**2. Trauma management/advanced trauma life saving**

No matter the method of injury, Emergency Medicine (EM) physicians should always adhere to the Advanced Trauma Life Support (ATLS) protocol when initially assessing a patient. Studies have shown that patient outcomes are significantly improved when trauma teams follow the ATLS guidelines [7, 8]. Beginning with the primary survey, physicians should immediately assess the most vital and basic aspects of the patient's status [7, 8].

*Airway:* Determine the patency of the airway. Be aware of any tongue swelling, blood, or other possible causes of occlusions. Injuries or deformities of the neck and foreign bodies embedded in the soft tissue can also cause obstruction. Placement of a hard cervical collar if deemed necessary. Consider intubation if significantly occluded and all attempts to alleviate obstruction fail (jaw thrust maneuver, manual removal of any foreign body, etc) and bag-valve-mask technique is partial or ineffective. Preparation for a surgical airway may be indicated.

*Breathing:* Assess for difficulties with respiration as this may indicate an injury to the chest wall or pneumothorax. Palpate and visually inspect the chest wall for tenderness, crepitus, or deformity. If stable, consider imaging of the lung fields during the secondary survey.

*Cardiovascular:* Check central and peripheral pulses. Inspect the skin for color, warmth, and compromised blood flow. If there is an openly bleeding wound, apply pressure and/or tourniquet. During the primary survey, consider an ultrasound per FAST exam protocol. Follow the Advanced Cardiac Life Support (ACLS) protocol if the cardiac injury is suspected.

*Disability:* Using the Glasgow Coma Scale (GCS), determine the neurologic status of the patient. Assess the pupillary size, pupillary response, and consider Head/Cervical Spine CT (computer tomography) if concerns are present. Consult

#### *Current Concepts: Pediatric Dog Bite Injuries DOI: http://dx.doi.org/10.5772/intechopen.102329*

neurosurgery if there are alterations from baseline or alarming findings (Cushing's triad, asymmetric pupils, focal neurologic deficits).

*Exposure:* Remove all articles of clothing to obtain full inspection of any deformities, lacerations, bruising, or excoriations. Ensure the patient's core temperature remains stable.

Once the primary survey has been completed, the secondary survey can begin. The provider can gather specific details about the event, particularly involving the history of both the dog and patient. For the patient, ask questions about the medical history, surgical history, and immunization status. In particular, when did the patient receive their last tetanus vaccine, and if they have ever been vaccinated against rabies. Determine if the patient has any comorbidities including immunodeficiency, immunocompromised status, vaccine status, surgical/dental implants, or diabetes mellitus. Lastly, inquire about drug allergies, particularly to penicillin, given antibiotics are often required. Other necessary questions include the events leading up to the attack, was it provoked or unprovoked, how many dogs were present, time of injury, how much time has elapsed since the bite, what was done before presenting to the ED to clean the wound, the last time they ate/drank, and the location of the attack (for example, was it in a home, at a park, etc). If available, determine the dog breed, rabies vaccine status, and if the dog has a previous record of biting humans.
