Shark bites are rare but potentially devastating traumatic injuries that predominantly affect the extremities and require a trauma-based approach with special attention to hemorrhage control, marine-specific wound microbiology, and delayed primary closure. Overall mortality is approximately 8.3%, with death primarily driven by vascular injury and exsanguination. [1-2] Most injuries (42%) are minor (SIT Scale Level 1), but 55% of patients presenting to trauma centers require immediate operative intervention. [3]
1. History
- Circumstances of attack: provoked vs. unprovoked, activity at time (surfing, spearfishing, swimming, diving) [4-5]
- Shark species if known (white, tiger, and bull sharks account for most serious attacks) [5]
- Body part(s) bitten, number of bites, estimated duration of contact
- Water type (saltwater vs. brackish) — informs microbiology [6-7]
- Time from injury to presentation; prehospital interventions (tourniquet, direct pressure, immobilization)
- Submersion time, aspiration of water, loss of consciousness
- Estimated blood loss (pooling, soaked clothing, bystander reports)
- Tetanus immunization status [8]
- Immunocompromised state, liver disease, diabetes — increases risk of Vibrio infection [9-10]
2. Alarm Features
- Active arterial hemorrhage or uncontrolled bleeding despite direct pressure
- Hemodynamic instability (tachycardia, hypotension, altered mental status)
- Traumatic amputation or near-amputation
- Vascular injury to major vessels — mortality exceeds 50% in the La Réunion series when major vessels were involved [2]
- Compartment syndrome signs (tense compartment, pain with passive stretch)
- Deep wounds penetrating joints, abdomen, or thorax [11]
- Signs of hypothermia from prolonged water exposure
- Rapidly progressive cellulitis or hemorrhagic bullae (suggests Vibrio vulnificus) [10]
3. Medications
- Empiric antibiotics for saltwater-contaminated wounds — must cover marine gram-negative pathogens (Vibrio spp., Aeromonas, Pseudomonas): [6-7]
- First-line: Doxycycline 100 mg IV/PO q12h + ceftazidime 2 g IV q8h, OR a fluoroquinolone (ciprofloxacin 400 mg IV / 500 mg PO q12h or levofloxacin) [6-7][12]
- Oral alternative for minor wounds: fluoroquinolone monotherapy or doxycycline [11][13]
- Amoxicillin-clavulanate alone is insufficient — does not reliably cover Vibrio spp. [11]
- Penicillin, ampicillin, erythromycin, and first-generation cephalosporins are not acceptable for marine wound infections [11]
- Tetanus prophylaxis: Tdap if last dose >5 years ago or <3 lifetime doses [8]
- Pain management: regional nerve blocks, parenteral opioids, ketamine for procedural sedation
- Tranexamic acid (TXA) 1 g IV within 3 hours of injury if significant hemorrhage [14]
- Rabies prophylaxis is not indicated (sharks are not mammals)
4. Diet
- NPO if operative intervention anticipated
- No specific dietary triggers or long-term dietary management
- Adequate hydration and nutrition during recovery to support wound healing
5. Review of Systems
- Neurologic: numbness, weakness, or loss of function distal to wound (nerve injury in 32% of hospitalized cases) [4]
- Vascular: pulselessness, pallor, coolness distal to injury
- Musculoskeletal: inability to move affected limb, deformity (fractures in 18%) [4]
- Respiratory: dyspnea, cough (aspiration, near-drowning)
- Constitutional: fever, chills (early infection or systemic inflammatory response)
- Skin: spreading erythema, bullae, crepitus (necrotizing soft tissue infection)
6. Collateral History and Family History
- Bystander account of attack (duration, shark behavior, water conditions)
- Prehospital interventions by lifeguards or bystanders (tourniquet application is a key survival factor) [2]
- Family history is generally not relevant
- Social context: occupation (commercial fishers, dive operators), recreational activity, travel location
7. Risk Factors
- Activities: surfing, spearfishing (most common context, 32%), swimming, diving [4-5]
- Geographic hotspots: Florida (49% of US attacks), California, Australia, South Africa, Réunion Island [5]
- Time of day: bimodal distribution around noon and early evening [15]
- Murky water, presence of bait fish, spearfishing with catch
- Risk factors for severe wound infection: chronic liver disease, immunosuppression, diabetes, iron overload states (dramatically increase Vibrio vulnificus mortality) [9-10]
8. Differential Diagnosis
- Boat propeller injury — parallel lacerations, often more uniform pattern
- Other marine animal injury — barracuda bite (narrower, more linear), stingray (puncture with envenomation)
- Coral laceration — superficial, irregular abrasions with retained foreign body
- Blunt/penetrating trauma from underwater objects
- Distinguishing feature of shark bites: crescent-shaped or semicircular wound pattern, tissue avulsion, disarticulation (unique to shark attacks) [2][16]
9. Past Medical History
- Prior shark encounters or marine injuries
- Chronic liver disease, cirrhosis, hemochromatosis — dramatically increases Vibrio vulnificus mortality (>50%) [9-10]
- Immunosuppression (HIV, transplant, chemotherapy)
- Diabetes mellitus, chronic kidney disease
- Anticoagulant or antiplatelet use (increases hemorrhage risk)
- Splenectomy (increased infection risk)
- Surgical history relevant to affected limb
10. Physical Exam
- Primary survey (ATLS): Airway, Breathing, Circulation — hemorrhage control is the immediate priority
- Vital signs: heart rate, blood pressure, respiratory rate, temperature, SpO2
- Wound assessment: location, depth, tissue loss, exposed bone/tendon/joint, wound pattern (crescent/semicircular), number of bite sites
- Vascular exam: distal pulses (palpation and Doppler), capillary refill, skin color/temperature
- Neurologic exam: motor and sensory function distal to wound (nerve injury in 32%) [4]
- Musculoskeletal: range of motion, joint stability, crepitus, deformity
- Assess for compartment syndrome: tense compartments, pain with passive stretch
- Full secondary survey for additional injuries (13% had both upper and lower extremity injuries) [3]
11. Lab Studies
- Type and crossmatch — anticipate need for transfusion
- CBC, BMP, lactate, coagulation studies (PT/INR, PTT, fibrinogen)
- Blood gas (assess for acidosis from hemorrhagic shock)
- Wound cultures — alert microbiology lab to supplement media with NaCl for marine bacteria [11]
- Blood cultures if signs of systemic infection
- Consider viscoelastic testing (TEG/ROTEM) for massive hemorrhage to guide resuscitation [17-18]
- Liver function tests if concern for underlying liver disease (Vibrio risk stratification)
12. Imaging
- X-ray of affected area — identify retained shark tooth fragments (radiopaque), fractures [3][11]
- CT angiography if concern for vascular injury (27% of hospitalized cases) [4]
- CT of chest/abdomen/pelvis if truncal involvement
- Ultrasound (FAST exam) if concern for internal hemorrhage
- Imaging is unnecessary for superficial abrasions without deep tissue involvement
13. Special Tests
- Shark-Induced Trauma (SIT) Scale — severity scoring system (Levels 1–5) to standardize communication: [1]
- Level 1 (42%): superficial lacerations/abrasions
- Level 5 (8%): massive tissue loss, major vascular injury, fatal or near-fatal
- Injury Severity Score (ISS) — median ISS of 5 in US trauma data [3]
- Point-of-care ultrasound for vascular assessment and FAST
- Ankle-brachial index (ABI) if concern for lower extremity vascular injury
- Compartment pressure measurement if clinical suspicion
14. ECG
- Indicated if hemodynamic instability, significant hemorrhage, or near-drowning
- Assess for signs of hemorrhagic shock: sinus tachycardia, ST changes from hypoperfusion
- Evaluate for hypothermia-related changes (Osborn waves, bradycardia) if prolonged cold water exposure
- Electrolyte-related changes (hyperkalemia from crush injury or massive transfusion)
15. Assessment
Shark bites produce a unique injury pattern characterized by crescent-shaped lacerations, tissue avulsion, and potential disarticulation. [2][16] Injuries predominantly affect the extremities (47% lower, 40% upper). [3] The most common context is recreational water activity. Severity ranges widely — 42% are minor (Level 1 SIT), but 83% of trauma center patients require surgical debridement, flap coverage, or skin grafting, and 11% require amputation. [3] Infectious complications are relatively uncommon (~9%) when appropriate empiric antibiotics are administered, but identified pathogens are characteristically polymicrobial and marine-derived (Vibrio spp., Pseudomonas, Aeromonas). [4][13] Immunocompromised patients and those with liver disease are at extreme risk for fulminant Vibrio vulnificus sepsis. [9-10]
16. Treatment Plan
Initial stabilization:
- Hemorrhage control: direct pressure, tourniquet for extremity bleeding — prehospital tourniquet application is strongly associated with survival in major vascular injuries [2][19]
- Damage-control resuscitation: permissive hypotension (target SBP ~80–90 mmHg until surgical hemostasis), balanced transfusion (1:1:1 ratio of PRBC:FFP:platelets), minimize crystalloid [17-18]
- TXA 1 g IV if within 3 hours of injury [14]
Wound management:
- Copious irrigation with normal saline
- Thorough exploration and debridement under aseptic conditions [1][6]
- Remove retained foreign bodies (shark teeth fragments)
- Delayed primary closure at 24–72 hours is preferred over immediate closure for contaminated marine wounds [20]
- Deep wounds into joints, abdomen, thorax, or fascial compartments of hand/foot require OR exploration [11]
Antibiotics:
- Empiric coverage for marine pathogens: doxycycline + ceftazidime (IV) or fluoroquinolone [6-7]
- Adjust based on wound cultures; alert lab to use NaCl-supplemented media [11]
Tetanus prophylaxis per guidelines [8]
Surgical intervention:
- 83% require debridement/grafting; 59% require orthopedic intervention; 28% have neurovascular injuries requiring repair [3]
- Amputation in ~11% [3]
17. Disposition
- Admission criteria: hemodynamic instability, major vascular/nerve injury, fractures, deep/extensive wounds requiring OR debridement, need for serial wound assessments, significant tissue loss [3]
- 96% of patients in the National Trauma Data Bank were admitted; 53% required ICU (median ICU stay 4.5 days) [3]
- Median hospital stay: 4–5 days [3-4]
- Discharge criteria: hemodynamically stable, minor superficial lacerations without neurovascular compromise, reliable follow-up — approximately 78% of ED-presenting patients in one series were safely discharged [15]
- Trauma center referral: all significant shark bites warrant referral to a trauma center capable of comprehensive surgical care (orthopedic, vascular, plastic surgery) [3]
- Specialist consultation triggers: vascular surgery (major vessel injury), orthopedics (fractures, joint involvement), plastic/reconstructive surgery (tissue loss, flap coverage), hand surgery (hand injuries), infectious disease (immunocompromised patients, Vibrio concerns)
18. Follow Up / Return Precautions
- Follow-up timing: wound check at 24–48 hours for delayed primary closure assessment; subsequent visits at 5–7 days for suture/staple management and infection surveillance [20]
- Return immediately for: fever, increasing wound pain/redness/swelling, purulent drainage, hemorrhagic bullae, red streaking (lymphangitis), signs of systemic illness
- Wound cultures should be obtained if signs of infection develop; alert lab to marine pathogen protocols [11]
- Physical/occupational therapy referral for nerve injuries and post-surgical rehabilitation
- Psychological support — PTSD screening is appropriate given the traumatic nature of the event [21]
- Expected recovery: highly variable depending on severity; minor wounds heal in 1–2 weeks; complex injuries may require months of reconstruction and rehabilitation
References
1. Mortality and Management of 96 Shark Attacks and Development of a Shark Bite Severity Scoring System. — Lentz AK, Burgess GH, Perrin K, et al. The American Surgeon. 2010.
2. Mortality and Management of 96 Shark Attacks and Development of a Shark Bite Severity Scoring System. — Lentz AK, Burgess GH, Perrin K, et al. The American Surgeon. 2010.
3. Mortality and Management of 96 Shark Attacks and Development of a Shark Bite Severity Scoring System. — Lentz AK, Burgess GH, Perrin K, et al. The American Surgeon. 2010.
4. Clinical Features of 27 Shark Attack Cases on La Réunion Island. — Ballas R, Saetta G, Peuchot C, Elkienbaum P, Poinsot E. The Journal of Trauma and Acute Care Surgery. 2017.
5. Clinical Features of 27 Shark Attack Cases on La Réunion Island. — Ballas R, Saetta G, Peuchot C, Elkienbaum P, Poinsot E. The Journal of Trauma and Acute Care Surgery. 2017.
6. Shark-Related Injuries in the United States: A National Trauma Data Bank Analysis. — Ganske W, Sharma R, Kaminski S, Johnson A. The American Surgeon. 2021.
7. Shark-Related Injuries in the United States: A National Trauma Data Bank Analysis. — Ganske W, Sharma R, Kaminski S, Johnson A. The American Surgeon. 2021.
8. Shark Bites in New Caledonia: A Retrospective Study of 22 Hospitalized Cases and Surgical Management. — Gosselin C, Maillaud C, Jourdel F. Injury. 2025.
9. Shark Bites in New Caledonia: A Retrospective Study of 22 Hospitalized Cases and Surgical Management. — Gosselin C, Maillaud C, Jourdel F. Injury. 2025.
10. Shark Attack-Related Injuries: Epidemiology and Implications for Plastic Surgeons. — Ricci JA, Vargas CR, Singhal D, Lee BT. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS. 2016.
11. Shark Attack-Related Injuries: Epidemiology and Implications for Plastic Surgeons. — Ricci JA, Vargas CR, Singhal D, Lee BT. Journal of Plastic, Reconstructive & Aesthetic Surgery : JPRAS. 2016.
12. Management of Extremity Trauma and Related Infections Occurring in the Aquatic Environment. — Noonburg GE. The Journal of the American Academy of Orthopaedic Surgeons. 2005.
13. Management of Extremity Trauma and Related Infections Occurring in the Aquatic Environment. — Noonburg GE. The Journal of the American Academy of Orthopaedic Surgeons. 2005.
14. Antibiotic Prophylaxis in Injury: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. — Appelbaum RD, Farrell MS, Gelbard RB, et al. Trauma Surgery & Acute Care Open. 2023.
15. Antibiotic Prophylaxis in Injury: An American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. — Appelbaum RD, Farrell MS, Gelbard RB, et al. Trauma Surgery & Acute Care Open. 2023.
16. Zoonotic Exposures: Bites, Scratches, and Other Hazards. — Caitlin M. Cossaboom, Ryan M. Wallace, and Casey Barton Behravesh CDC Yellow Book. 2025.
17. Zoonotic Exposures: Bites, Scratches, and Other Hazards. — Caitlin M. Cossaboom, Ryan M. Wallace, and Casey Barton Behravesh CDC Yellow Book. 2025.
18. Vibrio Vulnificus-a Review With a Special Focus on Sepsis. — Candelli M, Sacco Fernandez M, Triunfo C, et al. Microorganisms. 2025.
19. Vibrio Vulnificus-a Review With a Special Focus on Sepsis. — Candelli M, Sacco Fernandez M, Triunfo C, et al. Microorganisms. 2025.
20. Rapidly Progressive Soft Tissue Infections. — Vinh DC, Embil JM. The Lancet. Infectious Diseases. 2005.
21. Rapidly Progressive Soft Tissue Infections. — Vinh DC, Embil JM. The Lancet. Infectious Diseases. 2005.
22. Marine Envenomations. — Auerbach PS. The New England Journal of Medicine. 1991.
23. Marine Envenomations. — Auerbach PS. The New England Journal of Medicine. 1991.
24. Antibiotic Use for Vibrio Infections: Important Insights From Surveillance Data. — Wong KC, Brown AM, Luscombe GM, Wong SJ, Mendis K. BMC Infectious Diseases. 2015.
25. Antibiotic Use for Vibrio Infections: Important Insights From Surveillance Data. — Wong KC, Brown AM, Luscombe GM, Wong SJ, Mendis K. BMC Infectious Diseases. 2015.
26. Antibiotic Susceptibilities of Bacteria Isolated Within the Oral Flora of Florida Blacktip Sharks: Guidance for Empiric Antibiotic Therapy. — Unger NR, Ritter E, Borrego R, Goodman J, Osiyemi OO. PloS One. 2014.
27. Antibiotic Susceptibilities of Bacteria Isolated Within the Oral Flora of Florida Blacktip Sharks: Guidance for Empiric Antibiotic Therapy. — Unger NR, Ritter E, Borrego R, Goodman J, Osiyemi OO. PloS One. 2014.
28. Initial Care of the Severely Injured Patient. — King DR. The New England Journal of Medicine. 2019.
29. Initial Care of the Severely Injured Patient. — King DR. The New England Journal of Medicine. 2019.
30. Shark Related Injuries: A Case Series of Emergency Department Patients. — Tomberg RJ, Cachaper GA, Weingart GS. The American Journal of Emergency Medicine. 2018.
31. Shark Related Injuries: A Case Series of Emergency Department Patients. — Tomberg RJ, Cachaper GA, Weingart GS. The American Journal of Emergency Medicine. 2018.
32. The Anatomy of a Shark Attack: A Case Report and Review of the Literature. — Caldicott DG, Mahajani R, Kuhn M. Injury. 2001.
33. The Anatomy of a Shark Attack: A Case Report and Review of the Literature. — Caldicott DG, Mahajani R, Kuhn M. Injury. 2001.
34. Hemorrhagic Shock. — Cannon JW. The New England Journal of Medicine. 2018.
35. Hemorrhagic Shock. — Cannon JW. The New England Journal of Medicine. 2018.
36. Resuscitation and Care in the Trauma Bay. — Van Gent JM, Clements TW, Cotton BA. The Surgical Clinics of North America. 2024.
37. Resuscitation and Care in the Trauma Bay. — Van Gent JM, Clements TW, Cotton BA. The Surgical Clinics of North America. 2024.
38. Stopping Haemorrhage by Application of Rope Tourniquet or Inguinal Compression (SHARC Study). — Taylor NB, Lamond DW. Emergency Medicine Australasia : EMA. 2021.
39. Stopping Haemorrhage by Application of Rope Tourniquet or Inguinal Compression (SHARC Study). — Taylor NB, Lamond DW. Emergency Medicine Australasia : EMA. 2021.
40. A "Shark Encounter": Delayed Primary Closure and Prophylactic Antibiotic Treatment of a Great White Shark Bite. — Popa D, Van Hoesen K. The Journal of Emergency Medicine. 2016.
41. A "Shark Encounter": Delayed Primary Closure and Prophylactic Antibiotic Treatment of a Great White Shark Bite. — Popa D, Van Hoesen K. The Journal of Emergency Medicine. 2016.
42. Increased Shark Bite Survivability Revealed by Two Centuries of Australian Records. — Tucker JP, Santos IR, Kelaher BP, et al. Scientific Reports. 2022.
43. Increased Shark Bite Survivability Revealed by Two Centuries of Australian Records. — Tucker JP, Santos IR, Kelaher BP, et al. Scientific Reports. 2022.