Rosen & Barkin's 5-Minute Emergency Medicine Consult (437 page)

• Vital signs
  
• Airway
  
• Mental status
  
• Cardiopulmonary exam
  
• Dermatologic exam, foreign bodies, cellulitis, blistering
  

• Careful history, repeated evaluation of wound sites
  
• Assessment of ABCs
  

• CBC
  
• Electrolytes, BUN, creatinine, and glucose levels
  
• LFT
  
• Urinalysis
  
• Arterial blood gases if severe symptoms
  

Soft tissue radiographs to detect foreign body

• Allergic reaction
  
• Cellulitis
  
• Gastroenteritis
  
• Aspiration pneumonia
  
• Near drowning
  

TREATMENT

• Remove victim from water source.
  
• Control airway, breathing.
  
• Control hemorrhage.
  
• Detoxify venom with proper wound irrigation as discussed below.
  

• Airway, breathing, and circulation management (ABCs)
  
• Establish IV access with 0.9% normal saline (NS).
  

• General:
  
  • Prepare for anaphylactic reactions (epinephrine/steroids).
    
  • Prepare for intubation if needed.
    
  • Diphenhydramine for itch, burn, hives
    
  • Tetanus prophylaxis
    
  • Corticosteroids for severe local reactions
    
  • Narcotic analgesia for severe pain
    
  • Antibiotic prophylaxis for the following:
    
    • Large lacerations or burns
      
    • Deep puncture wounds
      
    • Grossly contaminated wounds
      
    • Elderly or chronically ill
      
  • Antibiotic choices:
    
    • Trimethoprim/sulfamethoxazole (TMP-SMX; Bactrim)
      
    • Tetracycline
      
    • Ciprofloxacin
      
    • 3rd-generation cephalosporin
      
• Sponges:
  
  • Gently dry skin and remove spicule:
    
    • Adhesive tape may aid in removal.
      
  • 5% acetic acid (vinegar) (or 40–70% isopropyl alcohol) soaks QID for 10–30 min
    
• Coelenterates (Cnidaria jellyfish):
  
  • Rinse wound with salt water or seawater:
    
    • Hypotonic (fresh or tap water solutions), trigger more nematocysts
      
  • Do not rub skin to avoid release of nematocysts.
    
  • Inactivate toxin with 30-min soak of 5% acetic acid (vinegar)
    
  • Remove remaining nematocysts with razor, clam shell.
    
  • Apply topical anesthetics once nematocysts are removed.
    
  • Sea Safe jellyfish sunblock products are available.
    
  • Box-jellyfish sting envenomation (Australia) emergent cases:
    
    • Administer
      Chironex
      antivenin: 1 amp (20,000 U) IV diluted 1:5 with crystalloid.
      
  • Corticosteroids for severe reactions
    
• Starfish:
  
  • Immerse in nonscalding hot water for pain relief.
    
  • Irrigate and explore all puncture wounds.
    
  • Prophylactic antibiotics for significant wounds
    
• Sea urchins:
  
  • Immerse in nonscalding hot water for pain relief.
    
  • Remove any remaining spines.
    
  • Prophylactic antibiotics for significant wounds.
    
• Sea cucumbers:
  
  • Immerse in nonscalding hot water for pain relief.
    
  • 5% acetic acid soaks
    
  • Ocular involvement:
    
    • Proparacaine for pain
      
    • Copious irrigation with NS
      
    • Careful slit-lamp exam
      
• Cone shells:
  
  • Hot water immersion for pain relief
    
  • Be prepared for cardiac or respiratory support.
    
• Stingrays:
  
  • Copious irrigation with removal of any visible spines
    
  • Local suction is controversial.
    
  • Hot water soaks for pain relief
    
  • Narcotics for pain control
    
  • High incidence of bacterial infection:
    
    • Administer prophylactic antibiotics for significant wounds.
      
• Scorpion fish:
  
  • Hot water soaks for pain relief and venom inactivation
    
  • Copious irrigation, removal of any visible spines
    
  • Local lidocaine or regional block for severe pain
    
  • Surgical exploration for deep penetration/foreign bodies
    
  • Stonefish antivenin for severe envenomations:
    
    • One 2-mL amp diluted in 50-mL saline IV slow
      
    • May cause serum sickness
      
• Catfish:
  
  • Hot water soaks for pain relief and venom inactivation
    
  • Copious irrigation, removal of any visible spines
    
  • Consider local lidocaine, regional block, or narcotics for severe pain.
    
  • Surgical exploration for deep penetration, foreign bodies
    
  • Leave puncture wounds open to heal.
    
  • Consider prophylactic antibiotics for hand, foot, or deep wounds.
    
• Sea snakes:
  
  • Immobilize bitten extremity.
    
  • Apply pressure bandage for venous occlusion (pre-hospital).
    
  • Keep victim warm and still.
    
  • Polyvalent sea snake antivenin reduces mortality to 3%:
    
• May require 3–10 amps (1000 U each)
  
• Prepare early for assisted ventilation.
  

• Cefixime: 400 mg (peds: 8 mg/kg/24h) PO daily
  
• Ciprofloxacin: 500 mg PO BID
  
• Epinephrine: 0.3–0.5 mL SC 1:1,000 (peds: 0.01 mL/kg)
  
• Tetracycline: 500 mg PO QID (caution with photosensitivity)
  
• TMP-SMX (Bactrim DS): 1 tab [peds: 5 mg liquid (40/200/5 mL)/10 kg per dose] PO BID (caution with photosensitivity)
  

FOLLOW-UP

Significant signs of systemic involvement or need for antivenom administration

No signs of systemic illness after 8 hr of observation

Zoos, aquariums for available supplies of antivenom; poison control centers: 800-222-1222

• Most toxins are detoxified with either temperature change (hot water) or pH alteration (more acidic).
  
• Specific antivenoms for box jellyfish, stone fish, and sea snake envenomations are available but in limited supply; acquire early in treatment course.
  

• Avelino-Silva VI, Avelino-Silva T. Images in clinical medicine.
  Evolution of a jellyfish sting. N Eng J Med
  . 2011;365(3):251.
  
• Balhara KS, Stolbach A. Marine envenomations.
  Emerg Clin North Am.
  2014;32(1):223--243.
  
• Fernadez I, Vallalolid G, Varon J, et al. Encounters with venomous sea life.
  J Emerg Med.
  2011;40(1):103--112.
  

CODES

• 692.89 Contact dermatitis and other eczema due to other specified agents
  
• 989.5 Toxic effect of venom
  

BASICS

• Infection of the breast causing pain, swelling, and erythema
  
• Most commonly in women who are breast-feeding
  
• Often with systemic symptoms also:
  
  • Malaise
    
  • Fever
    
• Incidence may be as high as 33% in lactating woman
  
• Onset typically 2–3 wk to months postpartum
  
• 75–95% occur before infant is 3 mo old
  
  • Rare during 1st postpartum week
    
• More common in advanced maternal age and patients with diabetes
  
• Complications:
  
  • Recurrence
    
  • Abscess
    
  • Sepsis
    
  • Necrotizing fasciitis
    
  • Fistula
    
  • Scarring
    
  • Breast hypoplasia
    

Can occur in full-term infants <2 mo of age

• Staphylococcus aureus
  most common
  
• Less common causes:
  
  • Coagulase-negative
    Staphylococcus
    
  • Streptococcus
    spp.
    
  • Escherichia coli
    
  • Haemophilus influenzae
    
  • Candida albicans
    
• Risk factors:
  
  • Cleft lip or palate
    
  • Cracked nipples
    
  • Infant attachment issues
    
  • Local milk stasis
    
  • Nipple piercing
    
  • Poor maternal nutrition
    
  • Previous mastitis
    
  • Primiparity
    
  • Restriction from a tight bra
    
  • Sore nipples
    
  • Short frenulum in infant
    
  • Use of a manual breast pump
    
  • Yeast infection