II. Epidemiology
- Stingray Envenomations are common
- Other ray-induced injuries (non-Envenomation)
- Stingray bites
- Electric ray shocks (220 volts)
III. Pathophysiology
- Stingrays reflexively whip their spiny tail into victim's extremity (esp. foot and ankle)
- One to four venom gland at spine (base of tail)
- Retro-serated spine and/or venom gland may embed in wound site
- Spines even penetrate wet suits
- Distribution
- Stings are most often on lower legs, ankles and feet (but may also affect trunk)
- Venom effects (local, sting region effects in most cases)
IV. Symptoms
V. Signs
- Local tissue effects
- Systemic Effects (uncommon to rare)
- Hypotention
- Cardiac Arrhythmias
VI. Imaging
- Consider for determining foreign body, esp. with deep wounds (e.g. retained spine sheath)
- Consider foreign body Ultrasound or XRay
- Suspected Retained Foreign Body, not seen on other imaging, is most likely to be seen on MRI
VII. Management
- Rinse wound site with water
- Control bleeding
- Apply heat to area
- Heat inactivates toxin
- Apply not scalding hot water as tolerated to affected area for 30 minutes
- Submerse affected hand or foot in 108-113 F (42-45 C) for 30-90 minutes (until pain resolves)
- Remove embedded foreign bodies after heat has been applied
- Do not remove spines embedded near vital organs
- Leave the Stingers in place initially (unless in chest or neck)
- Observe for signs of Wound Infection
-
Antibiotics not typically indicated unless infection (although consider prophylaxis in some cases)
- Consider Antibiotics if deep penetrating wound (esp. if Immunocompromised)
- Antibiotics should cover Vibrio and skin flora (e.g. Ciprofloxacin AND Doxycyline or Cephalexin)
- Update Tetanus Vaccine
- Consider observing 4 hours for systemic effects
- Close interval follow-up for wound recheck
- Exploration for abscess or Retained Foreign Body if persistent swelling or delayed healing
VIII. Prognosis
- Wound Healing is often prolonged
IX. Prevention
- Shuffle feet while walking through shallow waters
X. References
- Auerbach in Herbert (2017) EM:Rap 17(10): 6-7
- Habif (1996) Dermatology, p. 491
- Tomaszewski (2020) Crit Dec Emerg Med 34(9): 28
- Perkins (2004) Am Fam Physician 69(4): 885-90 [PubMed]