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Three Part Question

In [patients who have Irukandji syndrome after a jellyfish sting] is [vinegar better than tap water] at [relieving symptoms]?

Clinical Scenario

A 20 year old patient presents to the Emergency Department after swimming off a sunny coastal area of Queensland, Australia. He has been stung by a jellyfish. He has severe pain at the site of the sting. He is very restless with back pain, muscle cramps, nausea and vomiting. He is tachycardic and hypertensive. You diagnose Irukandji syndrome and begin treatment with intravenous opiates before attempting to control his adrenergic storm. He tells you that as a first aid measure he washed the leg at the vinegar station on the beach. You wonder whether a tap water wash would have been as effective, if indeed it has made any differnce.

Search Strategy

Medline 1946 to week 4 Sept 2014

[Irukandji syndrome.mp or jelly fish.mp or box fish.mp] And [vinegar.mp or acetic.mp or acetic acid.mp water.mp or tap water.mp or fresh water.mp]. Only 6 papers were identified, and none addressed the question.
Searching only Irukandji syndrome.mp 82 papers were found. Still none addressed the question directly, but several gave an insight into the use of vinegar in Irukandji syndrome. These are presented in the table

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nickson et al. 2009 Australia	87 cases of Irukandji syndrome reported from Australia's Northern Territory.	Case series collected prospectively and retrospectively from 1990 to 2007.	Use of topical vinegar as a first aid measure.	Vinegar used in 66% of patients (57/87 cases).Relief of symptoms not mentioned in the review article.	Prospective and retrospective series. Small number of cases over 17 years. The effect of tap water, if tried, was not documented.
Fenner and Harrison 2000 Australia	544 cases of Irukandji stings and 478 Box jellyfish stings.	Retrospective review from a large database of marine envenomations kept by one of the authors.	Use of vinegar as first aid treatment to remove/inactivate tentacles.	Only 51 victims of Irukandji stings had first aid treatment recorded, but 88.2% of these had vinegar poured on their sting sites. Vinegar was used in 90.5% of the 306 Box jellyfish stings for which first aid was given.	The outcome of these treatments was not recorded. Less first aid seems to have been used in Irukandji stings. This is probably because the tentacles are so small, stings may result from contact with the bell of the jellyfish, and the stings do not cause immediate obvious wheals.
Barnett et al. 2005 Australia	34 health facilities from coastal northern Australia.	Telephone survey to establish management policies for Irukandji syndrome.	Use of topical vinegar as a first aid measure.	79% of facilities admitted using vinegar. Spontaneous mention of this treatment associated with remoteness of the facility (p= 0.023).	Telephone survey. No indication of how effective vinegar might be. Inappropriate first aid measures were also reported.
Macrokanis et al. 2004 Australia	88 patients with Irukandji syndrome from a cohort of 111 patients with marine stings from Broome Health Service.	Retrospective case series on the demographics and treatment of Irukandji syndrome in Western Australia.	Use of topical vinegar as a first aid measure.	38% of patients had vinegar applied.	Retrospective study. The features of envenomation were slightly different suggesting that the causative jellyfish may not have been the same as those found in northern Australian waters.

Comment(s)

Irukandji syndrome is a relatively common occurrence on the coasts of tropical Australia. It is the result of envenomation by the tiny Carukia barnesi and other small jellyfish. Toxins released from the nematocysts in the tentacles of these jellyfish produce a hyperadrenergic state, which is also extremely painful. Most envenomation resolves spontaneously or with symptomatic management. A minority of patients develop life threatening complications such as pulmonary oedema, cardiomyopathy, cardiogenic shock or intracerebral haemorrhage. (Little et al. 2001) Deaths have been reported. (Fenner and Hadock 2002) There is no national data base to collect the reported cases and it is not a reportable condition in Australia; therefore it is difficult to estimate the exact number of cases of Irukandji syndrome. The Australian Resuscitation Council recommends the use of vinegar as first aid treatment for some jellyfish stings, including those which cause Irukandji syndrome. (Australian Resuscitation Council 2010) Vinegar inactivates undischarged nematocysts of Box jellyfish (Chironex fleckeri) in experimental studies. (Hartwick et al. 1980) Vinegar stations are frequently seen on northern Australian beaches. Irukandji jellyfish stings can initially seem innocuous leading to delay in treatment and effectiveness of vinegar. Vinegar does not relieve the pain caused by the sting. The value of vinegar treatment has recently been called into question by an in vitro study of Box jellyfish nematocysts, which showed that vinegar, which inactivates undischarged nematocysts, increased the amount of venom discharged by activated nematocysts, and so could make the envenomation worse. (Welfare et al. 2014) Whether this will be the case for the nematocysts of species responsible for Irukandji syndrome is not yet known. It seems worthy of further study.

Clinical Bottom Line

Although vinegar seems to be widely used in Irukandji syndrome here is a lack of evidence for its effectiveness. Lack of evidence does not mean lack of effectiveness and therefore until further research is available, use of vinegar for Irukandji syndrome may be continued, as suggested in the Australian Resuscitation Council Guideline.

References

1. Nickson CP, Waugh EB, Jacups SP, Currie BJ. Irukandji Syndrome case series from Australia’s tropical Northern Territory. Annals of Emergency Medicine 2009; 54(3):395-403.
2. Australian Resuscitation Council Guideline 9.4.5 Envenomation - Jellyfish stings Australian Resuscitation Council 2010; http://www.resus.org.au/policy/guidelines/section_9/jellyfish_stings.htm (accessed 13/10/2014)
3. Hartwick RF, Callanan VI, Williamson JA. Disarming the Box jellyfish. Nematocyst inhibition in Chironex fleckeri. Med J Aust 1980; 1: 15-20.
4. Welfare P, Little M, Pereira P, Seymour J. An in-vitro examination of the effect of vinegar on discharged nematocysts of Chironex fleckeri. Diving and Hyperbaric Medicine. 2014; 44 (March): 30-34.
5. Fenner PJ and Harrison SL. Irukandji and Chironex fleckeri jellyfish envenomation in tropical Australia. Wilderness and Environmental Medicine 2000; 11: 233-240.
6. Barnett FI, Durrheim DN, Speare R, Muller R. Management of Irukandji syndrome in northern Australia. Rural & Remote Health. 2005 (3); 369.
7. Fenner PJ and Hadock JC. Fatal envenomation by jellyfish causing Irukandji syndrome. Med J Aust 2002; 177: 362-363.
8. Little M, Mulcahy RF, Wenck DJ. Life-threatening cardiac failure in a healthy young female with Irukandji syndrome. Anaesth Intensive Care. 2001; 29: 178-180.
9. Macrokanis CJ, Hall NL, Mein JK. Irukandji syndrome in northern Western Australia: an emerging health problem. Med J Aust 2004; 181: 699-702.