6-14
occurring worldwide. Most jellyfish stings result only in local skin irritation and modest pain. However, a
box jellyfish (sea wasp) sting can result in death within 10 minutes from cardiovascular collapse, respiratory
failure and paralysis. Antivenin is available for box jellyfish toxin (see below for address). The Portuguese
man-of-war is rarely fatal but does cause similar generalized symptoms as the box jellyfish that resolve after
about a day. Stings from the man-of-war look like a red string of beads.
Coral: This porous, rock-like formation found in water often has sharp edges. Usually cuts from coral are
self-limiting and have only a mild skin reaction. Unfortunately, they usually take a long while to heal. Some
coral can sting (coelenterate family). One of the deadliest poisons known was found recently in coral (genus
Palythoa). If it is introduced into a deep cut in the body, it may be fatal. No antidote is known. Divers should
wear dive suits to protect them from coral cuts, especially in surging waves.
Octopi: The octopus is an underwater chameleon, changing colors often in the water trying to conceal
itself from its enemies. Most species of octopi found in the U.S. are harmless to humans. Octopi can
envenomate by biting and injecting venom from salivary glands. An octopus bite consists of two small
punctures, surrounded by swollen, red and painful tissue. Bleeding may be severe due to anticoagulant
effects of the venom. The blue ringed octopus found in Australian and Indo-Pacific waters is often deadly. It
injects a neuromuscular blocker called maculotoxin that may cause paralysis, vomiting, respiratory difficulty,
visual disturbances and cardiovascular collapse. No antivenin is available. Paralysis may last 4-12 hours
(with mechanical ventilation).
Sea Urchins: These round, spiny creatures carry venom in the long spines. Divers and bathers step on these
animals, impaling their feet on the long spines, which typically break off. The venom may cause numbness,
generalized weakness, paresthesias, nausea, and vomiting. Cardiac dysrhythmias have been reported. The
toxin is heat labile. Immersion of affected area in water above 115°F is recommended. Allergic reactions
can accompany these injuries.
Cone Shells: The cone shell is widely distributed throughout the world. The shell is a symmetrical spiral with
a distinctive head. Venom is contained in darts inside the proboscis, which extrudes out of the narrow end
but can reach most of the shell. A stinging or burning sensation begins at the site of the sting; followed
by numbness and tingling that spread from the wound to the rest of the body. Involvement of the mouth
and lips is severe. Generalized symptoms include muscular paralysis, difficulty swallowing or talking, visual
disturbances and respiratory distress. A cone shell sting should be viewed as severe as snakebite. Cone shell
victims will probably experience paralysis or paresis of skeletal muscle with our without myalgia. Symptoms
develop within minutes and can last up to 24 hours. No antivenin is available and mortality reaches 25%.
Sea Snakes: Sea snakes are air-breathing reptiles that swim underwater for great distances (over 100 miles
from land). They inhabit the Pacific and Indian Oceans and the Red Sea. There are some unsubstantiated
reports of sea snakes in the Caribbean Sea (reportedly coming through the Panama Canal). The neurotoxin
venom of a sea snake is 2-10 times more potent than that of a cobra. Bites are usually not painful, and only
about 25% cause envenomization. There is a latent period of 10 minutes to several hours after the bite before
generalized symptoms develop: muscle aches and stiffness, thick tongue sensation, progressive paralysis,
nausea, vomiting, difficulty with speech and swallowing, respiratory distress and failure, and smoky colored
urine from myoglobinuria (which may progress to kidney failure). The venom is heat-stable and antivenin is
available (see information below).
Assessment:
Differential Diagnosis - see different species of animals that envenomate
Plan:
Treatment/Procedures
Venomous Fish, Highly Toxic Fish, Stingrays
- Lay patient supine, reassure and observe for shock.
- Irrigate wound with cold saline or salt water to rinse remaining toxin. Minor surgery may be required