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118 Bites and stings – marine
envenomation, the differences in therapeutic approach justify attempts at
such identification.
For jellyfish stings, prophylaxis may be an option. Application of a sunscreen
containing a sting inhibitor decreases frequency and severity of stings from a
sea nettle common along the US Pacific coast (Chrysaora fuscescens), and also
from one of the more dangerous box jellyfish, the sea wasp Chiropsalmus
quadrumanus (found in the US southern coasts and in the Pacific). 7
Before removing remnant marine tissue, consider topical approaches such
as hot water immersion and other therapies outlined below. Pretreatment
maximizes chances of venom inactivation and may prevent further venom
delivery. Of course, application of topical therapies intended to inactivate
nematocysts will have no effect on pain from venom that has already been
delivered. Consequently, nematocyst inhibition therapies should be accompanied
by attempts at venom inactivation, and clinicians should be prepared
to administer adjuvant analgesia. Immobilization, compression bandages,
and other medical approaches outside the realm of this text (e.g. hemodialysis)
may also decrease pain. 1
Antivenoms (or antivenins) may be an option for some species of sea
snakes, jellyfish (e.g. box jellyfish Chironex fleckeri), and stonefish. When they
are available, antivenoms are known to have rapid and profound effects
upon pain. 8 Prehospital administration of jellyfish antivenom is demonstrated
to be a safe and effective means of treating pain. 9 While there is no RCT
evidence for antivenom’s analgesic effects, the case series and expert
opinion evidence is consistently positive. In fact, Australian clinicians have
acknowledged for decades that “early administration of the specific antivenom
appears to be the best treatment for the savage pain of the sting.” 10
The importance of antivenom therapy for C. fleckeri is augmented by the
fact that rapidity of systemic envenomation limits efficacy of hot water
immersion. 11
Injections of local anesthetics are occasionally mentioned as a means to
alleviate marine envenomation pain. 1,12,13 However, there is little or no highquality
evidence addressing the subject. For envenomations in which sympathetic
overactivity is a problem (e.g. Irukandji syndrome), the use of
epinephrine-containing local anesthetics seems unwise.