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STINGRAY INJURIES

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Classification   |    Detailed evidence-based information

Substances Included Synonyms

Therapeutic Toxic Class

    A) Stingray injuries may be traumatic (puncture wound) or toxic (envenomation). Intense pain and severe local tissue necrosis have been reported following stingray envenomation. These injuries are usually not fatal. Severe injuries and death may occur following puncture injuries to the thorax or abdomen. In the United States, there are about 750 to 2000 cases of stingray injuries every year. Fatalities are rare.

Specific Substances

    1) Butterfly rays
    2) Cownose rays
    3) Dasyatidae (whiptail stingrays)
    4) Dasyatis americana: Southern stingray
    5) Dasyatis Kuhlii: Blue-spotted stingray
    6) Dasyatis sephen: Cowtail stingray
    7) Dasytoidea
    8) Eagle rays
    9) Freshwater stingrays
    10) Gymnuridae (butterfly rays)
    11) Manta rays (barb-less tails)
    12) Mobulidae (manta rays; barb-less tails)
    13) Myliobatidae (eagle rays)
    14) Myliobatoidea
    15) Potamotrygon falkneri
    16) Potamotrygon motoro: Amazonian freshwater stingray
    17) Potamotrygonidae (freshwater stingrays)
    18) Rhinoptera bonasus: Cownose stingray
    19) Rhinopteridae (cow nose rays)
    20) Round stingrays
    21) Stingray
    22) Stingrays
    23) Stingrees
    24) Urobatis halleri: Round stingray
    25) Urolophidae (stingrees or round stingrays)
    26) Whiptail stingrays

Overview

Life Support

    A) This overview assumes that basic life support measures have been instituted.

Clinical Effects

    0.2.1) SUMMARY OF EXPOSURE
    A) BACKGROUND: Stingray injuries may be traumatic (puncture wound) or toxic (envenomation). Nonfatal stingray injuries include superficial laceration without envenoming, deeply penetrating lacerations, prolonged envenomation from retained glandular tissues, and combined penetrating and envenomated wounds with retained foreign body fragments. Fatal stingrays injuries are rare and may result from penetrating thoracic trauma with immediate or delayed cardiac tamponade, cervical lacerations with airway compromise, penetrating vascular wounds with hemorrhagic shock, and delayed wound infections with gangrene and septic shock.
    B) TOXICOLOGY: In most cases, stingray envenomation causes intense local pain and carry the potential for infection as these are puncture wounds that may contain retained fragments of the sting apparatus and waterborne bacteria. Stingray venom is a mixture of enzymatically active and heat sensitive proteins, including serotonin, 5-nucleotidase, and phosphodiesterase. The venom is cardiotoxic, possibly by a direct effect on the myocardium, but clinically significant cardiac toxicity is very rare.
    C) EPIDEMIOLOGY: In the United States, there are about 750 to 2000 cases of stingray injuries every year. Fatalities are rare. In the Indo-Pacific countries and the United States, there are usually 1 or 2 cases of death from stingray injuries every year. There are as many as 8 deaths per year in South American countries with freshwater or Amazonian stingrays (Family Potamotrygonidae).
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Patients with mild to moderate toxicity usually report pain. The pain peaks in about 50 to 60 minutes and may persist for 48 hours. Swelling, tenderness, diaphoresis, localized erythema, profuse bleeding, and bluish-grey discoloration around the wound may also occur. Wounds may develop tissue necrosis and infections. Weakness and paresthesias frequently occur. Nausea is a common complaint. Cardiovascular signs and symptoms may occur but they tend to be transient in nature.
    2) SEVERE TOXICITY: Vomiting, diarrhea, and abdominal cramps usually occur following severe envenomations. Other severe effects include syncope, hypotension, bradycardia, seizures, dysrhythmias, or supraventricular bigeminy. Stingray injuries to the abdominal or thoracic cavities or major arteries can rarely cause cardiovascular failure or death from trauma.

Laboratory Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs. Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    C) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    D) Ultrasound of the wound site may reveal a retained integumentary sheath or other foreign bodies. Soft tissue radiographs will miss material that is not radiopaque. Regardless of the findings, direct exploration of the wound should be performed.

Treatment Overview

    0.4.7) BITES/STINGS
    A) MANAGEMENT OF MILD TO MODERATE TOXICITY
    1) Submerge the injured part in hot water at as high a temperature as the patient can tolerate without injury (less than 113 degrees F or 45 degrees C), for 30 to 90 minutes or more. Control pain with NSAIDs or oral or parenteral opioids. Infiltration of local anesthetic or regional nerve blocks may be used for persistent pain despite an adequate trial of hot water immersion (at least 2 hours). Do NOT use a digital nerve block or local anesthesia administration and immersion in hot water simultaneously as it may lead to significant burns. TETANUS: Administer antitetanus as indicated. ANTIBIOTICS: Wounds may become infected; some authors use prophylactic antibiotics, they should be considered in contaminated wounds. Do not apply an arterial tourniquet or compression/immobilization bandaging of the wounds.
    B) MANAGEMENT OF SEVERE TOXICITY
    1) HYPOTENSIVE EPISODE: Administer IV 0.9% saline; transfusion may be necessary for patients with significant hemorrhage. Patients with significant hypotension or wounds to the thorax or abdomen should be evaluated for injuries to the heart, lungs, abdominal organs and arterial or large venous lacerations. SEIZURE: Attempt initial control with a benzodiazepine (diazepam or lorazepam). If seizures persist or recur, administer phenobarbital or propofol. ANTIBIOTICS: Some physicians administer prophylactic antibiotics routinely. If antibiotic prophylaxis is used, VIBRIO species should be covered. Trimethoprim-sulfamethoxazole is appropriate for oral administration, while third generation cephalosporins are best for IV administration.
    C) PAIN
    1) Submerge the injured part in hot water at as high a temperature as the patient can tolerate without injury (less than 113 degrees F or 45 degrees C), for 30 to 90 minutes or more, to reduce pain and inactivate any venom, because the stingray's venom is heat-labile. Do not apply a tourniquet or use the pressure immobilization technique. Nonsteroidal anti inflammatory agents, and oral or parenteral opioids can be used if pain persists.
    D) WOUND CARE
    1) Infiltrate wound with local anesthetic or perform a regional nerve block. Explore the wound, remove any foreign material and debride necrotic tissue. Irrigate the wound copiously. Ultrasound may be useful to identify retained foreign material in the wound. Surgical procedures may be required in patients with extensive injuries. Wounds should not be sutured initially, but rather use delayed primary closure or closure by secondary intention.
    E) AIRWAY MANAGEMENT
    1) Ensure adequate ventilation and perform endotracheal intubation early in patients with life-threatening cardiac dysrhythmias or hemodynamic instability.
    F) ANTIDOTE
    1) None.
    G) PATIENT DISPOSITION
    1) HOME CRITERIA: All patients should be sent to a medical facility for evaluation/treatment of the wound and treatment of any systemic symptoms.
    2) OBSERVATION CRITERIA: Patients with only local effects can be discharged once pain control is adequate and wound care is complete. Patients with stings that can cause systemic toxicity should be observed for 6 hours and may then be discharged if no systemic toxicity has developed. Patients who are discharged should return for a wound check in 48 hours to detect early infection.
    3) ADMISSION CRITERIA: Any patients with cardiovascular toxicity or neurologic symptoms more severe than pain and mild paresthesias should be admitted.
    4) CONSULT CRITERIA: A medical toxicologist or poison center should be consulted on all severe envenomations.
    H) PITFALLS
    1) Pitfalls include inadequate exploration of the wound, failure to provide tetanus prophylaxis, and failure to cover Vibrio species when prescribing antibiotics for wound infections. Patients with wounds to the thorax or abdomen, or near major vessels should be carefully evaluated for injury to the heart, lungs, abdominal organs, arterial or venous lacerations.
    I) PHARMACOKINETICS
    1) Absorption occurs rapidly following envenomation. The rate of metabolism and clearance is unknown.
    J) DIFFERENTIAL DIAGNOSIS
    1) Sea snake envenomation, jelly fish envenomation, or dinoflagellate poisoning, fish sting envenomation.

Range Of Toxicity

    A) TOXIC DOSE: Stingrays usually only cause local effects. Penetrating wounds from a barb may cause severe injury, dependent in part on the depth and location of the injury. Fatalities are rare, and are secondary to traumatic injury to vital organs or arteries, not venom effects.

Clinical Effects

Summary Of Exposure

    A) BACKGROUND: Stingray injuries may be traumatic (puncture wound) or toxic (envenomation). Nonfatal stingray injuries include superficial laceration without envenoming, deeply penetrating lacerations, prolonged envenomation from retained glandular tissues, and combined penetrating and envenomated wounds with retained foreign body fragments. Fatal stingrays injuries are rare and may result from penetrating thoracic trauma with immediate or delayed cardiac tamponade, cervical lacerations with airway compromise, penetrating vascular wounds with hemorrhagic shock, and delayed wound infections with gangrene and septic shock.
    B) TOXICOLOGY: In most cases, stingray envenomation causes intense local pain and carry the potential for infection as these are puncture wounds that may contain retained fragments of the sting apparatus and waterborne bacteria. Stingray venom is a mixture of enzymatically active and heat sensitive proteins, including serotonin, 5-nucleotidase, and phosphodiesterase. The venom is cardiotoxic, possibly by a direct effect on the myocardium, but clinically significant cardiac toxicity is very rare.
    C) EPIDEMIOLOGY: In the United States, there are about 750 to 2000 cases of stingray injuries every year. Fatalities are rare. In the Indo-Pacific countries and the United States, there are usually 1 or 2 cases of death from stingray injuries every year. There are as many as 8 deaths per year in South American countries with freshwater or Amazonian stingrays (Family Potamotrygonidae).
    D) WITH POISONING/EXPOSURE
    1) MILD TO MODERATE TOXICITY: Patients with mild to moderate toxicity usually report pain. The pain peaks in about 50 to 60 minutes and may persist for 48 hours. Swelling, tenderness, diaphoresis, localized erythema, profuse bleeding, and bluish-grey discoloration around the wound may also occur. Wounds may develop tissue necrosis and infections. Weakness and paresthesias frequently occur. Nausea is a common complaint. Cardiovascular signs and symptoms may occur but they tend to be transient in nature.
    2) SEVERE TOXICITY: Vomiting, diarrhea, and abdominal cramps usually occur following severe envenomations. Other severe effects include syncope, hypotension, bradycardia, seizures, dysrhythmias, or supraventricular bigeminy. Stingray injuries to the abdominal or thoracic cavities or major arteries can rarely cause cardiovascular failure or death from trauma.

Cardiovascular

    3.5.2) CLINICAL EFFECTS
    A) TRAUMATIC INJURY
    1) WITH POISONING/EXPOSURE
    a) Deep lacerations by multiple spines into the abdominal or thoracic cavity have occurred in stingray injuries and can lead to cardiovascular failure from hemorrhage, cardiac penetration with tamponade, hemothorax, or tension pneumothorax (Diaz, 2008; Diaz, 2007; Acott & Meier, 1995).
    B) BRADYCARDIA
    1) WITH POISONING/EXPOSURE
    a) Bradycardia may be seen with severe stingray envenomations (Forrester, 2005; Weiss & Wolfenden, 2001; Hanley et al, 2000; Auerbach, 1991).
    C) HYPOTENSIVE EPISODE
    1) WITH POISONING/EXPOSURE
    a) Severe stingray envenomations or traumatic injury to the heart, lungs or large arteries, may result in hypotension (Diaz, 2008; Forrester, 2005; Weiss & Wolfenden, 2001; Hanley et al, 2000; Auerbach, 1991; Derr et al, 2007).
    D) CONDUCTION DISORDER OF THE HEART
    1) WITH POISONING/EXPOSURE
    a) Cardiac dysrhythmias have rarely been reported following stingray envenomations (Diaz, 2008; Ikeda, 1989).
    E) CARDIAC TAMPONADE
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 33-year-old man developed cardiogenic shock, with sinus tachycardia (140 beats/min), hypotension (systolic BP of 70 mmHg), hypothermia, and cyanosis after having been struck in the chest by the tail of a stingray. Physical examination showed a 2-cm laceration in the lower left parasternal region. Transthoracic echocardiography showed moderate pericardial effusion, with the diastolic collapse of the right atrium and ventricle, which was consistent with cardiac tamponade. Foreign material was also noted in the pericardial space. Following pericardiocentesis, surgical repair, intravenous antibiotics, and supportive care to the wound site, the patient recovered uneventfully (Weiss & Wolfenden, 2001).
    b) CASE REPORT: A 12-year-old boy was struck by a stingray barb, penetrating the chest wall, the left lung, the pericardium and the right ventricle. He also had injuries to his left knee. He immediately complained of chest pain and difficulty breathing and was transported to a medical facility. On presentation, he had severe pain, but his vital signs were stable. An initial chest x-ray film was considered normal. Following supportive care, his condition improved over the next few days and he was discharged home the next day. On day 6, he suddenly collapsed and cardiopulmonary resuscitation was unsuccessful. He died on the way to the hospital. At this time, the initial x-ray films were reviewed again and a small pleural effusion (probably small amount of blood) was noted at the left costophrenic angle on the inspiratory film, suggesting pericardial distension at the left basal margin of the heart. Autopsy revealed significant bleeding into the pericardium an left pleural cavity, and a puncture wound to the right ventricle with surrounding necrotic myocardium. It was determined that the deposited venom caused an insidious and progressive localized myocardial muscle necrosis, resulting in an acute cardiac perforation, tamponade and sudden death (Fenner et al, 1989).
    F) SUPRAVENTRICULAR BIGEMINY
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 44-year-old man developed severe pain after being stung on his right upper arm by a stingray (Dasyatis akajei). The wound was about 5 mm in diameter with fasciculations of muscles around the wound. At this time, he was treated with IV furosemide, hydrocortisone, and IM d-chlorpheniramine maleate. Approximately 26 minutes after the injury and after the surgical opening of the wound, a bigeminal cardiac rhythm was noted by palpation. An ECG 40 minutes after injury revealed supraventricular bigeminy which lasted for 2 more minutes and then reverted to a pre-existing incomplete right bundle branch block (IRBBB) with occasional supraventricular extrasystoles. The patient's personal health record revealed a baseline IRBBB from an ECG that was performed 3 years before this incident. He recovered without receiving any antiarrhythmic agents (Ikeda, 1989).
    G) ANEURYSM
    1) WITH POISONING/EXPOSURE
    a) PSEUDOANEURYSM: An extensive hematoma on the left thigh with swelling of the entire leg occurred in a 33-year-old woman following a stingray envenomation. Ultrasound of the leg showed a large pseudoaneurysm of the superficial femoral artery. Following complications from surgical resection of the pseudoaneurysm, including fever and postoperative bleeding from the surgical site, the patient gradually recovered after further surgical intervention and supportive care (Campbell et al, 2003).
    H) LACERATION OF HEART
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: An 18-year-old woman immediately collapsed and died after being stuck by a barb from a stingray. The woman had incision wounds on her legs as well as a penetrating wound to the chest wall and heart. The determined cause of death was hemorrhage from the puncture wound to the heart (Liggins, 2006).
    b) CASE REPORT: An 81-year-old man who was driving a boat, was struck with a barb from a spotted eagle stingray. Physical examination showed a 2-mm irregular laceration to the anterior left chest wall just medial and slightly inferior to the nipple. A 5% left pneumothorax and a 2-cm linear foreign body penetrating the anterior chest wall were observed in a CT scan. He underwent a left anterior thoracotomy and a pericardiotomy. It was found that the foreign body was intracardiac and an echocardiogram revealed a barb across both the left and right ventricles. During a cardiopulmonary bypass, the right atrium was accessed and the barb was removed by pulling it through the free wall of the right ventricle. The day after the cardiopulmonary bypass, he developed an acute onset hemodynamic instability, distended abdomen, and a significant decrease in hemoglobin level. An abdominal ultrasonographic scan showed free intraabdominal fluid. Hemoperitoneum from a splenic injury was noted during an exploratory laparotomy and a splenectomy was performed. The abdomen remained open for 48 hours to avoid postoperative abdominal compartment syndrome. His condition gradually improved and he was discharged home 2 months later (Parra et al, 2010).
    I) SYNCOPE
    1) WITH POISONING/EXPOSURE
    a) Syncope may occur following stingray envenomation (Diaz, 2008).

Neurologic

    3.7.2) CLINICAL EFFECTS
    A) PAIN
    1) WITH POISONING/EXPOSURE
    a) Intense, severe pain is characteristic of a stingray envenomation (Dehghani et al, 2009; Fenner et al, 1989). The pain peaks in about 50 to 60 minutes and may persist for 48 hours (Auerbach, 1991). Severe pain and profuse bleeding may also occur with non-envenoming lacerations (Diaz, 2008).
    b) CASE REPORT: Severe pain developed, lasting for 45 minutes, following a stingray laceration to the instep of the right foot. The pain subsided following hot water immersion, but returned after removal of the foot from the hot water. Using a treatment locally accepted by fishing operators in the northern territory of Australia, half of an onion bulb was bandaged over the wound. After 30 minutes the majority of the pain had subsided, and within a week the patient could walk easily with only slight joint stiffness (Whiting & Guinea, 1998).
    c) CASE SERIES: Severe pain was reported in 100% of patients (n=84) who were injured by freshwater stingrays. The envenomations occurred in the Parana, Paraquay, Araguaia, and Tocantins rivers of Brazil and their respective tributaries. The onset of the pain occurred immediately and typically lasted for at least 2 hours. In approximately one-third of the patients, hot water immersion of the affected extremity appeared to be effective in decreasing the intensity of the pain (Haddad et al, 2004).
    d) CASE REPORT: A 37-year-old man experienced excruciating and throbbing pain after a stingray envenomation to his foot. The pain completely resolved within 24 hours after treatment with oral analgesics and hot water immersion (Cook et al, 2006).
    B) PARESTHESIA
    1) WITH POISONING/EXPOSURE
    a) Paresthesia/numbness around the wound is not uncommon (Haddad et al, 2004; Whiting & Guinea, 1998).
    C) PARALYSIS
    1) WITH POISONING/EXPOSURE
    a) Limb paralysis may be seen with severe stingray envenomations (Forrester, 2005; Auerbach, 1991).
    D) ANXIETY
    1) WITH POISONING/EXPOSURE
    a) Anxiety may occur following stingray envenomation (Diaz, 2008).
    E) SEIZURE
    1) WITH POISONING/EXPOSURE
    a) Seizures may occur with severe stingray envenomation (Forrester, 2005; Acott & Meier, 1995).
    F) DIZZINESS
    1) WITH POISONING/EXPOSURE
    a) Dizziness may occur with stingray envenomation (Brisset et al, 2006).

Gastrointestinal

    3.8.2) CLINICAL EFFECTS
    A) NAUSEA
    1) WITH POISONING/EXPOSURE
    a) Nausea is a common complaint in severe envenomations (Diaz, 2008; Brisset et al, 2006; Haddad et al, 2004; Auerbach, 1991).
    B) VOMITING
    1) WITH POISONING/EXPOSURE
    a) Vomiting may occur only following severe envenomations (Diaz, 2008; Haddad et al, 2004; Auerbach, 1991).
    C) DIARRHEA
    1) WITH POISONING/EXPOSURE
    a) Diarrhea may occur only following severe envenomations (Diaz, 2008; Brisset et al, 2006; Haddad et al, 2004; Auerbach, 1991).
    D) ABDOMINAL CRAMPS
    1) WITH POISONING/EXPOSURE
    a) Abdominal cramps may occur only following severe envenomations (Diaz, 2008; Haddad et al, 2004; Auerbach, 1991).

Hematologic

    3.13.2) CLINICAL EFFECTS
    A) BLEEDING
    1) WITH POISONING/EXPOSURE
    a) Profuse bleeding may occur (Diaz, 2008)
    B) PETECHIAE
    1) WITH POISONING/EXPOSURE
    a) Although earlier studies reported no anticoagulant effects from the venom, one study described petechiae formation around stingray wounds, suggesting local antiplatelet effects (Diaz, 2008).

Dermatologic

    3.14.2) CLINICAL EFFECTS
    A) SKIN FINDING
    1) WITH POISONING/EXPOSURE
    a) Swelling, tenderness, bluish-grey discoloration around the wound have been reported (Acott & Meier, 1995).
    b) Stingray wounds are deep, lacerated, jagged, and often develop a deep ulcer at the wound site (Liggins, 2006; Cook et al, 2006; Barss, 1984). Wounds tend to be more prone to infection due to retained parts of the stingray apparatus or water borne bacteria (Lehane & Rawlin, 2000; Baack et al, 1991).
    c) Resistant localized edema is attributed to lymphatic obstruction (Russell et al, 1958).
    d) Localized erythema, edema, and skin necrosis occurred in up to 100% of patients (n=84) following freshwater stingray envenomations in the Parana, Paraguay, Araguaia, and Tocantins rivers of Brazil and their respective tributaries (Haddad et al, 2004).
    e) CASE REPORT: A 46-year-old woman was stung by a stingray over the dorsum of her left third toe and initially responded well to minimal first aid. However, 3 or 4 days later, she developed soft tissue necrosis. Following antibiotic therapy, surgical intervention, and hyperbaric oxygen therapy, her symptoms gradually improved and at 6-month evaluation, the skin graft had healed completely (Rocca et al, 2001).
    f) CASE REPORTS: After being stung on the right middle finger by a 22-cm long Potamotrygon motoro stingray, a 45-year-old woman developed intense pain radiating to the shoulder (intensified with movement), noncompressive edema of the whole hand, moderate bleeding, nausea, dizziness, and diarrhea (one episode 3 hours after envenomation). Following supportive therapy, the swelling disappeared on the 4th day; pain and stiffness in the finger disappeared on the 12th day. Another patient was stung on the middle phalanx of the finger by a 26-cm Potamotrygon motoro stingray while cleaning an aquarium. He presented with erythema of the finger, edema of the whole hand, and severe bleeding. A small necrotic area was noted around the wound a day after the injury. Pain and edema was greatly reduced after 2 days of observation, and he left the hospital against advice (Brisset et al, 2006).
    B) EXCESSIVE SWEATING
    1) WITH POISONING/EXPOSURE
    a) Diaphoresis may occur following stingray envenomation (Diaz, 2008).

Musculoskeletal

    3.15.2) CLINICAL EFFECTS
    A) INCREASED MUSCLE TONE
    1) WITH POISONING/EXPOSURE
    a) Muscle spasm has been reported after a stingray envenomation (Dehghani et al, 2009).
    B) COMPARTMENT SYNDROME
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 46-year-old man was stung in his left medial thigh while releasing a stingray from a fishing line. He was initially hypotensive and tachycardic, with numbness in his left foot and severe pain around the wound site. Upon transfer to the hospital, wound exploration revealed a lacerated left popliteal artery. The patient also required a 4 compartment fasciotomy for compartment syndrome distal to the envenomation site. With antibiotic therapy and use of a wound vacuum, the patient made a full recovery (Derr et al, 2007).
    C) NECROTIZING FASCIITIS
    1) WITH POISONING/EXPOSURE
    a) CASE REPORT: A 43-year-old man presented to the ED with a stingray laceration of his right tibialis anterior muscle. The laceration was irrigated and sutured but antibiotics were not given. Four days later, the patient developed necrotizing fasciitis of the wound. Wound cultures showed the presence of Photobacterium damsela. The patient gradually recovered following aggressive antibiotic therapy, deep surgical debridement of the wound, physical therapy, and a skin graft for wound closure (Barber & Swygert, 2000).

Laboratory Monitoring

Monitoring Parameters Levels

    4.1.1) SUMMARY
    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs. Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    C) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    D) Ultrasound of the wound site may reveal a retained integumentary sheath or other foreign bodies. Soft tissue radiographs will miss material that is not radiopaque. Regardless of the findings, direct exploration of the wound should be performed.

Radiographic Studies

    A) RADIOGRAPHY
    1) Following a severe envenomation, a chest radiograph may be indicated.
    2) Ultrasound of the wound site may reveal a retained integumentary sheath or other foreign bodies. Regardless of the findings, direct exploration of the wound should be performed.
    3) In radiographic examinations of the wound sites, retained hyperdense, radio-opaque fragments of cartilaginous vasodentin spines or barbs may be seen, but hypodense fragments of integumentary and glandular tissues may not be visible. Spine fragments may also not be visible on conventional radiographic examinations. For this reason, ultrasound is generally preferred. In addition, hypodense, space-occupying foreign bodies retained in soft tissues, gas pockets, and cyst-abscesses in septic wounds may be observed using magnetic resonance imaging examinations of wound sites (Diaz, 2008).
    4) In a retrospective review of stingray stings over an 8-year period, 2 groups of patients (100 patients in group 1 and 19 patients in group 2) were identified. Radiography did not detect barbs or other foreign bodies in affected extremities (Clark et al, 2007).

Treatment

Life Support

    A) Support respiratory and cardiovascular function.

Patient Disposition

    6.3.6) DISPOSITION/BITE-STING EXPOSURE
    6.3.6.1) ADMISSION CRITERIA/BITE-STING
    A) Any patients with cardiovascular toxicity or neurologic symptoms more severe than pain and mild paresthesias should be admitted.
    6.3.6.2) HOME CRITERIA/BITE-STING
    A) All patients should be sent to a medical facility for evaluation/treatment of the wound and treatment of any systemic symptoms.
    6.3.6.3) CONSULT CRITERIA/BITE-STING
    A) A medical toxicologist or poison center should be consulted on all severe envenomations.
    6.3.6.5) OBSERVATION CRITERIA/BITE-STING
    A) Patients with only local effects can be discharged once pain control is adequate and wound care is complete. Patients with stings that can cause systemic toxicity should be observed for 6 hours and may then be discharged if no systemic toxicity has developed. Patients who are discharged should return in 48 hours to evaluate wound for infection.

Monitoring

    A) No specific laboratory tests are necessary unless otherwise clinically indicated.
    B) For severe envenomations, monitor vital signs. Following a severe envenomation, obtain a baseline ECG and institute continuous cardiac monitoring.
    C) Monitor serum electrolytes in patients with significant vomiting and/or diarrhea.
    D) Ultrasound of the wound site may reveal a retained integumentary sheath or other foreign bodies. Soft tissue radiographs will miss material that is not radiopaque. Regardless of the findings, direct exploration of the wound should be performed.

Range Of Toxicity

Summary

    A) TOXIC DOSE: Stingrays usually only cause local effects. Penetrating wounds from a barb may cause severe injury, dependent in part on the depth and location of the injury. Fatalities are rare, and are secondary to traumatic injury to vital organs or arteries, not venom effects.

Minimum Lethal Exposure

    A) CASE REPORT
    1) An 18-year-old woman immediately collapsed and died after being stuck by a barb from a stingray. The woman had incision wounds on her legs as well as a penetrating wound to the chest wall and heart. The determined cause of death was hemorrhage from the puncture wound to the heart (Yamamoto et al, 2010).
    2) A 12-year-old boy was struck by a stingray barb, penetrating the chest wall, the left lung, the pericardium and the right ventricle. He also had injuries to his left knee. He immediately complained of chest pain and difficulty breathing and was transported to a medical facility. On presentation, he had severe pain, but his vital signs were stable. An initial chest x-ray film was considered normal. Following supportive care, his condition improved over the next few days and he was discharged home the next day. On day 6, he suddenly collapsed and cardiopulmonary resuscitation was unsuccessful. He died on the way to the hospital. At this time, the initial x-ray films were reviewed again and a small pleural effusion (probably small amount of blood) was noted at the left costophrenic angle on the inspiratory film, suggesting pericardial distension at the left basal margin of the heart. Autopsy revealed significant blood in the pericardium and left pleural cavity, and a penetrating wound to the right ventricle with surrounding myocardial necrosis. It was determined that the deposited venom caused an insidious and progressive localized myocardial muscle necrosis, resulting in acute cardiac perforation, tamponade and sudden death (Fenner et al, 1989).

Maximum Tolerated Exposure

    A) CASE SERIES
    1) In a case series of fisherman (n=79) from the Israeli Mediterranean Coast, the most common injury reported by fisherman were due to stingrays (n=24; 30.4%) followed by weever fish (n=17; 21.5%), rabbit fish (n=10; 12.7%) and stripped sea catfish (n=8; 10.1%) and the remaining cases were due other fish. Most injuries were due to envenomation (80%) compared to secondary infections (11.5%) or other injuries. Most cases were of moderate (53%) or minor severity (29%) and 9% reported no effect. The remaining 9% of cases were considered severe (ie, loss of a finger, permanent severe scar). Secondary infections and an injury by a stingray (Dasyatis pastinaca) produced the greatest pain and toxicity resulting in 3 cases of hospitalization for over 10 days. No deaths occurred (Gweta et al, 2008).
    B) LD50: Venom extracts of Urolophus halleri: 28 mg/kg (Diaz, 2008; Acott & Meier, 1995).

Pharmacology Toxicology

Toxicologic Mechanism

    A) VENOM APPARATUS AND COMPOSITION
    1) Stingrays have one or several spines on the back of the tail. These spines are flat and pointed or serrated. They are located on different locations on the spine and vary in size. Spines contain a strong bone-like cartilaginous material (vasodentin). Two longitudinal grooves are on the underside of the spine, containing venom-secreting glandular cells. Vasodentin spine and glandular tissues are enveloped by the epidermis or sheathed in an integument. This glandular tissue tears open after the spine is entered into a victim and venom is injected into the wound. Small pieces of integument, spine barbs, and venom-secreting glandular cells can remain in the wound, increasing the risk of prolonged exposure to the venom. Broken spines are regenerated quickly (Acott & Meier, 1995; Diaz, 2008; Diaz, 2007; Cook et al, 2006).
    2) The extraction and isolation of the venom from stingrays is difficult because of the lack of venom glands. Stingray venom is a mixture of enzymatically active and heat sensitive proteins, including serotonin, 5-nucleotidase, and phosphodiesterase. Freeze drying of the venom can inactivate or reduce the toxicity of the venom. High temperatures can make the venom less stable. The venom is cardiotoxic, possibly by a direct effect on the myocardium, but no hemolytic or neuromuscular blocking properties have been observed. Although earlier studies reported no anticoagulant effects from the venom, one study described petechiae formation around stingray wounds, indicating local antiplatelet effects (Diaz, 2008; Diaz, 2007; Cook et al, 2006; Acott & Meier, 1995).
    3) Analysis of the venom extract of the freshwater stingray (Potamotrygon falkneri), using SDS-polyacrylamide gel electrophoresis (SDS-PAGE), detected at least 18 components with enzymatic activity, including proteolytic, gelatinolytic, and hyaluronidase activities. The enzymes are believed to be responsible for the degradation of the extracellular matrix of the dermis, resulting in the edema, erythema, and skin necrosis observed following freshwater stingray envenomation that occurred in the Parana, Paraguay, Araguaia, and Tocantins rivers in Brazil (Haddad et al, 2004).
    4) Urobatis halleri venom has a diphasic action on the vertebrate heart. Low concentrations produce vasoconstriction or vasodilatation followed by vasoconstriction. The venom affects the heart directly, causing cardiac standstill (Russell & Van Harreveld, 1954).

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