Marine Envenomation

Question 1

Sea Snake

Answer 1

Post synaptic neurotoxin- paralysis

Myotoxin- rhabdomyolysis

Question 2

Sea Snake: Clinical

Answer 2

Local: bite small, superficial, often painless, no local affects
Systemic:
-symetrical descending flaccid paralysis (blurred vision, ptosis, diplopia, difficulty swallowing, drooling)
- Respiratory failure & secondary hypoxic cardiac arrest
- rhabdomyolysis

Question 3

Sea Snake: Management

Answer 3

Pre Hospital: PIB, t/f to hosp able to address
Hospital:
- Resus time critical emergency
- Early life threats: Paralysis with resp failure/ hypotension
- Antivenom: sea snake 1 amp or tiger snake 3 amp

Ix: fbe, uec, ck, coags, fibrinogen, fdp, d-dimer
Bloods 1, 6, 12 hrs

Question 4

Sea Snake: DDz

Answer 4

tiger snake: paralysis & rhabdo + VICC
Black mulga: rhabdo + mild neurotoxicity
Death Adder: paralysis + no rhabdo

Question 5

Blue Bottle Jelly fish: clinical

Answer 5

• intense local burning pain
• dermal erythema linear or elliptical welts
• Systemic: Nausea, headache, malaise

Question 6

Blue Bottle: Mx

Answer 6

Mild & respond to 1st aid
Reassure
Hot water- 45 deg
Simple PO analgesia
(NO PIB, NO VINEGAR)
No antivenom

Question 7

Stone Fish: clinical

Answer 7

Local: 
-severe pain
-swelling
- bruising & puncture marks
Systemic:
-N&V
- dizziness
-dyspnea
-CVS: hypotension, bradycardia, collapse, pulmonary edema, cyanosis

Question 8

Stone fish: management

Answer 8

Pre hospital: 
- reassure
-simple analgesia
- immerse both limbs in hot water so monitor temp
Hospital
-if refractory pain
- supportive: hot water immersion
- IV Morphine
-regional anaesthesia
-antivenom 1 amp/ 2 puncture wounds- if refractory
NO PIB

Question 9

Stone Fish: Ix

Answer 9

Xray retained FB

Question 10

Stone Fish: Disposition

Answer 10

DC 2 hrs if no features systemic envenoming
DC 4 hrs if asymtomatic post opioid/ anti venom
warn of secondary infection

Question 11

Box Jelly Fish: clinical

Answer 11

Most benign & respond to supportive measures
Local:
- immediate severe pain lasts upto 8 hrs
- skin linear cross hatched pattern
-adherent tentecles
Systemic:
-CVS: HTN, hypotension, tachycardia, impaired cardiac contraction, arrhythmia
-delayed hypersensitivity in 50% px: pruritic erythema at sting site

Question 12

Box Jellyfish: Mx

Answer 12

Pre hospital
- Cardiac arrest: long CPR
- ice packs, simple analgesia
-Generous vinegar to inactivate undischarged nematocytes
- NO PIB
Hospital:
-Resus b/c rarely life threatening
- immediate life threats: cardiac arrest, hypo/ hypertension, arrhythmia
- Arrest: antivenom undiluted push 6 amp
- systemic signs: 3 amp in 100ml Nsaline
- Mg 10 mmols if no response to anti venom
- IV morphine if refractory pain

Question 13

Box Jellyfish: Ix

Answer 13

ECG: tachy, arrhythmia, BBB
exclude alternative dx
-fbe, uec, ck, trop
CXR

Question 14

Box Jellyfish: DDX

Answer 14

• irukandji
• blue bottle
• decompression illness

Question 15

Box Jellyfish: disposition

Answer 15

• 2 hr no systemic features or pain dc

- severe pain or received anti venom: d/c when asymptomatic 6 hrs

Question 16

Irukandji: Clinical

Answer 16

Local: sting not felt
Systemic: delay onset approx 30 min. severe envenoming within 4 hrs
-impending doom
- agitation
-dysphoria
-vomiting
-generalised sweating
-severe pain back, limbs, abdomen
-CVS: hypertension/ tachycardia
-cx: toxic cardiomyopathy, cardiogenic shock, pulmonary edema, may need Intub& Vent, ICH

Question 17

Irukandji: Mx

Answer 17

Preshosp:
- vinegar
-NO PIB
Hospital:
- Resus potentially life threatening HTN/ pulmonary edema
- IV fentanyl 0.5-1mcg/ kg/dose q 10 min till analgesia
- antiemmetic: promethazine 25 mg (0.5mg/kg child)
- control HTN refractory to analgesia: GTN 50mg in 100ml start 6ml/min. AIM SBP<160
-NO antivenom

Question 18

Irukandji: Ix

Answer 18

assess for alternate dx & complications
-ECG
CXR
FBE, UEC, Troponin, CK q 8 hr
Echo if : APO, cardiogenic shock

Question 19

Irukandji: DDx

Answer 19

• box jelly fish
• blue bottle jelly
• decompression illness

Question 20

Irukandji: disposition

Answer 20

• no systemic envenoming 2 hr no irukandji

- if envenomed d/c if well for 6 hrs

Question 21

Blue Ringed Octopus: clinical

Answer 21

local: Bite not painful
Systemic:
-rapid progressive symmetrical descending paralysis
- blurred vision, diplopia, ptosis, difficulty swallowing, respiratory failure
- paralysis last approx 24 hrs if supportive treatment

Question 22

Blue Ringed octopus: Mx

Answer 22

Pre Hosp
-PIB early
- expired air respiration if required
Hospital
-resuscitation lifethreats: descending paralysis & hypotension
- airway & ventilatory support life saving