Sea Snake Envenomation Clinical Presentation

  • Author: Dimitrios Papanagnou, MD, MPH; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Feb 8, 2011
 

History

The diagnosis of sea snake envenomation requires the establishment of the potential for exposure to a sea snake (eg, exposure to water in an area known to harbor sea snakes), identification of symptoms of envenomation, and demonstration of evidence of a bite (eg, multiple puncture wounds or reliable history of observed bite).

Symptoms are attributable to multiple organ systems, with neurological symptoms predominating. They may occur as early as 5 minutes or as late as 8 hours following the bite, but they usually occur within 2 hours. Initial symptoms include generalized aching, stiffness and tenderness of all muscle groups, as well as pain with passive muscle stretching. Trismus is also common. This is followed by progressive flaccid paralysis, starting with ptosis and paralysis of voluntary muscles. Paralysis of muscles responsible for swallowing and respiration can be fatal. Within 8 hours of envenomation, myoglobin, as a result of muscle breakdown, begins to rise in blood plasma; this eventually leads to myoglobinuria with resultant acute renal failure. If muscle breakdown is severe, hyperkalemia may ensue, possibly leading to cardiac arrest.

  • Euphoria
  • Anxiety
  • Malaise
  • Drowsiness or mild confusion
  • Headache
  • Myalgias (typically worse with movement, usually beginning in the afflicted extremity, as well as the neck, within 30-60 min after envenomation)
  • Arthralgias
  • Ptosis
  • Mydriasis with sluggish reaction to light
  • Ophthalmoplegia, leading to diplopia
  • Failing vision (usually a terminal symptom)
  • Sialorrhea
  • Trismus
  • Facial paralysis
  • Muscle paralysis (usually ascending, may be flaccid or spastic)
  • Dyspnea
  • Nausea, vomiting, abdominal pain, and cramping
  • Change in urine color (dusky yellow to reddish brown)
  • Oliguria
  • Thirst
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Physical

Physical examination findings of sea snake envenomation may include the following:

  • Fang marks (usually 2 or more small circular dots, which may be difficult to initially identify)
  • Local tissue reaction (usually absent or minimal)
  • Paralysis (typically ascending)
  • Hyporeflexia (progressing to loss of reflexes)
  • Hypersalivation
  • Trismus
  • Bulbar paralysis
  • Ptosis
  • External ophthalmoplegia
  • Dysarthria and slurred speech
  • Dysphagia
  • Respiratory distress or respiratory failure
  • Tachypnea
  • Cyanosis
  • Apnea
  • Cardiac arrest (secondary to hyperkalemia)
  • Fever (variable)
  • Lymphadenopathy (involving the nodes responsible for draining the site of envenomation)
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Causes

  • Occupational exposure - Usually fishermen handling nets
  • Accidental exposure - Stepping on sea snakes in shallow water
  • Nonaccidental exposure - Intentionally handling sea snakes (eg, home aquariums)
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Contributor Information and Disclosures
Author

Dimitrios Papanagnou, MD, MPH  Staff Physician, Department of Emergency Medicine, Bellevue Hospital Center

Dimitrios Papanagnou, MD, MPH is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, American Medical Student Association/Foundation, and Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

Coauthor(s)

Susi U Vassallo, MD, FACEP, FACMT  Assistant Professor of Emergency Medicine, New York University School of Medicine/Bellevue Hospital Center

Susi U Vassallo, MD, FACEP, FACMT is a member of the following medical societies: American Academy of Clinical Toxicology, American College of Emergency Physicians, American College of Medical Toxicology, New York Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

Disclosure: Nothing to disclose.

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, 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

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, James Foster, MD, to the development and writing of this article.

References

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  2. Ditmars RL. The MacMillan Company. Reptiles of the World, Revised Edition. 1933:329, pp 89.

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

  4. Auerbach PS. Marine envenomations. In: Auerbach PS, ed. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 3rd ed. Mosby-Year Book; 1995:1327-74.

  5. Baxter EH, Gallichio HA. Cross-neutralization by tiger snake (Notechis scutatus) antivenene and sea snake (Enhydrina schistosa) antivenene against several sea snake venoms. Toxicon. May 1974;12(3):273-8. [Medline].

  6. Chetty N, Du A, Hodgson WC, et al. The in vitro neuromuscular activity of Indo-Pacific sea-snake venoms: efficacy of two commercially available antivenoms. Toxicon. Aug 2004;44(2):193-200. [Medline].

  7. Dunson WA. The Biology of Sea Snakes. Baltimore, Md: University Park Press; 1975.

  8. Guenin DG, Auerbach PS. Trauma and envenomations from marine fauna. In: Tintinalli, et al, eds. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:868-73.

  9. Heatwole H. Sea Snakes. Krieger Publishing Company; 1999.

  10. Minton SA Jr. Paraspecific protection by elapid and sea snake antivenins. Toxicon. Jul 1967;5(1):47-55. [Medline].

  11. Pinney R. Sea snakes. Reptile & Amphibian. 1994;26:22-34.

  12. Reid HA. Antivenom in sea-snake bit poisoning. Lancet. Mar 15 1975;1(7907):622-3. [Medline].

  13. Reid HA. Epidemiology of sea-snake bites. J Trop Med Hyg. May 1975;78(5):106-13. [Medline].

  14. Reid HA, Chan KE. The paradox in therapeutic defibrination. Lancet. Mar 9 1968;1(7541):485-6. [Medline].

  15. Senanayake MP, Ariaratnam CA, Abeywickrema S. Two Sri Lankan cases of identified sea snake bites, without envenoming. Toxicon. Jun 1 2005;45(7):861-3. [Medline].

  16. Tu AT. Biotoxicology of sea snake venoms. Ann Emerg Med. Sep 1987;16(9):1023-8. [Medline].

  17. Tu AT, Fulde G. Sea snake bites. Clin Dermatol. Jul-Sep 1987;5(3):118-26. [Medline].

  18. Vick JA. Medical studies of poisonous land and sea snakes. J Clin Pharmacol. Jun 1994;34(6):709-12. [Medline].

 
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Technique for application of pressure immobilization in field management of sea snake bites. Figure 1, Apply a broad-pressure bandage over the bite site as soon as possible. Do not take off jeans because the movement of doing so assists venom to enter the bloodstream. Keep the bitten leg still. Figure 2, The bandage should be as tight as would be applied to a sprained ankle. Figure 3, Extend the bandage as high as possible.
Technique for application of pressure immobilization in field management of sea snake bites. Figure 4, Apply a splint to the leg. Figure 5, Bind the splint firmly to as much of the leg as possible. If the bandages and splint are applied correctly, they will be comfortable and may be left on for several hours. They should not be taken off until the patient has reached medical care. The doctor will decide when to remove the bandages. If venom has been injected, it will move into the bloodstream quickly once the bandages are removed. The doctor should leave the bandages and splint in position until he or she has assembled appropriate antivenom and drugs that may need to be used when the dressings and splint are removed. Figure 6, For bites on a hand or forearm, bind to the elbow with bandages, use a splint to the elbow, and use a sling.
Yellow-belly pelagic sea snake.
 
 
 
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