*local skin treatment involves immediate nematocyte inactivation, analgesia, and removal.

o Rinse the wound with sterile normal saline to prevent nematocyte activation. A lthough seawater can be used as a last resort, it carries marine pathogens into the wound. Avoid using fresh water and rubbing the skin, since these activities trigger unfired nematocytes. o Soak the wound in 5% acetic acid for 15-30 minutes to further inhibit nematocy te discharge. Although acetic acid inhibits nematocytes, it does not provide pai n relief. Other possible inhibitors include 70% isopropyl alcohol or the papain found in meat tenderizer to denature the proteinase toxins. Unfortunately, these other inhibitors have little effect on nonproteinaceous toxins. o After the inactivation, carefully remove any visible tentacles with forceps, f ollowed by the removal of the nematocytes/nematocysts, as described in Surgical Care. o Apply topical anesthetics once the nematocytes/nematocysts are removed. Cold p ack compresses at the sting site for 5-10 minutes relieve all but the most sever e site pain. Avoid direct application of ice to the area, since the hypotonic wa ter from the melting ice may stimulate unremovable, unfired nematocytes. Also, a void hot compresses, since they increase systemic uptake of venom. o Administer antihistamines and topical and systemic corticosteroids for severe local reactions as well as to decrease the probability of serum sickness symptom s from the antivenin, provided no secondary concurrent infection is present. o Administer muscle relaxants (eg, benzodiazepine, methocarbamol) for severe loc al spasms. o Narcotic analgesias are appropriate for severe local pain not responding to to pical anesthetics. o Administer a tetanus shot as a prophylactic measure. o Administer systemic antibiotics if signs of secondary infection exist. * Systemic treatment o Remove patient from danger. o Remove patient from water to prevent drowning. o Monitor ABCs to provide adequate airway, ventilation, and perfusion. o Provide supportive care (eg, central venous monitoring, fluids, inotropic supp ort, pressors for hypokinetic cardiac failure). o Immobilize and sedate the patient to prevent rapid absorption of venom resulti ng from muscle movement. o Apply a lymphatic-venous compression bandage proximally to the sting site to r educe venous and lymphatic flow of the venom but not to stop arterial flow. Usua lly, a range of 40-70 mmHg for the upper extremity and 55-70 mmHg for the lower extremity is used. Remove the bandaging only when the provider is ready to rende r systemic support and the antivenin has been initiated. o Antivenin for box jellyfish envenomation is obtained from the Commonwealth Ser um Laboratory of Melbourne, Australia. The dose is 1 ampule IV over 5 minutes or

3 ampules IM with repeat doses administered according to clinical circumstances . Unfortunately, the antivenin is ineffective if the toxin already has entered a cell. o Anaphylaxis is rare, but can be treated with airway support, oxygen, intravasc ular resuscitation, epinephrine, H1 and H2 blockers, steroids, and a beta2-agoni st nebulizer. o Treat catecholamine-excess hypertension with phentolamine. o Intraarterial urokinase has been anecdotally successful in the treatment of ar terial vessel thrombosis-induced severe limb ischemia. * Ophthalmic treatment o Nonaqueous topical anesthetic drops followed by copious irrigation with isoton ic normal saline are used. Avoid acetic acid irrigation, since it causes more da mage than the nematocysts. o Administer ophthalmic steroids to decrease the corneal inflammatory response. o Beta-blockers and carbonic-anhydrase inhibitors are used for documented increa sed intraocular pressure resulting from the corneal jellyfish sting. * Experimental treatments o Monoclonal antibody against jellyfish toxin o Phototherapy of the sting site with ultraviolet light to suppress immune respo nse resulting in chronic lesions o Verapamil adjunct to antivenin for decreasing venom-induced cardiotoxicity o Gadolinium for inhibiting nematocyte firing through blockade of the calcium-pe rmeable mechanosensitive ion channels involved in nematocyte activation Surgical Care: * Once the nematocytes are inactivated, they can be removed by dusting the area with a paste of shaving cream, baking soda, and talc for 1 hour to coalesce the nematocyte, followed by scraping the area with a dull object (eg, spoon). Strong adhesive tape applied to the area and then removed also can be used. * Clean ulcerating lesions 3 times per day, followed by application of antibioti c ointment (eg, erythromycin) effective against potential marine pathogens. Consultations: * Poison control centers or national aquariums may provide guidance in treating jellyfish envenomation. * Antivenom index published by the American Zoo and Aquarium Association lists t he location, amount, and types of antivenom stores. * Marine biologists may be consulted for nematocyst identification. Activity: Rest and immobilization of the sting site is recommended to prevent ra pid absorption of the venom into the circulation.