Stingray injury: Difference between revisions

 
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==Background==
==Background <ref>Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf</ref>==
*Stinger punctures skin to introduce heat-labile venom
[[File:Dasyatis pastinaca01.jpg|thumb|Common stingray (''Dasyatis pastinaca'')]]
[[File:Stringray's sting.jpg|thumb|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
*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.
*Often occurs when swimmers accidentally step on stingray in shallow water. Can be avoided by shuffling feet along bottom.
[[File:Dasyatis pastinaca01.jpg|thumb|Common stingray (''Dasyatis pastinaca'')]]
[[File:Stringray's sting.jpg|thumb|A stingray's stinger (ruler in cm)]]


==Clinical Features==
==Clinical Features==
[[File:Stingray injury.jpg|thumb|Treatment of stingray injury with hot water.]]
*Symptoms can vary by species
*Symptoms can vary by species
*Associated with puncture or jagged laceration
*Associated with puncture or jagged laceration
*Local pain, irritation, [[rash|erythema]]
*Local pain which can last up to 48 hours
*Systemic symptoms can include [[vomiting]], muscle cramps, [[hypotension]], [[weakness|paralysis]], [[cardiac arrest]]
*Limb ischemia secondary to vasospasm
*Cardiotoxicity (e.g. dysrhythmias, heart block, non-ST segment elevation myocardial infarction)<ref>Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf</ref>
*Systemic symptoms can include seizures, [[vomiting]], muscle cramps, [[hypotension]], [[weakness|paralysis]], and even [[cardiac arrest]]


==Differential Diagnosis==
==Differential Diagnosis==
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==Management==
==Management==
[[File:Stingray injury.jpg|thumb|Treatment of stingray injury with hot water.]]
*'''Immediately immerse wound in hot water (45°C for 30-90min)''' <ref>Atkinson PRT. Is hot water immersion an effective treatment for marine envenomation? Emergency Medicine Journal. 2006;23(7):503–508. doi:10.1136/emj.2005.028456.</ref>
*'''Immediately immerse wound in hot water (45°C for 30-90min)''' <ref>Atkinson PRT. Is hot water immersion an effective treatment for marine envenomation? Emergency Medicine Journal. 2006;23(7):503–508. doi:10.1136/emj.2005.028456.</ref>
**Hot water is thought to denature the thermolabile venom
**Hot water is thought to denature the thermolabile venom
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*XR for evaluation of foreign bodies
*XR for evaluation of foreign bodies
*[[Tetanus prophylaxis]]
*[[Tetanus prophylaxis]]
*Prophylactic [[antibiotics]] are controversial - if used, give [[ciprofloxacin]] to cover ''[[Vibrio vulnificus]]''
*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.<ref>Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf</ref>
*There is no antivenom available.


==Disposition==
==Disposition==

Latest revision as of 01:20, 1 September 2021

Background [1]

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)[2]
  • Systemic symptoms can include seizures, vomiting, muscle cramps, hypotension, paralysis, and even cardiac arrest

Differential Diagnosis

Marine toxins, envenomations, and bites

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) [3]
    • 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.[4]
  • There is no antivenom available.

Disposition

  • Discharge

See Also

External Links

References

  1. Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf
  2. Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf
  3. Atkinson PRT. Is hot water immersion an effective treatment for marine envenomation? Emergency Medicine Journal. 2006;23(7):503–508. doi:10.1136/emj.2005.028456.
  4. Hauglid, C., Kiel, J., & Schmidt, A. (2021, April 23). Emergen-Sea Medicine: Overview of Marine Envenomations - Page 8 of 9. ACEP Now.https://www.acepnow.com/wp-content/uploads/2021/08/ACEP_August-2021.pdf