Marine Marine Envenoming Envenoming

Chris NicksonChris Nicksonhttp://lifeinthefastlane.com http://lifeinthefastlane.com

September 2010September 2010

OverviewOverview

• Box jellyfishBox jellyfish

• Irukandji syndromeIrukandji syndrome

• Blue bottlesBlue bottles

• Blue-ringed octopusBlue-ringed octopus

• StonefishStonefish

• Many others!...Many others!...

When Doug met StruanWhen Doug met Struan……

When Doug met StruanWhen Doug met Struan……

• Doug:Doug:

‘So what do we do ‘So what do we do if we get bitten by if we get bitten by something deadly, something deadly, then?’then?’

• Struan:Struan:

‘Well what do you ‘Well what do you think you do?’think you do?’

‘You die of course. ‘You die of course. That’s what deadly That’s what deadly means.’means.’

Box JellyfishBox JellyfishChironex fleckeriChironex fleckeri

Box jellyfish worldwideBox jellyfish worldwide

Clinical featuresClinical features• Stinger season (Nov-Stinger season (Nov-

April)April)• Linear cross-hatched Linear cross-hatched

weltswelts• Adherent tentaclesAdherent tentacles• Severe pain (8h)Severe pain (8h)• Collapse and Collapse and

cardiovascular effectscardiovascular effects• ScarringScarring• Delayed hypersensitivityDelayed hypersensitivity

ManagementManagement

• Prehospital Prehospital – AnalgesiaAnalgesia– VinegarVinegar– No PIBNo PIB

• Resuscitation Resuscitation – HypotensionHypotension– DysrhythmiasDysrhythmias– Cardiac arrestCardiac arrest

• AnalgesiaAnalgesia– Ice (hot water?)Ice (hot water?)

• Wound careWound care• AntivenomAntivenom

– Arrest: 6 ampsArrest: 6 amps– Unstable: 3 ampsUnstable: 3 amps– Refractory pain: 1 Refractory pain: 1

ampamp

• Delayed type Delayed type hypersensitivityhypersensitivity– Steroid creamSteroid cream

Irukandji SyndromeIrukandji SyndromeCarukia barnesi Carukia barnesi & others& others

• ““The first Carybdeid was applied to an The first Carybdeid was applied to an adult (J.B.), and to a boy, aged nine adult (J.B.), and to a boy, aged nine years (N.B.). A robust young life-saver years (N.B.). A robust young life-saver (C.R.) volunteered to test the second (C.R.) volunteered to test the second specimen, of similar size to the first.specimen, of similar size to the first.””

Barnes, J. H. (1964). “Cause and Effect in Irukandji Stingings.” Med J Aust 1: 897-.

Clinical featuresClinical features

• Exmouth to Moreton BayExmouth to Moreton Bay

• Mild sting…Mild sting…

• Progressive severe pain andProgressive severe pain and“catecholamine excess “catecholamine excess syndrome”syndrome”

• Cardiovascular Cardiovascular complicationscomplications– Shock, acute pulmonary Shock, acute pulmonary

oedema, cardiomyopathy, oedema, cardiomyopathy, intracranial hemorrhageintracranial hemorrhage

ManagementManagement

•Prehospital Prehospital – Vinegar, no PIBVinegar, no PIB

•ResuscitationResuscitation

•MedicationsMedications– FentanylFentanyl– PromethazinePromethazine– GTN GTN – magnesiummagnesium

BluebottleBluebottlePhysaliaPhysalia spp.spp.

BluebottleBluebottlePhysaliaPhysalia spp.spp.

• Immediate burning (2h)Immediate burning (2h)

• Linear/ elliptical weltsLinear/ elliptical welts

• Non-specific symptoms, self-limitingNon-specific symptoms, self-limiting

• Management - hot waterManagement - hot water

• Immediate burning (2h)Immediate burning (2h)

• Linear/ elliptical weltsLinear/ elliptical welts

• Non-specific symptoms, self-limitingNon-specific symptoms, self-limiting

• Management - hot waterManagement - hot water

OCTOPUSSYOCTOPUSSY

BROBRO

HapalochlaenaHapalochlaena spp spp..

Clinical Clinical featuresfeatures

• Coastal watersCoastal waters

• ‘‘Innocuous’ biteInnocuous’ bite

• Rapidly progressive descending Rapidly progressive descending symmetrical paralysissymmetrical paralysis

ManagementManagement

•Prehospital Prehospital – PIBPIB

•ResuscitationResuscitation– respiratory supportrespiratory support– HypotensionHypotension

•Supportive careSupportive care

Maculotoxin = Maculotoxin = TetrodotoxinTetrodotoxin

PufferfishPufferfish

Sea Sea SlugSlug

Cone snailCone snailConus Conus spp.spp.

ConotoxiConotoxinn

StonefishStonefishSynanceia Synanceia sppspp..

Master of camouflageMaster of camouflage

Clinical featuresClinical features

• Immediate severe pain, Immediate severe pain, puncture wound, local puncture wound, local swellingswelling

• Non-specific symptoms,Non-specific symptoms,rarely cardiovascular rarely cardiovascular effectseffects

• ? Retained foreign bodies? Retained foreign bodies

ManagementManagement

• PrehospitalPrehospital– Analgesia, hot water, no PIBAnalgesia, hot water, no PIB

• Regional anaesthesiaRegional anaesthesia

• AntivenomAntivenom– 1 ampoule per 2 spines1 ampoule per 2 spines

• Wound careWound care

LionfishLionfishPterois Pterois spp.spp.

Sea snakeSea snakeHydrophiidaeHydrophiidae

• Paralysis & rhabdomyolysisParalysis & rhabdomyolysis

• ManagementManagement– PIB, Bloods, VDKPIB, Bloods, VDK– Antivenom: Antivenom: 1 amp or 3 amps of Tiger snake AV1 amp or 3 amps of Tiger snake AV

Seafood Seafood poisoningpoisoning• Shellfish poisoningShellfish poisoning

– NeurotoxicNeurotoxic– ParalyticParalytic– Diarrhetic, Diarrhetic,

AzaspiracidAzaspiracid– AmnesticAmnestic– PalytoxinPalytoxin– TetrodotoxinTetrodotoxin– Others…Others…

• Fish poisoningFish poisoning– CiguateraCiguatera– ScombroidScombroid– Tetrodotoxic fishTetrodotoxic fish– Clupetoxic fishClupetoxic fish– PalytoxinPalytoxin– Hypervitaminosis AHypervitaminosis A– Others…Others…

QUESTIONS?QUESTIONS?

http://http://lifeinthefastlane.com/lifeinthefastlane.com/education/toxicology/education/toxicology/