Echinoderm Envenomation Medication
- Author: Scott A Gallagher, MD, FACEP; Chief Editor: Joe Alcock, MD, MS more...
Medical therapy is directed primarily at local and systemic analgesia, with nonspecific supportive therapy required only in the most severe cases. Prophylactic antibiotics are generally not indicated, except in persons with deep puncture wounds or who are immunocompromised. However, once infection is established, prompt therapy must be instituted with emphasis on coverage for potential marine pathogens. No antivenoms are available. Tetanus prophylaxis is indicated in all marine animal injuries.
These are used to provide local or regional anesthesia as adjunctive or alternative pain control.
Any of the commonly used local anesthetics suffice; however, bupivacaine provides superior duration of anesthesia and pain relief for irrigation, wound exploration, and debridement.
Analgesics are for adjunctive pain control when immersion therapy and local and/or regional anesthesia are not sufficient. Analgesic route (oral or parenteral) is a matter of choice and may not be needed with appropriate local or regional anesthetic.
DOC for narcotic analgesia because of its reliable and predictable effects, safety profile, and ease of reversibility with naloxone.
Morphine sulfate administered IV may be dosed in a number of ways and is commonly titrated until desired effect obtained.
Antibiotics are indicated for outpatient treatment of early or minor wound infections and prophylaxis for high-risk wounds (deep puncture wounds, grossly contaminated wounds, persons who are chronically ill or immunocompromised).
Trimethoprim/sulfamethoxazole, ciprofloxacin, tetracycline, and doxycycline are referenced as the initial oral antibiotics of choice in different sources for uncomplicated wound infection or prophylaxis following marine-acquired injuries. Other antibiotics mentioned include cephalexin, amoxicillin, and amoxicillin clavulanate.
Broad-spectrum parenteral antibiotics are indicated for serious wound infections (eg, cellulitis, myositis, gas gangrene) or sepsis following injuries sustained in the marine environment. The mortality rate for a Vibrio species wound infection approaches 50% (usually patients with chronic liver disease), and serious Aeromonas species infection may mimic clostridial gas gangrene.
No controlled studies exist regarding efficacy of therapy. Several references suggest both a tetracycline and either an extended-spectrum cephalosporin or aminoglycoside.
Trimethoprim-sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. This results in inhibition of bacterial growth.
Ciprofloxacin is a bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA-gyrase in susceptible organisms.
Tetracycline treats susceptible bacterial infections of gram-positive and gram-negative organisms as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. It inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s) of susceptible bacteria.
Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.
Ceftazidime is a third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. It arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more of the penicillin-binding proteins.
Corticosteroids may be indicated for treatment of delayed tissue reactions. These occur in the form of either nodular or diffuse granulomatous lesions, occurring up to 3 months after penetrating echinoderm injuries, particularly those from sea urchins. Generally, though not exclusively, these result from unrecognized retained spine fragments. Intralesional and/or systemic corticosteroid therapy may be beneficial, although clearly less efficacious than surgical removal of spine fragments. Topical corticosteroids may be useful for treatment of dermatitis.
Prednisone is useful in the treatment of inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, it may decrease inflammation.
Triamcinolone treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of PMNs and reversing capillary permeability.
Hydrocortisone has mineralocorticoid activity and glucocorticoid effects. It decreases inflammation by suppression of the migration of PMNs and reversal of increased capillary permeability. It is useful in the management of inflammation caused by immune responses.
These agents are used to generate passive immunity.
Tetanus immune globulin is used for passive immunization of any person with a wound that may be contaminated with tetanus spores.
Generally, immunization against tetanus is considered for this type of envenomation. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin (Hyper-Tet).
Diphtheria-tetanus toxoid is used to induce active immunity against tetanus in selected patients. It is the immunizing agent of choice for most adults and children older than 7 years. It is necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, it may be administered into the deltoid or midlateral thigh muscles. In infants, the preferred site of administration is midlateral thigh.
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