Transcript Bites and Stings - Emory Department of Pediatrics

Marine Injuries
Kalpesh Patel, MD
Department of Pediatric
Emergency Medicine
August 2, 2006
Objectives
By the end of this lecture you should be able to:
 Describe the management and treatment for
• Marine invertebrate injuries
• Insect envenomations
 Understand and perform initial management of
these injuries, such as
• Local wound care
• Venom specific antidotes
• Stinger removal
2
Marine Invertebrates
 Irritants
• Hydras
• Anemones
• Common purple jellyfish
• Sea nettle
 Toxin producers
• Portuguese man-of-war
• True jellyfish
• Lion’s mane
 Handle with care
• Corals
• Sea Urchins
3
Irritants
 Hydras
• Maine to Florida and Texas coastline
• Attaches to solid objects
• Causes mild sting
• Requires local care
 Anemones
• US tidal zones
• Mildly toxic at worst – skin irritation
 Sea nettle and common purple jellyfish
• Atlantic coast
• Mildly toxic - skin irritation
4
Irritants - Treatment
 Wash copiously with sea water or normal saline
 Benadryl
 Topical/Oral Steroids
5
Toxin Producers
 Nematocysts
• Specialized organelles
which have toxin-coated
barbed threads that fire
when a tentacle is
touched.
• Cannot penetrate human
skin
• May discharge even
when the creature is
dead and washed up on
the beach
6
Toxin Producers
 Size matters
• Man of war can have tentacles
up to 75 feet long with 750,000
nematocysts each
7
Toxin Producers
8
 Toxin causes severe pain
• Made of polypeptides and degradative enzymes
• Causes release of inflammatory mediators,
histamine and histamine-releasing agents,
serotonin
• May cause systemic symptoms
 N/V, abdominal rigidity
 Respiratory distress
 Arthralgias
 Hemolysis, renal failure
 Coma
 Severe envenomation can cause death
Toxin Producers
 Lion’s mane
• Found on both coasts
• Highly toxic
 Instrument of death in
Sherlock Holmes classic
Adventure of the Lion’s
Mane
• Causes severe burning
• Prolonged exposure causes
muscle cramps and
respiratory failure
9
Toxin Producers - Treatment
 3 goals:
• Control shock – IV, fluids, etc.
• Control venom effects
 Remove tentacles from skin
– Inactivate unexploded nematocysts with vinegar,
meat tenderizer, or baking soda slurry
– Apply this to patient as well
• Pain relief
 Immobilize the wound area
 Codeine, Morphine, or Demerol
 Treat muscle spasms with 10% Calcium
gluconate 0.1ml/kg IV
 Topical/Oral steroids, Benadryl
10
Handle with Care
 Corals, Sea Urchins, Starfish
• Have jagged edges or hard spines
• Cause deep puncture wounds or sea lacerations
• Easily leave foreign bodies
• Stinging sensation, wheal formation, itching
• Wound infection very common
 Vibrio species, Erysipelothrix rhusiopathiae,
Mycobacterium marinum
 Fever
 Cellulitis
 Lymphangitis
11
Handle with Care - Treatment
 Copious irrigation with saline
 X-ray for foreign bodies
• Soak affected area in warm water
• Use local anesthetic and explore sterilely
 Wounds should be left open or loosely
approximated
 Antibiotics please
• >8 y/o: Tetracycline for 10 mg/kg/dose QID
• <8 y/o: Keflex or Bactrim
• Add staphylococcal coverage for foreign bodies
 Don’t forget tetanus prophylaxis
12
Marine Vertebrates
 Stingrays
 Catfish
 Scorpaenidea
 Sharks!
13
Stingrays
 Most common marine vertebrate injury
 Flat fish, bottom feeders, buried under sand or mud
 Easily stepped on causing reflex envenomation
• Venom apparatus is a serrated, retro-pointed
caudal spine on the tail
• Coated in venom sheath which ruptures on skin
penetration
 Heat labile toxin
 Can depress medullary respiratory centers
 Interfere with cardiac conduction
 PAINFUL
14
Stingrays - Treatment
15
 PreHospital:
• Irrigate copiously with cold salt water
• Flushing can help remove toxin
• Control bleeding with pressure
 ED:
• IV fluids, Morphine 0.1mg/kg/dose for pain
• Make an attempt to remove the spine
• Soak extremity in hot water (104-113F) to
inactivate the venom until pain relieved
• X-ray for foreign body (spine fragments)
• Re-explore wound after soaking
• Tetanus prophylaxis
• No prophylactic antibiotics
Scorpaenidae
16
 Zebrafish, scorpionfish, stone fish
 Non-migratory, slow swimming, buried in sand
 Envenomation occurs when handling fish on fishing
trips
 Venom delivered by many small spines like the
stingray
 Venom also heat-labile
 Symptoms
• Pain, N/V
• Hypotension
• Tachypnea leading to apnea
• MI with EKG changes
Scorpaenidae - Treatment
 Copious irrigation with saline
 Hot water immersion until pain relieved
 Morphine 0.1mg/kg/dose
 Close cardiopulmonary monitoring
 Admit to PICU if having significant systemic effects
17
Catfish
 Spines in the dorsal and pectoral fins
• Puncture wounds and laceration
• Easily break off as foreign body
• Venom causes local inflammation, pain, edema,
hemorrhage, tissue necrosis
 Treatment
• Irrigation
• Hot water immersion
• Morphine 0.1mg/kg/dose
• Antibiotics for gram negatives
• Delayed primary closure
18
Sharks!
 1 in 5,000,000 chance of attack in North America
 Gray reef, great white, blue, mako sharks
 Risk factors:
• Swimming near sewer outlets
• Swimming in the late afternoon/early evening
• Murky warm water
• Increased commotion
• Deep channels
• Wearing bright objects
• Surfers – boards are mistaken for elephant seals,
the shark’s usual diet in California
19
Sharks!
 Two types of bites:
• Tangential injury
 Close pass slashing movement teeth of open
shark mouth
• Definitive bite
 Vary according to the part of the body bitten
–
–
–
–
–
20
Lacerations
Soft tissue loss
Amputation of limb
Comminuted fractures
Hemicorpectomy
Sharks!
 Hypovolemic shock
• Control bleeding with pressure
• DON’T EXPLORE WOUNDS PREHOSPITAL
• IV fluids, blood products as soon as available
• Warmth
• Oxygen
• Surgery
• Prophylactic antibiotics – 3rd gen cephalosporin
or bactrim
• Tetanus prophylaxis
• Admit to PICU for significant injury
21
Questions?
22