1. Marine Trauma and Envenomations
Andrew Butterfass, MD FACEP
Cabrini Medical Center

2. Key Points Identify Hazardous Marine Life. Manage minor exposures.
Identify and stabilize major envenomations.

3. Introduction 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.

7. Introduction 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.

8. Introduction Envenomation- toxin involved
Can cause hypersensitivity reactions, anaphylaxis and specific toxic venom reactions.
Puncture
Examples include Cone shells, Octopus, and Sea snakes.
Contact
Usually caused by invertebrates including coelenterates (jellyfish), sponges and bristle worms..

9. Coelenterates 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.

10. Chinonex Fleckeri- Box Jellyfish

11. Box Jellyfish

12. Box Jellyfish Victim

13. Box 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.

14. Man-of-War

15. Nematocyst
Nematocyst- 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 complex
Nerve conduction affects due to tetramine which is similar to curare.
Pain and local histamine effects are due to 5-hydroxytryptamine.

16. Nematocyst

17. Coelenterate 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.

18. Coelenterate Sting Treatment
Apply topical analgesics and steroids.
For extreme hypersensitivity and systemic reactions
ABC’s
IV analgesics and steroids if needed.
Cardiovascular monitoring and support as needed.

20. Seabather’s Eruption Jelly Fish Larvae- Linuche unguiculata
Contact Dermatitis
Occurs 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.

21. Seabather’s Eruption

22. Seabather’s Eruption

23. Sponges Of 5000 known species, 12 are toxic.
Three produce contact dermatitis
Red-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.

24. Red-beard Sponge

25. Fire Sponge

26. Venomous Fish 200 known species of venomous fish Most Common STINGRAY
LIONFISH/SCORPIONFISH
STONEFISH
SALTWATER CATFISH
WEEVERFISH

27. Stingray 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.

28. Stingray

29. Stingray 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.

30. Stingray 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

31. Lionfish/Scorpionfish Stonefish
Lionfish/Scorpionfish found in tropical seas including Red sea, Indian ocean and Pacific ocean.
Stonefish found in waters of Australian coast.

32. Lionfish

33. Stonefish

34. Lionfish 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.

35. Saltwater Catfish Found in the warm tropical of Indo-pacific.
Fins contain complex venom
Symptoms 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).

36. Saltwater Catfish

37. Weeverfish Found in English channel. Venom is on dorsal fin.
Venom is thermolabile.
Similar treatment to other fish.

38. Weeverfish

39. Sea Snakes
Found 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.

40. Sea 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.

41. Sea Snakes

42. Sea Snakes

43. Sea Snake’s Treatment
Immobilize 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.

44. Cottonmouth 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

45. Cottonmouth

46. Cottonmouth

47. Cottonmouth

48. Cottonmouth

49. Cottonmouth 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.

50. Blue-Ringed Octopus
Found 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.

51. Blue-Ringed Octopus

52. Blue-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.

53. Cone 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.

54. Cone Shells

55. Cone Shells

56. Cone 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.

57. Cone Shells Treatment
Immobilize 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 paralysis
Naloxone 2-4mg IV may help severe hypotension. (blocks beta-endorphin vasodepressor response.
Wound care including tetanus, analgesia, and antibiotics.

58. Anaphylaxis ABC’s Epinephrine 1:1000 .2-.5mg SC/IM
Airway protection
100% Oxygen
Two IV lines- fluid resuscitation with RL or NS
Epinephrine 1: mg SC/IM
May repeat every 30min
In severe cases consider Epinephrine 1:10, mg IV.
Benadryl and Steroids IM/IV.

59. General 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.

60. Review
Remember 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.

61. Review
Treat 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 Care
Contact local poison control center or toxicologist for possible antivenin administration and transport of severe reactions.

63. Drowning and Near Drowning

64. Definition Near Drowning Drowning
Suffocation by submersion, with at least 24 hours of survival.
Drowning
Death within 24 hours of suffocation by submersion.