Review Question - QID 214742

Toxicology Toxicology Drug Introduction QID: 214742 (M2.OMB.4901)

QID 214742 (Type "214742" in App Search)

A 24-year-old man presents to the emergency department with burning, swelling, and pain in his leg that began when swimming in the ocean. The patient has no significant medical history and takes no medications. His temperature is 97.7°F (36.5°C), blood pressure is 114/74 mmHg, pulse is 60/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A. Which of the following is the appropriate management of this patient?

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Cold water immersion

21%

7/34

Diphenhydramine

24%

8/34

Epinephrine

2/34

Rinsing with vinegar

32%

11/34

Surgical debridement

18%

6/34

Select Answer to see Preferred Response

This patient is presenting after swimming in the ocean with pain, swelling, and a physical exam demonstrating tentacle prints suggesting a diagnosis of a jellyfish sting. One treatment for jellyfish stings involves rinsing with vinegar.

Jellyfish stings present with severe pain, swelling, edema, and tentacle prints on physical exam. It should be suspected with sudden onset and localized pain after swimming in the ocean. The management of a jellyfish sting is to first remove the stinging tentacles. Warm water immersion can also be attempted which may inactivate the nematocysts, the poisonous part of the tentacle. Rinsing with vinegar is generally recommended as vinegar impairs the release of venom from the nematocysts. Severe complications or envenomation may result in cardiac arrest or respiratory paralysis. Of note, urination in the affected area is not helpful despite popular belief.

Lam et al. studied a case of severe jellyfish envenomation in a 31-year-old man who presented with sudden hand numbness, swelling, and cyanosis 4 days after a jellyfish sting. The authors found that while most jellyfish stings present with a local, painful, papular urticaria, this patient developed severe complications that necessitated invasive treatments including a fasciotomy. The authors recommend that more research is needed to understand the severe complications of jellyfish stings and optimize management.

Figure A demonstrates the painful lesion of a jellyfish sting with erythema and sting marks with likely embedded nematocysts.

Incorrect Answers:
Answer 1: Cold water immersion would not help with jellyfish stings; however, warm water immersion may help alleviate symptoms by impairing nematocyst function and release.

Answer 2: Diphenhydramine may be indicated for urticaria which presents with pruritic and raised, erythematous skin lesions. It would also be indicated in scombroid (histamine fish poisoning) which presents after eating certain fish with a peppery taste in the mouth while eating (peppery from the bacteria on the fish and the enzyme they produce that increases histamine), urticaria, and hives.

Answer 3: Epinephrine (intramuscular) is the treatment for anaphylaxis which presents after allergen exposure with wheezing, hypotension, tachycardia, swelling of the upper airway, hives, abdominal pain, nausea, and vomiting.

Answer 5: Surgical debridement is indicated in the management of necrotizing fasciitis which presents with a fever, unstable vitals, and severe pain with a rapidly spreading rash with or without crepitus. Broad-spectrum antibiotics should also promptly be administered.

Bullet Summary:
Jellyfish stings present with pain and swelling when swimming in the ocean and should be treated with the removal of tentacles, immersion in warm water, and rinsing with vinegar.