Marine Trauma and
Envenomations
Andrew Butterfass, MD FACEP
Cabrini Medical Center
Key Points
• Identify Hazardous Marine Life.
• Manage minor exposures.
• Identify and stabilize major envenomations.
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.
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.
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..
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.
Chinonex Fleckeri- Box Jellyfish
Box Jellyfish
Box Jellyfish Victim
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.
Man-of-War
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 5hydroxytryptamine.
Nematocyst
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.
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.
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.
Seabather’s Eruption
Seabather’s Eruption
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.
Red-beard Sponge
Fire Sponge
Venomous Fish
• 200 known species of venomous fish
• Most Common
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STINGRAY
LIONFISH/SCORPIONFISH
STONEFISH
SALTWATER CATFISH
WEEVERFISH
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.
Stingray
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.
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
(110-113 degree F) for 30-60 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
Lionfish/Scorpionfish
Stonefish
• Lionfish/Scorpionfish found in tropical seas
including Red sea, Indian ocean and Pacific
ocean.
• Stonefish found in waters of Australian
coast.
Lionfish
Stonefish
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 3060 minutes to denature venom.
• Analgesia and wound care.
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).
Saltwater Catfish
Weeverfish
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•
•
•
Found in English channel.
Venom is on dorsal fin.
Venom is thermolabile.
Similar treatment to other fish.
Weeverfish
Sea Snakes
• Found in warm tropical waters in the Indopacific 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.
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.
Sea Snakes
Sea Snakes
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.
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
Cottonmouth
Cottonmouth
Cottonmouth
Cottonmouth
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.
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.
Blue-Ringed Octopus
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.
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.
Cone Shells
Cone Shells
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.
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.
Anaphylaxis
• ABC’s
– Airway protection
– 100% Oxygen
– Two IV lines- fluid resuscitation with RL or NS
• Epinephrine 1:1000 .2-.5mg SC/IM
• May repeat every 30min
• In severe cases consider Epinephrine 1:10,000 .2.5mg IV.
• Benadryl and Steroids IM/IV.
General Wound Care
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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.
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
30-90 minutes or until pain subsides.
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.
Drowning and Near Drowning
Definition
• Near Drowning
– Suffocation by submersion, with at least 24
hours of survival.
• Drowning
– Death within 24 hours of suffocation by
submersion.