Box jellyfish envenomation: Difference between revisions
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*''Chironex fleckeri'' or [[sea wasp]] is cause of most deaths | *''Chironex fleckeri'' or [[sea wasp]] is cause of most deaths | ||
*Largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely | *Largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely | ||
*Most stings are benign (requiring local treatment only), | *83% occur in < 1m of water. | ||
*Most stings are benign (requiring local treatment only), recent data suggests fatality rate is much lower than the 20% previously reported. | |||
**Morbidity and Mortality are dose- and time-dependent, which explains why majority of deaths have been children. | |||
===Mechanism=== | ===Mechanism<ref>Hauglid, Christopher, DO, et al. “EMERGEN-SEA MEDICINE: An Overview of Sea Urchins, Coral, Starfish, and More.” ACEP Now, vol. 40, no. 7, 2021, pp. 8–9.</ref>=== | ||
* | *Has about 15 tentacles (measure up to 3m in length) that contain millions of "stinging cells" called nematocysts. | ||
*Contact with the tentacles cause rapid onset of pruritic/burning | |||
*Thought to affect sodium/potassium/calcium channels | *Thought to affect sodium/potassium/calcium channels | ||
*Rhabodmyolysis can occur from sustained muscle contractions caused by myotoxins in venom. | |||
*Cardiovascular collapse can occur d/t dysrhythmia (from hyperkalemia) and osmotic dysregulation of endothelial and cardiac tissues from pore-forming toxins within the venom. | |||
*''[[Sea wasp|Chironex fleckeri]]'' venom causes cell membranes to become porous allowing K+ influx/hyperkalemia | *''[[Sea wasp|Chironex fleckeri]]'' venom causes cell membranes to become porous allowing K+ influx/hyperkalemia | ||
==Clinical Features== | ==Clinical Features== | ||
*Stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched pattern | [[File:PMC4756446 13104 2016 1931 Fig4 HTML.png|thumb|Patient stung by multiple box jellyfish tentacles.]] | ||
[[File:PMC4756446 13104 2016 1931 Fig1 HTML.png|thumb|Patient stung by multiple box jellyfish tentacles.]] | |||
[[File:PMC4756446 13104 2016 1931 Fig3 HTML.png|thumb|Box jellyfish sting.]] | |||
[[File:PMC4756446 13104 2016 1931 Fig2 HTML.png|thumb|Pediatric box jellyfish sting.]] | |||
*Stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched "ladder-rung" pattern | |||
**Erythematous maculopapular rash | |||
**May progress to blisters/necrosis | **May progress to blisters/necrosis | ||
*25-30% may still have tentacles attached | *25-30% may still have tentacles attached | ||
*Systemic envenomation (usually >10% [[BSA]]) can manifest as cardiac [[arrhythmias]], [[respiratory distress|respiratory dysfunction]], death | *Systemic envenomation (usually >10% [[BSA]]) can manifest as cardiac [[arrhythmias]], [[respiratory distress|respiratory dysfunction]], death | ||
** | **Usually manifests within 5 minutes of sting | ||
* | *Delayed [[hypersensitivity reaction]]s occur in >50% | ||
**[[Pruritus|Itching]], redness at sting sites 7-14d after initial incidence | **[[Pruritus|Itching]], redness at sting sites 7-14d after initial incidence | ||
| Line 38: | Line 48: | ||
*Antivenom for life-threatening envenomations | *Antivenom for life-threatening envenomations | ||
**Bovine IgG Fab with 20,000 units/ampule | **Bovine IgG Fab with 20,000 units/ampule | ||
*'''Avoid treating with fresh water, alcohol, methylated spirits, or urine as these have shown to increase nematocyst firing.''' <ref>Hauglid, Christopher, DO, et al. “EMERGEN-SEA MEDICINE: An Overview of Sea Urchins, Coral, Starfish, and More.” ACEP Now, vol. 40, no. 7, 2021, pp. 8–9.</ref> | |||
===Antivenom Indications^=== | ===Antivenom Indications^=== | ||
*[[Cardiac arrest]] | *[[Cardiac arrest]] | ||
**undiluted antivenom administered as an IV Push: up to 6 vials | **undiluted antivenom administered as an IV Push: up to 6 vials | ||
**if no response then give [[magnesium]] IV | **if no response then give [[magnesium]] IV (0.2mmol/kg, max 10mmol in adults) | ||
*[[Hypotension]], [[tachycardia]], [[shock]], [[arrhythmia]] | *[[Hypotension]], [[tachycardia]], [[shock]], [[arrhythmia]] | ||
**dilute 3 amps antivenom in 100mL [[NS]] and run over 20 minutes | **dilute 3 amps antivenom in 100mL [[NS]] and run over 20 minutes | ||
Latest revision as of 06:52, 27 November 2021
Background
- Cnidarian invertebrates distinguished by their cube-shaped medusae
- Chironex fleckeri or sea wasp is cause of most deaths
- Largely restricted to the Indo-Pacific Ocean/Australian waters but various species can be found widely
- 83% occur in < 1m of water.
- Most stings are benign (requiring local treatment only), recent data suggests fatality rate is much lower than the 20% previously reported.
- Morbidity and Mortality are dose- and time-dependent, which explains why majority of deaths have been children.
Mechanism[1]
- Has about 15 tentacles (measure up to 3m in length) that contain millions of "stinging cells" called nematocysts.
- Contact with the tentacles cause rapid onset of pruritic/burning
- Thought to affect sodium/potassium/calcium channels
- Rhabodmyolysis can occur from sustained muscle contractions caused by myotoxins in venom.
- Cardiovascular collapse can occur d/t dysrhythmia (from hyperkalemia) and osmotic dysregulation of endothelial and cardiac tissues from pore-forming toxins within the venom.
- Chironex fleckeri venom causes cell membranes to become porous allowing K+ influx/hyperkalemia
Clinical Features
- Stings associated with immediate pain, lasting up to 8 hours, and linear welts in a cross-hatched "ladder-rung" pattern
- Erythematous maculopapular rash
- May progress to blisters/necrosis
- 25-30% may still have tentacles attached
- Systemic envenomation (usually >10% BSA) can manifest as cardiac arrhythmias, respiratory dysfunction, death
- Usually manifests within 5 minutes of sting
- Delayed hypersensitivity reactions occur in >50%
- Itching, redness at sting sites 7-14d after initial incidence
Differential Diagnosis
Marine toxins, envenomations, and bites
- Toxins
- Ciguatera
- Scombroid
- Tetrodotoxin (e.g. pufferfish)
- Shellfish poisoning
- Amnesic shellfish poisoning
- Diarrheal shellfish poisoning
- Neurotoxic shellfish poisoning
- Paralytic shellfish poisoning
- Stingers
- Venomous fish
- Cone shell
- Lionfish
- Sea urchins
- Crown-of-Thorns Starfish
- Stonefish
- Other: Catfish, zebrafish, scorpion fish
- Nematocysts
- Coral reef
- Fire coral
- Jellyfish (Cnidaria)
- Portuguese man-of-war
- Sea anemones
- Seabather's eruption
- Phylum porifera (sponges)
- Bites
- Infections
Evaluation
- Generally a clinical diagnosis
Management
- First remove any tentacles
- tentacles separated from medusae can still emit venom
- 4-5% acetic acid/vinegar solution should be applied to the injured area for at least 30 seconds.[2]
- Pain control
- Supportive measures for minor envenomations
- Ice recommended but heat may actually work better
- Antihistamines and steroids for hypersensitivity reaction
- Do NOT pressure bandage
- Antivenom for life-threatening envenomations
- Bovine IgG Fab with 20,000 units/ampule
- Avoid treating with fresh water, alcohol, methylated spirits, or urine as these have shown to increase nematocyst firing. [3]
Antivenom Indications^
- Cardiac arrest
- undiluted antivenom administered as an IV Push: up to 6 vials
- if no response then give magnesium IV (0.2mmol/kg, max 10mmol in adults)
- Hypotension, tachycardia, shock, arrhythmia
- dilute 3 amps antivenom in 100mL NS and run over 20 minutes
- can repeat for a total of 6 vials
- Intractable pain
- give 1 amp diluted in 100mL NS run over 20 minutes
Anti-venom can cause serum sickness 4-14 days after administration
Disposition
See Also
References
- Bastian Bentlage, Paulyn Cartwright, Angel A. Yanagihara, Cheryl Lewis, Gemma S. Richards and Allen G. Collins.Evolution of box jellyfishes (Cnidaria: Cubozoa), a group of highly toxic invertebrates. Proceedings of the Royal Society, November 18, 2009 DOI:10.1098/rspb.2009.1707
- Currie BJ, Jacups SP. Prospective study of Chironex fleckeri and other box jellyfish stings in the “Top End” of Australia’s Northern Territory. Med J Aust 2005; 183: 631-636
- Hughes RJ, Angus JA, Winkel KD, Wright CE. A pharmacological investigation of the venom extract of the Australian box jellyfish, Chironex fleckeri, in cardiac and vascular tissues. Toxicol Lett. 2012 Feb 25;209(1):11-20. Epub 2011 Dec 2.
- http://www.toxinology.com/generic_static_files/cslavh_antivenom_boxjelly.html
- ↑ Hauglid, Christopher, DO, et al. “EMERGEN-SEA MEDICINE: An Overview of Sea Urchins, Coral, Starfish, and More.” ACEP Now, vol. 40, no. 7, 2021, pp. 8–9.
- ↑ Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 4 of 5. ACEP Now. https://www.acepnow.com/article/emergen-sea-medicine-overview-of-marine-envenomations/4/.
- ↑ Hauglid, Christopher, DO, et al. “EMERGEN-SEA MEDICINE: An Overview of Sea Urchins, Coral, Starfish, and More.” ACEP Now, vol. 40, no. 7, 2021, pp. 8–9.