There is a mind boggling amount of absolute rubbish (British National Health Service advises shaving cream), non evidence based opinion, unproven spooky advice and outright dangerous dogma on even otherwise credible web sites (Mayo Clinic, British Health Service and many others) .
In places where any one of the dozen or so life threatening species of box jellies (various species of both chirodropid and carybdeid families have been linked to fatalities) are often present, this can often be a life or death matter- this is especially true in the Philippines and the Indo-Pacific from North Queensland to Thailand.
The most important take home first aid advice to care for unconscious sting victims is to start CPR and O2 as soon as possible and keep up chest compressions for up to 45 min. The venom effects have been found to be transient and lives have now been saved by 20-40 min CPR and proper clinical care.
Now to the Worst and potentially lethal web advice:
1. "Scrape" the sting site with a "credit card, razor or stick" (British Medical Service web site advice) - NO do not do this! - Ocean Care Solutions sting first aid kits even contain scrapers- No !! These are not bee stings with stingers to be scraped off or removed with tweezers. Any contact of the live tentacle with tweezers, gloves or forceps will lead to more tentacle discharge ie stinging. The injecting cnidae tubules are left deep (up to 1 mm) in the skin like tiny fiberglass splinters and cannot be removed by any surface scraping.
To remove any adherent tentacles, flood site with vinegar or sea water, if there is no vinegar. Do not apply any type of pressure to the sting site ever!!! This will never help and will only make things worse.
2. Vinegar! Yes! Have it on hand to use FOR ALL stings. There is no validated proof that it is ever harmful. The 2 published studies claiming potential harm ( press release wild claims "Vinegar can Kill"..,) or slight increase in perceived site pain in physalia or chironex have never been validated and stand in contrast to 40 years of successful first aid tentacle cnidae inactivation and IMPROVED OUTCOMES
Just to be clear-Vinegar is not a treatment. In many stings there are undischarged cnidae left on the skin surface. The point of vinegar is not to reduce pain and not to _treat_ the sting but to clean the site to prevent additional stinging by undischarged cnidae. After cleaning the site hot water is an authentic treatment to inactivate venom.
3. Wear stinger suits or Lycra if you suspect any type of box jelly could be present
4. Ice packs - No-unless the person is unconscious in preparation for hypothermic resuscitation but even then ice has not been shown to improve survival in clinical trials. ALL studies show best outcomes with 42-45oC water immersion. The bogeyman of hot water "vasodilation" causing "venom to speed to the heart" is pure speculation and has not been validated in 15 years of published literature. There is no proof at all that ice packs lead to better outcomes. There is solid proof that 42-45oC normal tap hot not scalding water improves clinical outcomes in ALL marine stings studied to date.
Cortisone is an effective anti inflammatory agent to deal with post sting inflammation but does nothing to inhibit the venom directly.
To summarize
1. Douse with Vinegar
(or even better StingNoMore™ spray which contains vinegar, urea and other actives)
2. Soak 20 min in 42-45oC hot water.
(Apply StingNoMore™ cream instead of, or before and after hot water if available )
After vinegar (or StingNoMore™ spray) the tentacles and any shed undischarged cnidae left of the skin are irreversibly "acid fixed" and inactivated; fresh water is no longer a potential problem. The point is not to douse the sting with cold fresh water. Treating the sting with hot water before vinegar has a small down side but is far better than ice or doing nothing.
I think that this mess is a result of too few Peer Reviewed reports as well as too few researchers capable of appropriate peer review in this field. There just aren't enough bench researchers with expertise in sting pathophysiology doing the critical experiments. There aren't enough properly designed and statistically powered studies. There are far too many reviews reciting claims that have not been replicated. Proper scientific progress requires rigorous validation of experimental data by independent researchers . We have about 12 core papers, over 39 reviews and then over 100 web site distillations all taking additional editorial liberties in authoritative contexts without any true basis like the British shaving cream directive.
Bad science + myth+ lethal stingers + non accountable web sources= one big mess!
What should you do if you are stung by a jelly?
Look immediately around in the water to try to see the size, shape and color of the jelly that caused the sting. Seek information from local lifeguards or other professionals as to the type of jelly. Use a vinegar spray if possible or sea water to wash off tentacles if they are still adhering to the skin. If there is a suspicion of box jellyfish and if the victim experiences extreme burning pain, difficulty breathing, dry mouth and extreme anxiety, call 911. Here is a summary of recommendations (https://www.academia.edu/12014049/What_To_Know_About_Box_Jellie)
Are there home remedies you can use?
Hot water saturated with Epsom salts to soak the affected area can be used to heat inactivate the venom, as well partially remove injected venom from the sting site. Vinegar is not a “treatment” and will not inactivate venom that has been injected deep into the skin, but it rapidly inactivates undischarged stinging cells in the tentacles. Urine is likely a “do no harm” remedy that provides low pH but can lead to infection if the site is scratched.
Would you recommend calamine or lidocaine to ease itching and discomfort? Could you take an OTC pain reliever? Like ibuprofen or acetaminophen?
Calamine and lidocaine are virtually ineffective in actually inactivating the venom per se. They can be useful for post sting pain but these and other topical anesthetics do nothing to reduce the impact of the venom. Antihistamines and steroidal anti-inflammatories do work directly addressing the mechanism of action of the venom.
Must you see a doctor?
If there is a suspicion of box jellyfish and if the victim experiences extreme burning pain, difficulty breathing, abdominal cramping, dry mouth and extreme anxiety or cardiac symptoms.
What should you definitely not use to treat it?
Do not use alcohol, ammonia or fresh cold water. Do not apply dermaplast or other agents which contain alcohol or menthol. Do not scrape or rub the sting site. Do not use ice packs as they do nothing to inactivate the venom and only cause a temporary delay in symptoms.
Where are people most likely to be stung (which waters, which coasts in the US?)
There are jellies in all U.S. waters. There are increasing number of reports of box jellies in the Caribbean and Florida but they can be found over much of the southeastern seaboard. Box jellies washed up along the New Jersey shore last fall.
Are jelly stings ever fatal? Are they debilitating?
Box jellyfish stings can be fatal and deaths can be misattributed to drowning. It is critical to understand that jellyfish stings are not like bee stings and do not involve true “allergy” involving IgE with hypotensive shock. Unlike bee stings, box jelly stings lead to a spike in epinephrine with increase in blood pressure. For this reason the overzealous administration of epinephrine could lead to life-threatening elevation in blood pressure and organ failure or hemorrhage. Box jellyfish stings can also lead to months-long skin-site redness and itching. This can be treated with soaks in hot water saturated with Epsom salts, as well as topical steroids and antihistamines.
What are the symptoms of a box jellyfish sting and how are they different from, say, a Portuguese man-o'-war sting?
Both box jellyfish and man-o-war lead to immediate burning pain and can result in itchy welts or scars. The box jelly sting can also result in serious systemic responses. The venom contains pore-forming toxins that are structurally similar to anthrolysin O, the pore-forming toxin produced by anthrax. The box jelly sting is not like a bee sting. The amount of cellular rupture is over ten thousand times that of a bee sting. The venom acts more like a snake venom and causes cellular destruction. Specifically, red blood cells, platelets and white blood cells are lysed. This causes a very high rise in plasma catecholamines, histamine and cytokines. Altogether this presents a complicated clinical outcome that looks more like bacterial shock. The immediate reaction is not at all an IgE “allergy” or “allergic reaction”. Again, since box jelly venom contains these pore-forming proteins that act very quickly to break open blood cells and is not IgE-based allergy; use of an “epipen” is not appropriate.
What is the best treatment for a box sting (and would this be the same treatment for a man-o'-war)? I've read various things in various places. Some say use hot water, others say never use hot water. I'm sure you're familiar with the common home treatments: meet tenderizer, hot water, cold water, vinegar, urine? Do any of those things definitely work or definitely not work?
Double-blind controlled studies and retrospective studies have shown that hot water immersion is most effective. Laboratory work demonstrates that the venom porin is irreversibly inhibited by heat. Flooding the site with vinegar or Epsom salt saturated water can remove tentacles and nondischarged cnidae from the sting site. Magnesium sulfate (~Epsom salt) IV or bolus had been shown to reduce pain and the potentially life- threatening hypertension. Urine is likely a “do no harm” approach as it is mildly acidic and warm and would remove the undischarged cnidae. Cold fresh water is not helpful and can cause more stinging cells to discharge. Ice packs are perhaps the worst approach, as the pressure will increase the discharge and only temporarily slow the venom action. Once the tissue warms again the venom will continue to act and the sting victim may now be out of sight of the care giver. Alcohol or dermaplast should never be used.
What are some tips to avoid getting stung by a box jelly? Would that be the same for a man-o-war?
The best tip for either stinger is to stay out of the water if there are jellies on the beach. The next best tip to avoid box jellies is to avoid leeward Oahu beaches the mornings and evenings of the 8-10th days after each full moon. Additionally, wearing lycra long sleeve rash guard can protect the arms or a full-body exposure suit will protect the body from either stinger.
Are box jellyfish and man-o'-war the only two stinging jellyfish that swimmers in Hawaii's waters need to be concerned about?
These are the main stingers. There are other smaller species of box jellies that do not correlate with the lunar cycle but these are mainly in the marine harbors or far off shore.
Any idea how commonly people get stung by box jellyfish each month or year in Hawaii?
Up to 1,000 ambulance calls have been attributed to box jellies in a single month (July 1997, Honolulu Advertiser). It is hard to estimate the number of total stings but based on our data with an average number of box jellies of 500/month in a 400-meter-long section of Waikiki that could indicate about 10,000 box jellies per month or 120,000 per year. Given the numbers of swimmers, it would seem that 5,000-10,000 stings a year might occur.
RT QUESTION HERE
