AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

Cnidaria (formerly Coelenterata) are in the phylum of aquatic invertebrates responsible for more envenomations than any other marine phylum. Close to 9000 species of Cnidaria are known, of which approximately 100 are toxic to humans. These animals have a gastrovascular cavity with a single opening used in digestion and circulation. Another characteristic feature is the presence of stinging cells or nematocysts. Human envenomations occur from all 4 classes in this phylum: (1) Hydrozoa (Portuguese man-of-war and fire coral), (2) Scyphozoa (true jellyfish), (3) Cubozoa (box jellyfish), and (4) Anthozoa (soft corals and sea anemones). Of the many toxic species, 3 species or conditions deserve attention because they are life-threatening or extremely common: the box jellyfish Chironex fleckeri, the carybdeid Carukia barnesi (Irukandji syndrome), and the bluebottle or Portuguese man-of-war.  

Pathophysiology

The toxin of Cnidaria is located in cnidocytes, which are stinging cells composed of organelles called nematocysts. Nematocysts are present on the outer surfaces of tentacles or near the mouth. Nematocysts are contained within the cnidoblast or the outer capsule. On the external surface of the cnidoblast is the cnidocil (trigger point), which can be triggered by mechanical or chemical stimuli or may have remote and local control. At the base of the cnidocil is a hollow, coiled, sharp, threaded tube containing venom. The threaded tubes have denticles, which give the uncoiling thread cutting power like a drill. Extruded threads may reach up to 1 mm in length, a distance that is sufficient to penetrate the dermis of human skin. It is currently believed that the explosive release of the thread is caused by a sudden release of springlike tensions stored in the collagenous structural compartment. This is likely due to the sudden removal of bound calcium ions, resulting in a sudden increase in osmotic pressure in the capsular fluid.

The venom of many species is complex and largely unknown. The majority of toxins contain a complex mixture of polypeptides and proteins including (1) catecholamines, (2) histamine, (3) hyaluronidase, (4) fibrinolysins, (5) kinins, (6) phospholipases, and (7) various hemolytic, cardiotoxic, and dermatonecrotic toxins.

Hydrozoa class

The Hydrozoa class contains Physalia species (ie, Portuguese man-of-war or bluebottle) and hydroid corals. Portuguese man-of-war is not a true jellyfish but rather a siphonophore colony of hydrozoans with 4 different groups of animals. The result is a free-swimming organism with tentacles hanging from a gas-filled float, which acts as a sail, allowing wind-assisted travel. At least 2 Physalia species are of importance: (1) the larger Physalia physalis, which is found in the Atlantic Ocean from Nova Scotia to the Caribbean Sea; and (2) the smaller Physalia utriculus, which is found in the Pacific and Indian Oceans. Tentacles may reach up to 100 ft in length and contain up to a million nematocysts. 

Detached tentacles on the beach are hazardous because they are capable of releasing venom for several weeks. Physalia species are one of the most commonly encountered marine envenomations in the United States and South Pacific. At least 3 confirmed deaths are attributed to P physalis.

Fire corals (Millepora) are typically encountered off the Florida coast and in the Caribbean and produce minimal toxicity, predominantly local pain.

Hydroid corals are sessile creatures that can attach to rocks, coral, seaweed, or pilings. A typical reaction is a mild stinging sensation with occasional development of burning pain and lymphadenopathy.

Scyphozoa class

The Scyphozoa class contains true jellyfish. In the United States, true jellyfish are the most common Cnidaria species to cause envenomation. Sea nettles Chrysaora species and Cyanea species are located along the Atlantic coast, with a high concentration near the Chesapeake Bay. Envenomations caused by organisms in the class Scyphozoa are less severe than those caused by Portuguese man-of-war.

Cubozoa class

The Cubozoa class contains the most toxic marine organisms, box jellyfish (Chironex fleckeri) and sea wasp (Chiropsalmus quadrigatus). The box jellyfish is the most dangerous jellyfish known with at least 67 deaths attributed to its envenoming. They are known to move into shallow waters in pursue of prey, thereby invading popular swimming areas. It is the only jellyfish with an antivenom. These animals are found in northern Australia and have not been reported in North American waters.

Carukia barnesi is also in this class and produces Irukandji syndrome. The mechanism of Irukandji syndrome is not known. Although only C barnesi is conclusively known to cause this condition, a number of other jellyfish are also likely responsible. The venom of C barnesi contains a sodium channel modulator that is linked to increased catecholamine release, which explains the early hyperadrenergic state demonstrated by these patients. The mechanism for cardiac dysfunction is yet to be elucidated as to whether it is the result of a myotoxin, due to excessive catecholamines, or both.

Anthozoa class

Anthozoa class contains sea anemones and corals. Most Anthozoa organisms are sessile creatures, and anemones found within the United States tidal zones have minimal toxicity. The sea anemone Phyllodiscus semoni (night or wasp-sea anemone) located in the Western Pacific Ocean is reported to cause fulminant dermatitis and acute renal failure in humans.

Corals

Corals are important components of living reefs. Risk of infection from a coral cut is of greater concern than the toxic effects of the coral.

Frequency

United States

Jellyfish envenomations occur in coastal areas of the United States, with highest frequency during summer. Envenomations by Physalia species are the most common jellyfish encounter prompting evaluation in the emergency department. Cases of seabather's eruption occur in clusters along the East Coast and Caribbean.

International

An estimated 40,000-50,000 marine envenomations occur annually. Approximately 10,000 Cnidaria envenomations occur each summer off of the east coast of Australia, the vast majority of which are due to Physalia species. Each season, the Royal Darwin Hospital in Australia treats more than 40 patients with jellyfish encounters. A prospective evaluation of envenomings from that hospital over a 12-month period from 1999-2000 revealed that 70% resulted from the box jellyfish.¹ The remaining 30% mostly involved other Cubozoa species. This study may suggest that box jellyfish envenomings are common but also suggests the severity of the encounters. Many beaches in Australia have large amounts of vinegar placed in prominent positions along swimming beaches in jellyfish-endemic areas. This likely reduces the amount of emergency department visits for mild-to-moderate encounters.

Mortality/Morbidity

Fatal envenomations due to box jellyfish occur in tropical waters of northern Australia. Fatalities have occurred rapidly, within 60 seconds, from this species. At least 67 deaths have been attributed to the box jellyfish. 

At least 3 deaths have occurred due to Physalia species since 1989 in the United States. 

In addition, a 4-year-old boy died within 40 minutes from an apparent envenoming by the jellyfish Chiropsalmus quadrigatus in the Gulf of Mexico.²

Most patients who develop Irukandji syndrome recover within 1-2 days, but 2 deaths were reported in Queensland, Australia, in 2002. 

Patients have reported delayed hypersensitivity reactions as well as hypopigmented and hyperpigmented areas in the regions of the original tentacles.

Race

No scientific data substantiate any differences in Cnidaria envenomation that are attributable to race.

Sex

No scientific data substantiate any differences in Cnidaria envenomation that are attributable to gender.

Age

Although not well studied, a large number of pediatric cases are reported in the literature, likely due to the shallow water swimming. The smaller body mass and thinner skin may make infants and children more susceptible to jellyfish envenomations.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

• Envenomations usually result in 3 main types of mechanisms: immediate allergic, immediate toxic, and delayed allergic response.
• Obtain the following information regarding the envenomation:
• • Time of envenomation
  • Nature of incident - Geographic location, quality of symptoms, progression of symptoms
  • Description of animal
• Toxicity depends on the following:
• • Age of patient
  • Underlying health of patient (especially those with hepatic disease)
  • Potency of venom
  • Number of nematocysts triggered
  • Amount of skin involved
• Look for envenomation lesions in patients with unexplained near drowning or collapse in water.

Physical

• Chironex fleckeri is the most toxic jellyfish in the world. However, most encounters appear to result in mild envenoming. Stings from small C fleckeri are incapable of penetrating adult skin but may cause papular-urticarial eruptions in infants and small children. Stings from larger animals can be severe.
• • Patients initially develop severe pain despite removal of the tentacle. Tentacle marks are purple to brown and may resemble that made by a whip. Areas rapidly develop erythema, edema, and vesicles and may go on to full-thickness necrosis over the next 1-2 weeks. Death is probable if the total length of the wheals is greater than 6-7 meters.
  • Initial systemic reactions include headache, malaise, fever, nausea, vomiting, muscle spasm, pallor, respiratory distress, hemolysis, and acute renal failure.
  • Death may be rapid (minutes) and is often the result of combined cardiovascular and respiratory arrest. In northern Australia, 67 deaths have been reported as a result of C fleckeri envenomings. Deaths can also occur by drowning secondary to incapacitation following painful envenomations.
• Irukandji syndrome is most likely due to encounters with Carukia barnesi, although other jellyfish may also be responsible. It derives its names from the Aboriginal tribe that formerly inhabited the areas in and around Cairns. 
• • The initial sting from C barnesi is often mild to moderately painful but well tolerated. Approximately 30 minutes after envenomation (range, 5 min to 2 h) patients develop severe low back pain, cramping abdominal pain, nausea, vomiting, profuse sweating, headache, restlessness, agitation, tachycardia, and hypertension.
  • Severe toxicity may involve pulmonary edema and cardiac failure. Although the systemic reaction can be significant, the envenomation site frequently is not visible.
• In regards to most jellyfish encounters, the most common presentation is a painful papular-urticarial eruption at the site of contact. Lesions can last for minutes to hours, and the rash may progress to urticaria. Further progression can lead to vesicular, hemorrhage, or necrotizing lesions. "Sea lice" or seabather's eruption affects covered areas of the body and is a result of trapped larvae of certain thimble jellyfish. The severely pruritic urticarial lesions can last up to 2 weeks.
• • Uncommon local reactions include angioedema, recurrent reactions, contact dermatitis, and papular urticaria.
  • Systemic reactions can develop along with local cutaneous findings including weakness, headache, nausea, vomiting, muscle spasm, fever, pallor, syncope, respiratory distress, and paresthesias.
  • Ocular contact has resulted in conjunctivitis, chemosis, corneal ulcerations, and lid edema.
  • Immediate and delayed hypersensitivity reactions may occur, but anaphylaxis is rare.
  • Chronic reactions include keloids, granulomas, hyperpigmentations, fatty atrophy, contractions, and vascular spasms.
  • Ingestion of jellyfish has resulted in abdominal pain, cramping, and generalized urticaria.

Causes

Contact with a Cnidaria is the cause of envenomation, although some patients have developed mild symptoms after ingestion of jellyfish.

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Lab Studies

• No specific laboratory studies exist for Cnidaria envenomations. Obtain the following for severe envenomations:
• • Complete blood cell count
  • Serum glucose level
  • Arterial blood gases analysis
  • Electrolyte levels
  • Blood urea nitrogen level
  • Creatinine level
  • Urinalysis
  • Creatinine phosphokinase level
• Nematocysts may be identified by microscope from scalpel-blade scrapings of the sting site or sticky-tape sampling. These techniques generally demonstrated good specificity, and both appear to be equal in terms of nematocyst retrieval. However, Carukia barnesi nematocysts have traditionally been difficult to harvest from the sting site.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Prehospital Care

Prehospital personnel and rescuers on scene need to protect themselves from injury and protect the patient from further injury. When entering the water for rescue, protective clothing with wet suits and gloves is ideal. “Stinger suits” are highly recommended if available. 

• To prevent further injury to the patient, the following decontamination steps are important:
• • Inactivate nematocysts: Vinegar or acetic acid in solutions of 4-6% is the most widely accepted treatment of initial stings. Pour vinegar over adhering tentacles for at least 30 seconds. In the absence of vinegar, Coca cola or old wine may be used, but these are not as effective. Hot water (42-45°C) for 20 minutes is likely beneficial in envenomings by Carukia barnesi and Physalia species. Methylated spirits, ethanol, and urine should not be used. Commercial products containing aluminum sulfate have not been shown to be better than vinegar or sea water in the inactivation of nematocysts or resolution of pain.
  • Removal of tentacles: Vinegar-treated tentacles may be removed easily. If vinegar is not available, the tentacles may be picked off safely by rescuers since only a harmless pricking may occur on the fingers of the rescuer, although forceps may also be used. Detached live tentacles should be treated with caution as envenomation may still occur for several hours. 
• No animal studies have been performed to demonstrate a beneficial effect of pressure immobilization bandaging. In vitro models suggest additional venom release from naturally discharged nematocysts. It is not currently recommended by the Australian Resuscitation Council. Pressure immobilization bandaging remains controversial and cannot be routinely recommended at this time.
• Capturing organisms responsible for envenomation is not necessary.

Emergency Department Care

• General care
• • Treatment of Cnidaria envenomation is directed by the severity of the injury. Severe systemic symptoms may require respiratory and cardiovascular support.
  • Inactivate and remove tentacles as directed in Prehospital Care.
  • Treat anaphylaxis with airway support, supplemental oxygen, intravascular volume resuscitation, and epinephrine.
  • Wound care is paramount because both freshwater and saltwater contain numerous microbes. Infected wounds should be cultured for both aerobes and anaerobes. Antibiotics should be reserved for evidence of true infection and should not be given prophylactically.
  • Baking soda may be effective for stings caused by sea nettle (Chrysaora quinquecirrha).
  • Tetanus prophylaxis should be given if indicated.
  • Pruritus typically responds to antihistamines. Topical anesthetics and corticosteroids may also relieve pain. The majority of mildly painful stings respond to the application of ice after the application of vinegar.
  • A delayed recurrent reaction may occur after 1-2 months at the contact site and should be treated with corticosteroids.
• Box jellyfish (Chironex fleckeri)
• • Most stings are not life threatening and require only basic wound care and pain relief. Tentacles should be inactivated with vinegar.
  • Antivenom
  • • Box jellyfish antivenom is ovine-based concentrated immunoglobulins. Each ampule contains sufficient activity to neutralize 20,000 intravenous mouse doses (amount of toxin lethal in a 20 g mouse) of C fleckeri venom. Chironex antivenom will cross react with Chiropsalmus species venom to prevent neurotoxic and myotoxic effects. However, it has not prevented cardiovascular effects in vivo. Box jellyfish antivenom is available from Commonwealth Serum Laboratory in Melbourne, Australia.
    • Indications for use of antivenom
    • • Cardiopulmonary arrest, hypotension, dysrhythmias, coma
      • Difficulty with breathing, swallowing, or speaking
      • Severe pain
      • Can be considered when the possibility of severe scarring is high
    • The recommended dose is 3 ampules diluted 1:10 with normal saline and given intravenously. Six ampules can be administered in the setting of cardiac arrest. Ampules can be given intramuscularly if no intravenous access is established.
    • The use of verapamil has been advocated in the management of severe Chironex envenomations based on in vitro models. However, its use in clinical management remains controversial and cannot be recommended at this time.
    • Magnesium has been demonstrated to improve the effectiveness of antivenom in rats from 40% to 100%. However, prophylactic administration alone did not prevent cardiovascular collapse.
• Irukandji syndrome
• • Evidence as to the best management of Irukandji syndrome remains predominantly anecdotal.
  • Opiate analgesia is frequently required. Nitroglycerin and phentolamine have both been used with success in the treatment of hypertension. Magnesium has also been reported to improve the hyperadrenergic state and relieve pain. Chironex antivenom does not cross react with C barnesi.

Consultations

A poison center toxicologist can be consulted for treatment advice and access to antivenom.

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Analgesics and local anesthetics can be used to ameliorate pain associated with these bites. Antivenom exists for box jellyfish (C fleckeri). Chironex antivenom will cross react with Chiropsalmus species venom to prevent neurotoxic and myotoxic effects. However, it has not prevented cardiovascular effects in vivo. Antivenom is available in Australia and is produced by Commonwealth Serum Laboratories.

Drug Category: Antivenom

These agents neutralize toxins.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Patients with significant Cnidaria envenomation may need inpatient treatment for pain relief and further supportive care. Generally, only severe Portuguese man-of-war, C barnesi, or box jellyfish stings result in rapid clinical decompensation.
• In addition to cardiopulmonary supportive care, management should include treatment of renal consequences of rhabdomyolysis. Continuous monitoring for wound infection should take place because antibiotics are not always initially indicated.

Further Outpatient Care

• Warn patients that recurrent episodes of urticaria might occur for as long as 4 weeks at the site of envenomation. This delayed reaction responds well with a 2-week taper of glucocorticoids.

Deterrence/Prevention

• Prevention of jellyfish stings is best accomplished with a dive suit. A sunscreen containing jellyfish sting inhibitor is also available. The cream sting inhibitor may reduce the pain and erythema from jellyfish stings.

Complications

• Complications of jellyfish stings include the following:
• • Wound infection
  • Rhabdomyolysis
  • Acute renal failure
  • Hemolysis
  • Pulmonary edema
  • Respiratory paralysis
  • Cardiovascular collapse
  • Death

Prognosis

• If therapy is initiated in a timely manner for severe envenomations of Portuguese man-of-war, C barnesi (Irukandji syndrome), or box jellyfish, the prognosis remains excellent.

Patient Education

• For excellent patient education resources, visit eMedicine's Bites and Stings Center and Wilderness Emergencies. Also, see eMedicine's patient education articles Wilderness: Jellyfish Sting and Wilderness: Seaweed Irritation.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to rapidly remove the victim from the water
• Failure to recognize that vinegar or hot water can reduce pain and fresh water may exacerbate pain associated with Cnidaria envenomation
• Failure to recognize the need for tetanus prophylaxis
• Failure to consider appropriate antibiotic coverage for marine bacterial infections such as Vibrio species

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Chanida Sintuu, MD, Allison J Richard, MD, and Jeffery R Tucker, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Cnidaria and jellyfish envenomations. Close-up photograph of sea anemone demonstrating tentacles surrounding the central mouth structure. Contact with tentacles results in discharge of nematocysts. Photo courtesy of Scott A. Gallagher, MD.
	View Full Size Image
Media type:  Photo

Media file 2:  Cnidaria and jellyfish envenomations. Close-up photograph of a sea anemone demonstrating one of several tentacle types observed among different species. Photo courtesy of Scott A. Gallagher, MD.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

1. O'Reilly GM, Isbister GK, Lawrie PM, et al. Prospective study of jellyfish stings from tropical Australia, including the major box jellyfish Chironex fleckeri. Med J Aust. Dec 3-17 2001;175(11-12):652-5. [Medline].
2. Bengtson K, Nichols MM, Schnadig V, et al. Sudden death in a child following jellyfish envenomation by Chiropsalmus quadrumanus. Case report and autopsy findings. JAMA. Sep 11 1991;266(10):1404-6. [Medline].
3. Auerbach PS. Marine envenomations. N Engl J Med. Aug 15 1991;325(7):486-93. [Medline].
4. Bailey PM, Little M, Jelinek GA, et al. Jellyfish envenoming syndromes: unknown toxic mechanisms and unproven therapies. Med J Aust. Jan 6 2003;178(1):34-7. [Medline].
5. Brown CK, Shepherd SM. Marine trauma, envenomations, and intoxications. Emerg Med Clin North Am. May 1992;10(2):385-408. [Medline].
6. Brush DE. Marine envenomations. In: Flomembaum N, Goldfrank LR, Howland MA, Lewin NA, Hoffman RS, Nelson LS. Goldfrank's Toxicologic Emergencies. 8^th ed. New York, NY: McGraw-Hill; 2006:1629-1642.
7. Burnett JW, Calton GJ. Jellyfish envenomation syndromes updated. Ann Emerg Med. Sep 1987;16(9):1000-5. [Medline].
8. Burnett JW, Gable WD. A fatal jellyfish envenomation by the Portuguese man-o'war. Toxicon. 1989;27(7):823-4. [Medline].
9. Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol. 2003;41(3):301-8. [Medline].
10. Currie BJ, Jacups SP. Prospective study of Chironex fleckeri and other box jellyfish stings in the "Top End" of Australia's Northern Territory. Med J Aust. Dec 5-19 2005;183(11-12):631-6. [Medline].
11. Fenner PJ, Hadok JC. Fatal envenomation by jellyfish causing Irukandji syndrome. Med J Aust. Oct 7 2002;177(7):362-3. [Medline].
12. Fenner PJ, Williamson J, Callanan VI, et al. Further understanding of, and a new treatment for, "Irukandji" (Carukia barnesi) stings. Med J Aust. Dec 1-15 1986;145(11-12):569, 572-4. [Medline].
13. Fenner PJ, Williamson JA. Worldwide deaths and severe envenomation from jellyfish stings. Med J Aust. Dec 2-16 1996;165(11-12):658-61. [Medline].
14. Fenner PJ, Williamson JA, Burnett JW, et al. The "Irukandji syndrome" and acute pulmonary oedema. Med J Aust. Aug 1 1988;149(3):150-6. [Medline].
15. Freudenthal AR, Joseph PR. Seabather's eruption. N Engl J Med. Aug 19 1993;329(8):542-4. [Medline].
16. Giordano AR, Vito L, Sardella PJ. Complication of a Portuguese man-of-war envenomation to the foot: a case report. J Foot Ankle Surg. Jul-Aug 2005;44(4):297-300. [Medline].
17. Flomembaum N, Goldfrank LR, Howland MA, Lewin NA, Hoffman RS, Nelson LS. Goldfrank's Toxicologic Emergencies. 8^th ed. 2006.
18. Haddad L, Lee L. Toxic marine life. In: Clinical Management of Poisoning and Drug Overdose. 3^rd ed. WB Saunders Co; 1998:386-399.
19. Kimball AB, Arambula KZ, Stauffer AR, et al. Efficacy of a jellyfish sting inhibitor in preventing jellyfish stings in normal volunteers. Wilderness Environ Med. Summer 2004;15(2):102-8. [Medline].
20. Kizer KW. Marine envenomations. J Toxicol Clin Toxicol. 1983-1984;21(4-5):527-55. [Medline].
21. Little M. Is there a role for the use of pressure immobilization bandages in the treatment of jellyfish envenomation in Australia?. Emerg Med (Fremantle). Jun 2002;14(2):171-4. [Medline].
22. Lumley J, Williamson JA, Fenner PJ, et al. Fatal envenomation by Chironex fleckeri, the north Australian box jellyfish: the continuing search for lethal mechanisms. Med J Aust. May 16 1988;148(10):527-34. [Medline].
23. McGoldrick J, Marx JA. Marine envenomations. Part 2: Invertebrates. J Emerg Med. Jan-Feb 1992;10(1):71-7. [Medline].
24. Mizuno M, Nozaki M, Morine N, et al. A protein toxin from the sea anemone Phyllodiscus semoni targets the kidney and causes a severe renal injury with predominant glomerular endothelial damage. Am J Pathol. Aug 2007;171(2):402-14. [Medline].
25. Nimorakiotakis B, Winkel KD. Marine envenomations. Part 1--Jellyfish. Aust Fam Physician. Dec 2003;32(12):969-74. [Medline].
26. Pearn J. The sea, stingers, and surgeons: the surgeon's role in prevention, first aid, and management of marine envenomations. J Pediatr Surg. Jan 1995;30(1):105-10. [Medline].
27. Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. Feb 15 2004;69(4):885-90. [Medline].
28. Stein MR, Marraccini JV, Rothschild NE, et al. Fatal Portuguese man-o'-war (Physalia physalis) envenomation. Ann Emerg Med. Mar 1989;18(3):312-5. [Medline].
29. Tibballs J. Australian venomous jellyfish, envenomation syndromes, toxins and therapy. Toxicon. Dec 1 2006;48(7):830-59. [Medline].
30. Watters MR, Stommel EW. Marine Neurotoxins: Envenomations and Contact Toxins. Curr Treat Options Neurol. Mar 2004;6(2):115-123. [Medline].
31. Weisman R. Marine animals. In: Goldfrank LR. Goldfranks's Toxicologic Emergencies. 5^th ed. Appleton & Lange; 1994:1327-1332.

Article Last Updated: Aug 18, 2008