P031: LIMB SALVAGE IN PEDIATRIC TRAUMA: TEAM CARE AND ANESTHETIC MANAGEMENT AFTER A SHARK ATTACK
Juliet Galtes, MD1; Puri Suvikram, MD2; Tanjina Jalil, MA2; Enrico Camporesi, MD2; Heine Rivera Rodriguez, MD2; Jaison Udani, MD2; Jose J Rivera Melendez, MD2; Eugenio Oliveros, APRN2
1Department of Anesthesiology and Perioperative Medicine, Morsani College of Medicine; 2TEAMHealth, Anesthesia, Tampa General Hospital
Introduction: Traumatic amputations in pediatric patients are rare and catastrophic, requiring rapid, multidisciplinary coordination to preserve both limb and function. This case describes the emergency response and anesthetic management in the surgical replantation of a nearly avulsed hand in a 9-year-old patient following a shark attack near Boca Grande, Florida, in June 2025.
Case Description: A 9-year-old female snorkeling in the Gulf of Mexico was attacked by an 8-foot shark, resulting in a near-complete amputation of her right hand. Due to the lack of local microsurgical capabilities, she was transported via aeromedical helicopter to Tampa General Hospital. Real-time coordination between ground EMS, flight medics, and the receiving surgical and anesthesiology teams enabled immediate operative readiness. Informed consent to publish this case was obtained from guardian.
The anesthetic plan prioritized airway protection, maintenance of microvascular perfusion, and multimodal anesthesia. Following premedication with 2 mg intravenous midazolam, general anesthesia was induced with fentanyl, lidocaine, propofol, and rocuronium. Direct video laryngoscopy facilitated intubation with a 6.0 mm cuffed endotracheal tube. Following induction, the patient experienced profound hypotension, with noninvasive mean arterial pressures (MAP) decreasing to approximately 30 mmHg. This was managed with intermittent phenylephrine boluses totaling 200 mg. Once hemodynamics stabilized, further management prioritized the avoidance of vasoconstrictors to optimize microvascular flow during the six-hour replantation.
Intraoperative stability was maintained with 900 mL of crystalloid, 250 mL of 5% albumin, and 0.25 g of calcium chloride; notably, no blood products were required. To address marine-specific pathogens, perioperative prophylaxis included tetanus immune globulin 250 units and antimicrobial coverage with vancomycin 408 and doxycycline 54 mg to target Mycobacterium marinum.
Results: Microsurgical repair successfully restored vascular and neural patency. Postoperatively, the patient was admitted to the pediatric intensive care unit for five days, where analgesia was managed with scheduled acetaminophen, ketorolac, and gabapentin, supplemented by morphine and oxycodone for breakthrough pain. By six weeks post-injury, the patient had initiated active range-of-motion therapy with progressive functional recovery.
Discussion: This case highlights the critical role of anesthesiologists in pediatric trauma, specifically in balancing systemic hemodynamic stability with the microcirculatory requirements of complex replantation. The choice of vasopressor—phenylephrine for initial stabilization followed by a transition to fluid-based resuscitation—reflects the clinical challenge of preventing graft vasospasm while maintaining perfusion pressure. Furthermore, the selection of doxycycline for Mycobacterium Marinum underscores the importance of anesthesiologists in early, site-specific infectious disease management.
Conclusion: Successful pediatric limb salvage following high-energy marine trauma requires rapid transport, vigilant anesthetic planning, and precise interdisciplinary coordination. This case exemplifies how integrated perioperative management directly contributes to life-changing functional outcomes.