Marine Envenomations: Presentations and Management in the ED
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Identification and Management of Marine Envenomations in Pediatric Patients

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About This Issue

While most marine envenomations are mild, systemic and life-threatening reactions, as well as delayed presentations, can occur. The pediatric population is at greater risk for serious reactions to marine envenomations. Although the majority of the literature on marine envenomations is of low quality, the available literature suggests that management varies depending on the geographic location. This issue reviews some of the most common venomous marine creatures and describes the typical presentations associated with their envenomation. It also provides recommendations for management of marine envenomations based on the envenomating creature and the geographic location. You will learn:

Which marine creatures cause the most common envenomations, as well as those that cause life-threatening envenomations

Typical presentations of various marine envenomations

Key aspects of the history and physical examination that will help narrow the differential diagnosis

When diagnostic studies are warranted and which studies should be considered

Recommendations for managing patients with marine envenomations, including which jellyfish stings should be treated with water and which should be treated with acetic acid, what treatments are most effective for reducing pain, and when prophylactic antibiotics are indicated

Which patients should be admitted, which require observation, and which can be safely discharged

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Venom Delivery Mechanisms
    1. Cnidocytes
    2. Spines
    3. Bites
  6. Venomous Marine Creatures
    1. Invertebrates
      1. Cnidarians-1
        • Cubozoa
          • Irukandji Jellyfish
          • Box Jellyfish
        • Hydrozoa
          • Fire Coral
          • Portuguese Man-of-War
        • Scyphozoa
        • Anthozoa
      2. Echinoderms-1
      3. Mollusks-1
        • Conus
        • Hapalochlaena
    2. Vertebrates
      1. Stingrays-1
      2. Scorpaenidae-1
      3. Sea Snakes-1
  7. Differential Diagnosis
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. Initial Stabilization
    2. History
      1. Location and Circumstances
      2. Chronicity of Symptoms
      3. Quality and Severity of Symptoms
      4. History of Previous Envenomation
    3. Physical Examination
  10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
  11. Management
    1. Management of Invertebrate Envenomations
      1. Cnidarians-2
        • North American and Hawaiian Cnidarians
        • Indo-Pacific Cnidarians
      2. Echinoderms-2
      3. Mollusks-2
    2. Management of Vertebrate Envenomations
      1. Stingrays-2
      2. Scorpaenidae-2
      3. Sea Snakes-2
  12. Special Considerations
  13. Controversies and Cutting Edge
  14. Disposition
    1. Admission
    2. Discharge Criteria
      1. Observation Time for Sea Snake and Blue-Ringed Octopus Envenomation
    3. Follow-up
  15. Summary
    1. Recommendations for Specific Marine Creature Envenomations
      1. Cnidarians-3
      2. Echinoderms-3
      3. Mollusks-3
      4. Stingrays-3
      5. Scorpionfish
      6. Sea Snakes-3
    2. General Management Recommendations
      1. Hot Water Versus Acetic Acid
      2. Imaging Recommendations
      3. Antibiotic Recommendations
      4. Antivenom Recommendations
  16. Time- and Cost-Effective Strategies
  17. Risk Management Pitfalls for Pediatric Patients With Marine Envenomations
  18. Case Conclusions
  19. Clinical Pathway for the Management of North American Jellyfish Envenomation of the Pediatric Patient
  20. Tables and Figures
    1. Table 1. Common and Life-Threatening Marine Envenomations, Invertebrates
    2. Table 2. Common and Life-Threatening Marine Envenomations, Vertebrates
    3. Table 3. Management of Marine Envenomations
    4. Figure 1. Box Jellyfish Sting
    5. Figure 2. Fire Coral Envenomation
    6. Figure 3. Seabather’s Eruption
    7. Figure 4. Cone Snail Radulae
    8. Figure 5. Barbed Stingray Spine
    9. Figure 6. X-ray Demonstrating Sea Urchin Spines in Foot
  21. References

Abstract

Marine envenomations can cause a diverse array of clinical syndromes. Systemic and life-threatening reactions, as well as delayed presentations, can occur. The pediatric population is at higher risk for serious reactions to envenomations because their greater body surface area and smaller body mass can lead to a higher relative venom load. Although the majority of the literature on marine envenomations is of low quality, the available literature does suggest that management varies depending on the geographic location. This issue reviews both common and life-threatening presentations of marine envenomations, highlights key aspects of the history and physical examination that will help narrow the differential, and offers recommendations for management based on the envenomating creature and geographic location.

Case Presentations

A 4-year-old girl with the chief complaint of rash is brought to the ED. Her family is on a beach vacation to the Florida coast for the summer. After exiting the ocean today, she complained of a “stinging” feeling on her chest and abdomen. Later in the afternoon, while changing her clothes, her father noticed a rash and brought her to the ED. The girl complains that the rash is “very itchy.” On examination, you note an erythematous papular rash on her abdomen, chest, and buttocks, sparing the extremities, upper back, and face. Her vital signs are all within normal range, and she is well appearing, scratching occasionally at her rash. What is the best way to work up this patient? What treatment is needed? What is the expected clinical course of this condition?

An 11-year-old boy is brought into the ED by EMS. He is in severe pain after encountering a large, floating jellyfish while swimming off the Atlantic coast of the United States. The boy experienced immediate pain after contact, and EMS personnel say he became confused en route to the hospital. The boy's physical examination reveals linear, whip-like erythematous lesions on his neck and left upper extremity. Spasm and fasciculations of the bilateral upper extremities are observed. What type of jellyfish could cause these signs? What critical actions should be performed to manage this patient?

A 7-year-old girl presents to a Southern California ED by EMS. She is complaining of severe pain to her right foot that began after she jumped off her surfboard into waist-high water. On examination, a small puncture wound is noted on the plantar surface of her right midfoot, and edema is noted from the foot to the ankle. No foreign body is appreciated. EMS personnel administered intravenous opioids en route to the ED, but the patient is still in severe pain. What type of marine envenomation could cause this patient's pain? What laboratory or imaging studies—if any—should be ordered? What additional actions can be taken for pain control? Is the patient at risk for developing delayed sequelae?

Introduction

A marine envenomation occurs when a venom is delivered to a person by a marine creature. Marine creatures have developed complex venoms with mechanisms of delivery that include bites and stings. Although these strategies are a means of defense or for capturing prey, inadvertent human contact and resultant envenomation can lead to serious morbidity and mortality.

Although most envenomations are mild, some can be life-threatening. Populations at greater risk for serious envenomation syndromes include the pediatric population, often due to larger relative venom dose; the elderly are also at greater risk, due to comorbidities. Most serious and life-threatening marine envenomations occur in the temperate or tropical Indo-Pacific region; in particular, the waters off the coast of Australia. North American waters, however, also support a wide range of dangerous venomous creatures. This, combined with increased international travel and exotic home aquariums, should keep marine envenomations on the mind of all emergency clinicians.

In the United States, the emergency department (ED) is the most likely place of initial presentation for patients with a life-threatening marine envenomation. Emergency clinicians should be familiar with cardinal presentations of serious envenomation. Life-threatening marine envenomations require stabilization and expert consultation in the ED, as severe envenomations can cause significant morbidity and mortality if prompt initial stabilization efforts are unsuccessful. Access to medical toxicologists, either as in-house consultants or through local Poison Control services (in the United States, 1-800-222-1222), should be available and sought out in all cases of severe envenomation.

Delayed sequelae of envenomations may also present to the ED. Less severe presentations may still develop significant delayed sequelae (eg, infection from retained spines and wounds). Proper risk stratification and evaluation is a critical component of the emergency evaluation.

This issue of Pediatric Emergency Medicine Practice reviews some of the most common venomous marine creatures and describes the typical clinical presenting features associated with their envenomation. It also provides recommendations for management of marine envenomations based on the envenomating creature and the geographic location.

Critical Appraisal of the Literature

The PubMed database was searched using the following terms: marine envenomations, pediatric marine envenomations, jellyfish envenomation/sting, sea snake envenomation, cone snail envenomation/sting, stonefish envenomation/sting, scorpionfish envenomation/sting, lionfish envenomation/sting, stingray envenomation/sting, octopus envenomation, sea urchin envenomation/sting, crown-of-thorns envenomation/sting, box jellyfish envenomation/sting, Irukandji envenomation/sting, Portuguese man-of-war envenomation/sting, and Physalia envenomation/sting. No restrictions were placed on the publication date; article publication dates ranged from 1957 to 2018. Of the 255 articles selected as clinically relevant, 141 were included. The majority of the literature on marine envenomation is of low quality, primarily consisting of case reports, review articles, and uncontrolled studies.

Venom Delivery Mechanisms

Cnidocytes

The cnidocyte is a specialized cell unique to the phylum Cnidaria. These cells contain nematocysts (cnidocysts) that function as the mechanism for venom delivery. Each cnidarian tentacle contains thousands of cnidocytes. In response to osmotic pressure or chemical changes, the nematocyst will trigger and release a coiled harpoon bathed in venom. The harpoon penetrates into the epidermis, dermis, or occasionally the capillaries of its target, resulting in an envenomation.1,2

Spines

Many species of invertebrates and vertebrates employ spines as deterrent and direct defense mechanisms and as a means to deploy venom to potential predators and prey.

Several members of the phylum Echinodermata (sea urchins and sea stars) possess a venom apparatus connected to a spine that can deliver venom to an unsuspecting diver’s hand or a shore wader’s foot. These thin spines are generally comprised of calcium carbonate and lack a barb. In addition to facilitating venom delivery to tissues, the spines often break off and pose a danger as retained foreign bodies.

Predatory cone snails of the genus Conus use a modified dental structure (radula) that sits within a flexible feeding tube known as a proboscis. The proboscis is extended as a self-defense mechanism and to search for prey. Once deployed, the barbed, harpoon-like radula penetrates the tissue and delivers a potent neurotoxin.

Members of the Chondrichthyes class (stingrays) possess a modified spine that is located on the distal end of a whip-like tail. The barbed spine generally detaches and embeds into the victim, and venom is delivered through grooves in the internal structure of the spine, resulting in local direct tissue destruction and envenomation.

Members of the Scorpaenidae family (stonefish) have venom glands in dorsal spines that are used as a mechanism for venom delivery. In the case of the stonefish, pressure-sensitive nerves trigger venom injection through the wound created by the spine.

Bites

Both invertebrates and vertebrates may employ biting mechanisms in order to transfer venom to potential predators and prey. The most notable invertebrate example is cephalopods belonging to the genus Hapalochlaena. Blue-ringed octopods bite using a powerful, bony beak, and deliver potent neurotoxins into the tissues of a victim. Sea snakes are venomous elapids that also bite, delivering venom from glands in their skull through grooves in small, fixed front fangs that are similar to terrestrial cobras, kraits, and mambas.

Risk Management Pitfalls for Pediatric Patients With Marine Envenomations

3. “It doesn’t really matter where you are, treatment of these stings is always the same.”

Treatment recommendations may vary between geographic regions, mirroring the biodiversity of the animals involved. Acetic acid is commonly recommended for jellyfish envenomation in Australia and the South Pacific, but is generally not recommended for Portuguese man-of-war envenomations, due to concern for increased nematocyte firing. Hot water is recommended for pain control after North American jellyfish envenomations.

6. “I didn’t palpate a retained foreign body, and the plain film x-ray was negative, so I discharged the patient home.”

Missing a retained foreign body in the setting of a marine envenomation can have serious consequences. Advanced imaging (computed tomography/magnetic resonance imaging) may be indicated, depending on clinical presentation and pretest probability. Specialist consultation should be sought for the removal of foreign bodies if they are not removable in the ED.

8. “I’ve seen this envenomation in an adult, and he was fine. I didn’t know kids could have a different reaction.”

Likely due to their increased surface area compared to mass, longer times in the water, and lack of awareness of their surroundings, children are at higher risk for more serious envenomation syndromes.

Tables and Figures

Table 3. Management of Marine Envenomations

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. French KL, Horowitz BL. Critical care toxicology. In: Brent J, Burkhart K, Dargan P, et al eds. Critical Care Toxicology. 2nd ed. Cham, Switzerland: Springer International Publishing; 2017. (Textbook chapter)
  2. Anderson PA, Bouchard C. The regulation of cnidocyte discharge. Toxicon. 2009;54(8):1046-1053. (Review article)
  3. French KL, Horowitz BL. Marine vertebrates, cnidarians, and mollusks. In: Brent J, Burkhart K, Dargan P, et al eds. Critical Care Toxicology. 2nd ed. Cham, Switzerland: Springer International Publishing; 2017:1-30. (Textbook chapter)
  4. Barnes JH. Cause and effect in Irukandji stingings. Med J Aust. 1964;1:897-904. (Case report and review article)
  5. Huynh TT, Seymour J, Pereira P, et al. Severity of Irukandji syndrome and nematocyst identification from skin scrapings. Med J Aust. 2003;178(1):38-41. (Prospective study; 128 patients)
  6. Little M, Pereira P, Carrette T, et al. Jellyfish responsible for Irukandji syndrome. QJM. 2006;99(6):425-427. (Letter)
  7. Tibballs J, Li R, Tibballs HA, et al. Australian carybdeid jellyfish causing “Irukandji syndrome.” Toxicon. 2012;59(6):617-625. (Review article)
  8. Pereira P, Barry J, Corkeron M, et al. Intracerebral hemorrhage and death after envenoming by the jellyfish Carukia barnesi. Clin Toxicol (Phila). 2010;48(4):390-392. (Case report)
  9. Little M, Mulcahy RF, Wenck DJ. Life-threatening cardiac failure in a healthy young female with Irukandji syndrome. Anaesth Intensive Care. 2001;29(2):178-180. (Case report)
  10. Little M, Pereira P, Mulcahy R, et al. Severe cardiac failure associated with presumed jellyfish sting. Irukandji syndrome? Anaesth Intensive Care. 2003;31(6):642-647. (Retrospective review; 12 cases)
  11. Nickson CP, Currie BJ, Fenner PJ. Priapism and Irukandji syndrome. Ann Emerg Med. 2010;55(6):581-582. (Case report)
  12. Nickson CP, Waugh EB, Jacups SP, et al. Irukandji syndrome case series from Australia’s tropical Northern Territory. Ann Emerg Med. 2009;54(3):395-403. (Prospective study; 87 patients)
  13. Winkel KD, Tibballs J, Molenaar P, et al. Cardiovascular actions of the venom from the Irukandji (Carukia barnesi) jellyfish: effects in human, rat and guinea-pig tissues in vitro and in pigs in vitro. Clin Exp Pharmacol Physiol. 2005;32(9):777-788. (Animal research study)
  14. Tibballs J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon. 2006;48(7):830-859. (Review article)
  15. Currie BJ. Clinical toxicology: a tropical Australian perspective. Ther Drug Monit. 2000;22(1):73-78. (Review article)
  16. 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(11-12):631-636. (Prospective study; 225 patients)
  17. Thaikruea L, Siriariyaporn P. Severe dermatonecrotic toxin and wound complications associated with box jellyfish stings 2008-2013. J Wound Ostomy Continence Nurs. 2015;42(6):599-604. (Case report)
  18. Auerbach PS. Marine envenomations. N Engl J Med. 1991;325(7):486-493. (Review article)
  19. Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol. 2003;41(3):301-308. (Review article)
  20. McGoldrick J, Marx JA. Marine envenomations. Part 2: invertebrates. J Emerg Med. 1992;10(1):71-77. (Review article)
  21. Currie B. Clinical implications of research on the box-jellyfish Chironex fleckeri. Toxicon. 1994;32(11):1305-1313. (Review article)
  22. O’Reilly GM, Isbister GK, Lawrie PM, et al. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust. 2001;175(11-12):652-655. (Prospective study; 40 patients)
  23. Welton RE, Williams DJ, Liew D. Injury trends from envenoming in Australia, 2000-2013. Intern Med J. 2017;47(2):170-176. (Retrospective review)
  24. Vimpani G, Doudle M, Harris R. Child accident-mortality in the Northern Territory, 1978-1985. Med J Aust. 1988;148(8):392-395. (Retrospective review)
  25. Lumley J, Williamson JA, Fenner PJ, et al. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust. 1988;148(10):527-534. (Case report)
  26. Hughes RJ, Angus JA, Winkel KD, et al. A pharmacological investigation of the venom extract of the Australian box jellyfish, Chironex fleckeri, in cardiac and vascular tissues. Toxicol Lett. 2012;209(1):11-20. (Basic science)
  27. Saggiomo SL, Seymour JE. Cardiotoxic effects of venom fractions from the Australian box jellyfish Chironex fleckeri on human myocardiocytes. Toxicon. 2012;60(3):391-395. (Basic science)
  28. Mustafa MR, White E, Hongo K, et al. The mechanism underlying the cardiotoxic effect of the toxin from the jellyfish Chironex fleckeri. Toxicol Appl Pharmacol. 1995;133(2):196-206. (Basic science)
  29. Hornbeak KB, Auerbach PS. Marine envenomation. Emerg Med Clin North Am. 2017;35(2):321-337. (Review article)
  30. Sagi A, Rosenberg L, Ben-Meir P, et al. ‘The fire coral’ (Millepora dichotoma) as a cause of burns: a case report. Burns Incl Therm Inj. 1987;13(4):325-326. (Case report)
  31. Stein MR, Marraccini JV, Rothschild NE, et al. Fatal Portuguese man-o’-war (Physalia physalis) envenomation. Ann Emerg Med. 1989;18(3):312-315. (Case report)
  32. Kaufman MB. Portuguese man-of-war envenomation. Pediatr Emerg Care. 1992;8(1):27-28. (Case report)
  33. Guess HA, Saviteer PL, Morris CR. Hemolysis and acute renal failure following a Portuguese man-of-war sting. Pediatrics. 1982;70(6):979-981. (Case report)
  34. Burnett JW, Gable WD. A fatal jellyfish envenomation by the Portuguese man-o’war. Toxicon. 1989;27(7):823-824. (Case report)
  35. Mariottini GL, Giacco E, Pane L. The mauve stinger Pelagia noctiluca (Forsskal, 1775). Distribution, ecology, toxicity and epidemiology of stings. A review. Mar Drugs. 2008;6(3):496-513. (Review article)
  36. Burnett JW, Calton GJ. Venomous pelagic coelenterates: chemistry, toxicology, immunology and treatment of their stings. Toxicon. 1987;25(6):581-602. (Review article)
  37. Doyle TK, Headlam JL, Wilcox CL, et al. Evaluation of Cyanea capillata sting management protocols using ex vivo and in vitro envenomation models. Toxins (Basel). 2017;9(7):215. (Basic science)
  38. Tomchik RS, Russell MT, Szmant AM, et al. Clinical perspectives on seabather’s eruption, also known as ‘sea lice.’ JAMA. 1993;269(13):1669-1672. (Review article)
  39. Rossetto AL, Da Silveira FL, Morandini AC, et al. Seabather’s eruption: report of fourteen cases. An Acad Bras Cienc. 2015;87(1):431-436. (Case series; 14 patients)
  40. Villano JH, O’Connell CW, Clark RF. Prolonged, reversible neurologic symptoms after carpet sea anemone envenomation in a pet store worker. Clin Toxicol (Phila). 2015;53(2):137. (Case report)
  41. Tezcan OD, Gozer O. Severe toxic skin reaction caused by a common anemone and identification of the culprit organism. J Travel Med. 2015;22(4):269-271. (Case report)
  42. Garcia PJ, Schein RM, Burnett JW. Fulminant hepatic failure from a sea anemone sting. Ann Intern Med. 1994;120(8):665-666. (Case reports)
  43. Mizuno M, Nishikawa K, Yuzawa Y, et al. Acute renal failure after a sea anemone sting. Am J Kidney Dis. 2000;36(2):E10. (Case report)
  44. Haddad V Jr, Lupi O, Lonza JP, et al. Tropical dermatology: marine and aquatic dermatology. J Am Acad Dermatol. 2009;61(5):733-750. (Review article)
  45. Caputo V, Fiorella S. Sea urchin granuloma. Dermatology. 2005;210(3):254-256. (Case report)
  46. Nakagawa H, Kimura A, Takei M, et al. Histamine release from rat mast cells induced by an extract from the sea urchin Toxopneustes pileolus. Toxicon. 1982;20(6):1095-1097. (Basic science)
  47. Nakagawa H, Tu AT, Kimura A. Purification and characterization of Contractin A from the pedicellarial venom of sea urchin, Toxopneustes pileolus. Arch Biochem Biophys. 1991;284(2):279-284. (Basic science)
  48. Nakagawa H, Yanagihara N, Izumi F, et al. Inhibition of nicotinic acetylcholine receptor-mediated secretion and synthesis of catecholamines by sea urchin toxin in cultured bovine adrenal medullary cells. Biochem Pharmacol. 1992;44(9):1779-1785. (Basic science)
  49. Asada M, Komura J, Hosokawa H, et al. A case of delayed hypersensitivity reaction following a sea urchin sting. Dermatologica. 1990;180(2):99-101. (Case report)
  50. Liram N, Gomori M, Perouansky M. Sea urchin puncture resulting in PIP joint synovial arthritis: case report and MRI study. J Travel Med. 2000;7(1):43-45. (Case report)
  51. Guyot-Drouot MH, Rouneau D, Rolland JM, et al. Arthritis, tenosynovitis, fasciitis, and bursitis due to sea urchin spines. A series of 12 cases in Reunion Island. Joint Bone Spine. 2000;67(2):94-100. (Retrospective study; 12 patients)
  52. Baden HP. Injuries from sea urchins. Clin Dermatol. 1987;5(3):112-117. (Review article)
  53. Kucewicz A, Miller MA. Eosinophilic pneumonia associated with foot injury from a sea urchin. Am J Emerg Med. 2007;25(7):862.E5-862.E6. (Case report)
  54. Wu ML, Chou SL, Huang TY, et al. Sea-urchin envenomation. Vet Hum Toxicol. 2003;45(6):307-309. (Case report)
  55. Shiomi K, Yamamoto S, Yamanaka H, et al. Purification and characterization of a lethal factor in venom from the crown-of-thorns starfish (Acanthaster planci). Toxicon. 1988;26(11):1077-1083. (Basic science)
  56. Shiomi K, Yamamoto S, Yamanaka H, et al. Liver damage by the crown-of-thorns starfish (Acanthaster planci) lethal factor. Toxicon. 1990;28(5):469-475. (Basic science)
  57. Shiomi KA, Kazama A, Shimakura K, et al. Purification and properties of phospholipases A2 from the crown-of-thorns starfish (Acanthaster planci) venom. Toxicon. 1998;36(4):589-599. (Basic science)
  58. Karasudani I, Koyama T, Nakandakari S, et al. Purification of anticoagulant factor from the spine venom of the crown-of-thorns starfish, Acanthaster planci. Toxicon. 1996;34(8):871-879. (Basic research)
  59. Lin B, Norris RL, Auerbach PS. A case of elevated liver function tests after crown-of-thorns (Acanthaster planci) envenomation. Wilderness Environ Med. 2008;19(4):275-279. (Case report)
  60. Auerbach PS, Cushing TA, Harris NS. Auerbach’s wilderness medicine. 7th ed. Philadelphia: Elsevier/Mosby; 2017. (Textbook)
  61. Olivera BM, Gray WR, Zeikus R, et al. Peptide neurotoxins from fish-hunting cone snails. Science. 1985;230(4732):1338-1343. (Basic science)
  62. Fegan D, Andresen D. Conus geographus envenomation. Lancet. 1997;349(9066):1672. (Case report)
  63. Rice RD, Halstead BW. Report of fatal cone shell sting by Conus geographus Linnaeus. Toxicon. 1968;5(3):223-224. (Case report)
  64. Kohn AJ. Human injuries and fatalities due to venomous marine snails of the family Conidae. Int J Clin Pharmacol Ther. 2016;54(7):524-538. (Retrospective review; 139 cases)
  65. Cestele S, Catterall WA. Molecular mechanisms of neurotoxin action on voltage-gated sodium channels. Biochimie. 2000;82(9-10):883-892. (Review article)
  66. Cavazzoni E, Lister B, Sargent P, et al. Blue-ringed octopus (Hapalochlaena sp.) envenomation of a 4-year-old boy: a case report. Clin Toxicol (Phila). 2008;46(8):760-761. (Case report)
  67. Williamson JA. The blue-ringed octopus bite and envenomation syndrome. Clin Dermatol. 1987;5(3):127-133. (Review article)
  68. Flachsenberger WA. Respiratory failure and lethal hypotension due to blue-ringed octopus and tetrodotoxin envenomation observed and counteracted in animal models. J Toxicol Clin Toxicol. 1986;24(6):485-502. (Basic science)
  69. Clark RF, Girard RH, Rao D, et al. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. J Emerg Med. 2007;33(1):33-37. (Retrospective study; 119 patients)
  70. Clark AT, Clark RF, Cantrell FL. A retrospective review of the presentation and treatment of stingray stings reported to a poison control system. Am J Ther. 2017;24(2):e177-e180. (Retrospective study; 576 patients)
  71. Ikeda T. Supraventricular bigeminy following a stingray envenomation: a case report. Hawaii Med J. 1989;48(5):162, 164. (Case report)
  72. Dehghani H, Sajjadi MM, Rajaian H, et al. Study of patient’s injuries by stingrays, lethal activity determination and cardiac effects induced by Himantura gerrardi venom. Toxicon. 2009;54(6):881-886. (Basic science)
  73. Hambright D, Guss D, Smith JT. Unique case of posterior tibial tendon dysfunction after stingray strike. Foot Ankle Spec. 2016;9(3):275-278. (Case report)
  74. Derr C, O’Connor BJ, Macleod SL. Laceration of the popliteal artery and compartment syndrome resulting from stingray envenomation. Am J Emerg Med. 2007;25(1):96-97. (Case report)
  75. Liggins JB. Death due to a stingray barb piercing the heart: a New Zealand case from 1939. An unusual bathing fatality. N Z Med J. 2006;119(1241):U2164. (Case report)
  76. Fenner PJ, Williamson JA, Skinner RA. Fatal and non-fatal stingray envenomation. Med J Aust. 1989;151(11-12):621-625. (Case report)
  77. Evans LA, Evans CM. Stingray hickey. Cutis. 1996;58(3):208-210. (Case report)
  78. Church JE, Hodgson WC. Dose-dependent cardiovascular and neuromuscular effects of stonefish (Synanceja trachynis) venom. Toxicon. 2000;38(3):391-407. (Basic science)
  79. Gwee MC, Gopalakrishnakone P, Yuen R, et al. A review of stonefish venoms and toxins. Pharmacol Ther. 1994;64(3):509-528. (Review article)
  80. Kreger AS. Detection of a cytolytic toxin in the venom of the stonefish (Synanceia trachynis). Toxicon. 1991;29(6):733-743. (Basic science)
  81. Brenneke F, Hatz C. Stonefish envenomation--a lucky outcome. Travel Med Infect Dis. 2006;4(5):281-285. (Case report and literature review)
  82. Haddad V Jr, Martins IA, Makyama HM. Injuries caused by scorpionfishes (Scorpaena plumieri Bloch, 1789 and Scorpaena brasiliensis Cuvier, 1829) in the Southwestern Atlantic Ocean (Brazilian coast): epidemiologic, clinic and therapeutic aspects of 23 stings in humans. Toxicon. 2003;42(1):79-83. (Review article)
  83. Auerbach PS, McKinney HE, Rees RS, et al. Analysis of vesicle fluid following the sting of the lionfish Pterois volitans. Toxicon. 1987;25(12):1350-1353. (Basic science)
  84. Kizer KW, McKinney HE, Auerbach PS. Scorpaenidae envenomation. A five-year poison center experience. JAMA. 1985;253(6):807-810. (Retrospective review; 51 patients)
  85. Resiere D, Cerland L, De Haro L, et al. Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies--a two-year prospective study in Martinique. Clin Toxicol (Phila). 2016;54(4):313-318. (Prospective study; 117 patients)
  86. Tang WM, Fung KK, Cheng VC, et al. Rapidly progressive necrotising fasciitis following a stonefish sting: a report of two cases. J Orthop Surg (Hong Kong). 2006;14(1):67-70. (Case report)
  87. Lehmann DF, Hardy JC. Stonefish envenomation. N Engl J Med. 1993;329(7):510-511. (Case report)
  88. Abdun-Nur D, Marcus CS, Russell FE. Pericarditis associated with scorpionfish (Scorpaena buttata) sting. Toxicon. 1981;19(4):579-581. (Case report)
  89. Smith JLB. Two rapid fatalities from stonefish stabs. Copeia. 1957;3:249. (Case report; 2 patients)
  90. Sahagan L. Rare, venomous sea snake found slithering on Southern California shores. Are more coming? 2018. Accessed March 15, 2020. (News article)
  91. Reid HA, Lim KJ. Sea-snake bite; a survey of fishing villages in northwest Malaya. Br Med J. 1957;2(5056):1266-1272. (Survey)
  92. Reid HA. Epidemiology of sea-snake bites. J Trop Med Hyg. 1975;78(5):106-113. (Review article)
  93. Marsden AT, Reid HA. Pathology of sea-snake poisoning. Br Med J. 1961;1(5235):1290-1293. (Basic science)
  94. Walker MJ, Peng Nam Y. The in vitro neuromuscular blocking properties of sea snake (Enhydrina schistosa) venom. Eur J Pharmacol. 1974;28(1):199-208. (Basic science)
  95. Kularatne SA, Hettiarachchi R, Dalpathadu J, et al. Enhydrina schistosa (Elapidae: Hydrophiinae) the most dangerous sea snake in Sri Lanka: three case studies of severe envenoming. Toxicon. 2014;77:78-86. (Case report; 3 patients)
  96. Tu AT. Biotoxicology of sea snake venoms. Ann Emerg Med. 1987;16(9):1023-1028. (Review article)
  97. Vithanage KK, Thirumavalavan K. A case of a sea snake bite resulting in fatal envenoming. Ceylon Med J. 2012;57(4):174-175. (Case report)
  98. Reid HA. Myoglobinuria and sea-snake-bite poisoning. Br Med J. 1961;1(5235):1284-1289. (Case series; 38 patients)
  99. Illston B LM, Cauddell MJ, DiCarlo J. Intra-articular foreign body evaluation: ultrasound vs fluoroscopy. Ann Emerg Med. 2009;54(3). (Abstract)
  100. Pereira PL, Carrette T, Cullen P, et al. Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Med J Aust. 2000;173(11-12):650-652. (Basic science)
  101. Ward NT, Darracq MA, Tomaszewski C, et al. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med. 2012;60(4):399-414. (Review article)
  102. Li L, McGee RG, Isbister G, et al. Interventions for the symptoms and signs resulting from jellyfish stings. Cochrane Database Syst Rev. 2013(12):CD009688. (Review article; 7 trials, 435 participants)
  103. Loten C, Stokes B, Worsley D, et al. A randomised controlled trial of hot water (45 degrees C) immersion versus ice packs for pain relief in bluebottle stings. Med J Aust. 2006;184(7):329-333. (Randomized controlled trial; 96 patients)
  104. Bowra J GM, Morgan J, et al. A trial comparing hot showers and icepack in the treatment of Physalia envenomation. Emerg Med J. 2006;23:503-508. (Randomized trial; 54 patients)
  105. Nomura JT, Sato RL, Ahern RM, et al. A randomized paired comparison trial of cutaneous treatments for acute jellyfish (Carybdea alata) stings. Am J Emerg Med. 2002;20(7):624-626. (Randomized controlled trial; 25 patients)
  106. Thomas CS, Scott SA, Galanis DJ, et al. Box jellyfish (Carybdea alata) in Waikiki. The analgesic effect of sting-aid, Adolph’s meat tenderizer and fresh water on their stings: a double-blinded, randomized, placebo-controlled clinical trial. Hawaii Med J. 2001;60(8):205-207, 210. (Double-blinded, randomized, placebo-controlled clinical trial; 62 patients)
  107. Thomas CS, Scott SA, Galanis DJ, et al. Box jellyfish (Carybdea alata) in Waikiki: their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: a randomized, placebo-controlled, clinical trial. Hawaii Med J. 2001;60(4):100-107. (Randomized, placebo-controlled, clinical trial; 127 patients)
  108. Birsa LM, Verity PG, Lee RF. Evaluation of the effects of various chemicals on discharge of and pain caused by jellyfish nematocysts. Comp Biochem Physiol C Toxicol Pharmacol. 2010;151(4):426-430. (Basic science)
  109. Turner B, Sullivan P. Disarming the bluebottle: treatment of Physalia envenomation. Med J Aust. 1980;2(7):394-395. (Controlled study; 20 patients)
  110. Exton DR. Treatment of Physalia physalis envenomation. Med J Aust. 1988;149(1):54. (Letter)
  111. Burnett JW, Rubinstein H, Calton GJ. First aid for jellyfish envenomation. South Med J. 1983;76(7):870-872. (Uncontrolled trial)
  112. Exton DR, Fenner PJ, Williamson JA. Cold packs: effective topical analgesia in the treatment of painful stings by Physalia and other jellyfish. Med J Aust. 1989;151(11-12):625-626. (Review article)
  113. Atkinson PR, Boyle A, Hartin D, et al. Is hot water immersion an effective treatment for marine envenomation? Emerg Med J. 2006;23(7):503-508. (Review article)
  114. Guevara BEK, Dayrit JF, Haddad V Jr. Seabather’s eruption caused by the thimble jellyfish (Linuche aquila) in the Philippines. Clin Exp Dermatol. 2017;42(7):808-810. (Case report)
  115. Australian Resuscitation Council. Guideline 9.4.5 envenomation jellyfish stings. Accessed March 15, 2020. (Guideline)
  116. Yanagihara AA, Wilcox CL. Cubozoan sting-site seawater rinse, scraping, and ice can increase venom load: upending current first aid recommendations. Toxins (Basel). 2017;9(3):105. (Basic science)
  117. Hartwick R, Callanan V, Williamson J. Disarming the box-jellyfish: nematocyst inhibition in Chironex fleckeri. Med J Aust. 1980;1(1):15-20. (Basic science)
  118. Isbister GK, Palmer DJ, Weir RL, et al. Hot water immersion v icepacks for treating the pain of Chironex fleckeri stings: a randomised controlled trial. Med J Aust. 2017;206(6):258-261. (Randomized controlled trial; 42 patients)
  119. Little M, Fitzpatrick R, Seymour J. Successful use of heat as first aid for tropical Australian jellyfish stings. Toxicon. 2016;122:142-144. (Case report)
  120. Wilcox CL, Yanagihara AA. Heated debates: hot-water immersion or ice packs as first aid for cnidarian envenomations? Toxins (Basel). 2016;8(4):97. (Review article)
  121. Berling I, Isbister G. Marine envenomations. Aust Fam Physician. 2015;44(1-2):28-32. (Review article)
  122. Andreosso A, Smout MJ, Seymour JE. Dose and time dependence of box jellyfish antivenom. J Venom Anim Toxins Incl Trop Dis. 2014;20:34. (Basic science)
  123. Isbister GK. Antivenom efficacy or effectiveness: the Australian experience. Toxicology. 2010;268(3):148-154. (Review article)
  124. Williamson JA, Le Ray LE, Wohlfahrt M, et al. Acute management of serious envenomation by box-jellyfish (Chironex fleckeri). Med J Aust. 1984;141(12-13):851-853. (Case report; 2 patients)
  125. Tibballs J, Williams D, Sutherland SK. The effects of antivenom and verapamil on the haemodynamic actions of Chironex fleckeri (box jellyfish) venom. Anaesth Intensive Care. 1998;26(1):40-45. (Basic science)
  126. Little M, Somerville A. Clonidine to treat Irukandji syndrome. Emerg Med Australas. 2016;28(6):756-757. (Case report)
  127. Corkeron M, Pereira P, Makrocanis C. Early experience with magnesium administration in Irukandji syndrome. Anaesth Intensive Care. 2004;32(5):666-669. (Case series; 10 patients)
  128. Little M. Failure of magnesium in treatment of Irukandji syndrome. Anaesth Intensive Care. 2005;33(4):541-542. (Case report)
  129. McCullagh N, Pereira P, Cullen P, et al. Randomised trial of magnesium in the treatment of Irukandji syndrome. Emerg Med Australas. 2012;24(5):560-565. (Randomized controlled trial; 39 patients)
  130. Bultmann CA, Steiss JO, Langner C, et al. Complicated sea urchin-induced wound infection caused by Vibrioalginolyticus and Staphylococcus lugdunensis in a 14-year-old boy. JMM Case Rep. 2016;3(6):e005074. (Case report)
  131. Barnett S, Saggiomo S, Smout M, et al. Heat deactivation of the stonefish Synanceia horrida venom - implications for first-aid management. Diving Hyperb Med. 2017;47(3):155-158. (Basic science)
  132. Stonefish Antivenom package insert. Accessed March 15, 2020. (Package insert)
  133. Gomes HL, Menezes TN, Carnielli JB, et al. Stonefish antivenom neutralises the inflammatory and cardiovascular effects induced by scorpionfish Scorpaena plumieri venom. Toxicon. 2011;57(7-8):992-999. (Basic science)
  134. McGoldrick J, Marx JA. Marine envenomations; part 1: vertebrates. J Emerg Med. 1991;9(6):497-502. (Review article)
  135. White J. Australian and pacific snakes. In: Brent J, Burkhart K, Dargan P, et al eds. Critical Care Toxicology. 2nd ed. Cham, Switzerland: Springer International Publishing; 2017:2405-2439. (Textbook chapter)
  136. Reid HA. Sea-snake antivenene: successful trial. Br Med J. 1962;2(5304):576-579. (Case control series; 3 patients)
  137. Reid HA. Antivenom in sea-snake bit poisoning. Lancet. 1975;1(7907):622-623. (Retrospective study; 101 patients)
  138. Laboratories CS. Sea Snake Antivenom package insert. Accessed March 15, 2020. (Package insert)
  139. Glastein M AD, Galil B et al. Pediatric jellyfish envenomation in the Mediterranean Sea. Eur J Emerg Med. 2018;25(6):434-439. (Retrospective study; 41 patients)
  140. Armoni M, Ohali M, Hay E. Severe dyspnea due to jellyfish envenomation. Pediatr Emerg Care. 2003;19(2):84-86. (Case report)
  141. Ikawa Y, Fujita N, Yachi Y, et al. Cover image: life-threatening complications of jellyfish Chrysaora pacifica stings in a 5-year-old child. Br J Dermatol. 2016;175(4):837-838. (Case report)
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Publication Information
Authors

Meghan B. Spyres, MD; Jeff Lapoint, DO

Peer Reviewed By

Chris Pitotti, MD, FACEP; Mark Waltzman, MD

Publication Date

April 2, 2020

CME Expiration Date

April 3, 2023

CME Credits

4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits.

Pub Med ID: 32192283

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