Lionfish envenomations in an urban wilderness

Understanding the pain experience of lionfish envenomation

Introduction

Stings from the lionfish (Pterois volitans) constitute one of the most painful wounds in the ocean. This species has invaded the Atlantic coast of the United States, Gulf of Mexico, Caribbean, and Mediterranean Sea. In addition to its ecological impact on local fish populations, stings from the lionfish pose a medical problem because of the debilitating nature of the pain they produce. However, there are no studies examining the human pain experience of lionfish stings.

Objective

To characterize the various aspects of the pain experience following a lionfish sting.

Methods

We developed a pain questionnaire that includes validated scales used with patients having acute or chronic pain to understand the pain variability, as well as the use of health care resources and treatments.

Results

We provide the first study of the pain experience from lionfish stings. Here, we show that the pain is intense from the start and peaks approximately 1 hour later, resolving itself in 7 days for most victims. Furthermore, pain intensity can be influenced by several factors, including (1) age of the victim, where older victims experience significantly higher pain intensities, (2) the number of spines involved, (3) and whether infection occurred at the injury site. However, pain intensity was not different between male and female participants.

Conclusion

These findings will inform the medical community on the pain experience and can be used by local authorities to better appreciate the impact of lionfish envenomations to develop programs aimed at curtailing the expansion of the lionfish.

Iatrogenic Thermal Burns Secondary to Marine Sting Treatment

Hot water immersion (HWI) therapy is an effective and validated treatment for a variety of marine stings. Unsupervised, however, it poses a significant risk of thermal injury. Herein, we describe our experience of iatrogenic thermal injury secondary to marine sting treatment. A 5-year retrospective review of all iatrogenic thermal burns secondary to marine stings referred to the State Adult Burn Service was conducted. Nine patients were identified, all sustaining stings to the feet from estuarine cobblerfish, stonefish, and stingrays. All patients continued unsupervised HWI at home and sustained thermal injury to their feet. The majority were treated conservatively with dressings and elevation. One patient required surgical debridement. While heat application is an effective treatment for marine stings, further patient education is required following discharge from point of care. We recommend that first-aid treatment guidelines be updated to reflect that patients are not recommended to continue scalding water immersion at home. However, if patients wish to continue HWI, water temperature should be checked manually with a thermometer or with a nonstung limb and limited to 30 minutes immersion, with 30-minute skin recovery time between.

Watch Out for Wild Animals: A Systematic Review of Upper Extremity Injuries Caused by Uncommon Species

BACKGROUND

Across the world, many species of nondomesticated animals dwell among humans in metropolitan areas. Rare animal bites pose a dilemma for hand surgeons, as they often result in operative injuries and recalcitrant infections. The authors treated an 85-year-old man who experienced severe cellulitis of the index finger following an opossum bite. This case prompted a systematic review of upper extremity injuries caused by species other than dogs, cats, snakes, and insects.

METHODS

The authors conducted a systematic review of PubMed and Scopus databases to identify relevant articles published between 1980 and 2016. Two reviewers critically appraised the studies that met inclusion and exclusion criteria.

RESULTS

The hand infection in the man who sustained an opossum bite at the authors' institution was successfully treated with targeted antibiotic therapy, hand elevation, and splinting. Seventy-one articles met inclusion criteria for and were included in this systematic review. The vast majority of existing articles represent level IV and level V evidence. The relevant literature suggests that the majority of hand infections attributable to animal bites and stings are polymicrobial.

CONCLUSIONS

Injuries secondary to aquatic animals appear to be the most frequently described in the literature, and hot water immersion should be used for the majority of envenomation attributable to aquatic species. Infections can often be treated with an aminopenicillin antibiotic combined with a beta-lactamase inhibitor. Given the variability in presentation and potential for sequelae such as soft-tissue necrosis and systemic reactions, hand surgeons should approach such upper extremity injuries with a high degree of caution.

A Case of Lionfish Envenomation Presenting to an Inland Emergency Department

Lionfish envenomation can cause erythema, edema, necrosis, and severe pain at the exposed site. Treatment often includes supportive wound care, pain management, and hot water immersion. We report a case of lionfish exposure presenting to an inland emergency department treated successfully with these measures.

Envenomation by the invasive Pterois volitans species (lionfish) in the French West Indies--a two-year prospective study in Martinique

CONTEXT

The invasion of the lionfish (Pterois volitans) in the French West Indies represents one of the most important marine invasions by alien species in history. Since its first recognition in Martinique in February 2011, the lionfish presence has strongly progressed, resulting in increasing envenomation cases. Our objective was to report features of lionfish envenomation and outcome.

METHODS

A prospective study conducted at the Martinique University Hospital by the emergency departments, general practitioners, and the pre-hospital emergency ambulance service included all the patients referred from November 2011 to February 2014 for one or several stings by lionfish, as strongly suggested by the fish description and the association with marked local pain and edema. Recommended management included immersion of the affected body part in hot water at 35-40 °C for 60 min, analgesics, tetanus toxoid, and antibiotics.

RESULTS

117 patients [98M/19F; age: 42 ± 14 years [mean ± SD]; with significant past morbidities (16%)] were included. Envenomation resulted in marked pain and local edema (100%), paresthesia (90%), abdominal cramps (62%), extensive edema (53%), tachycardia (34%), skin rash (32%), gastrointestinal disorders (28%), fainting (27%), transient weakness (24%), hypertension (21%), hypotension (18%), hyperthermia (9%), bradycardia (3%), hypophosphatemia (12%), elevated aspartate aminotransferase (AST) (10%), and thrombocytopenia (3%). The sting was complicated by local infection (18%) including skin abscess (5%), cellulitis (3%), skin necrosis (3%), and septic arthritis (2%). 26 patients (22%) were hospitalized requiring surgery (8%). Lionfish stings were single (81%) or multiple (19%). Localization was preferentially at one upper (67%) or lower limb (32%). All patients actually improved. Based on multivariate analyses, pain duration > 24 h was significantly associated with skin eruption (p = 0.001) and muscle cramps (p = 0.0002). Local infectious complications occurred more frequently in patients presenting multiple stings (p = 0.008). Immersion in hot water (44%, performed less than 3 h after the sting in 36% of the cases) significantly reduced pain duration (p = 0.02) and local infection (p = 0.02).

CONCLUSION

Lionfish represents a major health threat in Martinique with increasing envenomation and significant morbidities. Outcome is favorable if promptly managed, with possible reduction in pain duration and local infections with the rapid immersion of the stung body part in hot water. Our data encourage the authorities to develop investigations on the exact extent of the lionfish invasion and set up a regional taskforce to inform the ecosystem users and register all lionfish-attributed incidents.

Envenomations

Numerous types of envenomations may be encountered by health care workers depending on where in North America they work. Clinicians should be familiar with the animals in their region that may lead to envenomation.A rational approach with use of poison center or medical toxicology consultation services ensures that cases are managed appropriately.

Injuries caused by scorpionfishes (Scorpaena plumieri Bloch, 1789 and Scorpaena brasiliensis Cuvier, 1829) in the Southwestern Atlantic Ocean (Brazilian coast): epidemiologic, clinic and therapeutic aspects of 23 stings in humans

Fishes of the family Scorpaenidae are responsible for severe injuries and occasionally deaths in humans around the world. The more venomous fishes on the Brazilian coast and in the Southwestern Atlantic region are classified in the genus Scorpaena (family Scorpaenidae). However, there are few studies on the venomous apparatus, the effects of the venom, or clinical aspects of human envenoming provoked by Atlantic scorpionfishes. In this communication, the authors present 23 accidents caused by scorpionfishes of the genus Scorpaena among fishermen, and report the species that provoked the injuries, the circumstances of contacts, the clinical aspects observed and the therapeutic measures utilized for control of the symptoms of the victims. The intense pain and the systemic findings observed in the patients were very frequent and we think that the injuries provoked by scorpionfishes should be considered the most important manifestations caused by venomous fishes of the East Atlantic Ocean.

Environmental injuries

Environmental injuries and illnesses can happen in home, work, or recreational settings. The variety and severity of these injuries might require the clinician to call on skills from internal medicine, emergency medicine, and toxicology. Diseases of thermoregulation are hypothermia and hyperthermia. In each instance, treatment is based on the need to restore the patient's core temperature to normal and on monitoring for complications. The victim of a fire might suffer inhalation injury in addition to burns, and it is more likely that the inhalation injury will be fatal. Oxygen deprivation and inhalation of irritant or asphyxiant chemicals contribute to injury. Toxic plants can be the source of poisoning emergencies, especially in children. Misinformation and myths that surround common plants can create diagnostic problems (i.e., which plants really are toxic and require emergency measures). Venomous marine organisms can cause a wide range of injury, from cutaneous eruption to fatal envenomation. Most are encountered in a recreational setting, such as water sports, but keepers of home aquariums are subject to stings from venomous fish. Lightning injury can present many diagnostic and treatment dilemmas. An important point in this regard is that lightning injury and high-voltage electrical injury are different in pathology and require different approaches for treatment. A discussion of electrical, chemical, and thermal burns makes such differences apparent.