Transcript Marine Envenomations

Marine Toxicology
Rob Hall PGY3 and Dr. I. Vicas
Toxicology Rounds
Jan 9th, 2003
GOALS FOR TODAY
• ENVENOMATIONS
• Three mechanisms of envenomation
• Standard treatment for each mechanism
• Recognize life – threatening
• MARINE FOOD POISONING
• Common causes
• Presentation, diagnosis, management!
Not the band Venom!
• Phil
• Tony
• Robbie
Drummond
MARINE ENVENOMATIONS
• 2000 species of venemous marine animals
• General Mx
•
•
•
•
Remove from water: drowning MCC of death
Local wound care
? Specific antivenom
Be prepared to manage anaphylaxis
Three Mechanisms of
Envenomation
Oh, Look at the cute little fishy!
Marine Envenomation
Mechanisms
Bites
Nematocysts
Stings
Octopi
Seasnakes
Jellyfish
Man-o-war
Sea wasp
Fire corals
Bony Fish
Sea Urchin/starfish
Cone Shells
Stingrays
BITES
• Octopi
• Local wound care: irrigate,
debride, dress, tetanus,
analgesia
• Blue - ringed Octopus can be
lethal (tetrodotoxin like
venom)
BITES
• Seasnakes
• 50 species, all toxic, 7 fatal
• Most bites do not result in
envenomation b/c fangs
short/loose ---> poor
delivery of venom
• Local wound care +
polyvalent sea snake
antivenom
NEMATOCYSTS
• Nematocyst = spring - loaded venom gland
•
•
•
•
that suddenly everts and delivers venom
Often located on tentacles
Remain functional after animals death
May still be “loaded”when in skin
Local reaction, allergic reaction, toxic
reaction (N/V/D, CP, cramps, SOB,
paralysis, cardiorespiratory collapse)
What is a Nematocyst?
NEMATOCYSTS
• General Mx
•
•
•
•
•
Cut off tentacles
Inactivate nematocysts: VINEGAR
Remove nematocyts: credit card scrape
Antihistamine, analgesia
Antivenom only exists for seawasp
NEMATOCYSTS
• Jellyfish
• Usually only local reaction
• Remove tentacle, vinegar,
credit card scrape,
antihistamine, analgesia
NEMATOCYSTS
NEMATOCYSTS
• Box Jellyfish (Seawasp)
•
•
•
•
•
•
Australia, Indian ocean
MOST deadly of all envenomating marine life
25% fatality rate; more deaths than sharks!
One box can kill 10 humans
Cardioresp arrest within minutes
Mx: ABCs, remove tentacles, VINEGAR,
credit card scrape, ANTIVENOM (Chironex)
NEMATOCYSTS
NEMATOCYTS
• Portuguese Man -o - war
•
•
•
•
•
•
Southern US coast line
Not a true jellyfish
Usually only local reaction
Potential for full CV collapse
Many deaths reported
Mx: ABCs, remove tentacles, vinegar, credit
card scrape, NO antivenom exists
STINGS
• Stinger = specialized apparatus that
punctures skin and delivers venom
• Mx
• Remove stinger (? Xray to r/o stinger in tissue)
• Irrigate copiously, tetanus, analgesia
• HOT WATER for 30 - 90 min (inactivates the
heat labile venom; hot as possible)
• Antivenom exists for stonefish stings
STINGS
• Starfish
• Most nonvenomous
• Crown - of - thorns: severe
local reaction
STINGS
• Sea Urchins
•
•
•
•
Toxic coated spines
Severity depends on species
Usually only local reaction
Imbedded spines problematic
STINGS
• Stingray
•
•
•
•
Barbs on tail
Stepped on in shallow water
Tail spines ---> laceration
Stinger: local +/- systemic rxn
(N/V/D, cramps, CP, SOB)
• Remove stinger, irrigate, HOT
water, tetanus, abx to cover
vibrio
STINGS
•
•
•
•
•
•
Bony fish (Lionfish, Stonefish)
Venomous spins on fins
Stepped on or handled
Will attack b/f swimming away
Severe local rxn: pain, swelling
Systemic rxn: N/V/D, syncope,
SOB, paralysis, CV collapse
• ANTIVENOM exists
The Goods on Marine
Envenomations
Look but DON'T touch
Management
BITES
octopi
seasnakes
NEMATOCYSTS
jellyfish, sea wasp
man - of - war
STINGS
starfish, urchins
stingray, bonyfish
Local wound care
Antivenom for snakes
Remove tentacles
VINEGAR
Credit card scrape
Antivenom for sea wasps
Remove stinger
Irrigate
HOT WATER
Antivenom for stonefish
MARINE FOOD POISONING
• Consider the patient who is sick after eating
seafood…………..
MARINE FOOD POISONING
• 30YO male at fish from BOYD’S
SEAFOOD on New Year’s Eve
• Presents 2hrs after eating fish (Red snapper
and Mahi mahi)
• Nausea, vomiting, diarrhea, cramps
• Perioral peresthesias, burning fingertips,
ataxia, vertigo, ice pack on forehead felt
hot, watery eyes, diaphoretic
MARINE FOOD POISONING
•
•
•
•
What is your ddx?
Is this tetrodotoxin…..why or why not?
How are you going to make the diagnosis?
What is your management?
MARINE FOOD POISONINGS
• Food Poisoning
• Allergic reaction
• Other ddx of ? Food poisoning presenting
with neurological signs/symptoms……
• MG, botulism, MSG, encephalitis, polio, tick
paralysis, carbon monoxide, organophosphates,
anticholinergics, heavy metals, diptheria, eatonlambert, plant ingestion, migraine, the bends!
FISH POISONINGS
• Ciguatera
• Scombroid
• Tetrodotoxin
CIGUATERA
• Most common vertebrate fish poisoning
• World wide, warm waters, 90% in
spring/summer
• > 500 species of fish but ALL ARE LARGE
• red snapper, seabass, baracuda, grouper,
kingfish, sturgeon, parrot fish
CIGUATERA
• Ciguatoxin
•
•
•
•
•
•
Algae/protozoa ------- small fish ----- large fish
Heat stable thus cooking does NOT kill
Binds Na+ channels and increases permeability
Variable toxins thus variable symptoms
Ciguatoxin can be assayed (? Can our lab do it)
Toxin is absorbed quickly thus ONSET of
symptoms is 1 – 6 hrs after eating
CIGUATERA
Ciguatera Poisoning
Presenting Features
GI
NEURO
OTHER
Nausea
Vomiting
Diarrhea
Cramps
Perioral peresthesias
Metallic taste
Temperature reversal
Ataxia/weakness/vertigo/sz
Diaphoresis
Watery eyes
brady
hypotension
CIGUATERA
• Management
•
•
•
•
ABCs (including fluid resusc)
Activated charcoal if < 2hrs
Cathartics if no diarrhea
Mannitol
• Case reports of 1 gm/kg over 30 min decreasing
neurological effects of ciguatera
SCOMBROID
• Any large fish (MahiMahi + amberjack)
• Preventable with proper preparation
• Spoilage: bacteria convert hisitidine to saurine
and histamine which are the toxins
• Spoiled fish may have “honeycombing” or
peppery taste
• Onset of symptoms within minutes - hours
SCOMBROID
• Presentation similar to allergic reaction
• FLUSHING of face, neck, torso (diffuse erythema)
………can progress to urticaria
• Numbness, tingling, burning around mouth
• Can have bronchospasm
• Diagnosis = increased histamine levels in serum or
urine (can also test fish)
• NOT a fish allergy if others with same symptoms
or if fish can be tested
SCOMBROID
• Consider ddx of flushing, bronchospasm,
and headache
• Anaphylaxis, anaphylactoid reaction, scombroid,
MSG, tyramine, ethanol flush, tartrazine, metabisulfites
• Management
•
•
•
•
Benadryl, ranitidine
Ventolin prn
? Activated charcoal if early, ? Cathartic
Epinephrine if needed
TETRODOTOXIN
• Japan, California, Africa, Australia
• > 100 fish
• Puffer fish (FUGU), blow fish, toad fish,
balloon fish, globe fish
• Also crab eggs,blue-ringed octopus, newts
TETRODOTOXIN
• Toxin
•
•
•
•
•
Heat stable
Concentrated in ovary, liver, skin, intestine
Watch out for the female fishy in heat!!
Can be assayed
Blocks Na/K+ activity and blocks
neuromuscular activity
• Onset within MINUTES of ingestion
TETRODOTOXIN
• Presentation
• Headache, diaphoresis
• Paresthesias of lips, tongue, mouth, fingers/toes
• Dysphagia, dysarthria, ataxia, fasiculations
• Ascending paralysis and resp arrest
• Management
• ABCs, supportive, ? AC and cathartics, call the
priest (mortality 50%)
SHELLFISH POISONING
• General
• Mollusks filter dynoflagellates and algae
• More common during red tides when dinoflagellates go
crazy (can occur inbetween red tides)
• Any shellfish ingestion: clam, oyster, muscle, scallops
• Three Patterns
• Paralytic Shellfish Poisoning (PSP)
• Neurotoxic Shellfish Poisoning (NSP)
• Amnestic Shellfish Poisoning (ASP)
PARALYTIC SHELLFISH
POISONING (PSP)
• Onset < 30 min
• Saxitoxin blocks Na+ voltage gated channel
• Neuro symptoms predominate
• Paresthesias, ataxia, vertigo, weakness,
paralysis, cranial neuropathies, resp failure
• N/V/D/cramps LESS common
• Mx
• Supportive =/- lavage and cathartics
NEUROTOXIC SHELLFISH
POISONING (NSP)
• Onset ave 3hrs (15 min – 18hrs)
• Toxin = Brevitoxin
• GI + Neuro symptoms
• GI: N/V/D/cramps
• Neuro: paresthesias, temp reversal, ataxia, vertigo,
areflexia, NO paralysis
• Bradycardic and mydriasis, bronchospasm
• Mx
• Supportive, ventolin, ? decontamination
AMNESTIC SHELLFISH
POISONING (ASP)
• Onset ave 5hrs (15 min – 36hrs)
• Toxin = Domoic acid (Canadian outbreak 1987)
• GI + Neuro + CV
• GI: N/V/D/cramps
• Neuro: MEMORY LOSS (damage to amydala and
hippocampus)……..sz, grimacing, chewing,
opthalmoplegia less common
• CV: hypotension and arrythmias
• Mx: supportive, ? decontamination
OTHER POISONINGS
• Botulism
• Canned foods classic but can be from fresh fish
• GI = neuro (diplopia, dysphagia, dysarthria,
weakness)
• Toxin binds at NMJ
• Consider with………
• Myasenia gravis, eaton lambert, tick paralysis,
gullian barre’, miller fisher syndrome
SUMMARY of
FISH POISONING
INGESTION OF FISH
What kind of fish?
Onset of symptoms?
Symptom pattern?
Large fish
Not tetrodotoxic fish
Onset w/i hours
GI + Neurologic
Large fish
Not tetrodotoxic
Onset w/i hours
? allergic rxn (flush etc)
Tetrodotoxic fish
(puffer, blow, etc)
Onset w/i minutes
Ascending paralysis,etc
CIGUATERA
SCOMBROID
Tetrodotoxin
SUMMARY of SHELL FISH
INGESTION
Clam, muscles, oysters, scallops
Consider symptom/sign
presentation
Neurologic only
Paralytic
Shellfish
Poisoning
Neurologic +
GI
paresth,ataxia,
vertigo,no paralysis
memory loss
predominates
Neurotoxic
Poisoning
Amnestic Shellfish
Poisoning