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Lionfish and Stonefish: Treatment & Medication
Updated: Dec 2, 2008
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Treatment
Prehospital Care
- Prehospital care should address recognition of the injury as a potential envenomation, gentle removal of visible spines, direct pressure to control bleeding, administration of analgesia, and transport for definitive medical evaluation.
- Recognition of serious systemic symptoms and prompt institution of appropriate life-saving procedures, such as cardiopulmonary resuscitation (CPR) and treatment for anaphylaxis, should be paramount in the prehospital care setting.
Emergency Department Care
Emergency department (ED) management of Scorpaenidae envenomations involves addressing the venom exposure as well as the accompanying inflicted trauma. General rules of therapy include prompt analgesia, wound management, antivenom administration, and supportive treatment for significant envenomations.
- CPR and advanced cardiac life support (ACLS) procedures are rarely indicated but always take absolute precedence.
- Wound debridement
- Gentle manual removal of obviously protruding spines prevents further penetration or breakage.
- With proper anesthesia, surgical removal of embedded spines is indicated when they are in proximity to joints, nerves, or vessels.
- Weight-bearing surfaces may require removal of spines to prevent chronic pain.
- Always irrigate copiously after adequate anesthesia.
- Hot water immersion technique
- Heat treatment is widely recommended as effective initial treatment for envenomations by Scorpaenidae, as well as echinoderms, stingrays, and other venomous spine injuries.
- The affected limb should be immersed in water no warmer than 114 degrees Fahrenheit, or 45 degrees Celsius.
- Be careful not to inflict thermal burns by placing an insensate limb (as a result of local anesthesia or decreased sensitivity as a result of pain) into scalding water.
- Local or regional anesthesia, if available, is a suggested means of adjunctive analgesia.
- Methods of recommended analgesia vary depending upon the reference cited and range from immersion techniques to local or regional anesthesia to parenteral analgesics.
- Most references recommend that initial therapy consist of immersion in nonscalding hot water (upper limit of 114 degrees Fahrenheit or 45 degrees Celsius) after removal of visible spines and sheath, in order to inactivate the thermolabile components of the venom that might otherwise cause a severe systemic reaction.
- Adjunctive regional or local anesthesia offers several benefits that are not conferred by immersion techniques with analgesia. In addition to the absence of the risk of thermal injury, reliable, prompt, and prolonged analgesia allows for simultaneous debridement of the wound.
- Parenteral analgesics and/or sedatives may be needed for patients who have wounds that are difficult to immerse or anesthetize, or for persons exhibiting significant anxiety reactions to the envenomation.
- Wound management principles include identification of foreign material, adequate debridement, tetanus prophylaxis, and appropriate referral for retained fragments that are not easily accessible in the ED.
- Although the spines rarely break off into the skin, debridement of loose spines should be undertaken promptly, because retained spines continue to envenomate. Embedded structures should be pulled straight out with forceps to avoid breaking them.
- Ultrasound and plain radiography may help locate retained fragments, many of which require referral for consideration of operative removal (eg, proximity to nerves, vessels, joints, weight-bearing surfaces). Retained fragments act as foreign bodies, causing inflammation and eventually becoming encapsulated into granulomata, which may lead to delayed healing and secondary infection.
- Tetanus prophylaxis is indicated in all patients who have experienced traumatic marine injury and who have insufficient or uncertain immunization histories.
- Severe to life-threatening systemic symptoms of envenomation most commonly result from envenomations by the Synanceia genus and only rarely result from envenomations by other genera of the Scorpaenidae family.
- Stonefish antivenom
- Stonefish antivenom from Australia's Commonwealth Serum Laboratories (CSL) is recommended only for predilution intramuscular usage. However, for serious envenomations, this route may not be ideal because of erratic absorption. Following dilution, a slow intravenous administration may be preferable: 1 ampule (2000 U) for every 1-2 punctures, up to 3 ampules for more than 4 punctures. It should be diluted in 50-100 mL of isotonic sodium chloride solution and run through at least 20 minutes.
- As this is a hyperimmunized equine antisera, there are risks of allergic reaction and serum sickness in the recipient. Skin testing and/or pretreatment should precede administration. Rather than skin testing, Australian sources tend to recommend pretreatment with subcutaneous epinephrine and an intramuscular antihistamine, adding an intramuscular corticosteroid for known hypersensitivity.
Consultations
Consultation with an appropriate surgical specialist is advised for all complicated puncture wounds, including those in proximity to articular and neurovascular structures.
- Spine extraction is best performed acutely with an operating microscope in the surgical suite.
- Plantar puncture wounds are a potentially complicated injury, and they may require consultation or referral for foreign material that is not easily extracted in the ED.
- Consultation and admission to a general internist for supportive care may be warranted when symptoms of serious envenomation are present.
- Protracted pain, nausea, muscular weakness, respiratory distress, and hypotension are a few systemic symptoms that indicate the need for admission.
- Additionally, in the rare case of Vibrio or Aeromonas sepsis, a coordinated multispecialty effort is needed to address wound debridement, antibiosis, and critical care support.
Medication
The goal of therapy is to control pain and prevent infections in high-risk wounds. Medical therapy is directed at providing local and systemic analgesia, wound care, and supportive therapy, including antivenom when necessary. With the exception of persons with deep puncture wounds and those who are immunocompromised, prophylactic antibiotics generally are not indicated. Once infection is established, however, prompt therapy must be instituted with emphasis on coverage for potential marine pathogens. Tetanus prophylaxis is indicated in all marine animal injuries.
Local anesthetics
Provide local or regional anesthesia as adjunctive or alternative pain control.
Bupivacaine (Marcaine, Sensorcaine)
In general, any of the commonly used local anesthetics suffices; however, bupivacaine provides superior duration of anesthesia for irrigation, wound exploration, and debridement as compared to shorter-acting anesthetics. Bupivacaine increases the patient's electrical excitation threshold, which slows nerve impulse propagation and reduces the action potential; therefore, it prevents the generation and conduction of nerve impulses.
Adult
10-20 mL of 0.25-0.5% intralesionally; not to exceed 3-4 mg/kg
Pediatric
Not established; 1.25 mg/kg/dose intralesionally suggested
May enhance effects of CNS depressants; coadministration may increase toxicity of MAOIs, TCAs, beta-blockers, vasopressors, and phenothiazines
Documented hypersensitivity; septicemia, spinal deformities, severe hypertension, and existing neurologic disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Test a dose and monitor for CNS toxicity, cardiovascular toxicity, and signs of unintended intrathecal administration; caution with inflammation or sepsis in region of proposed injection; monitor patient's state of consciousness after each injection; caution in hypertension, cerebral vascular insufficiency, peripheral vascular disease or heart block, and arteriosclerotic heart disease
Analgesics
Used for adjunctive pain control when immersion therapy and local/regional anesthesia are not sufficient.
Morphine sulfate (MS Contin, Astramorph, Oramorph)
DOC for narcotic analgesia due to its reliable and predictable effects, safety profiles, and ease of reversibility with naloxone. Morphine sulfate administered IV may be dosed in a number of ways and is commonly titrated until the desired effect is obtained. The analgesic route, whether oral or parenteral, is a matter of choice. With appropriate local or regional anesthesia, this medication may not be necessary.
Adult
0.1 mg/kg IV/IM/SC initially followed by a maintenance dose of 5-20 mg/70 kg IV/IM/SC q4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of the dose
Alternatively, 0.1 mg/kg IV/IM/SC
Pediatric
Neonates: 0.05-0.2 mg/kg/dose IV prn
Children: 0.1-0.2 mg/kg/dose IV q2-4h prn; not to exceed 15 mg/dose IV
Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAOIs, and other CNS depressants may potentiate adverse effects of morphine
Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid airway control would be difficult
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Avoid in hypotension, respiratory depression, nausea, emesis, constipation, and urinary retention; caution in atrial flutter and other supraventricular tachycardias; has vagolytic action and may increase ventricular response rate
Antibiotics
Used for outpatient treatment of early or minor wound infections and as prophylaxis for high-risk wounds (eg, 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. Others mentioned include cephalexin, amoxicillin, and amoxicillin clavulanate.
Parenteral antibiotics are indicated for the treatment of serious wound infections (eg, extensive cellulitis, myositis, gas gangrene) or sepsis following injuries sustained in the marine environment. Vibrio wound infection approaches 50% mortality (usually patients with chronic liver disease), and serious Aeromonas infection may mimic clostridial gas gangrene.
Trimethoprim/sulfamethoxazole (Bactrim, Septra)
Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic, acid-inhibiting, folic acid synthesis. This results in the inhibition of bacterial growth. The antibacterial activity of TMP-SMZ includes the common urinary tract pathogens except Pseudomonas aeruginosa.
Adult
160 mg TMP/800 mg SMZ IV q12h for 10-14 d
Pediatric
<2 months: Do not administer
>2 months: 15-20 mg/kg/d IV, based on TMP, tid/qid for 14 d
May increase PT when used with warfarin (perform coagulation tests and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Discontinue drug at first appearance of skin rash or any sign of adverse reaction; frequently obtain CBCs; if a significant reduction in the count of any formed blood element is noted, discontinue therapy; goiter production, diuresis, and hypoglycemia may occur; high IV doses or prolonged infusions may cause bone marrow depression manifested as thrombocytopenia, leukopenia, or megaloblastic anemia; caution in patients with possible folate deficiency, such as chronic alcoholics, the elderly, and those receiving anticonvulsant therapy or with malabsorption syndrome
Hemolysis may occur in G-6-PD deficiency; if signs of bone marrow depression occur, give leucovorin as needed to restore normal hematopoiesis (PO leucovorin, 5-15 mg/d, has been recommended); because of their unique immune dysfunction, patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment; administer adequate fluid intake to prevent crystalluria and stone formation; perform urinalyses and renal function tests during therapy
Ciprofloxacin (Cipro)
Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms. Indicated for pseudomonal infections and those that are due to multidrug resistant gram-negative organisms. Duration of treatment depends upon severity of infection. Generally, treatment should be continued for at least 2 d after the signs and symptoms of infection have disappeared. The usual treatment duration is 7-14 d. No controlled studies exist regarding efficacy of therapy. Several references suggest both a tetracycline and either an extended-spectrum cephalosporin (eg, ceftazidime) or an aminoglycoside.
Adult
250-500 mg PO bid for 7-14 d
Pediatric
<18 years: Not recommended
>18 years: Administer as in adults
Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism of fluoroquinolones; ciprofloxacin reduces therapeutic effects of phenytoin; probenecid may increase ciprofloxacin serum concentrations; may increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy
Tetracycline (Sumycin)
Treats susceptible bacterial infections of both gram-positive and gram-negative organisms as well as infections caused by Mycoplasma, Chlamydia, and Rickettsia species. Inhibits bacterial protein synthesis by binding with the 30S, and possibly the 50S, ribosomal subunit(s) of susceptible bacteria.
Adult
250-500 mg PO q6h
Mild-to-moderate infections: 500 mg PO bid or 250 mg PO qid for 7-14 d
Severe infections: 500 mg PO qid for 7-14 d
Pediatric
<8 years: Not recommended
>8 years: 10-20 mg/lb (25-50 mg/kg) PO qid
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Doxycycline (Doryx, Bio-Tab)
Inhibits protein synthesis and, thus, bacterial growth by binding with the 30S, and possibly the 50S, ribosomal subunits of susceptible bacteria
Adult
Acute infection: 200 mg PO/IV immediately and 100 mg hs followed by 100 mg bid for 3 d
Alternatively, administer 300 mg PO/IV immediately followed by 300 mg in 1 h, or 100 mg PO/IV bid for 7 d
Pediatric
<8 years: Not recommended
>8 years: 2-5 mg/kg/d PO/IV in 1-2 divided doses; not to exceed 200 mg/d
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Ceftazidime (Fortaz, Ceptaz)
Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to one or more of the penicillin-binding proteins, it arrests bacterial cell wall synthesis and inhibits bacterial growth
Adult
500 mg to 2 g IV/IM q8-12h
Pediatric
1-4 weeks: 30 mg/kg q12h IV/IM
1 month to 12 years: 30-50 mg/kg/dose IV/IM q8h; not to exceed 6 g/d
>12 years: Administer as in adults
Nephrotoxicity may increase with aminoglycosides, furosemide, and ethacrynic acid; probenecid may increase ceftazidime levels
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment
Ampicillin (Marcillin, Omnipen)
Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms.
Adult
2 g IV/IM 30 min prior to procedure
Pediatric
50 mg/kg IV/IM 30 min prior to procedure
Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction
Cardiovascular agents
Premedication is recommended by several sources because of the risks of allergic reaction and serum sickness with antivenom. In the presence of clear and severe clinical signs of stonefish envenomation, antivenom should not be withheld solely because of such considerations. The choice of specific premedication drugs is controversial but generally should include an antihistamine and epinephrine (when not contraindicated).
Epinephrine (EpiPen, Adrenalin)
DOC for the treatment of anaphylactoid reactions and should be considered as pretreatment prior to giving antivenom.
Adult
0.01 mL/kg IM/SC of a 1:1,000 solution initially to a maximum of 0.5 mL of the 1:1,000 solution (0.5 mg)
Pediatric
0.1 mcg/kg/min SC IM/SC q15 min for 2 doses, then q4h with increments of 0.1 mcg/kg/min prn; not to exceed 1.5 mcg/kg/min
Epinephrine may potentiate hypertension when combined with MAOIs, tricyclic antidepressants, and vasopressors; increases toxicity of beta- and alpha-blocking agents and of halogenated inhalational anesthetics
Documented hypersensitivity; cardiac arrhythmias or angle-closure glaucoma; local anesthesia in areas such as fingers or toes because vasoconstriction may produce sloughing of tissue; labor (may delay second stage of labor)
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in elderly patients, prostatic hypertrophy, hypertension, cardiovascular disease, diabetes mellitus, hyperthyroidism, and cerebrovascular insufficiency; rapid IV infusions may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Antihistamines
Another antivenom premedication choice to minimize adverse effects.
Diphenhydramine (Benadryl)
Used for the symptomatic relief of allergic symptoms caused by histamine release in response to allergens.
Adult
25-50 mg PO q6-8h prn; not to exceed 400 mg/d
If necessary, 10-50 mg IV/IM q6-8h; not to exceed 400 mg/d
Pediatric
12.5-25 mg PO/IV/IM, tid/qid, or 5 mg/kg/d, or 150 mg/m2/d divided tid/qid; not to exceed 300 mg/d
Potentiates effect of CNS depressants; due to alcohol content, do not give syrup dosage form to patients taking medications that can cause disulfiramlike reactions
Documented hypersensitivity; MAOIs
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer, or urinary tract obstruction; xerostomia may occur
Corticosteroids
May be useful in preventing or treating serum sickness associated with antivenom use.
Hydrocortisone (Hydrocortone Phosphate, Solu-Cortef)
Prophylactic corticosteroids may prevent later serum sickness, although to date, there have been no cases reported in the literature of delayed serum sickness following any administration of marine antivenom. Hydrocortisone decreases inflammation by suppression of migration of polymorphonuclear leukocytes and reversal of increased capillary permeability.
Adult
Loading dose of 250 mg IV up to 1 g, followed by 7 mg/kg/d IV/PO for 1-2 d
Pediatric
Children: Not established
Adolescents: Administer as in adults
Corticosteroid clearance may decrease with estrogens; may increase digitalis toxicity secondary to hypokalemia
Documented hypersensitivity; viral, fungal, or tubercular skin infections
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in hyperthyroidism, osteoporosis, peptic ulcer, cirrhosis, nonspecific ulcerative colitis, diabetes, and myasthenia gravis
Methylprednisolone (Solu-Medrol, Depo-Medrol)
Useful to treat inflammatory and allergic reactions. By reversing increased capillary permeability and suppressing PMN activity, may decrease inflammation.
A multitude of corticosteroid preparations are available. Methylprednisolone is widely available in the ED due to its other uses (eg, acute asthma, spinal cord injury) and is supplied in both parenteral and oral formulations. It is therefore discussed here as a typical drug of this class.
Adult
2-60 mg PO qd
40-250 mg IV q6h
40-250 mg IM q6h
Pediatric
1-2 mg/kg PO qd
1-2 mg/kg IV q6h
1-2 mg/kg IM q6h
NSAIDs may cause ulcers when taken concurrently; anticholinesterases may increase weakness in patients with myasthenia gravis when taken concurrently with steroids; risk exists of possible viral dissemination with live virus vaccines
Documented hypersensitivity; some evidence exists for fetal harm from corticosteroids, so both benefits and risks should be considered for use during pregnancy; immunosuppressed patients receiving corticosteroids are at risk for dissemination, activation, or certain infections, and this should be considered when prescribing for these patients
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Short-term use of corticosteroids, even in large doses, has minimal harmful effects; chronic usage has multiple adverse effects
Possible complications include hyperglycemia, edema, osteonecrosis, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, growth suppression, myopathy, or infections
Immunizations
Tetanus results from elaboration of an exotoxin from Clostridium tetani. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome. Patients who may not have been immunized against C tetani products (eg, immigrants, the elderly) should receive tetanus immune globulin (Hyper-Tet)
Diphtheria-tetanus toxoid (dT)
Used for the passive immunization of any person with a wound that might be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 Units IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3000-10,000 Units IM
Pediatric
Prophylaxis: 250 Units IM in opposite extremity as tetanus toxoid lesion
Clinical tetanus: Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization due to poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol since it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)
Documented hypersensitivity; history of any type of neurological symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections, or for immediate prophylaxis of unimmunized individuals (use instead tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be seen in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy is discontinued; routine immunization of persons with symptomatic and asymptomatic HIV infection is recommended; persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA
Do not perform skin testing, since the intradermal injection of concentrated gamma globulin may cause a localized area of inflammation that can be misinterpreted as a positive allergic reaction when it is actually a localized chemical tissue irritation; true allergic responses to human gamma globulin given in the prescribed IM manner are extremely rare; do not admix with other medications, usually incompatible
Immunoglobulins
Used in previously unvaccinated individuals to provide passive immunity to tetanus when individuals become exposed.
Tetanus immune globulin (Hyper-Tet)
Used for passive immunization of any person with a wound that might be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 Units IM in opposite extremity to tetanus toxoid lesion
Clinical tetanus: 3000-10,000 Units IM
Pediatric
Prophylaxis: 250 Units IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3000-10,000 Units IM
None reported
Since antibodies in globulin preparation may interfere with immune response to vaccination, do not administer within 3 mo of live virus immune globulin administration; may be necessary to revaccinate persons who received immune globulin shortly after live virus vaccination
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Persons with isolated immunoglobulin A (IgA) deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA; do not perform skin testing since intradermal injection of concentrated gamma globulin may cause localized area of inflammation and can be misinterpreted, causing the medication to be withheld from a patient not allergic to this material; true allergic responses to human gamma globulin given in prescribed IM manner are extremely rare; do not admix with other medications since usually incompatible
Antivenom
Has clearly established efficacy for analgesia and diminution of tissue damage following envenomation by Synanceia species and may be considered for serious or nonresponding stings of other members of the Scorpaenidae family. It generally is not indicated for Pterois envenomations.
Unlike box jellyfish (Chironex) envenomations, which often require immediate antivenom administration, the clinical situation after stonefish envenomation may allow for a skin test for sensitivity to horse serum to be performed. The purpose of skin testing is to allow for adequate preparation of pretreatment, if needed, not to decide whether to administer the antivenom. This decision is based upon the clinical condition of the patient before skin testing. In addition to pretreatment, a positive skin test may warrant greater antivenom dilution in order to be safely administered.
Stonefish antivenom (Purified Equine)
All Australian marine antivenoms were previously made by and available from the Commonwealth Serum Laboratories, 45 Poplar Road, Parkville, Vic 3052, Australia. However, Australian venom research is now centered at the Australian Venom Research Unit, Department of Pharmacology, University of Melbourne, Parkville, Vic 3052, Australia (tel: 61-3-934447753; fax: 61-3-93482048). Stonefish antivenom is no longer available at the Health Services Department, Sea World, San Diego, CA; Sharp Cabrillo Hospital, San Diego, CA; Steinhart Aquarium, San Francisco, CA; or at Sea World, Aurora, OH. Regional poison control centers may be the most helpful sources of information. Known severe sensitivity to horse serum may prompt consideration of supportive therapy without antivenom administration.
Adult
1 ampule (2000 Units) IV for every 1-2 punctures, up to 3 ampules for >4 punctures
Australia's Commonwealth Serum Laboratories (CSL) stonefish antivenom is recommended only for prediluted IM use (This route may not be ideal in serious envenomations because of erratic absorption)
Slow IV administration requires dilution in 50-100 mL of normal saline run through at least 20 min
Premedication is recommended
Pediatric
Administer as in adults; dosage is not reduced for small patients or children
None reported
If history is positive (allergic reaction upon exposure to horses or prior injections of horse serum) and skin test is positive, administration may be dangerous, especially if positive sensitivity test is accompanied by systemic allergic manifestations; in such instances, the risk of administering antivenom must be weighed against the risk of withholding it
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Appropriate therapy for the treatment of anaphylaxis should be ready for immediate use
More on Lionfish and Stonefish |
| Overview: Lionfish and Stonefish |
| Differential Diagnoses & Workup: Lionfish and Stonefish |
 Treatment & Medication: Lionfish and Stonefish |
| Follow-up: Lionfish and Stonefish |
| Multimedia: Lionfish and Stonefish |
| References |
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Further Reading
Keywords
lionfish envenomations, stonefish envenomations, scorpionfish envenomations, Scorpaenidae, Pterois species, Scorpaena species, Synanceia species, Scorpaenidae envenomations
