Emergency Department Care
If a patient has demonstrated any sign of systemic effect, it should be addressed quickly.
No specific antidote is available, and supportive care is recommended, including use of analgesics.
An easy and important initial treatment that can be started (sometimes at the scene of the injury) is immersion of the injured extremity in hot water (preferably 110-115°F). The water should be as hot as the patient can tolerate but should not cause burns. The water should be exchanged for more hot water as it cools, for an immersion duration of 30-90 minutes.
Very little has been written about the toxin left in wounds after a stingray injury. It is known that the stingray toxin is a protein and is very sensitive to heat. The patient should obtain very rapid symptomatic improvement with heat as the poison denatures and becomes neutralized. Some thought exists that the protein does not truly denature but that some sort of gateway effect occurs on the nerve conduction. Whatever the mechanism, heat is a rapid, effective treatment to reduce pain almost instantaneously.
In addition, some practitioners also infiltrate the wound with a local anesthetic, such as lidocaine (lignocaine) [15] or the longer-acting bupivacaine. Oral or parenteral narcotics may also be given if the patient is suffering severe pain. The effectiveness of hot water immersion may eliminate the need for local anesthetic infiltration.
After the toxin has been deactivated by the hot water, attention to local wound care should begin because it is not uncommon for part of the stinging apparatus to break off in the wound.
Obtain a plain radiographic image of the injured area to look for retained barbs or other foreign material. Explore the wound thoroughly and irrigate it. Perform any necessary debridement. [16]
Remove any foreign body from the wounds, including the spine and sheath from the stingray stinger (if present), as well as any dirt or sand.
As with other potentially contaminated wounds, consider allowing the wound to heal without closure. Because most of the wounds are small, this usually is not an issue. If the wound is very large or gaping, consider loose primary closure.
Address the patient's tetanus immunization status and administer a booster as needed.
Long-Term Monitoring
Give patients explicit instructions regarding attention to local wound care and advise them to watch for infection. Requesting that the patient seek a wound check in 2-3 days (with a family doctor or at the ED) is not unreasonable.
It is especially vital that the patient understands that for any sign of infection with Vibrio organisms, time is of the essence in returning to the ED for immediate care.
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Typical stingray puncture wound on a foot, approximately 60 minutes after injury. Photo by John L. Meade, MD.
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Stingray barb in forearm. Photo by John L. Meade, MD.
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Stingray barb broken off in ring finger. Photo by John L. Meade, MD.
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Spine removed from stingray injury. Image courtesy of Scott Plantz, MD.
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Stingray.
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Stingray.
