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120 Bites and stings – marine
jellyfish other than the classic Australian cubozoan (box) culprit, the tiny
Carukia barnesi; the syndrome has been reported around the world (e.g. in
Florida). 24
Therapies for the Irukandji syndrome tend to focus on systemic complications
such as hypertension. Severe muscle cramping, which can present in
delayed fashion, is treated with benzodiazepines. 25,26 There is no role for
either antihistamines or corticosteroids. 26–28
No RCT data address use of opioids for marine envenomation, but case
series consistently demonstrate this class’ utility in treating refractory pain
from a variety of marine-inflicted bites and stings. Analysis of a large series of
C. fleckeri stings found that parenteral opioids were required in nearly a third
of patients. 29 Nearly all clinicians with experience in treating Irukandji syndrome
consider IV opioids part of the standard treatment. 14,30 Stonefish
envenomation, notable for its severe pain, is often controllable with opioids
(and hot water immersion). 31,32 Hot water immersion and opioids are also
recommended for pedicellarial stings from sea urchins. 33 There is no guiding
trial evidence, but if allergic or anaphylactic symptoms are present it may be
prudent to use fentanyl (which does not release histamine) rather than
morphine.
There are no data on use of NSAIDs for marine envenomation, but there are
theoretical reasons to avoid this class. Most notably, the antiplatelet effects of
the NSAIDs may be problematic in situations where punctures have occurred.
n Summary and recommendations
First line: hot water immersion or shower (40–45 °C as tolerated, for 90 min);
jellyfish: acetic acid dousing with 4–5% solution (household vinegar)
Reasonable: morphine (initial dose 4–6 mg IV, then titrate)
Pregnancy: topical hot water and acetic acid dousing with 4–5% solution
(household vinegar)
Pediatric: topical hot water and acetic acid dousing with 4–5% solution
(household vinegar)