride-based and solitary attacks in a wide range of captive and wild settings, including three cases of deliberate engagement with the animal (one person hunting,⁴⁰ one ritual fight²² and one suicide⁴⁵). Lions engaged in two episodes of post-mortem scavenging including the bowel and genitals^16,45 which was not seen in the other cats where limbs were predominantly attacked post-mortem.^44,48

Paediatric and captivity analysis

Paediatric injury patterns did not differ from adults, with primary head or neck injury remaining the dominant injury form in 78% of victims.^{10,21,22,25,27,29,30} The sole paediatric fatality was due to polytrauma from a leopard in a 2-year-old female with major skull and neck wounds.²⁹

Head and neck also remained the most injured region irrespective of location or captivity (wild 56%, captive 73%). Captive settings introduced unusual injury patterns in the form of the isolated mauling of limbs placed through cage bars^28,38 and the participation of multiple tigers, who typically hunt alone, in an attack (n = 3).^33,36,42

Of the 83 cases where the setting was clear, deaths in the wild group (n = 22, 53%) were slightly commoner than in the captive group (n = 11, 46%); however, 17 of the wild deaths were from a low detail case series and further commentary was unfeasible.²³

Of the recorded times to the hospital, the median time in the wild group was long at 18 h (range 2–96 h) versus a median time of 5.5 h (range 0.16–7.5 h) in the captive group.

Discussion

This study demonstrated attacks by big cats are typified by open cervical spine fractures, exsanguinating jugular-carotid injury and complex soft tissue neck wounds caused by bites; in survivors, this produced infection, cerebrovascular pathology and occult injury. The soft tissue and bony injury patterns seen in this study correlate well with known large felid anatomy and physiology surrounding their canines, claws and hunting techniques.

The teeth of big cats can apply high bite forces to bone (up to 2152 N⁵⁴) causing compound fractures.⁴⁸ Additionally, tiger canines can reach 7 cm in diameter and 9 cm in length¹⁹ with inter-canine distances of 4–6.8 cm^17,29 recorded in this study for leopards, and 7–9 cm for tigers.^19,48 This explains the location of the large, paired bite wounds at the inferior and superior extremes of the neck seen in this review. These anatomical features combined with canine proprioception, a physiological trait allowing them to target intervertebral spaces with their teeth,^17,43 accounts for the bony, ligamentous and spinal cord injuries seen.

The claws of big cats, reaching lengths of 10 cm,¹⁸ are less rounded and more blade-shaped than the canines and inflict deeply penetrating yet appearing superficial incisional wounds.¹⁸ Carrying these claws are the muscular paws and forelimbs, and combined, can inflict serious visceral and orthopaedic injury with little outward sign.^18,35,36 Therefore, all wounds, whether from claws or canines should be evaluated individually to avoid missing serious and treatable pathology.

The high survivorship despite extensive neck wounds in 11 cases^{5,6,9,10,21,22,30,42,47,49,53} may be due to the sparing of the great neck vessels, of which no surviving patients had penetrating injuries. Cervical spine fracture was still common in these surviving patients (n = 5)^{5,22,42,47,49} and so even superficial neck wounds should raise suspicion of occult spinal injury.^5,54

The greater number of fractures outside of the neck and head region seen in lions and tigers is likely due to their preferred hunting method of knocking large prey to the floor with their body weight,^16,18,34 which is > 200 kg for adult male Siberian (Amur) tigers,²⁶ a pattern not seen in leopards who weighed substantially less in this review (maximally 72 kg¹⁷). Leopard attacks however displayed a preponderance of anterior midline structures injury of the neck, which may be due to their natural targeting of anterior structures such as the carotid sheath.¹⁷

Notable was the lack of haemostasis in 11 cases, where bleeding persisted for up to 2 days, mostly from capillary ooze, which may be explained by the degree of associated crush injury.⁴⁹ This is an important haemodynamic consideration for those delayed in seeking healthcare, which is likely in the rural locations these attacks occur.⁵⁵ The reasons for these time delays to attend a treatment facility in wild cases were not well documented, although the event was often remote from definitive facilities^6,21 (up to 30 miles⁹) and in areas with poor access to transport.^9,22 Delays to definitive care also existed in high-income countries with transfers from local hospitals to specialist centres,^20,22 highlighting the need to recognise the complexity of these injuries at the scene.

Infection was responsible for 80% of in-patient deaths and addressing infection should form part of the holistic treatment for those surviving to hospital. The polymicrobial nature of these infections fit recorded examples from big cat bites,³⁹ who are prone to impart tetanus, rabies²³ and species-specific pathogens such as P. multocida.²⁶ The high survivorship seen in paediatrics may be due to the child either being rescued^10,27,30 or the attack itself is short,^22,28 preventing further injury. In paediatric cases, the animal frequently had to be moved, killed, or distracted before victims could be attended too.^{10,18,19,27,43,47,51,52}

Thus, these injuries occur in remote locations with on-scene threats from the animal, and appropriate trauma services are usually located an average of 126 min⁵⁶ by road from wildlife reserve entrances. Given the primary mode of death is exsanguination, this introduces time and hazard barriers to key medical interventions. These attacks, therefore, generate public-health needs surrounding trauma care infrastructure, which has not followed the human population into these remote regions.⁶

There was little difference in the resulting anatomical injury pattern regardless of captivity status or population characteristics. These are non-domesticated animals, and despite being held in captivity they appeared to instinctually attack as though in the wild,^17,35 aiming for the neck.

An apparent gap existed between the high number of recorded attacks globally, and the documented attacks available for review, of which only 42 studies were found. This bias is likely multi-factorial due to the rurality of the exposure, reporting to local authorities,⁷ lack of reporting by local authorities^3,7 and the availability⁵⁷ and affordability^58–60 of health services in habitat countries. Collectively the challenge to human–wildlife conflict within the scope of human injury not only lies in the medical complexity of these injuries but the health-inequity relating to trauma care in those areas most affected by animal-related incidents.

Limitations

Habitat countries are non-English primary language regions highlighting the language restriction as an inherent flaw in researching regional topics without local stakeholders, which other researchers have attempted to address.⁶¹

Publication bias from a selection of high-interest cases was identified in high-income countries; only nine cases were included from the United States when it is recorded that up to nine attacks per year from captive tigers may occur.⁶²

The quality varied in all included papers with a heterogeneous final data set in methodology, population and exposure. The inclusion of the large case series by Nabi et al.²³ describing leopard attacks as a group rather than individual cases may have introduced reporting bias, especially surrounding the finding of oesophageal and pharyngeal injury where the survivorship was not known.

Conclusion

This review demonstrates a clear pattern of injury inflicted by big cats, involving complex bony, neurovascular and soft tissue wounds to the neck. These were survivable if patients made it to the hospital. If occurring, fatality did so at the scene and was due to exsanguination and central nervous system injury, highlighting a public health and pre-hospital care opportunity for improved outcomes.

Further research should be founded in the form of a dedicated, species-specific, big cat study including government and community stakeholders to facilitate complete and consecutive inclusion, and precise case details.

Footnotes

Acknowledgements

We would like to thank Jacqueline Rappoport for their kind guidance on the initial formatting of this project. I would like to thank all those organisations and experts around the world who replied to the authors request for information without whom this review would not have been possible.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Provenance and peer review - Not commissioned, externally peer reviewed.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical approval

Ethical approval was not sought for this article because it is a systematic review of previously published material.

Informed consent

Informed consent was not sought for this article because it is a systematic review of previously published material.

Trial registration

Not applicable - this article is not a trial.

Contributorship

JK was the primary author and reviewer. JLT was the secondary reviewer, provided veterinarian expertise and contributed significantly to the authorship. CT assisted significantly in the authorship and provided extensive expert guidance on the topics of this review.

ORCID iD

Jack Kirtland

Supplemental material

Supplemental material for this article is available online.

Correction (February 2024):

This article has been updated to move the Appendices to Supplemental Material since its original publication

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Traumatic injury patterns in humans from large feline predators: A systematic review and descriptive analysis

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Registration and protocol

PEO and inclusion criteria

Search strategy and data collection

Data screening and extraction

Quality assessment

Meta-analysis

Results

Search results

Quality of included research

Key characteristics of study population and exposures

Pooled data from all cats: Anatomical injuries

Pooled data from all cats: Pattern of injury themes

Pooled injury pattern of all cats: Wound morphology and fracture pattern

Unique injury patterns per species

Paediatric and captivity analysis

Discussion

Limitations

Conclusion

Footnotes

Acknowledgements

Declaration of conflicting interests

Funding

Ethical approval

Informed consent

Trial registration

Contributorship

ORCID iD

Supplemental material

Correction (February 2024):

References