II. Epidemiology

  1. Stingray Envenomations are common
  2. Other ray-induced injuries (non-Envenomation)
    1. Stingray bites
    2. Electric ray shocks (220 volts)

III. Pathophysiology

  1. Stingrays reflexively whip their spiny tail into victim's extremity (esp. foot and ankle)
    1. One to four venom gland at spine (base of tail)
    2. Retro-serated spine and/or venom gland may embed in wound site
    3. Spines even penetrate wet suits
  2. Distribution
    1. Stings are most often on lower legs, ankles and feet (but may also affect trunk)
  3. Venom effects (local, sting region effects in most cases)
    1. Serotonin release
    2. Phosphodiesterase release
    3. Vasoconstriction

IV. Symptoms

  1. Intense pain onset at time of sting (out of proportion to wound)
  2. Nausea or Vomiting
  3. Diarrhea
  4. Muscle cramps
  5. Salivation
  6. Dyspnea
  7. Headaches

V. Signs

  1. Local tissue effects
    1. Edema
    2. Erythema
    3. Cyanosis
    4. Petechiae
    5. Local tissue necrosis
    6. Ulcerated wound
  2. Systemic Effects (uncommon to rare)
    1. Hypotention
    2. Cardiac Arrhythmias

VI. Imaging

  1. Consider for determining foreign body, esp. with deep wounds (e.g. retained spine sheath)
  2. Consider foreign body Ultrasound or XRay
  3. Suspected Retained Foreign Body, not seen on other imaging, is most likely to be seen on MRI

VII. Management

  1. Rinse wound site with water
  2. Control bleeding
  3. Apply heat to area
    1. Heat inactivates toxin
    2. Apply not scalding hot water as tolerated to affected area for 30 minutes
    3. Submerse affected hand or foot in 108-113 F (42-45 C) for 30-90 minutes (until pain resolves)
  4. Remove embedded foreign bodies after heat has been applied
    1. Do not remove spines embedded near vital organs
    2. Leave the Stingers in place initially (unless in chest or neck)
  5. Observe for signs of Wound Infection
  6. Antibiotics not typically indicated unless infection (although consider prophylaxis in some cases)
    1. Consider antibiotics if deep penetrating wound (esp. if Immunocompromised)
    2. Antibiotics should cover Vibrio and skin flora (e.g. Ciprofloxacin AND Doxycyline or Cephalexin)
  7. Update Tetanus Vaccine
  8. Consider observing 4 hours for systemic effects
  9. Close interval follow-up for wound recheck
    1. Exploration for abscess or Retained Foreign Body if persistent swelling or delayed healing

VIII. Prognosis

  1. Wound Healing is often prolonged

IX. Prevention

  1. Shuffle feet while walking through shallow waters

X. References

  1. Auerbach in Herbert (2017) EM:Rap 17(10): 6-7
  2. Habif (1996) Dermatology, p. 491
  3. Tomaszewski (2020) Crit Dec Emerg Med 34(9): 28
  4. Perkins (2004) Am Fam Physician 69(4): 885-90 [PubMed]

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