Debridement is more effective than irrigation at removing bacteria and debris. Crushed or devitalized
tissue should be removed with sharp dissection to provide clean wound edges and encourage brisk healing
with minimal infection risk. The limitations are those imposed by anatomy, specifically skin tautness or the
presence of vital structures. Anesthesia of wound edges may be attained by regional nerve block or local
infiltration with lidocaine, which do not damage local tissue defenses. A topical anesthetic mixture of
tetracaine, epinephrine, and cocaine may be less desirable because of the vasoconstrictive effect of
epinephrine and theoretical infection-potentiating effects. Definitive wound exploration, debridement, and
repair should be undertaken in the most appropriate sterile environment. It is inappropriate to explore complex
wounds in the emergency department. Whenever necessary, operating loupes should be used to inspect the
wound for residual foreign material, such as sand, seaweed, teeth, spine fragments, or integumentary sheath
shards. Standard radiographs, static soft tissue techniques, MRI, or fluoroscopy may be used preoperatively or
perioperatively to localize spines or teeth.
WOUND CLOSURE
The decision to close a wound weighs the cosmetic result against the risk of infection. The incidence
of infection is high in wounds acquired in natural bodies of water because such wounds may be contaminated
with venom, potentially virulent microorganisms, or both; because early adequate irrigation and debridement
are often unavailable; and because definitive care is often delayed. Tight wound closure restricts drainage and
promotes bacterial proliferation. Wounds at high risk in this regard include those on the hands, wrists, or feet;
punctures and crush injuries; wounds into areas of fat with poor vascularity; and wounds to victims who are
immunosuppressed.
PROPHYLAXIS AGAINST TETANUS
Any wound that disrupts the skin can become contaminated with Clostridium tetani. Anaerobic
bacteria, predominantly of the genus Clostridium, have been isolated in shark tissue and as part of the oral
flora of alligators and crocodiles. Proper immunization with tetanus toxoid virtually eliminates the risk of
disease. However, while it was previously accepted that the protective level of toxin-neutralizing antibody is
0.01 antitoxin unit/ml, it appears that clinical tetanus can develop despite an antibody level many times that
amount. Therefore, it is imperative to provide an early and adequate booster injection.
Bacteriology of the Aquatic Environment
Wounds acquired in the aquatic environment are soaked in natural source water and sometimes
contaminated with sediment. Penetration of the skin by the spines or teeth of animals, the razor edges of coral
or shellfish, or the blades of a boat propeller may inoculate pathogenic organisms into a wound. Sports
activities, such as surfing, snorkeling, and diving, lead to ubiquitous abrasions and minor lacerations that heal
slowly and with marked soft tissue inflammation. Wounds acquired in the aquatic environment tend to
become infected and may be refractory to standard antimicrobial therapy. Not infrequently, indolent or
extensive soft tissue infections develop in the normal or immunocompromised host. A clinician faced with a
serious infection after an aquatic injury frequently needs to administer antibiotics to a patient before definitive
laboratory identification of pathogenic organisms.
Marine Environment
Ocean water provides a saline milieu for microbes. Marine bacteria are generally halophilic,
heterotrophic, motile, and gram-negative rod forms. Most marine bacteria are facultative anaerobes, which
can thrive in oxygen-rich environments. Few are obligatory aerobes or anaerobes. Some marine bacteria are
highly proteolytic, and the proportion of proteolytic bacteria seems to be greater in the oceans than on land or
in freshwater habitats.
Diversity of Organisms
Unique conditions of nutrient and inorganic mineral supply, temperature, and pressure have allowed
the evolution of unique, highly adapted marine microbes. In addition, numerous other bacteria, microalgae,
protozoa, fungi, yeasts, and viruses have been identified in or cultured from seawater, marine sediments,
marine life, and marine-acquired or marine-contaminated infected wounds or body fluids of septic victims.
Enteric pathogenic bacteria have been isolated from sharks. A shark attack victim in South Africa who
sustained serious injuries to his lower extremities was reported to have developed a fulminant infection
attributed to Bacillus cereus shown to be sensitive to fluoroquinolones, amikacin, clindamycin, vancomycin
and tetracyclines, and resistant to penicillin and cephalosporins (including third generation). In another report,
