Chironex fleckeri 18.May.2012-Expires: 7 days - Do not archive IDENTIFICATION FAMILY NAME Chirodropidae   GENUS NAME Chironex    SPECIES NAME Chironex fleckeri   COMMON NAME(S) Australian box jellyfish Box jellies Box jelly Box jellyfish Chironex box jellyfish Indringa Sea stinger Sea wasp   HABITAT Distribution These tropical jellyfish are mainly found in coastal waters in tropical areas of northern Australia. These animals frequent the shore area adjacent to mangrove creeks in which they breed, and from which they swim to feed in summer (October to May). The closer the geographical location to the equator, the greater the number of months Chironex fleckeri is found.  In Darwin, Chironex fleckeri stings have occurred for every month of the year, except for one month. When fishing for prey they favor calm water close to shore, free of snags over clear sandy bottoms, where they extend and trail their curtain of tentacles behind them.[1]   INTERVENTION CRITERIA Intervention Level Child and Adult Medical observation, preferably in an advanced care facility with Box Jellyfish Antivenom available is recommended for: Any individual stung or suspected to have been stung by a box jellyfish   Observation Period Observation at Home All patients require medical attention.   Medical Observation Asymptomatic patients should be observed for 2 hours. If they remain asymptomatic in this time frame, the patient may be discharged into the care of a reliable observer and given instructions to return should any symptoms develop.   Stings may result in severe envenoming; symptomatic patients must not therefore be discharged until their symptoms have subsided.   Investigations Sticky tape or scalpel sampling can be performed to identify the jellyfish in question, sticky tape is applied to skin or the skin is scraped with a scalpel and then transferred to a microscope slide for examination; this allows nematocysts to be identified on the basis of morphology.[2][3]However this currently is a research tool only. A negative result does not rule out a jellyfish sting.   Admission Criteria Any patient with symptoms must be admitted to a medical facility with Box Jellyfish Antivenom and advanced life support.   TREATMENT TREATMENT SUMMARY Most stings are minor but all must be treated as potentially lethal.   In all cases retrieve and restrain the victim on the beach, prevent rubbing of attached tentacles and vigorous muscular activity. Commence and sustain cardiopulmonary resuscitation (CPR) if indicated, this always takes absolute priority.   Flush the affected area liberally with vinegar for at least 30 seconds, and only then carefully remove any adherent tentacles.[4] If the effects are minor, pain may be managed with local application of ice,[5] simple analgesia, and oral antihistamines; there should be early medical inspection in case of local skin damage. If pain does not respond, parenteral opioid analgesia may be required, or administration of Box Jellyfish  Antivenom (CSL) which appears effective for pain relief if administered early. Antivenom is also indicated in severe envenomings to reduce life-threatening complications, and possibly reduce scarring.[6]   Cardiac dysrhythmia and arrest are particular concerns, and possibly may develop within minutes of the stinging contact. Pulmonary edema and respiratory depression/failure may subsequently evolve. Multiple vials of antivenom should be administered for these indications, but its efficacy in the management of cardiorespiratory dysfunction remains uncertain,[6] and advanced supportive care, including mechanical ventilation, is likely required to maintain such patients.   Dermonecrosis is a frequent complication of serious stings, and box jellyfish antivenom has been reported to improve both acute and long-term cutaneous damage.[7] Acute skin markings often resolve spontaneously. Thus acute dermonecrosis should be treated as a burn with specific attention to avoiding secondary bacterial infection. Delayed hypersensitivity reactions are a common late complication of stings occurring some 7 to 14 days after the event.[8] Serum sickness is a potential concern in those receiving antivenom, particularly multiple doses.   Emergency Stabilization Ensure adequate cardiorespiratory function Cardiac arrest Hypotension Flush with vinegar Emergency monitoring Decontamination Skin Irrigate Eye Irrigate immediately Antivenom(s) Box Jellyfish  Antivenom  (CSL) Enhanced Elimination Not recommended Supportive Care Monitoring Neurologic Pain Anxiety Cardiovascular Cardiac dysrhythmia Respiratory Pulmonary edema Respiratory failure Hematologic Hemolysis Dermatologic Dermal necrosis Immunologic Hypersensitivity reaction Serum sickness EMERGENCY STABILIZATION Ensure Adequate Cardiopulmonary Function Airway Ensure the airway is protected if compromised (intubation may be necessary).   Immediately establish secure intravenous access.   Cardiac Arrest Cardiac dysrhythmia or arrest may occur within minutes of a sting – particularly in children. Commence and sustain cardiopulmonary resuscitation (CPR) if indicated, this takes priority over application of vinegar to neutralize tentacle stinging apparatus.   Prolonged cardiac resuscitation following standard ACLS protocols is warranted as recovery with a good neurological outcome is occasionally reported in poisoned patients receiving CPR for periods of 3 to 5 hours.[9]   Cardiopulmonary resuscitation should therefore be prolonged, and ideally not abandoned until at least 6 vials of intravenous box jellyfish antivenom have been administered.[10]   Hypotension CHILD Where the systolic blood pressure is below normal blood pressure ranges for the age group:[11]   Age (years) Normal Systolic Blood Pressure (mmHg) <1 70 to 90 1 to 2 80 to 95 2 to 5 80 to 100 5 to 12 90 to 110 >12 100 to 120   Administer normal (0.9%) saline 10 mL/kg IV over 5 to 10 minutes   If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes. If intravenous access cannot be obtained consider intra-osseus access   ADULT Administer a bolus of normal saline if systolic blood pressure is less than 100 mmHg.   Normal (0.9%) saline dose: 10 mL/kg IV over 5 to 10 minutes   If the systolic blood pressure does not return to the normal range, give a further 10 mL/kg body weight normal saline over 5 to 10 minutes.   Flush with Vinegar Retrieve and restrain the victim on the beach and prevent tentacle rubbing and vigorous muscular activity. Immediately douse the sting area liberally with vinegar for a minimum of 30 seconds;[12] do not attempt to remove adherent tentacles before this step, unless no vinegar is available, in which case carefully pick off the tentacles.   Pressure-Immobilization First Aid Pressure immobilization first aid was proposed to be beneficial because of its effectiveness in treating elapid snake and funnel web spider bites,[13][14] however there is no evidence to support the use of pressure immobilization bandages in the management of jellyfish stings.[15][16] Evidence suggests it may actually increase the amount of venom that is injected into the victim.[17] The Australian resuscitation council has announced a change in advice to a more neutral position.[18]   Emergency Monitoring If there are signs of systemic envenoming: Heart rate/rhythm Pulmonary function Level of consciousness DECONTAMINATION Skin Flush the affected area with vinegar (3 to 10 % acetic acid in water) as soon as possible,[19][20] and continue to irrigate for 30 seconds. After flushing, carefully remove any adherent tentacles.[4]   Vinegar may irritate the sting sites, but should still be applied.[21] It is not designed to relieve pain associated with jellyfish stings, but to prevent further discharge of nematocysts. Nematocyst inhibition and analgesia are two distinct and separate areas of management.   The fresh sting area should never be rubbed with sand, towels or anything else. Methylated spirits is not recommended.[4]   Eye Remove contact lenses. Irrigate immediately with water or saline for at least 30 minutes. If the eye is contaminated with solid particles, the eyelid should be completely everted and any solid material removed as quickly as possible whilst continuing to irrigate. A topical anesthetic may be necessary in some patients to enable the patient to open their eyelids sufficiently for effective irrigation.   The eye should be examined immediately following flushing with a slit-lamp microscope and fluorescein stain. All patients should be reviewed the following day. Any evidence of injury requires specialist ophthalmological assessment.   SIGNS AND SYMPTOMS The Box jellyfish is one of the most dangerous venomous creatures in the world, however, most typical stings rarely require hospitalization.[10][8][5]   Following exposure, the victim may experience immediate excruciating pain which increases in mounting waves, despite removal of the tentacle. The victim may scream and become irrational.[22][23] Areas of contact appear as purple or brown lines often compared to the marks made by a whip.[22] A pattern of transverse bars is usually visible and whealing is prompt and massive. Edema, erythema, and vesiculation soon follow and when these subside patches of full thickness necrosis are revealed.[22]   Patients may develop a variety of systemic effects that include acute pulmonary edema, cardiovascular instability, shock, and cardiac arrest. When death occurs it is usually due to a (presumed) cardiac arrest on the beach.   Routes of Exposure Clinical effects may develop following contact with intact or dismembered jellyfish, or nets containing body parts. Exposures generally occur when people are swimming in the sea or when specimens are washed up on the beach and handled or stood on. Jellyfish do not “attack” humans and stings are usually the result of a creature drifting into humans or humans colliding into a jellyfish.   Onset/Duration of Symptoms Local effects are generally noted immediately. Victims experience intense excruciating localized skin pain, peaking at 15 minutes and waning over the subsequent 24 hours; edema, erythema and vesiculation occur initially and when these subside (after some 10 days) patches of full thickness necrosis are revealed. Death, if it occurs, is usually within 20 minutes of the sting.[10]   Severity of Envenoming Severity is dependent upon area of discharging tentacle contact. Involvement of greater than 10% skin area is potentially lethal, especially in children.[6] Death follows cardiopulmonary failure.   Mild Box Jellyfish Envenoming Moderate Box Jellyfish Envenoming Severe Box Jellyfish Envenoming Local pain Cutaneous linear marks of sting Severe local or generalized pain Nausea Vomiting Tachycardia Acute respiratory distress Dysrhythmias Shock Acute pulmonary edema Respiratory failure Cardiac arrest Death   CHRONIC EFFECTS Delayed hypersensitivity reactions may occur in patients following stings. The reaction consists of a pruritic erythematous maculopapular rash that appears at the initial tentacle contact points and occurs 7 to 14 days after envenoming. The reaction may spontaneously resolve; most recover following treatment with oral antihistamines and topical corticosteroids.[8]   REFERENCES [1] Williamson J, Burnett J. Clinical toxicology of marine coelenterate injuries. In: Meier J, White J, editors. Handbook of clinical toxicology of animal venoms and poisons. Boca Raton (FL): CRC Press; 1995. p. 89-115. [2] Currie BJ, Wood YK. Identification of Chironex fleckeri envenomation by nematocyst recovery from skin. Med J Aust 1995 May 1; 162 (9): 478-80. [3] Huynh TT, Seymour J, Pereira P, Mulcahy R, Cullen P, Carrette T, Little M. Severity of Irukandji syndrome and nematocyst identification from skin scrapings. Med J Aust 2003 Jan 6; 178 (1): 38-41. [4] Hartwick R, Callanan V, Williamson J. Disarming the box-jellyfish: nematocyst inhibition in Chironex fleckeri. Med J Aust 1980 Jan 12; 1 (1): 15-20. [5] Fenner PJ, Harrison SL. Irukandji and Chironex fleckeri jellyfish envenomation in tropical Australia. Wilderness Environ Med 2000 Winter; 11 (4): 233-40. [6] White J. CSL antivenom handbook. Melbourne: CSL Ltd: 2001. p. 59-61. [7] King GK. Acute analgesia and cosmetic benefits of box-jellyfish antivenom. [Letter] Med J Aust 1991 Mar 4; 154 (5): 365-6. [8] O'Reilly GM, Isbister GK, Lawrie PM, Treston GT, Currie BJ. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust 2001 Dec 3-17; 175 (11-12): 652-5. [9] Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 8: advanced challenges in resuscitation: section 2: toxicology in ECC. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation 2000 Aug 22; 102 (8 Suppl): I223-8. [10] Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol 2003; 41 (3): 301-8. [11] Mackway-Jones K, Molyneux E, Phillips B, Wieteska S, editors. Advanced paediatric life support: the practical approach. 3rd ed. London: BMJ Books; 2001. [12] Fenner PJ, Williamson JA, Blenkin JA. Successful use of Chironex antivenom by members of the Queensland Ambulance Transport Brigade. Med J Aust 1989 Dec 4-18; 151 (11-12): 708-10. [13] Sutherland SK, Duncan AW. New first-aid measures for envenomation: with special reference to bites by the Sydney funnel-web spider (Atrax robustus). Med J Aust 1980 Apr 19; 1 (8): 378-9. [14] Williamson JA, Callanan VI, Unwin ML, Hartwick RF. Box-jellyfish venom and humans. [Letter] Med J Aust 1984 Mar 31; 140 (7): 444-5. [15] Little M. Is there a role for the use of pressure immobilization bandages in the treatment of jellyfish envenomation in Australia? Emerg Med (Fremantle) 2002 Jun; 14 (2): 171-4. [16] Seymour J, Carrette T, Cullen P, Little M, Mulcahy RF, Pereira PL. The use of pressure immobilization bandages in the first aid management of cubozoan envenomings. Toxicon 2002 Oct; 40 (10): 1503-5. [17] Pereira PL, Carrette T, Cullen P, Mulcahy RF, Little M, Seymour J. Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Med J Aust 2000 Dec 4-18; 173 (11-12): 650-2. [18] Jacobs I. Use of pressure immobilisation bandage in jellyfish stings. Australian Resuscitation Council Press Release, 5 Aug 2002. [cited 2003 November 17]. URL: http://www.resus.org.au/newsletters/newsletter_july_2002.pdf [19] Fenner PJ, Williamson JA, Burnett JW, Rifkin J. First aid treatment of jellyfish stings in Australia. Response to a newly differentiated species. Med J Aust 1993 Apr 5; 158 (7): 498-501. [20] Currie B, Ho S, Alderslade P. Box-jellyfish, Coca-Cola and old wine. [Letter] Med J Aust 1993 Jun 21; 158 (12): 868. [21] Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Management of a major box jellyfish (Chironex fleckeri) sting. Lessons from the first minutes and hours. Med J Aust 1992 May 4; 156 (9): 655-8. [22] BARNES JH. Observations on jellyfish stingings in North Queensland. Med J Aust 1960 Dec 24; 47(2) (): 993-9. [23] Maguire EJ. Chironex fleckeri ("sea wasp") sting. Med J Aust 1968 Dec 21; 2 (25): 1137-8. Do Not Archive. This document is current on day of issue, NZ: 18.May.2012

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