TOXCard: Stingray Injuries
Author: Kathleen Yip MD (Harbor-UCLA Medical Center) // Edited by: David Tanen MD (Harbor-UCLA Medical Center), Cynthia Santos (Rutgers New Jersey Medical School), Alex Koyfman, MD (@EMHighAK, UTSW / Parkland Memorial Hospital), and Brit Long, MD (@long_brit)
A 26-year-old male walks with an antalgic gait into the emergency department. He reports running in the shallow waters at the beach nearby about an hour ago when he felt sudden pain in the back of his right ankle. When he looked down, he saw a stingray swimming away and a thin trail of blood from his ankle dissipating into the water. The bleeding has stopped, but now he reports excruciating pain, even after taking a Tylenol his friend gave him.
- What is the management of stingray injuries?
- What are potential complications?
- What prevention strategies are there to avoid future injuries?
- Stingrays live in temperate and tropical oceans. They are often found buried in the sand and are docile creatures that would rather swim to escape than attack.1
- Most injuries are due to unintentional contact (stepping on the wings) or from unraveling fishing equipment.2
- The bilaterally serrated spine is located dorsally on the tail; it is contained within the integumentary sheath, which holds the venom.1
- The injury occurs in two steps: 1) mechanical injury from the sharp and jagged spine, causing a laceration or puncture wound, and 2) envenomation, resulting in systemic symptoms.3
- There are approximately 2000 reported stingray injuries per year in the United States.4
Clinical signs and symptoms
- Intense pain and edema peaks around 30 minutes to 90 minutes and lasts up to 48 hours.2
- Systemic signs of venom toxicity include nausea, vomiting, diarrhea, diaphoresis, hypotension, arrhythmias, and seizures.5
- Hot water immersion
- There is a risk of sustaining a thermal burn, but this can be mitigated by testing the uninjured limb in the hot water bath first.
- Water as hot as tolerated should be used; one study used 110°-114°F (43.3°-45.6°C).3
- One retrospective study showed that 88% of patients who were treated with hot water immersion alone achieved complete pain relief within 30 minutes.6
- Wound care
- Consider removing the spine if it is superficially embedded in the wound; do not remove any spines causing through and through penetrations or any located in the neck, thorax, or abdomen (consult surgery for penetrating injuries in these regions).
- Even if the spine or sheath does not break off into the wound, irrigation is key to removing debris such as sand.
- Tetanus prophylaxis.
- Stingrays have cartilaginous exoskeletons, so spine fragments may not be seen on radiographs.
- One study suggested that radiographs were low yield; of the 68 patients that received an X-ray, two had radio-opaque foreign bodies (sand as well as an unidentified object that was unsuccessfully removed in the ED).6
- One case report described the development of tenosynovitis in a patient who had a retained stingray spine that was not imaged on multiple visits.7
- Antibiotic prophylaxis
- In a retrospective chart review, 17% of patients who did not receive antibiotic prophylaxis versus 1.4% who did receive antibiotics returned with an infection. There was no information on the patients who developed infections (e.g. risk factors, age, wound characteristics, etc.).6
- In a prospective study that consisted of mostly healthy young males in which none received antibiotic prophylaxis, 4.5% of patients returned with an infection.8
- If antibiotics are prescribed, a 5-day course of quinolones to cover for Vibrio, Streptococcus, and Staphylococcus is recommended.6
- Observation for patients experiencing systemic manifestations of stingray envenomation.
Mechanism of toxicity
- For a variety of reasons, stingray venom is difficult to study.
- Based on one study, the venom contains cardiotoxic and heat labile proteins9, which explains why hot water is key to pain management.
- Retained foreign body
- Avoid touching marine life.
- Wear gear that covers exposed skin.
- Do the “stingray shuffle” —shuffle feet when walking in shallow sandy areas to alert nearby stingrays.5
Take home points
- Hot water is very effective at treating pain.
- Consider radiographs and antibiotics, and regardless, provide patients with good return precautions for the development of infections.
- Diaz JH. The evaluation, management, and prevention of stingray injuries in travelers. J Travel Med 2008;15:102-9.
- Balhara KS, Stolbach A. Marine envenomations. Emerg Med Clin North Am 2014;32:223-43.
- Clark RF, Girard RH, Rao D, Ly BT, Davis DP. Stingray envenomation: a retrospective review of clinical presentation and treatment in 119 cases. J Emerg Med 2007;33:33-7.
- Auerbach PS. Envenomation by aquatic vertebrates: Stingrays. 6 ed. Philadelphia, PA: Elsevier; 2011.
- Hornbeak KB, Auerbach PS. Marine Envenomation. Emerg Med Clin North Am 2017;35:321-37.
- Clark AT, Clark RF, Cantrell FL. A Retrospective Review of the Presentation and Treatment of Stingray Stings Reported to a Poison Control System. Am J Ther 2017;24:e177-e80.
- O’Malley GF, O’Malley RN, Pham O, Randolph F. Retained Stingray Barb and the Importance of Imaging. Wilderness Environ Med 2015;26:375-9.
- Myatt T, Nguyen BJ, Clark RF, Coffey CH, O’Connell CW. A Prospective Study of Stingray Injury and Envenomation Outcomes. J Emerg Med 2018;55:213-7.
- Russell FE, Van Harreveld A. Cardiovascular effects of the venom of the round stingray, Urobatis halleri. Arch Int Physiol Biochim 1954;62:322-33.