ENVIRONMENTAL

ResponseBox Jellyfish (Chironex) - collapse and sudden death within minutes of sting from dysrythmia and probable direct cardiotoxicity
Irukandji
Sea Snake - postsynapic neurotoxin + myotoxin. Collapse from descending flaccid paralysis
Blue ring octopus

ResponseTrauma - Head injury, C spine injury with cord involvement, tension PTx
Marine envenomnation - Irukandji, chironex, sea snake
Tox - Intoxication or withdrawal
Drowning
Medical problem - Asthma, SAh, Seizure
Anaphylaxis
Barotrauma with CAGE (If diving)

ResponsePain delayed 15-30 mins
Generalised pain (Not at site)
No skin changes/rash
Typically does not arrest

ResponsePrehospital

• Vinegar, no PBI

Hospital

• Fentanyl titrated to pain
• MgSO4? (controversial), PCA, Ketamine
• Control hypertension, GTN infusion SBP<160
• HDU admission
• Seek and treat complications (MI, pulmonary oedema)

ResponseImmediate pain at site of sting
Characteristig laddering lesion “linear wheels”
Early cardiac arrest

ResponseBox Jellyfish (Chironex) stings with systemic envenomnation

ResponseWidespread linear welt (“laddering” - purple/red)
Venom load from discharging nematocysts
Direct cardiotoxicity

ResponseVinegar lipberally to visible sting sites and remove tentacles
Ice
Analgesia - IV opioids (+/- MgSO4)
Cardiac monitoring ? arrhythmia
antivenom

ResponseAntivenom - 1-3 amps in 100 mL/ N/S over 20 mins

ResponseCardiorespiratory arrest
Cardiovascular instability - Collapse, hypotension, dysrythmia
Local pain refractory to opioids
Respiratory depression - hypoventilation, difficulty swallowing/speaking/breathing

ResponseAntivenom 3-6 amps IV push (IM if delay to IV access)
Vinegar to remaining tentacles + remove
Prolonged CPR if antivenom given
Airway, treat secondary injuries/causes (Eg: hypothermia, trauma), ICU referral

ResponseTetrodotoxin - sodium channel blocker neurotoxin (similar to puffer fish toxin but more rapid onset)

ResponseRapidly progressing descending flaccid paralysis within minutes
Early - perioral parasthesia, ptosis, blurred vision, diplopia, dysphagia
Late - progressive descending flaccid paralysis
Terminal - respiratory failure + respiratory arrest

ResponseIntubation and mechanical ventilation- paralysis usually resolves in 24h
No antivenom available

ResponseSedation (venom paralysis but does not affect consciousness)
Retrieval to ICU
Ongoing fluid resus
Address stem - support for parents, seek and treat other injuries etc.