Basics
Description
Marine envenomation refers to poisoning caused by sting or bite from a vertebrate or invertebrate marine species.
Etiology
- Sponges:
- Contain sharp spicules with irritants that cause pruritic dermatitis
- Coelenterates (Cnidaria jellyfish):
- Contain stinging cells known as nematocysts on their tentacles
- Fluid-filled cysts eject sharp, hollow thread-tube on contact.
- Thread-tube penetrates skin and envenomates the victim.
- Box jellyfish can kill within minutes
- Starfish:
- Sharp, rigid spines are coated with slimy venom.
- Sea urchins:
- Hollow, sharp spines filled with various toxins
- Sea cucumbers:
- Hollow tentacles secrete holothurin, a liquid toxin.
- Cone shells:
- Venom injected through dart-like, detachable tooth.
- Active peptides interfere with neuromuscular transmission.
- Presents with puncture wounds similar to wasp stings.
- Stingrays:
- Most common cause of human marine envenomations.
- Tapered spines attached to tail inject venom into victim.
- Scorpion fish:
- Lionfish usually mild; stonefish can be life threatening.
- Sharp spines along dorsum and pelvis of fish
- Often stepped on inadvertently
- Neurotoxic venom
- Catfish:
- Dorsal and pectoral spines contain venom glands.
- Sea snakes:
- Hollow fangs with associated venom glands
- Highly neurotoxic venom blocks neuromuscular transmission.
Diagnosis
Signs and Symptoms
- Sponges:
- Itching and burning a few hours after contact
- Local joint swelling and soft tissue edema
- Fever
- Malaise
- Dizziness
- Nausea
- Muscle cramps
- In severe cases, desquamation in 10 days to 2 mo
- Coelenterates (Cnidaria jellyfish):
- Mild envenomation:
- Immediate stinging sensation
- Pruritus
- Paresthesia, burning sensation
- Throbbing
- Blistering/local edema/wheal formation
- Moderate/severe:
- Neurologic: Ataxia, paralysis, delirium, seizures
- Cardiovascular: Anaphylaxis, hemolysis, hypotension, dysrhythmias
- Respiratory: Bronchospasm, laryngeal edema, pulmonary edema, respiratory failure
- Musculoskeletal: Muscle cramps or spasm, arthralgias
- Gastrointestinal: Nausea, vomiting, diarrhea, dysphagia, hypersalivation/thirst
- Ophthalmologic: Conjunctivitis, corneal ulcers, elevated intraocular pressure
- Echinodermata:
- Starfish:
- Immediate pain
- Bleeding
- Mild edema
- Paresthesias, nausea, vomiting if severe
- Sea urchins:
- Intense pain and severe local muscle aches
- Nausea, vomiting
- Paresthesias, hypotension, or respiratory distress with multiple stings
- Sea cucumbers:
- Mild contact dermatitis
- Corneal and conjunctival involvement: Severe reactions can lead to blindness.
- Mollusks:
- Cone shells:
- Puncture wounds similar to wasp stings
- Sharp burning and stinging
- Paresthesias indicate severe envenomation.
- Can evolve into muscular paralysis and respiratory failure, dysphagia, syncope, disseminated intravascular coagulation
- Stingrays:
- Puncture wounds or jagged lacerations
- Local, intense pain, edema, bleeding; necrosis if severe
- Nausea, vomiting, diarrhea
- Diaphoresis
- Headache
- Tachycardia
- Seizures
- Paralysis
- Hypotension
- Dysrhythmias
- Scorpion fish:
- Intense local pain for 6 " 12 hr
- Erythema may progress to cellulitis.
- Headache
- Nausea, vomiting, diarrhea
- Pallor
- Delirium
- Seizures
- Fever
- Hypertension
- Catfish:
- Local pain, ischemic appearance progressing to erythema
- Swelling, bleeding, and edema
- Local muscle spasms
- Diaphoresis
- Neuropathy, fasciculations, weakness, syncope
- Sea snakes:
- Bite initially causes very little pain.
- Pin-like pairs of fang marks
- Onset from 5 min to 6 hr
- Muscle pain, lower extremity paralysis, arthralgias
- Trismus, blurred vision, dysphagia, drowsiness
- Severe signs include:
- Ascending paralysis
- Aspiration
- Coma
- Renal and liver failure
- If untreated, 25% mortality
History
- Time of envenomation
- Body part envenomated
- Activity when envenomated (scuba diving, swimming, surfing, fishing, boating, pet care)
- Type of water (salt water, fresh water, aquarium)
- Geographic location (resort, international, remote, local, aquarium, zoo, pet store)
- Onset of symptoms, pain
- Mental status changes
- Near drowning
Physical Exam
- Vital signs
- Airway
- Mental status
- Cardiopulmonary exam
- Dermatologic exam, foreign bodies, cellulitis, blistering
Essential Workup
- Careful history, repeated evaluation of wound sites
- Assessment of ABCs
Diagnosis Tests & Interpretation
Lab
- CBC
- Electrolytes, BUN, creatinine, and glucose levels
- LFT
- Urinalysis
- Arterial blood gases if severe symptoms
Imaging
Soft tissue radiographs to detect foreign body
Differential Diagnosis
- Allergic reaction
- Cellulitis
- Gastroenteritis
- Aspiration pneumonia
- Near drowning
Treatment
Pre-Hospital
- Remove victim from water source.
- Control airway, breathing.
- Control hemorrhage.
- Detoxify venom with proper wound irrigation as discussed below.
Initial Stabilization/Therapy
- Airway, breathing, and circulation management (ABCs)
- Establish IV access with 0.9% normal saline (NS).
Ed Treatment/Procedures
- General:
- Prepare for anaphylactic reactions (epinephrine/steroids).
- Prepare for intubation if needed.
- Diphenhydramine for itch, burn, hives
- Tetanus prophylaxis
- Corticosteroids for severe local reactions
- Narcotic analgesia for severe pain
- Antibiotic prophylaxis for the following:
- Large lacerations or burns
- Deep puncture wounds
- Grossly contaminated wounds
- Elderly or chronically ill
- Antibiotic choices:
- Trimethoprim/sulfamethoxazole (TMP-SMX; Bactrim)
- Tetracycline
- Ciprofloxacin
- 3rd-generation cephalosporin
- Sponges:
- Gently dry skin and remove spicule:
- Adhesive tape may aid in removal.
- 5% acetic acid (vinegar) (or 40 " 70% isopropyl alcohol) soaks QID for 10 " 30 min
- Coelenterates (Cnidaria jellyfish):
- Rinse wound with salt water or seawater:
- Hypotonic (fresh or tap water solutions), trigger more nematocysts
- Do not rub skin to avoid release of nematocysts.
- Inactivate toxin with 30-min soak of 5% acetic acid (vinegar)
- Remove remaining nematocysts with razor, clam shell.
- Apply topical anesthetics once nematocysts are removed.
- Sea Safe jellyfish sunblock products are available.
- Box-jellyfish sting envenomation (Australia) emergent cases:
- Administer Chironex antivenin: 1 amp (20,000 U) IV diluted 1:5 with crystalloid.
- Corticosteroids for severe reactions
- Starfish:
- Immerse in nonscalding hot water for pain relief.
- Irrigate and explore all puncture wounds.
- Prophylactic antibiotics for significant wounds
- Sea urchins:
- Immerse in nonscalding hot water for pain relief.
- Remove any remaining spines.
- Prophylactic antibiotics for significant wounds.
- Sea cucumbers:
- Immerse in nonscalding hot water for pain relief.
- 5% acetic acid soaks
- Ocular involvement:
- Proparacaine for pain
- Copious irrigation with NS
- Careful slit-lamp exam
- Cone shells:
- Hot water immersion for pain relief
- Be prepared for cardiac or respiratory support.
- Stingrays:
- Copious irrigation with removal of any visible spines
- Local suction is controversial.
- Hot water soaks for pain relief
- Narcotics for pain control
- High incidence of bacterial infection:
- Administer prophylactic antibiotics for significant wounds.
- Scorpion fish:
- Hot water soaks for pain relief and venom inactivation
- Copious irrigation, removal of any visible spines
- Local lidocaine or regional block for severe pain
- Surgical exploration for deep penetration/foreign bodies
- Stonefish antivenin for severe envenomations:
- One 2-mL amp diluted in 50-mL saline IV slow
- May cause serum sickness
- Catfish:
- Hot water soaks for pain relief and venom inactivation
- Copious irrigation, removal of any visible spines
- Consider local lidocaine, regional block, or narcotics for severe pain.
- Surgical exploration for deep penetration, foreign bodies
- Leave puncture wounds open to heal.
- Consider prophylactic antibiotics for hand, foot, or deep wounds.
- Sea snakes:
- Immobilize bitten extremity.
- Apply pressure bandage for venous occlusion (pre-hospital).
- Keep victim warm and still.
- Polyvalent sea snake antivenin reduces mortality to 3%:
- May require 3 " 10 amps (1000 U each)
- Prepare early for assisted ventilation.
Medication
- Cefixime: 400 mg (peds: 8 mg/kg/24h) PO daily
- Ciprofloxacin: 500 mg PO BID
- Epinephrine: 0.3 " 0.5 mL SC 1:1,000 (peds: 0.01 mL/kg)
- Tetracycline: 500 mg PO QID (caution with photosensitivity)
- TMP-SMX (Bactrim DS): 1 tab [peds: 5 mg liquid (40/200/5 mL)/10 kg per dose] PO BID (caution with photosensitivity)
Follow-Up
Disposition
Admission Criteria
Significant signs of systemic involvement or need for antivenom administration
Discharge Criteria
No signs of systemic illness after 8 hr of observation
Issues for Referral
Zoos, aquariums for available supplies of antivenom; poison control centers: 800-222-1222
Pearls and Pitfalls
- Most toxins are detoxified with either temperature change (hot water) or pH alteration (more acidic).
- Specific antivenoms for box jellyfish, stone fish, and sea snake envenomations are available but in limited supply; acquire early in treatment course.
Additional Reading
- Avelino-Silva VI, Avelino-Silva T. Images in clinical medicine. Evolution of a jellyfish sting. N Eng J Med. 2011;365(3):251.
- Balhara KS, Stolbach A. Marine envenomations. Emerg Clin North Am. 2014;32(1):223 " 243.
- Fernadez I, Vallalolid G, Varon J, et al. Encounters with venomous sea life. J Emerg Med. 2011;40(1):103 " 112.
Codes
ICD9
- 692.89 Contact dermatitis and other eczema due to other specified agents
- 989.5 Toxic effect of venom
ICD10
- T63.511A Toxic effect of contact with stingray, accidental (unintentional), initial encounter
- T63.621A Toxic effect of contact with other jellyfish, accidental (unintentional), initial encounter
- T63.691A Toxic effect of contact with other venomous marine animals, accidental (unintentional), initial encounter
- T63.631A Toxic effect of contact with sea anemone, accidental (unintentional), initial encounter
SNOMED
- 403163002 Skin reaction to noxious and/or venomous marine invertebrate (disorder)
- 241833002 Poisoning by box jellyfish sting (disorder)
- 241826002 Poisoning by sting ray (disorder)
- 241836005 Poisoning by sea urchin spine (disorder)
- 241827006 Poisoning by venomous mollusc (disorder)
- 241835009 Poisoning by sea anemone (disorder)
- 241837001 Poisoning by sea cucumber (disorder)