Stingray injury

Background

Common stingray (Dasyatis pastinaca)

A stingray's stinger (ruler in cm)

• Stinger contains a retroserrate barb and venom glands located on the tail.
• There are two phases to injury.
  • Phase one is d/t the traumatic injury from the barb, which can inflict injury to vital organs (e.g. Steve Irwin)
  • Phase two is d/t heat-labile venom release, which causes vasospasm with possible limb ischemia, cardiotoxicity, seizure, and/or death.
• Generally causes local symptoms without systemic effects
• Often occurs when swimmers accidentally step on stingray in shallow water. Can be avoided by shuffling feet along bottom.

Clinical Features

Treatment of stingray injury with hot water.

• Symptoms can vary by species
• Associated with puncture or jagged laceration
• Local pain which can last up to 48 hours
• Limb ischemia secondary to vasospasm
• Cardiotoxicity (e.g. dysrhythmias, heart block, non-ST segment elevation myocardial infarction)
• Systemic symptoms can include seizures, vomiting, muscle cramps, hypotension, paralysis, and even cardiac arrest

Differential Diagnosis

Marine toxins, envenomations, and bites

• Toxins
  • Ciguatera
  • Scombroid
  • Tetrodotoxin (e.g. pufferfish)
  • Shellfish poisoning
    • Amnesic shellfish poisoning
    • Diarrheal shellfish poisoning
    • Neurotoxic shellfish poisoning
    • Paralytic shellfish poisoning
• Stingers
  • Stingray injury
• Venomous fish
  • Cone shell
  • Lionfish
  • Sea urchins
  • Crown-of-Thorns Starfish
  • Stonefish
  • Other: Catfish, zebrafish, scorpion fish
• Nematocysts
  • Coral reef
  • Fire coral
  • Jellyfish (Cnidaria)
    • Box jellyfish
      • Irukandji syndrome
    • Sea wasp
  • Portuguese man-of-war
  • Sea anemones
  • Seabather's eruption
• Phylum porifera (sponges)
• Bites
  • Alligator and crocodile attacks
  • Octopus bite
  • Shark bite
• Infections
  • Vibrio species in saltwater
  • Aeromonas species in freshwater

Evaluation

• Clinical diagnosis
• Consider x-ray to evaluate for retained foreign body (stinger)

Management

• Immediately immerse wound in hot water (45°C for 30-90min)
  • Hot water is thought to denature the thermolabile venom
• Supportive care
• Remove spines and stinger, if visible
• XR for evaluation of foreign bodies
• Tetanus prophylaxis
• Prophylactic antibiotics are controversial - if used, give doxycycline or ciprofloxacin to cover Vibrio vulnificus
• Infusion of prostaglandin E1 has resulted in successful salvage of an ischemic leg, but insufficient datat exists to recommend this as routine therapy.
• There is no antivenom available.

Disposition

• Discharge

See Also

• Marine toxins and envenomations