Transcript Marine Envenomations

Hussein Unwala , Dr. Ingrid Vicas
February 4, 2010
GOALS FOR TODAY
 MARINE ENVENOMATIONS
 Three mechanisms of envenomation
 Standard treatment for each mechanism
 Recognize life threatening
MARINE ENVENOMATIONS
 2000 species of venemous marine animals
 General Mx
 Remove from water: drowning MCC of death
 Local wound care, analgesia
 ? 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
Cone Snails
BITES
 Octopi
 Local wound care: irrigate,
debride, dress, tetanus,
analgesia
 Blue - ringed Octopus can
be lethal (tetrodotoxin like
venom)
BITES
 Seasnakes
 52 species, all venemous, 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
BITES
 Cone Snails
 Envenomation occurs
with handling
 Contain a tooth bathed
in venom
 Peptides currently being
studied in chronic pain
 Supportive Care
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 box jellyfish
NEMATOCYSTS
 Jellyfish
 Usually only local reaction
 Remove tentacle, vinegar,
credit card scrape,
antihistamine, analgesia
NEMATOCYSTS
NEMATOCYSTS
 Box Jellyfish (Seawasp)
 Australia, Indian ocean
 15-20% fatality rate; more deaths than sharks!
 Severe pain, whiplike linear rash, then systemic
symptoms
 Cardioresp arrest within minutes = Irukandji syndrome
 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,
ice packs for mild stings
 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
Consider pressure
bandage
Cases??
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, eaton-lambert, 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