Serious injury from a marine animal attack is not very common. Nevertheless, there are over 1000 marine vertebrates and even more numerous invertebrates that are believed to be either venomous or poisonous [1]. Bites and stings from marine animals can be painful, become infected and require extensive medical treatment [2].

In Jordan, injuries caused by marine animals are restricted to the Gulf of Aqaba at the north end of the Red Sea. Swimmers are at risk of different marine animal injuries, some of them well known to the locals such as Sea Urchin, Lionfish and Stonefish [3].

Black Sea Urchin, fig 1, is an invertebrate marine animal [4]. It can bite and sting [5], it also has many black long sharp and brittle spines which break off after they have penetrated the skin producing mostly local reaction.

Lionfish, fig 2, is a vertebrate marine animal, it attacks with its dorsal spines producing local reaction and to a lesser extent mild systemic reactions.

Stonefish, fig 3, is a vertebrate marine animal, it looks like a stone or a piece of rock, it usually lies dormant in shallow waters, buried in mud, sand or rocks indistinguishable from surroundings. It is the most venomous fish, has thirteen dorsal spines that become erect when the fish is disturbed and are capable of piercing skin and sneakers. Each spine has 5-10 mg of venom (myotoxin), which acts on skeletal, involuntary and cardiac muscle, blocking conduction in these tissues, this results in a muscular paralysis, respiratory depression, peripheral vasodilatation, shock, cardiac arrhythmias and arrest [1].

A prospective study was carried out for children 14 years and below who sustained different marine animal injuries in the Gulf of Aqaba and who were treated at Princess Haya Hospital in the period between January 2004 and January 2006. Patients were evaluated and information was obtained as to age and sex of children, type of injury, clinical manifestations, time of presentation to hospital, complications, and outcome.

The total study population with marine animal injuries was 152 patients 138(90.8%) males and 14(9.2%) females with male to female ratio of (9.9:1). Their ages ranged from 5-14 years with a mean age of 9 years. Sea Urchin was encountered in most of the cases 136 (89.5%) while Lionfish and Stonefish were the cause of 14 (9.2%) and 2 (1.3%) respectively. The majority of injuries 136(89.5%) occurred during summer months Fig 4. 114 (75%) of injuries presented during the night time. All injuries involved the limbs with feet injured in 130 (85.5%) and hands injured in 22 (14.5 %). Most of the involved subjects 110 (72%) were visitors rather than local residents. All cases of Stonefish and Lionfish injuries were admitted to the intensive care unit, whereas there were no admissions among Sea Urchin cases. No longterm complications or deaths were reported in this study.

Marine animal injuries in Jordan are restricted to the southern part of the country that is in the Gulf of Aqaba. It is a seasonal problem, usually in the summer months [6]. Penetrating wounds, stings and inoculation of venom are common marine animal injuries to unwary walkers during the summer season [7].

In our study, injuries were most frequent during the summer, when many families would visit the Gulf of Aqaba to spend their summer holidays, which is obvious from the fact that 72% of patients were visitors rather than locals. A significant percentage of injuries (75%) occurred during the evening and night time which could be explained by the local habits of dining and chatting at the seaside.

The most common clinical manifestation for all three species was localized pain, erythema and swelling (table 1). The pain caused by Sea Urchin and lionfish could be bearable, but the pain caused by Stonefish is excruciating and could be severe enough in some cases to cause unconsciousness and thus drowning [1]. In our study the severity of pain caused by Sea Urchin and Lionfish was mild to moderate while the pain caused by Stonefish was severe.

Most injuries involving the feet were caused by Sea Urchin and Stonefish. This usually occurs while children are playing in areas of shallow water where the Stonefish is usually buried in the sand or rocks indistinguishable from surroundings. Sea Urchin on the other hand is usually attached to rocks. Hands were involved mostly by Lionfish stings during trials by children to catch fish with beautiful shapes and colours.

Fatalities caused by Stonefish injuries usually occur within 5- 20 minutes of the sting [8]. In our study, no fatalities were reported although three patients presented about 20 minutes after the injury with signs of circulatory collapse. In a study involving adults conducted in the same hospital in 1996, one out of the three patients injured by Stonefish died before reaching the hospital [3].

Regarding management, all patients received supportive and symptomatic treatment included antihistamines, steroids, and immersion of the involved limb in bearable hot water. The use of hot water leads to destruction of the venom and minimizes the severity of pain [1]. In addition to the above measures, patients with Stonefish injury were managed in the intensive care unit and Stonefish antivenom was given. The dose of antivenom (Stonefish antivenom) ® administered was guided by the number of spinal stings, as recommended by the manufacturers. The use of Stonefish antivenom has the benefit of neutralizing the venom and relieving the excruciating pain [8].

Sea Urchin was the commonest cause of marine animal injuries while stonefish was the cause of the most serious injuries. Early presentation and prompt antivenom administration may save the lives of Stonefish injured patients.

In planning based on the recommendations, three targets need to be addressed. First would be required of the local authorities who should make the coasts safe for public use. They should also work on increasing public awareness by providing suitable warning signs or pamphlets. Next is required of the health authorities where physicians must be educated in treating marine animal injuries. Lastly would be the public who should wear thick sole shoes when walking in areas of shallow waters, and should keep a careful eye on the sea floor over which one is swimming and in the waters around.