Finger injury

TS Au

PYNEH

Toxicology Case Presentation

Case presentation

M/32 good PH Rt M/F finger injury – stung by the tail of a

fish while washing the fresh water tank at home at 3AM

Intense burning sensation with numbness, & acute swelling at the involved finger

Triage : BP 109/49, Pulse 86 , Temp 36.1 , RR 16/min (at 03:33) – Cat. IV℃

ATT first dose given

Clinical photo

What is it?

Progress in AED

Pethidine IMI (pain not relieved) Rt hand immersed in hot tap water as

tolerated as possible → immediate effect but not long-lasting until 75 min

XR of right M/F: no FB seen No FB seen at wound exploration Antibiotic: ciproxin 500 mg BD started

Progress

Stayed at O ward till next day Pain can now be tolerated Swelling: slightly decrease in size Discharged with dologesic, piriton, &

ciproxin and continue QD dressing in GOPD

Stingray injury

Stingray (魔鬼魚 )

Widely distributed in tropical to temperate waters

Not aggressive Injury usually occurs when a swimmer or

diver accidentally steps on it One of the most common dive- and beach-

related injuries

Pathoanatomy

A flat body + a long slender tail with sharp serrated spines (stingers)

There are 1 or more barbed stingers and 2 ventrolateral venom-containing grooves that are encased in an integumentary sheath

Stinger apparatus injects a heat labile protein-based toxin

Injury may occur without envenomation because many stingrays lose or tear the sheath of the venom glands

Clinical features (local)

Immediate and intense pain radiating up proximally and lasting up to 48 hours

Edema, erythema, petechiae Local skin necrosis, extent depending on

different species and areas

Case reports

2 cases of extensive tissue necrosis: reported in Australia (Barss P, 1984), wound exploration and debridement required

1 case of femoral pseudoaneurysm (Campell J, et al, 2003) with graft failure due to tissue necrosis, repair surgery finally required

Clinical effects (systemic)

Systemic effects of envenomation: nausea & vomiting, abdominal cramps, diaphoresis, dyspnoea, syncope, headache, convulsion, muscle weakness, muscle fasciculations, hypotension, & arrhythmia

Rarely fatal: due to profuse wound bleeding or direct penetration to vital organs

Fatal case

One fatal case was reported in Australia due to penetrating chest wall injury of a M/12 resulting in cardiac tamponade (Fenner PJ, et al, 1989).

Venom-induced myocardial necrosis occurred, leading to spontaneous myocardial perforation 6 days after injury

Stingray Envenomation – 1

Study of clinical effects in 84 cases of freshwater stingray injuries in Brazil (Haddad Jr V et al, 2004)

Intense pain – commonest symptom Tissue necrosis – high percentage, mostly

fishermen Tx of immersion in hot water was effective

in initial phase of envenomation; but this does not prevent skin necrosis

Stingray Envenomation – 2

Chemical analysis of a fresh water stingray (Potamotrygon falkneri) extract was done by polyacrylamide gel electrophoresis (PAGE)

Consists of multiple components of high molecular weight, (12 kDa – 100 kDa) with gelatinolytic, caseinolytic & hyaluronidase activities

The result showed the local clinical features can be partially explained by these enzymes

Complications

Anaphylaxis

Infections : mainly staphylococci & streptococci, other pathogens are not uncommon: Aeromonas species in freshwater or Vibrio species in saltwater

Investigation

Plain X Ray: Identify any FB, e.g. retained spine(s),

which are typically radio-opaque. (Perkins RA, 2004)

Clinical picture: a spine removed from a wound (different pt)

Management – aim

Resuscitate for anaphylaxis Aims to reverse the local and systemic

effects of the venom: pain relief and prevention of infection

Other considerations: antitetanus prophylaxis

Management – Pain relief

Immersion of the injured extremity in hot water, preferably 42-45°C (110-115°F) as hot as the patient can tolerate but should not cause burns

Immersion duration: 30 – 90 minutes: need to add more hot water as it cools

Evidence level C: expert opinion/consensus guidelines (Isbister G K. Am J Em Med, 2001)

Management – Wound Tx

- Flush wound with fresh water (prehospital)

- Removal of any FB: spine / sand

- Debridement: prevent secondary infection

- Avoid primary suturing

- Daily dressing

- Tetanus prophylaxis

- Antibiotics

Antibiotic prophylaxis

Optimal coverage for Staphylococci, Streptococci, and pathogens expected in the involved water:

1. Freshwater: Aeromonas species 2. Saltwater: Vibrio species

Antibiotics of choice: quinolones (ciprofloxacin, levofloxacin), doxycycline, septrin, cefuroxime or other late-generation cephalosporins

Duration: a short course (5 days)

Heat treatment – widely accepted as effective initial Mx for envenomation of :

Scorpaenidae: 1. Lionfish

2. Scorpionfish

3. Stonefish Echinoderms Other venomous spine injuries

Low

High

Toxic potency

References – 1 www.emedicine.com Barss P. Wound necrosis caused by the venom of

stingrays. Pathological findings and surgical management. Medical Journal of Australia 1984; 141: 854-5.

Campell J, Grenon K, You CK. Pseudoaneurysm of the superficial femoral artery resulting from stingray envenomation. Annals of Vascular Surgery 2003; 17(2): 217-220.

Fenner PJ, Williamson JA, Skinner RA. Fatal and non-fatal stingray envenomation. Medical Journal of Australia 1989; 151: 621-5.

References – 2 Haddad Jr V, et al. Freshwater stingrays: Study of

epidemiologic, clinic and therapeutic aspects based on 84 envenomings in humans and some enzymatic activities of the venom. Toxicon 2004; 43(3): 287-294.

RJ Evans, RS Davies. Stingray injuries. Journal of Accident and Emergency Medicine 1996;13:224-5.

R Allen Perkins, Shannon S Morgan. Poisoning, envenomation, and trauma from marine creatures. American Family Physician 2004; 69(4): 885-890.

Isbister GK. Venomous fish stings in tropical northern Australia. American Journal of Emergency Medicine 2001; 19: 561-5.

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