Envenomation by Marine Life
Interactions with various forms of marine life can result in anaphylactic reactions or envenomation.
Reaction to Sponges
Sponges (see Plate 36) are stationary animals that attach to the sea floor or coral beds. Embedded in their connective tissue matrices are spicules of silicon dioxide or calcium carbonate. Other chemical toxins and secondary coelenterate (stinging) inhabitants contribute to the skin irritation and systemic manifestations that result from dermal contact.
Signs and Symptoms
Treatment
2. To remove embedded microscopic spicules, apply sticky adhesive tape, a commercial facial peel, or a thin layer of rubber cement; then peel away the adherent spicules.
3. Apply a 5% acetic acid (vinegar) soak for 10 to 30 minutes three or four times a day. If vinegar is not available, use isopropyl alcohol 40%. Do not use a topical steroid preparation as the primary (initial) decontaminant because this may worsen the reaction.
4. After decontamination and at least two vinegar applications, use a mild emollient cream (e.g., hydrocortisone or triamcinolone) to soothe the skin.
5. If the allergic component is mild, apply a topical steroid preparation. If the allergic component is severe, as manifested by weeping, crusting, and vesiculation, administer a systemic corticosteroid (e.g., prednisone, 60 to 100 mg, tapered over 14 days).
6. Perform frequent follow-up wound checks because significant infections sometimes develop. Culture infected wounds and administer antibiotics (see Chapter 52).
Jellyfish Stings (Also Fire Coral, Hydroids, and Anemones)
Signs and Symptoms
1. Skin irritation: stinging, pruritus, paresthesias, burning, throbbing, redness, tentacle prints, impression patterns (see Plate 37), blistering, local edema, petechial hemorrhages, skin ulceration, necrosis, and secondary infection
2. Neurologic: malaise, headache, aphonia, diminished touch and temperature sensation, vertigo, ataxia, spastic or flaccid paralysis, mononeuritis multiplex, parasympathetic dysautonomia, plexopathy, peripheral nerve palsy, delirium, loss of consciousness, and coma
3. Cardiovascular: anaphylaxis, hemolysis, hypotension, small artery spasm, bradycardia, tachycardia, congestive heart failure, and ventricular fibrillation
4. Respiratory: rhinitis, bronchospasm, laryngeal edema, dyspnea, cyanosis, pulmonary edema, and respiratory failure
5. Musculoskeletal: abdominal rigidity, myalgias, muscle cramps/spasm, arthralgia, and arthritis
6. Gastrointestinal: nausea, vomiting, diarrhea, dysphagia, hypersalivation, and thirst
7. Ocular: conjunctivitis, chemosis, corneal ulcer, iridocyclitis, elevated intraocular pressure, and lacrimation
8. Other: chills, fever, acute renal failure, and nightmares
Treatment
a. Maintain the airway and administer oxygen.
b. Obtain intravenous access. Administer lactated Ringer’s solution or normal saline solution to support the blood pressure to at least 90 mm Hg systolic.
c. Treat anaphylaxis if present (see Chapter 26).
d. If the sting is from the box jellyfish (Chironex fleckeri) (see Plates 38 and 39) or severe and from the sea wasp (Chiropsalmus quadrigatus), consider immediate administration of C. fleckeri antivenom. Administer this in a dose of one ampule (20,000 units per ampule) IV diluted 1 : 5 to 1 : 10 in isotonic crystalloid. A large sting in an adult may require the initial administration of two ampules. Alternatively, administer this in a dose of three ampules intramuscularly into the thigh. Antivenom administration may be repeated once or twice every 2 to 4 hours until there is no further worsening of the reaction (skin discoloration, pain, or systemic effects).
e. If the sting is from the Irukandji (Carukia barnesi), hypertension from catecholamine stimulation may be severe. If necessary, administer an α-adrenergic blocking agent (phentolamine, 5 mg IV initially, followed by an infusion of up to 10 mg/hr).
f. Authorities no longer recommend the pressure immobilization technique to treat a box jellyfish sting or any other jellyfish sting.
a. If possible, apply a topical decontaminant immediately (described in step d, later). If more than 1 or 2 minutes will elapse before the application of the decontaminant, rinse the wound with seawater. Do not rinse gently with freshwater; if freshwater is to be used, the stream must be forceful (e.g., jet stream from a shower or hose).
b. Hot packs or showers to tolerance (45° C [113° F]) may be more effective than dry, (nonmoist), cold (insulated ice) packs.
c. Do not rub or abrade the wound.
d. If these have been done, apply a topical decontaminant. The efficacy may vary depending on the stinging species.
• Acetic acid 5% (vinegar) is the decontaminant of choice with a box jellyfish (C. fleckeri) sting.
• For other stings, diminish the pain using vinegar, isopropyl (rubbing) alcohol 40%, sodium bicarbonate (baking soda), papain (papaya latex or nonseasoned meat tenderizer, the latter in a brief [<15 minutes] application), or dilute household ammonia. Other substances that may be effective include sugar or olive oil, or lemon or lime juice. Urinating on the sting is generally not helpful. A sting from the Australian Physalia physalis, a recently differentiated species, should not be doused with vinegar.
• Do not apply a solvent (e.g., formalin, ether, gasoline).
• Perfume, aftershave, or high-proof liquor may worsen the skin reaction.
e. After decontamination, remove the adherent nematocysts. Apply shaving cream or a paste of soap or baking soda, flour, or talc, and shave the area with a razor or other sharp edge.
f. Apply a local anesthetic ointment or mild steroid preparation to soothe the skin.
g. If the reaction is severe, administer a systemic corticosteroid (e.g., prednisone, 60 to 100 mg, tapered over 14 days).
h. Inspect the wound regularly for ulceration and the onset of infection.
3. If the eye is involved, it should be anesthetized with proparacaine 0.5% and irrigated to 100 to 250 mL of normal saline to remove foreign matter. Slit lamp examination and fluorescein staining to identify corneal defects are recommended.
Prevention
1. Give all jellyfish a wide berth when swimming or diving.
2. Wear a “stinger suit” when immersed in jellyfish-infested water.
3. When diving, scan for surface concentrations of stinging animals.
4. If “stinger enclosures” are present, do not venture beyond their confines.
5. Consider the use of a topical skin protective preparation such as Safe Sea (jellyfish-safe sunblock).
Sea Bather’s Eruption
Signs and Symptoms
1. Stinging of the skin while still in the water or immediately on exiting; may be intensified by the application of fresh water
2. Skin redness, papules (see Plate 40), urticaria, and blisters minutes to 12 hours after exposure
a. Most common areas: buttocks, genitals, and under breasts (women)
b. Individual lesions resembling insect bites
c. Also seen under bathing caps and swim fins and along the edge of the cuffs of wet suits
3. Fever, chills, headache, fatigue, malaise, vomiting, conjunctivitis, and urethritis
Treatment
1. Apply a topical decontaminant. Acetic acid 5% (vinegar) seems to be less effective than papain. Otherwise, scrub thoroughly with soap and water.
2. After decontamination, apply calamine lotion with 1% menthol to control itching. A high-potency topical corticosteroid preparation may be of benefit.
