Treatment Insight After a Great White Bite

One potentially lethal pathogen to consider when making a treatment decision is Vibrio vulnificus.

Although rare, shark bites are often given a lot of attention in the mainstream media, while few reports exist in the medical literature on the management of wounds caused by these creatures. This case, published in the Journal of Emergency Medicine, discusses the management of a patient with high-risk wounds who did not require surgical intervention.

The patient, a 50-year-old man from Europe, was scuba diving off the coast of California when he was bit by a great white shark while diving in a cage. As he leaned up against the cage for a better look, the shark opened its mouth and grazed the bars; the patient suffered two puncture wounds on the anterior aspect of his left thigh. The patient was immediately brought to the boat where fragments of the shark teeth were removed; he underwent freshwater irrigation and application of a pressure bandage helped stopped the bleeding. 

He presented to the emergency department 24 hours after the shark bite where physical examination revealed puncture wounds approximately 2.5–3cm long but with no active bleeding; teeth fragments were still visible in the wounds. The patient did not appear distressed and showed full range of motion at the knee and ankle, with sensation intact in the foot and calf. The two puncture wounds, while exposing muscle belly and violating the fascia, did not involve the muscle; imaging of the femur showed no acute osseous injury or retained foreign body (although tooth fragments were seen with the naked eye).

Because the patient was unaware of his tetanus status, he was given a tetanus, diphtheria, and pertussis vaccine; an injection of  lidocaine with epinephrine into the wounds aided further exploration and irrigation. After discussing next steps with the patient, the clinicians decided to loosely close the wounds (using 3-0 Prolene sutures). The patient was also given doses of cephalexin 500mg and ciprofloxacin 500mg and the wounds were covered with bacitracin and pressure dressings. At discharge, he was given a prescription for cephalexin 500mg 4 times daily and ciprofloxacin 500mg twice daily, both to be taken for 10 days; a wound check was scheduled 48 hours later.

At follow-up, no evidence of infection was noted; the patient was then scheduled for another follow-up 4 days later because of evidence of erythema surrounding the wound (the patient was asked to send photos from his hotel room so clinicians could monitor his progress). Examination showed no evidence of infection and the erythema appeared to be as a result of a reaction to the adhesive bandage he was using. Ten days after the injury, the patient returned home after his sutures were removed and he had finished the antibiotic courses; he continued to do well with no evidence of infection.