Injuries From Nonvenomous Aquatic Animals

Wound Management

• 1.

  If the bill or spine of an animal is seen to be lodged in the patient and has penetrated deeply into the chest, abdomen, neck, femoral region, or popliteal space and may have violated a critical blood vessel or the heart, it should be managed as would be a weapon of impalement (e.g., a knife). In this case, the impaling object should be left in place if possible and secured from motion until the patient is brought to a controlled operating room environment where emergency surgery can be performed to guide its extraction and control bleeding that may occur upon its removal.

• 2.

  Irrigate all wounds with a sterile diluent, preferably normal saline (NS) solution. Seawater is not recommended because it carries a hypothetical risk for infection. Use disinfected potable or tap water if NS solution is not available.

  • a.

    Note that proper irrigation technique involves using a 19-gauge needle or 18-gauge plastic IV catheter attached to a syringe to deliver a pressure of 10 to 20 psi.

  • b.

    Flush a minimum of 100 to 250 mL of irrigant through each wound.

  • c.

    If the wound was caused by a stingray, stonefish, scorpion fish, or lionfish, warm the irrigant to 45°C (113°F; see Chapter 53 ).

• 3.

  Add an antiseptic to the irrigation fluid. Add concentrated povidone-iodine solution (not “scrub”) to the irrigant to achieve a final concentration of 1% to 5%. Allow a contact time of 1 to 5 minutes. After irrigation with the antiseptic-containing solution, thoroughly irrigate the wound with unadulterated NS solution.

• 4.

  With a coral cut or abrasion, scrub the area to remove debris that cannot be irrigated from the wound.

• 5.

  Remove any crushed or devitalized tissue using sharp dissection.

• 6.

  In the field, perform wound closure using the technique that is least constrictive and therefore less prone to trap bacteria, which could initiate a wound infection. From an infection risk perspective, unless wound preparation equivalent to that achieved in a hospital is undertaken, it is often better to approximate the wound edges with adhesive strips or loosely placed sutures than to perform a tight approximation of the margins (see Chapter 20 ).

• 7.

  At the earliest sign of wound infection, release sufficient fasteners to allow prompt and thorough drainage from the wound. Initiate antibiotic therapy.

• 8.

  Administer appropriate tetanus prophylaxis.

Antibiotic Therapy

The following recommendations are based on the malignant potential of soft tissue infections caused by Vibrio (sea water) or Aeromonas (natural freshwater) species.

• 1.

  Be aware that minor abrasions or lacerations (e.g., coral cuts, superficial sea urchin puncture wounds) do not require prophylactic antibiotics in a person with normal immunity. However, for persons who are chronically ill (e.g., diabetes, hemophilia, thalassemia), are immunologically impaired (e.g., leukemia, AIDS, chemotherapy, prolonged corticosteroid therapy), or have serious liver disease (e.g., hepatitis, cirrhosis, hemochromatosis), particularly those with elevated serum iron levels, immediately begin a regimen of oral ciprofloxacin, trimethoprim/sulfamethoxazole (co-trimoxazole), or tetracycline/doxycycline. Note that penicillin, ampicillin, amoxicillin, and erythromycin are not acceptable alternatives. Although other quinolones have not been extensively tested against Vibrio species, they may be useful alternatives.

• 2.

  Note that the appearance of an infection indicates the need for prompt débridement and antibiotic therapy. If an infection develops, choose antibiotic coverage that will also be efficacious against Staphylococcus and Streptococcus species. Vancomycin is recommended in the event of methicillin resistance.

• 3.

  From an infection perspective, consider the following as serious injuries: large lacerations, extensive or deep burns, deep puncture wounds, and a retained foreign body.

  • a.

    These injuries may be caused by shark, barracuda or other fish bites, stingray spine wounds, impalement by a fish bill, any spine puncture that enters a joint space, and full-thickness coral cuts.

  • b.

    If the patient will require hospitalization for any of these serious injuries and intravenous antibiotics are accessible, the recommended drugs for prophylaxis include gentamicin, tobramycin, amikacin, and trimethoprim-sulfamethoxazole. Cefoperazone, cefotaxime, and ceftazidime may not be effective; if they are used, they should be combined with another agent listed or with tetracycline.

• 4.

  Manage infected wounds with antibiotics as noted earlier, with consideration of adding imipenem-cilastatin or meropenem for severe, progressive infections and sepsis.

• 5.

  If a wound infection is minor and has the appearance of a classic erysipeloid reaction (Erysipelothrix rhusiopathiae ; see Plate 34 ), penicillin, cephalexin, or ciprofloxacin should be administered.