Injuries in the Marine EnvironmentJustin Hensley, MD

Assistant Professor of Emergency Medicine

Texas A&M Health Science Center/CHRISTUS Spohn

Disclosures

None

Injuries

From being underwater From things in the water

Injuries from being underwater

Submersion injuries Barotrauma

Submersion Injuries

Water rescue No treatment

Submersion injury Needs treatment

Drowning Wet Dry

Submersion Injuries

Treatment Rescue

breathing/CPR Oxygen

Do not: Heimlich Attempt to

drain water

Diving Injuries

Blackout Barotrauma Arterial gas

embolism Nitrogen narcosis Decompression

sickness

Blackout

Hypoxia Shallow water

5m

Deep water >10M

Dalton’s law

Barotrauma

Boyle’s law P1V1=P2V2

Mask Barotrauma

“Mask squeeze” Failure to maintain

pressure in facemask

Treatment Symptomatic Ophthalmology

Sinus Barotrauma

“Sinus squeeze” Congestion of

mucosal lining Treatment

Vasoconstrictors Analgesics Steroids No diving

External Auditory Canal Barotrauma

Air trapped in canal Tight hood Cerumen

Treatment Analgesics Ear drops

Middle Ear Barotrauma

“Ear squeeze” Usually near surface Eustachian tube collapses due to

pressure differential Treatment

Equalize before eustachian tube blocked Decongestants No diving

Equalization Techniques

Valsalva Toynbee’s

Swallowing with closed lips and nostrils

Frenzel Moving jaw forward and down

with closed lips and nose

Inner Ear Barotrauma

Labyrinthine window rupture

Overly forceful Valsalva or rapid descent

Treatment Bed rest Recovery=3-12 weeks No diving

Other squeezes

Suit squeeze Tooth squeeze Lung squeeze

Ascent Barotrauma

Alternobaric vertigo

Alternobaric facial palsy

Gastrointestinal barotrauma

Pulmonary Barotrauma

Ascent without exhaling 4 ft

Alveolar hemorrhage Chest pain,

cough, hemoptysis

Pneumomediastinum Most common

Pneumothorax Infrequent Can become tension

Arterial Gas Embolism Symptoms

Instant CVA 5% die immediately,

5% die in hospital

Treatment Dive chamber

High flow O2

Maintain CPP No flying

Nitrogen Narcosis

“Rapture of the deep” 70-100ft Treatment

Ascend

Use Heliox

Decompression Sickness

Caisson disease Bubbles of nitrogen

Intravascular Extravascular

Multiple types

Musculoskeletal Decompression Sickness Most common

form 70%

Joint pain “The bends” “Niggle”

Scuba divers Shoulders and

elbows

Saturation divers, aviators, caisson workers Hips and knees

Treatment

Cutaneous Decompression Sickness “Skin bends” “cutis marmorata” Treatment

Dive chamber

Itches or “the creeps”

Pulmonary Decompression Sickness

“Chokes” Bubbles in

pulmonary vasculature

“Mill wheel” heart murmur

Treatment Dive chamber

Neurologic Decompression Sickness

Spinal cord most common

Peripheral nerves or brain 50-60% of sport diver

casualties Treatment

Dive chamber

USN Table 6

Injuries from things in the water

Sharks

Sharks

Some sharks agressive

Fight back Eyes Nose Gills

Barracuda

Tropical and subtropical waters

Piranhas

Freshwater South American rivers

Moray Eels

Fresh, brackish, and saltwater

Alligators

Alligators

6-14ft Largest was 19ft >500kg

No verified alligator deaths in Texas

Alligator Attacks 1928-2008

Langley RL. Adverse encounters with alligators in the United States: an update. Wilderness Environ Med. 2010 Jun;21(2):156-63.

Alligator Attacks

 >90% of fatalities occur in Florida 29.2% consistent with humans as prey  Most fatal attacks involve alligators

>8ft 38 bacteria and 20 fungal species have

been cultured from alligator

Langley RL. Adverse encounters with alligators in the United States: an update. Wilderness Environ Med. 2010 Jun;21(2):156-63.

Alligators

Stay away from endemic areas

Run away Do not run in a zig zag Top speed 10-15 mph

Fight back

http://www.fws.gov/southeast/news/2004/r04-073.html

Turtles

Large crushing jaws

Can amputate fingers/toes/ hands

Underwater animal injuries

Trauma Puncture Laceration

Treatment ATLS Irrigate copiously Xrays

Antibiotics TMP-SMX Ceftriaxone Doxycycline Ciprofloxacin

Stingrays

Stingray

Sting Edema Tissue

necrosis

Treatment Hot water

Envenomation N/V/D Seizures Syncope Dysrhythmias

Goldfrank’s Toxicologic Emergencies, Ninth Edition. Lewis Nelson, Neal Lewin, Mary Ann Howland, Robert Hoffman, Lewis Goldfrank, Neal Flomenbaum. Chapter 116. pp 1629-1640. Author D. Eric Bush, July 2010Meyer PK. Stingray injuries. Wilderness Environ Med. 1997 Feb;8(1):24-8. Review.

Catfish

1000 species in fresh and salt water

Spines Venoms vary by

species

Catfish

Symptons Stinging, throbbing

pain Erythema and edema Muscle spasm Diaphoresis

Treatment Hot Water Xrays

Lionfish

Lionfish

http://nas.er.usgs.gov/taxgroup/fish/lionfishdistribution.aspx

Lionfish

Native to Indo-Pacific

12-13 dorsal spines Aggressive

Treatment Hot water Wound

exploration Antibiotics

Jellyfish

Portuguese Man of War

Box Jellyfish True Jellyfish

http://ocean.si.edu/jellyfish-and-comb-jellies

Bengtson K, Nichols MM, Schnadig V, Ellis MD. Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings. JAMA. 1991 Sep 11;266(10):1404-6.

Portuguese man of war

Polymorphic colonial siphonophore

Warm seas

True Jellyfish

Tentacles circumferential around umbrella

Ubiquitous

Box Jellyfish

Tropical and subtropical waters

Tentacles from corners of umbrella

Directional movement

Jellyfish

Anaphylaxis discovered Nobel Prize 1913

Tentacles up to 100 ft

1000s of nematocysts

Spines penetrate to capillary bed

Venom Dermonecrosis Hemolysis Cardiotoxicity

Tibballs J, Yanagihara AA, Turner HC, Winkel K. Immunological and toxinological responses to jellyfish stings. Inflamm Allergy Drug Targets. 2011. Oct;10(5):438-46. 

http://www.tampabay.com/news/environment/wildlife/man-of-wars-sting-like-a-hot-knife/520573 http://www.destination-scuba.com/Box-Jellyfish.html

Management

Proposed Treatments Alcohol

Meat tenderizer

Vinegar

Ammonia

Acetone

Urine

Seawater

Pressure bandage

Stingose

AHA and ARC International Consensus Vinegar, or Baking soda,

then Heat, or Ice pack

Markenson D, Ferguson JD, Chameides L, et al; on behalf of the First Aid Chapter Collaborators. Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment

Evidence Based Treatment

Hot water Lidocaine (4-

5%) Vinegar Saltwater

Portuguese Man of War

Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med.2012 Oct;60(4):399-414.

Irukadji Syndrome

Carukia barnesii Massive

catecholamine release

Treatment Phentolamine Standard jellyfish

treatment

Seabather’s Eruption

“Sea Lice” Larvae of thimble

jellyfish

Treatment Sensitization

effects

Regional and Seasonal Florida Caribbean Brazil

Coral injuries

Stony corals Erythametous wheal

Coral poisoning

Cellulitis, ulceration, and tissue sloughing

Heal over 3-6 weeks

Fire Coral

Cutaneous reaction Pain, pruritis,

urticaria

Systemic effects Nephrotic syndrome

Fire Coral Treatment

Rinse Pat dry Vinegar Hot water Isopropyl alcohol Steroids

Fire Sponges

Spicules embedded in connective tissue

Colonizing animals on the matrix

Fire Sponges

Pruritic dermatitis Erythema multiforme Anaphylactoid

response Irritant dermatitis

Spicules

Treatment Remove spicules Vinegar/Hot

water/Isopropyl alcohol

Topical steroids

High dose oral steroids

Epinephrine

Cone Snails

Mild envenomations Localized sx

Serious envenomations Muscle paralysis Death

Cone Snail Treatment

No antivenom Pressure-

immobilization bandage

Supportive care Tensilon

Atropine

Blue Ringed Octopus

Venom apparatus is salivary glands and beak

Bites occur with handling

Blue Ringed Octopus

Venom Vibrio

Neuromuscular blockade

Symptoms Numbness Paralysis

Treatment Pressure immobilization Supportive care Recovery in 2-4 days

Anemones Dermatitis similar

to fire coral Species specific

reactions Urticaria Paresthesias Edema Local hemorrhage Necrosis

Systemic reactions Fever, Malaise, N/V Hepatic failure

Anemones

Mild envenomations Resolve

Severe reactions Eschar Keloids

Treatment Irrigate copiously Hot water/Vinegar

Echinoderms Sea stars

Hemolysins Pain, bleeding, edema

Sea cucumber Holothurin-cardiac glycoside Skin dermatitis

Sea urchins Glycosides, Hemolysins Pain, N/V, Paresthesias Paralysis

Echinoderms

Treatment Hot water Steroids Wound

exploration Supportive care

Annelid Worms

Bite Bristles

Pain, urticaria

Treatment Remove bristles Steroids

Sea Snakes

80% of bites dry Venom

Neurotoxic, Hemolytic, Myotoxic

Symptoms Painful muscle

movement Blurred vision,

dysphagia, ptosis, paralysis

Treatment Pressure

immobilization Antivenom Supportive

measures

Summary

Dive injuries HBO

Large animals ATLS

Envenomations Hot water Antivenom

Questions?

hensley@tamhsc.edu ebmgonewild.com