Page 114 - PJ MED OPS Handbook 8th Ed

c. Pain tends to peak 30–60 minutes after puncture and can last for several days.
d. Rare systemic symptoms include limb paralysis, hypotension, and bradycardia.
4. Envenomation by sea urchin:
a. Frequently cause multiple deep puncture wounds when stepped on.
b. Puncture and envenomation cause immediate, intense pain, erythema and local swelling.
c. If more than 15–20 punctures are present, then severe systemic symptoms can occur.
5. Envenomation by bristleworms:
a. Is caused by contact with bristle-like setae on feet of animal.
b. Contact is like brushing against a cactus plant and may result in many fine bristles embedded
in the skin.
c. Causes painful inflammation, which is almost never serious.
6. Envenomation by fish spines:
a. First symptom is usually immediate localized pain out of proportion to clinical manifestations,
lasting minutes to hours.
b. Puncture wound is usually cyanotic, with surrounding erythema and edema.
c. Pain is often noted in proximal lymph nodes.
d. Symptoms can progress to delirium, malaise, nausea, vomiting, and elevated temperature.
e. Infrequently leads to shock and death.
7. Envenomation by sea snake bites:
a. Fang and teeth marks consist of small puncture wounds and may number from 1–20.
b. Latent period of 10 minutes to several hours between bite and onset of symptoms.
c. May initially present with mental status changes, including euphoria, anxiety or restlessness.
d. Progresses to dry throat, nausea, vomiting, generalized weakness and paralysis, leading to
respiratory distress/failure.
8. Envenomation by blue-ringed octopus bite:
a. Bite is painless and may go unnoticed.
b. Patient may become paralyzed with respiratory distress.
c. Symptoms are usually rapid in onset and extremely variable in severity.

Management:
1. Stings (Jellyfish, Sea Wasp):
a. Remove stinger, tentacles, etc. if possible, with gloved hand, forceps or tape.
b. Immediately flush with dilute acetic acid (vinegar). Alternative flush is isopropyl alcohol and
seawater. Do not use fresh water.
c. Apply topical lidocaine.
d. Apply topical steroid.
e. Follow Pain Management Protocol
2. Bites (Sea snakes, blue ringed octopus) – See Envenomation Protocol.
3. Punctures (Sea urchin, stingray, fish spines, bristleworms):
a. Remove all penetrating foreign bodies with gloved hand, forceps or tape.
b. Irrigate with cold seawater.
c. Soak the affected area in nonscalding water (110°–115°) for 30–90 minutes to inactivate
toxins.
d. Ultrasound or x-ray (if available for retained foreign body).
e. Antibiotics for deep puncture wounds: moxifloxacin.
f. Follow Pain Management Protocol.

112 n Pararescue Medical Operations Handbook / 8th Edition