emDOCs Podcast – Episode 91: Marine Envenomation and Trauma

Major Marine Trauma

Shark Bites

• Tend to be neurovascular injury and tissue loss
• Death from hemorrhage
• Don’t chew—result in tearing injuries

Treatment of Major Marine Trauma

1. Remove from water
2. Control bleeding
3. Supportive management
4. Radiographs for foreign body, fracture, or bony involvement
5. Consider culture
6. Do not suture!!
7. Possible early antibiotic treatment

Minor Marine Trauma

• Mechanism: Bites, Stings, Nematocysts
• Envenomation Presentation:
  • All can cause localized pain, erythema, and warmth
  • Dermatologic: Urticaria, burning, pruritus, localized paresthesia.
    • Sponges and hydrozoa—bullae and blistering
  • GI: nausea and vomiting
  • Neurologic- paresthesia, paralysis, mental status changes, headache, vertigo/ataxia, seizures, weakness
  • Cardiovascular: hypotension, syncope, respiratory distress/dyspnea, arrhythmia
  • Constitutional: chills, muscle cramps, sweating, and diaphoresis
• Echinoderms—(starfish, sea cucumbers, and sea urchins)
  • Starfish
    • Mechanism of injury: surface spines, tufts or pincers
    • Presentation: localized dermatologic
  • Sea Urchin
    • Mechanism of injury: sharp venomous spines for sea urchins
    • Presentation: synovitis if in joint, discoloration, bleeding over several hours
  • Sea Cucumber:
    • Mechanism of injury: spray/release toxin
    • Presentation: contact dermatitis, corneal inflammation, and blindness
    • Treatment: vinegar, proparacaine and saline irrigation
•  Mollusks—(Octopus, Cone snail)
  • Blue Ringed Octopus
    • Mechanism of Injury: bite
    • Toxin: Tetrodotoxin
    • Presentation: respiratory arrest, localized puncture mark, vomiting, flaccid paralysis, perioral and intraoral paresthesia, diplopia, dysphagia, ataxia
    • Recovery: 1-5 days
    • Treatment: Supportive
  • Cone Snail
    • Mechanism of Injury: sting from disposable tooth fired at target
    • Presentation: localized pain and numbness, variable spastic or flaccid paralysis, respiratory failure
    • Treatment consideration: Avoid Na channel blockers
•  Annelids—(Bristleworms)
  • Mechanism of Injury: Sting from chitinous spines
  • Presentation: Reddened urticarial rash
•  Porifera—(Sponges)
  • Clinical Presentation: localized paresthesia, bullae and blisters, desquamation up to 2 months
• Cnidarians—(true jellyfish, hydroids i.e. Portuguese man of war, Cuboids i.e. box jellyfish, anemones)
  • More envenomations than any other phylum
  • Mechanism of injury: spring loaded venom gland called nematocyst that penetrates and injects prey
  • Hydroids—Portuguese Man-o-war
    • Presentation: “String of pearls”—linear erythematous eruption, local paresthesia, nausea, headache, chills, respiratory distress, drowning, death
    • Special treatment considerations: vinegar may help
  • Cubozoa
    • Chironex fleckeri–box jellyfish
      • Found Indo-pacific Ocean
      • Presentation: Very severe pain and systemic toxicity
    • Carukia Barnesi—Irujandji
      • North Australia
      • Cause catecholamine excess
      • Presentation: Irukandji syndrome—hypertension, elevated troponin, tachycardia, agitation, sweating, impending sense of doom, piloerection
      • Treatment: phentolamine, magnesium, nitroglycerin, nitroprusside, nicardipine
    • Treatment: Box Jelly Antivenom
•  Bony Fish—(Stonefish, Scorpionfish, Weeverfish, Lionfish )
  • Stonefish—severe local pain with occasional systemic symptoms
  • Scorpionfish—warm erythematous vesicles with intense pain
  • Weeverfish- may develop necrosis
  • Treatment: observe for 2 hours and antivenom for Stonefish
• Cartilaginous fish—rays & skates
  • Mechanism of Injury: venomous spines in tail/sting; usually when stepped on
  • Presentation: Intense local pain and occasionally systemic symptoms
• Snakes
  • Mechanism of Injury: bite
  • Presentation: GI symptoms, malaise, rhabdomyolysis and aki, ascending flaccid or spastic paralysis, ophthalmoplegia, ptosis, pupillary changes, respiratory failure, seizures and coma
  • Treatment: Polyvalent sea snake antivenom, supportive management, treat anaphylaxis or serum sickness

Treatment of Minor Marine Trauma

Top 5 Do’s

1. Use Heat and salty water
2. Remove foreign bodies
3. Provide pain relief like topical anesthetics
4. Use Glucocorticoids and antihistamines
5. Give antivenom if applicable

Top 5 Don’ts

1. Avoid urine or Ammonia use
2. Avoid ethanol
3. Don’t use fresh water to remove nematocysts
4. Avoid friction
5. Depending on the species and your location avoid vinegar

References:

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2. Edward OJ. Venomous Marine Animals. In: Marx JA, Hockenberger RS, Biros MH, et al., eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice (2 Volumes). Vol 1. Philadelphia: Elsevier Saunders; 2014:805-807.
3. Dustin Taliaferro, Dustin, Cynthia Santos, MD, Alex Koyfman, MD, and Brit Long. (2020, September 26) EM@3AM: Marine Animal Bites and Stings. EmDocs. http://www.emdocs.net/em3am-marine-animal-bites-and-stings/
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11. Zafren K, Thurman R, Jones ID. Cone Snail Envenomation. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 5e. McGraw Hill; 2021. Accessed August 25, 2022. https://accessemergencymedicine.mhmedical.com/content.aspx?bookid=2969&sectionid=250461163
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