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5C-3.4.5 Symptomatic Treatment. Symptomatic treatment can include topical steroid therapy, anesthetic ointment (xylocaine, 2 percent) antihistamine lotion, systemic antihistamines or analgesics. Benzocaine topical anesthetic preparations should not be used as they may cause sensitization and later skin reactions.

Anaphylaxis. Anaphylaxis (severe allergic reaction) may result from jellyfish stings.

Antivenin. Antivenin is available to neutralize the effects of the sea wasp or box jellyfish (Chironex fleckeri). The antivenin should be administered slowly through an IV, with an infusion technique if possible. IM injection should be administered only if the IV method is not feasible. One container (vial) of sea wasp antivenin should be used by the IV route and three containers if injected by the IM route. Each container of sea wasp antivenin is 20,000 units and is to be kept refrigerated, not frozen, at 36-50°F (2-10°C). Sensitivity reaction to the antivenin should be treated with a subcutaneous injection of epinephrine (0.3cc of 1:1,000 dilution), corticosteroids, and antihistamines. Treat any hypotension (severely low blood pressure) with IV volume expanders and pressor medication as necessary. The antivenin may be obtained from the Commonwealth Serum Laboratories, Melbourne, Australia (see Reference 4 for address and phone number).

5C-3.5 Coral. Coral, a porous, rock-like formation, is found in tropical and subtropical waters. Coral is extremely sharp and the most delicate coral is often the most dangerous because of their razor-sharp edges. Coral cuts, while usually fairly superficial, take a long time to heal and can cause temporary disability. The smallest cut, if left untreated, can develop into a skin ulcer. Secondary infections often occur and may be recognized by the presence of a red and tender area surrounding the wound. All coral cuts should receive medical attention. Some varieties of coral can actually sting a diver since coral is a coelenterate like jellyfish. Some of the soft coral of the genus Palythoa have been found recently to contain the deadliest poison known to man. This poison is found within the body of the organism and not in the stinging nematocysts. The slime of this coral may cause a serious skin reaction (dermatitis) or even be fatal if exposed to an open wound. No antidote is known.

5C-3.5.1 Prevention. Extreme care should be used when working near coral. Often coral is located in a reef formation subjected to heavy surface water action, surface current, and bottom current. Surge also develops in reef areas. For this reason, it is easy for the unknowing diver to be swept or tumbled across coral with serious consequences. Be prepared.

5C-3.5.2 Protection Against Coral. Coral should not be handled with bare hands. Feet should be protected with booties, coral shoes or tennis shoes. Wet suits and protective clothing, especially gloves (neoprene or heavy work gloves), should be worn when near coral.

5C-3.5.3 First Aid and Treatment.

1. Control local bleeding.

2. Promptly clean with hydrogen peroxide or 10-percent povidone-iodine solution and debride the wound, removing all foreign particles.

3. Cover with a clean dressing.

4. Administer tetanus prophylaxis as appropriate.

5. Topical antibiotic ointment has been proven very effective in preventing secondary infection. Stinging coral wounds may require symptomatic management such as topical steroid therapy, systemic antihistamines, and analgesics. In severe cases, restrict the patient to bed rest with elevation of the extremity, wet-to-dry dressings, and systemic antibiotics. Systemic steroids may be needed to manage the inflammatory reaction resulting from a combination of trauma and dermatitis.

5C-3.6 Octopuses. The octopus inhabits tropical and temperate oceans. Species vary depending on region. It has a large sac surrounded by 8 to 10 tentacles (Figure 5C-9). The head sac is large with well-developed eyes and horny jaws on the mouth. Movement is made by jet action produced by expelling water from the mantle cavity through the siphon. The octopus will hide in caves, crevices and shells. It possesses a well-developed venom apparatus in its salivary glands and stings by biting. Most species of octopus found in the U.S. are harmless. The blue-ringed octopus common in Australian and Indo-Pacific waters may inflict fatal bites. The venom of the blue-ringed octopus is a neuromuscular blocker called tetrodotoxin and is also found in Puffer (Fugu) fish. Envenomation from the bite of a blue-ringed octopus may lead to muscular paralysis, vomiting, respiratory difficulty, visual disturbances, and cardiovascular collapse. Octopus bites consist of two small punctures. A burning or tingling sensation results and may soon spread. Swelling, redness, and inflammation are common. Bleeding may be severe and the clotting ability of the blood is often retarded by the action of an anticoagulant in the venom.

Blue Ring Octopus Envenomation
Figure 5C-9. Octopus.

5C-3.6.1 Prevention. Extreme care should be used when reaching into caves and crevices.

Regardless of size, an octopus should be handled carefully with gloves. One should not spear an octopus, especially the large ones found off the coast of the Northwestern United States, because of the risk of being entangled by its tentacles. If killing an octopus becomes necessary, stabbing it between the eyes is recommended.

5C-3.6.2 First Aid and Treatment.

1. Control local bleeding.

2. Clean and debride the wound and cover with a clean dressing.

3. For suspected blue-ringed octopus bites, do not apply a loose constrictive band. Apply direct pressure with a pressure bandage and immobilize the extremity in a position that is lower than the heart using splints and elastic bandages.

4. Be prepared to administer mouth-to-mouth resuscitation and cardiopulmonary resuscitation if necessary.

5. Blue-ringed octopus venom is heat stable and acts as a neurotoxin and neuromuscular blocking agent. Venom is not affected by hot water therapy. No antivenin is available.

6. Medical therapy for blue-ringed octopus bites is directed toward management of paralytic, cardiovascular, and respiratory complications. Respiratory arrest is common and intubation with mechanical ventilation may be required. Duration of paralysis is between 4 and 12 hours. Reassure the patient.

7. Administer tetanus prophylaxis as appropriate.

5C-3.7 Segmented Worms (Annelida) (Examples: Bloodworm, Bristleworm). This invertebrate type varies according to region and is found in warm, tropical or temperate zones. It is usually found under rocks or coral and is especially common in the tropical Pacific, Bahamas, Florida Keys, and Gulf of Mexico. Annelida have long, segmented bodies with stinging bristle-like structures on each segment. Some species have jaws and will also inflict a very painful bite. Venom causes swelling and pain.

5C-3.7.1 Prevention. Wear lightweight, cotton gloves to protect against bloodworms, but wear rubber or heavy leather gloves for protection against bristleworms.

5C-3.7.2 First Aid and Treatment.

1. Remove bristles with a very sticky tape such as adhesive tape or duct tape. Topical application of vinegar will lessen pain.

2. Treatment is directed toward relief of symptoms and may include topical steroid therapy, systemic antihistamines, and analgesics.

3. Wound infection can occur but can be easily prevented by cleaning the skin using an antiseptic solution of 10 percent povidone-iodine and topical antibiotic ointment. Systemic antibiotics may be needed for established secondary infections that first need culturing, aerobically and anaerobically.

5C-3.8 Sea Urchins. There are various species of sea urchins with widespread distribution. Each species has a radial shape and long spines. Penetration of the sea urchin spine can cause intense local pain due to a venom in the spine or from another type of stinging organ called the globiferous pedicellariae. Numbness, generalized weakness, paresthesias, nausea, vomiting, and cardiac dysrhythmias have been reported.

5C-3.8.1 Prevention. Avoid contact with sea urchins. Even the short-spined sea urchin can inflict its venom via the pedicellariae stinging organs. Protective footwear and gloves are recommended. Spines can penetrate wet suits, booties, and tennis shoes.

5C-3.8.2 First Aid and Treatment.

1. Remove large spine fragments gently, being very careful not to break them into small fragments that remain in the wound.

2. Bathe the wound in vinegar or isopropyl alcohol. Soaking the injured extremity in hot water up to 122°F (50°C) may help. Caution should be used to prevent scalding the skin which can easily occur after a brief period in water above 122°F (50°C).

3. Clean and debride the wound. Topical antibiotic ointment should be used to prevent infection. Culture both aerobically and anaerobically before administering systemic antibiotics for established secondary infections.

4. Remove as much of the spine as possible. Some small fragments may be absorbed by the body. Surgical removal, preferably with a dissecting microscope, may be required when spines are near nerves and joints. X-rays may be required to locate these spines. Spines can form granulomas months later and may even migrate to other sites.

5. Allergic reaction and bronchospasm can be controlled with subcutaneous epi-nephrine (0.3 cc of 1:1,000 dilution) and by using systemic antihistamines. There are no specific antivenins available.

6. Administer tetanus prophylaxis as appropriate.

7. Get medical attention for deep wounds.

5C-3.9 Cone Shells. The cone shell is widely distributed in all regions and is usually found under rocks and coral or crawling along sand. The shell is most often symmetrical in a spiral coil, colorful, with a distinct head, one to two pairs of tentacles, two eyes, and a large flattened foot on the body (Figure 5C-10). A cone shell sting should be considered as severe as a poisonous snake bite. It has a highly developed venom apparatus: venom is contained in darts inside the proboscis which extrudes from the narrow end but is able to reach most of the shell. Cone shell stings are followed by a stinging or burning sensation at the site of the wound. Numbness and tingling begin at the site of the wound and may spread to the rest of the body; involvement of the mouth and lips is severe. Other symptoms may include muscular paralysis, difficulty with swallowing and speech, visual disturbances, and respiratory distress.

5C-3.9.1 Prevention. Avoid handling cone shells. Venom can be injected through clothing and gloves.

5C-3.9.2 First Aid and Treatment.

1. Lay the patient down.

2. Do not apply a loose constricting band or ligature. Direct pressure with a pressure bandage and immobilization in a position lower than the level of the heart using splints and elastic bandages is recommended.

3. Some authorities recommend incision of the wound and removal of the venom by suction, although this is controversial. However, general agreement is that if an incision is to be made, the cuts should be small (one centimeter), linear and penetrate no deeper than the subcutaneous tissue. The incision and suction should only be performed if it is possible to do so within two minutes of the sting. Otherwise, the procedure may be ineffective. Incision and suction by inexperienced personnel has resulted in inadvertent disruption of nerves, tendons, and blood vessels.

4. Transport the patient to a medical facility while ensuring that the patient is breathing adequately. Be prepared to administer mouth-to-mouth resuscitation if necessary.

5. Cone shell venom results in paralysis or paresis of skeletal muscle, with or without myalgia. Symptoms develop within minutes of the sting and effects can last up to 24 hours.

6. No antivenin is available.

7. Respiratory distress may occur due to neuromuscular block. Patient should be admitted to a medical facility and monitored closely for respiratory or cardiovascular complications. Treat as symptoms develop.

8. Local anesthetic with no epinephrine may be injected into the site of the wound if pain is severe. Analgesics which produce respiratory depression should be used with caution.

9. Management of severe stings is supportive. Respiration may need to be supported with intubation and mechanical ventilation.

10. Administer tetanus prophylaxis as appropriate.

5C-3.10 Sea Snakes. The sea snake is an air-breathing reptile which has adapted to its aquatic environment by developing a paddle tail. Sea snakes inhabit the Indo-Pacific area and the Red Sea and have been seen 150 miles from land. The most dangerous areas in which to swim are river mouths, where sea snakes are more numerous and the water more turbid. The sea snake is a true snake, usually 3 to 4 feet in length, but it may reach 9 feet. It is generally banded (Figure 5C-11). The sea snake is curious and is often attracted by divers and usually is not aggressive except during its mating season.

Figure 5C-11. Sea

Snake.

Figure 5C-11. Sea

Snake.

5C-3.10.1 Sea Snake Bite Effects. The sea snake injects a poison that has 2 to 10 times the toxicity of cobra venom. The bites usually appear as four puncture marks but may range from one to 20 punctures. Teeth may remain in the wound. The neurotoxin poison is a heat-stable nonenzymatic protein; hence, sea snake bites should not be immersed in hot water as with venomous fish stings. Due to its small jaws, bites often do not result in envenomation. Sea snake bites characteristically produce little pain and there is usually a latent period of 10 minutes to as long as several hours before the development of generalized symptoms: muscle aching and stiffness, thick tongue sensation, progressive paralysis, nausea, vomiting, difficulty with speech and swallowing, respiratory distress and failure, plus smoky-colored urine from myoglobinuria, which may go on to kidney failure.

5C-3.10.2 Prevention. Wet suits or protective clothing, especially gloves, may provide substantial protection against bites and should be worn when diving in waters where sea snakes are abundant. Also, shoes should be worn when walking where sea snakes are known to exist, including in the vicinity of fishing operations. Do not handle sea snakes. Bites often occur on the hands of fishermen attempting to remove snakes from nets.

5C-3.10.3 First Aid and Treatment.

1. Keep victim still.

2. Do not apply a loose constricting band or tourniquet. Apply direct pressure using a compression bandage and immobilize the extremity in the dependent position with splints and elastic bandages. This prevents spreading of the neu-rotoxin through the lymphatic circulation.

3. Incise and apply suction (see cone shell stings, paragraph 5C-3.9).

4. Transport all sea snake-bite victims to a medical facility as soon as possible, regardless of their current symptoms.

5. Watch to ensure that the patient is breathing adequately. Be prepared to administer mouth-to-mouth resuscitation or cardiopulmonary resuscitation if required.

6. The venom is a heat-stable protein which blocks neuromuscular transmission. Myonecrosis with resultant myoglobinuria and renal damage are often seen. Hypotension may develop.

7. Respiratory arrest may result from generalized muscular paralysis; intubation and mechanical ventilation may be required.

8. Renal function should be closely monitored and peritoneal or hemodialysis may be needed. Alkalinization of urine with sufficient IV fluids will promote myoglobin excretion. Monitor renal function and fluid balance anticipating acute renal failure.

9. Vital signs should be monitored closely. Cardiovascular support plus oxygen and IV fluids may be required.

10. Because of the possibility of delayed symptoms, all sea snake-bite victims should be observed for at least 12 hours.

11. If symptoms of envenomation occur within one hour, antivenin should be administered as soon as possible. In a seriously envenomated patient, antivenin therapy may be helpful even after a significant delay. Antivenin is available from the Commonwealth Serum Lab in Melbourne, Australia (see Reference D of this appendix for address and phone number). If specific antivenin is not available, polyvalent land snake antivenin (with a tiger snake or krait Elapidae component) may be substituted. If antivenin is used, the directions regarding dosage and sensitivity testing on the accompanying package insert should be followed and the physician must be ready to treat for anaphy-laxis (severe allergic reaction). Infusion by the IV method or closely monitored drip over a period of one hour, is recommended.

12. Administer tetanus prophylaxis as appropriate.

5C-3.11 Sponges. Sponges are composed of minute multicellular animals with spicules of silica or calcium carbonate embedded in a fibrous skeleton. Exposure of skin to the chemical irritants on the surface of certain sponges or exposure to the minute sharp spicules can cause a painful skin condition called dermatitis.

5C-3.11.1 Prevention. Avoid contact with sponges and wear gloves when handling live sponges.

5C-3.11.2 First Aid and Treatment.

1. Adhesive or duct tape can effectively remove the sponge spicules.

2. Vinegar or 3- to 10-percent acetic acid should be applied with saturated compresses as sponges may be secondarily inhabited by stinging coelenterates.

3. Antihistamine lotion (diphenhydra-mine) and later a topical steroid (hydrocortisone), may be applied to reduce the early inflammatory reaction.

4. Antibiotic ointment is effective in reducing the chance of a secondary infection.

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