Conidae Treatment & Management

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Barry E Brenner, MD, PhD, FACEP   more...
 
Updated: May 27, 2011
 

Prehospital Care

Focus prehospital care on maintenance of vital functions and prevention of toxin transport from the injection site.

  • Airway maintenance and ventilation may prove lifesaving.
  • Transport the patient appropriately, as the patient may have oropharyngeal muscle paralysis, and the risk of aspirating vomitus is real.
  • Keep the stung extremity in a dependent position, and keep the patient still. Careful, knowledgeable use of the lymphatic-occlusion pressure immobilization bandage suggested for Australian snakebites may be effective (for information on the immobilization technique, see Snake Envenomation, Coral). Tourniquet use is not recommended because it may result in significant iatrogenic injury.
  • No role exists for attempted suctioning of conotoxin from the wound.
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Emergency Department Care

  • For initial management of suspected cone shell envenomation, place emphasis on immediate resuscitation and treatment of respiratory failure.
  • No antivenin is available for cone shell envenomation.
  • Examine the wound for the presence of a radular tooth and cleanse. Determine the patient's tetanus status and update as appropriate.
  • Place the affected limb in hot (not scalding) water to tolerance, with pain relief as the goal. Patients who have experienced a significant envenomation may not obtain adequate pain relief with hot-water immersion and may require additional local anesthesia (1-2% lidocaine without epinephrine) and/or oral or intravenous analgesia.
  • A lymphatic-occlusive pressure immobilization bandage may have been placed proximal to an extremity wound site in the prehospital setting. Do not jeopardize arterial circulation distal to this bandage. This bandage may be applied for 4-6 hours; do not remove until the provider is prepared to render systemic support. Incision and drainage followed by soaking the affected site in 45°C water (not scalding) has also been recommended.
  • Cardiovascular and respiratory supports are the keystones of management; therefore, the provider must be prepared to support the patient systemically.
    • Data from case reports suggest that edrophonium 10 mg IV may be used as empiric therapy for paralysis. A 2-mg test-dose should first be administered, and if effective, followed by an additional 8-mg dose. Atropine 0.6 mg should be immediately available for intravenous administration in case of an adverse reaction to the edrophonium.
    • A 2- to 4-mg dose of intravenous naloxone may help treat severe hypotension because it blocks the beta-endorphin vasodepressor response.
    • Consider central venous access for fluid resuscitation in cases of severe envenomation.
    • Further study of the infrequent coagulopathy associated with these incidents may provide guidelines for the use of blood products, fresh frozen plasma, cryoprecipitate, desmopressin, and fibrinolytic/antifibrinolytic agents.
  • Mild envenomations should resolve within 6-8 hours and the patient can be discharged.
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Consultations

Upon encountering a cone shell envenomation, consult the appropriate local poison control center or toxicologist.

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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Specialty Editor Board

Samuel M Keim, MD  Associate Professor, Department of Emergency Medicine, University of Arizona College of Medicine

Samuel M Keim, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Public Health Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: eMedicine Salary Employment

James Steven Walker, DO, MS  Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, and American Osteopathic Association

Disclosure: Nothing to disclose.

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

Barry E Brenner, MD, PhD, FACEP  Professor of Emergency Medicine, Professor of Internal Medicine, Program Director, Emergency Medicine, Case Medical Center, University Hospitals, Case Western Reserve University School of Medicine

Barry E Brenner, MD, PhD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Chest Physicians, American College of Emergency Physicians, American College of Physicians, American Heart Association, American Thoracic Society, Arkansas Medical Society, New York Academy of Medicine, New York Academy of Sciences, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References

  1. Yuan DD, Liu L, Shao XX, Peng C, Chi CW, Guo ZY. Isolation and cloning of a conotoxin with a novel cysteine pattern from Conus caracteristicus. Peptides. Sep 2008;29(9):1521-5. [Medline].

  2. Duda TF Jr. Differentiation of venoms of predatory marine gastropods: divergence of orthologous toxin genes of closely related Conus species with different dietary specializations. J Mol Evol. Sep 2008;67(3):315-21. [Medline].

  3. Han TS, Teichert RW, Olivera BM, Bulaj G. Conus venoms- a rich source of peptide-based therapeutics. Current Pharmaceutical Design. 2008;14(24):2462-79. [Medline].

  4. Ekberg J, Craik DJ, Adams DJ. Conotoxin modulation of voltage-gated sodium channels. Int J Biochem Cell Biol. 2008;40(11):2363-8. [Medline].

  5. Atanassoff PG, Hartmannsgruber MW, Thrasher J, Wermeling D, Longton W, Gaeta R, et al. Ziconotide, a new N-type calcium channel blocker, administered intrathecally for acute postoperative pain. Reg Anesth Pain Med. May-Jun 2000;25(3):274-8. [Medline].

  6. Auerbach PS. Marine envenomations. N Engl J Med. Aug 15 1991;325(7):486-93. [Medline].

  7. Brown CK, Shepherd SM. Marine trauma, envenomations, and intoxications. Emerg Med Clin North Am. May 1992;10(2):385-408. [Medline].

  8. Cox B. Calcium channel blockers and pain therapy. Curr Rev Pain. 2000;4(6):488-98. [Medline].

  9. Cruz LJ, White J. Clinical toxicology of Conus snail stings. In: Handbook of Clinical Toxicology of Animal Venoms and Poisons. CRC Press; 1995:117-128.

  10. Dutertre S, Lewis RJ. Toxin insights into nicotinic acetylcholine receptors. Biochem Pharmacol. Sep 14 2006;72(6):661-70. [Medline].

  11. Hahin R, Wang GK, Shapiro BI, Strichartz G. Alterations in sodium channel gating produced by the venom of the marine mollusc Conus striatus. Toxicon. 1991;29(2):245-59. [Medline].

  12. Hawdon GM, Winkel KD. Venomous marine creatures. Aust Fam Physician. Dec 1997;26(12):1369-74. [Medline].

  13. Heinemann SH, Leipold E. Conotoxins of the O-superfamily affecting voltage-gated sodium channels. Cell Mol Life Sci. Jun 2007;64(11):1329-40. [Medline].

  14. Jain KK. An evaluation of intrathecal ziconotide for the treatment of chronic pain. Expert Opin Investig Drugs. Oct 2000;9(10):2403-10. [Medline].

  15. Jin AH, Brandstaetter H, Nevin ST, Tan CC, Clark RJ, Adams DJ, et al. Structure of alpha-conotoxin BuIA: influences of disulfide connectivity on structural dynamics. BMC Struct Biol. 2007;7:28. [Medline].

  16. Kobayashi J, Nakamura H, Hirata Y, Ohizumi Y. Effect of venoms from Conidae on skeletal, cardiac and smooth muscles. Toxicon. 1982;20(5):823-30. [Medline].

  17. Livett BG, Sandall DW, Keays D, Down J, Gayler KR, Satkunanathan N, et al. Therapeutic applications of conotoxins that target the neuronal nicotinic acetylcholine receptor. Toxicon. Dec 1 2006;48(7):810-29. [Medline].

  18. McIntosh JM, Jones RM. Cone venom--from accidental stings to deliberate injection. Toxicon. Oct 2001;39(10):1447-51. [Medline].

  19. Miljanich GP. Ziconotide: neuronal calcium channel blocker for treating severe chronic pain. Curr Med Chem. Dec 2004;11(23):3029-40. [Medline].

  20. Norton RS, Olivera BM. Conotoxins down under. Toxicon. Dec 1 2006;48(7):780-98. [Medline].

  21. Olivera BM. Conotoxins and other biologically active peptides in Conus venoms. Toxicon. 1990;28:256.

  22. Olivera BM, Rivier J, Clark C, Ramilo CA, Corpuz GP, Abogadie FC, et al. Diversity of Conus neuropeptides. Science. Jul 20 1990;249(4966):257-63. [Medline].

  23. Pi C, Liu J, Peng C, Liu Y, Jiang X, Zhao Y, et al. Diversity and evolution of conotoxins based on gene expression profiling of Conus litteratus. Genomics. Dec 2006;88(6):809-19. [Medline].

  24. Rauck RL, Wallace MS, Leong MS, Minehart M, Webster LR, Charapata SG, et al. A randomized, double-blind, placebo-controlled study of intrathecal ziconotide in adults with severe chronic pain. J Pain Symptom Manage. May 2006;31(5):393-406. [Medline].

  25. Sharpe IA, Gehrmann J, Loughnan ML, Thomas L, Adams DA, Atkins A, et al. Two new classes of conopeptides inhibit the alpha1-adrenoceptor and noradrenaline transporter. Nat Neurosci. Sep 2001;4(9):902-7. [Medline].

  26. Teichert RW, Jacobsen R, Terlau H, Yoshikami D, Olivera BM. Discovery and characterization of the short kappaA-conotoxins: a novel subfamily of excitatory conotoxins. Toxicon. Mar 1 2007;49(3):318-28. [Medline].

 
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