Case reports

Mebs 1980: 1 case; Potamotrygon motoro.

Australia
Cross 1976: 1 case; not identified.
Fenner et al. 1989b: 4 serious cases, 1 of which ended fatally; not identified. Summary of 100 minor stingray injuries.
Wright-Smith 1945: 1 case, which ended fatally; not identified.

Baja California
Halstead and Bunker 1953: 2 cases, both of which ended fatally; Holorhinus californicus 1/2, Aetobatus narinari 1/2.

New Zealand
Liggins 1939: 1 case, which ended fatally; not identified.

Japan
Ikeda 1989: 1 case; Dasyatis akajei.

Papua New Guinea
Barss 1984: 2 cases; Dasyatis kuhlii 1/2, not definitely identified 1/2.
Cadzow 1960: 1 case; not identified.

Seychelles
Grainger 1980: 1 case; Dasyatis sp.

Solomon Islands
Cross 1976: 1 case; not identified.

Suriname
Rathjen and Halstead 1969: 1 case; not definitely identified: Dasyatis violacea?

USA
Russell et al. 1958: 2 cases; Dasyatis longus 1/2; not identified 1/2; both cases ended fatally.

Venezuela
Horn and Wassilew 1988: 1 case; Potamotrygon sp.

West Atlantic
Rathjen and Halstead 1969: 1 case; Himantura schmardae (= Dasyatis schmardae) (Werner).

Signs & symptoms

Stingray venom contains venom components that can induce severe pain and cause local tissue necroses.

Local injury: superficial or deep puncture wounds or lacerated wounds.

Injury to internal organs with or without additional damaging effects of venom have been described. Penetration of the spine into the pericardial cavity with subsequent toxic myocardial necrosis, ventricle perforation, cardiac tamponade and death 6 days after the accident (Fenner et al. 1989b). Penetration of the pleural cavity (Barss 1984). Penetration of the abdominal cavity (Cross 1976). Penetration of the liver (Cadzow 1960).

If the spine breaks off, parts of it may remain in the wound, as may other foreign matter, and, in addition to causing local toxic effects and bacterial infections, can lead to poor wound healing and extensive necroses (Brass 1984, Fenner et al. 1989b, Halstead and Bunker 1953, Horn and Wassilew 1988).

Local effects

Stingray venom contains venom components that cause extensive necroses. It is important to bear this in mind in particular with deep injuries in which the venom may be introduced into regions that are inaccessible for inspection. The death of a child 6 days after a sting came about in this manner (see above; Fenner et al. 1989b). Extensive, deep necroses that may be missed on superficial inspection of the wound can also occur with soft tissue injuries, e.g. of the extremities. For this reason, in addition to the removal of foreign matter, it is necessary to carry out surgical examination of the wound (see below; Barss 1984, Fenner et al. 1989b).

Wound infections: tetanus, which was fatal (Rathjen and Halstead 1969). Extensive, untended wound with consequent osteomyelitis (Fenner et al. 1989b).

Systemic effects

Supraventricular bigeminy, commencing 25 min after the sting, duration approx. 15 min. This cardiac dysrhythmia was attributed to a systemic effect of the venom (Ikeda 1989).

Morbidity

Wound infections, including tetanus (Fenner et al. 1989b, Rathjen and Halstead 1969), necroses (Barss 1984, Fenner et al. 1989b). Sequelae from injury to internal organs, nerves and vessels (Fenner et al. 1989b, Barss 1984, Cross 1976, Cadzow 1960).

Case fatality rate

Fatalities due to wound infections (tetanus) and injury to internal organs (Fenner et al. 1989b, Liggins 1939, Rathjen and Halstead 1969, Russel et al. 1958, Wright-Smith 1945).

First aid and treatment

Immersion of the affected extremity in water as hot as can be tolerated, especially if it is not possible to get immediate medical assistance (water temperature approx. 45°C, temperature should be checked by a companion or with a healthy extremity in order to avoid burns, duration of treatment if necessary >30 min). Stingray venom, which, in addition to the physical injury, is responsible for pain and tissue destruction, is believed to be heat-labile. It is assumed that the hot water treatment may have an inactivating effect on the venom. However, this method is controversial, due to the risk of additional tissue damage. Its efficacy has not yet been documented in a controlled study.

Symptomatic treatment

Pain

Injection of a local anaesthetic without the addition of a vasoconstrictor (lignocaine 1%) directly into and around the wound (Fenner et al. 1989b). Nerve block anaesthesia with lignocaine 1% or preferably bupivacaine because it has a longer duration of action (Dormon 1985).

Injury

X-ray examination to find foreign matter (parts of the spine) that may be buried deep in the wound.

Wound exploration in order to remove foreign matter (parts of the spine and the spine sheath). Wound exploration must be carried out along the entire wound to the depth to which the spine penetrated. It must be ensured that the spine did not penetrate the abdominal, pleural or pericardial cavities and that no internal organs, vessels or nerves were injured. Laparoscopy/laparotomy or thoracoscopy/thoracotomy may be necessary.

Removal of foreign matter, wound cleaning with hexachlorophene in 70% alcohol. Possibly also drainage of the wound and leaving it open to granulate. Tetanus prophylaxis. Antibiotic treatment in the case of an extensive wound, if more than 6 hours have elapsed since the accident occurred or if there is a clinically evident wound infection.

Regular wound inspection and dressing changes until the wound has healed fully (Grainger 1985, Fenner et al. 1989b).