Marine Injuries TexMed 2014

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Information about Marine Injuries TexMed 2014
Health & Medicine

Published on May 5, 2014

Author: EBMGoneWild



Talk on Injuries in the marine environment given at TexMed 2014

Injuries in the Marine Environment Justin Hensley, MD Assistant Professor of Emergency Medicine Texas A&M Health Science Center/CHRISTUS Spohn

Disclosures None

Injuries From being underwater From things in the water

Injuries from being underwater Submersion injuries Barotrauma

Submersion Injuries Water rescue No treatment Submersion injury Needs treatment Drowning Wet Dry

Submersion Injuries Treatment Rescue breathing/CPR Oxygen Do not: Heimlich Attempt to drain water

Diving Injuries Blackout Barotrauma Arterial gas embolism Nitrogen narcosis Decompression sickness

Blackout Hypoxia Shallow water 5m Deep water >10M Dalton’s law

Barotrauma Boyle’s law P1V1=P2V2

Mask Barotrauma “Mask squeeze” Failure to maintain pressure in facemask Treatment Symptomatic Ophthalmology

Sinus Barotrauma “Sinus squeeze” Congestion of mucosal lining Treatment Vasoconstrictors Analgesics Steroids No diving

External Auditory Canal Barotrauma Air trapped in canal Tight hood Cerumen Treatment Analgesics Ear drops

Middle Ear Barotrauma “Ear squeeze” Usually near surface Eustachian tube collapses due to pressure differential Treatment Equalize before eustachian tube blocked Decongestants No diving

Equalization Techniques Valsalva Toynbee’s Swallowing with closed lips and nostrils Frenzel Moving jaw forward and down with closed lips and nose

Inner Ear Barotrauma Labyrinthine window rupture Overly forceful Valsalva or rapid descent Treatment Bed rest Recovery=3-12 weeks No diving

Other squeezes Suit squeeze Tooth squeeze Lung squeeze

Ascent Barotrauma Alternobaric vertigo Alternobaric facial palsy Gastrointestinal barotrauma

Pulmonary Barotrauma Ascent without exhaling 4 ft Alveolar hemorrhage Chest pain, cough, hemoptysis Pneumomediastinum Most common Pneumothorax Infrequent Can become tension

Arterial Gas Embolism Symptoms Instant CVA 5% die immediately, 5% die in hospital Treatment Dive chamber High flow O2 Maintain CPP No flying

Nitrogen Narcosis “Rapture of the deep” 70-100ft Treatment Ascend Use Heliox

Decompression Sickness Caisson disease Bubbles of nitrogen Intravascular Extravascular Multiple types

Musculoskeletal Decompression Sickness Most common form 70% Joint pain “The bends” “Niggle” Scuba divers Shoulders and elbows Saturation divers, aviators, caisson workers Hips and knees Treatment

Cutaneous Decompression Sickness “Skin bends” “cutis marmorata” Treatment Dive chamber Itches or “the creeps”

Pulmonary Decompression Sickness “Chokes” Bubbles in pulmonary vasculature “Mill wheel” heart murmur Treatment Dive chamber

Neurologic Decompression Sickness Spinal cord most common Peripheral nerves or brain 50-60% of sport diver casualties Treatment Dive chamber

USN Table 6

Injuries from things in the water


Sharks Some sharks agressive Fight back Eyes Nose Gills

Barracuda Tropical and subtropical waters

Piranhas Freshwater South American rivers

Moray Eels Fresh, brackish, and saltwater


Alligators 6-14ft Largest was 19ft >500kg No verified alligator deaths in Texas

Alligator Attacks 1928-2008 Langley RL. Adverse encounters with alligators in the United States: an update. Wilderness Environ Med. 2010 Jun;21(2):156-63.

Alligator Attacks  >90% of fatalities occur in Florida 29.2% consistent with humans as prey Most fatal attacks involve alligators >8ft 38 bacteria and 20 fungal species have been cultured from alligator Langley RL. Adverse encounters with alligators in the United States: an update. Wilderness Environ Med. 2010 Jun;21(2):156-63.

Alligators Stay away from endemic areas Run away Do not run in a zig zag Top speed 10-15 mph Fight back

Turtles Large crushing jaws Can amputate fingers/toes/ hands

Underwater animal injuries Trauma Puncture Laceration Treatment ATLS Irrigate copiously Xrays Antibiotics TMP-SMX Ceftriaxone Doxycycline Ciprofloxacin


Stingray Sting Edema Tissue necrosis Treatment Hot water Envenomation N/V/D Seizures Syncope Dysrhythmias Goldfrank’s Toxicologic Emergencies, Ninth Edition. Lewis Nelson, Neal Lewin, Mary Ann Howland, Robert Hoffman, Lewis Goldfrank, Neal Flomenbaum. Chapter 116. pp 1629-1640. Author D. Eric Bush, July 2010 Meyer PK. Stingray injuries. Wilderness Environ Med. 1997 Feb;8(1):24-8. Review.

Catfish 1000 species in fresh and salt water Spines Venoms vary by species

Catfish Symptons Stinging, throbbing pain Erythema and edema Muscle spasm Diaphoresis Treatment Hot Water Xrays



Lionfish Native to Indo-Pacific 12-13 dorsal spines Aggressive Treatment Hot water Wound exploration Antibiotics

Jellyfish Portuguese Man of War Box Jellyfish True Jellyfish Bengtson K, Nichols MM, Schnadig V, Ellis MD. Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings. JAMA. 1991

Portuguese man of war Polymorphic colonial siphonophore Warm seas

True Jellyfish Tentacles circumferential around umbrella Ubiquitous

Box Jellyfish Tropical and subtropical waters Tentacles from corners of umbrella Directional movement

Jellyfish Anaphylaxis discovered Nobel Prize 1913 Tentacles up to 100 ft 1000s of nematocysts Spines penetrate to capillary bed Venom Dermonecrosis Hemolysis Cardiotoxicity Tibballs J, Yanagihara AA, Turner HC, Winkel K. Immunological and toxinological responses to jellyfish stings. Inflamm Allergy Drug Targets. 2011. Oct;10(5):438-46. wars-sting-like-a-hot-knife/520573

Management Proposed Treatments  Alcohol  Meat tenderizer  Vinegar  Ammonia  Acetone  Urine  Seawater  Pressure bandage  Stingose AHA and ARC International Consensus Vinegar, or Baking soda, then Heat, or Ice pack Markenson D, Ferguson JD, Chameides L, et al; on behalf of the First Aid Chapter Collaborators. Part 13: first aid: 2010 American Heart Association and American Red Cross International Consensus on First Aid Science With Treatment

Evidence Based Treatment Hot water Lidocaine (4-5%) Vinegar Saltwater Portuguese Man of War Ward NT, Darracq MA, Tomaszewski C, Clark RF. Evidence-based treatment of jellyfish stings in North America and Hawaii. Ann Emerg Med.2012 Oct;60(4):399-414.

Irukadji Syndrome Carukia barnesii Massive catecholamine release Treatment Phentolamine Standard jellyfish treatment

Seabather’s Eruption “Sea Lice” Larvae of thimble jellyfish Treatment Sensitization effects Regional and Seasonal Florida Caribbean Brazil

Coral injuries Stony corals Erythametous wheal Coral poisoning Cellulitis, ulceration, and tissue sloughing Heal over 3-6 weeks

Fire Coral Cutaneous reaction Pain, pruritis, urticaria Systemic effects Nephrotic syndrome

Fire Coral Treatment Rinse Pat dry Vinegar Hot water Isopropyl alcohol Steroids

Fire Sponges Spicules embedded in connective tissue Colonizing animals on the matrix

Fire Sponges Pruritic dermatitis Erythema multiforme Anaphylactoid response Irritant dermatitis Spicules Treatment Remove spicules Vinegar/Hot water/Isopropyl alcohol Topical steroids High dose oral steroids Epinephrine

Cone Snails Mild envenomations Localized sx Serious envenomations Muscle paralysis Death

Cone Snail Treatment No antivenom Pressure-immobilization bandage Supportive care Tensilon Atropine

Blue Ringed Octopus Venom apparatus is salivary glands and beak Bites occur with handling

Blue Ringed Octopus Venom Vibrio Neuromuscular blockade Symptoms Numbness Paralysis Treatment Pressure immobilization Supportive care Recovery in 2-4 days

Anemones Dermatitis similar to fire coral Species specific reactions Urticaria Paresthesias Edema Local hemorrhage Necrosis Systemic reactions Fever, Malaise, N/V Hepatic failure

Anemones Mild envenomations Resolve Severe reactions Eschar Keloids Treatment Irrigate copiously Hot water/Vinegar

Echinoderms Sea stars Hemolysins Pain, bleeding, edema Sea cucumber Holothurin-cardiac glycoside Skin dermatitis Sea urchins Glycosides, Hemolysins Pain, N/V, Paresthesias Paralysis

Echinoderms Treatment Hot water Steroids Wound exploration Supportive care

Annelid Worms Bite Bristles Pain, urticaria Treatment Remove bristles Steroids

Sea Snakes 80% of bites dry Venom Neurotoxic, Hemolytic, Myotoxic Symptoms Painful muscle movement Blurred vision, dysphagia, ptosis, paralysis Treatment Pressure immobilization Antivenom Supportive measures

Summary Dive injuries HBO Large animals ATLS Envenomations Hot water Antivenom

Questions?  

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