Pnnted in the USA. CopyrIght 0 1992 Pergamon Press plc
The Journal of Emergency Medicine, Vol 10. pp 71-77, 1992
MARINE ENVENOMATIONS PART 2: INVERTEBRATES John McGoldrick, MD,and John A. Marx, Reprint address:
MD*
Department of Emergency Medicine, Denver General Hospital, Denver, Colorado John McGoldrick, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver CO, 80204
0 Abstract - As more people travel to the oceans for sport diving and other marine-related activities, the incidence of marine envenomations has risen. This article is designed to give the emergency medicine physician an overview of varying marine envenomations, their clinical presentation, and recommended treatment. Part 1 of this article dealt with general wound management and vertebrate envenomations. Part 2 addresses invertebrate envenomations.
reaction, and treatment for anaphylaxis will be necessary. Part I of this paper dealt with general wound management and treatment of vertebrate envenomations.
INVERTEBRATES Treatments of invertebrate summarized in Table 1.
0 Keywords - marine envenomations; vertebrates; marine antivenins: detoxification
marine
envenomations
are
Coelenterates
There are over 9000 species of coelenterates, of which at least 100 are dangerous to humans (2). They exist in two basic morphologies: 1) The polyp, which is sedentary and anchored at its caudal end, with a mouth and tentacles at the opposite end; 2) The medusa, which is a free-floating dome-shaped form with tentacles and a mouth on the concave side (2). Those coelenterates having venom-bearing stinging cells called nematocysts are known as cnidaria. The cnidaria can be divided into three main groups: 1) hydrozoans; 2) scyphozoans; and 3) anthozoans. There is a wide range of severity to coelenterate stings, which varies with the species (venom potency and nematocyst configuration), size of the animal (venom inoculation), size and age of the victim, and the underlying health of the victim (14). The nematocyst is contained within an outer capsule called the craidoblast, to which is attached a pointed
INTRODUCTION Most hazardous marine organisms are found in temperate or tropical oceans, particularly the Indo-Pacific region. With more people traveling to exotic locales for sport diving and other marine-related activities, and with the increase in private salt water aquariums, the incidence of marine envenomations has risen (1). When treating a marine envenomation or wound, the general principles of emergency medicine apply. Occasionally, an envenomation will be accompanied by an allergic
*Dr. Marx is currently in the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina.
w
Emergency Medicine in Review presents comprehensive surveys plus evaluation and critical interpretation of significant management problems in emergency medicine. Ann Harwood-Nuss, MD, of the University Hospital of Jacksonville, Florida, coordinates this section.
RECEIVED:7 August 1990; FINAL SUBMISSION RECEIVED:27 November ACCEYIED:16 December 1990. 71
1990;
07364679192
$5.00 + .OO
72
John McGoldrick
and John A. Marx
Table 1. Treatment of Marlne Envenomatlons: Invertebrates Marine Organism
Detoxification
ED Treatment
Hydroids
Irrigate with sea water (not fresh water). Topical 5% acetic acid (vinegar). Shave affected area.
Topical corticosteroid cream for dermatitis.
Fire coral
Same as for hydroids. Topical 5% acetic acid.
Topical corticosteroid cream for dermatitis.
Portuguese man-of- war
Same as for hydroids. Topical 5% acetic acid. Use forceps or gloves to remove tentacles.
Topical corticosteroid for dermatitis. All patients with systemic symptoms should be observed for 8 h. Severe systemic symptoms mandate hospitalization with supportive care.
Sea nettles
Same as for hydroids. Topical 5% acetic acid.
Same as for Portuguese man-of-war.
Box jellyfish
Same as for hydroids. Topical 5% acetic acid. Use forceps or gloves to remove tentacles.
Give chironex antivenin. Supportive care for hypotension and respiratory depression.
Anenomes
Same as for hydroids. Topical 5% acetic acid.
Topical corticosteroid cream for dermatitis.
Blue-ringed octopus
Pressure immobilization bandage.
Supportive care for respiratory depression.
Cone shell
Hot water (105 “F). Pressure immobilization bandage.
Supportive care for hypotension and respiratory depression.
Starfish
Irrigation with fresh water.
Exploration and removal of any spines. Topical corticosteroid for dermatitis.
Sea urchin
Hot water (105 “F). Removal of any spines or pedicellariae.
Exploration and removal of any retained spines.
Sea cucumber
Topical 5% acetic acid.
Topical cotticosteroid for dermatitis.
trigger or coridocil. The nematocyst is venom filled and contains a hollow, pointed, coiled tube. It is usually located on the outer surface of the tentacles or near the mouth and is triggered on contact with the victim’s body surface. When the coridocil is stimulated, either by physical contact or by chemoreceptor mechanism, it causes opening of the craidoblast. The venom-containing tube is everted, penetrates the skin, and results in envenomation. The venom varies from species to species and contains many protein fractions, some of which have been shown to be cardiotoxic, neurotoxic, and dermatonecrotic. The venom also contains histamine, prostaglandins, serotonin, and kinin-like factors (2). The effects of the venom range from a mild dermatitis to the most toxic venom known in sea animals, able to cause death within 30 to 60 seconds (box jellyfish) (3,5). Hydrozoans
The hydrozoans range from the sedentary Millepara hydroid corals (fire coral) to the free floating colonial siphonophore Physalia physalis (Portuguese man-ofwar), which is a floating colony composed of several types of polypoid individuals attached to a free-floating
stem. The clinical syndrome produced by stings of hydrozoans varies with the toxicity of the species and the number of nematocysts discharged into the victim. Hydroids. The feather hydroids are animals resembling
feathers or plumes that sting anyone who brushes up against or handles them (1). They are the most numerous of the hydrozoans. Clinical Presentation. The nematocysts of a feather hydroid usually induce a mild syndrome consisting of immediate burning, itching, and urticaria. This rarely progresses to an erythema multiforme type of reaction (2,6). During a storm, the branches may be broken up and fragments can cause skin irritation or be washed into a diver’s mask or regulator mouthpiece, producing a burning sensation in the conjunctivae and oral mucous membranes (1). Treatment. At the scene, the skin should be immediately irrigated with sea water and gently dried. Rinsing with fresh water or briskly rubbing will result in discharge of any nematocysts remaining on the skin, thereby worsening the envenomation. Five percent acetic acid (vinegar) or 40 to 70% isopropyl alcohol should then be applied to inactivate any remaining undischarged nematocysts. This should be continued for 15 to 30 minutes or until pain is relieved. There is
Marine Envenomations,
73
Part 2
some evidence that alcohol may stimulate the discharge of nematocysts in vitro, but clinical experience supports its use (14). Other substances reported to be effective as alternatives are dilute ammonia hydroxide, urine, sodium bicarbonate, and papain (6,7). The pressure immobilization technique for venom sequestration should not be used, as the pressure may stimulate any remaining nematocysts to discharge (1,3). Once the wound has been rinsed and soaked with acetic acid or isopropyl alcohol, the remaining nematocysts should be removed by shaving the area with a razor (1,2). Topical anesthetic ointments or cordicosteroid lotions may be used once the toxin has been inactivated. Fire Coral. These coelenterates are widely distributed
in tropical waters and frequently envenomate unwary divers. They possess a razor sharp lime carbonate exoskeleton ranging in color from white to yellow-green. These form blade-like, branching calcareous growths over corals and other objects. The tiny nematocyst bearing tentacles protrude from numerous minute surface gastropores (2,3). Clinical Presentation. Immediately following contact there is a burning or stinging pain. Intense pruritus usually follows within seconds. Rubbing the affected area will discharge more nematocysts, worsening the envenomation. Over 5 to 30 minutes, urticarial wheals develop that generally reach maximum size in 30 to 60 minutes. Untreated, the wheals and pruritis will resolve over 3 to 7 days (1,2). Treatment. The treatment is the same as outlined for hydroids . Portuguese Man-of- War. The Portuguese Man-of-War (Physalia physalis) is one of many pelagic (open sea)
colonial siphonophores that inhabit the surface of the sea and depend on the winds and tides to mobilize them. They are found in tropical and semitropical Atlantic and Pacific oceans. They consist of a floating sail filled with nitrogen and carbon monoxide, from which are suspended multiple nematocyst-bearing tentacles that may attain lengths of 30 meters (2). There are many different species of varying toxicity. Clinical Presentation. Depending on which species is involved and the amount of nematocysts discharged, symptoms may range from a mild dermatitis to severe systemic reactions. There is immediate localized buming pain usually with central radiation. The skin contacted by the tentacles becomes erythematous. There may be local edema, urticaria, and bullae formation. If envenomation is severe, this may progress to skin necrosis. A moderate or severe envenomation may result
in systemic symptoms, which begin 5 minutes to several hours after envenomation. Allergic reactions may play a significant role in severe envenomations (8,9,10). Multiple organ systems can be involved, including 1) Neurological: malaise, headache, delirium, syncope, aphonia, vertigo, ataxia, paralysis, coma, and death; 2) Respiratory: dyspnea, bronchospasm, and laryngeal edema (1,4); 3) Cardiovascular: anaphylaxis, hemolysis, dysrhythmias, hypotension; 4) Gastrointestinal: nausea, vomiting, diarrhea, dysphagia, thirst, hypersalivation; 5) Musculoskeletal: abdominal rigidity, myalgias, cramps, extremity spasm, arthralgias; 6) Ocular: conjunctivitis, chemosis, cornea1 ulcerations, lacrimation (1,3). Treatment. Treatment is directed toward major systemic reactions, pain alleviation, and control of dermatitis. Stabilization should be done in concert with detoxification with sea water rinse, acetic acid soak, and nematocyst removal. Care must be taken not to envenomate oneself when removing tentacles and remaining nematocysts. All patients with a systemic component should be observed for at least 6 to 8 hours, as rebound phenomena are not uncommon (2,4,11). A urinalysis should be obtained to screen for hemoglobinuria. Scyphozoans
This group contains the true jellyfish. These are mostly free-swimming pelagic creatures ranging in size from a few millimeters to more than two meters in width across the bell, with tentacles of up to 40 meters in length (2). Sea Nettles. These are found in both tropical and tem-
perate waters, particularly in Chesapeake Bay. They are capable of giving a moderately severe sting. Clinical Presentation. Symptoms and signs are similar to Physalia species with perhaps a greater incidence of systemic manifestations. Death has been reported (2,3). Severe reactions may be the result of prior sensitization. Elevated levels of serum anti-sea-nettle venom IgM, IgG, and IgE may persist for years in patients with exaggerated reactions ( 12). Treatment. The treatment is the same as that outlined for Physalia species. Box JellyJish. There are a variety of cubomedusean scyphozoans with highly toxic venom that inhabit the Indo-Pacific oceans (2). Chironexfleckeri, the box jellyfish, is reported to be the most venomous sea creature known and is able to cause death within 30 to 60 seconds of envenomation (2,13,14). The box jellyfish is primarily found off the coast of Northern Australia, but is located throughout the Indo-Pacific region. At least 72 fatalities have been verified in Australian and
74
Table 2. Hazardous Marlne Life Invertebrates Phylum Coelenterata (Cnidaria) Hydrozoans (hydroids, fire coral, Portuguese man-of-war) Scyphozoans (jellyfish, sea nettles, box jellyfish) Anthozoans (sea anemones, corals) Phylum Mollusca octopus, cone shells Phylum Echinodermata starfish, sea urchins, sea cucumbers
(1). The box jellyfish ranges in size from 2 to 10 cm across the bell, is usually transparent, and possesses a number of dangling tentacles. Clinical Presentation. A person is usually stung while swimming in shallow waters. Many stings are minor, but with a significant envenomation the sting will be intensely painful immediately and the victim may collapse within 1 to 2 minutes (13). The toxic skin reaction can be intense, with rapid formation of wheals, vesicles, and skin discoloration. With major envenomations, skin blistering occurs within 6 hours, with superficial necrosis in 12 to 18 hours. Death is attributed to hypotension, profound muscle spasm, muscular and respiratory paralysis, and subsequent cardiac arrest. The overall mortality rate following a box jellyfish sting is estimated at 15% to 20% (1,2,4). Treatment. Treatment consists of stabilization, concomitant detoxification, and antivenin administration (1,3,4). It is essential to immediately apply acetic acid to any adherent tentacles before removing them in order to detoxify the nematocysts and prevent further envenomation. The rescuer should be careful not to envenomate himself by wearing heavy protective gloves or using forceps. The pressure immobilization technique should not be used (13). Chironex antivenin should be administered intravenously as soon as possible. This is prepared from hyperimmunized sheep, and the risk of serum sickness and anaphylaxis should be assumed to be the same as for equine preparations. The antivenin is produced by Commonwealth Serum Laboratories in Melbourne, Australia (2). Southeast Asian waters
Anthozoans
This class includes the sea anemones, stony or true corals, and the soft corals. Anemones. There are over 1000 species of sea anemo-
nes. They are multicolored animals with sessile habits and a flowerlike appearance. They are composed of stalked, fingerlike projections used for stinging and
John McGoldrick
and John A. Marx
paralyzing passing fish. The tentacles are covered with nematocysts that discharge when a victim touches or brushes up against the anemone (2). Clinical Presentation. The dermatitis caused by contact is similar to that caused by fire coral. Systemic reactions are less frequent (6,15). Sponge fisherman’s disease is caused by contact with an anemone (Sargartia) that attaches itself symbiotically to the base of a sponge. It consists of a dermatitis of the hands (2). Treatment. The treatment is the same as outlined for Physalia species. Stony Corals. These are animals that live in colonies
and possess calcareous outer skeletons. Snorklers, divers, waders, and surfers frequently suffer lacerations from coral. Clinical Presentation. A coral laceration is usually painful initially. The development of erythema and pruritus varies with the species of coral and size of the laceration. Treatment. All acute coral cuts and abrasions should be scrubbed with soap and water, then irrigated with normal saline to remove all foreign material. If stinging is a major symptom, there may be an element of nematocyst envenomation that may respond to a brief rinse with acetic acid (2,3). Despite the best primary irrigation and debridement, the wound may heal slowly, with soft tissue inflammation and ulcer formation (1,3). All devitalized tissue should be debrided regularly. Infections should be treated appropriately. Chronic foreign body granulomas should be referred to a surgeon.
Mollusks The phylum Mollusca encompasses a group of unseg-
mented, soft-bodied invertebrates, many of which secrete calcareous shells. There are 5 main classes (Table 2), of which 3 are hazardous to humans: 1) the cephalopods (squid, octopus, cuttlefish); 2) the gastropods (snails, slugs); and 3) the pelecypods (scallops, oysters, clams, muscles), which are usually implicated in poisonous ingestions (1,2,3). Octopus. Octopuses are usually harmless unless cornered or provoked. Any octopus is capable of inflicting a bite wound, but envenomation of clinical significance is seen with bites of the Australian spotted or blue ringed octopus, Hapalochlena lunulata and Hapalochlena maculosa (2,3,16). These animals are found throughout the Indo-Pacific region and rarely exceed a length of 20 cm with tentacles extended. They are generally found in tidal pools and shallow coastal waters. When the animal is at rest it is usually dark brown
Marine Envenomations,
Part 2
75
ration of clinically significant neuromuscular blockade is 4 to 10 hours, after which a victim who has not sustained significant hypoxia will show rapid improvement (2,3). Management of the bite wound remains controversial, with some clinicians recommending excision of the wound and some conservative irrigation, debridement, and observation for signs of infection (18).
Flgure 1. Cone shell. with yellow bands over the body and tentacles, covered by blue patches or rings. When excited the entire body darkens and the blue circles have an iridescent glow (2). The venom apparatus consists of the anterior and posterior salivary glands, salivary ducts, buccal mass, and beak. The salivary glands secrete maculotoxin via the salivary ducts into the pharynx. This venom is normally released into the water to paralyze crabs and small fish, but can be deeply injected via a bite. The venom contains many fractions, one of which is similar to tetrodotoxin in blocking peripheral nerve conduction by interfering with sodium conductance (2,13,16). This rapidly produces neuromuscular blockade. Other components of the venom include hyaluronidase, histamine, tyramine, and serotonin (2,13). Clinical Presentation. Most victims are bitten on an extremity. The bite consists of 1 to 2 small puncture wounds produced by the chitinous jaws. This initially causes only a small amount of discomfort. This may be followed by a burning sensation radiating up the extremity. A wheal may develop with erythema, tenderness, and pruritus. More often, there is no local tissue reaction or a tiny blanced area. Serious systemic symptoms are related to the neurotoxic property of the venom. These include perioral and intraoral paresthesias, diplopia, aphonia, dysphagia, ataxia, weakness, myoclonus, nausea, vomiting, flaccid muscle paralysis, and respiratory failure leading to death (2,14,17,18). Treatment. Initial management is aimed at limiting systemic absorption of the venom with the pressure immobilization technique that has been popularized in Australia (19). There is no antivenin available. Treatment depends on severity and is supportive. The need for respiratory support should be anticipated in anyone demonstrating clinical signs of envenomation. The du-
Cone Shells. There are over 400 species of these carnivorous snails, which are univalve, coneshaped shelled mollusks (see Figure 1). Most of them carry a highly developed venom apparatus, and at least 18 species have been implicated in human envenomations, with occasional fatalities (20). Most of the harmful cone shells are found in shallow Indo-Pacific waters. The venom apparatus consists of a set of minute, barbed, detachable, hypodermic-like radular teeth associated with a venom bulb, duct, and radular sheath within which the teeth are stored. To envenomate a fish or unwary person, a tooth is released from the sheath into the pharynx, loaded with venom from the venom duct, and transferred to an extensible proboscis. The proboscis grasps the venom impregnated tooth and thrusts it into the victim (2,3). The proboscis of some species can reach as far back as the spire of the shell. The venom is poorly characterized, but may have a curariform effect that interferes with neuromuscular transmission (2). Clinical Presentation. Most stings occur on the fingers or hands from picking up the shell. The sting is a puncture wound that is initially painful (20). Envenomation from a more toxic species may induce paresthesias at the wound site, which may become perioral and then generalized. Systemic effects include pruritus, dysphagia, weakness, aphonia, diplopia, paralysis, and respiratory failure leading to death (2,20). Treatment. There is no antivenin available for cone shell envenomation. Recommended initial management includes soaking in nonscalding hot water to tolerance until pain is relieved, pressure immobilization technique of venom containment, and cardiovascular and respiratory support. Naloxone has been used in cases of severe persistent hypotension with mixed results (2-4). Rare cases of disseminated intravascular coagulation (DIC) have been described following cone shell envenomation (2).
Echinodermata The phylum Echinodermata contains three classes that produce medical illness: starfish, sea urchins, and sea cucumbers (Table 2). Stafish. These are free-living animals covered with thorny spines of calcium carbonate crystals. Glandular
76
John McGoldrick
and John A. Marx
Figure 2. Sea urchin.
in the epidermis produces a slimy venomous substance that causes a contact dermatitis. The crownof-thorns sea star can produce acute systemic reactions if the spines penetrate the victim’s skin (2,21). Treatment. The dermatitis should be treated with irrigation and a topical steroid cream. Treatment for systemic reactions is supportive. Chronic foreign body granulomas induced by spines may require surgical retissue
moval . Sea Urchins. These free-living echinoderms (see Figure 2) have a hard shell surrounding the viscera, covered by regularly arranged spines and triple-jawed pedicelMae. The venom apparatus consists of the hollow, venom-filled spines or the pedicellariae. Generally, only one or the other is present in a single species. The spine can be of the sharp venom-filled variety or blunt, non-venom-containing. The pedicellariae are small, delicate seizing organs scattered among the spines. The terminal ends have three pincer jaws. The outer surface of each jaw is covered by a large venom gland that is triggered to contract upon contact. The venom contains various toxic fractions, including steroid glycosides, serotonin, and cholinergic substances (2). Clinical Presentation. Venomous spines produce immediate intense burning stings followed by erythema,
edema, and local aching. Spines frequently break off and lodge in the victim. The stings of pedicellariae usually cause immediate intense radiating pain and can produce systemic symptoms, including faintness, numbness, generalized muscular paralysis, aphonia, and respiratory distress. Deaths have been reported (2,18). Treatment. Treatment is based on symptoms and is supportive. Hot water may provide pain relief. Any pedicellariae still attached to the skin must be removed or envenomation will continue. Some spines have dye in them, which may give a false impression of spines left in the skin. Soft tissue density x-ray techniques may be diagnostic in these cases. Sea Cucumbers. These are worm-like bottom feeders that produce a visceral liquid toxin called holothurin (2). This can induce a contact dermatitis and an intense inflammatory reaction that can lead to blindness if the corneas are involved. Holothurin is contained in tentacular organs that can be projected and extended anally as a defense response. Some cucumbers ingest nematocysts and can secrete coelenterate venom as well. For this reason, the initial treatment should include the topical application of 5% acetic acid or isopropyl alcohol for detoxification, followed by standard therapy for chemical irritant dermatitis (1,3).
REFERENCES 1. Auerbach, PS, Geehr EC. Management of wilderness and environmental emergencies. 2nd Ed. St. Louis: Mosby; 1989. 2. Halstead BW. Poisonous and venomous marine animals of the world. Princeton, New Jersey: The Darwin Press; 1978.
3. Auerbach PS. Clinical therapy of marine envenomation and poisoning. In: TU AI, ed. Handbook of natural toxins, vol 4: marine toxins and venoms. New York: Marcel Dekker; 1988. 4. Auerbach PS. Hazardous marine animals. Bmerg Med Clin
Marine Envenomations, Part 2
North Am. 1984;2:531-44. 5. Burnett JW, Calton GJ, Burnett HW, Mandojame RM. Local and systemic reactions from jellyfish stings. Clin Dermatol. 1987;5(3):14-28. 6. Fisher AA. Atlas of aquatic dermatology. New York: Grune and Stratton; 1978. stings: treat7. Arnold HL. Portuguese man-of-war (“bluebottle”) ment with papain. Straub Clin Proc. 1971;37:30-3. 8. Stein MR. Meraccin JW, Rothschild NE, Burnett JW. Fatal portuguese man-of-war (Physalia phydis) envenomation. Ann Emerg Med. 1989;18:312-15. 9. Russo AJ, Calton GJ, Burnett JW. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon. 1983;21:475-80. 10. Togias AG, Burnett JN, Kagey-Sobotka A, Lichtenstein LM. Anaphylaxis after contact with a jellyfish. J Allergy Clin Immunol. 1985;75:672. 11. Marr JJ. Portuguese man-of-war envenomation: a personal experience. JAMA. 1967;199:337-8. 12. Burnett JW, Calton GJ. Use of IgE antibody determinations in cutaneous coelenterate envenomations. Cutis. 1981:27:50-2.
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13. Sutherland SK. Venomous creatures of Australia. Melbourne: Oxford University Press; 198 1. 14. Walker DG. Survival after severe envenomation by the blueringed octopus (Hapolochlaene maculosa). Med J Aust. 1983;2: 663-5. 15. Bemheimer AW, Lai CY. Properties of a cytolytic toxin from the sea anemone, stoichactis kerti. Toxicon. 1985;23:791. 16. Williamson JA. The blue-ringed octopus (genus Hapalochlena). Clin Dermatol. 1987;5(3):127-33. 17. Hopkins DG. Venomous effects and treatment of octopus bite. Med J Amt. 1964;l:Sl. 18. Soutbcott RV. Human injuries from invertebrate animals in the Australian seas. Clin. Toxicol. 1970;3:617-36. 19. Anker RC, Straffer WG, Loiselle DS, Anker KM. Retarding the uptake of “mock venoms” in humans: comparison of three first-aid treatments. Med J Aust. 1982;1:212-14. 20. Manowitz NR, Rosenthal RR. Cutaneous systemic reactions to toxins and venoms of common marine organisms. Cutis. 1979;23: 450-4. 21. Lucas T. The crown of thorns starfish. Oceanus. 1986;29(2):55.
The Journal of Emergency Medicine, Vol 10. pp 71-77, 1992
MARINE ENVENOMATIONS PART 2: INVERTEBRATES John McGoldrick, MD,and John A. Marx, Reprint address:
MD*
Department of Emergency Medicine, Denver General Hospital, Denver, Colorado John McGoldrick, MD, Department of Emergency Medicine, Denver General Hospital, 777 Bannock Street, Denver CO, 80204
0 Abstract - As more people travel to the oceans for sport diving and other marine-related activities, the incidence of marine envenomations has risen. This article is designed to give the emergency medicine physician an overview of varying marine envenomations, their clinical presentation, and recommended treatment. Part 1 of this article dealt with general wound management and vertebrate envenomations. Part 2 addresses invertebrate envenomations.
reaction, and treatment for anaphylaxis will be necessary. Part I of this paper dealt with general wound management and treatment of vertebrate envenomations.
INVERTEBRATES Treatments of invertebrate summarized in Table 1.
0 Keywords - marine envenomations; vertebrates; marine antivenins: detoxification
marine
envenomations
are
Coelenterates
There are over 9000 species of coelenterates, of which at least 100 are dangerous to humans (2). They exist in two basic morphologies: 1) The polyp, which is sedentary and anchored at its caudal end, with a mouth and tentacles at the opposite end; 2) The medusa, which is a free-floating dome-shaped form with tentacles and a mouth on the concave side (2). Those coelenterates having venom-bearing stinging cells called nematocysts are known as cnidaria. The cnidaria can be divided into three main groups: 1) hydrozoans; 2) scyphozoans; and 3) anthozoans. There is a wide range of severity to coelenterate stings, which varies with the species (venom potency and nematocyst configuration), size of the animal (venom inoculation), size and age of the victim, and the underlying health of the victim (14). The nematocyst is contained within an outer capsule called the craidoblast, to which is attached a pointed
INTRODUCTION Most hazardous marine organisms are found in temperate or tropical oceans, particularly the Indo-Pacific region. With more people traveling to exotic locales for sport diving and other marine-related activities, and with the increase in private salt water aquariums, the incidence of marine envenomations has risen (1). When treating a marine envenomation or wound, the general principles of emergency medicine apply. Occasionally, an envenomation will be accompanied by an allergic
*Dr. Marx is currently in the Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina.
w
Emergency Medicine in Review presents comprehensive surveys plus evaluation and critical interpretation of significant management problems in emergency medicine. Ann Harwood-Nuss, MD, of the University Hospital of Jacksonville, Florida, coordinates this section.
RECEIVED:7 August 1990; FINAL SUBMISSION RECEIVED:27 November ACCEYIED:16 December 1990. 71
1990;
07364679192
$5.00 + .OO
72
John McGoldrick
and John A. Marx
Table 1. Treatment of Marlne Envenomatlons: Invertebrates Marine Organism
Detoxification
ED Treatment
Hydroids
Irrigate with sea water (not fresh water). Topical 5% acetic acid (vinegar). Shave affected area.
Topical corticosteroid cream for dermatitis.
Fire coral
Same as for hydroids. Topical 5% acetic acid.
Topical corticosteroid cream for dermatitis.
Portuguese man-of- war
Same as for hydroids. Topical 5% acetic acid. Use forceps or gloves to remove tentacles.
Topical corticosteroid for dermatitis. All patients with systemic symptoms should be observed for 8 h. Severe systemic symptoms mandate hospitalization with supportive care.
Sea nettles
Same as for hydroids. Topical 5% acetic acid.
Same as for Portuguese man-of-war.
Box jellyfish
Same as for hydroids. Topical 5% acetic acid. Use forceps or gloves to remove tentacles.
Give chironex antivenin. Supportive care for hypotension and respiratory depression.
Anenomes
Same as for hydroids. Topical 5% acetic acid.
Topical corticosteroid cream for dermatitis.
Blue-ringed octopus
Pressure immobilization bandage.
Supportive care for respiratory depression.
Cone shell
Hot water (105 “F). Pressure immobilization bandage.
Supportive care for hypotension and respiratory depression.
Starfish
Irrigation with fresh water.
Exploration and removal of any spines. Topical corticosteroid for dermatitis.
Sea urchin
Hot water (105 “F). Removal of any spines or pedicellariae.
Exploration and removal of any retained spines.
Sea cucumber
Topical 5% acetic acid.
Topical cotticosteroid for dermatitis.
trigger or coridocil. The nematocyst is venom filled and contains a hollow, pointed, coiled tube. It is usually located on the outer surface of the tentacles or near the mouth and is triggered on contact with the victim’s body surface. When the coridocil is stimulated, either by physical contact or by chemoreceptor mechanism, it causes opening of the craidoblast. The venom-containing tube is everted, penetrates the skin, and results in envenomation. The venom varies from species to species and contains many protein fractions, some of which have been shown to be cardiotoxic, neurotoxic, and dermatonecrotic. The venom also contains histamine, prostaglandins, serotonin, and kinin-like factors (2). The effects of the venom range from a mild dermatitis to the most toxic venom known in sea animals, able to cause death within 30 to 60 seconds (box jellyfish) (3,5). Hydrozoans
The hydrozoans range from the sedentary Millepara hydroid corals (fire coral) to the free floating colonial siphonophore Physalia physalis (Portuguese man-ofwar), which is a floating colony composed of several types of polypoid individuals attached to a free-floating
stem. The clinical syndrome produced by stings of hydrozoans varies with the toxicity of the species and the number of nematocysts discharged into the victim. Hydroids. The feather hydroids are animals resembling
feathers or plumes that sting anyone who brushes up against or handles them (1). They are the most numerous of the hydrozoans. Clinical Presentation. The nematocysts of a feather hydroid usually induce a mild syndrome consisting of immediate burning, itching, and urticaria. This rarely progresses to an erythema multiforme type of reaction (2,6). During a storm, the branches may be broken up and fragments can cause skin irritation or be washed into a diver’s mask or regulator mouthpiece, producing a burning sensation in the conjunctivae and oral mucous membranes (1). Treatment. At the scene, the skin should be immediately irrigated with sea water and gently dried. Rinsing with fresh water or briskly rubbing will result in discharge of any nematocysts remaining on the skin, thereby worsening the envenomation. Five percent acetic acid (vinegar) or 40 to 70% isopropyl alcohol should then be applied to inactivate any remaining undischarged nematocysts. This should be continued for 15 to 30 minutes or until pain is relieved. There is
Marine Envenomations,
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Part 2
some evidence that alcohol may stimulate the discharge of nematocysts in vitro, but clinical experience supports its use (14). Other substances reported to be effective as alternatives are dilute ammonia hydroxide, urine, sodium bicarbonate, and papain (6,7). The pressure immobilization technique for venom sequestration should not be used, as the pressure may stimulate any remaining nematocysts to discharge (1,3). Once the wound has been rinsed and soaked with acetic acid or isopropyl alcohol, the remaining nematocysts should be removed by shaving the area with a razor (1,2). Topical anesthetic ointments or cordicosteroid lotions may be used once the toxin has been inactivated. Fire Coral. These coelenterates are widely distributed
in tropical waters and frequently envenomate unwary divers. They possess a razor sharp lime carbonate exoskeleton ranging in color from white to yellow-green. These form blade-like, branching calcareous growths over corals and other objects. The tiny nematocyst bearing tentacles protrude from numerous minute surface gastropores (2,3). Clinical Presentation. Immediately following contact there is a burning or stinging pain. Intense pruritus usually follows within seconds. Rubbing the affected area will discharge more nematocysts, worsening the envenomation. Over 5 to 30 minutes, urticarial wheals develop that generally reach maximum size in 30 to 60 minutes. Untreated, the wheals and pruritis will resolve over 3 to 7 days (1,2). Treatment. The treatment is the same as outlined for hydroids . Portuguese Man-of- War. The Portuguese Man-of-War (Physalia physalis) is one of many pelagic (open sea)
colonial siphonophores that inhabit the surface of the sea and depend on the winds and tides to mobilize them. They are found in tropical and semitropical Atlantic and Pacific oceans. They consist of a floating sail filled with nitrogen and carbon monoxide, from which are suspended multiple nematocyst-bearing tentacles that may attain lengths of 30 meters (2). There are many different species of varying toxicity. Clinical Presentation. Depending on which species is involved and the amount of nematocysts discharged, symptoms may range from a mild dermatitis to severe systemic reactions. There is immediate localized buming pain usually with central radiation. The skin contacted by the tentacles becomes erythematous. There may be local edema, urticaria, and bullae formation. If envenomation is severe, this may progress to skin necrosis. A moderate or severe envenomation may result
in systemic symptoms, which begin 5 minutes to several hours after envenomation. Allergic reactions may play a significant role in severe envenomations (8,9,10). Multiple organ systems can be involved, including 1) Neurological: malaise, headache, delirium, syncope, aphonia, vertigo, ataxia, paralysis, coma, and death; 2) Respiratory: dyspnea, bronchospasm, and laryngeal edema (1,4); 3) Cardiovascular: anaphylaxis, hemolysis, dysrhythmias, hypotension; 4) Gastrointestinal: nausea, vomiting, diarrhea, dysphagia, thirst, hypersalivation; 5) Musculoskeletal: abdominal rigidity, myalgias, cramps, extremity spasm, arthralgias; 6) Ocular: conjunctivitis, chemosis, cornea1 ulcerations, lacrimation (1,3). Treatment. Treatment is directed toward major systemic reactions, pain alleviation, and control of dermatitis. Stabilization should be done in concert with detoxification with sea water rinse, acetic acid soak, and nematocyst removal. Care must be taken not to envenomate oneself when removing tentacles and remaining nematocysts. All patients with a systemic component should be observed for at least 6 to 8 hours, as rebound phenomena are not uncommon (2,4,11). A urinalysis should be obtained to screen for hemoglobinuria. Scyphozoans
This group contains the true jellyfish. These are mostly free-swimming pelagic creatures ranging in size from a few millimeters to more than two meters in width across the bell, with tentacles of up to 40 meters in length (2). Sea Nettles. These are found in both tropical and tem-
perate waters, particularly in Chesapeake Bay. They are capable of giving a moderately severe sting. Clinical Presentation. Symptoms and signs are similar to Physalia species with perhaps a greater incidence of systemic manifestations. Death has been reported (2,3). Severe reactions may be the result of prior sensitization. Elevated levels of serum anti-sea-nettle venom IgM, IgG, and IgE may persist for years in patients with exaggerated reactions ( 12). Treatment. The treatment is the same as that outlined for Physalia species. Box JellyJish. There are a variety of cubomedusean scyphozoans with highly toxic venom that inhabit the Indo-Pacific oceans (2). Chironexfleckeri, the box jellyfish, is reported to be the most venomous sea creature known and is able to cause death within 30 to 60 seconds of envenomation (2,13,14). The box jellyfish is primarily found off the coast of Northern Australia, but is located throughout the Indo-Pacific region. At least 72 fatalities have been verified in Australian and
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Table 2. Hazardous Marlne Life Invertebrates Phylum Coelenterata (Cnidaria) Hydrozoans (hydroids, fire coral, Portuguese man-of-war) Scyphozoans (jellyfish, sea nettles, box jellyfish) Anthozoans (sea anemones, corals) Phylum Mollusca octopus, cone shells Phylum Echinodermata starfish, sea urchins, sea cucumbers
(1). The box jellyfish ranges in size from 2 to 10 cm across the bell, is usually transparent, and possesses a number of dangling tentacles. Clinical Presentation. A person is usually stung while swimming in shallow waters. Many stings are minor, but with a significant envenomation the sting will be intensely painful immediately and the victim may collapse within 1 to 2 minutes (13). The toxic skin reaction can be intense, with rapid formation of wheals, vesicles, and skin discoloration. With major envenomations, skin blistering occurs within 6 hours, with superficial necrosis in 12 to 18 hours. Death is attributed to hypotension, profound muscle spasm, muscular and respiratory paralysis, and subsequent cardiac arrest. The overall mortality rate following a box jellyfish sting is estimated at 15% to 20% (1,2,4). Treatment. Treatment consists of stabilization, concomitant detoxification, and antivenin administration (1,3,4). It is essential to immediately apply acetic acid to any adherent tentacles before removing them in order to detoxify the nematocysts and prevent further envenomation. The rescuer should be careful not to envenomate himself by wearing heavy protective gloves or using forceps. The pressure immobilization technique should not be used (13). Chironex antivenin should be administered intravenously as soon as possible. This is prepared from hyperimmunized sheep, and the risk of serum sickness and anaphylaxis should be assumed to be the same as for equine preparations. The antivenin is produced by Commonwealth Serum Laboratories in Melbourne, Australia (2). Southeast Asian waters
Anthozoans
This class includes the sea anemones, stony or true corals, and the soft corals. Anemones. There are over 1000 species of sea anemo-
nes. They are multicolored animals with sessile habits and a flowerlike appearance. They are composed of stalked, fingerlike projections used for stinging and
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paralyzing passing fish. The tentacles are covered with nematocysts that discharge when a victim touches or brushes up against the anemone (2). Clinical Presentation. The dermatitis caused by contact is similar to that caused by fire coral. Systemic reactions are less frequent (6,15). Sponge fisherman’s disease is caused by contact with an anemone (Sargartia) that attaches itself symbiotically to the base of a sponge. It consists of a dermatitis of the hands (2). Treatment. The treatment is the same as outlined for Physalia species. Stony Corals. These are animals that live in colonies
and possess calcareous outer skeletons. Snorklers, divers, waders, and surfers frequently suffer lacerations from coral. Clinical Presentation. A coral laceration is usually painful initially. The development of erythema and pruritus varies with the species of coral and size of the laceration. Treatment. All acute coral cuts and abrasions should be scrubbed with soap and water, then irrigated with normal saline to remove all foreign material. If stinging is a major symptom, there may be an element of nematocyst envenomation that may respond to a brief rinse with acetic acid (2,3). Despite the best primary irrigation and debridement, the wound may heal slowly, with soft tissue inflammation and ulcer formation (1,3). All devitalized tissue should be debrided regularly. Infections should be treated appropriately. Chronic foreign body granulomas should be referred to a surgeon.
Mollusks The phylum Mollusca encompasses a group of unseg-
mented, soft-bodied invertebrates, many of which secrete calcareous shells. There are 5 main classes (Table 2), of which 3 are hazardous to humans: 1) the cephalopods (squid, octopus, cuttlefish); 2) the gastropods (snails, slugs); and 3) the pelecypods (scallops, oysters, clams, muscles), which are usually implicated in poisonous ingestions (1,2,3). Octopus. Octopuses are usually harmless unless cornered or provoked. Any octopus is capable of inflicting a bite wound, but envenomation of clinical significance is seen with bites of the Australian spotted or blue ringed octopus, Hapalochlena lunulata and Hapalochlena maculosa (2,3,16). These animals are found throughout the Indo-Pacific region and rarely exceed a length of 20 cm with tentacles extended. They are generally found in tidal pools and shallow coastal waters. When the animal is at rest it is usually dark brown
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ration of clinically significant neuromuscular blockade is 4 to 10 hours, after which a victim who has not sustained significant hypoxia will show rapid improvement (2,3). Management of the bite wound remains controversial, with some clinicians recommending excision of the wound and some conservative irrigation, debridement, and observation for signs of infection (18).
Flgure 1. Cone shell. with yellow bands over the body and tentacles, covered by blue patches or rings. When excited the entire body darkens and the blue circles have an iridescent glow (2). The venom apparatus consists of the anterior and posterior salivary glands, salivary ducts, buccal mass, and beak. The salivary glands secrete maculotoxin via the salivary ducts into the pharynx. This venom is normally released into the water to paralyze crabs and small fish, but can be deeply injected via a bite. The venom contains many fractions, one of which is similar to tetrodotoxin in blocking peripheral nerve conduction by interfering with sodium conductance (2,13,16). This rapidly produces neuromuscular blockade. Other components of the venom include hyaluronidase, histamine, tyramine, and serotonin (2,13). Clinical Presentation. Most victims are bitten on an extremity. The bite consists of 1 to 2 small puncture wounds produced by the chitinous jaws. This initially causes only a small amount of discomfort. This may be followed by a burning sensation radiating up the extremity. A wheal may develop with erythema, tenderness, and pruritus. More often, there is no local tissue reaction or a tiny blanced area. Serious systemic symptoms are related to the neurotoxic property of the venom. These include perioral and intraoral paresthesias, diplopia, aphonia, dysphagia, ataxia, weakness, myoclonus, nausea, vomiting, flaccid muscle paralysis, and respiratory failure leading to death (2,14,17,18). Treatment. Initial management is aimed at limiting systemic absorption of the venom with the pressure immobilization technique that has been popularized in Australia (19). There is no antivenin available. Treatment depends on severity and is supportive. The need for respiratory support should be anticipated in anyone demonstrating clinical signs of envenomation. The du-
Cone Shells. There are over 400 species of these carnivorous snails, which are univalve, coneshaped shelled mollusks (see Figure 1). Most of them carry a highly developed venom apparatus, and at least 18 species have been implicated in human envenomations, with occasional fatalities (20). Most of the harmful cone shells are found in shallow Indo-Pacific waters. The venom apparatus consists of a set of minute, barbed, detachable, hypodermic-like radular teeth associated with a venom bulb, duct, and radular sheath within which the teeth are stored. To envenomate a fish or unwary person, a tooth is released from the sheath into the pharynx, loaded with venom from the venom duct, and transferred to an extensible proboscis. The proboscis grasps the venom impregnated tooth and thrusts it into the victim (2,3). The proboscis of some species can reach as far back as the spire of the shell. The venom is poorly characterized, but may have a curariform effect that interferes with neuromuscular transmission (2). Clinical Presentation. Most stings occur on the fingers or hands from picking up the shell. The sting is a puncture wound that is initially painful (20). Envenomation from a more toxic species may induce paresthesias at the wound site, which may become perioral and then generalized. Systemic effects include pruritus, dysphagia, weakness, aphonia, diplopia, paralysis, and respiratory failure leading to death (2,20). Treatment. There is no antivenin available for cone shell envenomation. Recommended initial management includes soaking in nonscalding hot water to tolerance until pain is relieved, pressure immobilization technique of venom containment, and cardiovascular and respiratory support. Naloxone has been used in cases of severe persistent hypotension with mixed results (2-4). Rare cases of disseminated intravascular coagulation (DIC) have been described following cone shell envenomation (2).
Echinodermata The phylum Echinodermata contains three classes that produce medical illness: starfish, sea urchins, and sea cucumbers (Table 2). Stafish. These are free-living animals covered with thorny spines of calcium carbonate crystals. Glandular
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John McGoldrick
and John A. Marx
Figure 2. Sea urchin.
in the epidermis produces a slimy venomous substance that causes a contact dermatitis. The crownof-thorns sea star can produce acute systemic reactions if the spines penetrate the victim’s skin (2,21). Treatment. The dermatitis should be treated with irrigation and a topical steroid cream. Treatment for systemic reactions is supportive. Chronic foreign body granulomas induced by spines may require surgical retissue
moval . Sea Urchins. These free-living echinoderms (see Figure 2) have a hard shell surrounding the viscera, covered by regularly arranged spines and triple-jawed pedicelMae. The venom apparatus consists of the hollow, venom-filled spines or the pedicellariae. Generally, only one or the other is present in a single species. The spine can be of the sharp venom-filled variety or blunt, non-venom-containing. The pedicellariae are small, delicate seizing organs scattered among the spines. The terminal ends have three pincer jaws. The outer surface of each jaw is covered by a large venom gland that is triggered to contract upon contact. The venom contains various toxic fractions, including steroid glycosides, serotonin, and cholinergic substances (2). Clinical Presentation. Venomous spines produce immediate intense burning stings followed by erythema,
edema, and local aching. Spines frequently break off and lodge in the victim. The stings of pedicellariae usually cause immediate intense radiating pain and can produce systemic symptoms, including faintness, numbness, generalized muscular paralysis, aphonia, and respiratory distress. Deaths have been reported (2,18). Treatment. Treatment is based on symptoms and is supportive. Hot water may provide pain relief. Any pedicellariae still attached to the skin must be removed or envenomation will continue. Some spines have dye in them, which may give a false impression of spines left in the skin. Soft tissue density x-ray techniques may be diagnostic in these cases. Sea Cucumbers. These are worm-like bottom feeders that produce a visceral liquid toxin called holothurin (2). This can induce a contact dermatitis and an intense inflammatory reaction that can lead to blindness if the corneas are involved. Holothurin is contained in tentacular organs that can be projected and extended anally as a defense response. Some cucumbers ingest nematocysts and can secrete coelenterate venom as well. For this reason, the initial treatment should include the topical application of 5% acetic acid or isopropyl alcohol for detoxification, followed by standard therapy for chemical irritant dermatitis (1,3).
REFERENCES 1. Auerbach, PS, Geehr EC. Management of wilderness and environmental emergencies. 2nd Ed. St. Louis: Mosby; 1989. 2. Halstead BW. Poisonous and venomous marine animals of the world. Princeton, New Jersey: The Darwin Press; 1978.
3. Auerbach PS. Clinical therapy of marine envenomation and poisoning. In: TU AI, ed. Handbook of natural toxins, vol 4: marine toxins and venoms. New York: Marcel Dekker; 1988. 4. Auerbach PS. Hazardous marine animals. Bmerg Med Clin
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North Am. 1984;2:531-44. 5. Burnett JW, Calton GJ, Burnett HW, Mandojame RM. Local and systemic reactions from jellyfish stings. Clin Dermatol. 1987;5(3):14-28. 6. Fisher AA. Atlas of aquatic dermatology. New York: Grune and Stratton; 1978. stings: treat7. Arnold HL. Portuguese man-of-war (“bluebottle”) ment with papain. Straub Clin Proc. 1971;37:30-3. 8. Stein MR. Meraccin JW, Rothschild NE, Burnett JW. Fatal portuguese man-of-war (Physalia phydis) envenomation. Ann Emerg Med. 1989;18:312-15. 9. Russo AJ, Calton GJ, Burnett JW. The relationship of the possible allergic response to jellyfish envenomation and serum antibody titers. Toxicon. 1983;21:475-80. 10. Togias AG, Burnett JN, Kagey-Sobotka A, Lichtenstein LM. Anaphylaxis after contact with a jellyfish. J Allergy Clin Immunol. 1985;75:672. 11. Marr JJ. Portuguese man-of-war envenomation: a personal experience. JAMA. 1967;199:337-8. 12. Burnett JW, Calton GJ. Use of IgE antibody determinations in cutaneous coelenterate envenomations. Cutis. 1981:27:50-2.
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13. Sutherland SK. Venomous creatures of Australia. Melbourne: Oxford University Press; 198 1. 14. Walker DG. Survival after severe envenomation by the blueringed octopus (Hapolochlaene maculosa). Med J Aust. 1983;2: 663-5. 15. Bemheimer AW, Lai CY. Properties of a cytolytic toxin from the sea anemone, stoichactis kerti. Toxicon. 1985;23:791. 16. Williamson JA. The blue-ringed octopus (genus Hapalochlena). Clin Dermatol. 1987;5(3):127-33. 17. Hopkins DG. Venomous effects and treatment of octopus bite. Med J Amt. 1964;l:Sl. 18. Soutbcott RV. Human injuries from invertebrate animals in the Australian seas. Clin. Toxicol. 1970;3:617-36. 19. Anker RC, Straffer WG, Loiselle DS, Anker KM. Retarding the uptake of “mock venoms” in humans: comparison of three first-aid treatments. Med J Aust. 1982;1:212-14. 20. Manowitz NR, Rosenthal RR. Cutaneous systemic reactions to toxins and venoms of common marine organisms. Cutis. 1979;23: 450-4. 21. Lucas T. The crown of thorns starfish. Oceanus. 1986;29(2):55.
