1. Who’s Up for a Swim
@ the BEACH?
By Kane Guthrie

2. The Lucky Country
Australia home to:
• 38 terrestrial snakes
• 23 sea snakes
• 22 spiders
• 7 jellyfish
• 2 blue ringed octopuses,
• 2 stone fish
• Plus many more venomous creatures.

3. Marine Envenomation
• Australian waters contain great variety of
venomous sea creatures.
• Includes jellyfish, sea snakes, blue-ringed
octopus, stonefish,& stingrays.
• Jellyfish stings most common marine medical
emergency.
• It’s estimated 10 000 jellyfish stings occur
each year.

4. The Approach
http://www.marine-medic.com.au/

5. Sea Snakes
• Found in most waters around Aust.
• Venom contains neuro toxins (paralysis) and
Myotoxins (rhabdomyolysis).
• Close resemblance to land snakes.
• Inquisitive, but rarely aggressive.
• Bites normally occur during handling.
• Fatalities & Paralysis rare!!

6. Clinical Presentation
Localised:
• Bite- small, superficial, relatively painless,
generally no local swelling.
Systemic:
• Non specific – headache, nausea & vomiting.
• Symmetrical descending flaccid paralysis
manifest within 6 hours.
• Rhabdo develops leading to ARF.

7. Emergency Department
Management
Pre-Hospital:
• PIB
In ED:
• Check CK- give fluids
• Paralysis can lead to Resp failure
• Prepare to secure the airway
• CSL Sea Snake Antivenom or Tiger Snake
(Reverses paralysis)
• Observe for 12 hours, Don’t D/C @ night.

8. Bluebottle Jellyfish
• Responsible for thousand of stings each year!
• Causes intense local pain and dermal
erythema.

9. Clinical Presentation
Localised:
• Immediate burning pain – lasting up 2 hours.
• Erythematous welts.
Systemic:
• Non specific symptoms include – nausea,
headache or malaise.

10. Emergency Department
Management
Pre-Hospital:
• Hot shower for 20mins (45°C optimal
temperature).
• Reassurance.
In ED:
• Provide hot shower if not already done.
• Simple analgesia.
• D/C when symptoms improving.

11. Box Jellyfish
• Found in tropical Australian waters.
• Most stings are benign, respond well to
supportive management.
• Severe envenoming has been associated with
70 deaths in Aust.
• Deaths occur through venoms direct cardiac
toxicity.

12. Clinical Presentation
Localised:
• Immediate severe pain, lasting up to 8 hours.
• Linear welts in cross hatched pattern.
• In 25-30% cases tentacles still adherent.
Systemic:
• Within minutes collapse and cardiac arrest can occur.
• HT, tachycardia, hypotension, impaired cardiac
conduction and arrhythmias.
Ongoing:
• Delayed hypersensitivity pruritic erythema rash can
occur 7-14 days after sting.

14. Emergency Department
Management
Pre-hospital:
• Apply vinegar to deactivate nematocyst.
In ED:
Minor:
• Apply vinegar, ICE packs, analgesia.
Severe:
• Cardiac monitor, analgesia-opiate, fluid boluses.
• CSL Box Jellyfish antivenom (3 ampoules)
• Cardiac arrest – 6 ampoules of antivenom, if
refractory try Mg.

15. Irukandji Syndrome
• Poorly understood condition!
• Characterized by:
 Severe pain
 Sympathomimetic state
 Potential for life threatening cardiovascular
complications.
• Caused by Jellyfish envenomation –
Carukiabarnesiis one specie of jellyfish that cause
it, many other jellyfish are postulated as causing
it.

16. Locations of Attacks
• Found in tropical waters.
• Fatalities have been reported r/t ICH.
• We have had Pt’s T/F to SCGH ED for ongoing
management.

17. Clinical Presentation
Localised:
• Initial sting generally not felt – leads to short period
before systemic symptoms.
Systemic:
• Multiple systemic effects occur 30-90 minutes –
agitation, dsyphoria, vomiting, diaphoresis, severe pain
back, limbs, abdomen.
• HT and tachycardia common.
Rare:
• Life threatening HT & APO may develop leading to
cardiovascular collapse.

18. Emergency Department
Management
Pre-hospital:
• Generous application of vinegar to all sting sites
(deactivates nematocyst).
In ED:
• Manage initially in resus – full monitoring!
• Provide analgesia – may need PCA.
• Treat nausea & control HT.
• Mg may treat refractory pain.
• Severe envenoming develops within 4/24
subsides by 12 hours.

19. Blue-ringed Octopus
• Found in shallow coastal waters
• Envenoming causes rapid paralysis.
• When handled or enraged it changes colour –
develops blue rings.
• Maculotoxin –leads to sodium channel
blockade causes neuro-toxicity resulting in
paralysis.

20. Clinical Presentation
Localised:
• The bite may not be painful.
• Local symptoms are minimal or absent.
Systemic:
• Characterised by rapidly progressive
descending paralysis.
• Early signs- blurred vision, diplopia, ptosis,
difficulty swallowing.

21. Emergency Department
Management
Pre-hospital:
• Apply PIB, assisted ventilation.
In ED:
• Monitored in resus bay – watch for paralysis, resp
failure and hypotension.
• Resp failure occurs- secure airway provide
mechanical ventilation.
• Paralysis resolves with 24 hours.
• No antidote available.

22. Stonefish
• Extremely well camouflaged reef fish.
• Found in shallow waters around rocks & coral
reefs.
• Found in northern Australian waters!
• Their dorsal spines contain venom.

23. Clinical Presentation
Localised:
• Pain @ site. (Usually severe)
• Swelling, bruising & puncture marks.
Systemic:
• Non-specific signs: nausea, vomiting, dyspnoea &
dizziness.
Rare:
• Hypotension, bradycardia, collapse, APO- have
been rarely reported. No deaths in Aust.

24. Emergency Department
Management
Pre-hospital:
• Analgesia, immerse limb in hot water 45°C
In ED:
• IV opioid analgesia – continue hot water
• Wound management – debridement, ADT, AB’s
• X-ray detect FB
• Antivenom – neutralizes some components of
venom. (unproven – generally not required).

25. Questions

26. Take Home Points
• Marine envenomation is common depending
on were you work.
• PIB on for BRO & sea snake bite.
• Antivenom’s have a limited role & risks.
• Supportive care is paramount!
• Avoid D/C @ night!

27. Thank-You