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Stingray Stings — NUEM Blog
Written by: Mike Tandlich, MD (NUEM ‘24) Edited by: Peter Serina, MD, MPH (NUEM ‘22)
Expert Commentary by: Mike Macias, MD (NUEM ‘17)
Expert Commentary
Thank you Drs. Tandlich and Serina for this excellent infographic summarizing stingray envenomation! The good news is that the majority of stingray injuries are nonfatal and will heal without any complications! You hit all of the key points however I just wanted to highlight a few management tips below:
Treat as a Trauma!
While majority of the pain from stingray envenomation occurs as a result of its venom, it is important to remember that this is also a traumatic injury. Treat the injury just like you would any other penetrating trauma. Consider the location as well as surrounding structures and make sure to properly examine for tendon, nerve, and vascular injury. Injuries to the chest or abdominal regions should prompt advanced imaging and trauma consultation.
Hot Water is Key!
Stingray envenomation is noted to cause severe pain that is often out of proportion to your examination findings. While the exact mechanism is not clear, the venom can lead to not only pain but also local tissue necrosis. The good news is the venom is heat labile! The faster you can get the injured area into hot water the better. You want the water to be as hot as tolerable without causing a thermal burn. A good rule of thumb is to have the patient place their unaffected limb in the water first to see if it is tolerable. As this often occurs at a beach, lifeguards are often your best resource to get hot water fast! Oral analgesics can be administered if needed however often they are unnecessary as soon as the injured area is submerged in hot water.
Retained Barb?
While uncommon, a retained barb from the envenomation can occur so be sure to consider this and evaluate appropriately. Traditionally, x-ray imaging of the affected area is performed to evaluate for a radio-opaque barb however some evidence suggests this to be a relatively low yield practice [1]. Ultrasound can also be considered if there is suspicion for retained barb or other material. In general ultrasound has been shown to be highly sensitive for identification of foreign body [2]. Not only can it be used to identify the barb but it can be used to facilitate removal [3].
Give Prophylactic Antibiotics
Prophylactic antibiotics are recommended for stingray envenomation given that the limited data suggest a higher rate of wound infection in patients who were not initially treated with antibiotics [1]. Given these injuries often occur in the ocean make sure to cover for salt water species such as Vibro. Levofloxacin is my go to option.
Teach The Stingray Shuffle!
Keeping these key management points in mind, the good news is that the majority of stingray injuries are nonfatal and will heal without any complications! Before your patient is discharged don’t forget to remind them that the next time they are going out for a surf to do the stingray shuffle!
References
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 Jul;33(1):33-7
Aras MH, Miloglu O, Barutcugil C, Kantarci M, Ozcan E, Harorli A. Comparison of the sensitivity for detecting foreign bodies among conventional plain radiography, computed tomography and ultrasonography. Dentomaxillofac Radiol. 2010;39(2):72-78. doi:10.1259/dmfr/68589458
Nwawka OK, Kabutey NK, Locke CM, Castro-Aragon I, Kim D. Ultrasound-guided needle localization to aid foreign body removal in pediatric patients.
J Foot Ankle Surg. 2014;53(1):67-70. doi:10.1053/j.jfas.2013.09.006
Michael Macias, MD
Systems Clinical Ultrasound Director,
Emergent Medical Associates
Ultrasound Director,
UHS SoCal MEC Residency Programs
How To Cite This Post:
[Peer-Reviewed, Web Publication] Tandlich, M. Serina, P. (2021, Nov 15). Stingray Stings. [NUEM Blog. Expert Commentary by Macias, M]. Retrieved from http://www.nuemblog.com/blog/stingray-stings
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Posted on November 15, 2021 by NUEM Blog and filed under Environmental and tagged environmental medicine emergency medicine toxicology.
What Happens When a Stingray Stings You? Here’s What You Should Do
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Stingrays became known as sand-swimming villains following Steve Irwin’s death, but what happens when a stingray stings you?
Source: Getty Images
Stingrays are unique, winged fishes that are closely related to sharks, soaring about in shallow coastal waters or floating just below the surface of an aquarium touch pool. Armed with a barbed and wicked-looking stinger, stingrays are a common source of beachgoer injury. Many claim that they are even responsible for the death of beloved animal icon, Steve Irwin.
But what usually happens when a stingray stings you is quite different than what happened to the Crocodile Hunter.
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Source: Getty Images
What happens when a stingray stings you?
First, you’re likely to feel extreme pain. According to Very Well Health, that pain can last as long as two days and be accompanied by a bevy of additional symptoms including bleeding, inflammation, redness, or blue coloration at the wound site. Some also experience dizziness, muscle cramps, or weakness. Rare cases have seen victims exhibit seizures, low blood pressure, and pulse irregularity as well.
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Very Well Health reports that approximately 1,500 stingray stings happen in the U. S. each year and most of those occur in places like Florida or California, where there are warm, coastal waters. Common injuries usually occur when the stingray is accidentally stepped on, so wounds tend to be on the feet and legs. Fishermen, however, tend to get stung on the arms as they reach into nets to excise the stingray.
Source: Getty Images
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Why do stingrays sting?
Stingrays have long, thin tails that are tapered at the edge to look like a whip. These tails are tipped with barbed spines covered by a sheath. Hidden, barbed spines would be enough for most creatures, but not the stingray. They had to up the ante by also including venom, which grants the cantankerous little rays a painful, powerful sting.
In general, stingrays prefer not to sting if they can help it. Stingrays aren’t combative by nature and would rather flee from a fight than risk a sting. According to Healthline, they only sting when they are disturbed, manhandled, or stepped on by unwary swimmers. Even then, they try to float away before their victim can conduct any sort of retaliation.
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How to avoid being stung:
Most experts agree that it’s best to shuffle you’re feet as you wade into the water, to alert a stingray you’re coming. Making a racket of any kind will usually cause them to scurry off, but anything can happen.
Source: Getty Images
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What to do if a stingray stings you:
According to eMedicineHealth, treating a stingray sting is fairly uncomplicated, but that doesn’t mean that it’s painless. The steps are as follows: First, flush the wound with fresh water and if possible, soak the wound in water as hot as the person can tolerate. Next, if the stinger or stingers are still present, carefully excise them with tweezers.
When the stingers are out, scrub the wound with soap and more fresh water. If bleeding, apply pressure until it stops. Do not cover or attempt to stitch the wound yourself, but if there are any signs of infection like redness, heat, or swelling, make sure to contact a doctor.
Either way, though, be sure to contact a doctor, as they might suggest antibiotic ointment to prevent infection. Most stingray encounters are rarely fatal, though — they’re just painful.
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