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MARINE TRAUMA

Human contact with the marine environment is becoming more frequent as recreational and commercial use of the world’s oceans increases. In addition to the hazards of drowning and cold exposure, the marine environment provides the habitat for dangerous marine fauna. Many marine animals have evolved sharp teeth and spines or venom glands for defense and predation. Encounters with marine life may result in traumatic injury or envenomation, requiring emergency medical management. Providing care for these conditions may be further complicated by the marine environment’s geographic isolation from locations with definitive health care.

EPIDEMIOLOGY

The most common reported U.S. exposures are to jellyfish (31%), stingrays (16%), venomous fish (including lionfish, catfish, and others) (28%), and gastropods (6%).1 However, data likely favor the reporting of more severe injuries and the exclusion of common minor injuries. Human impact may be altering the geographic distribution of marine fauna as climate change affects migration patterns and artificial waterways connect previously separated bodies of water and their ecosystems.2,3

The International Shark Attack File recorded 2944 unprovoked shark attacks between 1958 and 2017, with the United States reporting the most attacks. Within the United States, 56% of attacks occur in the waters off Florida, with Hawaii, California, and the Carolinas rounding out the top five states reporting unprovoked shark attacks.4 Despite the public perception, the risk of shark attack is extremely small compared with almost any other injury, with only 70 to 100 shark attacks worldwide each year, resulting in only 5 to 15 deaths.4,5 Although the incidence of shark attacks has steadily risen since 1900, the mortality has fallen from 40% in the 30 years following World War II to current rates of approximately 10% to 20%.6 Death is usually a result of a lack of prehospital resuscitation, hemorrhagic shock, or drowning.

Other marine creatures implicated in traumatic injuries to humans include barracuda, giant groupers, sea lions, seals, crocodiles, alligators, and piranhas. Some fish with sharp spines and fins (needlefish, wahoo, and triggerfish) can inadvertently injure humans. Wounds resulting from interactions with such creatures are a combination of crush injury, abrasion, puncture, and/or laceration.

BACTERIOLOGY OF MARINE SOFT TISSUE INFECTIONS

Marine soft tissue infections are often polymicrobial, halophilic, gram-negative infections that may be resistant to first- and second-generation penicillins and cephalosporins.7 Infecting bacteria are numerous and can vary with the environment, type of injury, and marine organism. Bacteria include staphylococci, streptococci, Aeromonas hydrophilia, Escherichia coli, Pseudomonas species, Erysipelothrix species, Chromobacterium, Edwardsiella, Shewanella, Mycobacterium species, Mycoplasma species, and Vibrio species.8-10 Marine-associated infections are frequently diagnosed late because the history of marine exposure or injury is poorly recalled, and patients are often initially given inappropriate antibiotics, which potentially increases the morbidity of an already virulent infection. Patients with underlying conditions such as liver ...

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