FIRST AID AND MEDICAL MANAGEMENT
OF STINGRAY TRAUMA -- ENVENOMATION
Although stingray injuries are more common than one would expect, deleterious sequelae are a rarity thanks to quick and careful disinfection of the wound, preferably under medical or veterinary supervision. Professional assistance is necessary to make sure there are no traces of venom left at the site by assuring that any remaining parts of the integumentary sheath or broken spine pieces are removed, surgically if necessary. These can be visualized by x-ray.
First-Aid measures include the following essential steps:
1. Control any visible hemorrhage; if a blood vessel is pierced, apply hard direct pressure, regardless of how painful that might be, over the source of the bleeding.
2. Do not apply a tourniquet or pressure bandage on the entire limb; widespread swelling and systemic effects are unlikely in limb bites.
3. Immediately place the bitten spot into water as hot as one can stand; caregivers might test it before placing the victim's sting in it. This should quickly help to lessen pain, and the area should remain immersed until pain subsides.
4. Disinfect the area immediately on removal from hot water. The sting area can be treated with Betadine [tm] solution and scrubbed with a soft bristle brush with clean cool water and a mild disinfectant soap, such as Phisohex [tm] or similar preparation.
5. Seek medical help even if the bite is considered trivial. The site should, at the very least, be x-rayed for the presence of broken spines and spine barbs.
Medical care measures include the following essential steps:
1. Treating physicians can use an infiltrating injection of 1% lidocaine to control pain if indicated. The lidocaine infiltration can be made directly into the sting or wound. Curiously, this technique has proved to be helpful in minimizing tissue necrosis, although the mechanism is not clear.
2. If unbearable pain persists, the victim may require a regional nerve block, which should be performed by an anesthesiologist under controlled conditions.
3. The wound area should be radiographed for the presence of spine and barb fragments.
4. If the radiology results are positive or suggestive, the wound should be explored under anesthesia. The use of an operating microscope is helpful in confirming the presence of the sheath and smaller fragments, as well as aiding in their removal.
5. The area should be left open to granulate and sutures should not be used, or used loosely if surgery requires
6. The patient should be observed in the hospital overnight for symptoms and signs of allergy, and these treated accordingly.
7. Tetanus prophylaxis should always be given, unless recently boostered.
8. Patients should be discharged on a broad-spectrum antibiotic such as is recommended for cutaneous lesions
9. If the patient is hospitalized, antibiotics can be loaded by injection or via an IV administration until discharge. The most troublesome expected sequelae of this type of sting are tissue necrosis and secondary bacterial infection.
10. All penetrating wounds of the trunk (as mentioned previously) must be thoroughly worked up. The patient should be admitted to the hospital and given IV antibiotics immediately. Insidious necrosis and bacterial infection of internal organs in the vicinity of such stings is a possibility, and can be a fatal result of such wounds, sometimes days or even weeks after the initial incident. Symptomatology may be absent until infection and tissue destruction become overwhelming. At this point, little or no result from medical intervention can be expected.
11. Penetrating stings to the chest in the region of the heart should be evaluated by echocardiography. The presence of even a small pericardial effusion may indicate pericardial and possibly myocardial penetration. Such cases should also be followed on the basis of serial laboratory studies of cardiac enzymes such as creatine kinase. CK levels have risen to high levels within 8 hours of penetration, but even this evidence may present itself critically late for meaningful intervention. A decision may need to be reached to open the chest and disinfect and clean the area of penetration prior to the possibility of cardiac muscle destruction.