Presentation on theme: "Marine Trauma and Envenomations"— Presentation transcript:
1Marine Trauma and Envenomations Andrew Butterfass, MD FACEPCabrini Medical Center
2Key Points Identify Hazardous Marine Life. Manage minor exposures. Identify and stabilize major envenomations.
3Introduction Marine life injuries are extremely diverse. Many organisms are endemic to one region.Most injuries occurs in populated costal waters or freshwater inland area’s.High profile injuries include shark and alligator attacks.Reality about 100 attacks a year worldwide with only about 5-10 deaths.
7Introduction 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.
8Introduction Envenomation- toxin involved Can cause hypersensitivity reactions, anaphylaxis and specific toxic venom reactions.PunctureExamples include Cone shells, Octopus, and Sea snakes.ContactUsually caused by invertebrates including coelenterates (jellyfish), sponges and bristle worms..
9Coelenterates 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.
13Box 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.
15NematocystNematocyst- 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 complexNerve conduction affects due to tetramine which is similar to curare.Pain and local histamine effects are due to 5-hydroxytryptamine.
17Coelenterate 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.
18Coelenterate Sting Treatment Apply topical analgesics and steroids.For extreme hypersensitivity and systemic reactionsABC’sIV analgesics and steroids if needed.Cardiovascular monitoring and support as needed.
20Seabather’s Eruption Jelly Fish Larvae- Linuche unguiculata Contact DermatitisOccurs 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.
23Sponges Of 5000 known species, 12 are toxic. Three produce contact dermatitisRed-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.
26Venomous Fish 200 known species of venomous fish Most Common STINGRAY LIONFISH/SCORPIONFISHSTONEFISHSALTWATER CATFISHWEEVERFISH
27Stingray 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.
29Stingray 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.
30Stingray Envenomation Treatment 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 ( degree F) for 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
31Lionfish/Scorpionfish Stonefish Lionfish/Scorpionfish found in tropical seas including Red sea, Indian ocean and Pacific ocean.Stonefish found in waters of Australian coast.
34Lionfish 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 minutes to denature venom.Analgesia and wound care.
35Saltwater Catfish Found in the warm tropical of Indo-pacific. Fins contain complex venomSymptoms 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).
39Sea SnakesFound 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.
40Sea Snakes Venom is a heat-stable nonenzymatic protein. Venom blocks acetylcholine.Asymptomatic latent period of 10 minutes to 6-8 hours.Symptom’s include malaise, anxiety, and stiffness.Late symptom’s include aching, paralysis, trismus, ptosis, hepatic, renal, and respiratory instability.Cardiovascular collapse and death.10% of untreated cases are fatal.
43Sea Snake’s TreatmentImmobilize site, soaking in hot water not effective.ABC’s, 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.
44Cottonmouth Also know as Water Moccasin. Snake found in fresh water area’s.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
49Cottonmouth 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.
50Blue-Ringed OctopusFound 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.
52Blue-Ringed Octopus Treatment Neurotoxin blocks peripheral nerve conduction.May need cardiovascular and ventilatory support.Immobilize the affected limb.Pressure dressing.Clean bite- tetanus and antibiotic coverage.
53Cone Shells Found in costal reef’s 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.
56Cone 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.
57Cone Shells TreatmentImmobilize 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 paralysisNaloxone 2-4mg IV may help severe hypotension. (blocks beta-endorphin vasodepressor response.Wound care including tetanus, analgesia, and antibiotics.
58Anaphylaxis ABC’s Epinephrine 1:1000 .2-.5mg SC/IM Airway protection100% OxygenTwo IV lines- fluid resuscitation with RL or NSEpinephrine 1: mg SC/IMMay repeat every 30minIn severe cases consider Epinephrine 1:10, mg IV.Benadryl and Steroids IM/IV.
59General 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.
60ReviewRemember ABC’s 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 minutes or until pain subsides.
61ReviewTreat 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 CareContact local poison control center or toxicologist for possible antivenin administration and transport of severe reactions.