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Finger injury

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

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Finger injury

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  1. Finger injury TS Au PYNEH Toxicology Case Presentation

  2. 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

  3. Clinical photo What is it?

  4. 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

  5. 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

  6. Stingray injury

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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) withgelatinolytic, caseinolytic & hyaluronidase activities • The result showed the local clinical features can be partially explained by these enzymes

  15. Complications • Anaphylaxis • Infections : mainly staphylococci & streptococci, other pathogens are not uncommon: Aeromonas species in freshwater or Vibrio species in saltwater

  16. 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)

  17. 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

  18. 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)

  19. 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

  20. 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)

  21. 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

  22. 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.

  23. 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.

  24. Thank you

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