Marine Injuries

1. Marine Injuries Kalpesh Patel, MD Department of Pediatric Emergency Medicine August 2, 2006

2. Objectives By the end of this lecture you should be able to: • Describe the management and treatment for • Marine invertebrate injuries • Insect envenomations • Understand and perform initial management of these injuries, such as • Local wound care • Venom specific antidotes • Stinger removal

3. Marine Invertebrates • Irritants • Hydras • Anemones • Common purple jellyfish • Sea nettle • Toxin producers • Portuguese man-of-war • True jellyfish • Lion’s mane • Handle with care • Corals • Sea Urchins

4. Irritants • Hydras • Maine to Florida and Texas coastline • Attaches to solid objects • Causes mild sting • Requires local care • Anemones • US tidal zones • Mildly toxic at worst – skin irritation • Sea nettle and common purple jellyfish • Atlantic coast • Mildly toxic - skin irritation

5. Irritants - Treatment • Wash copiously with sea water or normal saline • Benadryl • Topical/Oral Steroids

6. Toxin Producers • Nematocysts • Specialized organelles which have toxin-coated barbed threads that fire when a tentacle is touched. • Cannot penetrate human skin • May discharge even when the creature is dead and washed up on the beach

7. Toxin Producers • Size matters • Man of war can have tentacles up to 75 feet long with 750,000 nematocysts each

8. Toxin Producers • Toxin causes severe pain • Made of polypeptides and degradative enzymes • Causes release of inflammatory mediators, histamine and histamine-releasing agents, serotonin • May cause systemic symptoms • N/V, abdominal rigidity • Respiratory distress • Arthralgias • Hemolysis, renal failure • Coma • Severe envenomation can cause death

9. Toxin Producers • Lion’s mane • Found on both coasts • Highly toxic • Instrument of death in Sherlock Holmes classic Adventure of the Lion’s Mane • Causes severe burning • Prolonged exposure causes muscle cramps and respiratory failure

10. Toxin Producers - Treatment • 3 goals: • Control shock – IV, fluids, etc. • Control venom effects • Remove tentacles from skin • Inactivate unexploded nematocysts with vinegar, meat tenderizer, or baking soda slurry • Apply this to patient as well • Pain relief • Immobilize the wound area • Codeine, Morphine, or Demerol • Treat muscle spasms with 10% Calcium gluconate 0.1ml/kg IV • Topical/Oral steroids, Benadryl

11. Handle with Care • Corals, Sea Urchins, Starfish • Have jagged edges or hard spines • Cause deep puncture wounds or sea lacerations • Easily leave foreign bodies • Stinging sensation, wheal formation, itching • Wound infection very common • Vibrio species, Erysipelothrix rhusiopathiae, Mycobacterium marinum • Fever • Cellulitis • Lymphangitis

12. Handle with Care - Treatment • Copious irrigation with saline • X-ray for foreign bodies • Soak affected area in warm water • Use local anesthetic and explore sterilely • Wounds should be left open or loosely approximated • Antibiotics please • >8 y/o: Tetracycline for 10 mg/kg/dose QID • <8 y/o: Keflex or Bactrim • Add staphylococcal coverage for foreign bodies • Don’t forget tetanus prophylaxis

13. Marine Vertebrates • Stingrays • Catfish • Scorpaenidea • Sharks!

14. Stingrays • Most common marine vertebrate injury • Flat fish, bottom feeders, buried under sand or mud • Easily stepped on causing reflex envenomation • Venom apparatus is a serrated, retro-pointed caudal spine on the tail • Coated in venom sheath which ruptures on skin penetration • Heat labile toxin • Can depress medullary respiratory centers • Interfere with cardiac conduction • PAINFUL

15. Stingrays - Treatment • PreHospital: • Irrigate copiously with cold salt water • Flushing can help remove toxin • Control bleeding with pressure • ED: • IV fluids, Morphine 0.1mg/kg/dose for pain • Make an attempt to remove the spine • Soak extremity in hot water (104-113F) to inactivate the venom until pain relieved • X-ray for foreign body (spine fragments) • Re-explore wound after soaking • Tetanus prophylaxis • No prophylactic antibiotics

16. Scorpaenidae • Zebrafish, scorpionfish, stone fish • Non-migratory, slow swimming, buried in sand • Envenomation occurs when handling fish on fishing trips • Venom delivered by many small spines like the stingray • Venom also heat-labile • Symptoms • Pain, N/V • Hypotension • Tachypnea leading to apnea • MI with EKG changes

17. Scorpaenidae - Treatment • Copious irrigation with saline • Hot water immersion until pain relieved • Morphine 0.1mg/kg/dose • Close cardiopulmonary monitoring • Admit to PICU if having significant systemic effects

18. Catfish • Spines in the dorsal and pectoral fins • Puncture wounds and laceration • Easily break off as foreign body • Venom causes local inflammation, pain, edema, hemorrhage, tissue necrosis • Treatment • Irrigation • Hot water immersion • Morphine 0.1mg/kg/dose • Antibiotics for gram negatives • Delayed primary closure

19. Sharks! • 1 in 5,000,000 chance of attack in North America • Gray reef, great white, blue, mako sharks • Risk factors: • Swimming near sewer outlets • Swimming in the late afternoon/early evening • Murky warm water • Increased commotion • Deep channels • Wearing bright objects • Surfers – boards are mistaken for elephant seals, the shark’s usual diet in California

20. Sharks! • Two types of bites: • Tangential injury • Close pass slashing movement teeth of open shark mouth • Definitive bite • Vary according to the part of the body bitten • Lacerations • Soft tissue loss • Amputation of limb • Comminuted fractures • Hemicorpectomy

21. Sharks! • Hypovolemic shock • Control bleeding with pressure • DON’T EXPLORE WOUNDS PREHOSPITAL • IV fluids, blood products as soon as available • Warmth • Oxygen • Surgery • Prophylactic antibiotics – 3rd gen cephalosporin or bactrim • Tetanus prophylaxis • Admit to PICU for significant injury

22. Questions?