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Marine Trauma and Envenomations

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Title: 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 areas.
  • High profile injuries include shark and alligator
    attacks.
  • Reality about 100 attacks a year worldwide with
    only about 5-10 deaths.

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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
  • ABCs
  • IV analgesics and steroids if needed.
  • Cardiovascular monitoring and support as needed.

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20
Seabathers 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
Seabathers Eruption
22
Seabathers 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.
  • Symptoms include malaise, anxiety, and
    stiffness.
  • Late symptoms 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 SnakesTreatment
  • Immobilize site, soaking in hot water not
    effective.
  • ABCs, 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 areas.
  • 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.

51
Blue-Ringed Octopus
52
Blue-Ringed OctopusTreatment
  • Neurotoxin blocks peripheral nerve conduction.
  • May need cardiovascular and ventilatory support.
  • Immobilize the affected limb.
  • Pressure dressing.
  • Clean bite- tetanus and antibiotic coverage.

53
Cone Shells
  • Found in costal reefs throughout the world.
  • Shelled animal have detachable, dart-like,
    muscular, extensible proboscis.
  • Venom is complex. It inhibits acetylcholine and
    effects sodium channels causing sustained
    contractions.
  • Venom is Thermolabile.

54
Cone Shells
55
Cone Shells
56
Cone Shells
  • Stings usually occur on hand or foot.
  • Minor sting cause local blanching, cyanosis and
    edema.
  • Systemic findings include pain, numbness and
    paresthesia of mouth and lips.
  • Paralysis and respiratory failure possible.
  • No antivenin is available.

57
Cone ShellsTreatment
  • Immobilize the limb and apply pressure dressing
    (not tourniquet).
  • Soak in hot water 30 to 90 minutes.
  • Severe reactions including paralysis may require
    CPR and ventilatory support.
  • Edrophonium 10mg IV may be used for paralysis
  • Naloxone 2-4mg IV may help severe hypotension.
    (blocks beta-endorphin vasodepressor response.
  • Wound care including tetanus, analgesia, and
    antibiotics.

58
Anaphylaxis
  • ABCs
  • Airway protection
  • 100 Oxygen
  • Two IV lines- fluid resuscitation with RL or NS
  • Epinephrine 11000 .2-.5mg SC/IM
  • May repeat every 30min
  • In severe cases consider Epinephrine 110,000
    .2-.5mg IV.
  • Benadryl and Steroids IM/IV.

59
General Wound Care
  • Irrigate wounds and keep clean and dry.
  • Pressure dressings.
  • Remove any foreign bodies.
  • Broad spectrum antibiotic coverage. (include
    Vibrio sp.)
  • Analgesia and steroids (topical or systemic).
  • Tetanus prophylaxis.

60
Review
  • Remember ABCs including c-spine immobilizations
    in suspected marine trauma.
  • Puncture wounds due to saltwater catfish,
    scorpionfish, sea-urchins, starfish, stingrays,
    cone shells and weever fish should be immersed in
    hot water (113 degree F) for 30-90 minutes or
    until pain subsides.

61
Review
  • Treat rash associated with anemone, fire coral,
    jellyfish, and sponges with seawater bath or 5
    acetic acid.
  • Handle and remove nematocysts with care.
  • Be prepared to treat anaphylaxis and
    cardiovascular instability.
  • Wound Care
  • Contact local poison control center or
    toxicologist for possible antivenin
    administration and transport of severe reactions.

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63
Drowning and Near Drowning
64
Definition
  • Near Drowning
  • Suffocation by submersion, with at least 24 hours
    of survival.
  • Drowning
  • Death within 24 hours of suffocation by
    submersion.
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