Marine Emergencies

1
Marine Emergencies

• Matthew T. Hamonko MD, MPH

2
Part 1 Immersion/Submersion and Drowning
3
Cold Water Immersion

• Neutral water 33C to 35C (91.4F to 95F)
• Heat loss heat production
• Hypothermia may occur at any temperature below
  neutral water
• Significant risk of hypothermia 25C (77F)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
4
Cold Water Immersion
Gulf of Maine Research Institute data for Casco
Bay - http//www.gomoos.org/
5
Cold Water Immersion

• Phases
• Phase 1 Cold Shock Response (0-2 minutes)
• Immersion gasp response
• Inability to breath hold
• Hyperventilation
• Peripheral vasoconstriction
• Increased heart rate, cardiac output and blood
  pressure
• Myocardial ischemia
• Arrhythmia

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Giesbrecht GG, Pretorius T. Survey of
Public Knowledge and Reponses to Educational
Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 200819261-66.
6
Cold Water Immersion

• Phases
• Phase 2 Cold Incapacitation (5-15 minutes)
• Peripheral vasoconstriction and decreased
  circulation
• Decreased coordination
• Loss of fine motor skills
• Loss of strength

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Giesbrecht GG, Pretorius T. Survey of
Public Knowledge and Reponses to Educational
Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 200819261-66.
7
Cold Water Immersion

• Phases
• Phase 3 Hypothermia (gt30 minutes)
• Physical and mental impairment
• Respiratory and cardiac suppression
• arrhythmia
• Phase 4 Circum-Rescue Collapse
• Decreased stress hormone output and BP drop
• After drop
• Hypoxia
• Acidosis

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Giesbrecht GG, Pretorius T. Survey of
Public Knowledge and Reponses to Educational
Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 200819261-66. Giesbr
echt GG, Hayward JS. Problems and Complications
with Cold Water Rescue. Wilderness and Environ
Med.20061726-30.
8
Cold Water Immersion

• Cooling factors
• Water temperature
• Heat transfer 100 times that of air at same temp.
• Wind chill does not significantly effect this
• Sea State
• Thermal protection
• Wet suits are more effected by rough water
• Full 4.8 mm wet suit in 10C water 0.7C/hour
• Full 4.8 mm dry suit in 10C water 0.5C/hour

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
9
Cold Water Immersion

• Cooling factors
• Body morphology
• larger surface area to mass ratio
• Decreased subcutaneous fat
• Amount of body immersed/surface area exposure
• Activity level
• Increased activity may increase rate of heat loss
  by 50
• Diving factors
• Hypoxia, hypercapnia and hyperbaric nitrogen
  increase rate of cooling

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Giesbrecht GG, Hayward JS. Problems and
Complications with Cold Water Rescue. Wilderness
and Environ Med.20061726-30.
10
Cold Water Immersion

• Survival
• The 1-10-1 rule
• 1 minute to control breathing
• 10 minutes to get out of water or establish
  stable position
• 1 hour before you become unconscious from
  hypothermia
• Public perception underestimates survival time

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Giesbrecht GG, Pretorius T. Survey of
Public Knowledge and Reponses to Educational
Slogans Regarding Cold-Water Immersion.
Wilderness and Environ Med. 200819261-66.
11
Cold Water Immersion

• Survival
• HELP (heat-escaping-lessening-position)
• Huddle Technique

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
12
Cold Water Submersion

• Also known as Near-drowning
• Reports of survival with submersion time gt 60
  minutes.
• Well documented in children
• Adult cases less common (oldest reported age 62)
• Differences attributed to increased cooling rate
  and preserved dive reflex in children

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Chochinov
AH, Baydock BM, Bristow GK, Giesbrecht GG.
Recovery of a 62 year old Man From Prolonged Cold
Water Submersion. Ann of Emerg Med.199831(1)127-
31.
13
Cold Water Submersion

• The mammalian diving reflex
• Components
• Apnea
• Bradycardia
• Peripheral vasoconstriction
• Decreased cardiac output with a maintained or
  increased stroke volume
• Increased mean arterial blood pressure
• Partially inhibited by alcohol consumption

Wittmers LF, Pozos RS, Fall G, Beck L.
Cardiovascular Responses to Face Immersion (the
Diving Reflex) in Human Beings after Alcohol
Consumption. Ann of Emerg Med.198716(9)162-4.
14
Cold Water Submersion

• Factors contributing to Survival
• Decreased metabolic requirements
• Attenuate ischemia induced cell damage
• Reduced free radical production
• Delayed terminal depolarization and potassium
  release

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Chochinov
AH, Baydock BM, Bristow GK, Giesbrecht GG.
Recovery of a 62 year old Man From Prolonged Cold
Water Submersion. Ann of Emerg Med.199831(1)127-
31.
15
Cold Water Submersion

• Negative prognostic factors for Children
• Maximum submersion time gt 5 minutes
• In coma on admission to ED
• Blood gas pH 7.1
• Age lt 3
• Delay in resuscitation for at least 10 minutes
  after rescue
• 5 survival rate for a score of 3 or more

Chochinov AH, Baydock BM, Bristow GK, Giesbrecht
GG. Recovery of a 62 year old Man From Prolonged
Cold Water Submersion. Ann of Emerg
Med.199831(1)127-31.
16
Drowning

• Wet Drowning (80 to 90)
• Aspiration of fluid after laryngospasm resolves
  and glottis opens
• Dry Drowning (10 to 15)
• Persistent laryngospasm and closed glottis
• Both types may lead to pulmonary edema
• Marine bacterial pneumonia may occur in survivors

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Sims JK,
Enomoto PI, Frankel RI, Wong MF. Marine Bacteria
Complicating Seawater Near-drowning and Marine
Wounds A Hypothesis. Ann of Emerg Med.
198312(4)212-16. Martin TG. Neardrowning and
Cold Water Immersion. Ann of Emerg Med.
198413(4)81-91.
17
Drowning

• Aspiration
• The amount not the type of water is significant
• 11 ml/kg volume required to alter blood volume
• 22 ml/kg volume required to alter electrolytes
• 3-4 ml/kg aspirated in most drowning victims
• Aspirating more than 200 ml or 3-4 ml/kg is
  uncommon

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Martin
TG. Neardrowning and Cold Water Immersion. Ann of
Emerg Med. 198413(4)81-91.
18
Cold Water Immersion/Submersion Diagnostics

• Studies
• Complete blood count
• Basic metabolic panel
• Coagulation studies
• Liver function tests
• Arterial blood gas
• Chest x-ray
• EKG
• Creatine kinase
• urinalysis

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
19
Cold Water Immersion/Submersion Medical Management

• Handle gently
• Maintain in a horizontal position
• Minimize physical activity
• BLS, ACLS, ATLS
• Remove wet clothing
• Insulation
• Passive re-warming (must be shivering)
• CPAP

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Dottorini
M, Eslami A, Baglioni S, Fiorenzano G, Todisco T.
Nasal-continuous Positive Airway Pressure in the
Treatment of Near-Drowning in Fresh Water. Chest,
1996 110(4)1122-4. Giesbrecht GG, Hayward JS.
Problems and Complications with Cold Water
Rescue. Wilderness and Environ Med.20061726-30.
20
Cold Water Immersion/Submersion Medical Management

• Active re-warming
• Heated humidified air
• Warmed intravenous fluids
• Heating pads (neck, thorax, groin)
• Forced air re-warming (i.e. Bear Hugger)
• Cardiopulmonary bypass
• Extracorporeal membrane oxygenation (ECMO)
• Body cavity lavage (peritoneal, pleural, gastric,
  bladder)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Tisherman
S, Chabal C, Safar P, Stezoski W. Resuscitation
of Dogs from Cold Water Submersion Using
Cardiopulmonary Bypass. Ann of Emerg Med.
198514(5)25-32.
21
Cold Water Immersion/Submersion Disposition

• Asymptomatic victims
• Observe 4-6 hours and discharge with follow-up
• Symptomatic victims
• Admit abnormal vital signs, positive x-ray
  findings, abnormal blood gas results or other
  significant lab result abnormalities
• Discharge asymptomatic with no significant
  diagnostic abnormalities after 4-6 hours of
  observation with follow-up
• Pulmonary dysfunction may be delayed 12-72 hours

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Pratt FD,
Haynes BE. Incidence of Secondary Drowning
After Saltwater Submersion. Ann of Emerg Med.
198615(9)137-40.
22
Part 2 Non-venomous Venomous Marine Animal
Emergencies
23
Non-venomous Marine Animal Emergencies

• Biting and spearing marine animals
• General wound management
• Trauma resuscitation
• X-ray imaging for foreign bodies
• Tetanus prophylaxis
• Prophylactic antibiotics (Vibrio, Aeromonas, /-
  Pseudomonas)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Link KW,
Counselman FL, Steele J, Caughey M. A New Hazard
for Windsurfers Needlefish Impalement. Journ of
Emerg Med. 199917(2)255-9. Ajmal N, Nanney LB,
Wolfort SF. Catfish Spine Envenomation A Case
of Delayed Presentation. Wilderness and Environ
Med.200314101-5. Riordan C, Hussain M, McCann
J. Moray Eel Attack I the Tropics A Case Report
and Review of the Literature. Wilderness and
Environ Med.200415194-7. Erickson T, Vanden
Hoek TL, Kuritza A, Leiken JB. The Emergency
Management of Moray Eel Bites. Ann of Emerg
Med.199221(2)148-52.
24
Venomous Marine Animal Emergencies

• Coelenterates (jelly fish)
• Approximately 100/10,000 species are considered
  dangerous
• Box jellyfish cardiotoxic effects, cardiac
  arrest within minutes
• Irukandji sympathetic hyperreactivity, heart
  failure, pulmonary edema, Intracranial
  hemorrhage, death, onset approx. 1-60 minutes

Fernandez I, Valladolid G, Varon J, Sternbach G.
Encounters with Venomous Sea-Life. Journ of Emerg
Med. 201140(1)103-12. McIver LJ, Tjhung IG,
Parish ST Derkenne, RC, Kippin AN. Irukandji
Syndrome in the Torres Strait A Series of 8
Cases. Wilderness and Environ Med. 201122338-42.
25
Venomous Marine Animal Emergencies

• Ceolenterates (jelly fish)
• Nematocysts
• Located on the tentacle or near the mouth
• Contain a sharp, barbed coiled tubule
• Triggered by contact with the victims body or a
  chemoreceptor
• Signs and Symptoms
• Mild envenomation rash, pain, pruritus
• Moderate to severe envenomation rash, pain,
  pruritus, multisystem organ dysfunction, death

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
26
Venomous Marine Animal Emergencies

• Ceolenterates (Jelly Fish)
• Diagnostics
• Irukandji syndrome elevated cardiac enzymes and
  EKG changes (T-wave inversions and biphasic
  T-waves) have been reported.

McIver LJ, Tjhung IG, Parish ST Derkenne, RC,
Kippin AN. Irukandji Syndrome in the Torres
Strait A Series of 8 Cases. Wilderness and
Environ Med. 201122338-42.
27
Venomous Marine Animal Emergencies

• Ceolenterates (jelly fish)
• Treatment
• Immediate wash with seawater (not freshwater)
• Do not rub wound, remove tentacles with forceps
• Acetic acid (vinegar) application for 30 seconds,
  may deactivate nematocysts (may be of no help or
  activate nematocysts in some species, i.e Man of
  War)
• Various other liquids used (including urine)
• Anti-venom available for Chironex fleckeri
  (box-jellyfish)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Fernandez
I, Valladolid G, Varon J, Sternbach G. Encounters
with Venomous Sea-Life. Journ of Emerg Med.
201140(1)103-12.
28
Venomous Marine Animal Emergencies

• Ceolenterates (Jelly fish)
• Treatment (continued)
• Hot water immersion questionable
• Remove any remaining invisible nematocysts by
  scraping or shaving
• Topical anti-histamine or anesthetic ointment
• Tetanus prophylaxis
• Treat allergic reaction and bronchospasm per
  normal protocol
• Treat seizure with benzodiazepines
• Treat adrenergic overstimulation with
  phentolamine

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Fernandez
I, Valladolid G, Varon J, Sternbach G. Encounters
with Venomous Sea-Life. Journ of Emerg Med.
201140(1)103-12.
29
Venomous Marine Animal Emergencies

• Echinodermata (starfish, sea urchin)
• Venomous spines
• Signs and Symptoms
• rash, pain, pruritus as well as systemic symptoms
  such as nausea, vomiting, paralysis,
  parasthesias, syncope, hypotension, respiratory
  distress
• Diagnostics
• X-ray imaging to evaluate for foreign body
• Treatment
• 30 to 90 minute immersion in 45C (113F) water

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
30
Venomous Marine Animal Emergencies

• Stingrays
• 1 cause of fish envenomation annually
• Approx. 14 species off the U.S. Atlantic coast
• 1500-2000 ED visits in U.S. per year
• 1-4 venom and mucous coated stingers at the end
  of the tail
• Puncture wound

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Clark RF,
Girard RH, Rao D, Ly BT, Davis DP. Stingray
Evenomation A Retrospective Review of Clinical
Presentations and Treatment in 119 Cases. Journ
of Emerg Med. 200733(1) 33-7. Fernandez I,
Valladolid G, Varon J, Sternbach G. Encounters
with Venomous Sea-Life. Journ of Emerg Med.
201140(1)103-12. Meyer PK. Stingray Injuries.
Wild and Environ med. 1997824-8.
31
Venomous Marine Animal Emergencies

• Stingrays
• Signs and Symptoms
• Local effects pain, bleeding, edema, blisters,
  necrosis
• Systemic effects nausea, vomiting, diarrhea,
  vertigo, paralysis, arrhythmia, syncope, seizure,
  hypotension, spasms/fasciculations
• Secondary bacterial infection is common
• Deaths usually related to penetration of the
  heart or abdomen

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Clark RF,
Girard RH, Rao D, Ly BT, Davis DP. Stingray
Evenomation A Retrospective Review of Clinical
Presentations and Treatment in 119 Cases. Journ
of Emerg Med. 200733(1) 33-7. Meyer PK.
Stingray Injuries. Wild and Environ med.
1997824-8.
32
Venomous Marine Animal Emergencies

• Stingrays
• Diagnostics
• X-ray imaging to evaluate for foreign body
• Treatment
• Soak wound in 45C (113F) water for 30-90
  minutes
• Local exploration, debridement and removal of
  retained foreign body
• Secondary closure
• Prophylactic antibiotics
• Tetanus prophylaxis

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
33
Venomous Marine Animal Emergencies

• Stingray
• 2007 San Diego, California retrospective Study
• 101 cases presenting within 24 hours
• 88 of patients had pain relief with hot water
  treatment alone (mechanism questionable)
• 1/71 (2) of patients who were given prophylactic
  antibiotics returned with a wound infection
• 5/30 (17) who did not receive prophylactic
  antibiotics returned with a wound infection

Clark RF, Girard RH, Rao D, Ly BT, Davis DP.
Stingray Evenomation A Retrospective Review of
Clinical Presentations and Treatment in 119
Cases. Journ of Emerg Med. 200733(1)
33-7. Meyer PK. Stingray Injuries. Wild and
Environ med. 1997824-8.
34
Venomous Marine Animal Emergencies

• Scorpionfish
• 2nd most common marine fish envenomation
  worldwide annually
• Common aquarium fish (33 calls to Chicago poison
  center over a 2 year period)
• Three groups based on venom organ structure
• Pterois zebrafish, lionfish, butterfly cod
• Scorpaena scorpionfish, bullrout, sculpin
• Synanceja Stonefish

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Vetrano
SJ, Lebowitz JB, Marcus S. Lionfish Envenomation.
Journ of Emerg Med. 200223(4) 379-82. Aldred B,
Erickson T, Lipscomb J. Lionfish Envenomation in
an Urban Wilderness. Wilderness and Environ
Med.19964291-6.
35
Venomous Marine Animal Emergencies

• Scorpionfish
• Venom
• Venom injected via 12-13 dorsal, 2 pelvic and 3
  anal spines with associated venom glands
• Lionfish venom is least potent, stonefish venom
  is most potent (3 reported deaths in Australia)
• Heat labile protein
• Hemolytic and neurologic effects
• Vascoconstriction, increased vascular
  permeability, myotoxicity

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Vetrano
SJ, Lebowitz JB, Marcus S. Lionfish Envenomation.
Journ of Emerg Med. 200223(4) 379-82. Lyon RM.
Stonefish Poisoning. Wilderness and Environmed.
200415284-88.
36
Venomous Marine Animal Emergencies

• Scorpionfish
• Signs and Symptoms
• Local effects severe pain (92), erythema (grade
  I), swelling, warmth, vesicles (grade II),
  necrosis (grade III)
• Pain onset immediate or delayed, may last days
• Systemic effects (13) altered mental status,
  nausea, vomit, diarrhea, seizure, fever, hyper or
  hypotension, respiratory distress, arrhythmia,
  heart failure, pericarditis

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Vetrano
SJ, Lebowitz JB, Marcus S. Lionfish Envenomation.
Journ of Emerg Med. 200223(4) 379-82. Aldred B,
Erickson T, Lipscomb J. Lionfish Envenomation in
an Urban Wilderness. Wilderness and Environ
Med.19964291-6.
37
Venomous Marine Animal Emergencies

• Scorpionfish
• Diagnostics
• X-ray imaging to evaluate for foreign body
• Wound culture if evidence of infection (may
  require NaCl)
• Treatment
• Immersion in 45C (113F) water for 30-90 minutes
• Vigorous irrigation
• Heal by secondary intention
• Prophylactic antibiotics for high risk areas
  (ciprofloxacin, trimethoprim/sulfamethoxazole)
• Infection treatment with 3rd generation
  cephalosporin, aminoglycoside or carbapenem
• Tetanus prophylaxis
• Antivenom available for stonefish

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Vetrano
SJ, Lebowitz JB, Marcus S. Lionfish Envenomation.
Journ of Emerg Med. 200223(4) 379-82.
38
Venomous Marine Animal Emergencies

• Sea Snakes
• 52 species, all venomous
• None in the Atlantic ocean
• Short fangs
• 20 of bites lead to significant envenomation
• Neurotoxin more potent than terrestrial snakes
• Signs and Symptoms
• Local no pain, small fang marks
• Systemic paralysis, trismus, blurred vision,
  dysphagia, drowsiness, vomiting, ptosis,
  arthralgia, respiratory distress, coma

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
39
Venomous Marine Animal Emergencies

• Sea Snakes
• Treatment
• Immobilize bitten extremity and place in
  dependent position
• Australian pressure immobilization technique
• Antivenom available for the beaked sea snake

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
40
Part 3 Marine Infectious Disease
41
Marine Infectious Disease

• Pseudomonas aeruginosa (gram (-) aerobe)
• Fresh and Salt water infection
• Clinical presentation
• Hot tub folliculitis
• Treatment systemic antibiotics for severe cases
• Green nail syndrome (paronychial infection)
• Treatment removal of affected nail area and
  topical gentamcin
• Otitis externa
• Treatment cortisporin or ofloxacin drops in mild
  cases, systemic antibiotics in severe cases
• Mastoiditis
• Case reports associated with Red Tide Exposure

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Honner S,
Kudela RM, Handler E. Bilateral Mastoiditis From
Red Tide Exposure. Journ of Emerg Med. 20101-4
42
Marine Infectious Disease

• Aeromonas Hydrophila (gram (-) facultative
  anaerobe)
• Classic fresh water infection
• Clinical presentation
• Soft tissue infection, i.e. cellulitis,
  Necrotizing Fasciitis
• Other infections gastroenteritis, endocarditis,
  peritonitis, meningitis, sepsis
• Treatment
• Tetracycline, aminoglycosides, trimethoprin-sulfam
  ethoxazole, 3rd generation cephalosporins,
  carbapenems, flouroquinolones
• Treatment should also cover for possible
  Pseudomonas and Serratia co-infection.

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Jesus JE,
Berg HS, Tibbles C, Wolfe R. Necrotizing
Fasciitis in the Setting of Marine Injury. Journ
of Emerg Med.201040(5)539-42.
43
Marine Infectious Disease

• Mycobacterium marinum (acid fast rod shaped
  bacilli)
• Fresh and salt water infection
• Clinical presentation
• Granulomas are common, may ulcerate become
  purulent and/or develop cellulitis
• Bursitis, tenosynovitis, septic arthritis,
  osteomyelitis and sepsis may occur
• Treatment
• Most lesions are self limited
• Poor consensus on treatment, consider
  trimethoprim-sulfamethoxazole or ethambutol
  rifampin for months to years

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
44
Marine Infectious Disease

• Vibrio vulnificus (gram (-) rod)
• Classic salt water infection
• Clinical Presentation
• Rapidly progressing cellulitis, may develop
  bulla, necrotizing fasciitis and sepsis, or
  gastroenteritis leading to septicemia
• Primary septicemia 56 mortality, septic shock
  92 mortality
• Patients with liver disease at increased risk
• Treatment
• Early, aggresive surgical debridement
• Doxycycline, quinolones, carbapenems, 3rd
  generation cephalosporins, aztreonam,
  trimethoprim-sulfamethoxazole

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Jesus JE,
Berg HS, Tibbles C, Wolfe R. Necrotizing
Fasciitis in the Setting of Marine Injury. Journ
of Emerg Med.201040(5)539-42. Kumamoto KS,
Vukich DJ. Clinical Infection of Vibrio
vulniificus A Case Report and Review of the
Literature. Journ of Emerg Med.199816(1)61-6.
45
Marine Infectious Disease

• Vibrio Parahaemolyticus (gram (-) rod)
• Classic Salt water infection
• Clinical presentation
• Explosive diarrhea, nausea and vomiting,
  headache, abdominal pain, and fever 6-72 hours
  after ingestion
• Mean symptom duration 3 days
• Serious skin infections may also occur
• Severe disease in immunocompromised hosts
• Treatment
• Usually self limited but may prescribe
  ciprofloxacin, trimethoprim/sulfamethoxazole or
  tetracycline

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Auerbach
P, Yajko DM, Nassos PS, Kizer KW, McCosker JE,
Geehr EC, Hadley WK. Bacteriology of the Marine
Environment Implications for Clinical Therapy.
Ann of Emerg Med. 198716(6)643-8.
46
Part 4 Marine Toxidromes
47
Marine Toxidromes

• Scombroid
• Dark flesh/red muscled fish Albacore, bluefin
  and yellowfin tuna, mackerel, saury, needlefish,
  wahoo, skipjack, bonito, mahimahi, kahawai,
  sardine, black marlin, pilchard, anchovy,
  herring, amberjack, Australian ocean salmon
• Heat stable toxin production by multiple bacteria
  during decay
• Possibly related to decarboxylation of
  L-histidine to histamine

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
48
Marine Toxidromes

• Scombroid
• Clinical Presentation
• Symptoms occur within minutes of ingestion and
  are self limited
• Similar to allergic reaction (headache, erythema,
  nausea, vomit, diarrhea, abdominal cramps,
  conjunctival injection, pruritus, dizziness,
  burning sensation in the oropharnyx, flushing,
  bronchospasm, urticaria, hypotension,
  palpitations, dysrhythmia
• Treatment anti-histamines, bronchodilators,
  anti-emetics

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
49
Marine Toxidromes

• Tetrodotoxin
• Puffer fish, California Newt, blue ringed
  octopus, poison dart frog, ivory shell, trumpet
  shell
• Heat stable toxin produced by bacteria or
  microalgae on/in the fish
• Potent sodium channel blocker
• First case reported in fish caught in the
  Atlantic Ocean in 2010
• Toxin not effected by heating or freezing

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Fernandez-Ortega JF, de los Santos JM,
Herrera-Gutierrez ME, Fernande-Sanchez V, Loureo
PR, Rancano AA, Tellez-Andrade A. Seafood
Intoxication by Tetrodotoxin First Case in
Europe. Journ of Emerg Med. 201039(5)612-17.
50
Marine Toxidromes

• Tetrodotoxin
• Clinical presentation
• Symptom onset 10 minutes to 4 hours
• Initial paresthesias of the lips and tongue with
  progressive numbness and weakness of extremities
• Progress to hypersalivation, diaphoresis,
  lethargy, headache, weakness, ataxia, tremor,
  paralysis, cyanosis, aphonia, dysphagia, seizure,
  dyspnea, bronchorrhea, bronchospasm, respiratory
  failure, hypotension, severe GI upset, DIC like
  syndrome

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007.
51
Marine Toxidromes

• Tetrodotoxin
• Diagnostics
• Standard CVA/altered mental status workup
• Test is available to detect toxin in blood and
  urine
• Treatment
• Supportive care
• Intubation may be necessary for several hours
• Activated charcoal GI decontamination
• Disposition
• At least 8 hours of observation for minor cases

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier
2007. Fernandez-Ortega JF, de los Santos JM,
Herrera-Gutierrez ME, Fernande-Sanchez V, Loureo
PR, Rancano AA, Tellez-Andrade A. Seafood
Intoxication by Tetrodotoxin First Case in
Europe. Journ of Emerg Med. 201039(5)612-17.
52
Marine Toxidromes

• Ciguatera
• Most common non-bacterial food poisoning
  associated with fish in the U.S.
• Dinoflagellate produced toxin concentrated in
  fish
• Effects voltage gated sodium channels
• Adrenergic and cholinergic effects in animal
  models

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Asaeda G.
The Transport of Ciguatoxin A Case Report. Journ
of Emerg Med. 200120(3)263-65. Farstad DJ, Chow
T. A Breif Case Report and Review of Ciguatera
Poisoning. Wilderness and Environ Med.
200112263-69.
53
Marine Toxidromes

• Ciguatera
• Clinical Presentation
• Symptom onset minutes to several hours after
  ingestion but rarely after 24 hours. Symptom
  duration 48 to 72 hours (neuro symptoms may last
  months)
• GI symptoms diarrhea, nausea, vomit abdominal
  pain
• Neuro symptoms parasthesias (36-89), hot and
  cold reversal (88), headache, ataxia, cranial
  nerve palsy, ptosis, vertigo, loose teeth
  sensation
• Cardiac Symptoms hypotension and bradycardia
  (10-15)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Asaeda G.
The Transport of Ciguatoxin A Case Report. Journ
of Emerg Med. 200120(3)263-65. Farstad DJ, Chow
T. A Breif Case Report and Review of Ciguatera
Poisoning. Wilderness and Environ Med.
200112263-69.
54
Marine Toxidromes

• Ciguatera
• Treatment
• Supportive treatment
• Possible role for mannitol, amitriptyline and
  gastric decontamination early in disease course
• Avoid exercise, marijuana, opiates, barbiturates,
  fish, shellfish, alcohol, nuts and nut oils for
  3-6 months after symptoms resolution.
• Disposition
• Dependent upon treatment severity and response to
  therapy. (rare cases of death secondary to
  respiratory paralysis)

Auerbach P. Wilderness Medicine. 5th ed.
Philadelphia, PA Mosby-Elsevier 2007. Farstad
DJ, Chow T. A Breif Case Report and Review of
Ciguatera Poisoning. Wilderness and Environ Med.
200112263-69.
55
Summary

• Four stages to cold water submersion shock,
  incapacitation, hypothermia, circum-rescue
  collapse
• You are better off in the air than in the water
• You have longer than you may think before you die
  of hypothermia
• Individuals have survived after gt 60 minute
  submersion time in cold water
• The amount, not the type of water is important in
  regards to aspiration

56
Summary

• Handle near drowning victims gently and observe
  for at least 4-6 hours
• After non-venomous marine animal attacks have
  high suspicion for foreign bodies and consider
  antibiotic prophylaxis
• Wash Jellyfish stings with salt water not fresh
  water
• Vinegar is recommended in the case of many
  jellyfish stings but not all
• Warm water immersion is recommended for sea
  urchin, starfish, stingray and scorpion fish
  stings

57
Summary

• Antivenom is available for the stone fish and
  beaked sea snake
• Pseudomonas is associated with water associated
  infections
• Vibrio is associated with salt water infections
• Aeromonas is associated with fresh water
  infections
• Scombroid is associated with a histamine like
  syndrome
• Ciguatera is associated with hot cold reversal
• Tetrodotoxin is associated with paralysis

58
Sources

• Ajmal N, Nanney LB, Wolfort SF. Catfish Spine
  Envenomation A Case of Delayed Presentation.
  Wilderness and Environ Med.200314101-5.
• Aldred B, Erickson T, Lipscomb J. Lionfish
  Envenomation in an Urban Wilderness. Wilderness
  and Environ Med.19964291-6.
• Asaeda G. The Transport of Ciguatoxin A Case
  Report. Journ of Emerg Med. 200120(3)263-65.
• Auerbach P. Wilderness Medicine. 5th ed.
  Philadelphia, PA Mosby-Elsevier 2007.
• Auerbach P, Yajko DM, Nassos PS, Kizer KW,
  McCosker JE, Geehr EC, Hadley WK. Bacteriology of
  the Marine Environment Implications for Clinical
  Therapy. Ann of Emerg Med. 198716(6)643-8.
• Chochinov AH, Baydock BM, Bristow GK, Giesbrecht
  GG. Recovery of a 62 year old Man From Prolonged
  Cold Water Submersion. Ann of Emerg
  Med.199831(1)127-31.
• Clark RF, Girard RH, Rao D, Ly BT, Davis DP.
  Stingray Evenomation A Retrospective Review of
  Clinical Presentations and Treatment in 119
  Cases. Journ of Emerg Med. 200733(1) 33-7.
• Erickson T, Vanden Hoek TL, Kuritza A, Leiken JB.
  The Emergency Management of Moray Eel Bites. Ann
  of Emerg Med.199221(2)148-52.
• Farstad DJ, Chow T. A Breif Case Report and
  Review of Ciguatera Poisoning. Wilderness and
  Environ Med. 200112263-69.
• Fernandez I, Valladolid G, Varon J, Sternbach G.
  Encounters with Venomous Sea-Life. Journ of Emerg
  Med. 201140(1)103-12.

59
Sources

• Fernandez-Ortega JF, de los Santos JM,
  Herrera-Gutierrez ME, Fernande-Sanchez V, Loureo
  PR, Rancano AA, Tellez-Andrade A. Seafood
  Intoxication by Tetrodotoxin First Case in
  Europe. Journ of Emerg Med. 201039(5)612-17.
• Giesbrecht GG, Hayward JS. Problems and
  Complications with Cold Water Rescue. Wilderness
  and Environ Med.20061726-30.
• Giesbrecht GG, Pretorius T. Survey of Public
  Knowledge and Reponses to Educational Slogans
  Regarding Cold-Water Immersion. Wilderness and
  Environ Med. 200819261-66.
• Honner S, Kudela RM, Handler E. Bilateral
  Mastoiditis From Red Tide Exposure. Journ of
  Emerg Med. 20101-4
• Jesus JE, Berg HS, Tibbles C, Wolfe R.
  Necrotizing Fasciitis in the Setting of Marine
  Injury. Journ of Emerg Med.201040(5)539-42.
• Kumamoto KS, Vukich DJ. Clinical Infection of
  Vibrio vulniificus A Case Report and Review of
  the Literature. Journ of Emerg Med.199816(1)61-6
  .
• Link KW, Counselman FL, Steele J, Caughey M. A
  New Hazard for Windsurfers Needlefish
  Impalement. Journ of Emerg Med. 199917(2)255-9.
• Lyon RM. Stonefish Poisoning. Wilderness and
  Environmed. 200415284-88.
• Martin TG. Neardrowning and Cold Water Immersion.
  Ann of Emerg Med. 198413(4)81-91.
• McIver LJ, Tjhung IG, Parish ST Derkenne, RC,
  Kippin AN. Irukandji Syndrome in the Torres
  Strait A Series of 8 Cases. Wilderness and
  Environ Med. 201122338-42.

60
Sources

• Meyer PK. Stingray Injuries. Wild and Environ
  med. 1997824-8.
• Pratt FD, Haynes BE. Incidence of Secondary
  Drowning After Saltwater Submersion. Ann of
  Emerg Med. 198615(9)137-40.
• Riordan C, Hussain M, McCann J. Moray Eel Attack
  I the Tropics A Case Report and Review of the
  Literature. Wilderness and Environ
  Med.200415194-7.
• Sims JK, Enomoto PI, Frankel RI, Wong MF. Marine
  Bacteria Complicating Seawater Near-drowning and
  Marine Wounds A Hypothesis. Ann of Emerg Med.
  198312(4)212-16.
• Tisherman S, Chabal C, Safar P, Stezoski W.
  Resuscitation of Dogs from Cold Water Submersion
  Using Cardiopulmonary Bypass. Ann of Emerg Med.
  198514(5)25-32.
• Vetrano SJ, Lebowitz JB, Marcus S. Lionfish
  Envenomation. Journ of Emerg Med. 200223(4)
  379-82.
• Wittmers LF, Pozos RS, Fall G, Beck L.
  Cardiovascular Responses to Face Immersion (the
  Diving Reflex) in Human Beings after Alcohol
  Consumption. Ann of Emerg Med.198716(9)162-4.

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Questions?