eMedicine Specialties > Emergency Medicine > Environmental

Conidae: Treatment & Medication

Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine
Coauthor(s): William H Shoff, MD, DTM&H, Director, PENN Travel Medicine, Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania
Contributor Information and Disclosures

Updated: Apr 30, 2009

Treatment

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.

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.

Consultations

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

Medication

No antivenin is available for cone shell envenomation.

More on Conidae

Overview: Conidae
Differential Diagnoses & Workup: Conidae
Treatment & Medication: Conidae
Follow-up: Conidae
References
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References

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  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].

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  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].

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Further Reading

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Keywords

cone shell toxin, cone shell envenomation, cone shell sting, Conidae family, cone shell venom, conotoxin, conus, mollusca envenomation, conotoxin peptides, Conus geographicus, Conus geographus, C geographus, C geographicus, ziconotide, Conus aulicus, C aulicus, Conus gloria-maris, Conus gloriamaris, C gloriamaris, C gloria-maris, Conus marmoreus, C marmoreus, Conus omaria, C omaria, Conus striatus, C striatus, Conus tulipa, C tulipa, Conus textile, C textile, Mollusca, mollusk, mollusc, oligopeptide toxin, radula, radular sheath, cone shell poisoning

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Contributor Information and Disclosures

Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM, Associate Professor, 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 Consulting fee Consulting; Glaxo Smith Kline Honoraria Speaking and teaching

Medical Editor

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.

Pharmacy Editor

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

Managing Editor

James Steven Walker, DO, MS, Clinical Professor of Surgery, Department of Surgery, University of Oklahoma Health Sciences Center
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.

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

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

 
 
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