Envenomation by Marine Life

Within a few hours after contact: burning and itching of the skin, sometimes progressing to local joint swelling and stiffness, soft tissue edema, and blistering

• Skin becoming mottled or purpuric in appearance

• If untreated, subsidence of minor reaction in 3 to 7 days; major reaction may require weeks to resolve

With involvement of large areas of skin: fever, chills, malaise, dizziness, nausea, muscle cramps, and formication

• Bullae becoming purulent

• Surface skin desquamation after 10 days

Gently dry the skin.

To remove embedded microscopic spicules, apply sticky adhesive tape, a commercial facial peel, or a thin layer of rubber cement; then peel away the adherent spicules.

Apply a 5% acetic acid (vinegar) soak for 10 to 30 minutes three or four times a day. If vinegar is not available, use isopropyl alcohol 40%. Do not use a topical steroid preparation as the primary (initial) decontaminant because this may worsen the reaction.

After decontamination and at least two vinegar applications, use a mild antiinflammatory cream (e.g., hydrocortisone or triamcinolone) to soothe the skin.

If the allergic component is mild, apply a topical steroid preparation. If the allergic component is severe, as manifested by weeping, crusting, and vesiculation, administer a systemic corticosteroid (e.g., prednisone, 60 to 100 mg, tapered over 14 days).

Perform frequent follow-up wound checks because significant infections sometimes develop. Culture infected wounds and administer antibiotics (see Chapter 52 ).

Erythema multiforme or dyshidrotic eczema may be treated with oral prednisone, 60 to 100 mg, tapered over 2 to 3 weeks.

Ensure that all divers and net handlers wear proper gloves.

Do not allow sponges to be broken, crumbled, or crushed with bare hands.

Be aware that dried sponges may remain toxic.

Skin irritation: stinging, pruritus, paresthesias, burning, throbbing, redness, tentacle prints, impression patterns (see Plate 37 ), blistering, local edema, petechial hemorrhages, skin ulceration, necrosis, and secondary infection

Neurologic: malaise, headache, aphonia, diminished touch and temperature sensation, vertigo, ataxia, spastic or flaccid paralysis, mononeuritis multiplex, parasympathetic dysautonomia, plexopathy, peripheral nerve palsy, delirium, loss of consciousness, and coma

Cardiovascular: anaphylaxis, hemolysis, hypotension, small artery spasm, bradycardia, tachycardia, congestive heart failure, and ventricular fibrillation

Respiratory: rhinitis, bronchospasm, laryngeal edema, dyspnea, cyanosis, pulmonary edema, and respiratory failure

Musculoskeletal: abdominal rigidity, myalgias, muscle cramps/spasm, arthralgia, and arthritis

Gastrointestinal: nausea, vomiting, diarrhea, dysphagia, hypersalivation, and thirst

Ocular: conjunctivitis, chemosis, corneal ulcer, iridocyclitis, elevated intraocular pressure, and lacrimation

Other: chills, fever, acute renal failure, and nightmares

For systemic reactions:

• a.

  Maintain the airway and administer oxygen.

• b.

  Obtain intravenous access. Administer lactated Ringer's solution or normal saline solution to support the blood pressure to at least 90 mm Hg systolic.

• c.

  Treat anaphylaxis if present (see Chapter 26 ).

• d.

  If the sting is from the box jellyfish (Chironex fleckeri) (see Plates 38 and 39 ) or severe and from the sea wasp (Chiropsalmus quadrigatus) , consider immediate administration of C. fleckeri antivenom. Administer this in a dose of one ampule (20,000 units per ampule) IV diluted 1 : 5 to 1 : 10 in isotonic crystalloid. A large sting in an adult may require the initial administration of two ampules. Alternatively, administer this in a dose of three ampules intramuscularly into the thigh. Antivenom administration may be repeated once or twice every 2 to 4 hours until there is no further worsening of the reaction (skin discoloration, pain, or systemic effects).

• e.

  If the sting is from the Irukandji (Carukia barnesi) , hypertension from catecholamine stimulation may be severe. If necessary, administer an α-adrenergic blocking agent (phentolamine, 5 mg IV initially, followed by an infusion of up to 10 mg/hr). Magnesium sulfate (loading dose 10 mmol = 2.5 g = 20 mEq followed by an infusion of 5 mmol/hr) might be helpful.

• f.

  Authorities no longer recommend the pressure immobilization technique to treat a box jellyfish sting or any other jellyfish sting.

For dermatitis:

• a.

  If possible, apply a topical decontaminant immediately (described in step d, later). If more than 1 or 2 minutes will elapse before the application of the decontaminant, rinse the wound with seawater. Do not rinse gently with freshwater; if freshwater is to be used, the stream must be forceful (e.g., jet stream from a shower or hose).

• b.

  Hot packs or showers to tolerance (45°C [113°F]) may be more effective than dry, (nonmoist), cold (insulated ice) packs.

• c.

  Do not rub or abrade the wound.

• d.

  If these have been done, apply a topical decontaminant. The efficacy may vary depending on the stinging species.

  • Acetic acid 5% (vinegar) is the decontaminant of choice with a box jellyfish (C. fleckeri) sting.

  • For other stings, diminish the pain using vinegar, isopropyl (rubbing) alcohol 40%, sodium bicarbonate (baking soda), papain (papaya latex or nonseasoned meat tenderizer, the latter in a brief [<15 minutes] application), or lidocaine. Other substances that may be effective include sugar or olive oil, or lemon or lime juice. Household ammonia may irritate skin and is not recommended. Urinating on the sting is generally not helpful. A sting from the Australian Physalia physalis , a recently differentiated species, should not be doused with vinegar.

  • Do not apply a solvent (e.g., formalin, ether, gasoline).

  • Perfume, aftershave, or high-proof liquor may worsen the skin reaction.

• e.

  After decontamination, remove the adherent nematocysts. Apply shaving cream or a paste of soap or baking soda, flour, or talc, and shave the area with a razor or other sharp edge.

• f.

  Apply a local anesthetic ointment or mild steroid preparation to soothe the skin.

• g.

  If the reaction is severe, administer a systemic corticosteroid (e.g., prednisone, 60 to 100 mg, tapered over 14 days).

• h.

  Pain control may require narcotic administration (see Chapter 24 ).

• i.

  Inspect the wound regularly for ulceration and the onset of infection.

• j.

  Administer tetanus prophylaxis.

If the eye is involved, it should be anesthetized with proparacaine 0.5% and irrigated to 100 to 250 mL of normal saline to remove foreign matter. Slit lamp examination and fluorescein staining to identify corneal defects are recommended.

Give all jellyfish a wide berth when swimming or diving.

Wear a “stinger suit” when immersed in jellyfish-infested water.

When diving, scan for surface concentrations of stinging animals.

If “stinger enclosures” are present, do not venture beyond their confines.

Consider the use of a topical skin protective preparation such as Safe Sea (jellyfish-safe sunblock).

Stinging of the skin while still in the water or immediately on exiting; may be intensified by the application of fresh water

Skin redness, papules (see Plate 40 ), urticaria, and blisters minutes to 12 hours after exposure

• Most common areas: buttocks, genitals, and under breasts (women)

• Individual lesions resembling insect bites

• Also seen under bathing caps and swim fins and along the edge of the cuffs of wet suits

Fever, chills, headache, fatigue, malaise, vomiting, conjunctivitis, and urethritis

Apply a topical decontaminant. Acetic acid 5% (vinegar) seems to be less effective than papain. Otherwise, scrub thoroughly with soap and water. A lidocaine-containing preparation may be helpful.

After decontamination, apply calamine lotion with 1% menthol to control itching. A high-potency topical corticosteroid preparation may be of benefit.

If the reaction is severe, administer a systemic corticosteroid (e.g., prednisone, 60 to 100 mg, tapered over 14 days).

Intense pain, bleeding, local soft tissue edema

With multiple stings: paresthesias, nausea, vomiting, lymphadenopathy, muscular paralysis