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We have a 17 year old patient in route. Patient was involved in a shark attack while surfing. Her friends brought her to the shore as quickly as possible and wrapped a shirt around the site. The shark bit off her entire left arm, so the shirt was wrapped tightly around her shoulder. She has lost a lot of blood and is going into hypovolemic shock. Blood pressure is 70/40, O2 is 90% with a non-rebreather at 10 L, and heart rate is 112. We have started a 20 g IV to the right AC and have a NS fluid bolus running- She has received 1 L so far, blood pressure is now 85/55. Patient has remained conscious but is becoming more lethargic, has a GCS of 12. We administered 2 mg of Morphine. Parents have been notified and are right behind us. Will arrive in 3 minutes.

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Shark Attack! | Soul Surfer (2011) | Now Playing

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X-Ray Report

Patient Name: Bethany Hamilton
Patient ID: [Patient ID]
Date of Examination: October 31, 2013
Referring Physician: Dr. M. Thapa
Imaging Modality: X-Ray of the Left Upper Extremity and Chest

Findings:

Left Upper Extremity:

A complete amputation of the left arm is noted at the level of the shoulder, approximately at the mid-upper arm. No identifiable bone fragments are seen distal to the amputation site.

The proximal humerus shows irregular bone edges consistent with the traumatic nature of the injury, but there is no remaining skeletal continuity distal to the site of amputation.

Soft Tissues:

Significant disruption of the soft tissues is observed at the amputation site, with swelling and lacerations around the wound. The soft tissue damage corresponds with the traumatic shark bite injury.

No visible foreign bodies are present within the soft tissues.

There is no evidence of subcutaneous gas or infection at the site, but the injury carries a high risk for infection and other complications.

Chest:

Mild bilateral consolidation is observed in the lower lung fields, likely consistent with water inhalation during the traumatic event.

The presence of some patchy alveolar infiltrates suggests aspiration of water, but no acute pneumothorax or significant effusion is identified.

The heart size and mediastinal contours are within normal limits, with no acute injury or signs of pulmonary edema.

Additional Findings:

No fractures or skeletal injuries are seen in the remaining portion of the left arm.

The shoulder joint remains intact with no signs of dislocation or additional skeletal trauma.

Impression:

1. Complete Left Arm Amputation: Shark bite injury resulting in a complete amputation at the mid-upper arm level, with significant soft tissue disruption. There are no bone fragments seen distal to the injury site.

2. Soft Tissue Damage: Considerable soft tissue trauma around the amputation site with swelling and irregularities. Given the nature of the injury, the patient is at high risk for infection, and urgent surgical management is recommended.

3. Water Inhalation: Mild bilateral consolidation and patchy infiltrates in the lower lung fields, consistent with aspiration or inhalation of water during the incident. Close monitoring for respiratory distress or further complications related to aspiration is recommended.

4. No Additional Skeletal Injuries: No other fractures or dislocations are seen in the remaining left arm or chest.

Radiologist: Dr. M. Thapa
Signature: ____________________
Date: October 31, 2013

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With the infiltrates noted in the lower lung fields, when would you recommend a follow up chest x-ray to re-evaluate this?

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CMP (reference range)

Glucose 120 mg/dL (74-1.04)

BUN 11 mg/dL(7.0-17.0)

Creatinine 0.5 mg/dL (0.43-1.07)

BUN/Crea Ratio 22 (7.0-25.0)

Sodium 137 mmol/L (135-144)

Potassium 3 mmol/L (3.5-5.1)

Chloride 105 mmol/L (98-110)

CO2 23 mmol/L (22-30)

Anion Gap 9 mmol/L (7.0-15.0)

Calcium 8.4 mg/dL (8.4-10.2)

Protein, Total 5.2 g/dL (6.3-8.2)

Albumin 3.3 g/dL (3.5-5.0)

A/G Ratio 1.7 (1.1-1.8)

ALP 71 U/L (38-126)

AST 35 U/L (14-36)

ALT 25 U/L (<35)

Bilirubin, Total 0.5 mg/dL (0.0-1.1)

GFR >60 mL/min/1.7 (>=60)

CBC (reference range)

WBC 19.4 x 10^3/uL (4.00-10.50)

RBC 3.5 x 10^6/uL (4.00-6.00)

HGB 9 gm/dL (11.5-16.0)

HCT 31.4 % (40.0-54.0)

MCV 84 fL (80.0-96.0)

MCH 27.1 pg (28.0-36.0)

MCHC 30.5 g/dL (33.0-39.0)

PLT 170 x 10^3/uL (150-450)

MPV 6.9 fL (6.1-9.2)

NEUT 67 % (40.0-75.0)

LYPMH 27 % (20.5-45.5)

MONO 4 % (0.0-10.0)

EO 1 % (0.9-2.9)

BASO 1 % (0.2-1.0)

IMM GRAN <0% (0.0-0.1)

NEUT 12.4 x 10^3/uL (1.5-7.5)

LYMPH 5.2 x 10^3/uL (1.1-4.4)

MONO 0.7 x 10^3/uL (0.3-0.8)

EO 0.2 x 10^3/uL (0.0-0.2)

BASO 0.1 x 10^3/uL (0.0-0.1)

VBG (reference range)

pH: 7.2 (7.35-7.45)

pCO2: 20 mmHg (35-45)

pO2: 80 mmHg (90-100)

HCO3: 7.6 mEq/L (22-26)

BE: -18.4 mEq/L (-2.0-2.0)

LA: 10 mmol/L (<2.1)

Coagulation Studies (reference range)

PT: 20 seconds (10-13)

PTT: 50 seconds (25-35)

INR: 2.0 seconds (0.8-1.1)

Type & Screen

O Negative

Negative Antibody Screen

HCG Qualitative

Positive

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I noticed that the HCG qualitative was positive. Is this a definitive test for pregnancy? Are there further labs we should draw because of this?

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I noticed in your report that it mentions there was no evidence of subcutaneous gas or infection. What kinds of evidence would suggest infection in imaging of a traumatic amputation site? Also, what factors would affect the accuracy of a chest X-Ray? Thank you! - Sarah Bone (RN)

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What are the main considerations in managing a traumatic amputation like a shark bite, especially regarding the timing of possible reattachment versus immediate wound care?

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What specific tests or markers should I prioritize for this patient, considering the trauma from a shark bite and potential infection risk?

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She shows a WBC of 19, in the acute phase, why would the shark bite patient already have a white count? and infection surely couldn't start that rapidly, and with the blood loss wouldn't we expect to see a global decrease in her CBC?

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Do we need to consider BiPAP or CPAP for the aspiration? surgically speaking she would be intubated? is there any benefit to incubating earlier base on the water in the lungs?