198 Toxinology Emergencies
MARINE ENVENOMATION2 Poisonous fish such as the stonefish, lionfish, bullrout (Australia) or lesser
weever (UK):
(i) These fish have venomous spines that can cause extreme local
pain and oedema.
(ii) Systemic effects include diarrhoea, respiratory depression and
hypotension.
3 Sea urchins, fire coral (worldw ide)
(i) Sea urchins cause local erythema and pain from the many tiny
spines which may break off and enter a joint cavity or the deep
palmar or plantar spaces.
(ii) Fire coral causes local burning similar to a jellyfish sting.MANAGEMENT
1 Assess and secure the airway first and provide basic life support to patients
with cardiovascular collapse and systemic toxicity.
2 Jellyfish first aid
(i) Box jellyfish and Irukandji: rinse jellyfish wounds with seawater,
remove adherent tentacles, and prevent further nematocyst
discharge with 5% acetic acid (vinegar).
(ii) Bluebottle: rinse with seawater (not vinegar), remove adherent
tentacles, and immerse the affected area in warm water at
40–45°C without scalding.
3 Jellyfish systemic envenomation
(i) Irukandji
(a) administer oxygen and give opiate analgesia, e.g. with
fentanyl 5 g/kg i.v. every 10 min until pain is controlled
(b) commence a glyceryl trinitrate (GTN) infusion if severe
hypertension is not controlled with pain management.
(ii) Box jellyfish
(a) administer oxygen and commence i.v. fluid resuscitation for
hypotension. Give morphine 5–10 mg i.v. for severe local
pain
(b) administer box jellyfish antivenom if the pain is refractory to
opiates, the patient is shocked, or in cardiac arrest:- give three vials (60 000 units) diluted 1 in 10 with normal
saline i.v. over 30 min or six vials as a bolus in cardiac arrest.
4 Poisonous fish
(i) Immerse the affected area in warm water at 40–45°C without
scalding. If pain persists, perform a regional block with 2%
lignocaine (lidocaine) and give morphine 5–10 mg i.v.
(ii) Debride the wound, remove spines and give tetanus prophylaxis
according to the patient’s immune status.