Presentation is loading. Please wait.

Presentation is loading. Please wait.

Sam L. Alexander, M.D..  2000 species of venomous marine animals  Initial, generalized treatment modalities:  Remove from water; avoid drowning  Local.

Similar presentations


Presentation on theme: "Sam L. Alexander, M.D..  2000 species of venomous marine animals  Initial, generalized treatment modalities:  Remove from water; avoid drowning  Local."— Presentation transcript:

1 Sam L. Alexander, M.D.

2  2000 species of venomous marine animals  Initial, generalized treatment modalities:  Remove from water; avoid drowning  Local wound care  Specific antivenin (available?)  Manage anaphylaxis prn

3

4  Octopi ◦ Local wound care:  Irrigate  Debride  Dress  Tetanus  Analgesia ◦ Blue-ringed Octopus (~lethal)  Tetrodotoxin-like venom

5  Sea snakes (Hydrophiidae) ◦ 50 species, all toxic, 7 fatal ◦ Most bites = No Envenomation: fangs short/loose ---> poor delivery of venom  Local wound care  Polyvalent Sea snake antivenin

6  Nematocyst: spring-loaded venom glands, suddenly evert = delivering venom  Tentacles are common location  Functional after animal death  May still be ‘loaded’ while in victim flesh ◦ Local Reaction ◦ Allergic Reaction ◦ Toxic Reaction (n/v/d, CP, cramps, SOB, paralysis, cardio-respiratory collapse)

7

8  General Medical Treatment ◦ Cut off tentacles ◦ Inactivate nematocysts: VINEGAR ◦ Remove nematocysts: credit card scrape ◦ Antihistamine ◦ Analgesia ◦ Antivenin exists only for sea wasp (box jelly fish)

9 NEMATOCYSTS  JELLYFISH ◦ Local reaction (usually) ◦ Remove tentacle~  Vinegar  Credit card scrape ◦ Antihistamine ◦ Analgesia

10 NEMATOCYSTS  BOX JELLYFISH (Sea wasp) ◦ Australia, Indian Ocean ◦ Most deadly of all E.M.L. ◦ 25% fatality rate; >sharks ◦ One BOX can kill 10 humans ◦ Cardio-respiratory arrest  Occurs within minutes ◦ Medical Treatment:  ABC’s  Remove tentacles  Vinegar  Credit card scrape  ANTIVENIN! (Chironex)

11 NEMATOCYSTS  PORTUGUESE MAN-O-WAR ◦ Southern US coast ◦ Not a true jellyfish ◦ Local reaction (usually) ◦ Potential full CV collapse ◦ Several reported deaths ◦ Medical Treatment:  ABC’s  Remove tentacles  Vinegar  Credit card scrape  NO Antivenin exists

12 NEMATOCYSTS  Fire coral ◦ Worldwide reef crests & shallow waters  Hawaii: conspicuously absent ◦ Local reaction  Welts, redness, swelling, blisters, pus filled encystations  Possible N/V up to 3 hr post  Gone within 24 hr  Allergic reaction(uncommon)  Anaphylactic shock (rare)  Infection  Delayed Type IV hypersensitivity reaction

13 NEMATOCYSTS  Medical treatment ◦ Irrigate copiously with HOT WATER; inactivates the proteinaceous toxin ◦ Vinegar ◦ Tetanus ◦ Topical anesthetics ◦ It may also ease suffering to repeatedly issue forth numerous expletives in a loud voice! ◦ Antibiotics: if infected ◦ Topical antihistamines: cortisone or Benedryl with poison ivy-like reaction

14  Stinger: specialized apparatus that punctures skin = delivers venom  Medical Treatment: ◦ Remove stinger(s)  r/o stinger in tissue with Xray ◦ Irrigate copiously with HOT WATER  Hot as possible  30-90 minutes; inactivates heat labile venom ◦ Antivenin exists for Stonefish stings

15 STINGS  STARFISH ◦ Most species non- venomous ◦ Crown-of-thorns  Severe local reaction

16 STINGS  SEA URCHINS ◦ Toxin coated spines ◦ Severity depends on species ◦ Local reaction (usually) ◦ Problem: embedded spines

17 STINGS  STINGRAY ◦ Barbs on tail ◦ Shallow water hazard ◦ Tail spines  laceration(s) ◦ Stinger  Local reaction  =/- systemic reaction  (N/V/D, cramps, CP, SOB)  Medical Treatment:  stinger removal  Irrigate HOT water  Tetanus  Antibiotics (cover vibrio)

18 STINGS  BONY FISH (Lionfish, Stonefish) ◦ Venomous spines on fins ◦ Handled or stepped on ◦ Will attack then swim away ◦ Severe local reaction  Pain, swelling ◦ Systemic reaction ◦ N/V/D, syncope, SOB, paralysis, CV collapse ◦ ANTIVENIN exists for Stonefish

19

20  Person who is sick after eating seafood…

21  44 y/o male ate seafood from a well-known, national seafood chain restaurant  Presents in E.D. 2 hr after eating variety/sampler of shrimp scampi, fried shrimp, red snapper and mahi mahi  C/O: N/V/D, cramps, perioral paresthesias, burning fingertips, ataxia, vertigo  Exam: Ice pack to forehead, skin hot to touch, watering eyes, diaphoretic

22  Diagnosis?  Tetrodotoxin? Why or why not  How did you make the diagnosis?  Medical management?

23  Food poisoning  Allergic reaction  Other diagnosis?  Other ddx of ? food poisonings presenting with neurological signs/symptoms: ◦ MG, botulism, MSG, encephalitis, polio, organophosphates, anticholinergics, heavy metals, diptheria, Eaton-Lambert, plant ingestions, migraine, the bends!

24  Ciguatera  Scombroid  Tetrodotoxin

25  Most common vertebrate fish poisoning  World wide, warm water, 90% occurs in spring/summer months  >500 species of fish but ALL ARE LARGE ◦ Red snapper, seabass, baracuda, grouper, kingfish, sturgeon, parrot fish

26  Ciguatoxin ◦ Algae/protozoa…….small fish…….large fish ◦ Heat stable; cooking does NOT kill ◦ Binds Na+ channels & increases permeability ◦ Variable toxins thus variable symptoms ◦ Ciguatoxin can be assayed (? can our lab) ◦ Toxin is absorbed quickly thus ONSET of symptoms is 1 -6 hrs after eating

27

28  Management ◦ ABC’s (include fluid resuscitation) ◦ Activated charcoal (<2hr) ◦ Cathartics (if no diarrhea) ◦ Mannitol  1 g/kg over 30 min; decreases neurological effects of the ciguatera toxin

29  Any large fish (Mahi mahi, amberjack)  Preventable ◦ Proper food handling  Spoiled fish may have honeycombing appearance  Peppery taste  Bacteria converts histidine to the toxins saurine and histamine  Onset signs/symptoms within minutes-hours

30  Presents similar to allergic reaction ◦ Diffuse erythema (face, neck, torso)  may progress to urticaria ◦ Numbness, tingling, perioral burning ◦ Bronchospasm  Diagnosis ◦ Increased serum or urine histamine levels ◦ Test fish  NOT a fish allergy if ◦ Others having same symptoms ◦ Fish can be tested

31  ? Alternate diagnosis of s/s ◦ Anaphylaxis, anaphylactoid reaction, ethanol flush, tartrazine, metabisulfites, tyramine, scombroid, MSG  Management ◦ Benadryl, ranitidine ◦ Ventolin prn ◦ ? Activated charcoal (if early) ◦ ? Cathartic ◦ Epinephrine (if needed)

32  Primary sites: ◦ Japan ◦ California ◦ Africa ◦ Australia  > 100 fish species ◦ Puffer fish (FUGU) ◦ Blow fish ◦ Toad fish ◦ Balloon fish ◦ Globe fish  ALSO ◦ Crab eggs ◦ Blue-ringed octopus ◦ Newts

33  Tetrodotoxin ◦ Heat stable ◦ Concentrated in ovary, liver, skin, intestine ◦ Be afraid of female fishy in heat! ◦ Can be assayed ◦ Blocks Na/K+ activity ◦ Blocks neuromuscular activity ◦ Onset within MINUTES of ingestion

34  E.D. presentation ◦ H/A ◦ Paresthesias (lips, tongue, mouth, fingers/toes) ◦ Dysphagia, dysarthria, ataxia, fasiculations ◦ Ascending paralysis ◦ Respiratory arrest  Management ◦ ABC’s ◦ AC and cathartics ◦ 50% MORTALITY rate

35  General information ◦ Mollusks filter dinoflagellates and algae ◦ Most common during red tides (dinoflagellates go crazy) ◦ Any shellfish ingestion  Clam  Oyster  Muscle scallops  Three types ◦ Paralytic (PSP) ◦ Neurotoxic (NSP) ◦ Amnesic (ASP)

36  Onset <30 minutes  Saxitoxin blocks Na+ voltage gated channel  Neuro symptoms predominately ◦ Paresthesias, ataxia, vertigo, weakness, paralysis, cranial neuropathies, respiratory failure ◦ N/V/D/cramps LESS common, not unlikely  Management ◦ Supportive ◦ Possible lavage and cathartics

37  Onset 15 min-18 hr; average 3 hours  Brevitoxin  GI + Neuro symptoms ◦ N/V/D/cramps ◦ Paresthesias, temp reversal, ataxia, vertigo, areflexia, NO paralysis  Management ◦ Supportive ◦ Ventolin ◦ (?) decontamination

38  Onset 15 min-36 hr; average 5 hours  Domoic acid (Canada 1987)  GI + Neuro + CV symptoms ◦ N/V/D/cramps ◦ MEMORY LOSS (damage to amygdala and hippocampus) Seizures, grimacing, chewing  Opthalmoplegia less common ◦ Hypotension & arrhythmias  Management ◦ Supportive ◦ (?) decontamination

39  Botulism ◦ Canned foods classic, can be from fresh fish ◦ GI = neuro  Diplopia, dysphagia, dysarthria, weakness ◦ Toxin binds at NMJ ◦ Alternate diagnosis considerations  Myasenia gravis, eaton-lambert, tick paralysis, gullian barre’, miller-fisher syndrome

40

41

42  QUESTIONS???


Download ppt "Sam L. Alexander, M.D..  2000 species of venomous marine animals  Initial, generalized treatment modalities:  Remove from water; avoid drowning  Local."

Similar presentations


Ads by Google