headache, syncope, seizures, inguinal or axillary pain, muscle cramps, fasciculations, generalized edema (with
truncal wounds), paralysis, hypotension, arrhythmias, and death. The paralysis may represent spastic muscle
contractures induced by pain, which are a tremendous hazard for a diver or swimmer.
The success of therapy is largely related to the rapidity with which it is undertaken. Treatment is
directed at combating the effects of the venom, alleviating pain, and preventing infection. If hot water for
immersion and irrigation (see below) is not immediately available, the wound should be irrigated immediately
with non-heated water or saline. If sterile saline or water is not available, tap water may be used. This
removes some venom and mucus, and may provide minimal pain relief.
As soon as possible, the wound should be soaked in nonscalding hot water to tolerance (upper limit
113
o
F or 45
o
C) for 30 to 90 minutes. This might attenuate some of the thermolabile components of the
protein venom (although this has never been proven in vivo) and/or interrupt nerve impulse transmission, and
in some envenomations, relieves pain. There is no indication for the addition of ammonia, magnesium sulfate,
potassium permanganate, or formalin to the soaking solution. Under these circumstances they are toxic to
tissue and may obscure visualization of the wound. During the hot water soak (or at any time, if soaking is not
an option), the wound should be explored and debrided of any readily visible pieces of the sting or its
integumentary sheath, which would continue to envenom the victim. Cryotherapy is disastrous, and no data
yet support the use of antihistamines or steroids. One local remedy, application of half a bulb of onion directly
to the wound, has been reported to decrease the pain and perhaps inhibit infection following a sting from the
blue-spotted stingray Dasyatis kuhlii. The author noted that this approach is used in the Northern Territory of
Australia for other fish spine stings, and that the medicinal use of the Liliaceae plant family has been recorded
in many cultures. No other folk remedy, such as the application of macerated cockroaches, cactus juice,
"mile-a-minute" leaves, fresh human urine, or tobacco juice, has been proven effective.
Local suction, if applied in the first 15 to 30 minutes, has been suggested by some clinicians to be of potential
value (this is controversial), as may a proximal constriction band (also controversial) that occludes only
superficial venous and lymphatic return. This should be released for 90 seconds every 10 minutes to prevent
ischemia.
Pain control should be initiated during the first debridement or soaking period. Narcotics may be
necessary. Local infiltration of the wound with 1% to 2% lidocaine (Xylocaine) or bupivicaine 0.25% (not to
exceed 3 to 4 mg/kg total dose in adults; not approved in children under the age of 12 years) without
epinephrine may be useful. A regional nerve block may be necessary.
After the soaking procedure, the wound should be prepared in a sterile fashion, reexplored, and
thoroughly debrided. Wounds should be packed open for delayed primary closure or sutured loosely around
adequate drainage in preference to tight closure, which might increase likelihood of wound infection. Another
approach that has been mentioned is wound excision followed by packing with an alginate-based wick
dressing. Prophylactic antibiotics are recommended because of the high incidence of ulceration, necrosis, and
secondary infection. Necrotizing fasciitis due to Vibrio alginolyticus has followed stingray injury in a victim
with preexisting hepatic cirrhosis. If the abdominal cavity is penetrated, the victim should receive cefoxitin or
clindamycin-gentamicin intravenously in addition to any antibiotic(s) chosen to cover marine microbes.
If the treatment plan is to treat and release, the victim should be observed for at least 3 to 4 hours for
systemic side effects.
Wounds that are not properly debrided or explored and cleansed of foreign material may fester for
weeks or months. Such wounds may appear infected, when what really exists is a chronic draining ulcer
initiated by persistent retained organic matter. Within the first few weeks after an envenomation, a foreign
body can sometimes be observed by soft tissue radiograph, ultrasound, or magnetic resonance imaging. After
a few weeks, exploration may reveal erosion of adjacent soft tissue structures and the formation of an
epidermal inclusion cyst or other related foreign body reaction. As with other marine-acquired wounds,
indolent infection should prompt a search for unusual microorganisms. A case of invasive fusariosis
(Fusarium solani) after stingray envenomation responsive to sequential debridement and ketoconazole (the
latter of indeterminate effect) has been reported.
Scorpionfish
Scorpionfish are members of the family Scorpaenidae and follow stingrays as perpetrators of piscine
stings. Distributed in tropical and less commonly in temperate oceans, several hundred species are divided
