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Cnidaria Envenomation: Treatment & Medication

Author: G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center
Contributor Information and Disclosures

Updated: Aug 18, 2008

Treatment

Prehospital Care

Prehospital personnel and rescuers on scene need to protect themselves from injury and protect the patient from further injury. When entering the water for rescue, protective clothing with wet suits and gloves is ideal. “Stinger suits” are highly recommended if available. 

  • To prevent further injury to the patient, the following decontamination steps are important:
    • Inactivate nematocysts: Vinegar or acetic acid in solutions of 4-6% is the most widely accepted treatment of initial stings. Pour vinegar over adhering tentacles for at least 30 seconds. In the absence of vinegar, Coca cola or old wine may be used, but these are not as effective. Hot water (42-45°C) for 20 minutes is likely beneficial in envenomings by Carukia barnesi and Physalia species. Methylated spirits, ethanol, and urine should not be used. Commercial products containing aluminum sulfate have not been shown to be better than vinegar or sea water in the inactivation of nematocysts or resolution of pain.
    • Removal of tentacles: Vinegar-treated tentacles may be removed easily. If vinegar is not available, the tentacles may be picked off safely by rescuers since only a harmless pricking may occur on the fingers of the rescuer, although forceps may also be used. Detached live tentacles should be treated with caution as envenomation may still occur for several hours. 
  • No animal studies have been performed to demonstrate a beneficial effect of pressure immobilization bandaging. In vitro models suggest additional venom release from naturally discharged nematocysts. It is not currently recommended by the Australian Resuscitation Council. Pressure immobilization bandaging remains controversial and cannot be routinely recommended at this time.
  • Capturing organisms responsible for envenomation is not necessary.

Emergency Department Care

  • General care
    • Treatment of Cnidaria envenomation is directed by the severity of the injury. Severe systemic symptoms may require respiratory and cardiovascular support.
    • Inactivate and remove tentacles as directed in Prehospital Care.
    • Treat anaphylaxis with airway support, supplemental oxygen, intravascular volume resuscitation, and epinephrine.
    • Wound care is paramount because both freshwater and saltwater contain numerous microbes. Infected wounds should be cultured for both aerobes and anaerobes. Antibiotics should be reserved for evidence of true infection and should not be given prophylactically.
    • Baking soda may be effective for stings caused by sea nettle (Chrysaora quinquecirrha).
    • Tetanus prophylaxis should be given if indicated.
    • Pruritus typically responds to antihistamines. Topical anesthetics and corticosteroids may also relieve pain. The majority of mildly painful stings respond to the application of ice after the application of vinegar.
    • A delayed recurrent reaction may occur after 1-2 months at the contact site and should be treated with corticosteroids.
  • Box jellyfish (Chironex fleckeri)
    • Most stings are not life threatening and require only basic wound care and pain relief. Tentacles should be inactivated with vinegar.
    • Antivenom
      • Box jellyfish antivenom is ovine-based concentrated immunoglobulins. Each ampule contains sufficient activity to neutralize 20,000 intravenous mouse doses (amount of toxin lethal in a 20 g mouse) of C fleckeri venom. Chironex antivenom will cross react with Chiropsalmus species venom to prevent neurotoxic and myotoxic effects. However, it has not prevented cardiovascular effects in vivo. Box jellyfish antivenom is available from Commonwealth Serum Laboratory in Melbourne, Australia.
      • Indications for use of antivenom
        • Cardiopulmonary arrest, hypotension, dysrhythmias, coma
        • Difficulty with breathing, swallowing, or speaking
        • Severe pain
        • Can be considered when the possibility of severe scarring is high
      • The recommended dose is 3 ampules diluted 1:10 with normal saline and given intravenously. Six ampules can be administered in the setting of cardiac arrest. Ampules can be given intramuscularly if no intravenous access is established.
      • The use of verapamil has been advocated in the management of severe Chironex envenomations based on in vitro models. However, its use in clinical management remains controversial and cannot be recommended at this time.
      • Magnesium has been demonstrated to improve the effectiveness of antivenom in rats from 40% to 100%. However, prophylactic administration alone did not prevent cardiovascular collapse.
  • Irukandji syndrome
    • Evidence as to the best management of Irukandji syndrome remains predominantly anecdotal.
    • Opiate analgesia is frequently required. Nitroglycerin and phentolamine have both been used with success in the treatment of hypertension. Magnesium has also been reported to improve the hyperadrenergic state and relieve pain. Chironex antivenom does not cross react with C barnesi.

Consultations

A poison center toxicologist can be consulted for treatment advice and access to antivenom.

Medication

Analgesics and local anesthetics can be used to ameliorate pain associated with these bites. Antivenom exists for box jellyfish (C fleckeri). Chironex antivenom will cross react with Chiropsalmus species venom to prevent neurotoxic and myotoxic effects. However, it has not prevented cardiovascular effects in vivo. Antivenom is available in Australia and is produced by Commonwealth Serum Laboratories.

Antivenom

These agents neutralize toxins.


Box Jellyfish Antivenom

Box jellyfish antivenom is ovine-based concentrated immunoglobulins. Each ampule contains sufficient activity to neutralize 20,000 IV mouse doses of C fleckeri venom. Chironex antivenom will cross react with Chiropsalmus species venom to prevent neurotoxic and myotoxic effects. However, it has not prevented cardiovascular effects in vivo. Box jellyfish antivenom is available from Commonwealth Serum Laboratory in Melbourne, Australia.

Adult

3 ampules IV/IM over 5 min diluted in 1:10 normal saline 6 ampules can be given in cardiac arrest

Pediatric

<12 years: Not established
>12 years: Administer as in adults

Documented hypersensitivity to ovine serum (may still be indicated for severe envenomation, despite hypersensitivity)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Anaphylaxis may occur; appropriate therapeutic agents for treatment of anaphylaxis should be ready for immediate use

More on Cnidaria Envenomation

Overview: Cnidaria Envenomation
Differential Diagnoses & Workup: Cnidaria Envenomation
Treatment & Medication: Cnidaria Envenomation
Follow-up: Cnidaria Envenomation
Multimedia: Cnidaria Envenomation
References
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Further Reading

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Keywords

jellyfish envenomation, cnidaria envenomation, jellyfish sting, box jellyfish, aquatic invertebrates, Hydrozoa, Portuguese man-of-war, fire coral, Scyphozoa, true jellyfish, Cubozoa, Anthozoa, sea anemone, coelenterate envenomation,  

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Contributor Information and Disclosures

Author

G Patrick Daubert, MD, Assistant Professor, Assistant Medical Director, Sacramento Division, California Poison Control System; Director of Clinical and Medical Toxicology Education, Department of Emergency Medicine, University of California, Davis Medical Center
G Patrick Daubert, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Medical Toxicology, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Dana A Stearns, MD, Assistant Director of Undergraduate Education, Department of Emergency Medicine, Massachusetts General Hospital
Dana A Stearns, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

A Antoine Kazzi, MD, Chair and Medical Director, Department of Emergency Medicine, American University of Beirut, Lebanon
A Antoine Kazzi, MD is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Scott H Plantz, MD, FAAEM, Associate Clinical Professor of Emergency Medicine, Rosalind Franklin University of Medicine and Science, Chicago Medical School; Medical Director, WeCare Med,Inc
Scott H Plantz, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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