ALEX DEL ROSARIO MD:

HAWAII TRAVELERS MEDICAL ADVICE

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Driving and Discovering Virtual Hawaii Guidebook: Dr. Alex del Rosario’s Medical Advice For Travel.

Jellyfish stings, Portuguese Man o war stings, insect bites, intestinal illness, traveler’s diarrhea, coral cuts, marine life injuries, sunburn, heat stroke, giardia.

Alex del Rosario M.D. Medical Advice Jellyfish stings on discovering Hawaii dot com

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TREATING SKIN INJURIES FROM MARINE LIFE: STINGRAYS

(potentially serious injury)


Stingrays, Skates and Rajiformes are cartilagenous fish related to sharks. As bottom feeders hiding in the sand, they may be stepped on by the people while wading in shallow water. Stingrays posses a long tail with a venomous barb at the end. If a ray is stepped on, it will flail its tail around vigorously. The sharp barbed tail can result in considerable damage to the hapless reef walker. The venom in the barb affects the cardiovascular system (heart and blood vessels) and can even cause irregular heart rhythms and in some cases cause the heart to stop beating altogether!



Symptoms of Stingray Venom Injury


    —The barbed tail itself can do considerable damage and there may be significant bleeding (hemorrhage).

      Pain at the site of injury is immediate and intensifies over 30-90 minutes. and will gradually subside over the next 6-48 hours depending on the amount of venom delivered.

    —The venom from the barbed tail affects the cardiovascular system (heart and blood vessels), causing both peripheral vasoconstriction (blanched white extremities) or dilatation (beefy red extremities).

    —The venom may also cause arrhythmias (irregular heartbeats) or even asystole (the heart may stop beating altogether).

    — The venom can act on respiratory centers in the brain and cause a slowing of respiration.

    — Convulsion may develop from the venom's effect on other brain center.


Treatment of Skin Injuries from Stingrays


   1. SEEK PROMPT MEDICAL ATTENTION! --The venom of stingrays can affect both respiration and heart rate. Intravenous medication may be necessary to maintain heart rate, and if respiration is slow enough, mechanical ventilation may be required!

   2. The wound should be well irrigated with saline solution.

   3. Stingray venom is destroyed by heat, and it is advisable to soak the affected extremity in hot water (120°F) for 30 minutes to 1 hour.

   4. Intravenous calcium gluconate may be required to prevent muscle spasms.

   5. Local infiltration of the wound with lidocaine may be required for pain relief, as well as meperidine or some other narcotic analgesic.

   6. Surgical debridment (removal of dead tissue) may be necessary if the wound is severe. The patient should be given tetanous toxoid and antibiotics to prevent secondary infection.  Coral Cuts & Sea Anemones


The phylum Colenterata - are hollow bodied animal often with stinging units called nematocysts. This phylum includes the class Anthozoa (true corals and sea anemones), the class Hydrozoa (Potuguese man-of-war), and the class Scyphozoa (true jelly fish).


Symptoms of Anthozoa Stings (True Corals & Sea Anemones)


    * Toxins from corals can cause cuts with a stinging sensation.

    * Cuts can break down and form painful ulcers

    * Sea anemone stings can vary from mild to severe.

    * Local swelling (edema) and even localized skin breakdown (necrosis) may result, leading to slowly healing ulcers.


Treatment


—There is no specific treatment of coral cuts or sea anemone stings

—The wound should be irrigated thoroughly with water, and kept meticulously clean to prevent secondary infection.

—If painful ulcers develop, you should seek medical attention, since these may indicate secondary bacterial infection, and will require antibiotics.


Skin Injuries from Marine Life:  Jellyfish & Portuguese Man-of-war stings


The phylum Colenterata - are hollow bodied animals often equipped with stinging units called nematocysts. Phylum Colenterata contains the class Hydrozoa (Portuguese man-of-war) which is a separate class from Scyphozoa (true jelly fish).

The severity of jellyfish and Portuguese man-of-war stings are variable. Since the nematocytes are located at frequent interval along the length of the tentacle, the exposure length of tentacle involved is a good measure of the number of stings delivered.


Symptoms of Hydrozoa & Scyphozoa Stings (Portuguese Man-of-war stings & True Jellyfish)


    * Painful raised red lesions (papules) in lines (consistent with contact with the tentacle

    * Muscle spasms may develop in the affected extremity

    * The raised red lesions may develop into fluid filled lesions (vesicles) and may heal with pigmentation.

    * With extensive or repeated exposures systemic reactions can take place, such as; nausea, vomiting, headaches, dizziness (vertigo), muscle weakness and irregular heart rate (arrhythmias) may occur.

    * Other symptoms like, excessive tearing, runny nose and painful breathing (pleuritic chest pain)


Treatment of Skin injuries from Jellyfish & Portuguese Man-of-war


   1. First remove any adherent tentacles that will cause further delivery of venom. The tentacles should be lifted off the skin (don't scrape them off -- this causes further stings). Use a stick or some other object to remove the tentacle(s) so as not to get your fingers stung.

   2. Next, rinse the affected area with sea water to wash away any adherent nematocysts. DO NOT use fresh water, since this will activate the nematocysts. DO NOT scrub as this will only activate the nematocysts and cause further venom delivery.

   3. Nematocysts are inactivated by vinegar (or dilute acetic acid 5-10%). NOTE: If no vinegar is handy, then human urine will do in a pinch. If you have a choice in the matter, use a man's urine rather than a woman's urine. This is because females are more prone to occult urinary tract infections, thus introducing bacteria. Male urine is considered sterile, since men are much less likely to have a urinary tract infection.

   4. If there are any nematocyst still adherent after rinsing with sea water and inactivation with vinegar/ urine, then try the following to remove any remaining nematocysts:

          * Dust the area with baking powder, or flour, then carefully scrape off with the dull back edge of a butter knife....

          * Or use aerosol spray shaving cream to coat the area, then shave off any remaining nematocyst

   5. Symptoms of pain can be treated with topical anesthetics; these are generally contained in sunburn preparations; look for the active ingredients like lidocaine or benzocaine.

   6. Persistent redness, inflammation or itchiness can be treated with topical steroid cream like Hydrocortisone 0.5% cream.

   7. If you begin to develop persistent muscle spasms, seek medical attention; your doctor will need to administer intravenous calcium gluconate.

   8. Secondary bacterial infection may set in, especially if vesicles form. If this happens you will need to see a doctor for antibiotics.


Sunburns: Prevention & Treatment


    Lanette Wolf wrote:


       I will be traveling to Hawaii soon. I have red hair and fair skin. In the past I suffered a severe sunburn with blisters and was extremely ill for 2 weeks.

        What should I use as a sun screen while in the islands, and what symptoms should I look for so that I don't become ill again. I haven't had any prolonged sun exposure in years.


    Dear Lanette,


        Based on the description of your skin and hair color, you and your children sound like you'd be at a very high risk for sun exposure. It would be useful to know how long you were exposed to the sun before you developed blisters -- as this would give me some indication of your sensitivity. As for what you can do to avoid getting ill --as you described on your previous exposure-- here are some suggestions:


               1. The intensity of the sun in Hawaii is far more intense than it is on the mainland due to its geographical location. Initial exposure to summer sun midday should be limited to less than 30 minutes, even with sun screen.

               2. Broad brimmed hats are an excellent way to protect the delicate thin skin of the face and neck, and can be quite fashionable too. If you're going to be at the beach for the whole day, don't forget to bring along lightweight beach pants and a lightweight long sleeve shirt to cover up during the mid day (between 10:00AM to 4:00PM) to prevent exposure to the most intense sun of the day. Inexpensive beach umbrellas can often be purchased at discount stores (like ABC stores and Long's Drugs) in Hawaii.

               3. If you live in a temperate zone, you may want to "warm up" for your trip to Hawaii by gradually lengthening your exposure to the sun a month or so before your trip. In temperate zones, sun exposure is less hazardous before 10:00AM and after 3:00PM because the sun burning wavelengths of ultraviolet light are usually filtered out when the sun is at these angles.

               4. You should definitely use a sun screen containing PABA (5% para-aminobenzoic acid). Normally the minimum suggested SPF is at least a 15. Since you have particular sensitive skin you should use at least a 30. Be sure to apply the sun screen at least 30-60 minutes before your exposure to the sun to allow the PABA time to bind to you skin so it can do it's job. If you apply it while you are out in the sun, its like being under the sun for 30 minutes without any protection! Early application will also minimize the amount of sun screen which otherwise would also be diluted or washed away by perspiration while you're in the sun.

               5. If you're one of the few people who have allergic reactions to PABA look for sunscreen with BENZOPHENONE. Alternately opaque ZINC OXIDE cream physically prevent ultraviolet rays from reaching the skin. Some zinc oxide formulas come is skin colors and are more cosmetically acceptable.

                     1. Prevention is the key to sunburns. Some common areas people forget to apply sun screen to are: a. tops of feet (if your walking along the beach this area will burn!).

                     2. Ears (and just like washing, don't forget behind the ears)

                     3. For men, bald spots on the head (since most men pretend their bald spots aren't there they forget to apply sun screen to them).

                     4. Backs of the knees - when you're laying on your stomach, this thin-skinned area is particularly vulnerable and can be very painful when burned.

                     5. Many medications may make you more susceptible to sunburn; antibiotics such as Tetracycline or Erythromycin (commonly used for acne) should be discontinued at least a week before heavy sun exposure; however be sure to consult your personal physician before stopping any medication. Also perfumes, colognes, deodorants and antiperspirants applied to the skin can cause a rash in combination with sun exposure.


        What to do about sunburns:


               1. Further exposure should be avoided until the skin has had time to heal. This means wearing light opaque clothing over sun damaged skin areas.

               2. Topical corticosteroids (like hydrocortisone cream) are often NO more effective than cold tap water compresses at relieving symptoms of sunburns.

               3. Be sure to keep yourself VERY well hydrated --meaning drink lots of water.

               4. The so-called "after sun" lotions containing benzocaine, a local anesthetic (or nearly any chemical ending in "-caine") can offer temporary relief, but their prolonged used should be avoided, since they can cause a paradoxical "hypersensitivity" of the skin making the pain of a sunburn worse.

               5. If you develop an extensive sunburn, systemic corticosteroids such as Prednisone 20 to 30 milligrams orally twice daily for 4 days usually significantly lessens symptoms and eases discomfort, but you'll need a prescription for this.

Alternately over-the-counter Benedryl (or any other antihistamine) can offer some symptomatic relief, however be careful as antihistamines are sedating -- you wouldn't want to fall asleep in the sun and make things worse!



    Traveler's Diarrhea & Other Diarrheal Illnesses:


    The last thing that anyone plans for on their vacation is a case of diarrhea. But as any traveler will tell you, many expensive vacation plans has been ruined by a diarrheal illness.


    Diarrhea is a condition of increased frequency in bowel movements usually marked by watery or sometimes even bloody stools.


    For some this may be merely an annoyance, but if it is severe, it can ruin your vacation. For others, namely the already sick, the elderly, or the immunicompromised, diarrheal illnesses can be life threatening.


    While your are enjoying your vaction in the Hawaiian Islands, be aware of some of the following circumstances where you are more likely to come into contact with some of the various pathogens that can cause diarrhea.



Traveler's Diarrhea (E. coli):


        The diarrhea that most people associate with travel is caused by a pathogen called Eschersia coli (E. coli, for short). There are actually many subtypes of E. coli. Most are of the enterotoxic variety and cause a watery diarrhea with increased frequency of bowel movements. Another more serious variety of E coli is of the enteroinvassive type and can actually cause a bloody form of diarrhea which to the unsuspecting traveler can be quite alarming.



                Method of contact:

                Contaminated water supply


                Traveler's Advice:

                Generally water from the hotel tap is safe. But be cautious about rural water supplies, water from beach showers, and bathrooms may not be safe. If your are unsure, or immunocompromized and there for at greater risk, you should boil water from these water sources before drinking it, or better yet bring your own supply of fresh battled water before visitng outlying areas, or the beach.


Giardiasis (Giardia lamblia)


        The pathogen Giardia lamblia, causes giardiasis. This type if diarrhea is characterized not so much by watery diarrhea but by increased frequency of bowel movements and by stool which is often described as particularly fowl smelling, accompanied by increased amounts of gas and intestinal cramping. In the immunocompromised patient, these symptoms can be considerably more severe. Giardia is actaully a parasite! A single celled organism that infests the upper intestinal tract.



                Method of Contact:

                Contaminated water supply, as in island streams and waterfalls. Usually these water supplies are associated with goats, cows, pigs or other live stock.


                Traveler's Advice:

                Many open streams & waterfalls are fed by upland water sources which pass by grazing land for cattle and other live stock. So avoid drinking water from island streams, waterfalls or wells and keep you mouth closed while swimming in ALL stream fed waters.


Heat Stroke


Much of this article is taken from the recent paper entitle "Heatstroke" by Teofilo L. Lee-Chiong, MD, FCCP & John T. Stitt, PhD, which appeared in the journal "Hospital Practice Volume 33, Number 7.



    Excessive heat exposure causes a significant number of deaths in the United States each year, estimates range from 150 to 1,700 deaths depending on the year. Some areas of the United States are hotter "hot spots" than others, most notably Alabama, Arkansas, Arizona, Georgia, Kansas Mississippi, Missouri, Oklahoma and South Carolina.


    Fortunately Hawaii does not rank among the problem spots. Heat stroke for the most part affects two groups of travelers:


            * elderly who are on certain medications

            * young active people who over exert themselves on vacation.


    As always moderation is the rule, try to avoid exercising or exerting yourself during the hotter times of the day, drink plenty of fluid (unless your doctor has told you to limit your intake of fluids), and be sure to use your air conditioner in the car and in the hotel.




Dr. Alex del Rosario is a specialist in Internal Medicine and HIV Disease, He maintains a private practice in Los Angeles.






Map of Hawaii by Richard Sullivan, Driving & Discovering Hawaii Books

Our virtual Hawaii guidebook presents the Doctor’s prescription for Hawaii travelers and information on prevention and treatment of jellyfish stings, Portuguese Man o War stings, leptospirosis, sunstroke, corals & sea anemone injuries, traveler's diarrhea, giardia, sunburn, and more.