Which Marine Animal Sting Results In A Laceration?

In the grade of their clinical work or during leisure activeness, family physicians occasionally may meet patients with injuries from marine creatures. Poisoning, envenomation, and direct trauma are all possible in the marine environment. Ciguatera poisoning tin can result from ingestion of predatory fish that take accumulated biotoxins. Symptoms can be gastrointestinal or neurologic, or mixed. Management is mostly symptomatic. Scombroid poisoning results from ingestion of fish in which histamine-similar substances have adult because of improper refrigeration. Gastrointestinal and systemic symptoms occur. Handling is based on antihistamines. Envenomations from jellyfish in U.Southward. waters and the Caribbean are painful but rarely deadly. Household vinegar deactivates the nematocysts, and manual removal of tentacles is important. Treatment is symptomatic. Rut immersion may assistance with the pain. Stingrays cause localized damage and a typically severe envenomation. The venom is deactivated past estrus. The stingray spine, including the venom gland, typically is difficult to remove from the victim, and radiographs may be necessary to localize the spine or fragment. Surgical débridement occasionally is needed. Straight trauma can issue from contact with marine creatures. Hemorrhage and tissue impairment occasionally are astringent. Infections with organisms unique to the marine environment are possible; antibiotic choices are based on location and blazon of injury. Shark attacks, although rare, require immediate attending.

The Usa has more fourscore,000 miles of coastline and a population showing increasing interest in scuba diving, snorkeling, surfing, and other water sports. Thus, more persons in this country will be coming in contact with marine life, and the potential for disease and injury from marine creatures is likely to increment. Family unit physicians may be called on to care for patients who accept suffered trauma, envenomation, or poisoning from marine creatures. Marine medicine is still relatively new, then treatment recommendations for these weather condition are largely based on case reports and proficient stance, with few randomized controlled studies available to guide management. Misdiagnosis is mutual, peculiarly if the contact took place while the patient was traveling overseas or if the patient has been poisoned by improperly refrigerated seafood. This article describes ailments and injuries occurring as a consequence of direct contact with marine creatures, and discusses prevention and management options.

Poisoning

CIGUATERA

Ciguatera poisoning is acquired by ingestion of reef fish (Table 1)¹ that have bioaccumulated sufficient amounts of the dinoflagellate Gambierdiscus toxicus through directly ingestion or ingestion of smaller reef fish. Although limited to tropical regions, the dinoflagellate is oestrus- and lipid-soluble and tin survive transport to other areas. The toxin becomes more than concentrated as information technology is passed up the nutrient concatenation.

Each year, ciguatera poisoning accounts for several thousand illnesses in Puerto Rico, the U.S. Virgin Islands, Hawaii, and Florida. Patients exhibit primarily gastrointestinal or neurologic symptoms, or a mixed pattern of symptoms. A cold sensation reversal, in which the patient perceives common cold temperatures as hot sensations, and vice versa, occurs in 80 percent of patients and is considered pathognomonic for ciguatera poison (Table 2).^1,ii

The attack charge per unit may be every bit high equally 80 to 90 percent in persons who ingest afflicted fish, depending on the size of the fish and the toxin load. Symptoms also are related to the number of exposures, with patients typically having more astringent symptoms with subsequent exposures. No immunity is acquired through exposure. Symptoms begin one to six hours afterwards ingestion, although a delay of 12 to 24 hours is possible. The duration of symptoms is typically 7 to 14 days, with symptoms occasionally persisting for months to years.²

Currently, recommended treatment for ciguatera poisoning is supportive (Table 3).¹ [Prove level C, expert opinion/consensus guidelines] In almost cases, provision of intravenous fluids to supersede gastrointestinal losses is adequate. The use of atropine is indicated in patients with bradycardia, and temporary electrical pacing may be required in patients with refractory symptoms. Severe hypotension may require the utilize of pressors. Although mannitol (Osmitrol) often is cited as effective in reducing the duration of neurologic symptoms, the only double-blind trial failed to show any benefit.³ [Evidence level A, randomized controlled trial (RCT)]

The ciguatera toxin is not deactivated by cooking, freezing, smoking, or salting. There are no outward signs of ciguatera—the affected fish await, taste, and smell normal. Although several commercial assays are available, they are not sensitive or specific enough to be relied on to prevent ciguatera poisoning. The only preventive measure is to avoid eating warm-water reef fish, especially those defenseless where ciguatera poisoning is known to occur, and big game fish from loftier in the food chain. If such fish are eaten, the run a risk of poisoning may be decreased by avoiding the consumption of internal organs and limiting the amount of initial ingestion. Although most cases of poisoning outcome from direct ingestion, in some cases ciguatera has been passed through sexual contact and chest milk.^one

SCOMBROID

In the United States, scombroid poisoning is nigh common in Hawaii and California. Scombroid toxicity commonly results from improper treatment between the fourth dimension the fish is caught and the fourth dimension it is cooked. Improper preservation and refrigeration lead to production of histamine and histamine-like substances in the nighttime meat of certain fish such every bit tuna and mackerel.⁴ The histamine reaction develops twenty to 30 minutes after ingestion. The symptoms—which include any or all of the following: flushing, nausea, airsickness, diarrhea, severe headache, palpitations, abdominal cramping, dizziness, dry mouth, urticaria, and conjunctival injection—typically last less than six to eight hours.^four

For treatment, antihistamines (50 mg of diphenhydramine [Benadryl] or its equivalent) are delivered intravenously or intramuscularly in severe cases, and orally in milder cases. In severe cases, 300 mg of cimetidine (Tagamet) may be added for more than complete histamine-receptor blockade. If ingestion was recent, induced emesis may exist considered.^four [Show level of testify C, adept stance/consensus guidelines] Patients should exist instructed that they have not had an allergic reaction to fish, because the histamine is exogenous. Prevention is possible in regions where food storage and preparation are monitored through identification and removal of suspect fish.⁴

Envenomation

Many marine creatures are venomous, and beachgoers experience envenomation regularly. Jellyfish and related creatures (Cnidaria), sea urchins (Echinodermata), and stingrays (Chondrichthyes) are some of the more than easily identified marine creatures involved with envenomations.

JELLYFISH

These invertebrates have stinging cells, called nematocysts, that continue to part when separated from the organism. For example, jellyfish nematocysts tin sting if the tentacle is separated from the torso and after the jellyfish is expressionless. The venom is antigenic and tin can crusade a dermatonecrotic, hemolytic, cardiopathic, or neurotoxic reaction. The severity of the reaction depends on several variables, including the number of nematocysts that belch, the toxicity of the coelenterate involved, and the unique antigenic response of the patient.

Although fatal anaphylaxis occurs occasionally in the Usa and the Caribbean area, the primary business organisation from these stings is pain, which is almost always self-limiting (Tabular array 4).^5,6 The symptoms may last ii to three days. Certain Pacific jellyfish are much more than dangerous, but they are limited to the waters around Australia.⁵

Treatment of jellyfish stings in the United states of america and the Caribbean area is concerned mostly with limiting pain and neurologic symptoms. The following general guideline tin can be applied. The patient should remove any visible tentacles carefully, using gloves or forceps if available to prevent further stings. If a towel is used for protection, whatever nematocysts adhering to the towel volition discharge. Household vinegar can block discharge of the remaining nematocysts on the skin and should exist practical liberally. If vinegar is not bachelor, salt water can be used to wash off the nematocysts. Other solutions such as urine or fresh water and rubbing with sand should be avoided.⁵

If the patient presents to the physician's function, household vinegar (5 percent acetic acrid) should exist applied for 30 minutes or until the pain subsides, followed by removal of the nematocysts, using gloves or forceps. Another method of removing the nematocysts is to utilize shaving foam or a baking soda slurry to the area and then scrape off the nematocysts with a razor.⁵ [Evidence level B, double-blinded randomized trial]

Application of common cold in the form of an ice pack or hot-water immersion have variously been shown to relieve hurting, simply because of the self-limited nature of the discomfort, it is hard to approximate an optimal therapy. Hot or cold therapy probably is adequate until the patient is comfortable. Meat tenderizer has been found to be ineffective.^six–8 [Reference eight—Evidence level A, RCT] Although not supported past evidence, local anesthetics, antihistamines, and steroids take been used to command prolonged symptoms. Antibiotics mostly are not necessary.

ECHINODERMS

The echinoderm family unit includes sea urchins. Urchins have toxin-coated spines that pause off, leaving calcareous material in the wound that potentially tin cause infection. Symptoms include local hurting, burning, and discoloration. The discoloration is thought to be a temporary tattooing of the skin resulting from dye in the spines. Absence of a spine in the skin is indicated if the discoloration spontaneously resolves inside 48 hours.

Theoretically, hot water disables the toxin, although there is no evidence that this treatment is effective in humans. If a spine is present and easily accessible, it should be removed with fingers or forceps. If it is close to a joint or a neurovascular construction, information technology should exist removed surgically. If the patient is not symptomatic, retained pieces of spine likely will blot into the skin.⁵

STINGRAYS

Although many fish are venomous, stingrays are the most clinically important, accounting for an estimated ane,500 (by and large pocket-size) injuries in the United states of america annually. These creatures partially bury themselves in the sandy bottom of the bounding main shallows, where h2o enthusiasts may accidentally step on them.

Stingrays have a spine at the base of their tail that contains a venom gland. The spine, including the venom gland, may be broken off in the assail and may remain in the wound. The venom has vasoconstrictive properties that tin lead to cyanosis and necrosis, with poor wound healing and infection. Symptoms include immediate and intense hurting, salivation, nausea, vomiting, diarrhea, muscle cramps, dyspnea, seizures, headaches, and cardiac arrhythmias. Fatalities are rare and usually a upshot of exsanguination at the scene or penetration of a vital organ.

Habitation intendance should include rinsing the area thoroughly with fresh water, if available (common salt h2o may be used if necessary) and removing any strange body. If the damage is minimal, the patient may soak the wound in warm water at home. The patient should watch for signs of infection and seek care for excessive bleeding, a retained strange torso, or infection.^5,9 [Reference 9—Prove level C, expert opinion/consensus guidelines] Medical treatment includes achieving hemostasis followed by submersion of the afflicted region in hot, but non scalding, water (42° to 45°C [108° to 113°F]) for 30 to 90 minutes or until the pain resolves. Typically, spines and stingers are radiopaque, so radiography or ultrasonography may be used to locate any remaining pieces.

The wound should exist thoroughly apple-pie, and delayed closure should be allowed. Tetanus immunization status should be reviewed and updated as advisable. Surgical exploration may be necessary to remove remainder strange bodies. Safe antibiotics (Table five)^five are typically non necessary unless there is a residual strange body or the patient is immunosuppressed.⁹

Trauma

Abrasions, bites, and lacerations are ordinarily the event of a marine creature'southward instinct to protect itself against a perceived danger. The most unremarkably involved creatures are octopi, sharks, moray eels, and barracuda. The trauma lonely creates problems for patients, but the injury tin can exist complicated past envenomation. It oft is difficult to identify the marine creature involved in the assail. Treatment is symptomatic; local cleansing and topical dressing usually are adequate. If the wound becomes infected, antibiotics that cover mutual organisms should be selected (Table 5).^five

Although sharks receive much publicity, nearly 50 shark attacks occur worldwide annually, and these result in fewer than 10 deaths.¹⁰ Most of these attacks are in S African waters. Typically, these attacks involve tiger, bang-up white, gray reef, and balderdash sharks. Attacks generally occur in shallow water inside 100 feet of shore during the evening hours when sharks tend to feed. Common sense dictates fugitive areas of water where aggressive shark feeding has been noted.

Symptoms of shark attack range from abrasions to death from hemorrhage. Abrasions and lacerations occur when sharks castor against or aggressively investigate humans. Soft tissue and neurovascular impairment, and fractures result from attacks. About attacks event in minor injuries that require general wound care and, sometimes, simple suturing. The morbidity increases when wounds are greater than 20 cm or when more than one myofascial compartment is lost.

General principles of first aid in marine creature injuries are listed in Table half-dozen ^5,9 and should be followed in any and all marine injuries. Although it would seem self-evident, practices such equally urinating on the injury, applying oil or gasoline to the injury, or applying any strong oxidizing agents, such as bases or acids, should be counseled against in patient education nearly self-care.

Source: https://www.aafp.org/pubs/afp/issues/2004/0215/p885.html

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