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Marine Envenomations Marine Envenomations Lindsay Ballard, MD OHSUOHSU EM PGY-3 I have no financial OHSUdisclosures. OHSU Lindsay Ballard - PADI Master Scuba Diver Trainer I Definition + Epidemiology Envenomation: process of introduction of a venom or toxin via bite, sting or puncture Typically due to direct contact either passive or active Likely underreported DAN 2019 annual report: 214 marine OHSUenvenomations American Association of Poison Control Centers 2011 annual report: ~1800 aquatic exposures Pathophysiology is varied: Direct trauma or wound Mast cell degranulation Disruption of cell metabolism Neuronal transmission interference OHSUMyocardial depression OHSU Marine microbes OHSUPolymicrobial, gram negatives, often diagnosed late Cool photographs OHSU Typical envenomation treatment - Remove patient from water (scene safety) - Remove any obvious external debris, leave penetrating barbs/spines if large - Vinegar for 30 seconds - Hot water immersion in water up to 43C (45 often recommended, but can cause burns) for 20 minutes - Administer pain medication -- lidocaine often helpful - Consider radiographs for retained foreign body (or ultrasound) OHSU- Antibiotics, if indicated - Tetanus prophylaxis, if indicated - Consider closure by secondary intention (don’t close it!) Antivenom is available for box jellies, stonefish, and sea snakes OHSU Jellyfish envenomation - the to do list Invertebrates OHSU Cnidaria (jellyfish et al) Creatures that have cnidae, microscopic stingingOHSU apparati Jellyfish stings -- to pee or not to pee OHSUURINE Cubozoa Not a TRUE jellyfish, although they look like an archetypical jelly Square shaped top, evenly spaced tentacles, well shaped eyes Greatest morbidity and mortality of Cnidaria OHSU20 species known, most famously… Chironex fleckeri - box jellyfish Problem: called “world’s most venomous animal” and has tentacles Presentation: severe pain, dermatitis, frosted ladder rash, nausea, vomiting, headache, fevers, muscular spasm, arrhythmia, respiratory arrest. cardiovascular collapse Treatment:OHSU ABCs Decontamination Symptomatic control Antivenom for severe events Carukia barnesi - Irukanji jellyfish Problem: Can be deadly to humans; Irukanji syndrome Presentation: initially asyptomatic, then pain, hypertension, tachycardia, diaphoresis, spasms Treatment:OHSU ABCs + decontamination Vinegar Control pain and blood pressure EKG + troponin Hydrozoa - Portuguese man of war + fire coral Problem: painful stings. Tentacles Presentation: pain Treatment: NO vinegar Decontamination, symptomaticOHSU control Hot water immersion Scyphozoa - true jellies Problem: all over the world, increasing blooms Presentation: stinging, pain, wheal, pruritis Treatment: Vinegar (unless hydrozoa) Hot water immersion OHSUSymptomatic control Anthozoa + Porifera Problem: everywhere, easy for inadvertent contact Presentation: pain, stinging, abrasions Treatment: almost always solelyOHSU symptomatic Cephalopoda - octopus, squid, cuttlefish Problem: so cute looking! Presentation: mild pain, wheal, diplopia, aphona, dysphagia, weakness, ataxia, flaccid paralysis, death Treatment: ABCs, lymphatic occlusion, symptomatic control, wound management, tetanus OHSUCan have near total reversal of paralysis in 23-48 hours Gastropoda - cone snails Problem: people touch shells, they have pretty shells Presentation: stinging, pain, cyanosis, numbness, can progress to rapid death Treatment: ABCs Pressure immobilization Hot water immersion OHSUSymptomatic control + wound care Echinodermata - sea urchins, stars, sand dollars, cucumbers Problem: ubiquitous, inadvertent contact with bottom Presentation: puncture, pain, dermatitis Treatment: Symptomatic + wound care Hot water immersion OHSUXrays for retained foreign body Antibiotics + tetanus Vertebrates OHSU Chondrichthyes - stingrays Problem: tail has barbs, stingrays sit in the sand, unintentional contact Presentation: puncture, laceration, pain Treatment: symptomatic control/hemostasis hotOHSU water immersion xray for evaluation of retained foreign body antibiotics + tetanus Scorpaenidae - Stonefish/lionfish Problem: stonefish blend in - incidental contact, lionfish are hunted Presentation: pain, spines in hands Treatment:OHSU Stonefish: antivenom Symptomatic control/hemostasis Hot water immersion Consider imaging, antibiotics, tetanus Trachinidae - weeverfish Problem: most venomous fish in the temperate zone, incidental contact Presentation: excruciating pain Treatment: Symptomatic control/hemostasis OHSUHot water immersion Consider imaging, antibiotics, tetanus Sea snakes Problem: snakes Presentation: bite, pain, weakness, myalgias, dysphagia, trismus, ptosis Treatment: immobilization of extremity Antivenom OHSUsymptomatic control Eels Problem: they reside in holes where lobsters also live Presentation: bite, pain Treatment: OHSUSymptomatic wound care Radiographs for retained foreign body Antibiotics and tetanus Sharks Problem: they have teeth Presentation: mass hysteria, trauma Treatment: ABCs ATLSOHSU OHSU Shark attack OHSU Antidotes Scombroid Ciguatera HIstamine fish poisoning: inadequate Toxin from larger fish that eat smaller refrigeration fish that eat dinoflagellates Symptoms within 30 minutes of eating Odorless, tasteless, heat stable fish N/V/D, abdominal pain, ataxia, “Peppery” taste, flushing, headache, cold/heat reversal, tooth looseness OHSUN/V/D, palpitations sensation, hypotension, bradycardia Treatment: anti-histamine Treatment: symptomatic OHSU Hasta la vista Divers Alert Network. “Hazardous Marine Life” <https://www.diversalertnetwork.org/health/hazardous-marine-life/envenomations-introduction> Accessed 30 Aug 2020. Denoble, Petar, ed. DAN Annual Diving Report 2019 edition - A report on 2017 diving fatalities, injuries and accidents. Durham, NC: Divers Alert Network, 2019. Balhara KS, Stolbach A. Marine envenomations. Emerg Med Clin North Am. 2014;32(1):223-243. doi:10.1016/j.emc.2013.09.009 Hastrich, Carl “Up Cycle like a Nudibranch” 24 Sept 2011 <https://bouncingideas.wordpress.com/2011/09/24/up-cycle-like-a-nudibranch/> 15 Nov 2018 French LK, Horowitz Z. Marine Vertebrates, Cnidarians, and Mollusks. Iin: Critical Care Toxiicology . Brent et al, eds. 2 nd ed. DOI 10.1007/978-3-319- 17900-1_148 Accessed 15 Nov 2018 Wikipedia. Weever. <https://en.wikipedia.org/wiki/Weever> Accessed 31 August 2020. Marine Education Society of Australasia. Sea Snakes of Austrailia: Beaked Sea Snake . <http://www.mesa.edu.au/sea_snakes/sea_snakes05.asp> Accessed 31 Aug 2020. Purohit MP. Beaked Sea Snake Bite. <http://www.mesa.edu.au/sea_snakes/sea_snakes05.asp> Mar 16 2020.. Accessed 31 Aug 2020. Wikipedia. Marine vertebrate. <https://en.wikipedia.org/wiki/Marine_vertebrate> Accessed 31 Aug 2020. Collins A, Waggoner B, Smith D. “Introduction to Cnidaria” UCMP Berkeley <http://www.ucmp.berkeley.edu/cnidaria/cnidaria.html> 15 Nov 2018 ”Chironex fleckeri” 5 Nov 2018 Wikipedia <https://en.wikipedia.org/wiki/Chironex_fleckeri> 15 Nov 2018 SiladanOHSU Resort and Spa “Bunaken’s Deadliest Crritter” <https://www.siladen.com/bunakens-deadliest-critter/> 15 Nov 2018 MacDonald H “When Crown-of-Thorns Starfish Attack” 17 Jan 2018 JSTOR Daily <https://daily.jstor.org/when-crown-of-thorns-starfish-attack/> 16 Nov 2018 Long N. “Sea Snake Antivenom” Life in the Fast Lane 12 Jan 2016 <https://lifeinthefastlane.com/tox-library/antivenom/sea-snake-antivenom/> 16 Nov 2018 Auerbach et al. Dermatological Presentation of a Probable Box Jellyfish STing. Wilderness & Environmental Medicine. 2019: 30(3):310-20. Blohm E, Brush D. Marine Envenomations. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank's Toxicologic Emergencies, 11e. McGraw-Hill; Accessed September 01, 2020. https://accessemergencymedicine-mhmedical- com.liboff.ohsu.edu/content.aspx?bookid=2569&sectionid=21027667 Rosh Review questions Devlin JJ, Knoop KJ. Marine Trauma and Envenomation. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill; Accessed August 30, 2020. https://accessemergencymedicine- mhmedical-com.liboff.ohsu.edu/content.aspx?bookid=2353&sectionid=220746848 Lakkis NA, Maalouf GJ, Mahmassani DM. Jellyfish Stings: A Practical Approach. Wilderness & Environmental Medicine. 2016. 26:422-429. Diaz JH: Skin and soft tissue infections following marine injuries and exposures in travelers. J Travel Med 21: 207, 2014. Alerhand S. Jellyfish Sting Management: To Pee or not to pee? Mt Sinai EM blog. <https://sinaiem.org/should-you-pee-on-that-jellyfish-sting/> Accessed 2 Sept 2020. Cales S. Why Risk Messaging is Risky: Lessons from a Shark Attack. FunEasyPopular Blog. 10 Aug 2017.<https://blog.funeasypopular.com/why-risk- messaging-is-risky-lessons-from-a-shark-attack> Accessed 2 Sep 2020. 9 OHSU.
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