In patients with freshwater stings in Brazil, hot water immersion was found to help reduce pain but did not decrease rates of skin necrosis. Only 2% of patients required additional pain control at discharge. Oral NSAIDs or opioids were used concurrently with hot water immersion in the other 10% of patients. Another retrospective study found that hot water immersion alone provided effective pain relief in 9 out of 10 patients. A small prospective study found that hot water immersion alone resulted in statistically significant pain reduction. Hot water immersion should be initiated as soon as possible, ideally in the field by lifeguards or paramedics.
Water should be heated to a temperature that will not result in burns, and the temperature should be tested on a non-affected extremity, as the patient may have impaired sensation on the injured extremity. Stingray venom is heat-labile and can be inactivated by heat.
The standard treatment for stingray injuries is hot water immersion. The most common venomous effect is severe pain, but the venom can also cause headaches, diaphoresis, vertigo, nausea, vomiting, diarrhea, syncope, muscle cramps, fasciculations, dyspnea, cardiac arrhythmias, hypotension, and seizures. The sheath of the barb can also remain in the patient's skin, which may require debridement for removal. In most cases, these wounds are minor, but there are reports of arterial or spinal cord injury related to stingray wounds. First, the barbs pierce through the skin, causing a laceration or puncture wound. The mechanism of stingray stings includes both mechanical and venomous injury. One way to prevent this is to slide or shuffle through the sand instead of walking. Human injuries are most common on the extremities of swimmers and divers and those who accidentally step on a stingray. However, when attacked by a predator or stepped on, the ray will use its tail to puncture and envenomate its potential attacker. In fact, the primary defensive action of the stingray is simply to swim away from the area. Stingrays are not known to be aggressive, nor are they known to act defensively. In the United States and Indo-Pacific nations, fatalities related to stingray injuries occur one to two times a year, compared to fatality rates up to 8 per year in South American nations related to Amazonian stingrays. The majority of stingray injuries have low morbidity, with higher rates of serious injuries and complications in freshwater stings compared to marine stings. The most common site of injury is the lower extremities, followed by the upper extremities. In a prospective study of freshwater stingray injuries in Brazil, 80% to 90% of the injuries were in men. In one retrospective review of 119 cases seen in a California emergency department over 8 years, 80% of stingray victims were male, with an average age of 28 years (range 9 to 68 years old). There are estimated thousands of cases per year in tropical regions with freshwater stingrays that occupy inland rivers. In the United States, there are approximately 750 to 2000 stingray injuries reported annually. Stingrays often feed in or near coral reefs, causing frequent human injuries. There are over 150 species of stingray worldwide, ranging in size from inches to 6.5 feet and in the larger species weighing as much as 800 pounds. Stingrays are very common throughout tropical marine waters and freshwaters.
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