Stingray Stings – Injuries; Poisoning

By

Robert A. Barish

, MD, MBA, University of Illinois at Chicago;

Thomas Arnold

, MD, Department of Emergency Medicine, LSU Health Sciences Center Shreveport

Reviewed/Revised Jan 2022 | Modified Sep 2022

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Stingrays once caused about 750 stings/year along North American coasts; the present incidence is unknown, and most cases are not reported. Venom is contained in one or more spines on the dorsum of the animal’s tail. Injuries usually occur when an unwary swimmer wading in ocean surf, bay, or backwater steps on a stingray buried in the sand and provokes it to thrust its tail upward and forward, driving the dorsal spine (or spines) into the patient’s foot or leg. The integumentary sheath surrounding the spine ruptures, and the venom escapes into the patient’s tissues.

The main symptom of a stingray sting is immediate severe pain. Although often limited to the injured area, the pain may spread rapidly, reaching its greatest intensity in &lt 90 minutes; in most cases, pain gradually diminishes over 6 to 48 hours but occasionally lasts days or weeks. Syncope, weakness, nausea, and anxiety are common and may be due, in part, to peripheral vasodilation. Lymphangitis, vomiting, diarrhea, sweating, generalized cramps, inguinal or axillary pain, respiratory distress, and death have been reported.

The wound is usually jagged, bleeds freely, and is often contaminated with parts of the integumentary sheath. The edges of the wound are often discolored, and some localized tissue destruction may occur. Generally, some swelling is present. Open wounds are subject to infection.

Stingray stings to an extremity should be gently irrigated with salt water in an attempt to remove fragments of spine, glandular tissue, and integument. 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. Significant bleeding should be staunched with local pressure. Warm water immersion, although recommended by some experts, has not been verified as an effective early treatment for stingray injuries.

In the emergency department, the wound should be reexamined for remnants of the sheath and debrided; a local anesthetic may be given as needed. Embedded spines are treated similarly to other foreign bodies. Patients stung on the trunk should be evaluated closely for puncture of viscera. Treatment of systemic manifestations is supportive. Tetanus prophylaxis should be given (see table ), and an injured extremity should be elevated for several days. Use of antibiotics and surgical wound closure may be necessary.

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Bites, First Aid, Symptoms, and Treatment

Stingrays are flat, disk-shaped creatures with fins that resemble wings. Species of stingray can be either saltwater or freshwater. They’re most often associated with tropical ocean climates, and their sting is a commonly reported beachgoer injury.

A stingray’s tail is long, thin, and tapered, much like a whip. In the middle of the tail are one or more barbed spines covered by a sheath. Each spine contains venom, and the stingray’s tail can pack a powerful, incredibly painful sting.

Stingrays generally aren’t dangerous — in fact, they have a reputation for being gentle. They often burrow beneath the sand in the shallows and swim in the open water. Stingrays will usually only sting when disturbed or stepped on by unaware swimmers.

Most of the time, you can avoid being stung by a stingray. But if you do experience a stingray sting, there are several things you can do immediately to start relieving the pain.

When stung by a stingray, you’ll feel immediate, severe pain at the wound site. You need to begin treating the wound right away if it’s superficial.

If the barb has punctured your throat, neck, abdomen, or chest, or has pierced completely through part of your body, don’t attempt to remove it. Seek emergency medical attention immediately.

Otherwise, remain in the ocean and pull the barb out if you can. Allow the salt water to clean the wound while applying pressure over it to both slow the bleeding and encourage the venom to come out.

Try to clear out any additional debris you might see in the cut or puncture while you’re still in the water.

Pay close attention to how you feel in the sting’s aftermath. It’s possible to have a life-threatening allergic reaction to stingray venom, which requires emergency medical care. Expect the area to swell.

Hot water kills stingray venom and may relieve the pain associated with the sting. Once you’ve determined you’re not having an allergic reaction, you might want to try soaking the sting in hot water.

The ideal temperature for a soak is 110°F to 115°F (43°C to 46°C). Reheat your water every 10 minutes to keep it continually hot, and soak the wound for 30 to 90 minutes, or as long as it takes for the pain to subside. The hot water may also draw out venom, which resembles jelly.

Once you’ve relieved the pain, apply antibiotic ointment or cream to the wound and cover it with gauze.

If you’re stung by a stingray, you may experience these symptoms:

• abdominal pain
• anxiety
• bleeding
• diarrhea
• dizziness
• extreme pain at the wound site
• fatigue
• headache
• low blood pressure
• muscle cramps
• nausea
• necrosis (death) of surrounding tissue
• pain in the extremities
• painful, swollen lymph nodes near the site
• skin discoloration
• swelling
• vomiting

The following symptoms could be signs of a systemic reaction or respiratory distress and require immediate emergency medical care:

• fainting
• irregular heartbeat
• muscle paralysis
• seizures
• shortness of breath
• sweating

It’s possible for the heart to stop or for the body to go into shock after a stingray sting. Some people have died as a result of stings in their chests and abdomens.

If you have a puncture wound and aren’t up to date on your tetanus booster, it’s time to get it renewed.

If you’ve had the wound for a while but are slow to recover, you experience redness or additional swelling at the site, or the site begins to ooze pus, get treatment right away. The site may be infected, and your doctor may prescribe antibiotics (oral or intravenous) to treat it.

Because stingrays camouflage themselves under sand to hunt for prey, they can be hard to spot and easy to step on if you don’t know what to look for.

Once it’s been threatened, a stingray will whip its tail in defense — which can reach up and over its head — leaving a laceration or puncture wound in your skin.

When a stingray whips its tail at you, one or more of its spines may pierce your skin. The sheath around each spine then breaks apart and releases venom into the wound and surrounding tissue.

Stingrays most often sting people in their feet, ankles, and legs, but sometimes a sting may occur elsewhere on the body.

To avoid a stingray sting, shuffle your feet in the sand as you wade through shallow water. This will give stingrays a warning that you’re coming their way. Another option is to throw shells or small rocks into the water ahead of you as you wade.

If you do seek emergency medical care, your healthcare providers will closely inspect your wound. They will need to remove any debris left in the wound from the spines or the sheath.

They may take X-rays of the sting site to determine whether all the debris has been cleared. Spine and sheath fragments are visible on an X-ray.

You might receive an antibiotic via prescription or IV, as well as stitches if the wound is large or deep. You may also receive a tetanus booster.

In some cases, you might require surgery after a stingray sting to remove dead tissue or to repair a severe wound.

For most people, stingray stings heal within a few weeks. Expect localized numbness and tingling around the wound site during the healing period.

Location of the sting, amount of venom in the tissue, extent of tissue damage, and promptness of treatment will affect healing time. If you have to undergo surgery after the sting, your recovery will take more time.

Consequences of being stung by a venomous stingray

Southern stingray spines (Dasyatis americana)

Rays form one of the largest and most important groups of venomous marine animals. 2,000 stingray stings are reported annually in the US. They live in warm, subtropical and tropical waters. The favorite habitat of these passive, secretive animals is the sandy or muddy bottom of closed lagoons and estuaries, where they feed on crustaceans and molluscs.

Rays have one to four venomous stingers on the back of an elongated whip-like appendage. This tail is a cartilaginous process studded with serrated spines. It is covered with a thin layer of skin that hides two ventrolateral areas with venom glands. When the tail plunges into the prey, the epithelial lining of the glands ruptures, releasing the venom. Like other venomous fish, the shell breaks on contact with prey, allowing the venom to enter the wound. The venom contains at least 10 amino acids and toxic substances, including phosphodiesterases, 5′-nucleotidase and serotonin. When extracted, the poison is very quickly destroyed, as it is very unstable and thermolabile.

Rays only attack defensively, and this usually happens when humans inadvertently touch or step on an animal. If you touch the wings of a stingray, then it throws its tail forward, plunging it into the victim. Out of the water, a stingray can also prick a person while in a net or on a hook. There has been a documented case of injury by a person stepping on a dead, decaying animal.

Rays occasionally appear on the coast of Wales. Below is a case of a fisherman getting a lacerated wound on his lower leg from contact with a stingray.

Case description
Stingrays appeared on the coast of Wales in July 1994. An angler caught a 19 kilogram (42 lb) stingray in south Wales but was able to avoid contact with the venomous stinger. On the west coast of Wales, a fisherman caught an 18-kilogram (40 lb) stingray during a fishing event run by the Welsh Fire Department. Several colleagues helped him get the animal to shore, and, unfortunately, one of them hit the stingray, which stuck its tail into the fisherman. The sting penetrated boots (modified rubber) and trousers, tearing the shin of the left leg. The patient reported acute pain in the area of ​​the wound. Later the pain spread to the ankle. The fisherman went to the nearest emergency room. The doctor who examined him reported the incident to the Welsh National Poisons Unit, who gave advice on how to treat the injury. The wound was washed with warm water to neutralize thermolabile poisons. Then it was disinfected, and the edges of the wound were treated surgically under general anesthesia. The wound was not sutured, but bandaged, and the patient was left overnight for further observation. The patient was prescribed antibiotics, tetanus toxoid vaccine was not required. The angler was discharged the next morning and was seen by his therapist. Follow-up showed that the patient went to the emergency room again because the leg was swollen and red. The soft tissues of the leg were examined several times, and the wound healed in two months. There was an 8 cm scar on the lower leg.

Discussion
Clinical manifestation
The symptoms of the injection appear immediately. Severe pain appears in the area of ​​the wound, proportional to the severity of the injury. Swelling around the wound is constant, but its severity may vary. The wound turns blue, then erythema (violent reddening of the skin caused by capillary dilation) and petechiae (tiny hemorrhages) may appear. As a result, local tissue necrosis, ulceration, gangrene may occur. Pain peaks within 90 minutes. Without medical treatment of the wound, the pain lasts up to 48 hours. Systemic manifestations and signs can vary greatly and include nausea and vomiting, muscle cramps and fasciculations, sweating, fainting, and headaches. Cardiac arrhythmias, hypotension, convulsions and, in rare cases, death have also been reported.

Soft tissue injury from a stingray sting can be quite extensive. In addition to the stab wound, the cutting action of the spikes leads to damage and rupture of the underlying soft tissues. Most often, people injure the lower and upper limbs. Serious injuries and deaths from stings from rays are described in Cooper’s article, including fatal cases from tail strikes to the chest and abdomen. Foreign components (cartilage and epithelium) can get into the wound. Secondary infection is quite common due to the unique environment created by seawater. Pathogenic marine bacteria can be halophilic (bacteria that live in environments with high salt concentrations), heterotrophic (bacteria that need complex compounds for nutrition, since the possibilities for their synthesis are limited), motile, gram-negative. The genus of bacteria Vibrio (Vibrio) is quite common and can be very dangerous for people with weakened immune systems.

Treatment
The goal of treatment is to neutralize the local and systemic effects of the poison, reduce pain and prevent infection. The wound should be treated immediately with any available liquid. In practice, as a rule, this is sea water. Any noticeable pieces of stinger or epithelial tissue should be removed. As soon as possible, the wound should be washed with warm water (about 40 ° C) for 30-90 minutes, avoiding possible thermal damage. Heat will inactivate any thermolabile poisons. If the pain persists, it can be relieved by lavage with warm water, regional anesthesia, or wound infiltration. Vesicular fluid should be removed in a timely manner under sterile conditions. Then the wound is washed again, examined, necrotic tissues and foreign bodies are removed. With the help of X-rays, the remains of radiopaque cartilage spikes can be determined. It may be necessary to leave the wound open for a while or perform additional surgery. The prophylactic use of antibiotics is controversial, but they can be given to people who are immunosuppressed or have very serious wounds. Always remember to prevent tetanus. Patients should be observed within four hours after the injection for possible systemic reactions. Sometimes the ingestion of poison is accompanied by an allergic reaction, in which case prompt treatment of anaphylaxis is required.

Fortunately, a large number of stingrays lose or rupture the epithelial lining of glands (45% of 4000 in one study), so stingray attacks are limited to soft tissue injury without venom.
——
from: RJ Evans, R S Davies. Stingray injury. Accid EmergMed 1996;13:224-225

Treatment of bumblebee stings and allergies

Treatment of Bumblebee Bite Sites and Allergies

Provides information about bumblebee stings, advice on how to reduce the chance of being bitten, as well as information on possible reactions to the sting and treatment of the sting site. You can download a poster about bumblebee stings and allergies here.

Bumblebee, honey bee and wasp stings

Bumblebees occur naturally in many countries. In addition, bumblebees and bees are used as pollinators on agricultural and horticultural crops. There are various subspecies with different appearances, including different colors and patterns. In general, bumblebees are larger than honey bees and have more hairs than wasps.

Only worker bumblebees and queens have a sting, as is the case with honey bees and wasps. Drones can’t sting. The sting is a defensive weapon. When a bee stings, poison is injected into the wound through the sting. In humans, this causes short-term sharp pain, which then passes. Sometimes (in about 1% of cases) an allergic reaction to the injected poison develops.
The reaction to a bumblebee sting can vary.

The stinger of the bumblebee or wasp does not have notches. This means that a working bumblebee or queen can pull out the stinger and apply it again. On the sting of the honey bee there are notches. When the honey bee tries to extract the sting, it bursts out of the abdomen along with the venom gland.

How to prevent bumblebee stings?

Bumblebees rarely sting. The chance of being stung by a bumblebee can be reduced by not provoking them or making them aggressive. First of all, it is important to remain calm while working with bumblebees. Don’t wave your arms around bumblebees, hit the hive, don’t touch or hold bumblebees, etc.

Be aware that bumblebees can react aggressively to odors such as alcohol, sweat, perfumes, scented soaps, aftershave, etc. In addition, rings, bracelets and watches can cause aggressive behavior (due to the smell of oxidation between the skin and jewelry). Bumblebees are attracted to the color blue, including blue and especially light blue clothing. Protective clothing can reduce the risk of being bitten. Bumblebees can sting through clothing.

Have you been stung? Bumblebee sting reaction

Usually a bumblebee sting results in a non-allergic local reaction of swelling, itching and redness at the site of the sting, lasting only a couple of hours. This can happen immediately after being bitten, but usually starts after a few hours. Swelling and itching may persist for hours or even days. In some cases, a local reaction may spread throughout the body; in this case, it may take longer for the symptoms to disappear. This is still considered a local, non-allergic reaction.

Measures for non-allergic, local reactions

Usually no medical treatment is required. Measures can be taken to minimize the local reaction, particularly if the bite affects a sensitive area, such as near the eyes. Anti-inflammatory drugs should be taken as soon as possible after the bite. A cold compress can be applied to the bite site. In addition, there are a number of antipruritic ointments (for example, containing diethyl-m-toluamide).

In rare cases where the bite is in the mouth or throat, the victim should be taken to hospital immediately because this can lead to airway asphyxia. At the hospital, the patient will be given corticosteroids and kept under observation.

Allergic reaction

In about 1% of the population, multiple bumblebee stings (or in some cases as few as two or three stings) can lead to an allergic reaction, also called a generalized allergic reaction, a systemic allergic reaction, or an anaphylactic reaction. Since antibodies formed during previous exposure to the antigen are involved in the allergic reaction, it is not possible to develop an allergic reaction after the first bite. An allergic reaction usually occurs very soon after the bite (from a few seconds to half an hour after the bite).

Allergic reactions are divided into four levels in order of increasing severity:
Grade 1 – Itching, redness and swelling (urticaria, rash) all over the body
Grade 2 – Grade 1 symptoms and bowel problems (vomiting, diarrhea
Grade 3 – Grade 1 and/or 2 symptoms and difficulty breathing and/or choking
Grade 4 – Grade 1 and/or 2 and/or 3 symptoms and palpitations, syncope, anaphylactic shock (accompanied by dizziness, excessive sweating and chills)

Allergic Reaction Measures

In case of fever or level 1 reaction, seek medical attention. It may be necessary to follow the development of the situation. It is advisable to observe the victim in the hospital for some time, as the reaction may progress over time.

In the event of vomiting, and certainly with Grade 3 or 4 symptoms, the victim should be taken to hospital immediately.
If an allergic reaction occurs, it is useful to use an antihistamine. The antihistamine reduces tumors caused by the histamine in the venom. Sometimes corticosteroids may be prescribed. In the case of reactions of 3 or 4 degrees, adrenaline must first be administered. Adrenaline stimulates the heart, constricts blood vessels and opens the airways. Adrenaline auto-injectors are sold by prescription only, for example, if the patient has already had an allergic reaction to a bumblebee sting. Depending on local regulations, an epinephrine auto-injector may also be available from companies that work with bumblebees.

Toxic reactions

Toxic reactions only occur if the victim has been stung dozens of times in a short period. General allergic reactions may occur in the nervous or circulatory system, such as cardiac arrhythmias or breathing difficulties. In this case, the victim should be taken to the hospital for treatment and observation.

Hyperventilation

In addition to a severe grade 4 allergic reaction, hyperventilation resulting from shock can also lead to unconsciousness. In such cases, it is also necessary to immediately call for emergency medical care.

Increased risk

People who use certain medications (beta-blockers) and pregnant women are at increased risk for allergic reactions after bumblebee stings.

Bumblebee Allergy

If you’ve had an allergic reaction in the past, it won’t necessarily happen the next time you bite. The chances are especially slim if you’ve had a Grade 1 or 2 reaction. The reaction to bumblebee stings can vary from case to case. Currently, a test using purified bumblebee venom can be done to determine if you will have an allergic reaction the next time you are stung. You can also use purified poison to reduce sensitivity.

Bee venom immunotherapy does not necessarily protect patients from bumblebee sting allergy. This treatment is intended to reduce susceptibility to bumblebee venom. If you don’t want to be treated for desensitization, you can get a prescription for an adrenaline auto-injector from your doctor. It can be carried around and used to inject epinephrine into the thigh in case of a bite.

Information for physicians

Detailed information on measures to manage allergic reactions is available from Koppert upon request.
Ask your allergist or GP for more information.

Literature

A printed poster with illustrations can be ordered from Koppert. This poster is also available for download (URL).
Tip: Put on the poster the contact information for a doctor or emergency call.

This information is provided for educational purposes only and should not be used to diagnose or treat health problems as it is not a substitute for medical care.