Jellyfish Envenomation

Jellyfish EnvenomationSummer is officially in full swing and we all love it! Well, my kids do get tired of hearing about all of the potential hazards that lurk around every corner, but I just have a hard time turning that part of my brain off. I mean, someone has to anticipate the Fish Hook FBs, Vehicular Hyperthermia, and Heat Related Injuries, right? Of course someone also needs to be paying attention to the water related dangers as well (ex, Submersion Injury Prevention, C-Spine Injury and Submersions) and that brings to mind all of the crazy sea creatures that want to cause us pain. Let’s take a minute to digest a Morsel of info on Jellyfish Envenomations:

 

Jellyfish: Basics

  • Jellyfish (belong to Cnidaria) sting via microscopic cnidae
    • Contain nematocysts – sharp, coiled tubes surrounded by venom
    • Can penetrate through surgical gloves [Balhara, 2014]
  • Stings typically occur: [Ping, 2011]
    • During the warm months (of course… that’s when humans go to Jellyfish environs)
    • To visitors/vacationers (because they aren’t familiar with the native hazards)
  • Cnidaria include 4 classes that contain 10,000 species. [Balhara, 2014]
    • >100 species are known to be dangerous to humans.
    • Classes:
      • Anthozoa
        • includes anemone and coral
      • Cubozoa
        • Box Jellyfish: may be the world’s most venomous animal; resides in Indo-Pacific (around Australia, ‘cause all horrifically poisonous animals live around Australia).
        • Irukandji Jellyfish: venom can cause catecholamine release and Irujandji Syndrome; also around Australia
      • Hydrozoa
        • Portuguese Man-of-War: found around the world; very long tentacles (~30 meters); nematocysts remain active for months after being washed up on shoreline; venom causes hemolysis
        • Blue Bottle Jellyfish: found around Australia; tentacles ~15 meters
      • Scyphozoa
        • Considered “true jellyfish.”
        • Sea Nettles
        • Large Hair Jellyfish

 

Jellyfish Envenomation: Symptoms

  • Most jellyfish envenomations are self-limited, local, nuisances. [Balhara, 2014; Sando, 2010]
    • Superficial pain and itch.
    • Skin irritation
      • Wheals and uritcaria
      • Vesicles and blistering (necrosis has occurred)
      • May persist for days
  • Can develop systemic reactions (especially, the more deadly jellyfish)
    • Nausea / vomitting
    • Malaise and myalgias
    • Headaches
    • Syncope and Dysrhythmias
    • Anaphlyactic like reactions
    • Hypotension
    • Respiratory failure (can occur within minutes)
  • Any structure that comes in contact with nematocysts can be affected (ex, Corneal Injuries) [Sonmez,2008]
  • Irukandji Syndrome [Balhara, 2014; Sando, 2010]
    • Can be caused by other jellyfish other than Irukandji, so can occur in the US waters also (not just an Australian issue). [Sando, 2010]
    • Severe systemic reaction that occurs within 30 minutes
    • Severe pain in head, truck and limbs
    • Sweating, piloerection, agitation/anxiety (catecholamine release)
    • Tachycardia and HYPERtension
    • Muscle spasms in the back and abdomen
    • Can lead to pulmonary edema and intracerebral hemorrhage

 

Jellyfish Envenomation: Management

  • There are no standard, consensus management strategies [Isbister, 2017; Balhara, 2014; Ping, 2011]
    • There is conflicting evidence, but this may be due to different species used in testing.
    • Alcohol, urine, or sand are NOT good options (so don’t pee on your friend!).
    • Below is a reasonable starting approach, understanding that tactics may need to be adjusted based on specific situations.
  • First things first:
    • Get person out of the water! Pain and panic while swimming are not a good combination.
    • Protect yourself! Nematocysts that have not been discharged can still fire, and can injure the rescuer.
    • Attend to airway, breathing, and circulation stabilization when needed (goes without saying really).
  • Deactivate the unfired nematocysts 
    • Do not rub the affected area as this may discharge more nematocysts.
    • Household vinegar (4-6% acetic acid) has been widely used.
    • Baking Soda slurry may also be applied.
    • Meat-tenderizer (papain) may hydrolyze the protein and inactivate.
  • Remove tentacles
    • Carefully… use a blunt object to scrap them off.
    • Wear thick gloves
  • Denature injected toxin / Treat the pain
    • Hot water immersion [Nomura, 2002]
      • Cubozoan venoms are heat-labile (inactivated by temps >43 degrees C)
      • Hot water shower treatment (20-30 min) is often noted to lead to improved symptoms. [Nomura, 2002]
      • Hot compresses can also be used on the scene. [Ping, 2011]
    • Cold packs [Isbister, 2017]
    • Oral or parenteral analgesia can also be provided based on severity of pain.
  • Anticipate problems
    • Allergic reactions have been known to occur
    • Irukanji Syndrome? Place on cardiac monitors, treat HTN (perhaps with Magnesium), treat pain.
  • Treat Symptoms
    • Using symptomatic therapies like anti-histamines is reasonable.
    • Antivenom does exist for the Box Jellyfish, but rarely used/needed.
    • THE MAJORITY CAN BE TREATED on the scene and don’t need to be transported to Emergency Departments. [Ping, 2011]

 

Moral of the Morsel

  • Being prepared doesn’t mean you’re paranoid. If your going to the beach, throw some vinegar in the trunk of the car.
  • A dead jellyfish doesn’t equal a safe jellyfish. The tentacles can still sting after being detached from the jellyfish’s body even.
  • Deactivate, Decontaminate, and Denature, but protect yourself also!
  • Hot Water Shower over Morphine! Instead of pumping in a bunch of opiates, find a shower… unless you have to attend to the ABC’s of lifesaving.

 

References

Isbister GK1, Palmer DJ2, Weir RL2, Currie BJ3. Hot water immersion v icepacks for treating the pain of Chironex fleckeri stings: a randomised controlled trial. Med J Aust. 2017 Apr 3;206(6):258-261. PMID: 28359008. [PubMed] [Read by QxMD]

Glatstein M1, Adir D, Galil B, Scolnik D, Rimon A, Pivko-Levy D, Hoyte C. Pediatric jellyfish envenomation in the Mediterranean Sea. Eur J Emerg Med. 2017 Jun 20. PMID: 28639958. [PubMed] [Read by QxMD]

Bouyer-Monot D1, Pelczar S1, Ferracci S2, Boucaud-Maitre D3. Retrospective study of jellyfish envenomation in emergency wards in Guadeloupe between 2010 and 2016: When to diagnose Irukandji syndrome? Toxicon. 2017 Oct;137:73-77. PMID: 28711467. [PubMed] [Read by QxMD]

Friedel N1, Scolnik D2, Adir D1, Glatstein M1,3. Severe anaphylactic reaction to mediterranean jellyfish (Ropilhema nomadica) envenomation: Case report. Toxicol Rep. 2016 Mar 15;3:427-429. PMID: 28959564. [PubMed] [Read by QxMD]

Mao C1, Hsu CC2, Chen KT3. Ocular Jellyfish Stings: Report of 2 Cases and Literature Review. Wilderness Environ Med. 2016 Sep;27(3):421-4. PMID: 27436284. [PubMed] [Read by QxMD]

Mohd Suan MA1, Tan WL2, Soelar SA2, Cheng HP3, Osman M3. Jellyfish stings on Langkawi Island, Malaysia. Med J Malaysia. 2016 Aug;71(4):161-165. PMID: 27770113. [PubMed] [Read by QxMD]

Li L1, McGee RG2, Webster AC1,3. Pain from bluebottle jellyfish stings. J Paediatr Child Health. 2015 Jul;51(7):734-7. PMID: 26135148. [PubMed] [Read by QxMD]

Balhara KS1, Stolbach A. Marine envenomations. Emerg Med Clin North Am. 2014 Feb;32(1):223-43. PMID: 24275176. [PubMed] [Read by QxMD]

Ping J1, Onizuka N. Epidemiology of jellyfish stings presented to an American urban emergency department. Hawaii Med J. 2011 Oct;70(10):217-9. PMID: 22162597. [PubMed] [Read by QxMD]

Sando JJ1, Usher K, Buettner P. ‘To swim or not to swim’: the impact of jellyfish stings causing Irukandji Syndrome in Tropical Queensland. J Clin Nurs. 2010 Jan;19(1-2):109-17. PMID: 20500249. [PubMed] [Read by QxMD]

Sonmez B1, Beden U, Yeter V, Erkan D. Jellyfish sting injury to the cornea. Ophthalmic Surg Lasers Imaging. 2008 Sep-Oct;39(5):415-7. PMID: 18831428. [PubMed] [Read by QxMD]

Nomura JT1, Sato RL, Ahern RM, Snow JL, Kuwaye TT, Yamamoto LG. A randomized paired comparison trial of cutaneous treatments for acute jellyfish (Carybdea alata) stings. Am J Emerg Med. 2002 Nov;20(7):624-6. PMID: 12442242. [PubMed] [Read by QxMD]

O’Reilly GM1, Isbister GK, Lawrie PM, Treston GT, Currie BJ. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust. 2001 Dec 3-17;175(11-12):652-5. PMID: 11837877. [PubMed] [Read by QxMD]

Benmeir P1, Rosenberg L, Sagi A, Vardi D, Eldad A. Jellyfish envenomation: a summer epidemic. Burns. 1990 Dec;16(6):471-2. PMID: 1981471. [PubMed] [Read by QxMD]

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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2 Responses

  1. Health_Kenya says:

    How does Household vinegar help in Jellyfish Envenomation.

  1. July 22, 2018

    […] pee on your friends,” and other valuable pearls for managing jellyfish envenomations can be found in this recent Peds EM Morsels. Deactivate, decontaminate, and denature the toxin and […]

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