Marine Trauma and Envenomations

1. Marine Trauma and Envenomations Andrew Butterfass, MD FACEP Cabrini Medical Center

2. Key Points • Identify Hazardous Marine Life. • Manage minor exposures. • Identify and stabilize major envenomations.

3. Introduction • Marine life injuries are extremely diverse. • Many organisms are endemic to one region. • Most injuries occurs in populated costal waters or freshwater inland area’s. • High profile injuries include shark and alligator attacks. • Reality about 100 attacks a year worldwide with only about 5-10 deaths.

7. Introduction • Traumatic Encounter • Bite or puncture with fin, spine, scale. • Examples- Shark, barracuda, alligators, moray eels, and sea urchins. • Cause direct and indirect injury by force and secondary infection.

8. Introduction • Envenomation- toxin involved • Can cause hypersensitivity reactions, anaphylaxis and specific toxic venom reactions. • Puncture • Examples include Cone shells, Octopus, and Sea snakes. • Contact • Usually caused by invertebrates including coelenterates (jellyfish), sponges and bristle worms..

9. Coelenterates • Only 12 out of 500 species of jelly fish are venomous. • Reaction is dose and individual dependant. • Most Coelenterates cause local reaction. • Box Jelly Fish and Man-of-War are exceptions.

10. Chinonex Fleckeri- Box Jellyfish

11. Box Jellyfish

12. Box Jellyfish Victim

13. Box Jellyfish and Man-of-War • Box Jellyfish may be most potent marine envenomations. • Stings can be severe enough to cause loss of consciousness. • Sting can cause muscle cramps, abdominal pain, fever, chills, nausea, vomiting, respiratory distress, delirium, paralysis and death. • Most causes of death are from drowning secondary to panic or cardiovascular collapse.

14. Man-of-War

15. Nematocyst • Nematocyst- Stinging Cell activated by direct contact, changes in temperature and osmolality. • Initial response is pain or prickling. • Red hot and swollen rash with pustule and vesicle formation. • Venom is complex • Nerve conduction affects due to tetramine which is similar to curare. • Pain and local histamine effects are due to 5-hydroxytryptamine.

16. Nematocyst

17. Coelenterate Sting Treatment • Initial treatment includes washing area with salt water. (fresh water will destabilize nematocysts.) • Denature the neomocyts with 5% acetic acid (vinegar) for 30 min. • Remove nematocyst with forceps. • Howell suggests using shaving cream and shaving affected area.

18. Coelenterate Sting Treatment • Apply topical analgesics and steroids. • For extreme hypersensitivity and systemic reactions • ABC’s • IV analgesics and steroids if needed. • Cardiovascular monitoring and support as needed.

20. Seabather’s Eruption • Jelly Fish Larvae- Linuche unguiculata • Contact Dermatitis • Occurs in eastern coast of Florida between March and August. • Puritic, erythematous, papules that appear in distribution of bathing suit. • Present within 24 hours of exposure, but may be delayed 3 to 4 days. • Treatment includes systemic and topical steroids and antihistamines.

21. Seabather’s Eruption

22. Seabather’s Eruption

23. Sponges • Of 5000 known species, 12 are toxic. • Three produce contact dermatitis • Red-beard sponge Micronia prolifera. • Fire sponge Tedania ignis. • Poison-bun sponge Fibulila sp. • Treatment similar for jellyfish. • Small needle like spicules can be removed with piece of tape.

24. Red-beard Sponge

25. Fire Sponge

26. Venomous Fish • 200 known species of venomous fish • Most Common • STINGRAY • LIONFISH/SCORPIONFISH • STONEFISH • SALTWATER CATFISH • WEEVERFISH

27. Stingray • Cause tissue damage with sharp tail. • Tail has one to four sharp spines on dorsal surface. • Spines have membrane that tears to release venom. • Most injuries occur when ray is stepped on. • Spines are fired into foot or leg.

28. Stingray

29. Stingray Venom • Venom is Thermolabile. • Symptoms include blue discoloration at wound site secondary to vasoconstriction. • Intense pain at site, local ischemia and edema. • Systemic effects include -Salivation, sweating, vomiting, diarrhea, cramps, hypotension, and cardiovascular collapse.

30. Stingray EnvenomationTreatment • Keep person quiet- activity circulates venom. • Place constricting band above wound if on a limb (not tourniquet) • Venom is Thermolabile- Soak wound in hot water (110-113 degree F) for 30-60 minutes or until pain subsides. Heat denatures venom proteins. • Irrigate and remove any remaining spine. • Wound care including antibiotic coverage and tetanus prophylaxis. • Pain relief

31. Lionfish/ScorpionfishStonefish • Lionfish/Scorpionfish found in tropical seas including Red sea, Indian ocean and Pacific ocean. • Stonefish found in waters of Australian coast.

32. Lionfish

33. Stonefish

34. Lionfish and Stonefish Treatment • Venom is similar to stingray. • Antivenin is available through the Australia Commonwealth serum lab. • Symptoms include immediate intense pain, erythema, cyanosis, edema, nausea, vomiting, hypotension, delirium and cardiovascular collapse. • Irrigate, debride and soak wound in hot water 30-60 minutes to denature venom. • Analgesia and wound care.

35. Saltwater Catfish • Found in the warm tropical of Indo-pacific. • Fins contain complex venom • Symptoms include Intense pain. Systemic response is rare, but may include muscle cramps, tremor, fatigue, syncope, and cardiovascular collapse. • Venom is thermolabile. • Wound care including broad-spectrum antibiotics (Vibrio species).

36. Saltwater Catfish

37. Weeverfish • Found in English channel. • Venom is on dorsal fin. • Venom is thermolabile. • Similar treatment to other fish.

38. Weeverfish

39. Sea Snakes • Found in warm tropical waters in the Indo-pacific and off the coast of Australia. • Air breathing and usually not aggressive. • Venom is extremely toxic. (more than cobra venom.) • Most sea snake bites can not penetrate a 1/8 inch wetsuit and do not envenomate with every bite.

40. Sea Snakes • Venom is a heat-stable nonenzymatic protein. • Venom blocks acetylcholine. • Asymptomatic latent period of 10 minutes to 6-8 hours. • Symptom’s include malaise, anxiety, and stiffness. • Late symptom’s include aching, paralysis, trismus, ptosis, hepatic, renal, and respiratory instability. • Cardiovascular collapse and death. • 10% of untreated cases are fatal.

41. Sea Snakes

42. Sea Snakes

43. Sea Snake’sTreatment • Immobilize site, soaking in hot water not effective. • ABC’s, may require hemodialysis and respiratory support. • Hospitalize and administer antivenin. • Polyvalent sea snake antivenin from Australia Commonwealth serum lab. • Use polyvalent land snake antivenin if sea snake antivenin is unavailable.

44. Cottonmouth • Also know as Water Moccasin. • Snake found in fresh water area’s. • North American cottonmouth found in southern states as far north as Virginia and as west as Texas. • Aggressive, territorial snake with lightning-fast, bacteria-rich hemotoxic bite. • Symptoms include nausea, vomiting, hypotension, DIC, hemolysis, seizures and respiratory paralysis

45. Cottonmouth

46. Cottonmouth

47. Cottonmouth

48. Cottonmouth

49. Cottonmouth Treatment • Remove jewelry and tight fitting clothing around wound. • Clean (Betadine), immobilize, pressure dressing. • Administer antivenin (horse serum, test for hypersensitivity,). • IV sedation, analgesics and antibiotics. • Do not use ice, tourniquets, incision and oral suction.

50. Blue-Ringed Octopus • Found in costal waters of New Zealand and Australia. • Painless bite followed by abnormal sensation in mouth, neck and head. • Nausea, vomiting, dyspnea, and apnea. • May also have visual disturbances, impaired speech and swallowing, weakness and paralysis.