J Emer Med. © 2020 HMP. J Postgrad Med. Accessed April 4, 2015. One subject was diagnosed with cellulitis on post-sting day 8 and was treated with antibiotics. Shuffle your feet and know what to do if stung. The most dangerous jellyfish, the major box jellyfish (C. … Procedures, encoded search term (Stingray Envenomation) and Stingray Envenomation, Botulinum Toxin Injections in Plastic Surgery, Pathophysiology and Etiology of Lead Toxicity, EMA Panel Recommends DPD Testing Prior to Fluorouracil Treatment, CDC Panel Recommends Pfizer's COVID-19 Vaccine for People 16 and Over, Model May Predict Post-treatment Hodgkin Lymphoma Outcomes, Famous Patients: From Goethe to Beethoven, Marley to Bogart, Don't Use N95 Masks for More Than 2 Days, Research Suggests, Lower Back Pain: NSAID + Muscle Relaxant No Better Than NSAID + Placebo, A 30-Year-Old Man With Hallucinations After a House Party, Add Delirium to Checklist of COVID-19 Symptoms in Seniors. 868-73. N Engl J Med. The culture yielded a growth of Streptococcus agalactiae (Group B) sensitive to ampicillin, cipro­ floxacin, ceftriaxone, chloramphenicol, clindamycin, erythromycin, and cephalothin, and resistant to tetracycline and gentamicin. Addressing Lower Extremity Ischemia Issues After The Use Of Vasopressors. Fatal stings are rare but have been reported.2 In 2006, Steve Irwin, an Australian wildlife expert and television personality, was killed by a stingray strike when the stinger penetrated his thoracic wall, causing massive trauma.3, Stingray spines are covered in an integumentary sheath that contains their protein-based venom. Share cases and questions with Physicians on Medscape consult. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. A study by Clark and colleagues showed a very high number of infections in stingray wounds in patients who did not receive prophylactic antibiotics upon the initial presentation. 5. It is an advanced-generation cephalosporin.Its advantages include a once-per-day dosing schedule and broad spectrum. The venom is released via a harpoon-like mechanism that injects venom into the dermis. 2002 The tail of the stingray contains a barbed stinger attached to a venom gland and contained within an integumentary sheath. Stingray injuries are further complicated by retained barbs and foreign bodies, which also may lead to considerable morbidity. Stingray stings are common along coastal regions of this country and the world. Emer Med J. Evans RJ, Davies RS. 7. 1989;151(11-12):621-625. 2004 Feb 15. Optimal coverage should include staphylococci, streptococci, and pathogens expected in the involved water (freshwater or saltwater). Blohm E; Brush DE. Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency MedicineDisclosure: Nothing to disclose. O'Malley GF, O'Malley RN, Pham O, Randolph F. Retained Stingray Barb and the Importance of Imaging. Mosby-Year Book; 1998. Fernandez I, Valladolid G, Varon J, Sternbach G. Encounters with venomous sea-life. [podiatrytoday.com] It causes severe pain, vasoconstriction, ischemia, and poor wound healing, along with systemic effects such as disorientation, syncope, seizures, salivation, nausea, vomiting, abdominal pain , diarrhea, muscle cramps or fasciculations, pruritus, allergic [mdedge.com] Beware of stingrays! When There Is Forefoot Varus: Is The Lapidus Bunionectomy More Effective Than The Cotton Osteotomy? Apply topical antibiotic ointment if signs of infection, such as pus, redness, or heat, occur. J Travel Med. In addition, the serrated spines of the stingray’s tail can cause lacerations and/or puncture wounds which may result in bleeding. Such antibiotics include quinolones (eg, ciprofloxacin, levofloxacin), doxycycline, trimethoprim/sulfamethoxazole (Bactrim, Septra), cefuroxime or other late-generation cephalosporins, an aminoglycoside, or chloramphenicol. 11. Callinan R. Death of a Crocodile Hunter. Diseases & Conditions, 2002 Trauma and envenomations from marine fauna. Ellenhorn's Medical Toxicology. pain, seizures and hypotension. Photo by John L. Meade, MD. ... You may need to take antibiotics and/or apply healing ointments. Lippincott Williams & Wilkins; 1997. Fino P, Onesti MG, Felli A, Scuderi N. Clinical Examination and Treatment of a Leg Ulcer Caused by a Stingray Puncture. 8. Ellenhorn's Medical Toxicology. Trauma and envenomations from marine fauna. 924-40. 2006;23(7):503-508. 1989 Dec 4-18. Fatal and non-fatal stingray envenomation. J Accid Emerg Med 1996; 13:224. Int J Lower Extrem Wounds. Fenner PJ, Williamson JA, Skinner RA. 2008;15(2):102-109. 6. Lippincott Williams & Wilkins; 1997. Continue antibiotics for at least 5 days after all signs of infection have cleared. 1737-98. 17(2):217-20. Foot Ankle Int. Rosen P, et al, eds. [6] showed a significant number of patients returning to the ED with wound infections when prophylactic antibiotics were not administered at initial presentation, many physicians choose to treat the wounds associated with stingray envenomations prophylactically with a short course (~5 d) of oral antibiotics. Ultrasound is also recommended for evaluation if radiographs are negative and one can ultrasound to aid foreign body removal as well.8, Following radiographic/ultrasound evaluation, one should explore the wounds, remove all foreign material and debride necrotic tissue.1,15 Clinicians should thoroughly irrigate the wound and allow it to heal via secondary intention if the wound is small or with loose primary closure if it is very large.1,15 Determine the patient’s tetanus immunization status and administer a booster if needed.15. Pseudoaneurysm of the superficial femoral artery resulting from stingray envenomation. 2007 Jul. Clark RF, Girard RH, Rao D, Ly BT, Davis DP. John L Meade, MD CEO, Statdoc Consulting, Inc However, pathogens of specific concern to such envenomations are Vibrio species in saltwater and Aeromonas species in freshwater. Stings usually occur when swimmers or divers accidentally step on a stingray, but a human is less likely to be stung by simply brushing against the stinger. 2000;342(11):824. While rare, the spines may potentially injure neurovascular structures. sources in all stingray wound patients; some sources suggest prophylactic antibiotics only with immunocompromised pa­ tients or with injuries to high-riskareas such as hands and feet [3,7,15,31,32]. [Medline]. Generic versions are inexpensive. Since there is a strong likelihood of infection developing in the wound area, antibiotics may be prescribed along with medications for pain control. Levofloxacin is first-line treatment for infections caused by Vibrio species found in saltwater. Clark RF, Girard RH, Rao D, Ly BT, Davis DP. John L Meade, MD is a member of the following medical societies: American College of Emergency Physicians, Medical Association of the State of AlabamaDisclosure: Nothing to disclose. 2013;59(4):309-311. Local effects of stingray venom include: severe pain, edema, cyanosis, erythema, petechiae, local necrosis, ulceration and delayed wound healing.4 Systemic effects of stingray venom include: syncope, nausea, vomiting, diarrhea, diaphoresis, muscle cramps, fasciculations, abdominal pain, seizures and hypotension.5, Stingray venom is a very heat sensitive protein. In Tintinalli JE SS, Cline DM (ed. In Seal Beach one summer we treated over 350 stingray wounds, that year the nation reported 1,200 total injuries…I’ve had a little experience with those mean buggers. 15. Ann Vasc Surg. Please confirm that you would like to log out of Medscape. de Haro L, Pommier P. Envenomation: a real risk of keeping exotic house pets. Venomous animal injuries. 69(4):885-90. 33(1):33-7. Prescribing oral narcotics for patients to use as needed upon discharge is appropriate. Not seeing a doctor, you could even lose your foot. Cephalexin is a first-generation cephalosporin, which is usually effective against Staphylococcus and Streptococcus species. Stingray injuries: a lesson in debridement. Fenner PJ, Williamson JA, Skinner RA. Poisoning, envenomation, and trauma from marine creatures. Snyder CC. The evaluation, management, and prevention of stingray injuries in travelers. Doxycycline inhibits protein synthesis and, thus, bacterial growth, by binding to 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. 4. The spines have serrated edges and strikes often result in a deep, jagged laceration. Auerbach PS. 151(11-12):621-5. Br J Dermatol. Risk for infection is compounded by any saltwater-resistant bacteria that may be on the stingray barb as well. Wilderness Environ Med. If you or a companion is stung by a jellyfish: Avoid moving the affected limb. After recovering from the initial sting, the wound may later blister and become necrotic (tissue death). The sting is painful, but usually not very harmful. Staphylococci and streptococci remain the most common infecting agents and must not be ignored. 2003 Mar. Envenomations: bites and stings. It covers Vibrio species well, although coverage is not as good for Staphylococcus and Streptococcus species. The one thing you have to do to make the stingray sting feel better: Get your foot in the hottest possible water that your skin can take without getting burned. Photo by John L. Meade, MD. Hot water, antibiotics, and aggressive pain management are the primary treatment mechanisms for people who have been stung by stingrays. Medical Association of the State of Alabama, American Society of Health-System Pharmacists. The spines are covered with a thin integumentary layer that concentrates venom secreted by glands on their inferior surface.1 Stingrays are not aggressive toward humans. Envenomations: bites and stings. Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. Generally, these are aquatic animals that have a flat body with long, slender tails with serrated spines which contains the venom. 5 Stingray venom is a very heat sensitive protein. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. Stingray barb broken off in ring finger. Perform cardiopulmonary resuscitation (CPR) if necessary. 5 Prophylactic antibiotic selection should cover Staphylococci, Streptococci and pathogens expected in the involved water. 1991;325(7):486-493. ): Emergency Medicine: A Comprehensive Study Guide. Disturbing a stingray triggers a defensive flip of its “tail,” which contains one to four venomous spines. This combination inhibits bacterial growth by inhibiting the synthesis of dihydrofolic acid. Stingray stings are very painful and patients will at a minimum need to undergo treatment for pain control. Diseases & Conditions, 2002 J Emerg Med. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. Germain M, Smith KJ, Skelton H. The cutaneous cellular infiltrate to stingray envenomization contains increased TIA+ cells. Barber GR, Swygert JS. By binding to one or more of the penicillin binding proteins, cefixime arrests bacterial cell wall synthesis and inhibits bacterial growth. 3. Diaz JH. Podiatry Today is a trademark of HMP. Case report: iatrogenic infection from traditional treatment of stingray envenomation. The venom is a protein and is broken down by heat, so placing the injured area in water as hot as the person can tolerate (113°F or 45°C) for 30-90 minutes can dramatically relieve the pain. Atkinson PR, Boyle A, Hartin D, McAuley D. Is hot water immersion an effective treatment for marine envenomation? A stingray sting is one common beach injury caused by a stingray. 2003 Aug. 45(4):214-6. Stingray stings to an extremity should be gently irrigated with salt water in an attempt to remove fragments of spine, glandular tissue, and integument. Do not rub the sting area. X-rays and CT scans may be done. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. 9. Stingray stings are common along coastal regions of this country and the world. Guenin DG. 2009;122(1290):83-97. Med J Austral. Stingray venom and the stingray barbs are very nasty. Stingray barb in forearm. (This is important if the patient is on vacation or lives at the beach and is likely to get significant sun exposure while on the medication.). Pathological findings and surgical management. The patient of a stingray sting will need medical attention. Oral antibiotics are usually recommended for infection. Hyperbaric oxygen therapy in the treatment of soft tissue necrosis resulting from a stingray puncture. Am Fam Phys. A disadvantage is relatively high cost. Richard H Sinert, DO Professor of Emergency Medicine, Clinical Assistant Professor of Medicine, Research Director, State University of New York College of Medicine; Consulting Staff, Vice-Chair in Charge of Research, Department of Emergency Medicine, Kings County Hospital Center All material on this website is protected by copyright, Copyright © 1994-2020 by WebMD LLC. There is a high potential for bacterial contamination in stingray puncture wounds and these injuries can be complicated by secondary bacterial infections including cellulitis, osteomyelitis, necrotizing fasciitis and septicemia.16 Staphylococci and Streptococci are the most common bacteria causing infection secondary to stingray injury but bacteria specific to water environments, namely Vibrio species in saltwater and Aeromonas in freshwater, are also pathogens of concern. Stingray injury. Treating Stingray Envenomation And Injury In The Lower Extremity, http://content.time.com/time/world/article/0,8599,1531446,00.html, Recommending Basketball Shoes: Educating Athletes On Keys To Appropriate Selection, Current Insights On The Diagnostic Algorithm For Charcot Neuroarthropathy, Incorporating Remote Patient Monitoring Into Your Practice: Essential Considerations. J Emerg Med 2011; 40:103. A stingray sting can be quite painful and may lead to severe symptoms. Necrotizing fasciitis due to Photobacterium damsela in a man lashed by a stingray. 2018 Mar;98(3):929-32. Procedures, 2002 Find out first aid steps you can take immediately for these stings, symptoms to … In Summary Pain: There is no antivenom (antidote) to stingray toxin. Hønge LB, Patsche CB, Jensen MM, et al. Srinivasan S, Bosco JI, Lohan R. Marine stingray injuries to the extremities: Series of three cases with emphasis on imaging. However, prophylactic antibiotics after stingray exposure remains controversial because other studies suggest that the wounds are minor and antibiotics unnecessary . Poisoning, envenomation, and trauma from marine creatures. 1999;112(1086):137-138. ... How A Stingray Stings. 1011549-overview Call 911. It needs to soak for about 2 hours. Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency MedicineDisclosure: Nothing to disclose. Tintinalli JE, et al, eds. They only use their spines as a self-defense mechanism. Remove nematocysts and tentacles from the skin using gloves and forceps. It is indicated for Staphylococcus aureus and infections caused by multidrug resistant gram-negative organisms. https://profreg.medscape.com/px/getpracticeprofile.do?method=getProfessionalProfile&urlCache=aHR0cHM6Ly9lbWVkaWNpbmUubWVkc2NhcGUuY29tL2FydGljbGUvNzcyNjgzLW1lZGljYXRpb24=. Stingray strikes can result in several injuries including envenomation, laceration from the spine, retained spine fragments and secondary bacterial infection.1, A stingray's tails contain one or more barbed spines. The tail of the stingray contains a barbed stinger attached to a venom… You’ll also want to seek immediate medical help if you have swelling of the tongue or other body parts, difficulty breathing, palpitations, seizures, or excessive blood loss. Sting severity is related to: 1. the number of stinging cells that fire, which depends on the amount of tentacle contact with skin 2. the potency of injected venom, which depends on the species. Treatment of jellyfish stings. Jellyfish cause stings when their tentacles contact skin. Such antibiotics include quinolones (eg, ciprofloxacin, levofloxacin), doxycycline, trimethoprim/sulfamethoxazole (Bactrim, Septra), cefuroxime or other late-generation cephalosporins… John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals It is an inexpensive combination agent that covers Vibrio and some Staphylococcus and Streptococcus species. A study by Clark and colleagues showed a very high number of infections in stingray wounds in patients who did not receive prophylactic antibiotics upon the initial presentation.5 Prophylactic antibiotic selection should cover Staphylococci, Streptococci and pathogens expected in the involved water. Barss P. Wound necrosis caused by the venom of stingrays. 2. Ellenhorn MJ. The majority of stings occur on the lower extremity secondary to stepping on the fish. Radiography and ultrasound imaging, wound care including exploration, debridement and irrigation, and prophylactic antibiotics are the mainstays of management of these injuries. 1984;141(12-13):854-855. The spine should be removed in the field only if it is superficially embedded and is not penetrating the neck, thorax, or abdomen or creating a through-and-through injury of a limb. This website also contains material copyrighted by 3rd parties. 33(1):33-7. . Heat in theory rapidly denatures the venom protein, providing significant and rapid pain relief.5-7 Local anesthetic also theoretically counteracts stingray venom and physicians have used it to provide pain relief in the management of acute stingray injuries.8, Stingray venom can cause significant tissue necrosis, which can lead to delayed wound healing.9 Additionally, the venom causes local vasoconstriction and ischemia, which can contribute to delayed wound healing as well.10 There have been reports of chronic wounds secondary to stingray injuries.11-13 Numerous treatment modalities exist for these chronic wounds and they include debridement, hyperbaric oxygen and collagenase.11-13, Pieces of the stingray spine can break off in the deeper soft tissues, causing prolonged release of venom and foreign body reaction, and contributing to secondary bacterial infections.1 Stingray spines are typically radiopaque and visible on plain film radiographs, but may have radiolucent cartilaginous parts requiring ultrasound evaluation.14 Plain film radiographs are recommended to evaluate stingray wounds for any retained spines or foreign material. 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