Marine Injuries, Envenomation &

Poisoning

DEWI DIAN SUKMAWATI

Tropical & Infectious Diseases of
Internal Medicine Dept.
Sanglah Hospital – Medical School of Udayana
BALI INDONESIA
OUTLINE

• FACTS and STATS

• Pretravel consideration
• MARINE INJURIES
• Scuba Diving & flying after Diving

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 FACTS & STATS
• The ocean provides fun & enjoyable activities
for the traveler, it is wise to be prepared for
potential hazards.
• Increased interaction of people with the
marine environment has inevitability
increased the risk of related injuries & illness.

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 France
Greece
California

Mexico west Bahamas

coast

Maldives
Polynesian
Seychelles
Brazil

Cape Town

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OUTLINE

• FACTS and STATS

• Pretravel consideration
• MARINE INJURIES
• Scuba Diving & flying after Diving

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PRETRAVEL CONSIDERATION
• Updated Immunization Shots
– Divers special consideration: Tetanus vaccine
– Polluted water: Hepatitis A vaccine, Typhoid Fever
vaccine
• Schistosomiasis: Central Sulawesi (Lindu &
Napu valley)

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Schisostomiasis Risk Map
CDC Yellow Book 2014
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• Malaria & insect prevention
– Mefloquine (Lariam®) side effect mimics
decompression sickness (tremors, dizziness,
rashes,joint pain)

• Other risks: sunburn, hypothermia, motion

sickness, injuries from boat propellers &
drowning.

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Sea Sickness
• Basic Guideline • Drug Prevention
– Eat light food & – Scopolamine (Transderm
adequate fluid intake. Scop ®)
– Ginger reduces nausea – Cinnarizine (Stugeron ®)
– Keep active & monitor – Phenergan promethazine
the horizon. – Dimenhydrinate (Antimo ®)
– Acupressure wristbands

For best results all drug remedies should be

taken 1-2 hours (scopolamine patch 4 h) prior
to the sea voyage
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OUTLINE

• FACTS and STATS

• Pretravel consideration
• MARINE INJURIES
• Scuba Diving & flying after Diving

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MARINE INJURIES

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 THE APPROACH FOR SUSPECTED
MARINE ENVENOMATION

Very Painful Not/less

Painful
No Tentacles Tentacles
Puncture wound
Penetrating
barbs Jellyfish
Blue ringed
Stingray octopus
Sea Urchins Cone shell
Stone fish Vinegar, cold/ice Sea snake
Barbed fish pack

Pressure immobilization
Hot water, Heat Pack. bandage. Transfer to
Transfer to medical care medical care
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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

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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

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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

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Marine stings and spikes:
FACTS & STATS
• Male predominance (70%)
• Organism: Various fish species (40.5%), stingrays
(22.4%), jellyfish (20.5%), & sharks (2.4%)
• Spikes, spines, & barbs injuries (40.0%) vs. stings
(26.3%)
• Most (62%) injuries were to the limbs (hands or
feet)
– 19.5% injuries were associated with a retained foreign
body.
– 8.3%patients required admission to the hospital.
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 MARINE
ENVENOMATION
Major clinical Manifestation

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

Stone Fish
BITES Hydroids

Cobbler Fish
Jellyfish

Scorpion Fish Blue ringed Sea Snake

octopus

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PUNCTURE WOUNDS
• Stonefish, stingrays, sea urchins, scorpion fish,
lionfish, cobbler
• The spines contain venom-filled glands that
cause extreme burning pain (neurotoxin) &
often tissue discoloration with swelling.

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Stingray injury with Sea urchin injury
necrosis sloughing skin &
erythema

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Puncture wound: First Aid
• Lay victim down, elevate affected limb, wash
wound & gently remove spine if possible,
immerse both limbs (good limb provides safety
check) in hot water up to 45°C for 30 –45
minutes, treat for shock.
• X-rays may be required to help with the removal
of imbedded spines, particularly in the hand or
foot.
• All puncture wounds have the potential to cause
infection.
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Puncture wound: Prevention
• Wear thick-soled boots/shoes if reef-walking,
avoid lying or standing on bottom if diving

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Stingray fish natural habitat: can be found
in all part of the world

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Lionfish invasion new threat in the Atlantic

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RASH
• Fire coral, anemone, Hydroids, certain
sponges, Box jellyfish, Portuguese man of war
• Contain millions of stinging cells (nematocysts)
• The Portuguese man-of-war (bluebottle) & the
box jellyfish can kill an adult within minutes.
• The nematocyst venom gland is triggered by
several factors, including mechanical force &
fresh water.
Prevention: Stinger suit
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A B

A. Jelly fish sting ( whip – like cross

hatched skin lesions)
B. Fire coral injury with rash, blisters and
hives type.
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 Jellyfish Envenomation
• Sign & symptoms:
– Intense, stinging pain, itching, rash, and raised welts.
– The progressive effects may include nausea, vomiting,
diarrhea, lymph node swelling, abdominal pain,
numbness/tingling & muscle spasms.
• Management:
– Vinegar Ice/Cold pack
– Compression/ immobilization to decrease spread of
venom.
– CPR, 1st aid.

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Rash: First Aid
• DO NOT attempt to physically remove jellyfish
tentacles or rinse them with fresh water.
• Deactivated with vinegar then use ice packs,
analgesia. Treat for shock if present
• The nematocysts may be removed by shaving
or by the use of adhesive tape.
• Topical steroid creams can help ease the
inflammation

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BITE WOUND
• Sea snake, blue ringed octopus, (shark bite:
nasty but not poisonous)

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Sea Snakes
• Two families: Laticaudinae (amphibious, 20
species) & Hydropiinae (aquatic, 50 species)
• Characterized by: laterally compressed bodies
& vertically flattened tails and nostrils with
valve-like flaps (eel-like appearance)
• Generally, not aggressive, not actively pursue
swimming prey. Aggressive when taken out of
water.

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BEAKED SEA SNAKES, the most
common sea snakes
The venom 4 – 8 x more lethal than
cobra’s venom

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YELLOW BELLIED sea snakes, the
most widely distributed sea snake.
The venom toxicity ¼ of beaked sea
snake’s venom. More toxic than king
cobra.
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 The Faint-banded Sea Snake
(Hydrophis belcheri)
The most venomous snake in the world
100 x more lethal than the venom of
King Cobra
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• Nearly 80% of sea snake bites not give
significant envenomation.
• The clinically relevant toxins
– Neurotoxin causes peripheral paralysis
– Myotoxins causes muscle necrosis, with
consequent myoglobinemia & hyperkalemia
– The venom not significantly affect blood
coagulation

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• Mortality 10% (without antivenom)
• Symptoms:
– Occurs 5 min – 8 h (2 h) after bite (fang marks
with local tissue reaction)
– Multiple organs, neurological symptoms
predominating
– Within 8 h: myoglobinemia, myoglobinuria &
acute kidney failure. Hyperkalemia may leading to
cardiac arrest

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Sea Snake bites management
• Stabilization of (ABCs)
• IV line, Cardiac monitoring & continuous pulse
oxymetry
• Tetanus prophylaxis
• Antivenom:
– Polyvalent sea snake antivenom (Commonwealth
Serum Laboratories, Melbourne, Australia) or tiger
snake (Notechis scutatus) antivenom
– Dialysis if antivenom not available

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Blue Ringed Octopus
• May bite if stepped on, found in the Pacific
Ocean from Japan to Australia
• The poison contains maculotoxin &
tetrodotoxin  has no antivenin
• May result in almost instant death.
• ABC’s & artificial respiration
(continued up to 24 h)

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Poisoning & Fish for Consumption
• Shellfish poisoning
• Puffer fish poisoning
• Scombroid poisoning
• Ciguatera poisoning

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Shell Fish Poisoning
MOLLUSKS Cone shell

Oyster, Scallops
Feed on Dino flagellates
& unicellular organism Squids, octopuses

Neurotoxins (Saxitoxins)
accumulation

Inhibit neuromuscular Suppress Atrioventricular Depress medullary

transmission conduction respiration centre

WEAKNESS CARDIAC RESPIRATORY ARREST

BLOCK  ARREST

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Paralytic Shellfish Poisoning (PSP)
• Purely Supportive
• Gastric Lavage
• Activated Charcoal 1 gr/kg BW
• Cathartics
• Prevention of Further Anoxic Injury (in
Hospital)

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Puffer Fish Poisoning
• Toad fish, blow fish, globefish, swellfish, balloon fish
• Contains Tetrodotoxin (potent non protein
neurotoxin), 1200x more poisonous than cyanide
• Prepared as FUGU dish (Japan) have mood elevation
effect.

• Toxin in one fish can kill 30 adults

human

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Tetrodoxin (TTX)  sodium channel blocker &
depress
1. Medullary respiratory center
2. Atrioventricular conduction & myocardial
3. Skeletal muscle contractibility

Fatality rate 6.8 %

60% die within
6 Hours
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Challenging live, the absurd way to die

January 1975, Mitsugoro Bando VIII, a Kabuki actor, Japan

national treasure, died after having four servings of lethal
fugu livers
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Puffer fish Poisoning: MANAGEMENT
• Early treatment directed at inactivating &
eliminating the acid stable toxin
• Gastric Lavage with aliquots of 200 ml Sodium
Bicarbonate 2% at least total 2 liter followed by in
activated Charcoal 1 gram/ BW & sorbitol 30-50 ml
• Intubation + Mechanical ventilation for respiratory
distress & CNS depression
• Vasopressors
• Atropine

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Scombroid Poisoning
• The most common fish poisonings world wide.
– Mackarel, Tuna, Mahi mahi, Sardines, Marlin, Anchovy
• Risk: inadequate Fish Preservation or Refrigeration
– The fish have high HISTIDINE (H) content
– Bacteria convert (decarboxylation) Histidine to
HISTAMINE
– Histamine not destroyed by cooking canning or
autoclaving
– Symptoms: Histamine – like syndrome

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Histamine like syndrome
• 10 minutes – 2 hours after eating
contaminated food: Headaches, rashes,
itching, diarrhea & vomiting or abdominal
pain
• Resolve within 12 hours

Pruritus & Urticaria following

scombroid poisoning
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Scombroid Poisoning:
MANAGEMENT
• Counteract & reverse histamine effect:
• Histamine -2 Blocker (Cimetidine) 300 mg IV or Ranitidine
50 mg IV
• In severe form:
• Subcutaneus Epinephrine, Inhaled Brochodilators,
Corticosteroids, Vasopressors
• If present within an hour :
• Gastric Lavage
• Activated charcoal & Sorbitol

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Ciguatera Fish Poisoning (CFP)
The toxins: Ciguatoxin,
maitooxin, scaritoxin,
palytoxin

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• CFP onset of symptoms 15 min to 24 hours after
ingestion
• Acute gastroenteritis and neurological symptoms at
the same time.
– Neurological symptoms may permanent (misdiagnose as
MS)
– Patognomonic: the apparent reversal of hot and cold
sensation (allodynia)
• Hypotension and bradycardia may also occur

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CFP: Management
• If presented < 4 hours of ingestion : gastric lavage,
followed by charcoal and sorbitol
• Standard Antiemetics for nausea & vomiting
• Vasopressors
• Mannitol
• Prevention :
– Avoid eating oversized Reef Fish
– Avoid any ingestion of Marine Fish Viscera

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OUTLINE

• FACTS and STATS

• Pretravel consideration
• MARINE INJURIES
• Scuba Diving & flying after
Diving

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Scuba Diving & Flying after Diving
• Risks:
– Decompression Sickness (DCS)
– Barotrauma (PULMONARY, ears & sinuses)
• Flying after diving
– 12 hours after a non-decompression dive
– 24 hours after a dive requiring a decompression
stop
– 24 hours after daily,
multiple dives for several days

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Stings & Spikes
Envenomation
NEUROTOXIN
Cnidaria (Jellyfish, Coral,
Anemone)
Echinoderms (Sea Urchins,
Starfish)
Stingrays (Chondrichthyes)
Cottonmouth, water
moccasin
Sea Snake (Southeast Asia,
Persian gulf, Malaysia)
Octopus (Blue-ringed and
spotted)
Cone Shell (Australia, New
Guinea, California)
Scorpion Fish
Sea Sponges (Touch-me-not
and Fire sponge)
Bristle worms (Fire Worms)
MARINE INJURIES
Marine animal Pruritus after Poisoning & fish
bites & trauma water exposure for consumption
ANIMAL BITE AQUAGENIC PRURITUS Shellfish poisoning
Moray eel Swimmer's Itch (Fresh Pufferfish poisoning
Barracudas water exposure) Scombroid poisoning
Sharks Seabather's Eruption Ciguatera poisoning
(Salt water exposure)
ABRASIONS or
LACERATIONS from coral
or sharp rocks
Most common cause of
marine injury
High risk of infection
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Further Reading
• CDC Yellow Book 2014
• Textbook of Travel Medicine and Health, 2nd.Ed. DuPont
and Steffen. 2001. 376-389.
• Harrison’s Principle of Internal Medicine 18th 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
• Goldman’s Cecil Medicine 24th ed. Chapter 114:
Venoms and Poisons from Marine organisms
• http://www.fpnotebook.com/Sports/DER/MrnInjry.ht
m

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 Thank You

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