Australian Doctor 16th February 2024 AD 16th Feb issue | Page 21

tentacles , and hot water immersion

local pressure if there is significant

can be considered for pain relief .

bleeding or trauma and hot water

Cases rarely present to hospital

immersion for pain relief . As with fish

except if there is severe pain , ongoing

spines , only apply hot water for up to

systemic effects or delayed bullous or

90 minutes .

keloid skin reactions .

With potentially larger traumatic

PENETRATING VENOMOUS MARINE INJURIES

PENETRATING marine injuries are

injuries , parenteral analgesia and local anaesthesia will be required . Most wounds require irrigation and exploration under local anaesthetic , and larger wounds will require formal

the second major group of marine

debridement under general anaes-

stings and envenomings . They

thetic . Thoracoabdominal injuries

include a range of penetrating inju-

need to be managed as major trauma ,

ries from venomous fish spines and

with resuscitation and appropriate

some invertebrates — for example ,

surgical intervention .

sea urchins . Although they result

Prophylactic antibiotics are indi-

from a variety of creatures , the clin-

cated for large wounds , those with

ical effects and treatment are simi-

considerable amounts of foreign mate-

lar in most cases , including hot water

rial and any penetrating injury to a

immersion for first aid and follow-up

joint cavity , bone or body cavity . Fol-

for the risk of marine infections .

low-up of all cases is essential .

Marine infections are an important complication of penetrating marine injuries and , although rare , can result

Sea urchins

Sea urchin injuries are similar to spiny

in significant morbidity and mortal-

fish injuries ; however , almost all sea

ity . In addition to normal skin flora ,

urchin spines are non-venomous . The

marine infections can be caused by

other major difference is that almost

Vibrio sp . ( marine environment ) and

all sea urchin spines break off in the

Aeromonas sp . ( fresh water ), so it is

wound , meaning that removal of bro-

important to follow up all penetrat-

ken spines is a major problem . Almost

ing marine injuries . Ensure tetanus

all injuries occur when people tread on

vaccination is updated if required .

sea urchins in the water ( see figure 6 ).

The routine use of prophylactic anti-

Injuries to the hand when urchins are

biotics is not recommended . If a

handled are rare .

marine infection is suspected , col-

Sea urchin spines vary in their

lect swabs in the correct media for

strength and composition , ranging

marine bacteria . Consultation with

from chalk-like material that is easily

an infectious diseases specialist is

broken to more typical hard spines .

recommended if antibiotic therapy is

Crown-of-thorns sea star injuries are

initiated , and inpatient care is usu-

similar and occur in the Indo-Pacific

ally required .

region , including the Great Barrier

Venomous fish stings

There are many different types of

spiny fish in Australian coastal and fresh waters . A few of these com-

Figure 4 . Penetrating catfish spine to the fourth finger .

Reef .

Although pain occurs , this is often less severe except for the rare injuries with venomous sea urchin spines . Other symptoms relate to retained for-

monly cause significant injuries

eign bodies , with persistent pain from

because of their spines , including stonefish , bullrout , catfish and scor-

from fish spine injuries varies and depends on the size of the spines

Box 3 . First aid and treatment for penetrating marine injuries

pressure on the injury site — for example , walking on retained spines in the

pion fish . The spines range from non-venomous in many types of catfish to the venomous stings of stonefish , which are covered by a sheath that pushes back as the venom-covered spine penetrates the skin .

and the amount and potency of the venom injected . The pain is often out of proportion with the physical trauma and is severe and persistent in stonefish , bullrout and marine catfish stings . In more severe cases ,

• First aid : — Wash the wound site . — Immerse in hot water , about 45 ° C , for a maximum duration of 90 minutes . — Local pressure for bleeding .

foot . Infection appears to be much less common .

TREATMENT Wash the wound and immerse in hot water for pain relief . However , the

The anatomical location of the injury also differs for each species depending on the fish habitat — for example , a bottom dweller — and whether they are caught on fishing lines .

Stonefish and bullrout both cause injuries to the bottom of the foot when they are trodden on . Stonefish camouflage themselves on the sea floor , and bullrout are present in eastern Australia on the bottom of tidal estuaries and slow-moving streams .

Catfish probably cause more injuries than stonefish and bullrout ; these occur on the upper limbs when they are picked up or removed from

there will be erythema and oedema surrounding the wound site , which may spread proximally up the limb . In some cases , the spine may break off in the wound .

Infection from marine and aquatic micro-organisms is the most important , although rare , complication of penetrating marine injuries . Systemic effects are reported but are usually related to the severe pain that occurs in some cases .

TREATMENT The first-aid treatment for fish spine injuries consists of cleaning the wound site and hot water immersion . Hot water immersion ( 45 ° C ) may pro-

• Medical treatment : — Local irrigation of the wound and removal of foreign bodies . — Radiography or ultrasound to identify retained spines . — Oral or titrated parenteral analgesia ; occasionally local or regional anaesthesia for severe pain . — Stonefish antivenom is available for stonefish stings with severe pain or systemic effects . — Surgical consultation for deep injuries , involvement of joints or bones , or retained material . — Resuscitation and surgical intervention for major trauma from thoracic or abdominal stingray injuries . — Consider prophylactic antibiotics for large wounds with foreign material or delayed presentation . — Review all penetrating marine injuries every 24-48 hours for the first week .

normal saline ). IM antivenom will not

containing the spine whips upward

focus of treatment is to locate and remove broken and retained spines . Radiographical examination and ultrasound are required to locate spines . Superficial spines tend to be easily removed , but deeper spines require formal non-urgent surgical removal . A reasonable approach is to remove superficial spines first and then follow up with the patient to determine if further intervention is required .

OTHER MARINE STINGS AND ENVENOMINGS

Sea snakes

SEA snakes are venomous snakes that

fishing lines ( see figure 4 ). The most

vide pain relief but should only be

reach the systemic circulation and

to cause the injury rather than being

are closely related to Australasian

severe catfish injuries occur from

applied for up to 90 minutes . If the

should not be used .

static . The bony stingray spine will

elapids . They differ in that they have

the striped marine catfish ( Plotosus lineatus ). There are numerous other venomous or spiny fish , such as red

pain does not settle , then oral and / or parenteral pain relief is required . Local anaesthesia can also be used

Stingrays

There are both freshwater and marine

also leave venom in the wound , adding to the pain .

The major clinical effects of sting-

scales and no fins or gills . They occur in the tropical parts of the Indian and Pacific oceans . Most bites occur when

rock cod in NSW , soldier fish and

and is particularly effective when irri-

stingrays in Australia ; they vary in

ray injuries are severe localised pain ,

the snakes are picked up out of fishing

cobblers in southern Australia and

gating and exploring the wound site .

size and therefore the potential for

local trauma , bleeding and inflam-

nets or off the beach . The most com-

scats from the Indo-Pacific Ocean . 8 Again , most injuries occur when fish

Prophylactic antibiotics are not indicated in most spine injuries , but

major injury . Most stingray injuries are to the ankles when they are trod-

mation ( see figure 5 ). Like spiny fish injuries , systemic effects are rare ,

mon species to cause confirmed bites in Australia is the beaked sea snake

are removed from fishing lines or

regular review of the wound over

den on in shallow water . Thoraco-

and the major complication is sec-

( Hydrophis zweifeli ). 9

handled for other reasons .

subsequent days for infection is

abdominal injuries can occur when

ondary infection . The risk of infec-

Bites cause minor pain , and sys-

Box 3 outlines the first aid and

important .

divers swim past stingrays ; this may

tion is higher because of the extent

temic effects will develop over min-

treatment for penetrating marine

Stonefish antivenom is available ,

cause major trauma , which is rare .

of the trauma and the chance of

utes to hours . Systemic envenomation

injuries .

but there is limited evidence for its

Stingray injuries cause more

contamination .

is usually myotoxicity , with neuro-

effectiveness . Consider antivenom if

severe trauma than fish spine inju-

toxicity uncommon . Myotoxic enven-

CLINICAL EFFECTS

there is severe pain ; this is given as a

ries . This is because of the size of

TREATMENT

omation results in myalgia , painful

The extent of the clinical effects

slow IV infusion ( one vial in 200mL of

the spines and the fact that the tail

First aid includes cleaning the wound ,

muscle rigidity , trismus and muscle