Marine Envenomation




Venomous aquatic animals are hazardous to swimmers, surfers, divers, and fishermen. Exposures include mild stings, bites, abrasions, and lacerations. Severe envenomations can be life threatening. This article reviews common marine envenomations, exploring causative species, clinical presentation, and current treatment recommendations. Recommendations are included for cnidaria, sponges, bristle worms, crown-of-thorns starfish, sea urchins, venomous fish, stingrays, cone snails, stonefish, blue-ringed octopus, and sea snakes. Immediate and long-term treatment options and management of common sequelae are reviewed. Antivenom administration, treatment of anaphylaxis, and surgical indications are discussed.


Key points








  • Know the marine organisms in your clinical practice area.



  • Be prepared to treat anaphylaxis and acute life-threatening envenomations from box jellyfish, irukandji jellyfish, stonefish, cone snail, blue-ringed octopus, or sea snake.



  • Know where and how to obtain antivenom.



  • Decontamination is species specific and includes removing tentacles, embedded spines, and foreign bodies.



  • Attempt pain control with species-specific treatments, including 5% acetic acid (vinegar), hot water immersion, and saline rinse.






Introduction


Venomous aquatic animals are hazardous to swimmers, surfers, divers, and fishermen. Most marine exposures are mild, so victims may not seek medical care. These exposures include mild stings, bites, abrasions, and lacerations. Severe envenomations from box jellyfish, irukandji jellyfish, cone snails, blue-ringed octopus, stonefish, or sea snakes can be life threatening. In these cases, rapid effective treatment improves immediate outcomes (decrease pain, stabilize systemic symptoms, treat anaphylaxis) and minimizes secondary complications (local allergic response, infection, wound complications). Treatment recommendations evolve in response to acquisition of data, clinical observations, and expert opinion. This article outlines recent management and treatment recommendations for marine envenomations. For the treatment of all envenomations, apply appropriate tetanus immunization. Consider prophylactic or therapeutic antibiotics.




Introduction


Venomous aquatic animals are hazardous to swimmers, surfers, divers, and fishermen. Most marine exposures are mild, so victims may not seek medical care. These exposures include mild stings, bites, abrasions, and lacerations. Severe envenomations from box jellyfish, irukandji jellyfish, cone snails, blue-ringed octopus, stonefish, or sea snakes can be life threatening. In these cases, rapid effective treatment improves immediate outcomes (decrease pain, stabilize systemic symptoms, treat anaphylaxis) and minimizes secondary complications (local allergic response, infection, wound complications). Treatment recommendations evolve in response to acquisition of data, clinical observations, and expert opinion. This article outlines recent management and treatment recommendations for marine envenomations. For the treatment of all envenomations, apply appropriate tetanus immunization. Consider prophylactic or therapeutic antibiotics.




Sponges


Epidemiology


Sponges (phylum Porifera) are acellular creatures that attach to the ocean floor. They carry spicules of silicon dioxide or calcium carbonate. Many produce dermal irritants known as crinotoxins. Typical offenders include the fire sponge ( Tedania ignis ), poison bun sponge ( Fibularia nolitangere ), and red moss sponge ( Mammillaria prolifera ).


Presentation


Spicules and crinotoxins enter the skin, causing edema, vesiculation, joint swelling, and stiffness. Mild reactions subside within 7 days. Extensive exposure may induce fever, chills, malaise, dizziness, nausea, muscle cramps, and formication. Retained spicules can result in persistent bullae that take months to heal. Delayed systemic erythema multiforme or dyshidrotic eczema may develop. In severe cases, surface desquamation may follow.


Treatment


Remove spicules using adhesive tape, a thin layer of rubber cement, or facial peel. Apply 5% acetic acid (vinegar) soaks. Steroid cream or an oral antihistamine may provide symptomatic relief. Consider systemic corticosteroids for severe allergy, erythema multiforme, or dyshidrotic eczema. Arrange wound checks because infections may develop requiring antibiotic therapy ( Table 1 ).



Table 1

Presentation and treatment of envenomation by dermal contact












































Species Presentation Treatment
Portuguese man-of-war; blue bottle Local pain, skin blisters, nausea, vomiting, abdominal pain, muscle cramps, dyspnea Remove tentacles
Hot water (upper limit 45°C) immersion
Box jellyfish Excruciating pain, hypotension, paralysis, respiratory failure, cardiac arrest, skin blisters and necrosis Apply acetic acid 5% then remove tentacles
Support airway and breathing
Antivenom if severe symptoms
Avoid hot water immersion or pressure immobilization
Irukandji jellyfish Catecholamine release, muscle pain, abdominal pain, hypertension, troponin leak, heart failure, pulmonary edema Remove tentacles
Apply acetic acid 5%
Cardiac monitoring
Blood pressure control ( avoid β-adrenergic blockers )
Respiratory support
Jellyfish Mild pain, irritant dermatitis Remove tentacles
Apply acetic acid 5%, lidocaine-containing product, or hot water (upper limit 45°C) immersion
Seabather’s eruption Pruritic papules resembling insect bites in distribution of swim suit Treat skin with acetic acid 5%, or lidocaine-containing first aid remedy
Wash swim suit with hot water and detergent, then machine or sun dry
Sea anemone Erythema and pruritus
Petechiae, blisters, and ulceration
Acetic acid 5%
May require prolonged wound care
Feather hydroid; fire coral Stinging pain, urticaria, petechiae, ulceration, residual hyperpigmentation Acetic acid 5%
May require prolonged wound care
Sponge Pruritic irritant dermatitis, blisters, delayed desquamation Remove spicules with tape, rubber cement, or facial peel
Acetic acid 5%
Bristle worm Painful urticarial rash Remove bristles with tape, rubber cement, or facial peel
Acetic acid 5%




Cnidaria


The phylum Cnidaria is divided into four main groups: (1) hydrozoans, including feather hydroids, fire corals, and Portuguese man-of-war; (2) scyphozoans, such as true jellyfish; (3) anthozoans, such as soft corals and anemones; and (4) cubozoans, such as box jellyfish and irukandji.


Hydroids and Fire Coral


Epidemiology


Hydrozoans are multiorganism colonies of diverse configurations. Feather hydroids are plumelike species found in tropical waters. Fire coral has an appearance similar to hard coral. An example is Millepora , distributed in shallow tropical waters and dangling tiny nematocyst-bearing tentacles. The stinging tentacle-bearing Portuguese man-of-war ( Physalia physalis ) and blue bottle ( Physalia utriculus ) are widely distributed.


Presentation


Feather hydroids and fire coral cause immediate pain and urticaria, sometimes progressing to hemorrhagic or ulcerating lesions. Pain usually resolves by 90 minutes and inflammation resolves by 1 week, with occasional residual hyperpigmentation. Portuguese man-of-war and bluebottle envenomations cause immediate intense pain and linear rashes, with vesiculation and necrosis. Pain improves within hours, and local symptoms resolve within 72 hours. More severe systemic symptoms include nausea, vomiting, muscle cramps, dyspnea, anxiety, abdominal pain, and headache.


Treatment


For feather hydroid and fire coral envenomations, apply acetic acid 5% (vinegar) to the skin. Consider steroid cream or an oral antihistamine for symptomatic relief; if the reaction is eczematous or indolent, administer systemic corticosteroids. Portuguese man-of-war and bluebottle envenomation treatment is controversial. Acetic acid 5% is shown to worsen cnidocyst discharge in vitro, although some patients report symptomatic relief. A lidocaine-containing product may be equally effective. Recent research supports rinsing with seawater or saline followed by hot water (45°C) immersion. Consider topical steroid cream or ointment; an antihistamine; and for severe reactions, a systemic corticosteroid taper over 14 days (see Table 1 ).


Jellyfish


Epidemiology


Scyphozoans are single-organism jellyfish that range in size from 2 cm to 2 m across the bell and have different forms, including free-floating larva, sessile polyp, and large swimming medusa ( Fig. 1 ). Mauve stingers ( Pelagia ) are common in US Pacific Ocean coastal waters. The large lion’s mane jellyfish ( Cyanea capillata ) inhabits cold Arctic and Pacific waters. Stinging larval forms of multiple species are found in warm waters; these notably include pinhead-sized larvae of the thimble jellyfish ( Linuche unguiculata ).




Fig. 1


Medusa form of the moon jellyfish ( Aurelia aurita ).

( Courtesy of Kirsten B. Hornbeak, MD, Stanford, CA.)


Presentation


Contact with tentacles causes stinging pain and localized erythema that resolve in hours to days. Contact with the larval forms can cause seabather’s eruption; pruritic papules resembling bug bites in a bathing suit distribution (within which larvae are trapped) itch and annoy for 2 to 14 days. Other symptoms include fever, headache, chills, malaise, vomiting, conjunctivitis, and urethritis.


Treatment


Management of scyphozoan stings is identical to that for any cnidarian sting, namely, topical acetic acid 5%, hot water immersion, and corticosteroid or antihistamine cream, and in severe cases a systemic corticosteroid. A lidocaine-containing product may be effective as a topical decontaminant. To minimize or prevent seabather’s eruption, change swimwear on leaving the water. Use a hot water laundering scrub with detergent and full drying before reuse (see Table 1 ).


Sea Anemones


Epidemiology


Sea anemones and soft corals have tentacles loaded with stinging cnidocytes and secrete mucus that may contain cytolytic and hemolytic toxins, neurotoxins, cardiotoxins, and proteinase inhibitors.


Presentation


Victims experience painful skin lesions with central pallor and a halo of erythema and petechial hemorrhage, sometimes progressing to vesiculation and necrosis. Rare systemic reactions include fever, chills, malaise, weakness, nausea, vomiting, muscle spasm, and syncope. Mild envenomations resolve within 48 hours. Severe reactions may become indolent, leading to hyperpigmentation, hypopigmentation, or keloid formation.


Treatment


Treatment of anemone envenomation is similar to that for cnidarian sting (discussed previously). Severe dermatitis may require prolonged wound care with debridement and antibiotics for secondary infection (see Table 1 ).


Box-Shaped Jellyfish


Epidemiology


Some highly venomous box-shaped jellyfish inhabit tropical waters. These include the Hawaiian box jellyfish ( Carybdea alata ), Japanese box jellyfish ( Chironex yamaguchi ), and Australian box jellyfish ( Chironex fleckeri ). Each delivers potentially deadly venom.


Irukandji jellyfish are 1 cm to 2.5 cm box jellyfish and include Carukia barnesii and Malo species. The “irukandji syndrome” is local vasoconstriction and high blood pressure attributed to sympathetic nervous system stimulation.


Presentation


Box jellyfish stings are excruciating with rapid blistering, muscle spasm, hypotension, and sometimes paralysis. Victims collapse in 1 to 2 minutes from respiratory failure and cardiac arrest. Most deaths occur 5 to 20 minutes after the sting. Skin necrosis is common.


Irukandji envenomation symptoms begin 20 to 30 minutes post sting with muscle pain, abdominal and chest pain, nausea, vomiting, and respiratory failure. Massive catecholamine release causes severe hypertension and tachycardia, leading to cardiomyopathy, pulmonary edema, cerebral edema, troponin leak, and hypokinetic heart failure. Two deaths have occurred because of intracerebral hemorrhage. Symptoms resolve in 6 to 24 hours.


Treatment


If box jellyfish sting is suspected, support the airway and provide artificial ventilation. Immediately flood sting sites with 5% acetic acid (vinegar) for at least 30 seconds before removing adherent tentacles. Avoid contamination of rescue personnel. Administer specific antivenom one vial intravenous (IV) or introsseous 5 minutes, or three vials intramuscular (IM) at three different sites. Repeat as needed every 10 minutes up to three times immediately and then once or twice every 2 to 4 hours until there is no further progression of systemic symptoms. Antivenom use is under scrutiny because of poor efficacy noted during in vitro studies. However, until further notice it remains recommended.


For irukandji envenomation, in addition to standard cnidarian envenomation treatment measures and supportive therapy, serum troponin and cardiac monitoring should be obtained. β-Adrenergic blockers should not be used because these might contribute to unopposed α-adrenergic stimulation and myocardial ischemia (see Table 1 ).




Annelid worms


Epidemiology


Bristle worms (phylum Annelida, class Polychaeta) are covered with chitinous bristles that easily penetrate skin.


Presentation


Human contact causes bristles to break off into the skin, causing pricking sensation and urticarial rash with rare necrosis. Pain remits with a few hours, but urticaria may last for 2 to 3 days and skin discoloration for up to 10 days. Secondary infection and cellulitis may occur.


Treatment


Bristles should be removed with tape, facial peel, or a thin layer of rubber cement. Next, apply acetic acid 5% soaks. If the inflammatory reaction is severe, consider an oral antihistamine or corticosteroid (see Table 1 ).




Starfish and sea urchins


Epidemiology


The phylum Echinodermata includes starfish and sea urchins. The crown-of-thorns starfish ( Acanthaster planci ) is particularly venomous and produces a toxic slime that coats the spines ( Fig. 2 ). Venom is hemolytic, myonecrotic, hepatotoxic, and anticoagulant.




Fig. 2


Spines on the crown-of-thorns sea star ( Acanthaster planci ).

( Courtesy of Kirsten B. Hornbeak, MD, Stanford, CA.)


Sea urchins have globular bodies covered by calcified spines either rounded at the tip or hollow and venom-bearing ( Fig. 3 ). They may have pedicellariae (modified spines with flexible heads) that grasp to envenom. Various urchin venoms have been found to contain steroid glycosides, hemolysins, proteases, serotonin, and cholinergic substances.




Fig. 3


Spines of the banded sea urchin ( Echinothrix calamaris ).

( Courtesy of Kirsten B. Hornbeak, MD, Stanford, CA.)


Presentation


Crown-of-thorns starfish cause puncture wounds with immediate pain, bleeding, and edema. Wounds become dusky and tenosynovitis may develop. Multiple punctures can cause systemic reactions with paresthesias, nausea, vomiting, lymphadenopathy, and paralysis. Pain resolves in 30 minutes to 3 hours. Retained spines can cause granulomas.


Sea urchins cause painful puncture wounds with severe local muscle aching lasting up to 24 hours. Frequently, spines break off into the victim. A spine in a joint can cause synovitis. Systemic symptoms include nausea, vomiting, paresthesias, weakness, abdominal pain, syncope, hypotension, and respiratory distress. Secondary infections are common. Granulomas may develop.


Treatment


The puncture wounds should immediately be immersed in hot water to tolerance (upper limit 45°C) for 30 to 90 minutes or until there is significant pain relief. Local anesthetic infiltration or a nerve block may be required. Wounds should be irrigated and explored and spines removed if they are easily reached. Dark discoloration may indicate dye in the tissues in the absence of a spine. If this is the case, the discoloration disappears in 24 to 48 hours. If spines have entered a joint or are close to neurovascular structures a surgeon should be consulted and the joint splinted. Radiography, ultrasound, computed tomography, or MRI may be helpful in spine localization and removal. Reactive neuropathy may respond to a systemic corticosteroid. Secondary infections are common. Granulomas from retained spine fragments may require excision or ablation, and arthritis from retained spines may require synovectomy ( Table 2 ).



Table 2

Presentation and treatment of envenomation by puncture or laceration








































Species Presentation Treatment
Crown-of-thorns starfish Dusky puncture wound, pain, bleeding, edema
Multiple punctures cause nausea, vomiting, paresthesias
Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic
Locate retained spines
Surgical removal if spines near nerve, tendon, or joint
Sea urchin Red, purple, or black puncture wounds; local muscle aching; edema
Multiple punctures cause nausea, vomiting, paresthesias
Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic
Locate retained spines
Surgical removal if spines near nerve, tendon, or joint
Cone snail Puncture wound resembling bee sting, local cyanosis, limb paresthesias, paralysis, respiratory failure, cerebral edema, coma Pressure immobilization
Support breathing
Consider edrophonium, 10 mg IV, for paralysis
Consider naloxone, 2–4 mg, for severe hypotension
Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic
Remove retained radula
Blue-ringed octopus Painless small puncture wounds, facial numbness, paralysis, respiratory failure Support breathing
Supportive care
Lionfish and scorpionfish Painful puncture wound, blistering, nausea, vomiting Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic or nerve block
Locate retained spines
Surgical removal if spines near nerve, tendon, or joint
Stonefish Severely painful cyanotic puncture wound, necrotic ulceration, altered mentation, fever, nausea, vomiting, seizures, paralysis, heart block, heart failure, pulmonary edema Antivenom for severe envenomation
Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic or nerve block
Locate retained spines
Surgical removal if spines near nerve, tendon, or joint
Debride necrotic tissue
Stingray Dusky painful laceration, local hemorrhage and necrosis, barb lodged in victim
Large envenomation: nausea, vomiting, muscle cramps, syncope, arrhythmias
Hot water to tolerance (maximum 45°C) for 30–90 min
Local anesthetic or nerve block
Locate retained barb
Surgical removal of barb
Treat retained barb as stab wound if barb in thorax, abdomen, groin, or neck
Serial debridement of necrotic tissue
Sea snake Painless pinhead-sized fang marks, muscle pain and stiffness, nausea, vomiting, ascending paralysis, respiratory failure, muscle necrosis, renal failure Pressure immobilization
Maintain airway and breathing
Antivenom if any symptom
Monitor electrolytes and urine output
Alkalinize urine if myoglobinuria
Dialysis as needed for renal failure and hyperkalemia

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Dec 2, 2017 | Posted by in Uncategorized | Comments Off on Marine Envenomation
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