Shark BiteMANAGEMENT

ENVIRONMENTAL AND EXPOSURE PRESENTATIONS · 12 SECTIONS

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630 items

☷ Legend

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Cardiovascular Presentations71▾

Respiratory Presentations52▾

Neurological Presentations83▾

Gastrointestinal Presentations74▾

Genitourinary and Reproductive Presentations48▾

Infectious Disease Presentations148▾

Trauma Presentations89▾

Toxicologic Presentations80▾

Psychiatric Presentations26▾

Musculoskeletal and Rheumatologic Presentations96▾

Dermatology Presentations23▾

Environmental and Exposure Presentations27▾

Acute Mountain Sickness Arterial Gas Embolism Bee-Wasp Sting (Anaphylaxis)Chilblains Ciguatera Fish Poisoning Coral Cut Decompression Sickness Electrical Burn Injury Envenomation (snake, spider, insect)High Altitude Cerebral Edema (HACE)High Altitude Pulmonary Edema (HAPE)High-altitude illness Hypothermia Hypothermia (Mild)Hypothermia (Severe)Immersion Foot Lightning Strike Injury Scombroid Fish Poisoning Scorpion Envenomation Sea Urchin Injury Shark Bite Snake Envenomation Spider Bite (Black Widow)Spider Bite (Brown Recluse)Stingray Spine Injury Tick paralysis White Phosphorus Burn

Hematologic and Oncologic Presentations36▾

Pediatric-Specific Presentations19▾

Endocrine and Metabolic Presentations45▾

ENT and Maxillofacial Presentations27▾

Ophthalmologic Presentations19▾

Obstetric Presentations23▾

Systemic and Miscellaneous Presentations17▾

01Approach to the Critical Patient/attcp58

Hemorrhage control priorities

›Immediate hemorrhage control

›Direct pressure to all actively bleeding wounds

›Maintain until surgical hemostasis

›Pressure dressing application

›Tourniquet for extremity arterial hemorrhage

›Proximal to wound, tighten until bleeding stops

›Note application time

›Prehospital tourniquet strongly associated with survival in major vascular injury

›Wound packing for truncal or junctional hemorrhage not amenable to tourniquet

›Gauze or hemostatic agent

›Sustained pressure for minimum 3 minutes

›If active arterial hemorrhage uncontrolled, immediate OR activation

Resuscitation targets

›Damage-control resuscitation

›Permissive hypotension until surgical hemostasis achieved

›Target SBP 80 to 90 mmHg in penetrating trauma

›Avoid aggressive crystalloid

›Balanced blood product resuscitation

›1:1:1 ratio packed red blood cells to fresh frozen plasma to platelets

›Activate massive transfusion protocol early for ongoing hemorrhagic shock

›Tranexamic acid 1 g IV within 3 hours of injury

›Second dose 1 g IV over 8 hours

›NEJM evidence for survival benefit when given early

›Minimize crystalloid to reduce coagulopathy and acidosis

Airway and circulation threats

›Airway threats

›Facial or neck wound with airway compromise

02History/hx45

Attack circumstances

›Attack details

›Provoked vs unprovoked attack

›Activity at time of attack

›Surfing, spearfishing, swimming, diving

›Spearfishing most common context at 32% of cases

›Shark species if known

›White, tiger, and bull sharks account for most serious attacks

›Number of bites and estimated duration of contact

›Water type

›Saltwater vs brackish — informs microbiology

›Geographic location

›Florida 49% of US attacks

›Australia, South Africa, Reunion Island high incidence areas

›Time from injury to presentation

›Prehospital interventions

›Tourniquet application — key survival factor

›Direct pressure, immobilization

Hemorrhage and systemic history

›Blood loss assessment

›Estimated blood loss from bystander reports

›Soaked clothing, pooling

›Syncope or near-syncope at scene

›Submersion time

›Aspiration of water or loss of consciousness

›Medications relevant to hemorrhage

›Anticoagulant use

›Antiplatelet use

03Physical Exam/exam59

Vitals and stability

›Hemodynamic stability snapshot

›Heart rate

›Tachycardia as hemorrhagic shock marker

›HR > 120 beats/min high concern threshold

›Blood pressure

›SBP < 90 mmHg hemorrhagic shock threshold

›MAP monitoring when arterial line placed

›Respiratory rate

›Elevated with aspiration or tension pneumothorax

›Temperature

›Hypothermia from prolonged cold water immersion

›Osborn waves on ECG if severe hypothermia

›Oxygen saturation

›Near-drowning aspiration component

Wound characterization

›Wound assessment

›Crescent-shaped or semicircular wound pattern

›Pathognomonic for shark bite

›Tissue avulsion and disarticulation characteristic

›Injury location

›Lower extremity 47% of cases

›Upper extremity 40% of cases

›Trunk involvement with chest, abdomen, pelvis

›Depth of penetration

›Fascial involvement

›Joint space involvement

›Abdominal or thoracic cavity involvement

04Differential Diagnosis/ddx39

Life-threatening diagnoses

›Hemorrhagic shock

›ICD-10 T14.91 — traumatic shock

›Exsanguination primary cause of shark bite mortality

›Overall mortality approximately 8.3%

›Major vascular injury

›Femoral, popliteal, brachial, axillary vessel involvement

›Mortality exceeds 50% with major vessel injury in La Reunion series

›ICD-10 S75 lower extremity vascular injury codes

›Traumatic amputation or near-amputation

›11% amputation rate in trauma center series

›Limb salvage vs primary amputation decision

›Necrotizing soft tissue infection

›Vibrio vulnificus — fulminant course in liver disease and immunocompromise

›Aeromonas hydrophila — freshwater and brackish environments

›ICD-10 M72.6 necrotizing fasciitis

›Compartment syndrome

›Limb-threatening if untreated

›May develop hours after initial injury

Mimics and overlap diagnoses

›Other marine animal injuries

›Barracuda bite — narrower, more linear lacerations

›Stingray injury — puncture wound with envenomation

›Stingray barb may be retained

›Pain out of proportion characteristic

›Moray eel bite — smaller, ragged lacerations

›Other traumatic injuries

›Boat propeller injury — parallel lacerations, more uniform pattern

05Laboratory Tests/lt42

Hemorrhage and resuscitation labs

›Blood type and crossmatch

›Immediate type and screen in all significant injuries

›Crossmatch for packed red blood cells when surgical intervention anticipated

›Emergency release uncrossmatched O negative if life-threatening hemorrhage

›Complete blood count

›Baseline hemoglobin and hematocrit

›Platelet count for massive transfusion guidance

›Leukocytosis as early infection marker

›Coagulation studies

›Prothrombin time and INR

›Partial thromboplastin time

›Fibrinogen — critical in massive hemorrhage

›Viscoelastic testing if available

›TEG or ROTEM for comprehensive coagulation assessment

›Guides targeted blood product resuscitation

Metabolic and perfusion labs

›Lactate

›Elevated as hemorrhagic shock and organ hypoperfusion marker

›Serial monitoring to assess resuscitation response

›Target normalization

›Basic metabolic panel

›Electrolytes including potassium

›Hyperkalemia from crush injury or massive transfusion risk

›Renal function for antibiotic dosing

›Bicarbonate as acidosis marker

›Arterial blood gas

›pH for acidosis degree

06Diagnostic Tests/dt64

Scoring Systems

›Shark-Induced Trauma Scale

›SIT Level 1 — superficial lacerations or abrasions

›42% of attacks

›Minor injury, local wound care

›SIT Level 2 — deeper lacerations not requiring major repair

›SIT Level 3 — significant lacerations requiring surgical closure

›SIT Level 4 — major tissue loss, fractures, or vascular injury

›SIT Level 5 — massive tissue loss, major vascular injury, fatal or near-fatal

›8% of attacks

›Immediate OR and trauma activation

›Injury Severity Score

›Median ISS of 5 in US trauma data (National Trauma Data Bank)

›Higher ISS associated with ICU admission and longer hospital stay

›ABI — ankle-brachial index

›Ratio below 0.9 suggests significant vascular injury requiring further imaging

›Rapid bedside tool for lower extremity vascular assessment

MRI

›MRI role in shark bite

›Limited acute utility in trauma setting

›Availability and time constraints

›Motion artifact in unstable patient

›Subacute applications

›Nerve injury characterization

›Extent of brachial plexus or peripheral nerve injury

›Soft tissue infection extent

›Necrotizing fasciitis plane delineation when stable

›Retained foreign body localization when CT equivocal

07Disposition/dispo39

Admission and ICU criteria

›Admission indications

›Hemodynamic instability

›SBP < 90 mmHg

›Lactate elevation requiring resuscitation

›Major vascular injury requiring repair

›Fractures or joint involvement

›Deep or extensive wounds requiring OR debridement

›Serial wound assessment requirement

›Significant tissue loss requiring staged reconstruction

›96% of patients in National Trauma Data Bank were admitted

›ICU admission criteria

›Post-operative monitoring after vascular or major orthopedic repair

›Ongoing resuscitation from hemorrhagic shock

›Mechanical ventilation requirement

›Necrotizing infection with septic physiology

›53% of admitted patients required ICU in trauma data

›Median ICU stay 4.5 days

›Median hospital stay 4 to 5 days overall

Trauma center transfer

›Transfer indications

›All significant shark bites warrant trauma center capable of comprehensive surgical care

›Orthopedic, vascular, plastic surgery availability

›Transfer criteria

›Major vascular injury beyond local capability

›Traumatic amputation requiring replantation consideration

›Tissue loss requiring microvascular reconstruction

›Stabilize before transfer

08Treatment/t93

Immediate hemorrhage management

›Tourniquet and wound control

›Commercial tourniquet preferred for extremity

›Apply 5 to 8 cm proximal to wound

›Tighten until hemorrhage stops

›Record application time

›Junctional hemorrhage control

›Direct pressure or wound packing

›Hemostatic dressings for adjunct

›Vascular clamp or operative hemostasis when wound accessible

›Tranexamic acid

›TXA 1 g IV over 10 minutes as loading dose

›Administer within 3 hours of injury

›Beyond 3 hours: benefit unclear, may be harmful

›Maintenance dose 1 g IV over 8 hours

›CRASH-2 trial evidence for reduced hemorrhagic mortality

Resuscitation

›Massive transfusion protocol

›Packed red blood cells

›1:1:1 ratio with FFP and platelets

›Target hemoglobin when actively bleeding guided by clinical status

›Fresh frozen plasma

›15 mL per kg per dose as initial guidance

›Titrate by viscoelastic testing when available

›Platelets

›Target platelet count above 50 x10^9/L during active hemorrhage

›Above 100 x10^9/L if traumatic brain injury

›Cryoprecipitate

›Fibrinogen below 1.5 g/L indication

›10 units pooled cryoprecipitate

›Permissive hypotension

›Target SBP 80 to 90 mmHg until surgical hemostasis

›Avoid aggressive crystalloid resuscitation

›Lactated Ringer preferred over normal saline if crystalloid needed

Wound management

›Irrigation and debridement

›Copious normal saline irrigation of all wounds

›Minimum 1 L per wound

›High-pressure syringe irrigation for deep wounds

›Thorough surgical debridement under aseptic technique

›Remove all retained foreign bodies

›Shark tooth fragments exploration

›X-ray before closure to confirm clearance

›Wound closure strategy

›Delayed primary closure preferred for marine contaminated wounds

›Closure at 24 to 72 hours

›Allows wound inspection and reassessment

›Reduces infectious complication risk

›Immediate primary closure contraindicated in heavily contaminated wounds

›Deep wounds into joints, abdomen, thorax, or hand or foot fascial compartments require OR exploration

›83% require debridement, grafting, or flap coverage

›28% have neurovascular injuries requiring formal repair

Antibiotic therapy

›Empiric antibiotic selection for marine wounds

›First-line for significant marine contaminated wounds

›Doxycycline 100 mg IV every 12 hours

›Plus ceftazidime 2 g IV every 8 hours

›Alternative: fluoroquinolone

›Ciprofloxacin 400 mg IV every 12 hours

›Oral: ciprofloxacin 500 mg PO every 12 hours

›Or levofloxacin 750 mg IV or PO daily

›Oral alternative for minor wounds

›Fluoroquinolone monotherapy

›Or doxycycline 100 mg PO every 12 hours

›Avoid inadequate regimens

›Amoxicillin-clavulanate alone insufficient — does not reliably cover Vibrio spp

›Penicillin, ampicillin, erythromycin, first-generation cephalosporins — not acceptable for marine wound infections

›Duration of antibiotic therapy

›Minor wounds: 3 to 5 days empiric coverage

›Major wounds or operative debridement: 5 to 7 days minimum

›Necrotizing infection: extended course guided by surgical findings and clinical response

›Adjust based on wound culture results

Tetanus and other prophylaxis

›Tetanus prophylaxis

›Tdap if last dose more than 5 years ago

›Three-dose primary series if fewer than 3 lifetime doses

›Tetanus immunoglobulin for unimmunized patients or unclear status with high-risk wounds

›250 units IM in different site from vaccine

›Rabies prophylaxis

›Not indicated — sharks are not mammals and do not carry rabies virus

›Pain management

›Regional nerve blocks as first-line for extremity wounds

›Femoral nerve block for lower extremity

›Brachial plexus or digital block for upper extremity

›Parenteral opioids for severe pain

›Ketamine for procedural sedation during wound exploration

Surgical interventions

›Operative priorities

›Vascular repair for major vessel injury

›28% of hospitalized cases require neurovascular repair

›Orthopedic fixation for fractures

›59% require orthopedic intervention

›Debridement and negative pressure wound therapy staging

›Amputation in approximately 11% of trauma center cases

›Limb salvage vs primary amputation — multidisciplinary decision

›Compartment syndrome management

›Emergent four-compartment lower leg fasciotomy when indicated

›Forearm fasciotomy for upper extremity compartment syndrome

›Leave fasciotomy wounds open and plan delayed closure

09Special Populations/sp62

Pregnancy

›Pregnancy considerations

›Physiologic changes affecting assessment

›Expanded blood volume masks early hemorrhagic shock

›Baseline tachycardia and lower blood pressure complicate shock recognition

›Gravid uterus displaces abdominal contents — wound entry point may not predict internal injury

›Fetal assessment

›Fetal heart rate monitoring when viable gestation present

›Obstetric consultation in any significant truncal wound

›Premature rupture of membranes possible with abdominal trauma

›Imaging approach

›FAST exam without radiation as first-line

›CT when clinical need outweighs fetal radiation risk

›Fetal radiation dose per CT abdomen approximately 8 to 25 mGy

›Radiation risk acceptable when maternal life threatened

›Antibiotic selection

›Fluoroquinolones — generally avoided in pregnancy

›Doxycycline — contraindicated after first trimester

›Preferred alternatives: ceftriaxone plus azithromycin

›Cefepime or piperacillin-tazobactam for broad coverage if needed

›Infectious disease or obstetric consultation for antibiotic guidance

Geriatric

›Older adult considerations

›Physiologic reserve limitations

›Limited cardiovascular reserve masks hemorrhagic shock

›Beta-blocker use may blunt tachycardic response

›Baseline hypertension means normal BP may represent relative hypotension

›Anticoagulation and antiplatelet prevalence

10Background/b75

Epidemiology

›Global incidence

›Rare events globally — approximately 70 to 100 unprovoked shark attacks per year worldwide

›Approximately 5 to 15 fatalities annually worldwide

›Overall in-hospital mortality approximately 8.3%

›Survivability has increased over two centuries of Australian records

›Geographic distribution

›United States: Florida accounts for 49% of US attacks

›Global hotspots: Australia, South Africa, Reunion Island, Bahamas

›Bimodal time-of-day distribution: around noon and early evening

›Injury severity distribution

›42% Level 1 SIT Scale — minor injuries

›8% Level 5 SIT Scale — massive tissue loss or fatal

›55% to 96% of trauma center patients require operative intervention

›Median ISS of 5 in US National Trauma Data Bank analysis

›53% require ICU admission with median ICU stay 4.5 days

›Median hospital stay 4 to 5 days

›Injury patterns

›Lower extremity involved in 47% of attacks

›Upper extremity involved in 40% of attacks

›Vascular injury in 27% of hospitalized cases

›Nerve injury in 32% of hospitalized cases

›Fractures in 18% of hospitalized cases

›Amputation rate approximately 11%

Pathophysiology

›Mechanism of injury

›Predatory bite pattern

›Shark bites and releases — often single bite

›Bite-and-spit behavior leaves massive lacerations

›Rotational forces during bite cause avulsion and disarticulation

›Wound characteristics

›Crescent-shaped lacerations from dental arch curvature

›Deep penetration from shark bite force

›Serrated teeth cause jagged wound edges

›Hemorrhage mechanism

›Direct vascular laceration from teeth

›Tissue avulsion disrupts multiple vessels simultaneously

›Hypovolemic shock primary cause of death

›Marine microbiology

›Oral flora of sharks

›Vibrio spp including Vibrio vulnificus and Vibrio parahaemolyticus

›Pseudomonas aeruginosa

›Aeromonas hydrophila — primarily freshwater and brackish

›Staphylococcus and Streptococcus species

›Polymicrobial contamination typical

›Vibrio vulnificus pathophysiology

›Requires NaCl for growth — saltwater association

›Iron-dependent virulence — liver disease states increase susceptibility

›Produces cytolysins and collagenases causing rapid tissue necrosis

›Fulminant sepsis in immunocompromised and liver disease patients

Therapeutic Considerations

›Hemorrhage control principles

›Early tourniquet application is key survival factor in major vascular injury

›Prehospital tourniquet strongly associated with survival

›First responder and bystander tourniquet training important in coastal communities

›Damage control resuscitation preferred over permissive fluid loading

›Lethal triad of acidosis, hypothermia, coagulopathy must be aggressively prevented

›TXA efficacy

›CRASH-2 trial established survival benefit when given within 3 hours

›Beyond 3 hours may increase mortality — time of administration critical

›Antibiotic principles for marine wounds

›Empiric coverage must target marine gram-negative pathogens

›Vibrio spp are resistant to penicillins, ampicillin, first-generation cephalosporins

›Doxycycline plus third-generation cephalosporin or fluoroquinolone recommended

›Amoxicillin-clavulanate alone is insufficient for marine wound coverage

›Does not reliably cover Vibrio spp

›Infectious complication rate approximately 9% when appropriate antibiotics given

›Wound closure timing

›Delayed primary closure at 24 to 72 hours preferred

›Marine contamination risk of polymicrobial infection with immediate closure

›Allows daily wound inspection before definitive closure

›Negative pressure wound therapy as bridge to closure for large defects

›Infection complications unique to shark bites

›Vibrio vulnificus — must suspect in liver disease, immunocompromise

›Mortality above 50% in high-risk patients without early treatment

›Surgical debridement timing critical — early surgery improves survival

›Necrotizing fasciitis may require repeated debridement

›Hyperbaric oxygen as adjunct in some centers

11Patient Discharge Instructions/pdi34

copy discharge instructions

›Wound care at home

›Keep wound clean and dry as instructed

›Change dressings as prescribed by your doctor

›Do not submerge wound in water — no swimming, baths, or ocean until healed

›Elevate injured limb above heart level to reduce swelling

›Antibiotics and medications

›Take all antibiotics exactly as prescribed until the full course is finished

›Do not stop antibiotics early even if wound looks better

›Take pain medications as directed

›Avoid blood thinners unless prescribed by your doctor

›Activity restrictions

›No weight-bearing on injured extremity unless cleared by your surgeon

›Avoid strenuous activity until follow-up appointment

›Physical and occupational therapy referral as prescribed

›Follow-up appointments

›Wound check at 24 to 48 hours for delayed closure assessment

›Suture or staple removal appointment at 5 to 7 days

›Surgeon follow-up as scheduled

›Physiotherapy or occupational therapy if nerve or tendon injury

›Warning signs — return to emergency department immediately for

›Fever above 38.5 degrees Celsius or chills

›Increasing pain, redness, warmth, or swelling around wound

›Red streaking spreading from wound (lymphangitis)

›Blisters, bullae, or skin discoloration (dark purple or black) around wound

›Foul-smelling or increased discharge from wound

›Numbness, tingling, or weakness below the wound

›Pallor, coolness, or absent pulse below the wound

12References/r20

Guidelines and key sources

›Primary trauma and emergency medicine guidelines

›ATLS — Advanced Trauma Life Support guidelines for hemorrhagic shock and damage control resuscitation

›CRASH-2 trial — tranexamic acid in trauma (NEJM 2019, King DR review of initial care)

›Surviving Sepsis Campaign — septic shock management principles

›CDC Yellow Book 2025 — tetanus prophylaxis for animal bite wounds

›Shark bite specific literature

›Lentz AK et al. Mortality and Management of 96 Shark Attacks and Development of a Shark Bite Severity Scoring System. The American Surgeon. 2010. PMID 20135949

›Ganske W et al. Shark-Related Injuries in the United States: A National Trauma Data Bank Analysis. The American Surgeon. 2021. PMID 34126790

›Ballas R et al. Clinical Features of 27 Shark Attack Cases on La Reunion Island. J Trauma Acute Care Surg. 2017. PMID 28248805

›Gosselin C et al. Shark Bites in New Caledonia: A Retrospective Study. Injury. 2025. PMID 41037958

›Tomberg RJ et al. Shark Related Injuries: A Case Series of Emergency Department Patients. Am J Emerg Med. 2018. PMID 29970271

›Popa D, Van Hoesen K. A Shark Encounter: Delayed Primary Closure and Prophylactic Antibiotic Treatment. J Emerg Med. 2016. PMID 27623219

›Infection and microbiology sources

›Noonburg GE. Management of Extremity Trauma and Related Infections in the Aquatic Environment. JAAOS. 2005. PMID 16112981

›Auerbach PS. Marine Envenomations. NEJM. 1991

›Unger NR et al. Antibiotic Susceptibilities of Bacteria in Oral Flora of Florida Blacktip Sharks. PLoS One. 2014. PMID 25110948

›Candelli M et al. Vibrio Vulnificus — a Review With a Special Focus on Sepsis. Microorganisms. 2025. PMID 39858896

›Vinh DC, Embil JM. Rapidly Progressive Soft Tissue Infections. Lancet Infect Dis. 2005. PMID 16048719

›Appelbaum RD et al. Antibiotic Prophylaxis in Injury: AAST Critical Care Committee Clinical Consensus. Trauma Surg Acute Care Open. 2023

›Tucker JP et al. Increased Shark Bite Survivability Revealed by Two Centuries of Australian Records. Sci Rep. 2022. PMID 35986014

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