Stingray envenomation Stingrays are another source of marine envenomation. The stingray is not aggressive, but it has a venomous barb on its tail used for self-defense. The broad-bodied flat fish can hide in sandy shallow water, and injury often occurs when the fish is stepped on. The stingray thrusts its tail at the victim, resulting in a puncture wound or laceration from the serrated barb, and venom is injected resulting in excruciating pain. The barb may be left in the wound. Systemic symptoms may occur, usually as a result of severe pain.


Heat reduces the pain and should be provided immediately, either by immersing the affected area in water or applying a hot compress. The temperature should be kept between 100°F and 115°F, for 60 to 90 minutes. When heat is not sufficient for pain control, narcotic pain medications may be indicated. Some providers inject the wound with either lidocaine and/or bupivicaine for local anesthesia.5


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Other important aspects of care include assessing the wound for a retained foreign body, which may require radiology, updating tetanus prophylaxis, and appropriate wound care. The possibility of wound infection should be considered. If antibiotic prophylaxis is given, it should cover the usual Gram-positive skin organisms such as staphylococcal and streptococcal species, along with potentially dangerous vibrio species. 


A puncture wound resulting from a stingray can be treated with heat, narcotic pain medications, lidocaine, or bupivicaine.

Beach-related wounds

Bare feet are common on the beach, and when feet are bare lacerations and puncture wounds occur. In general, such wounds are treated as all wounds are, with careful cleaning, including irrigation, repair as appropriate, and tetanus prophylaxis. 

There are some special considerations for beach-related injuries, though. Some shells, especially oyster shells, are both sharp and brittle, often leaving embedded foreign bodies in deeper wounds. These foreign bodies are generally radio-opaque, so an x-ray can be helpful for finding them. Special care to debridement, wound cleansing, and foreign body removal can help prevent serious wound infections.


Infection Vibrio vulnificans is a motile Gram-negative organism common in warm waters off the Atlantic and Gulf Coasts. It can cause a rapid and often fatal wound infection in immune-compromised patients, especially those with alcoholism and chronic liver disease. This infection presents with cellulitis, hemorrhagic bullae, and severe systemic symptoms including high fever and hypotension, sometimes within hours of injury. 

When treating wounds that have been exposed to potentially contaminated seawater, careful history taking and, when indicated, aggressive antibiotic infection prophylaxis, is crucial. Appropriate coverage for this organism includes either doxycycline with a third-generation cephalosporin, or a fluoroquinolone such as ciprofloxacin.


In summary, fun at the beach exposes patients to several hazards, some avoidable, such as sunburn, and some less so. Knowledge about these conditions, their causes, and their treatment improves the safety, comfort, and care of our patients.


Deborah L. Morris, PA-C, MD, is the academic coordinator at the Methodist University Physician Assistant Program in Fayetteville, N.C.


References


  1. Driscoll M, Wagner R. Clinical management of the acute sunburn reaction. Cutis. 2000;66(1):53-58.

  2. Moore C, Cevikbas F, Pasolli HA, et al. UVB radiation generates sunburn pain and affects skin by activating epidermal TRPV4 ion channels and triggering endothelin-1 signaling. Proc National Acad Sci U S A. 2013;110(34) E3225-E3234. 

  3. Conover K. Earache. Emerg Med Clin North Am. 2013;31(2):413-442. 

  4. Li L, McGee RG, Isbister G, Webster AC. Interventions for the symptoms and signs resulting from jellyfish stings. Cochrane Database Syst Rev. 2013; Dec 9;12:CD009688.

  5. Clark RF, Girard RH, Rao D, et al. Stingray envenomation: A retrospective review of clinical presentation and treatment in 119 cases. J Emerg Med. 2007;33(1):33-37.