Management of a major box jellyfish ( Chironex fleckeri ) sting: Lessons from the first minutes and hours

Abstract

Objective To report the management of a serious box jellyfish (Chironex fleckeri) envenomation from the first minutes of bystander first aid and treatment by ambulance personnel to subsequent treatment in hospital. Clinical features A 14‐year‐old girl sustained a serious Chironex fleckeri sting. There was no loss of consciousness, but the patient suffered severe pain, myocardial irritability, acute pulmonary oedema and mild systemic hypotension, due to the direct toxic effects of the venom. Thirst was a dominant symptom. Intervention and outcome Management involved rapid bystander action and call for ambulance assistance; and early intervention with oxygen/nitrous oxide administration, compression bandaging, antivenom administration and electrocardiographic monitoring at the site by ambulance personnel. Echocardiography in hospital three hours after the sting showed a normal myocardium. In hospital management resulted in recovery. Nocturnal itching of the sting persisted for six weeks. Conclusions (i) Vinegar dousing may irritate freshly stung skin, but as a nematocyst inhibitor vinegar remains an essential part of the first aid treatment for cubozoan jellyfish stings. (ii) Compression/immobilisation bandaging was not associated with long‐term harm to the sting area. (iii) The pain of an intramuscular antivenom injection may not be felt by a chirodropid sting victim, so safe injection protocols must be strictly observed. (iv) Ambulance services in other States where there is a risk of box jellyfish (Chironex fleckeri or Chiropsalmus quadrigatus) stings should be similarly trained and equipped to deal with serious jellyfish envenomations.

Venom Proteome of the Box Jellyfish Chironex fleckeri

“…Symptoms of major C. fleckeri stings include excruciating pain, rapid acute cutaneous inflammation, dermonecrosis, permanent scarring, hypertension, hypotension, shock, dyspnoea, impaired consciousness, cardiac dysfunction and pulmonary oedema (reviewed in [6]). The onset of symptoms is extremely rapid [7] and in severe cases, death from pulmonary and/or cardiac failure can occur within minutes [8]. At least 70 deaths due to C. fleckeri envenoming have occurred in Australia and numerous deaths from related species have been reported in the Philippines, Maldives islands, Japan, Papua New Guinea, South India, Java, Malaysia and Gulf of Thailand [9].…”

Massive European wasp envenomation of a child

“…This raises questions about the potential for antivenom therapy in the setting of massive vespid wasp envenomation. There are some clinical similarities in this case to Australian marine envenomation by box jellyfish 44 ( Chironex fleckeri ), particularly the extreme pain and profound thirst. Postulated mechanisms for this thirst are a parasympatholytic anticholinergic mechanism, or a central CNS action.…”

Reply

“…Little et al ’s letter also mentions their anecdotal experience of PIB‐treated patients having ‘more severe and prolonged symptoms’. This needs valid epidemiological verification as there are also anecdotal published data suggesting that PIB helps severe envenomation 3 and there are no reports of increased or more severe stings involving its use occurring in 14 years of report forms completed by surf life savers and other personnel treating these stings, and supplied to the author 4 . Consequently, the Australian Resuscitation Council and all first‐aid organizations mentioned have not made any change to the first‐aid treatment of major chirodropid stings using PIB after prior dousing with vinegar for major stings, as set out in my article 5 …”