![Page 1: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/1.jpg)
Finger injury
TS Au
PYNEH
Toxicology Case Presentation
![Page 2: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/2.jpg)
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
![Page 3: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/3.jpg)
Clinical photo
What is it?
![Page 4: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/4.jpg)
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
![Page 5: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/5.jpg)
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
![Page 6: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/6.jpg)
Stingray injury
![Page 7: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/7.jpg)
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
![Page 8: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/8.jpg)
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
![Page 9: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/9.jpg)
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
![Page 10: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/10.jpg)
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
![Page 11: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/11.jpg)
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
![Page 12: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/12.jpg)
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
![Page 13: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/13.jpg)
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
![Page 14: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/14.jpg)
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
![Page 15: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/15.jpg)
Complications
Anaphylaxis
Infections : mainly staphylococci & streptococci, other pathogens are not uncommon: Aeromonas species in freshwater or Vibrio species in saltwater
![Page 16: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/16.jpg)
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)
![Page 17: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/17.jpg)
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
![Page 18: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/18.jpg)
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)
![Page 19: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/19.jpg)
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
![Page 20: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/20.jpg)
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)
![Page 21: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/21.jpg)
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
![Page 22: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/22.jpg)
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.
![Page 23: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/23.jpg)
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.
![Page 24: Finger injury TS Au PYNEH Toxicology Case Presentation](https://reader030.vdocument.in/reader030/viewer/2022032702/56649ce25503460f949ad1fd/html5/thumbnails/24.jpg)
Thank you