Treatment of jellyfish stings
Date First Published:
April 15, 2005
Last Updated:
May 11, 2005
Report by:
Heather Prestwich, GP (Isle of Arran)
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.
Search Details:
(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))
Outcome:
207 articles 6 articles were relevant
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A randomised paired comparison trial of cutaneous treatments for acute jellyfish (carybdea alata) stings. Nomura JT, Sato RL, Ahern RM, Snow JL, Kuwaye TT, Yamamoto LG. 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. | ||||
| Pressure immobilisation bandages in first-aid treatment of jellyfish envenomation: current recommendations reconsidered. Pereira PL, Carrette T, Culen P, Mulcahy RF, Little M and Seymour J. 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 |
| 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 Thomas CS, Scott SA, Galanis DJ and Goto RS. 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 |
| Cold packs:effective topical analgesia in the treatment of painful stings by physalia and other jellyfish. Exton DR, Fenner PJ, Williamson JA. 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 % | ||||
| First aid for jellyfish envenomation. Burnett JW, Rubinstein H, Calton GJ. 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 |
| 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. Thomas CS, Scott SA, Galanis DJ and Goto RS. 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 |
Author Commentary:
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.
worse.
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:
- 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.
- 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.
- 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
- Exton DR, Fenner PJ, Williamson JA.. Cold packs:effective topical analgesia in the treatment of painful stings by physalia and other jellyfish.
- Burnett JW, Rubinstein H, Calton GJ.. First aid for jellyfish envenomation.
- 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.