Emergency Medicine (2002) 14, 171–174

Blackwell Science, Ltd Toxicology

Is there a role for the use of pressure immobilization bandages in the treatment of jellyfish envenomation in Australia?Mark LittleDepartment of Emergency Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia and Tropical Australian Stinger Research Unit, Cairns, Queensland, Australia

Abstract

Background: The aim of this paper was to review the literature relating to the use of pressureimmobilization bandages in the first aid management of jellyfish sting in Australia andto attempt to make a recommendation about their use based on the current literature.

Methods: A descriptive review of all published cases of jellyfish envenomation in Australia wasperformed, with specific focus on the discussion of pressure immobilization bandagesin the management of such cases. A Medline search was performed using the keywords listed for this article. Selected articles were reviewed and further publicationswere identified from the published reference lists given in the selected articles.

Results: The published articles were grouped into three groups: in vitro evidence, case reportsand editorial comment (either in journals or book). Fifteen references were identifiedthat discussed the use of pressure immobilization bandages in the management ofjellyfish envenomation. Other articles were identified that had significant managementissues discussion.

Conclusion: Most of the ‘jellyfish’ literature is in relation to envenomation by Chironex fleckeri.This jellyfish is usually found in tropical Australia and has resulted in the deaths of67 people in Australia. The last death was near Cairns in 2000. Unfortunately, thereare few good data on marine envenomations, with most of the literature being Chironexenvenomation case reports. There are minimal data on the effect of pressureimmobilization bandages on other jellyfish envenomations. There is no good evidenceto support the use of pressure immobilization bandages in the management of jellyfishsting in Australia.

Key words: box jellyfish, box jellyfish/antivenom, Chironex fleckeri, Irukandji, jellyfish/Australia, pressureimmobilization bandage, pressure immobilization bandage/jellyfish.

Correspondence: Dr Mark Little, Department of Emergency Medicine, Sir Charles Gairdner Hospital, Nedlands, WA 6009, Australia; Email: Mark.little@health.wa.gov.au

Mark Little, MB BS, DTMH, FACEM, MPHTM, Toxicology Fellow and Staff Specialist.

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Introduction

The pressure immobilization bandage (PIB) tech-nique has been the accepted method of first aidtreatment for Australian elapid snakes since Suther-land described it in 1979.1 Pressure immobilizationbandages are currently recommended as the first aidtreatment for jellyfish stings in Australia by theAustralian Resuscitation Council,2 the QueenslandAmbulance Service3 and the Queensland Surf Life-saving Association.4 However, PIB are not recom-mended by the Northern Territory Department ofHealth.5,6

In the present review, evidence relating to theuse of PIB in the management of Australianjellyfish envenomation was divided into three groups,namely in vitro evidence, case reports and editorialcomment.

In vitro evidence

There is no reference to any experimental /animal/in vitro data to support the use of PIB in the treatmentof jellyfish envenomation in Australia.

Pereira et al.7 recently published an in vitro studyexamining the application of pressure, equal to thatof a PIB, on fully discharged Chiropsalmus nematocysts.The authors stated that, anecdotally, they felt thattheir patients with PIB demonstrated more serioussymptoms.

Using an invertebrate model, Pereira et al.7demonstrated that fully triggered nematocysts werenot fully discharged of their contents and furtherlethal toxin was released from these nematocystswhen pressure equivalent to PIB was applied. Theauthors concluded that PIB have the potential to causefurther harm and, because there is no proven benefit,this method of first aid should not be used in themanagement of jellyfish envenomation.

This study has been criticised.8,9 Fenner et al.8 andTibballs et al.9 claim that PIB may give benefit bycausing local sequestration of venom in the limb(as with Australian snake bites). There is no scientificevidence to support this claim.10 Tibballs et al. claimthat the study of Pereira et al.7 is invalid becausevinegar was not used, although the study demonstratedthat fully discharged nematocysts still contain toxicmaterial.10 Both authors8,9 have argued that PIB shouldbe promoted because the Australian ResuscitationCouncil2 recommends it.

Case report evidence

The suggestion of usage of PIB for the first aidtreatment of jellyfish envenomation first appeared inthe medical literature in a case report of two casesstung by the Chironex in Queensland in 1984.11

Although PIB were not used in either case (bothsurvived), the authors felt that, because the use of aPIB had been demonstrated to prevent the absorptionof snake and funnel web spider venom, this ‘… lead(s)to the suggestion of its [PIB] application to lifethreatening envenomation by the box jellyfish’.11

In 1988, there was a case12 of the death of a 6-year-old child in Gladstone, Queensland, who was stungby a Chironex, had vinegar immediately applied andwho was pulseless and cyanosed at the local ambul-ance station 15 min after being stung. The child didnot receive a PIB. The article goes on to describethe post-mortem findings, which included nematocystsscraped from the skin and found in tissue biopsies.In the discussion, the authors then discuss the man-agement of Chironex envenomation including the useof vinegar, PIB, resuscitation and antivenom, althoughthey acknowledge that, ‘… experimental evidence ofthe efficacy of compression/immobilization bandagingin C. fleckeri envenomation has yet to be performed’.12

Fenner et al.,13 in 1989, reported two cases in whichtwo children were stung by the Chironex and bothreceived antivenom, administered by Queenslandambulance officers at the beach. One of the childrenhad a PIB applied and both survived. Interestingly,in the case in which the PIB was applied, the clinicalsituation worsened and the patient required supple-mental analgesia en route to hospital.

Despite this, the authors again recommendedthe use of a PIB in cases of major stings and wheremore than 50% of one limb is covered by tentacle or incases in which there is an impaired conscious state.

Beadnell et al.14 reported a case of a 14-year-old girlenvenomated by a Chironex who was treated withvinegar, PIB and antivenom. She survived, althoughshe developed pulmonary oedema and was admitted tothe ICU for 24 h. It was theorized that the PIB arrestedfurther venom absorption; however, the authors acknow-ledged that experimental evidence for this was lacking.

Historically, there are case reports of patientssurviving Chironex envenomation without PIB, asdemonstrated by the two cases below.

Maguire15 reported on a case of a 12-year-oldboy who was stung on both legs. He stopped breath-ing and received expired air resuscitation (EAR). He

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received methylated spirits to the limbs and survived,although he had a stormy course, being ventilatedovernight for pulmonary oedema.

Williamson et al.16 reported the case of a 20-year-old pregnant female who collapsed after being stungby a Chironex. She became apnoeic and receivedvinegar and EAR at the site and antivenom in hospital.She was ventilated for 24 h and survived.

There has been a recent report of a patient’scondition worsening with the application of PIB. Littleet al.17 reported a case of a 23-year-old marine biologiststung by a jellyfish who developed severe symptomsof Irukandji syndrome. A small piece of tentaclewas recovered from the sting site, under the PIB. Themarine biologist was retrieved from a boat byhelicopter and described how the local and systemicpain seemed to worsen when the PIB was applied. Shespent a week ventilated in the ICU and is the mostsevere case of Irukandji syndrome reported.

Editorial evidence

In the Venomous and Poisonous Marine AnimalTextbook,18 the authors cite anecdotal reports assufficient evidence for the efficacy of PIB as first aidfor jellyfish envenomation in the absence of definitivedata. Their justification is the concept that this ‘… isan extrapolation from the known efficacy of thecompression/immobilization technique establishedby Sutherland for the management of snakeenvenomation’.6

Struan Sutherland,19 in his editorial discussingthe management of lethal jellyfish, did not mentionthe use of PIB. In a more recent publication, hemakes the point that jellyfish stings are the exceptionto the PIB method of first aid.20

Currie5 argues against the use of PIB in jellyfishstings. In the Northern Territory they do not advocatethe use of PIB and the Northern Territory sees thelargest number of Chironex stings in Australia. Currie5

argues that the PIB was developed to delay lymphaticabsorption; however, due to rapid onset of symptoms/death, it is highly likely that the venom is rapidlyabsorbed, probably directly into the blood vessels.Certainly post-mortem evidence8 clearly demonstratesdischarged nematocysts in the underlying vasculardermis. Figure 1 is from a post-mortem examinationof the last C. fleckeri death in a child near Cairns,Queensland, and the nematocysts can be seen on theskin and going into the vascular dermis.

Because most of the recent deaths have beenchildren, it is possible that the toxic effect of C. fleckeriis dose dependant and the application of a PIB mayincrease the total amount of venom injected into the body.

Currie5 also contends that most people who diehave a cardiac arrest and efforts should be directedtowards CPR. Application of PIB may, in fact, delaythe patient getting lifesaving measures or beingmoved rapidly to a medical facility.

Summary

The evidence for the continued use of PIB in thetreatment of Australian jellyfish sting is based onanecdotes and direct extrapolation of its use in elapidsnakebite envenomation. Expert opinion is clearlydivided.

There does not appear to be any experimental data,from either in vitro or animal studies, to support itsuse. The claim that the venom is sequestered in thelimb with the use of a PIB has not been demonstratedand because death due to C. fleckeri usually occurson the beach, it is likely that the venom is injecteddirectly into blood vessels.

Intact and triggered nematocysts have both beenfound at the sting site of patients.14 Unlike snakeor funnel-web spider bites, for which the PIB is used,the ‘venom delivery system’ (i.e. the nematocyst ofthe jellyfish) is still on the skin. The discharged nema-tocyst has been shown on postmortem specimensto penetrate the vascular dermis (Fig. 1).18

Figure 1. Nematocysts on the skin and underlying vascular dermis, from a post-mortem examination following Chironex fleckeri death of a child near Cairns, Queensland, Australia in 2000.

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Pressure (equal to a PIB) applied to an electricallydischarged nematocyst resulted in increased venomrelease.7

Conclusion

There is no uniformity in Australia on the first aidtreatment of jellyfish stings. There is no strongevidence that the PIB is of benefit in treating patientswith jellyfish stings and there are suggestions thatharm may occur as a result of the use of PIB.

The current recommendations need to be recon-sidered and standardized.

Recommendation

With the principle of primum non nocere (first dono harm), until further research is undertaken, PIBshould not be recommended for the treatment ofAustralian jellyfish envenomation until the PIB hasgood scientific evidence to support its safety andbenefit. However, there is need for the developmentof a jellyfish envenomation model that will allow thehypothesis to be tested accurately.

Accepted 28 September 2001

References

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2. Australian Resuscitation Council. Envenomation: Jellyfish Stings.Australian Resuscitation Council, Policy Statement No. 8.9.6.Melbourne: Australian Resuscitation Council, 1996.

3. Queensland Ambulance Service. Case Management Guidelinesfor Poisoning, Envenomation, Cuboidal Jellyfish. QueenslandAmbulance Service Clinical Practice Manual, AL10, guidelineA12-6. Brisbane: Queensland Ambulance Service, 1998.

4. Fenner P. The Marine Stinger Guide: Dangerous Jellyfish andOther Sea Creatures in Australia. Identification and Treatment.

Brisbane: The Surf Lifesaving Association of Australia,Queensland State Centre, 1985.

5. Currie B. Box-jellyfish in the Northern Territory. NthnTerritory Dis. Control. Bull. 1998; 5: 12–14.

6. Currie B. Clinical implications of research on the box jellyfishChironex fleckeri. Toxicon 1994; 32: 1305–13.

7. Pereira P, Carrette T, Cullen P et al. Pressure immobilisationbandages in first aid treatment of jellyfish envenomation:Current recommendations reconsidered. Med. J. Aust. 2000;173: 650–2.

8. Fenner PJ, Williamson JA, Burnett J. Pressure immobilisationbandages in first aid treatment of jellyfish envenomation. Med.J. Aust. 2001; 174: 665–6 (Letter).

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10. Pereira P, Carrette T, Cullen P et al. Pressure immobilisationbandages in first aid treatment of jellyfish envenomation:Reply. Med. J. Aust. 2001; 174: 666–7 (Letter).

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12. Lumley J, Williamson JA, Fenner PJ, Burnett JW, Colquhoun DM.Fatal envenomation by Chironex fleckeri, the north Australianbox jellyfish: The continuing search for lethal mechanisms.Med. J. Aust. 1988; 148: 527–34.

13. Fenner PJ, Williamson JA, Blenkin JA. Successful use ofChironex antivenom by members of the Queensland AmbulanceTransport Brigade. Med. J. Aust. 1989; 151: 708–10.

14. Beadnell CE, Rider TA, Williamson JA, Fenner PJ. Managementof a major box jellyfish (Chironex fleckeri ) sting. Med. J. Aust.1992; 156: 655–8.

15. Maguire EJ. Chironex fleckeri (sea wasp) sting. Med. J. Aust.1968; 2: 1137–8.

16. Williamson JA, Callanan VI, Hartwick RF. Seriousenvenomation by the northern Australian box jellyfish(Chironex fleckeri ). Med. J. Aust. 1980; 1: 13–15.

17. Little M, Mulcahy RF, Wenck DJ. Life threatening cardiacfailure in a young female with Irukandji syndrome. Anaesth.Intens. Care 2001; 29: 178–80.

18. Fenner PJ, Williamson JA, Burnett J, Rifkin J (eds). Venomousand Poisonous Marine Animals: A Medical and BiologicalHandbook. Sydney: NSW University Press, 1996.

19. Sutherland S. Lethal jellyfish. Med. J. Aust. 1985; 143: 536.

20. Sutherland S. Venomous Creatures of Australia. A Field Guidewith Notes on First Aid, revised edn. Melbourne: OxfordUniversity Press, 1994.