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Three Part Question

[In jellyfish envenomation] [which treatments] [improve outcome]?

Clinical Scenario

A young woman comes into casualty having just been stung by an unknown type of jellyfish while swimming in the sea at the local beach in the UK. There are large, painful weals on her leg and arm which she has wrapped in an ice pack. The nursing staff have suggested a wide variety of treatments to you, but you wonder which will be helpful in bringing rapid relief to your patient.

Search Strategy

Ovid Medline 1966 to Oct 2004 and The Cochrane Library.
(exp bites and stings/ or exp Cnidaria/ or jellyfish mp) AND (exp therapeutics/ or treatment mp or exp treatment outcome/ or outcome mp or exp outcome assessment (health care))

Search Outcome

207 articles 6 articles were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nomura et al USA 2002	30 medical staff all unpaid volunteers. 13 treated with heat (hot water 40-41'c) one arm and papain (meat tenderiser) the other, 15 treated with heat one arm and vinegar (weak acetic acid) the other, 5 excluded as only one arm became stung.	Paired randomised trial	10cm Pain visual scale	Pain scores at time =0 heat 3.6cm, vinegar/papain 3.7cm, time =20min heat 0.2cm, vinegar/papain 1.8cm (p<0.001)	Subjects being clinical assistants, nurses, medical students and doctors, may have influenced outcome; not possible to blind the trial; and results analysed by those performing trial
			skin appearance at end of trial	4 subjects arms were the same, 16 subjects heat treatment visibly better than vinegar/papain, 5 subjects vinegar/papain better than heat.
Pereira et al Australia 2000	In-vitro experiment on prawns, effect of pressure immobilisation bandaging on discharged nematocysts (stinging cells). Experiment to test the hypothesis that applying direct pressure to discharged nematocysts releases further venom	Laboratory experiment	Death of prawn	1st Saline washings of discharged nematocysts caused death in 3 prawns, 2nd saline washings did not kill 3 prawns, 3rd saline washings after application of 40mmHg pressure killed 3 prawns.	Not tested on people, anecdotal report that stings are worse after pressure bandaging prompted the research
Thomas 2001 Hawaii	133 Sting victims at a beach 7yrs of age or older. Randomised to chemical hot pack at 110'F, chemical cold pack at 42'F or spent chemical pack at air temperature after dousing sting with vinegar.	RCT	Pain gone within 15mins, 10cm pain visual scale at 0, 5, 10 and 15 minutes	Cold 33% (14/42) odds 0.5 (0.1 – 2.1). Hot 41% (18/44) odds 5.2 (1.3 – 22.8). Neutral 29% (12/41) odds 1.0. Cold 44 subjects 5 points reduction. Hot 42 subjects 6 points reduction. Neutral 41 subjects 0 reduction	No box jellyfish in UK. 90 dropped out of the study before the 10 and 15min readings
Exton et al Australia 1989	143 people stung on beaches in Queensland by Physalia (blue bottle) jellyfish, stings identified by trained surf life savers and any tentacles adhering washed off with water.	Trial	Pain assessed by surf life saver. Relief of pain after 1 or 2 applications of ice packs for 5 or 10 minutes. Ist ice pack.	Mild – 82% Moderate – 45% Severe – 16% relief	No control treatment
			2nd Ice pack	Mild 100% Moderate 77% Severe 62.5 %
Burnett et al USA 1983	In vitro experiment on tentacles of Chrysaora and Physalia jellyfish to detect prevention of nematocyst firing after application of various sting treatments.	Qualitative study	Prevention of discharge of nematocysts after application	Stingose (20% aluminium sulphate in detergent) effective, but stinging returns when washed. Household ammonia – noClorox – noAdolph's meat tenderiser possibly helpful, but need high concentrations. Lidocaine 1% - no comment. Witch hazel – no comment. Sodium Bicarbonate very effective on Chrysaora stings applied as a slurry, and dissolves tentacles. Vinegar effective on Physalia stings. Acetone – no20%aluminium chloride – no comment. Glycerol – noEthanol 33% and 100% - both make it worse. Magnesium chloride Sodium hydroxide- noPapain 0.1% and 1% - probably effective but causes skin blistering. Formalin 4% and 40% - both make it worse	Did not test on people or look at pain relief.Some of the chemicals will cause skin burns
Thomas et al, 2001 Hawaii	62 Sting victims over 7 years of age with jellyfish stings on the beach, vinegar was applied followed by one of 4 test solutions	RCT	10cm pain visual scale at 0, 5 and 10 mins	Salt water N=14, pain score 42.4 to 28.1. Fresh water N=19 pain score 44.3 to 34.5. Adolph's meat tenderiser N=14 pain score 40.7 to 36.9. Sting-Aid N=13 pain score 46.9 to 35.3	No box jellyfish in UK. Study terminated before clinical significance due to similarity of all four groups

Comment(s)

Heat 40-41'c is effective, ice packs are effective, baking soda will help sea nettle (Chrysaora) stings and disolves tentacles, vinegar may stop further stings but has little impact on pain and will cause firing of portuguese man-o-war nematocysts, pressure bandaging makes stings worse.

Clinical Bottom Line

Wash the stung area with any kind of water (Sea or fresh) and apply hot or cold packs for comfort, whichever is preferred by the patient.

References

1. Nomura JT, Sato RL, Ahern RM, Snow JL, Kuwaye TT, Yamamoto LG. A randomised paired comparison trial of cutaneous treatments for acute jellyfish (carybdea alata) stings. American Journal of Emergency Medicine. 20(7):624-6, 2002 Nov.
2. Pereira PL, Carrette T, Culen P, Mulcahy RF, Little M and Seymour J. Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Medical Journal of Australia 2000; 173: 650 – 652.
3. Thomas CS, Scott SA, Galanis DJ and Goto RS. Box jellyfish (Carybdea alata) in Waikiki: Their influx cycle plus the analgesic effect of hot and cold packs on their stings to swimmers at the beach: A randomised, placebo-controlled, clinical trial Hawaii Medical Journal vol 60 (4):100-7, 2001 Apr.
4. Exton DR, Fenner PJ, Williamson JA. Cold packs:effective topical analgesia in the treatment of painful stings by physalia and other jellyfish. Medical Journal of Australia 1989; 151: 625 – 626.
5. Burnett JW, Rubinstein H, Calton GJ. First aid for jellyfish envenomation. Southern Medical Journal 1983; 76: 870 – 872.
6. Thomas CS, Scott SA, Galanis DJ and Goto RS. Box jellyfish (Carybdea alata) in Waikiki. The analgesic effect of Sting-Aid, Adolph's meat tenderiser and fresh water on their stings: A double blinded, randomised, placebo controlled clinical trial. Hawaii Medical Journal 60 (8):205-10. 2001 Aug.