Irukandji is now the generic name given to at least 5 (probably more) small species and 2+ species of larger carybdeids (box jellyfish with one tentacle in each corner) that cause the Irukandji syndrome. The only one PROVEN to cause the Irukandji syndrome is Carukia barnesi a tiny transparent jellyfish with a maximum bell diameter of just 12-20mm that has only been caught to date, on and around the Cairns beaches in North Queensland.

Larger species that probably cause a severe Irukandji syndrome was discovered recently on the outer Great Barrier Reef [Gershwin, Seymour unpublished information 2000-2001]). They are larger with bell sizes of up to 70mm.

All species of Irukandji, small or large, are box jellyfish (carybdeids) with 4 tentacles, one in each corner that may be a few cms long when contracted, but extend out up to 10 times this length when extended. They are transparent and practically impossible to see in the water. These jellyfish, all currently grouped together under the name "Irukandji", all may cause the severe syndrome called the "Irukandji syndrome".

Irukandji occur in tropical waters from possibly Bundaberg, certainly from Agnes Water, central Queensland and follow a similar distribution to Chironex, northwards through Queensland, across the Northern Territory and then south to Exmouth, Western Australia. They occur in the summer months.

History of investigation into Irukandji

Southcott

Dr Ronald Southcott was stationed with the Australian Army in 1944 in the Cairns area. He noticed and described 2 types of stings (Southcott 1959): `Type A' stings were minor with a small and insignificant skin mark. However they were followed some time later (usually between 20 to 30 minutes) by a number of severe systemic symptoms that often caused prostration, even in the fittest of troops. `Type B' stings had extreme skin pain with obvious wheal marks visible on the stung area. Although many victims became somewhat sick and lethargic, there were no deaths in this group during the study.

In 1956 in north Queensland, as a result of brilliant field work by Dr Hugo Flecker, Southcott was given a specimen of a chirodropid. He was then able to identify the jellyfish causing Type `B' stings, naming it, aptly, Chironex fleckeri (Southcott 1956); and in 1967, following similar brilliant field work by Dr Jack Barnes, he identified the jellyfish causing the Type `A' stings, naming it Carukia barnesi (Southcott 1967).

Flecker

Dr Hugo Flecker was a Radiologist in Cairns, north Queensland in 1932. On January 20th 1955, when a 5-year-old boy died after being stung in shallow water at Cardwell, north Queensland, Flecker suggested that the police net the area. Three types of jellyfish were caught, one of which was an unidentified, box-shaped jellyfish with groups of tentacles arising from each corner.

Flecker sent it to Dr Ronald Southcott in Adelaide, and on December 29th 1955 Southcott published his article introducing it as a new Genus and species of lethal box jellyfish. He named it Chironex fleckeri, the name being derived from the Greek `cheiro' meaning `hand', and the Latin `nex' meaning `murderer', and `fleckeri' in honour of its discoverer.

Flecker was also interested in the Type `A' stinging and published his article in the Medical Journal of Australia in 1952 naming it the `Irukandji syndrome' after the "Irukandji" tribe of Aboriginals who lived in the Palm Cove area where the stings were frequently reported (Flecker 1952b). Flecker died in 1957 without finding the jellyfish responsible for the syndrome.*

Flecker's field and experiment notebook, containing almost certainly valuable information ahead of its time, disappeared with his death. Rediscovery of this notebook would be a major historical and possibly research advance.

Barnes

Dr. Jack Barnes was a Cairns General Practitioner who then took over the quest for the "Irukandji". He surmised that the organism had to be a very small jellyfish that swam very quickly, and probably close to the surface. After calculating the most likely time and place to catch the animal Barnes lay on the bottom of the seabed in shallow water wearing his SCUBA gear.

Many hours later his persistence was rewarded when he saw a very small jellyfish swim in front of his mask. He managed to catch this, and another when he saw a fish moving in an erratic fashion which was seen to be caught in the tentacles of another of these tiny jellyfish. To see if they caused the "Irukandji syndrome" Barnes stung himself, his son Nick, and a lifesaver friend. After the characteristic 30-minute delay all three developed the "Irukandji syndrome" and had to be admitted to hospital with severe back pain, muscle cramps, nausea, vomiting and headache (Barnes 1964).

These jellyfish specimens were also sent to Dr Ron Southcott and in 1966 he described them as a new genus and species of box jellyfish called Carukia barnesi. The `car' from Carybdea, the type of single-tentacled box-jellyfish in whose Family it belonged, and the `ruk' from "Irukandji"; `barnesi' named after its discoverer (Southcott 1967).

Barnes - as the Medical Adviser to the Surf Life Saving Association introduced `pantihose' as an effective protective barrier preventing a serious Chironex sting. It was thick enough to prevent penetration and consequent envenomation by the thread tubes of the stinging cells of Chironex. It became a common site in north Queensland to see Surf lifesavers wearing pantihose on patrol. One pair was worn as usual on the lower half of the body with the feet cut out and taped around the ankles, the other pair had a small hole cut in the crutch and they were pulled over the head with the arms put in the leg part, and the hands free. They were able to safely enter the water to drag long mesh nets through the shallows to see if Chironex were present, allow safer bathing for the general public. The idea was not to rid the area of dangerous jellyfish, but to detect their presence so the beach could be closed to prevent envenomation.

Irukandji Envenomation

The sting of an Irukandji jellyfish is usually a minor sting that usually is usually hardly felt, although rarely it may be more painful.

The mark on the skin is usually the small imprint of the jellyfish bell, making it very difficult, if not almost impossible to see; less often, tentacle marks may be seen. A couple of moments after the usual sting from the bell, the skin may develop a mild redness and a `goose-pimple' effect which may last from 30 minutes or so - in some cases this initial sting may be totally missed. The reddish imprint, if visible, may sometimes last several days.

Irukandji Syndrome

After a delay of usually 30 minutes (5-40 minutes) severe systemic symptoms of the basic 'Irukandji syndrome' start with: -

· A severe 'boring' pain in the sacral (low back) area. Other symptoms quickly develop with muscle pains or 'cramps' moving rapidly into all four limbs and the abdominal and chest wall muscles. These pains are severe, unbearable and come on in 'waves' (similar to labour pains), although never fading completely. In the past these have been confused for both appendicitis and, more commonly, for a heart attack. Chest pain or 'tightness' occurs from spasm of the intercostal muscles (those between the ribs) as well as probable heart muscle pain in some severe cases.

Other symptoms include:

· Sweating - which may be localised to the area of the sting, or even localized to a site well away from the stung area! However, more commonly the sweating is generalised, profuse and drenching;
· Severe nausea and vomiting may occur
· Localised (in the area of the sting) or generalised piloerection - "hairs standing on end" or "goose pimples" occurs
· Anxiety and 'wretchedness' - the victim feels "terrible" and often has "a feeling of impending doom" - a feeling that is often shared by the treating first aider!
· They are very restless with the victim unable to stay still, moving from sitting to lying to rolling around
· Severe frontal or global headache may occur, which may be incapacitating
· "Palpitations" - very fast heart rate with extra heart beats
· Increased respiratory (breathing) rate, often of a 'sighing nature' or quite fast with short breaths
· The victim usually has a marked tremor and looks very pale; they may have peripheral cyanosis (blue tinged nail beds and digits)
·Their urine output may be due to reduced kidney blood flow and fluid loss from the sweating and/or vomiting
·High blood pressure

"Severe Irukandji Syndrome"

As above but with

· Life-threatening high blood pressure - usually the top figure is over 230 - with levels as high as 280/180 mm. Hg, even in young fit people - the "normal blood pressure is usually about 120/80 and a doctor will start someone on tablets to reduce their blood pressure at about 150/100. The higher the pressure, the more likely it will blow a hole in the blood vessel - usually in the brain - and this causes a stroke. This was the cause of death in the two Irukandji deaths in January and March 2002.Toxic (poisonous) effects on the heart causing it to swell up (dilate - proven by echocardiography) and function inefficiently allowing: -

· Later complications of fluid on the lungs - acute pulmonary oedema, often starting some 10-18 hours post- envenomation (occasionally less).

Many of the signs and symptoms of the Irukandji syndrome resemble those that occur when you have a fight - e.g. your "fight or flight" mechanism caused by adrenaline. It is also similar to the medical problem of an adrenal medullary tumour (phaeochromocytoma), with excessive release of catecholamines into the bloodstream. The symptoms are also very similar to the symptoms of the bite a Funnel-web spider or a scorpion sting.

Recent work has shown that the venom is contains a potent neuronal sodium channel agonist and that C. barnesi venom powerfully stimulates noradrenaline (very similar to adrenaline) release explaining, at least in part, the clinical features of the "Irukandji syndrome."

First Aid

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First Aid

Vinegar is poured over the stung area and a vinegar-soaked pad is placed on.

There is no actual other first aid treatment although in the coming seasons a number of options will be tried to see if they are effective and will include trials using either cold packs (prevent or reduce venom being absorbed so more time to get to hospital) or hot packs maybe denature (break-down) the venom.

Current research also includes a planned trial of Nitrolingual spray to try reducing blood pressure to acceptable levels.

It may also be possible to control the pain using specialised ways of administering painkillers.

TREATMENT OF JELLYFISH STINGS WITH COLD PACKS OR ICE

Cold packs or ice (wrapped in a cloth) are very effective, applied to the area of a jellyfish sting to relieve local skin pain. It is the first aid treatment of choice. They may be used if no other treatment is available for Chironex Box Jellyfish stings, but are less effective because of the severe pain, and deep tissue destruction.

	Firstly, remove any remaining adherent tentacles by washing with water.
	Warn victim that ice pack may be uncomfortable at first!
	Wrap cold pack or ice in a wet cloth and apply directly over the sting site for 10-20 minutes (apply only to stung area to avoid hypothermia - especially small children).
	Reassess pain and reapply cold pack or ice if necessary.
	Send for medical assessment if cold fails to relieve pain, or other symptoms develop.

LARGE STINGS

	If a sting covers a large area, particularly if the victim is cold or wet, using a large number of cold packs, or packing the area with ice may encourage hypothermia.
	In these cases "ice massage" seems to help. A small block of ice is held with a glove, or grasped with a cloth, and rubbed by the first-aider all over the stung area for 10-20 minutes, or until pain relief occurs. At the same time the rest of the body can be kept warm with blankets or clothing.
	If this simple treatment is not effective the patient is referred to medical help.

Irukandji Envenomation - Protocol
(Fenner et al 1986b; Fenner et al 1988; Carney & Fenner 1997)

Table 1 - Primary hospital treatment of Irukandji stings:

Accident and Emergency

Identify the Irukandji syndrome: -
late onset symptoms after minor sting, back pain, sweating, piloerection, hypertension, chest pain, limb cramps, headache, vomiting, anxiety, restlessness

IV cannulation -

Pain -

Fentanyl 0.5 µg every 5 mins,
or
morphine infusion with boluses 5 - 10mg (adult)

Catecholamine symptoms -

- phentolamine 5 - 10mg boluses (adult)
OR
- IV GTN (50mg in 500ml 5% dextrose) commence at 3ml/hour

Pulse oximetry – administer oxygen to keep haemaglobin oxygen saturation > 93%

Check BP 15 minutely (automatic machine – dynamap, if possible)

Monitor ECG

Chest X-ray

Skin scrapings for nematocysts: -
- scrape a scalpel blade over stung area, place in saline and centrifuge. Nematocysts are placed on a microscope slide and examined.
OR
- put sticky tape onto skin of stung area. Inspect this under a microscope.

Blood for cardiac enzymes - CK, CK:MB, cardiac troponin, serology for jellyfish stings, catecholamines.

Fill in data sheet:
Time, Place, Winds, Temperature, Weather Conditions, Clothing?, Stinger Suit?, T-shirt?, Sunsuit? Wet Suit?, Other people in water?, Other people stung?, Tide, Time interval to onset of symptoms, Jellyfish seen?, Tentacles/bell seen, Skin Marks, Treatment?, Vinegar?, Fresh water exposure, ? other, site of sting/pain/marks, name, age, sex, address, holidays, ? stung before, activity when stung - ? swimming, surfing, ? wading ? snorkelling, ? diving?, brief patient medical history.

Admit to high dependency ward

I

Table 2 - Possible ICU treatment of Irukandji stings:

High Dependency Medical Ward / ICU

Analgesia - IV morphine infusion or fentanyl.

Control BP - Phentolamine 5-10mg bolus, IV GTN 3ml/hour.

Monitor - ECG, oxygen saturation.

If heart failure - high flow oxygen, CPAP, increase GTN, frusamide,
CVP line, inotropes.

IPPV if necessary for control of the oedema and of hypoxia.

Blood at 8 - 12 hours, 16 - 24 hours, 48 hours
- CK - CK:MB, cardiac troponin.

Chest X-ray at 24 hours.

Echocardiogram within first 24 hours.

Serology for jellyfish stings on day of discharge.

I

Table 3 - Follow-up treatment of Irukandji stings:

One Month After Discharge

Repeat echocardiogram if first one abnormal.

Serology, CK, CK:MB, cardiac troponin.

CXR if any abnormality on previous CXR in hospital.

I

Table 4 - Medical treatment of stings involving arterial compromise:

Stings involving arterial compromise

Preservation of local limb blood supply by keeping the patient warm takes priority over concern for possible increase in systemic absorption of the venom.

Peripheral pulses over the involved extremity should be monitored by direct physical examination and/or Doppler measurements and circulatory compromise treated aggressively with: -

Intra-arterial urokinase (50, 000 i.u.) infused over a period of 30 minutes and repeated if necessary (heparin, cervical sympathectomy and tolazoline gave little apparent benefit).

Rehydration, maintenance of good fluid balance, analgesia and oxygen (preferably 100%) are essential.

If necessary, anticoagulation and intravenous infusion of lignocaine, vasodilators (such as papaverine), prostaglandinE or antiplatelet aggregation agents (ie. prostacyclin) should be tried.

Monitor for possible development of a compartment syndrome.

Surgical intervention and/or hyperbaric oxygen therapy reserved for unresponsive cases, but needs to be early when indicated.

( Burnett, in Williamson et al 1996, p.115)

Similar presentations (differential diagnosis)
1. Myocardial infarction (Heart attack)

Cases with the initial chest pain of the Irukandji syndrome, especially if pulmonary oedema (fluid on the lungs) develops, have in the past been misdiagnosed as an acute myocardial infarction with developing heart failure.3 This may be reinforced by a history of swimming (exertion) especially if the history of a mild sting is not elicited, or is forgotten by the victim.

The situation is further confused if blood is taken for cardiac enzymes. In the past enzymes used were the Creatinine phosphokinase (CPK) level that was often raised well above the normal levels. However when it was differentiated into cardiac and general muscle factions (CK-MB) the cardiac enzyme faction may be normal, whereas the general muscle faction is elevated, often to very high levels - caused by the intense muscle cramps experienced by the hapless victim. However, some severe cases, usually with obvious pulmonary oedema, may have a CK-MB well above the normal range (<8), with an abnormal, and significant, ratio (NR <1.6).
These days' cardiac troponins are used as these are more accurate and immediately give a clear indication of heart involvement and damage if they are found to be high.

2. Decompression sickness (the "bends")

The Irukandji syndrome in a diver also resembles decompression sickness, and may present a difficult differential diagnostic problem. There have now been a number of cases around the Great Barrier Reef who have phoned the DES (Diving Emergency Services) number when, a short time after surfacing, a diver suddenly develops severe low back pain, chest pain (`trouble' breathing) and is distressed and restless.

A high index of suspicion and careful questioning is needed. A history of a minor sting on the back of the neck when surfacing, a small mark, often difficult to see, and/or careful differentiation of the symptoms is necessary. All this is conducted over a radiotelephone from a dive boat on the reef to the DES phone Base in Adelaide - no easy task.

Case histories of 3 severe cases

Three cases of Irukandji envenomation occurred in the Whitsunday's in north Queensland that developed severe myocardial toxicity and pulmonary oedema. Two occurred in March 1994, and the third in March 1996.

Case History 1

A 25-year-old previously healthy female had the typical onset of severe limb and abdominal pain followed by nausea, vomiting and anxiety thirty minutes after being stung by an unidentified jellyfish while swimming. Her BP was 160/100mm Hg, within one hour of envenomation. Seven hours after envenomation she was suffering severe muscle pains, was tachycardic -112 beats per minute (bpm), normotensive - BP 130/85, had piloerection over both arms but no erythema, and had a clear chest with SaO2 of 92% on air. She was commenced on a morphine infusion at 2mg/hour IV. Shortly after her Sa02 dropped to 88% on air and she had bilateral crepitations in her lungs with a raised jugular venous pulse. Frusemide 40mg was administered intravenously (IV), and oxygen via a mask commenced. However she rapidly became sweaty, agitated and had peripheral shut down.

An infusion of intravenous glyceryl trinitrate (GTN) was commenced and titrated to keep the systolic blood pressure in the range of 100-120mm Hg throughout the night. The next morning a chest X-ray showed interstitial oedema with a normal heart size. Her central venous pressure (CVP) was 11cm H2O and CPAP of 5cm H2O via a facemask with Fi02 of 0.7 was given. The CK:MB was elevated (Table 6).

At 0530 on day two after admission the blood pressure again fell to 82/52 mm Hg and fluid loading was attempted while the GTN infusion was weaned and CPAP ceased. Urine output fell to 24 ml/hour at 0700 that morning, and an infusion of Dopamine was commenced and gradually increased to 3 mcg/kg/min. The ECG showed a minor degree of ST depression in the inferior leads; the chest was clinically clear, but a third heart sound was audible.

On the third morning after admission an echocardiogram was performed, which showed severe, global left ventricular hypokinesis (Table 5). An ECG showed a diminished R wave in V3. Enalapril was commenced at a dose of 2.5 mg daily, which was increased to 2.5mg bd the following day. She clinically improved and was discharged on day six; a Swiss tourist, she has unfortunately been lost to follow-up.

Case History 2

A 25-year-old previously well female was envenomated at the same time as case 1 with findings: Initial BP 160/110mm Hg, HR 120bpm, restless, sweaty and having several small patches of erythema over the lower sternum and right arm; her chest was clear. On admission to hospital, a morphine infusion of 1 - 2 mg/hour IV was commenced was commenced which eased her muscle pains, but she was still sweating profusely, tachycardic and had a severe tremor. At 1120 pm on the night of admission eighty milligrams of propranolol was given orally in an attempt to alleviate the tremor, anxiety and tachycardia.

At 0200 the patient was cold and clammy with obvious peripheral shutdown and HR of 80pm. Her femoral and carotid pulses were only just palpable, and she had a blood pressure of 60/25mm Hg; despite the severe hypotension, the patient was alert and communicative. A bolus of 500ml of haemaccel was given with moderate effect (BP 63/47mm Hg). A femoral artery catheter was inserted which revealed a dampened waveform and a mean blood pressure of 60-mm Hg. The morphine infusion was ceased temporarily at that point. An electrocardiograph was grossly abnormal with a sinus rhythm of 78 bpm, a first-degree heart block, broad complex QRS morphology, tall T waves and poor R wave progression. At 0300 that the patients serum potassium was to 8.5 (NR <5.5 mmol/litre), and CK 331 IU. The hyperkalaemia was treated with 50 ml of 50% dextrose IV and short acting insulin subcutaneously; the CVP was 20 cm H2O, and chest X-ray was normal. An isoprenaline infusion was commenced at 0350; electrolytes at this point showed K+ of 8.0 mmol/litre, HCO3 19 (NR 23-32 mmol/l) and Creatinine of was mildly elevated at 0.122 (NR 0.04 -0.12 mmol/l). Five ml of 10% Calcium chloride was given intravenously and a repeat ECG showed normal sinus rhythm. The K+ was subsequently 6.5 with a pH of 7.28 and a further 5 ml of 10% Calcium chloride was given. The isoprenaline infusion was titrated against the blood pressure until 0630 when the BP was 112/79 with an infusion rate of 12 mcg/hour.

Hypoglycaemia of 1.8 (NR 3.5-8.0 mmol/l) was noted and 10 ml of 50% dextrose was infused. At 0900 there were crepitations noted at the right lung base, and the SaO2 was 93 % while having FiO2 of 0.28

At 1300 the SaO2 was 92% on 12 litre/minute of oxygen via a facial mask, BP 121/62, CVP 13 cm H2O, HR 92 bpm ; the isoprenaline infusion was weaned and ceased at 1430. At 1530 5 cm H2O of CPAP was commenced via a face mask with an FiO2 of 0.6 yielding SaO2 of 92% ; an IV infusion of GTN was commenced. At 1700 the patient complained of severe pain in the lower limbs and profuse sweating and an intravenous infusion of morphine was again commenced.

The CPAP was increased to 10 cm H2O with an FiO2 of 0.6 giving an SaO2 of 95 %. At 2300 the FiO2 was increased to 0.7. Despite a fever of 38.1oC blood cultures and a urine specimen revealed no growth. The FiO2 and CPAP were gradually weaned and on the third morning after admission only oxygen via a face mask was needed at 35 % giving an SaO2 of 98 %. The K+ was 4.0, and CK 285, and CK:MB 11 (ratio 4.7%). Echocardiography was performed which showed a mild impairment on left ventricular systolic function (Table 5) and enalapril 2.5mg per day was commenced, and later increased to 5-mg bd. The patient clinically improved and was discharged on day five and was lost to follow-up.

Case History 3

A 19-year-old previously-well woman was stung on the left arm by a jellyfish while swimming in the Whitsunday's at 1130 is on the 26/03/96. She developed severe back pain and breathlessness 15 minutes later. She required 100 mg of pethidine IVand 50 mg IM during transport for muscle pains. The SaO2 during transfer was 96 % on oxygen.

On arrival in Proserpine Hospital she was treated with a total of 15 mg of intravenous phentolamine for mild hypertension (140/110), 5 mg of intravenous midazolam and 10 mg of intravenous diazepam for agitation; a pethidine infusion was commenced at 30 mg/hour for severe pain.

At 0300 the following night she woke with cough and a wheeze and became tachycardic with a heart rate of 130. The SaO2 fell to 75 % on room air, and 85 % on 2 litres/minute via the nasal prongs. Bilateral crepitations were noted, and a chest xray showed bilateral hazy infiltrates suggestive of pulmonary oedema. Nebulised salbutamol was given with no significant effect, and then two 40 mg IV boluses of frusemide were given. She started coughing pink frothy sputum at 0445. The oxygen saturation was 85 % on 15 litres/minute of oxygen via a non-rebreathing mask. The blood pressure did not rise above 140/90 during the night.

Intravenous glyceryl trinitrate was commenced at 0900 and she was transferred to the Mackay Base Hospital at 1130. She was commenced on CPAP by mask at 7.5 cm H20 and the SaO2s improved to 90 %. The CK was elevated at 330 (Table 6); subsequently the LDH rose to 255 two days after envenomation. The FBC showed a neutrophil leukocytosis (PMN 21.7, WCC 24.1). The UEC was normal, and LFT normal except AST 63. The ECG showed sinus rhythm, right axis deviation, non-specific lateral t-wave changes, and poor R-wave progression anteriorly.

In the ICU at 1230 the BP was 100/61, pulse 130 and SaO2 was 90 %. The intravenous GTN was weaned to 5 mcg/min. Pressure support ventilation of 10 cm H2O and CPAP 7.5 cm was commenced by mask and the SaO2 improved to 94 %. She was alert, orientated but still had bilateral crepitations, with an S3 gallop rhythm.

The first echocardiogram at 1630 showed severe global left ventricular dysfunction (Table 5) with trivial mitral regurgitation. A left radial intra-arterial line and a left subclavian central venous line were inserted. The initial CVP reading was 11 mm Hg.

The next morning (28/3) Lisinopril 2.5 mg mane was commenced and frusemide 40 mg bd orally continued. The blood pressure was 97/75 with pulse 130, SaO2 was 95 % on FiO2 0.7 and PS 10/CPAP 7.5. The ventilation was ceased and oxygen given via a non-rebreathing mask at 1200.

The following day (29/3) the BP fell to 82/54 and bilateral crepitations were still audible throughout both lung fields. Dopamine was commenced at 4 mcg/kg/min with no significant change in the blood pressure then Dobutamine was substituted and increased to 12 mcg/kg/min and the BP improved to 95/50. The urine output fell off during the day, and with a CVP recording of 2-mm Hg a total of 500 ml of Haemaccell was given in boluses and Dopamine recommenced at 5 mcg/kg/min, with a substantial improvement in urine output and blood pressure to 112/60. Hypokalaemia of 3.4 was treated oral potassium supplements.

The following day (30/3) the SaO2s were 94 % on room air, and the BP 109/50 and pulse 117 with a good urine output. The Dobutamine was weaned and the Lisinopril increased to 5 mg mane. An ECG showed sinus rhythm with a right axis deviation and t wave inversion in leads V1 - V4 with a diminished R wave in V2.

The next day (31/3) the Dopamine was ceased. A repeat echocardiogram showed an improvement in left ventricular function (Table 5). She was discharged on the 2/4/96 on Lisinopril 5-mg mane. An echocardiogram on the 3/2/96 showed normal LV function (Table 5).

Table 5 - Echocardiogram results

Table 6 - Clinical and Laboratory Parameters

Irukandji and vinegar

Use

1.
Vinegar poured freely over the stung area

2.
Vinegar-soaked pad on top of sting

History

In 1988 after Dr Fenner caught two specimens of Carukia barnesi (the Irukandji), vinegar, methylated spirits and 20% w/v aluminium sulphate were applied to isolated tentacle segments. The nematocysts of this carybdeid were completely inhibited by the vinegar and 20% aluminium sulphate ("stingose"), whereas methylated spirits resulted in mass discharge (Fenner & Williamson 1987), similar to that reported in Chironex (Hartwick et al 1980).

Due to the severity of the syndrome and Barnes experience with self-stinging when his son, a friend and Barnes himself ended up in hospital (Barnes 1964), no attempts were made at the above stinging experiments to see if inhibition or "failure to discharge" had occurred after the use of the above chemicals. However, these experiments seem to continue those proving to date, that vinegar is effective when used for nematocysts inhibition on any cubozoan sting.

After envenomation with Carukia there has never been a recorded case of tentacles remaining on the skin. However, it has been shown that there are still remaining, unfired nematocysts.

(Fenner PJ, Williamson JA, Burnett JW, Colquhoun DM, Godfrey S,Gunawardane K, Murtagh W. The "Irukandji syndrome" and acute pulmonary oedema (Med J Aust 1988;149:150-156)

The stung area is scraped with a scalpel blade in the manner first suggested by Barnes (1960). This technique has since been modified by Currie & Wood (1995) who also found that sticky tape was just as effective as it lifted the remaining nematocysts off the skin. These could then be observed under a microscope and as each nematocyst is different and a "blueprint" of its species. This test can be used to help identify the actual jellyfish responsible, as this is not always certain; many stings occur from unseen, or unknown, jellyfish.

Because the systemic symptoms and effects are so devastating for such a small total envenomation, the author suggested to the lifesavers and lifeguards who treat these stings, that further envenomation must be prevented.

Thus, treatment is vinegar poured on the stung area for a minimum of 30 secs, similar to that suggested for Chironex stings. Because of the time delay from the time of envenomation to the time of onset of symptoms is usually some 30 minutes (from 5-40mins), there is a "window of opportunity" for possible treatment. Experienced lifesavers and lifeguards will be able to identify the small mark of envenomation with its pinkish appearance, local sweating and piloerection. If the first sting should be missed, they frequently come in multiple stings and subsequent stings should be recognised much earlier. Consequently a further suggested treatment was that a vinegar-soaked pad be placed over the sting.