1. Marine Injuries Kalpesh Patel, MD Department of Pediatric Emergency Medicine August 2, 2006

2. 2 Objectives By the end of this lecture you should be able to:  Describe the management and treatment for Marine invertebrate injuries Insect envenomations  Understand and perform initial management of these injuries, such as Local wound care Venom specific antidotes Stinger removal

3. 3 Marine Invertebrates  Irritants Hydras Anemones Common purple jellyfish Sea nettle  Toxin producers Portuguese man-of-war True jellyfish Lion’s mane  Handle with care Corals Sea Urchins

4. 4 Irritants  Hydras Maine to Florida and Texas coastline Attaches to solid objects Causes mild sting Requires local care  Anemones US tidal zones Mildly toxic at worst – skin irritation  Sea nettle and common purple jellyfish Atlantic coast Mildly toxic - skin irritation

5. 5 Irritants - Treatment  Wash copiously with sea water or normal saline  Benadryl  Topical/Oral Steroids

6. 6 Toxin Producers  Nematocysts Specialized organelles which have toxin-coated barbed threads that fire when a tentacle is touched. Cannot penetrate human skin May discharge even when the creature is dead and washed up on the beach

7. 7 Toxin Producers  Size matters Man of war can have tentacles up to 75 feet long with 750,000 nematocysts each

8. 8 Toxin Producers  Toxin causes severe pain Made of polypeptides and degradative enzymes Causes release of inflammatory mediators, histamine and histamine-releasing agents, serotonin May cause systemic symptoms  N/V, abdominal rigidity  Respiratory distress  Arthralgias  Hemolysis, renal failure  Coma  Severe envenomation can cause death

9. 9 Toxin Producers  Lion’s mane Found on both coasts Highly toxic  Instrument of death in Sherlock Holmes classic Adventure of the Lion’s Mane Causes severe burning Prolonged exposure causes muscle cramps and respiratory failure

10. 10 Toxin Producers - Treatment  3 goals: Control shock – IV, fluids, etc. Control venom effects  Remove tentacles from skin –Inactivate unexploded nematocysts with vinegar, meat tenderizer, or baking soda slurry –Apply this to patient as well Pain relief  Immobilize the wound area  Codeine, Morphine, or Demerol  Treat muscle spasms with 10% Calcium gluconate 0.1ml/kg IV  Topical/Oral steroids, Benadryl

11. 11 Handle with Care  Corals, Sea Urchins, Starfish Have jagged edges or hard spines Cause deep puncture wounds or sea lacerations Easily leave foreign bodies Stinging sensation, wheal formation, itching Wound infection very common  Vibrio species, Erysipelothrix rhusiopathiae, Mycobacterium marinum  Fever  Cellulitis  Lymphangitis

12. 12 Handle with Care - Treatment  Copious irrigation with saline  X-ray for foreign bodies Soak affected area in warm water Use local anesthetic and explore sterilely  Wounds should be left open or loosely approximated  Antibiotics please >8 y/o: Tetracycline for 10 mg/kg/dose QID <8 y/o: Keflex or Bactrim Add staphylococcal coverage for foreign bodies  Don’t forget tetanus prophylaxis

13. 13 Marine Vertebrates  Stingrays  Catfish  Scorpaenidea  Sharks!

14. 14 Stingrays  Most common marine vertebrate injury  Flat fish, bottom feeders, buried under sand or mud  Easily stepped on causing reflex envenomation Venom apparatus is a serrated, retro-pointed caudal spine on the tail Coated in venom sheath which ruptures on skin penetration  Heat labile toxin  Can depress medullary respiratory centers  Interfere with cardiac conduction  PAINFUL

15. 15 Stingrays - Treatment  PreHospital: Irrigate copiously with cold salt water Flushing can help remove toxin Control bleeding with pressure  ED: IV fluids, Morphine 0.1mg/kg/dose for pain Make an attempt to remove the spine Soak extremity in hot water (104-113F) to inactivate the venom until pain relieved X-ray for foreign body (spine fragments) Re-explore wound after soaking Tetanus prophylaxis No prophylactic antibiotics

16. 16 Scorpaenidae  Zebrafish, scorpionfish, stone fish  Non-migratory, slow swimming, buried in sand  Envenomation occurs when handling fish on fishing trips  Venom delivered by many small spines like the stingray  Venom also heat-labile  Symptoms Pain, N/V Hypotension Tachypnea leading to apnea MI with EKG changes

17. 17 Scorpaenidae - Treatment  Copious irrigation with saline  Hot water immersion until pain relieved  Morphine 0.1mg/kg/dose  Close cardiopulmonary monitoring  Admit to PICU if having significant systemic effects

18. 18 Catfish  Spines in the dorsal and pectoral fins Puncture wounds and laceration Easily break off as foreign body Venom causes local inflammation, pain, edema, hemorrhage, tissue necrosis  Treatment Irrigation Hot water immersion Morphine 0.1mg/kg/dose Antibiotics for gram negatives Delayed primary closure

19. 19 Sharks!  1 in 5,000,000 chance of attack in North America  Gray reef, great white, blue, mako sharks  Risk factors: Swimming near sewer outlets Swimming in the late afternoon/early evening Murky warm water Increased commotion Deep channels Wearing bright objects Surfers – boards are mistaken for elephant seals, the shark’s usual diet in California

20. 20 Sharks!  Two types of bites: Tangential injury  Close pass slashing movement teeth of open shark mouth Definitive bite  Vary according to the part of the body bitten –Lacerations –Soft tissue loss –Amputation of limb –Comminuted fractures –Hemicorpectomy

21. 21 Sharks!  Hypovolemic shock Control bleeding with pressure DON’T EXPLORE WOUNDS PREHOSPITAL IV fluids, blood products as soon as available Warmth Oxygen Surgery Prophylactic antibiotics – 3 rd gen cephalosporin or bactrim Tetanus prophylaxis Admit to PICU for significant injury

22. 22 Questions?