Management of a major box jellyfish (Chironex fleckeri) sting: Lessons from the first minutes and hours

Abstract

Objective: To report the management of a serious box jellyfish (Chironex fleckeri) envonomation from the first minutes of bystander first aid and treatment by ambulance personnel to subsequent treatment in hospital. Clinical features: A 14-year-old girl sustained a serious Chironex fleckeri sting. There was no loss of consciousness, but the patient suffered severe pain, myocardial irritability, acute pulmonary oedema and mild systemic hypotension, due to the direct toxic effects of the venom. Thirst was a dominant symptom. Intervention and outcome: Management involved rapid bystander action and call for ambulance assistance; and early intervention with oxygen/nitrous oxide administration, compression bandaging, antivenom administration and electrocardiographic monitoring at the site by ambulance personnel. Echocardiography in hospital three hours after the sting showed a normal myocardium. In hospital management resulted in recovery. Nocturnal itching of the sting persisted for six weeks. Conclusions. (i) Vinegar dousing may irritate freshly stung skin, but as a nematocyst inhibitor vinegar remains an essential part of the first aid treatment for cubozoan jellyfish stings. (ii) Compression/immobilisation bandaging was not associated with long-term harm to the sting area. (iii) The pain of an intramuscular antivenom injection may not be felt by a chirodropid sting victim, so safe injection protocols must be strictly observed. (iv) Ambulance services in other States where there is a risk of box jellyfish (Chironex fleckeri or Chiropsalmus quadrigatus) stings should be similarly trained and equipped to deal with serious jellyfish envenomations.