Bites, stings and poisonings — marine
Box jellyfish sting
There are a number of species of box jellyfish. Major box jellyfish (Chironex fleckeri) sting most likely to be fatal. Symptoms usually obvious straight away. Really really hurts
Table 2.4
Do not
- Do not use pressure bandage
Do first
- Pour vinegar over sting area for at least 30 seconds
- Remove tentacles (even if no vinegar) especially from child
- Use gloves and/or forceps if available. If not use fingers — may cause minor stings if vinegar not used first, but not dangerous
- Always stay with person — send someone for help
Serious box jellyfish sting
Unconscious, serious breathing or circulation problems — see DRS ABC
- Give box jellyfish antivenom straight away
- 1 ampoule IV/intraosseous — mixed in 10mL normal saline
- Anaphylaxis due to antivenom rare, but can happen
- If no immediate response — give more antivenom
- If doesn’t get better OR breathing or circulation get worse — continue CPR with ventilation (people can survive hours with supported ventilation)
- AND urgent medical consult — to consider
- More box jellyfish antivenom (up to 6 ampoules if available)
- Adrenaline (epinephrine) IV/intraosseous — adult 1mg, child 0.01mg/kg/dose up to 1mg — doses
- Morphine for pain relief
Mild to moderate box jellyfish sting
Conscious, normal breathing and circulation
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- Repeat every 15 minutes
- Immunisation status — tetanus
Do
- Keep person still
- Use ice packs OR hot pack for pain. If pain not relieved — pain relief
- If pain relief ineffective — medical consult
Stonefish and Catfish sting
- No known antidote for catfish sting
Do not
- Do not use pressure bandage or tourniquet — increases pain, tissue damage
- Do not use hot water if lidocaine (lignocaine) has been injected
Symptoms
- Collapse
- Low heart rate
- Low BP
- Strong pain from time of sting
- Swelling of sting site and limb
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- Immunisation status — tetanus
Do
- Put stung area into hot water — 40–45°C (not burning)
- Test water first with unaffected limb
- Do not use for longer than 90 minutes
- If pain continues
- Inject lidocaine (lignocaine) 1% along sting track — up to 2mg/kg/dose
- Medical consult — opioid may be needed. Regional nerve block may be useful
- Medical consult if
- Stonefish — may need to g o to hospital for antivenom
- Catfish — may need x-ray or ultrasound sting site — piece of barb often breaks off in wound (no antidote)
Stingray barb injury
- No known antidote
Do not
- Do not use pressure bandage
- Do not let person eat or drink anything until sure they don’t need to go to hospital — consider IV fluids
Symptoms
- Pain at sting site — may get worse 30–90 minutes after injury
- Wound that bleeds then becomes pale and bluish-white
- Significant local trauma, damage to underlying structures — nerves, tendons and heart, lungs if chest wall puncture (rare)
- Swelling of limb
- Rarely — more serious symptoms like nausea, vomiting, increased saliva (spit), diarrhoea, sweating, fainting, muscle cramps, arrhythmia (irregular heartbeat), fits
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- Immunisation status — tetanus
Do
- Control any obvious bleeding
- Wash wound with soap and clean fresh water
- Put stung area into hot water — 40–45°C (not burning), test water first with unaffected limb
- If strong pain continues
- Inject lidocaine (lignocaine) 1% in and around wound — up to 2mg/kg/dose
- Medical consult — opioid may be needed, regional nerve block may be useful
- Medical consult
- May suggest antibiotics if wound more than 6 hours old
- May consider x-ray or ultrasound if penetrating injury
- May need surgery to look for pieces of barb, remove dead tissue
Irukandji syndrome
- Caused by various small 4-tentacled tropical jellyfish
- Serious symptoms can be delayed 2–12 hours after sting — occasionally comes on over several hours
- No known antidote
Do not
- Do not apply fresh water to sting site
- Do not rub affected area
- Do not use pressure bandage
Symptoms
Early symptoms
- At first person may have
- Pain or tingling at sting site. May be very mild, usually settles after 30 minutes
- Sting site is often slight or can't be seen
Late symptoms
- 5–60 minutes after sting person may
- Appear very unwell
- Have strong pain, often in waves. Often starts in lower back and spreads to limbs, abdomen, chest muscles
- Be sweating a lot in local areas or whole body and pale
- Feel anxious, restless, like they are going to die
- Have headache, nausea, vomiting
- Have fast pulse, high BP
- After 2–12 hours
- Rarely — develop acute cardiac-related pulmonary oedema
- Shortness of breath, BP drops, O2 sats low
- Symptoms can last 1–2 days
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
Do
- Pour vinegar over sting area (if seen) for at least 30 seconds
- Put in IV cannula
- Give pain relief — pain may be severe
- Medical consult if pain not relieved
- If settles quickly with treatment — observe in clinic for 6 hours
- Advise to stay in community for 24 hours, return to clinic or get help straight away if symptoms get worse or they feel sick
Blue ringed octopus bite
- Small venomous octopus found in Australian coastal waters. Saliva has potent fast-acting paralytic neurotoxin, tetrodotoxin
- No known antidote
Symptoms
- Small and/or painless bite, usually when octopus contacts bare skin out of water
- Tingling around lips or elsewhere
- Rapid onset progressive flaccid paralysis (muscle weakness) within 5–30 minutes
- In severe cases — respiratory paralysis, respiratory failure, cardiac arrest if untreated
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
Do
- Remove person from water
- Medical consult
- Support respiration if needed — may need prolonged ventilation (eg mouth-to-mouth, bag-valve-mask, mechanical ventilator)
- Must follow all doctor's instructions before stopping CPR and ventilation
- People can survive for hours with supported ventilation
- Put in IV cannula
- Apply pressure bandage to the bite site
Fish poisoning — ciguatera
- Poisoning caused by eating tropical or subtropical fish containing ciguatoxins (toxins from marine organisms)
- Mild to severe gastrointestinal illness and neurological effects
- No known antidote
May have
- Gastrointestinal effects that develop within 2–12 hours — diarrhoea, abdominal pain, nausea, vomiting
- Neurological effects that develop over 24 hours
- Paraesthesia (pins and needles) around mouth, hands, feet
- Cold allodynia — an unpleasant or painful sensation when touching cold water or cold objects
- Joint pain, myalgia (muscle pain), ataxia (unsteadiness)
- Rarely — trouble breathing, slow pulse, low BP, unconscious
Do
- Treat symptoms — NSAID may be useful (if no contraindications)
- Put in IV cannula
- Give IV fluids if severe diarrhoea — medical consult
Fish poisoning — tetrodotoxin (puffer fish)
- Tetrodotoxin in the flesh of some marine and freshwater fish (eg puffer fish) and crabs can cause paralysis
- No known antidote
Symptoms
- History of eating puffer or similar fish, or crabs
- Nausea, occasional vomiting, tingling lips, progressive weakness, ataxia (unsteadiness) — after 30 minutes to several hours
- Respiratory failure or paralysis in severe cases
Check
- Calculate age-appropriate REWS
- Adult — AVPU, RR, O2 sats, pulse, BP, Temp
- Child (less than 13 years) — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
- Weight, BGL
- Head-to-toe exam — with attention to muscle weakness
Do
- Medical consult
- Support respiration if needed — may need prolonged ventilation (eg mouth-to-mouth, bag-valve-mask, mechanical ventilator)
- People can survive for hours with supported ventilation
- Put in IV cannula
- If developing paralysis — send to hospital