Published on May 5, 2014
Injuries in the Marine Environment Justin Hensley, MD Assistant Professor of Emergency Medicine Texas A&M Health Science Center/CHRISTUS Spohn
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 http://www.fws.gov/southeast/news/2004/r04-073.html
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 http://ocean.si.edu/jellyfish-and-comb-jellies 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.
http://www.tampabay.com/news/environment/wildlife/man-of- wars-sting-like-a-hot-knife/520573 http://www.destination-scuba.com/Box-Jellyfish.html
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
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