title: The 2009 Sydney shark attacks: case series and literature review.
abstract: BACKGROUND
  There were 59 unprovoked shark attacks worldwide in 2008. Twelve of these occurred in Australia, ranking it as second only to the USA. In February 2009, two attacks occurred within 72 h in Sydney, Australia.
  
  
  METHODS
  The two patients involved survived severe limb trauma. Case 1 suffered bite trauma to the lower limb and hand and underwent staged debridement and early amputation. Case 2 presented with a hand severed at the level of the wrist that was initially replanted. However, it would succumb to progressive necrosis after 12 days. We discuss the aspects of these cases that contributed to the patients' survival and ultimately good functional outcomes.
  
  
  CONCLUSIONS
  New paradigms for the management of major trauma patients have emerged over the last decade. We consider recent advances in the understanding of pre-hospital tourniquet use, rapid transit to the operating suite and damage control surgery, and examine how they impacted on the management of our patients. Very little is known about the microbiology of shark bites. Organisms from sea water, the patient's skin and the shark's mouth must all be considered when selecting appropriate antimicrobial prophylaxis. The planning of definitive surgery in severe limb trauma is dependent on the interactions of a number of factors including physical, psychological and social issues. The decision to ultimately replant or amputate the effected limb is best made in union with the patient and their family.
authors.affiliation: The Department of Plastic and Reconstructive Surgery, St Vincent's Hospital, Darlinghurst, Australia. rtshiladze@hotmail.com
authors.forename: Michael Alexander
authors.initials: MA
authors.lastname: Rtshiladze
authors.forename: Sean Peter
authors.initials: SP
authors.lastname: Andersen
authors.forename: Dai Quoc Anh
authors.initials: DQ
authors.lastname: Nguyen
authors.forename: Anthony
authors.initials: A
authors.lastname: Grabs
authors.forename: Kevin
authors.initials: K
authors.lastname: Ho
mesh_terms: D000328:Adult; D000673:Amputation, Traumatic / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D000818:Animals; D001733:Bites and Stings / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D004632:Emergency Medical Services; D006230:Hand Injuries / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D006801:Humans; D007869:Leg Injuries / Q000473:pathology / Q000601:surgery / Q000628:therapy*; D008297:Male; D009517:New South Wales; D012092:Replantation; D012754:Sharks; D014111:Tourniquets / Q000009:adverse effects