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MARINE ENVENOMATION &

Seafood poisoning
Dewi Dian Sukmawati
Marine fauna vary widely by geographic
location. Antivenoms exist for stonefish, box
jellyfish, and sea snake envenomation but vary
in availability
Severe marine envenomations may cause
hypertension, paralysis, or rhabdomyolysis.
Box jellyfish, Irukandji jellyfish, sea snakes,
blue-ringed octopi, and cone snail exposure
can be fatal
General Injury Management
1. Remove patient from water (do not remove
wet suit)
2. ABC Management with control of bleeding
sites
3. Identify cause of injury if possible
4. Wound management
Standard wound care
Wound toilet & Repair
Copious irrigation
Consider primary closure only if absolutely
necessary
Sutures should be loose enough to allow drainage
Contraindication to suturing or closure
Puncture Wound
Crush injury
Wound involving distal hands or feet
5. Observe for signs of infection
Most common bacterial organisms
Cellulitis
Vibrio vulnificus (high risk of rapid progression)
Treat Cellulitis early if observed
Select antibiotics to cover Vibrio Cellulitis
Prophylaxis is usually not indicated
MARINE INJURIES

Stings & Spikes Marine animal Pruritus after Poisoning & fish
Envenomation bites & trauma water exposure for consumption

NEUROTOXIN ANIMAL BITE AQUAGENIC PRURITUS Shellfish poisoning


Cnidaria (Jellyfish, Coral, Moray eel Swimmer's Itch (Fresh Pufferfish poisoning
Anemone) Barracudas water exposure) Scombroid poisoning
Echinoderms (Sea Urchins, Sharks Seabather's Eruption Ciguatera poisoning
Starfish) (Salt water exposure)
Stingrays (Chondrichthyes) ABRASIONS or
Cottonmouth, water LACERATIONS from coral
moccasin or sharp rocks
Sea Snake (Southeast Asia, Most common cause of
Persian gulf, Malaysia) marine injury
Octopus (Blue-ringed and High risk of infection
spotted)
Cone Shell (Australia, New
Guinea, California)
Scorpion Fish
Sea Sponges (Touch-me-not
and Fire sponge)
Bristle worms (Fire Worms)
Summary presentation for selected
marine injury
Common Mechanisms of Morbidity and Mortality in Marine Envenomations
Stingray Exsanguination
Spiny fish Cardiotoxicity, neurotoxicity, hemolysis,
edema
Sea snakes Paralysis, respiratory failure,
rhabdomyolysis
Box jellyfish (Chironex fleckeri) Cardiotoxicity, catecholamine surge
Irukandji (Carukia barnesi) Severe hypertension
Portuguese man-of-war (Physalia physalis) Respiratory failure, hypotension
Cone snails Paralysis, respiratory failure, cardiotoxicity
Octopus (Hapalochlaena maculosa) Paralysis (without change in mental
status),
respiratory failure, hypotension
MARINE ENVENOMATION

Major clinical Manifestation


PUNCTURE WOUNDS RASH

Fire coral
Anemone
Sea Urchin
Portuguese man of war
Stingray Lion Fish

Hydroids

Stone Fish
Cobbler Fish

Scorpion Fish
Box Jellyfish Blue ringed octopus

Sea snake
Vertebrate marine organisms
Stingray (class Chondrichthyes)
Spiny fish (families Scorpaenidae and Trachinidae)
Stonefish (genus Synanceia)
Lionfish (genus Pterois)
Weeverfish (genus Echiichthys & genus Trachinus)
Sea Snakes (families Hydrophiidae and Laticaudinae)
Invertebrate marine organisms
Cnidaria
Class Cubozoa
Box jellyfish (Chironex fleckeri)
Irukandji jellyfish (Carukia barnesi)
Class Hydrozoa
Portuguese man-of-war (Physalia physalis)
Fire corals (Millepora alcicornis)
Class Scyphozoa
Thimble jellyfish (Linuche unguiculata)
Mollusca
Class Gastropoda
Cone snails (genus Conus)
Class Cephalopoda
Blue-ringed octopus (Hapalochlaena maculosa)
Echinodermata
Sea urchins (Diadema, Echinothrix, Asthenosoma)
Porifera
Sponges
Marine vertebrate envenomation
Marine Organism Treatment Management Adjuncts
Stingray Hot-water immersion Tetanus prophylaxis
Analgesia Antibiotic prophylaxis*
Wound exploration
Stonefish Hemostasis Tetanus prophylaxis
Hot-water immersion Antibiotic prophylaxis
Analgesia (controversial)
Wound exploration
Stonefish antivenom administration
Lionfish Hemostasis Tetanus prophylaxis
Hot-water immersion Antibiotic prophylaxis
Analgesia (controversial)
Wound exploration
Weeverfish Hemostasis Tetanus prophylaxis
Hot-water immersion Antibiotic prophylaxis
Analgesia (controversial)
Wound exploration
Sea snakes Patient stabilization Laboratory analysis:
Extremity pressure immobilization Creatinine kinase, Electrolytes
Rapid antivenom administration in Creatinine, Hematocrit/hemoglobin
envenomation Urinalysis
Fluid resuscitation (renal protection)
Bedside epinephrine plus antihistamines
in case of antivenom anaphylaxis
* Strongly consider
Marine invertebrate envenomation*
Marine Organism Treatment Management Adjuncts
Chironex fleckeri Patient stabilization Bedside epinephrine plus
(Box jellyfish) Decontamination (5% acetic acid) antihistamines in case of
Immediate antivenom antivenom anaphylaxis
Respiratory and cardiac support Cold pack application
Analgesia
Topical corticosteroids
Topical antihistamines
Carukia barnesi Decontamination (5% acetic acid) Electrocardiogram
(Irukandji) Blood pressure control# Cardiac enzymes (troponin)
Respiratory and cardiac support Consider echocardiogram if
troponins elevated
Cold pack application
Analgesia
Topical corticosteroids
Topical antihistamines
Physalia physalis Patient stabilization Prolonged observation
(Portuguese Decontamination (5% acetic acid) with systemic symptoms
man-of-war) Hot or cold pack application Topical corticosteroids
Analgesia Topical antihistamines
Tentacle removal
*Given the controversy regarding decontamination solution and temperature application, this table describes the American Heart
Associations guidelines and the most recent literature for Indo-Pacific envenomation.
#Use easily titrable agent
Marine invertebrate envenomation*
Marine Organism Treatment Management Adjuncts
Millepora Decontamination (5% acetic acid) Topical corticosteroids
alcicornis Topical antihistamines
(Fire corals)
Linuche Analgesia Wash or discard clothes
unguiculata Topical corticosteroids worn at time of eruption
(Thimble jellyfish Topical antihistamines
Calamine lotion with menthol
Cone snails Patient stabilization
Extremity pressure immobilization
Respiratory and cardiac support
Blue-ringed Patient stabilization
octopus Extremity pressure immobilization
Respiratory and cardiac support
Sponges Spicule removal
Sea urchins Oral analgesia Tetanus prophylaxis
Hot-water immersion Surgical management for
Visible spines/pedicellariae removal spines in joints or delayed
granuloma
*Given the controversy regarding decontamination solution and temperature application, this table describes the American Heart
Associations guidelines and the most recent literature for Indo-Pacific envenomation.
#Use easily titrable agent
Marine antivenoms
Antivenom Dosage Potential Benefits
Chironex fleckeri 1 ampule (may dilute 1:10 by May be effective against
Sheep-derived saline) intravenously pain/scarring if given within
whole IgG 3 ampules may be given for 46 h
coma, dysrhythmia, or Uncertain effect on
respiratory depression cardiotoxicity
Up to 6 ampules for patients
receiving CPR with refractory
dysrhythmia
Sea snake 1 ampule of either in 1:10 Reduction in mortality rate
Beaked sea snake dilution with 0.9% saline since introduction of
and terrestrial tiger antivenom
snake equine-derived Efficacy in all sea snake
IgG Fab fragment species
Stonefish 1 vial for 12 punctures Efficacy against pain
Equine-derived 2 vials for 34 punctures Unknown efficacy against
IgG Fab fragment 3 vials for 5 or more other
punctures spiny fish
Abbreviations: CPR, cardiopulmonary resuscitation; IgG, immunoglobulin G.
Stingray injury with Sea urchin injury
necrosis sloughing skin &
erythema
B
A

A. Box jelly fish sting.


B. Fire coral injury with rash, blisters and
hives type.
C. Blue ringed ooctopus sting
SEAFOOD POISONING
Scombroid
Most common reported fish-borne illness
Result of improperly refrigerated dark muscle fish
Classically described in Scombroidae species e.g., tuna,
mackerel, bonito but seen in many others
Scombroid-Associated Fish
Scombroid Mechanism of Toxicity
High concentrations of histidine in flesh
Various bacterial species proliferate without refrigeration e.g.,
Proteus, Morganella, Klebsiella, Aerobacter, Escherechia
Liberate histidine decarboxylase converting histidine to
histamine and saurine
Heat stable
Scombroid Clinical Presentation
Onset within minutes of eating can be delayed
Meal often described as peppery
Initial flushing of face and upper torso
Burning sensation of oropharynx and throat
Headache common
Nausea and vomiting
Multiple persons
Urticaria, bronchospasm, hypotension RARE consider
true allergic reaction
Scombroid Treatment
Self-limiting
Lasts 8 to 12 hours
H1 and H2 blockers
IVF crystalloid
Antiemetics
Monitor airway
Activated charcoal?
Ciguatera
Second most common behind Scombroid
Most commonly seen in Indian Ocean, South
Pacific, Carribean, Hawaii and Florida
Reported in fish caught between +35 and -35
latitudes BUT more in +32 and -32
Flash frozen fish
Ciguatera Areas
Why Ciguatera Occurs
Blue green algae dinoflagellate (Gambierdiscus
toxicus)
Adheres to coral eaten by small herbivore fish
Larger fish eat smaller fish bio- concentrated up
food chain
Over 400 different species have been reported
even jellyfish
Classic fish: Grouper, Snapper, Amberjack, Sea
Bass, Mahi Mahi
Ciguatera Mechanism of Toxicity
Three major ciguatoxins: CTX-1, CTX-2, CTX-3
possible additional toxins
Heat stable, odorless, tasteless
Increase sodium permeability leads to
spontaneous firing of neurons
Also cholinergic receptors and calcium channels
Ciguatera Classic Presentation: Hot/Cold
reversal
More correctly cold allodynia
Loose painful teeth
Ciguatera Clinical Presentation
Initial gastrointestinal N/V/D, abdominal pain seen
within 1 to 24 hours
Followed by neurologic within 3 to 72 hours
Paresthesia e.g., perioral, extremities
Headache
Ataxia
Vertigo
Cardiovascular
Orthostatic hypotension and bradycardia can be
followed by hypertension and tachycardia
Other : Pruritus, Myalgia, Hiccups, Dyspareunia,
infant from breast milk
Ciguatera Treatment
Supportive care
IVF crystalloid
Antiemetics
Lidocaine (sodium channel blocker)
Cyclic antidepressants (sodium channel blocker
and antimuscarinic)
Nifedidipine (calcium channel blocker)
Neostigmine, Edrophonium (may worsen)
MANNITOL
Controversial
Dose 1 g/Kg 20 % mannitol
Randomized control trial showed no benefit
May worsen dehydration
Theories
Competitive inhibitor of CTX
Free radical scavenger
Decrease Schwann cell edema

DONT EAT FISH LOCALS WILL NOT EAT


Tetrodotoxin

Classic Puffer fish


However, multiple species contain TTX e.g.,
newts, Blue Ringed Octopus, Poison Dart frogs
Most cases in Japan Fugu & San Diego
FUGU
Several deaths each year in Japan
Chef training: Several years
Flesh contains small concentrations
Ovaries, liver, testes contain most TTX
Heat stable
Goal is to leave some TTX
Tetrodotoxin Mechanism of Toxicity
TTX blocks sodium channels preventing initial
depolarization and neurotransmission
Also direct effect on vascular smooth muscle
causing vasodilation
Tetrodotoxin Clinical Presentation
Onset within one hour but may be delayed
Oral paresthesia followed by face and extremities
N/V, abdominal pain
Hypersalivation
Bronchorrhea
Bulbar paralysis
Extremity paralysis
Respiratory paralysis
Bradycardia and AV nodal blockade, hypotension
Tetrodotoxin Treatment
Aggressive supportive care
Early airway management
Gastric lavage?
Activated charcoal?
Atropine
Transvenous pacemaker
Admit for 24 hours
Long term sequelae rare
Shellfish Poisonings
Paralytic Shellfish Poisoning (PSP)

Dinoflagellates Red Tide


Bivalves
e.g., mussels, clams, scallops, oysters
Saxitoxin
Decreases sodium channel permeability
Inhibiting neuromuscular conduction
Paralytic Shellfish Poisoning Presentation
Generally onset within 20 to 60 minutes
Paresthesia of mouth and extremities
Ataxia
Headache
Dysarthria, dysphonia, dysphagia
N/V/D
Respiratory weakness less common than TTX but
can be fatal
Paralytic Shellfish Poisoning Treatment
Supportive care
Activated charcoal?
Prevention
Only eat shellfish in months with letter R
Shellfish Poisonings
Neurotoxic Shellfish Poisoning (NSP)

Neurotoxic Shellfish Poisoning


Different toxin than PSP
Also from Red Tide
Brevetoxin: Stimulates sodium transmission
Eating bivalves, whelks
Neurotoxic Shellfish Poisoning Presentation
Onset within minutes to hours
N/V/D, abd pain, rectal burning
Paresthesia of mouth, face, extremities
Muscle weakness, vertigo, ataxia
Seizures
Respiratory failure very rare
Neurotoxic Shellfish Poisoning
Less severe than Paralytic Shellfish Poisoning
Supportive care
Self-limited
Lasts less than three days

Large red tide blooms can aerosolize Brevetoxin


(BTX)
Cough, rhinorrhea, bronchospasm
Treat supportively
Shellfish Poisonings
Diarrhea Shellfish Poisoning (DSP)
Diarrhea Shellfish Poisoning (DSP)
Toxin Okadaic acid and others (inhibits intestinal
cellular dephosphorilation)
From dinoflagellates
Most common May through August
Rapid onset of diarrhea after eating shellfish usually
within 30 minutes to 2 hours
Can also see N/V, abdominal pain
Resolves 1 to 3 days
Supportive care
Shellfish Poisonings
Amnesic Shellfish Poisoning (ASP)

Amnesic shellfish poisoning


Ingestion of biotoxin: domoic acid (naturaly
produced by marine diatoms genus pseudo-
nitzschia) accumulation by shellfish dring filter
feeding
Also can be accumulate in marine organism that
consume phytoplankton (anchovies, sardines)
Heat stable
Amnesic shellfish poisoning
Domoic acid act as neurotoxin damages
hippocampus & amygdaloid nucleus) activation
AMPA & kainate receptors calcium influxs
degenerate neurons
Short term memory loss (permanent)
Brain damage
Death in severe case
Amnesic shellfish poisoning
Gastrointestinal V/N/D, cramps, hemorrhagic
gastritis 24 hours after ingestion
Severe cases: neurological symptoms (in several
hours 3 days) headache, dizziness,
disorientation, vision disturbance, short term
memory loss, motor weakness, seizure,
bronchorrhea, hiccups, unstopable blood
pressure, arrhytmia, coma
Amnesic shellfish poisoning
Death in cases with very high dose domoic acid,
elderly, kidney failure
Mortality 4 in 107 confirmed cases
Permanent sequelae: short term memory loss,
peripheral polyneuropathy
No antidote available
Further Reading
CDC Yellow Book 2016
Textbook of Travel Medicine and Health, 2nd.Ed.
DuPont and Steffen. 2001. 376-389.
Harrisons Principle of Internal Medicine 19th ed
2011 (Part 18: Poisoning, Drug Overdose, and
Envenomation 396. Disorders Caused by
Venomous Snakebites and Marine Animal
Exposures, Paul S. Auerbach, Robert L. Norris
Goldmans Cecil Medicine 24th ed. Chapter 114:
Venoms and Poisons from Marine organisms