BITES AND STINGS Sublingual glyceryl trinitrate as prehospital treatment for hypertension in Irukandji syndrome Peter J Fenner,* Morris Lewin† The treatment and clinical course of minutes after Carukia barnesi envenom- * National Medical Officer, and Associate Professor, each patient is described. ation on the same Whitsunday Island. School of Health and Sciences, School of Medicine, ■ James Cook University, Townsville, QLD; † Medical Patient 1 was a 43-year-old man with She was given three puffs of GTN, Officer, Hamilton Island; Surf Life Saving Australia, severe Irukandji syndrome (adrenergic which reduced her BP to 130/80 mmHg Sydney, NSW. Correspondence: Professor P J Fenner, symptoms, severe low-back and muscu- after 30 minutes. PO Box 3080, North Mackay, QLD 4740. lar pains) who presented 40 minutes None of the three patients had pre- [email protected] after Carukia barnesi envenomation on existing hypertension, or took medication. TO THE EDITOR: The Irukandji syn- an island in the Whitsundays. Despite GTN reduces hypertension by drome can cause severe hypertension being given 10 mg morphine intrave- vasodilation, and is now recommended (over 220/110 mmHg)1 and has caused nously, his BP was 200/112 mmHg. for hypertension from dysreflexia in two fatalities from cerebrovascular One puff of GTN was given, and after 5 patients with spinal injury,5 in whom haemorrhage.2 There is no first aid minutes his BP was 180/120 mmHg; similar high levels of serum catecho- treatment for the severe pain or hyper- another puff reduced it to 170/ lamines occur. Further assessment of tension, so developing an effective pre- 110 mmHg, and 10 minutes after a GTN use in patients with Irukandji hospital treatment is a priority. third puff it was 160/100 mmHg. After syndrome is necessary, but we believe it The venom from the jellyfish that transfer to a mainland hospital, his clin- should be considered as prehospital causes Irukandji syndrome (Carukia ical course was stormy. His hyperten- treatment under medical guidance. It is barnesi) is a sodium-channel agonist sion was poorly controlled by currently the recommended treatment which causes massive release of intravenous magnesium and he required by Ambulance Officers in the Queens- noradrenaline.3 Intravenous magnesium intravenous nitrates and morphine. land Ambulance Service.6 sulfate has proven to be an effective ■ Patient 2 was a 49-year-old man with pain (for which 10 mg morphine and Acknowledgements: Donations were received from Thyne treatment for the symptoms of Irukandji Reid Education Trust No 1, GBR Research Foundation, 4 syndrome, but requires in-hospital 50 mg promethazine were given intra- and the Australian Lions Foundation for Research on monitoring. We investigated the use of muscularly), adrenergic symptoms and a dangerous Marine Species. We thank Island Clinics for their cooperation and the doctors who encouraged us sublingual glyceryl trinitrate spray BP of 182/110 mmHg 25 minutes after despite initial opposition to the trial treatment. (GTN), which is a vasodilator, in three Carukia barnesi envenomation on a 1. Fenner PJ, Williamson J, Callanan VI, Audley I. Further sting victims, in whom it appeared to Whitsunday Island. One puff of GTN understanding of, and a new treatment for, “Irukandji” (Caru- effectively control hypertension. reduced his BP to 170/96 mmHg within kia barnesi) stings. Med J Aust 1986; 145: 569, 572-574. 2. Fenner PJ, Hadok JC. Fatal envenomation by jellyfish caus- Three patients with clinically con- 5 minutes; a second puff reduced it to ing Irukandji syndrome. Med J Aust 2002; 177: 362-363. firmed Irukandji syndrome were given 140/90mmHg at a further 5 minutes. 3. Tibballs J, Hawdon G, Winkel K. Mechanism of cardiac failure in Irukandji syndrome and first aid treatment for one puff of GTN sublingually for hyper- His BP remained at this level until he stings [letter]. Anaesth Intensive Care 2001; 29: 552. tension. Blood pressure (BP) was was transferred to hospital an hour later. 4. Corkeron MA. Magnesium infusion to treat Irukandji syn- drome [letter]. Med J Aust 2003; 178: 41. checked every minute for 5 minutes (by ■ Patient 3 was a 33-year-old woman 5. Queensland Health. The Queensland Spinal Cord Injuries electronic sphygmomanometer). Fur- with pain (treated with 10 mg morphine Service. Autonomic dysreflexia. Available at: www.health.qld.gov.au/qscis/INFOdysreflexia.htm ther puffs of GTN were given every 5 and 50 mg promethazine given intra- (accessed Sep 2003). minutes, with the aim of reducing the muscularly), adrenergic symptoms and 6. Queensland Ambulance Service. Marine envenomation education program. Facilitator guided overview. Brisbane: diastolic pressure below 100 mmHg. mild hypertension (143/98 mmHg) 35 QAS, 2003: 2. ❏ MJA Vol 179 1/15 December 2003 655.