Transcript Marine Emergencies

Marine Emergencies
Matthew T. Hamonko MD, MPH
Part 1: Immersion/Submersion and
Drowning
Cold Water Immersion
• Neutral water 33°C to 35°C (91.4°F to 95°F)
– Heat loss = heat production
• Hypothermia may occur at any temperature
below neutral water
• Significant risk of hypothermia = 25°C (77°F)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Cold Water Immersion
Gulf of Maine Research Institute data for Casco Bay - http://www.gomoos.org/
Cold Water Immersion
• Phases
– Phase 1: Cold Shock Response (0-2 minutes)
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Immersion gasp response
Inability to breath hold
Hyperventilation
Peripheral vasoconstriction
Increased heart rate, cardiac output and blood pressure
Myocardial ischemia
Arrhythmia
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Giesbrecht GG, Pretorius T. Survey of Public Knowledge and Reponses to Educational Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 2008;19:261-66.
Cold Water Immersion
• Phases
– Phase 2: Cold Incapacitation (5-15 minutes)
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Peripheral vasoconstriction and decreased circulation
Decreased coordination
Loss of fine motor skills
Loss of strength
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Giesbrecht GG, Pretorius T. Survey of Public Knowledge and Reponses to Educational Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 2008;19:261-66.
Cold Water Immersion
• Phases
– Phase 3: Hypothermia (>30 minutes)
• Physical and mental impairment
• Respiratory and cardiac suppression
• arrhythmia
– Phase 4: Circum-Rescue Collapse
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Decreased stress hormone output and BP drop
After drop
Hypoxia
Acidosis
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Giesbrecht GG, Pretorius T. Survey of Public Knowledge and Reponses to Educational Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 2008;19:261-66.
Giesbrecht GG, Hayward JS. Problems and Complications with Cold Water Rescue. Wilderness and Environ Med.2006;17:26-30.
Cold Water Immersion
• Cooling factors
– Water temperature
• Heat transfer 100 times that of air at same temp.
• Wind chill does not significantly effect this
– Sea State
– Thermal protection
• Wet suits are more effected by rough water
• Full 4.8 mm wet suit in 10°C water: 0.7°C/hour
• Full 4.8 mm dry suit in 10°C water: 0.5°C/hour
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Cold Water Immersion
• Cooling factors
– Body morphology
• larger surface area to mass ratio
• Decreased subcutaneous fat
– Amount of body immersed/surface area exposure
– Activity level
• Increased activity may increase rate of heat loss by 50%
– Diving factors
• Hypoxia, hypercapnia and hyperbaric nitrogen increase
rate of cooling
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Giesbrecht GG, Hayward JS. Problems and Complications with Cold Water Rescue. Wilderness and Environ Med.2006;17:26-30.
Cold Water Immersion
• Survival
– The 1-10-1 rule
• 1 minute to control breathing
• 10 minutes to get out of water or establish stable
position
• 1 hour before you become unconscious from
hypothermia
– Public perception underestimates survival time
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Giesbrecht GG, Pretorius T. Survey of Public Knowledge and Reponses to Educational Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 2008;19:261-66.
Cold Water Immersion
• Survival
– HELP (heatescapinglesseningposition)
– Huddle
Technique
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Cold Water Submersion
• Also known as “Near-drowning”
• Reports of survival with submersion time > 60
minutes.
– Well documented in children
– Adult cases less common (oldest reported age 62)
– Differences attributed to increased cooling rate
and preserved dive reflex in children
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Chochinov AH, Baydock BM, Bristow GK, Giesbrecht GG. Recovery of a 62 year old Man From Prolonged Cold Water Submersion. Ann
of Emerg Med.1998;31(1):127-31.
Cold Water Submersion
• The mammalian diving reflex
– Components
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Apnea
Bradycardia
Peripheral vasoconstriction
Decreased cardiac output with a maintained or
increased stroke volume
• Increased mean arterial blood pressure
– Partially inhibited by alcohol consumption
Wittmers LF, Pozos RS, Fall G, Beck L. Cardiovascular Responses to Face Immersion (the Diving
Reflex) in Human Beings after Alcohol Consumption. Ann of Emerg Med.1987;16(9):162-4.
Cold Water Submersion
• Factors contributing to Survival
– Decreased metabolic requirements
– Attenuate ischemia induced cell damage
– Reduced free radical production
– Delayed terminal depolarization and potassium
release
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Chochinov AH, Baydock BM, Bristow GK, Giesbrecht GG. Recovery of a 62 year old Man From Prolonged Cold Water Submersion. Ann of
Emerg Med.1998;31(1):127-31.
Cold Water Submersion
• Negative prognostic factors for Children
– Maximum submersion time > 5 minutes
– In coma on admission to ED
– Blood gas pH ≤ 7.1
– Age < 3
– Delay in resuscitation for at least 10 minutes after
rescue
• 5% survival rate for a score of 3 or more
Chochinov AH, Baydock BM, Bristow GK, Giesbrecht GG. Recovery of a 62 year old Man From Prolonged Cold Water Submersion. Ann of
Emerg Med.1998;31(1):127-31.
Drowning
• Wet Drowning (80% to 90%)
– Aspiration of fluid after laryngospasm resolves
and glottis opens
• Dry Drowning (10% to 15%)
– Persistent laryngospasm and closed glottis
• Both types may lead to pulmonary edema
• Marine bacterial pneumonia may occur in
survivors
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Sims JK, Enomoto PI, Frankel RI, Wong MF. Marine Bacteria Complicating Seawater Near-drowning and Marine Wounds: A Hypothesis. Ann of Emerg
Med. 1983;12(4):212-16.
Martin TG. Neardrowning and Cold Water Immersion. Ann of Emerg Med. 1984;13(4):81-91.
Drowning
• Aspiration
• The amount not the type of water is
significant
– 11 ml/kg volume required to alter blood volume
– 22 ml/kg volume required to alter electrolytes
– 3-4 ml/kg aspirated in most drowning victims
• Aspirating more than 200 ml or 3-4 ml/kg is
uncommon
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Martin TG. Neardrowning and Cold Water Immersion. Ann of Emerg Med. 1984;13(4):81-91.
Cold Water Immersion/Submersion
Diagnostics
• Studies
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Complete blood count
Basic metabolic panel
Coagulation studies
Liver function tests
Arterial blood gas
Chest x-ray
EKG
Creatine kinase
urinalysis
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Cold Water Immersion/Submersion
Medical Management
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Handle gently
Maintain in a horizontal position
Minimize physical activity
BLS, ACLS, ATLS
Remove wet clothing
Insulation
Passive re-warming (must be shivering)
CPAP
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Dottorini M, Eslami A, Baglioni S, Fiorenzano G, Todisco T. Nasal-continuous Positive Airway Pressure in the Treatment of NearDrowning in Fresh Water. Chest, 1996; 110(4):1122-4.
Giesbrecht GG, Hayward JS. Problems and Complications with Cold Water Rescue. Wilderness and Environ Med.2006;17:26-30.
Cold Water Immersion/Submersion
Medical Management
• Active re-warming
– Heated humidified air
– Warmed intravenous fluids
– Heating pads (neck, thorax, groin)
– Forced air re-warming (i.e. “Bear Hugger”)
– Cardiopulmonary bypass
– Extracorporeal membrane oxygenation (ECMO)
– Body cavity lavage (peritoneal, pleural, gastric,
bladder)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Tisherman S, Chabal C, Safar P, Stezoski W. Resuscitation of Dogs from Cold Water Submersion Using Cardiopulmonary Bypass. Ann of
Emerg Med. 1985;14(5):25-32.
Cold Water Immersion/Submersion
Disposition
• Asymptomatic victims
– Observe 4-6 hours and discharge with follow-up
• Symptomatic victims
– Admit: abnormal vital signs, positive x-ray findings,
abnormal blood gas results or other significant lab
result abnormalities
– Discharge: asymptomatic with no significant
diagnostic abnormalities after 4-6 hours of
observation with follow-up
• Pulmonary dysfunction may be delayed 12-72
hours
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Pratt FD, Haynes BE. Incidence of “Secondary Drowning” After Saltwater Submersion. Ann of Emerg Med. 1986;15(9):137-40.
Part 2: Non-venomous &
Venomous Marine Animal
Emergencies
Non-venomous Marine Animal
Emergencies
• Biting and spearing marine animals
– General wound management
– Trauma resuscitation
– X-ray imaging for foreign bodies
– Tetanus prophylaxis
– Prophylactic antibiotics (Vibrio, Aeromonas, +/Pseudomonas)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Link KW, Counselman FL, Steele J, Caughey M. A New Hazard for Windsurfers: Needlefish Impalement. Journ of Emerg Med.
1999;17(2):255-9.
Ajmal N, Nanney LB, Wolfort SF. Catfish Spine Envenomation: A Case of Delayed Presentation. Wilderness and Environ
Med.2003;14:101-5.
Riordan C, Hussain M, McCann J. Moray Eel Attack I the Tropics: A Case Report and Review of the Literature. Wilderness and Environ
Med.2004;15:194-7.
Erickson T, Vanden Hoek TL, Kuritza A, Leiken JB. The Emergency Management of Moray Eel Bites. Ann of Emerg
Med.1992;21(2):148-52.
Venomous Marine Animal
Emergencies
• Coelenterates (jelly fish)
– Approximately 100/10,000 species are considered
dangerous
– Box jellyfish: cardiotoxic effects, cardiac arrest
within minutes
– Irukandji: sympathetic hyperreactivity, heart
failure, pulmonary edema, Intracranial
hemorrhage, death, onset approx. 1-60 minutes
Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with Venomous Sea-Life. Journ of Emerg Med. 2011;40(1):103-12.
McIver LJ, Tjhung IG, Parish ST Derkenne, RC, Kippin AN. Irukandji Syndrome in the Torres Strait: A Series of 8 Cases. Wilderness and Environ
Med. 2011;22:338-42.
Venomous Marine Animal
Emergencies
• Ceolenterates (jelly fish)
– Nematocysts
• Located on the tentacle or near the mouth
• Contain a sharp, barbed coiled tubule
• Triggered by contact with the victims body or a
chemoreceptor
• Signs and Symptoms:
– Mild envenomation: rash, pain, pruritus
– Moderate to severe envenomation: rash, pain, pruritus,
multisystem organ dysfunction, death
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Venomous Marine Animal
Emergencies
• Ceolenterates (Jelly Fish)
– Diagnostics
• Irukandji syndrome: elevated cardiac enzymes and EKG
changes (T-wave inversions and biphasic T-waves) have
been reported.
McIver LJ, Tjhung IG, Parish ST Derkenne, RC, Kippin AN. Irukandji Syndrome in the Torres Strait: A Series of 8 Cases. Wilderness and Environ
Med. 2011;22:338-42.
Venomous Marine Animal
Emergencies
• Ceolenterates (jelly fish)
– Treatment
• Immediate wash with seawater (not freshwater)
• Do not rub wound, remove tentacles with forceps
• Acetic acid (vinegar) application for 30 seconds, may
deactivate nematocysts (may be of no help or activate
nematocysts in some species, i.e Man of War)
• Various other liquids used (including urine)
• Anti-venom available for Chironex fleckeri (box-jellyfish)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with Venomous Sea-Life. Journ of Emerg Med. 2011;40(1):103-12.
Venomous Marine Animal
Emergencies
• Ceolenterates (Jelly fish)
– Treatment (continued)
• Hot water immersion questionable
• Remove any remaining invisible nematocysts by
scraping or shaving
• Topical anti-histamine or anesthetic ointment
• Tetanus prophylaxis
• Treat allergic reaction and bronchospasm per normal
protocol
• Treat seizure with benzodiazepines
• Treat adrenergic overstimulation with phentolamine
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with Venomous Sea-Life. Journ of Emerg Med. 2011;40(1):103-12.
Venomous Marine Animal
Emergencies
• Echinodermata (starfish, sea urchin)
– Venomous spines
– Signs and Symptoms:
• rash, pain, pruritus as well as systemic symptoms such
as nausea, vomiting, paralysis, parasthesias, syncope,
hypotension, respiratory distress
– Diagnostics:
• X-ray imaging to evaluate for foreign body
– Treatment:
• 30 to 90 minute immersion in 45°C (113°F) water
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Venomous Marine Animal
Emergencies
• Stingrays
– #1 cause of fish envenomation annually
– Approx. 14 species off the U.S. Atlantic coast
– 1500-2000 ED visits in U.S. per year
– 1-4 venom and mucous coated stingers at the end
of the tail
– Puncture wound
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Clark RF, Girard RH, Rao D, Ly BT, Davis DP. Stingray Evenomation: A Retrospective Review of Clinical Presentations and Treatment in 119
Cases. Journ of Emerg Med. 2007;33(1): 33-7.
Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with Venomous Sea-Life. Journ of Emerg Med. 2011;40(1):103-12.
Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.
Venomous Marine Animal
Emergencies
• Stingrays
– Signs and Symptoms
• Local effects: pain, bleeding, edema, blisters, necrosis
• Systemic effects: nausea, vomiting, diarrhea, vertigo,
paralysis, arrhythmia, syncope, seizure, hypotension,
spasms/fasciculations
– Secondary bacterial infection is common
– Deaths usually related to penetration of the heart
or abdomen
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Clark RF, Girard RH, Rao D, Ly BT, Davis DP. Stingray Evenomation: A Retrospective Review of Clinical Presentations and Treatment in
119 Cases. Journ of Emerg Med. 2007;33(1): 33-7.
Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.
Venomous Marine Animal
Emergencies
• Stingrays
– Diagnostics
• X-ray imaging to evaluate for foreign body
– Treatment
• Soak wound in 45°C (113°F) water for 30-90 minutes
• Local exploration, debridement and removal of
retained foreign body
• Secondary closure
• Prophylactic antibiotics
• Tetanus prophylaxis
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Venomous Marine Animal
Emergencies
• Stingray
– 2007 San Diego, California retrospective Study
– 101 cases presenting within 24 hours
– 88% of patients had pain relief with hot water
treatment alone (mechanism questionable)
– 1/71 (2%) of patients who were given prophylactic
antibiotics returned with a wound infection
– 5/30 (17%) who did not receive prophylactic
antibiotics returned with a wound infection
Clark RF, Girard RH, Rao D, Ly BT, Davis DP. Stingray Evenomation: A Retrospective Review of Clinical Presentations and Treatment in 119 Cases.
Journ of Emerg Med. 2007;33(1): 33-7.
Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.
Venomous Marine Animal
Emergencies
• Scorpionfish
– 2nd most common marine fish envenomation
worldwide annually
– Common aquarium fish (33 calls to Chicago poison
center over a 2 year period)
– Three groups based on venom organ structure
• Pterois: zebrafish, lionfish, butterfly cod
• Scorpaena: scorpionfish, bullrout, sculpin
• Synanceja: Stonefish
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Vetrano SJ, Lebowitz JB, Marcus S. Lionfish Envenomation. Journ of Emerg Med. 2002;23(4): 379-82.
Aldred B, Erickson T, Lipscomb J. Lionfish Envenomation in an Urban Wilderness. Wilderness and Environ Med.1996;4:291-6.
Venomous Marine Animal
Emergencies
• Scorpionfish
– Venom
• Venom injected via 12-13 dorsal, 2 pelvic and 3 anal
spines with associated venom glands
• Lionfish venom is least potent, stonefish venom is most
potent (3 reported deaths in Australia)
• Heat labile protein
• Hemolytic and neurologic effects
– Vascoconstriction, increased vascular permeability,
myotoxicity
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Vetrano SJ, Lebowitz JB, Marcus S. Lionfish Envenomation. Journ of Emerg Med. 2002;23(4): 379-82.
Lyon RM. Stonefish Poisoning. Wilderness and Environmed. 2004;15:284-88.
Venomous Marine Animal
Emergencies
• Scorpionfish
– Signs and Symptoms
• Local effects: severe pain (92%), erythema (grade I),
swelling, warmth, vesicles (grade II), necrosis (grade III)
• Pain onset immediate or delayed, may last days
• Systemic effects (13%): altered mental status, nausea,
vomit, diarrhea, seizure, fever, hyper or hypotension,
respiratory distress, arrhythmia, heart failure,
pericarditis
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Vetrano SJ, Lebowitz JB, Marcus S. Lionfish Envenomation. Journ of Emerg Med. 2002;23(4): 379-82.
Aldred B, Erickson T, Lipscomb J. Lionfish Envenomation in an Urban Wilderness. Wilderness and Environ Med.1996;4:291-6.
Venomous Marine Animal
Emergencies
• Scorpionfish
– Diagnostics
• X-ray imaging to evaluate for foreign body
• Wound culture if evidence of infection (may require NaCl)
– Treatment
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Immersion in 45°C (113°F) water for 30-90 minutes
Vigorous irrigation
Heal by secondary intention
Prophylactic antibiotics for high risk areas (ciprofloxacin,
trimethoprim/sulfamethoxazole)
• Infection treatment with 3rd generation cephalosporin,
aminoglycoside or carbapenem
• Tetanus prophylaxis
• Antivenom available for stonefish
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Vetrano SJ, Lebowitz JB, Marcus S. Lionfish Envenomation. Journ of Emerg Med. 2002;23(4): 379-82.
Venomous Marine Animal
Emergencies
• Sea Snakes
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52 species, all venomous
None in the Atlantic ocean
Short fangs
20% of bites lead to significant envenomation
Neurotoxin more potent than terrestrial snakes
Signs and Symptoms:
• Local: no pain, small fang marks
• Systemic: paralysis, trismus, blurred vision, dysphagia,
drowsiness, vomiting, ptosis, arthralgia, respiratory distress,
coma
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Venomous Marine Animal
Emergencies
• Sea Snakes
– Treatment
• Immobilize bitten extremity and place in dependent
position
• Australian pressure immobilization technique
• Antivenom available for the beaked sea snake
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Part 3: Marine Infectious Disease
Marine Infectious Disease
• Pseudomonas aeruginosa (gram (-) aerobe)
– Fresh and Salt water infection
– Clinical presentation
• Hot tub folliculitis
– Treatment: systemic antibiotics for severe cases
• Green nail syndrome (paronychial infection)
– Treatment: removal of affected nail area and topical gentamcin
• Otitis externa
– Treatment: cortisporin or ofloxacin drops in mild cases, systemic
antibiotics in severe cases
– Mastoiditis
– Case reports associated with Red Tide Exposure
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Honner S, Kudela RM, Handler E. Bilateral Mastoiditis From Red Tide Exposure. Journ of Emerg Med. 2010:1-4
Marine Infectious Disease
• Aeromonas Hydrophila (gram (-) facultative
anaerobe)
– Classic fresh water infection
– Clinical presentation
• Soft tissue infection, i.e. cellulitis, Necrotizing Fasciitis
• Other infections: gastroenteritis, endocarditis, peritonitis,
meningitis, sepsis
– Treatment
• Tetracycline, aminoglycosides, trimethoprinsulfamethoxazole, 3rd generation cephalosporins,
carbapenems, flouroquinolones
• Treatment should also cover for possible Pseudomonas and
Serratia co-infection.
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Jesus JE, Berg HS, Tibbles C, Wolfe R. Necrotizing Fasciitis in the Setting of Marine Injury. Journ of Emerg Med.2010;40(5):539-42.
Marine Infectious Disease
• Mycobacterium marinum (acid fast rod shaped
bacilli)
– Fresh and salt water infection
– Clinical presentation
• Granulomas are common, may ulcerate become purulent
and/or develop cellulitis
• Bursitis, tenosynovitis, septic arthritis, osteomyelitis and
sepsis may occur
– Treatment
• Most lesions are self limited
• Poor consensus on treatment, consider trimethoprimsulfamethoxazole or ethambutol + rifampin for months to
years
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Marine Infectious Disease
• Vibrio vulnificus (gram (-) rod)
– Classic salt water infection
– Clinical Presentation
• Rapidly progressing cellulitis, may develop bulla, necrotizing
fasciitis and sepsis, or gastroenteritis leading to septicemia
• Primary septicemia 56% mortality, septic shock 92%
mortality
• Patients with liver disease at increased risk
– Treatment
• Early, aggresive surgical debridement
• Doxycycline, quinolones, carbapenems, 3rd generation
cephalosporins, aztreonam, trimethoprim-sulfamethoxazole
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Jesus JE, Berg HS, Tibbles C, Wolfe R. Necrotizing Fasciitis in the Setting of Marine Injury. Journ of Emerg Med.2010;40(5):539-42.
Kumamoto KS, Vukich DJ. Clinical Infection of Vibrio vulniificus: A Case Report and Review of the Literature. Journ of Emerg
Med.1998;16(1):61-6.
Marine Infectious Disease
• Vibrio Parahaemolyticus (gram (-) rod)
– Classic Salt water infection
– Clinical presentation
• Explosive diarrhea, nausea and vomiting, headache,
abdominal pain, and fever 6-72 hours after ingestion
• Mean symptom duration 3 days
• Serious skin infections may also occur
• Severe disease in immunocompromised hosts
– Treatment
• Usually self limited but may prescribe ciprofloxacin,
trimethoprim/sulfamethoxazole or tetracycline
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Auerbach P, Yajko DM, Nassos PS, Kizer KW, McCosker JE, Geehr EC, Hadley WK. Bacteriology of the Marine Environment: Implications for Clinical
Therapy. Ann of Emerg Med. 1987;16(6):643-8.
Part 4: Marine Toxidromes
Marine Toxidromes
• Scombroid
– Dark flesh/red muscled fish: Albacore, bluefin and
yellowfin tuna, mackerel, saury, needlefish,
wahoo, skipjack, bonito, mahimahi, kahawai,
sardine, black marlin, pilchard, anchovy, herring,
amberjack, Australian ocean salmon
– Heat stable toxin production by multiple bacteria
during decay
– Possibly related to decarboxylation of L-histidine
to histamine
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Marine Toxidromes
• Scombroid
– Clinical Presentation
• Symptoms occur within minutes of ingestion and are
self limited
• Similar to allergic reaction (headache, erythema,
nausea, vomit, diarrhea, abdominal cramps,
conjunctival injection, pruritus, dizziness, burning
sensation in the oropharnyx, flushing, bronchospasm,
urticaria, hypotension, palpitations, dysrhythmia
– Treatment: anti-histamines, bronchodilators, antiemetics
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Marine Toxidromes
• Tetrodotoxin
– Puffer fish, California Newt, blue ringed octopus,
poison dart frog, ivory shell, trumpet shell
– Heat stable toxin produced by bacteria or
microalgae on/in the fish
– Potent sodium channel blocker
– First case reported in fish caught in the Atlantic
Ocean in 2010
– Toxin not effected by heating or freezing
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Fernandez-Ortega JF, de los Santos JM, Herrera-Gutierrez ME, Fernande-Sanchez V, Loureo PR, Rancano AA, Tellez-Andrade A.
Seafood Intoxication by Tetrodotoxin: First Case in Europe. Journ of Emerg Med. 2010;39(5):612-17.
Marine Toxidromes
• Tetrodotoxin
– Clinical presentation
• Symptom onset 10 minutes to 4 hours
• Initial paresthesias of the lips and tongue with
progressive numbness and weakness of extremities
• Progress to hypersalivation, diaphoresis, lethargy,
headache, weakness, ataxia, tremor, paralysis, cyanosis,
aphonia, dysphagia, seizure, dyspnea, bronchorrhea,
bronchospasm, respiratory failure, hypotension, severe
GI upset, DIC like syndrome
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Marine Toxidromes
• Tetrodotoxin
– Diagnostics
• Standard CVA/altered mental status workup
• Test is available to detect toxin in blood and urine
– Treatment
• Supportive care
– Intubation may be necessary for several hours
• Activated charcoal GI decontamination
– Disposition
• At least 8 hours of observation for minor cases
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Fernandez-Ortega JF, de los Santos JM, Herrera-Gutierrez ME, Fernande-Sanchez V, Loureo PR, Rancano AA, Tellez-Andrade A.
Seafood Intoxication by Tetrodotoxin: First Case in Europe. Journ of Emerg Med. 2010;39(5):612-17.
Marine Toxidromes
• Ciguatera
– Most common non-bacterial food poisoning
associated with fish in the U.S.
– Dinoflagellate produced toxin concentrated in fish
– Effects voltage gated sodium channels
– Adrenergic and cholinergic effects in animal
models
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Asaeda G. The Transport of Ciguatoxin: A Case Report. Journ of Emerg Med. 2001;20(3):263-65.
Farstad DJ, Chow T. A Breif Case Report and Review of Ciguatera Poisoning. Wilderness and Environ Med. 2001;12:263-69.
Marine Toxidromes
• Ciguatera
– Clinical Presentation
• Symptom onset minutes to several hours after
ingestion but rarely after 24 hours. Symptom duration
48 to 72 hours (neuro symptoms may last months)
• GI symptoms: diarrhea, nausea, vomit abdominal pain
• Neuro symptoms: parasthesias (36-89%), hot and cold
reversal (88%), headache, ataxia, cranial nerve palsy,
ptosis, vertigo, loose teeth sensation
• Cardiac Symptoms: hypotension and bradycardia (1015%)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Asaeda G. The Transport of Ciguatoxin: A Case Report. Journ of Emerg Med. 2001;20(3):263-65.
Farstad DJ, Chow T. A Breif Case Report and Review of Ciguatera Poisoning. Wilderness and Environ Med. 2001;12:263-69.
Marine Toxidromes
• Ciguatera
– Treatment
• Supportive treatment
• Possible role for mannitol, amitriptyline and gastric
decontamination early in disease course
• Avoid exercise, marijuana, opiates, barbiturates, fish,
shellfish, alcohol, nuts and nut oils for 3-6 months after
symptoms resolution.
– Disposition
• Dependent upon treatment severity and response to
therapy. (rare cases of death secondary to respiratory
paralysis)
Auerbach P. Wilderness Medicine. 5th ed. Philadelphia, PA: Mosby-Elsevier; 2007.
Farstad DJ, Chow T. A Breif Case Report and Review of Ciguatera Poisoning. Wilderness and Environ Med. 2001;12:263-69.
Summary
• Four stages to cold water submersion: shock,
incapacitation, hypothermia, circum-rescue collapse
• You are better off in the air than in the water
• You have longer than you may think before you die of
hypothermia
• Individuals have survived after > 60 minute
submersion time in cold water
• The amount, not the type of water is important in
regards to aspiration
Summary
• Handle near drowning victims gently and observe for
at least 4-6 hours
• After non-venomous marine animal attacks have
high suspicion for foreign bodies and consider
antibiotic prophylaxis
• Wash Jellyfish stings with salt water not fresh water
• Vinegar is recommended in the case of many jellyfish
stings but not all
• Warm water immersion is recommended for sea
urchin, starfish, stingray and scorpion fish stings
Summary
• Antivenom is available for the stone fish and beaked
sea snake
• Pseudomonas is associated with water associated
infections
• Vibrio is associated with salt water infections
• Aeromonas is associated with fresh water infections
• Scombroid is associated with a histamine like
syndrome
• Ciguatera is associated with hot cold reversal
• Tetrodotoxin is associated with paralysis
Sources
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Questions?