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Marine Emergencies

Marine Emergencies. Matthew T. Hamonko MD, MPH. Part 1: Immersion/Submersion and Drowning. Cold Water Immersion. Neutral water 33°C to 35°C (91.4°F to 95°F) Heat loss = heat production Hypothermia may occur at any temperature below neutral water

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Marine Emergencies

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  1. Marine Emergencies Matthew T. Hamonko MD, MPH

  2. Part 1: Immersion/Submersion and Drowning

  3. Cold Water Immersion • Neutral water 33°C to 35°C (91.4°F to 95°F) • Heat loss = heat production • Hypothermia may occur at any temperature below neutral water • Significant risk of hypothermia = 25°C (77°F) 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. 2008;19:261-66.

  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. 2008;19:261-66.

  7. Cold Water Immersion • Phases • Phase 3: Hypothermia (>30 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. 2008;19:261-66. Giesbrecht GG, Hayward JS. Problems and Complications with Cold Water Rescue. Wilderness and Environ Med.2006;17:26-30.

  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 10°C water: 0.7°C/hour • Full 4.8 mm dry suit in 10°C water: 0.5°C/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.2006;17:26-30.

  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. 2008;19:261-66.

  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 > 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.1998;31(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.1987;16(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.1998;31(1):127-31.

  15. Cold Water Submersion • Negative prognostic factors for Children • Maximum submersion time > 5 minutes • In coma on admission to ED • Blood gas pH ≤ 7.1 • Age < 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.1998;31(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. 1983;12(4):212-16. Martin TG. Neardrowning and Cold Water Immersion. Ann of Emerg Med. 1984;13(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. 1984;13(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 • Creatinekinase • 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.2006;17:26-30.

  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. 1985;14(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. 1986;15(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. 1999;17(2):255-9. Ajmal N, Nanney LB, Wolfort SF. Catfish Spine Envenomation: A Case of Delayed Presentation. Wilderness and Environ Med.2003;14:101-5. Riordan C, Hussain M, McCann J. Moray Eel Attack I the Tropics: A Case Report and Review of the Literature. Wilderness and Environ Med.2004;15:194-7. Erickson T, Vanden Hoek TL, Kuritza A, Leiken JB. The Emergency Management of Moray Eel Bites. Ann of Emerg Med.1992;21(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. 2011;40(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. 2011;22:338-42.

  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. 2011;22:338-42.

  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. 2011;40(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. 2011;40(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 45°C (113°F) 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. 2007;33(1): 33-7. Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with Venomous Sea-Life. Journ of Emerg Med. 2011;40(1):103-12. Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.

  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. 2007;33(1): 33-7. Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.

  32. Venomous Marine Animal Emergencies • Stingrays • Diagnostics • X-ray imaging to evaluate for foreign body • Treatment • Soak wound in 45°C (113°F) 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. 2007;33(1): 33-7. Meyer PK. Stingray Injuries. Wild and Environ med. 1997;8:24-8.

  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. 2002;23(4): 379-82. Aldred B, Erickson T, Lipscomb J. Lionfish Envenomation in an Urban Wilderness. Wilderness and Environ Med.1996;4:291-6.

  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. 2002;23(4): 379-82. Lyon RM. Stonefish Poisoning. Wilderness and Environmed. 2004;15:284-88.

  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. 2002;23(4): 379-82. Aldred B, Erickson T, Lipscomb J. Lionfish Envenomation in an Urban Wilderness. Wilderness and Environ Med.1996;4:291-6.

  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 45°C (113°F) 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. 2002;23(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 • Otitisexterna • 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. 2010:1-4

  42. Marine Infectious Disease • AeromonasHydrophila (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-sulfamethoxazole, 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.2010;40(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 • Vibriovulnificus (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.2010;40(5):539-42. Kumamoto KS, Vukich DJ. Clinical Infection of Vibrio vulniificus: A Case Report and Review of the Literature. Journ of Emerg Med.1998;16(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. 1987;16(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. 2010;39(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.

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