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Echinoderm Envenomation Medication

  • Author: Scott A Gallagher, MD, FACEP; Chief Editor: Joe Alcock, MD, MS  more...
 
Updated: Oct 27, 2015
 

Medication Summary

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.

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Local anesthetics

Class Summary

These are used to provide local or regional anesthesia as adjunctive or alternative pain control.

Bupivacaine (Marcaine, Sensorcaine)

 

Any of the commonly used local anesthetics suffice; however, bupivacaine provides superior duration of anesthesia and pain relief for irrigation, wound exploration, and debridement.

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Analgesics

Class Summary

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.

Morphine sulfate (Duramorph, Astramorph, MS Contin)

 

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.

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Antibiotics

Class Summary

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 (Bactrim, Septra)

 

Trimethoprim-sulfamethoxazole inhibits bacterial synthesis of dihydrofolic acid by competing with PABA. This results in inhibition of bacterial growth.

Ciprofloxacin (Cipro)

 

Ciprofloxacin is a bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth, by inhibiting DNA-gyrase in susceptible organisms.

Tetracycline (Sumycin)

 

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 (Bio-Tab, Doryx, Vibramycin)

 

Doxycycline inhibits protein synthesis and, thus, bacterial growth by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria.

Ceftazidime (Fortaz, Ceptaz)

 

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.

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Corticosteroids

Class Summary

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 (Deltasone, Meticorten, Sterapred)

 

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 (Aristocort)

 

Triamcinolone treats inflammatory dermatosis that is responsive to steroids. It decreases inflammation by suppressing the migration of PMNs and reversing capillary permeability.

Hydrocortisone (Solu-Cortef)

 

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.

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Immune globulins

Class Summary

These agents are used to generate passive immunity.

Tetanus immune globulin (TIG)

 

Tetanus immune globulin is used for passive immunization of any person with a wound that may be contaminated with tetanus spores.

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Toxoids

Class Summary

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 (Decavac)

 

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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Contributor Information and Disclosures
Author

Scott A Gallagher, MD, FACEP Department of Emergency Medicine, Aspen Valley Hospital; Senior Clinical Instructor, Department of Surgery, School of Medicine, University of Colorado Health Sciences Center

Scott A Gallagher, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

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, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Norris, MD Professor, Department of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, International Society of Toxinology, American Medical Association, California Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

References
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  2. Marsh L, Slack-Smith S, Gurry D. Sea Stingers. Perth: Western Australian Museum; 1986. 133.

  3. Underhill D. Australia's Dangerous Creatures. Sydney: Reader's Digest; 1987. 368.

  4. Freyvogel TA. Poisonous and venomous animals in East Africa. Acta Trop. 1972. 29(4):401-51. [Medline].

  5. Edmonds C. Dangerous Marine Creatures. Frenchs Forest, NSW: Reed Books; 1989. 192.

  6. Smith MM. Sea and Shore Dangers: Their Recognition, Avoidance, and Treatment. Grahamstown, South Africa: JLB Smith Institute of Ichthyology, Rhodes University; 1977: 21-31.

  7. Auerbach PS. Medical Guide to Hazardous Life. 2nd ed. Best Pub Co; 1991. 21-23, 33-34.

  8. Auerbach PS. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 4th ed. Mosby-Year Book; 2001. 1473-1479.

  9. Bove AA, Davis J. Bove and Davis' Diving Medicine. 3rd ed. WB Saunders Co; 1997. 310-311.

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  12. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. Mosby-Year Book; 1996. 488-489, 493.

  13. Halstead BW, Auerbach PS. With prevention, first aid and treatment. Dangerous Aquatic Animals of the World: A Color Atlas. Darwin Press Inc; 1992. 45-49.

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  18. Perkins RA. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. 2004. 69 (4):885-90. [Medline].

  19. Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. 2004 Feb 15. 69(4):885-90. [Medline].

  20. Schwartz S, Meinking T. Venomous marine animals of Florida: morphology, behavior, health hazards. J Fla Med Assoc. 1997 Oct. 84(7):433-40. [Medline].

  21. Singletary EM, Rochman AS, Bodmer JC. Envenomations. Med Clin North Am. 2005 Nov. 89(6):1195-224. [Medline].

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  23. Strauss MB, MacDonald RI. Hand injuries from sea urchin spines. Clin Orthop Relat Res. 1976 Jan-Feb. (114):216-8. [Medline].

  24. Trott AT. Wounds and Lacerations: Emergency Care and Closure. 2nd ed. Mosby-Year Book; 1997. 285-295.

 
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Echinoderm envenomations. Close-up of brittle star arm. Although spiny, members belonging to this class (Ophiuroidea) generally are considered harmless. Of the phylum Echinodermata, only starfish (class Asteroidea), sea urchins (class Echinoidea), and sea cucumbers (class Holothuroidea) are capable of envenomation. Photo courtesy of Scott A. Gallagher, MD.
Echinoderm envenomations. Unlike most starfish that are typically pentamerous, the crown-of-thorns starfish (Acanthaster planci) may have as many as 23 arms and a body disc up to 60 cm in diameter. Photo courtesy of Dee Scarr.
Echinoderm envenomations. Detail of the crown-of-thorns starfish (Acanthaster planci) spines, which may grow to 6 cm in length. Photo courtesy of Dee Scarr.
Echinoderm envenomations. Detail of the crown-of-thorns starfish (Acanthaster planci). Photo courtesy of Scott A. Gallagher, MD.
Echinoderm envenomations. The common and toxic sea cucumber, Bohadschia argus, with extruded Cuvierian tubules. Contact with these sticky white tentaclelike organs or their free-floating fragments may result in intense skin or ocular irritation. Photo courtesy of Paul S. Auerbach, MD.
Echinoderm envenomations. Long-spined sea urchins, such as this Diadema species, inflict an acutely painful penetrating injury that may be accompanied by systemic symptoms and chronic wound sequelae. Photo courtesy of Dee Scarr.
 
 
 
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