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

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

• 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

• 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

• 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

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

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

• 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