Pediatric emergency medicine trisk 1998 1998
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soaking, the wound should be reexplored, debrided again if necessary, and
potentially closed, although delayed primary closure is preferred. Imaging can be
obtained to rule out retained spines. Pain relief is best achieved with morphine,
local anesthetic infiltration, or a nerve block. Tetanus prophylaxis should be
considered, but antibiotics are reserved for wounds that become secondarily
infected.
Sharks
Shark attacks may be preceded by one or more “bumps,” which may cause
extensive abrasions from the rough denticles of the shark’s skin. Two types of bite
wounds are described: tangential injury and a definitive bite. Tangential injury,
caused by the slashing movement of the open mouth as the shark makes a close
pass, causes severe lacerations, incised wounds, and loss of tissue. Definitive bite
wounds cause lacerations, loss of soft tissue, amputations, and comminuted
fractures. Most injuries involve only one or two bites and are confined to the
extremities.
Hypovolemic shock is the immediate threat to life in shark attacks. Bleeding
should be controlled at the scene with direct compression, and intravascular
volume should be replaced with crystalloid until blood products are available.
The victim should be kept warm and given oxygen when being transported to an
ED. Wounds should not be explored in the field. Tetanus immunization should be
considered, and prophylactic antibiotics with a third-generation cephalosporin or
trimethoprim-sulfamethoxazole is recommended.
Scorpaenidae
The 80 species found in the Scorpaenidae family include the zebra fish, scorpion
fish proper, and stonefish. In California, the sculpin is commonly involved.
Scorpaenidae are generally found in shallow water, around reefs, kelp beds, or
coral. They are nonmigratory, slow swimming, and often buried in sand. The
venom apparatus consists of a number of dorsal, anal, and pelvic spines covered
by integumentary sheaths containing venom glands that lie within anterolateral
grooves. The venoms are unstable, heat-labile compounds. Most often
envenomation occurs when the fish are handled during fishing excursions.
Severe pain at the site of the wound is the first and primary clinical sign for all
species. The wound and surrounding area becomes ischemic and then cyanotic.
Paresthesia and paralysis of the extremity may occur. Other clinical signs include
nausea, vomiting, hypotension, tachypnea proceeding to apnea, and myocardial
ischemia with electrocardiographic changes. In cases of serious envenomation,
