Who’s Up for a Swim @ the BEACH? By Kane Guthrie
The Lucky CountryAustralia 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.
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 PresentationLocalised:• 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 ManagementPre-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 PresentationLocalised:• Immediate burning pain – lasting up 2 hours.• Erythematous welts.Systemic:• Non specific symptoms include – nausea, headache or malaise.
Emergency Department ManagementPre-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 PresentationLocalised:• 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 Department ManagementPre-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 pain Sympathomimetic state Potential for life threatening cardiovascular complications.• Caused by Jellyfish envenomation – Carukiabarnesiis 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 PresentationLocalised:• 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 Department ManagementPre-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 PresentationLocalised:• 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 Department ManagementPre-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 PresentationLocalised:• 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 Department ManagementPre-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).
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!