marine envenomation

Who’s Up for a Swim @ the BEACH?

By Kane Guthrie

The Lucky Country

Australia home to:• 38 terrestrial snakes • 23 sea snakes• 22 spiders• 7 jellyfish• 2 blue ringed octopuses, • 2 stone fish• Plus many more venomous creatures.

Marine Envenomation

• Australian waters contain great variety of venomous sea creatures.

• Includes jellyfish, sea snakes, blue-ringed octopus, stonefish,& stingrays.

• Jellyfish stings most common marine medical emergency.

• It’s estimated 10 000 jellyfish stings occur each year.

The Approach

http://www.marine-medic.com.au/

Sea Snakes

• Found in most waters around Aust.• Venom contains neuro toxins (paralysis) and

Myotoxins (rhabdomyolysis).• Close resemblance to land snakes.• Inquisitive, but rarely aggressive.• Bites normally occur during handling.

• Fatalities & Paralysis rare!!

Clinical Presentation

Localised:• Bite- small, superficial, relatively painless,

generally no local swelling. Systemic:• Non specific – headache, nausea & vomiting.• Symmetrical descending flaccid paralysis

manifest within 6 hours.• Rhabdo develops leading to ARF.

Emergency Department Management

Pre-Hospital:• PIBIn ED:• Check CK- give fluids• Paralysis can lead to Resp failure• Prepare to secure the airway• CSL Sea Snake Antivenom or Tiger Snake (Reverses

paralysis)• Observe for 12 hours, Don’t D/C @ night.

Bluebottle Jellyfish

• Responsible for thousand of stings each year!• Causes intense local pain and dermal

erythema.

Clinical Presentation

Localised:• Immediate burning pain – lasting up 2 hours.• Erythematous welts. Systemic:• Non specific symptoms include – nausea,

headache or malaise.

Emergency Department Management

Pre-Hospital:• Hot shower for 20mins (45°C optimal

temperature).• Reassurance.In ED:• Provide hot shower if not already done.• Simple analgesia.• D/C when symptoms improving.

Box Jellyfish

• Found in tropical Australian waters.• Most stings are benign, respond well to

supportive management.• Severe envenoming has been associated with

70 deaths in Aust.• Deaths occur through venoms direct cardiac

toxicity.

Clinical Presentation

Localised:• Immediate severe pain, lasting up to 8 hours.• Linear welts in cross hatched pattern.• In 25-30% cases tentacles still adherent.Systemic:• Within minutes collapse and cardiac arrest can occur.• HT, tachycardia, hypotension, impaired cardiac conduction

and arrhythmias.Ongoing:• Delayed hypersensitivity pruritic erythema rash can occur 7-

14 days after sting.

Emergency DepartmentManagement

Pre-hospital:• Apply vinegar to deactivate nematocyst. In ED:Minor:• Apply vinegar, ICE packs, analgesia.Severe:• Cardiac monitor, analgesia-opiate, fluid boluses.• CSL Box Jellyfish antivenom (3 ampoules)• Cardiac arrest – 6 ampoules of antivenom, if refractory

try Mg.

Irukandji Syndrome

• Poorly understood condition!• Characterized by: Severe painSympathomimetic statePotential for life threatening cardiovascular

complications.• Caused by Jellyfish envenomation – Carukia

barnesi is one specie of jellyfish that cause it, many other jellyfish are postulated as causing it.

Locations of Attacks

• Found in tropical waters.• Fatalities have been reported r/t ICH. • We have had Pt’s T/F to SCGH ED for ongoing

management.

Clinical Presentation

Localised:• Initial sting generally not felt – leads to short period before

systemic symptoms. Systemic:• Multiple systemic effects occur 30-90 minutes – agitation,

dsyphoria, vomiting, diaphoresis, severe pain back, limbs, abdomen.

• HT and tachycardia common. Rare:• Life threatening HT & APO may develop leading to

cardiovascular collapse.

Emergency DepartmentManagement

Pre-hospital:• Generous application of vinegar to all sting sites

(deactivates nematocyst).In ED:• Manage initially in resus – full monitoring!• Provide analgesia – may need PCA.• Treat nausea & control HT.• Mg may treat refractory pain.• Severe envenoming develops within 4/24 subsides by

12 hours.

Blue-ringed Octopus

• Found in shallow coastal waters• Envenoming causes rapid paralysis.• When handled or enraged it changes colour –

develops blue rings.• Maculotoxin –leads to sodium channel

blockade causes neuro-toxicity resulting in paralysis.

Clinical Presentation

Localised:• The bite may not be painful.• Local symptoms are minimal or absent. Systemic:• Characterised by rapidly progressive

descending paralysis.• Early signs- blurred vision, diplopia, ptosis,

difficulty swallowing.

Emergency DepartmentManagement

Pre-hospital:• Apply PIB, assisted ventilation.In ED:• Monitored in resus bay – watch for paralysis, resp

failure and hypotension.• Resp failure occurs- secure airway provide

mechanical ventilation.• Paralysis resolves with 24 hours.• No antidote available.

Stonefish

• Extremely well camouflaged reef fish.• Found in shallow waters around rocks & coral

reefs. • Found in northern Australian waters!• Their dorsal spines contain venom.

Clinical Presentation

Localised:• Pain @ site. (Usually severe)• Swelling, bruising & puncture marks.Systemic:• Non-specific signs: nausea, vomiting, dyspnoea &

dizziness.Rare:• Hypotension, bradycardia, collapse, APO- have

been rarely reported. No deaths in Aust.

Emergency DepartmentManagement

Pre-hospital:• Analgesia, immerse limb in hot water 45°CIn ED:• IV opioid analgesia – continue hot water• Wound management – debridement, ADT, AB’s• X-ray detect FB• Antivenom – neutralizes some components of

venom. (unproven – generally not required).

Questions

Take Home Points

• Marine envenomation is common depending on were you work.

• PIB on for BRO & sea snake bite.• Antivenom’s have a limited role & risks.• Supportive care is paramount!• Avoid D/C @ night!

Thank-You