Stingray Injury

Underwater image of a stingray.

Stingrays do not actually attack. Injuries from these shark-like creatures are usually defensive actions.

Once disturbed, their venomous stinger (spine) near the base of their tails lashes out and can cause punctures or lacerations (cuts). Their mouthparts do not cause injury, but a hickey can occur if they try to suck you.

Stingrays are aquatic, cartilaginous vertebrates who are members of the shark family. They have flat bodies and winglike fins. Stingrays are nonassertive and can be found lying in the sand in shallow water at the beach or swimming free in open waters. Most are saltwater creatures, but a few live in freshwater.

• In 1608, Captain John Smith, the explorer who founded the Jamestown settlement, was injured by a stingray in the Chesapeake Bay.
• Annually, about 1,500 stingray-induced injuries occur in the United States.

Most stingray injuries typically occur when a person accidentally steps on a ray as it lies on the shallow, sandy bottom of a beach area. Rays often cover themselves with sand for camouflage while resting or hiding from predators, so they can be hard to see.

When stepped upon or harassed, they swing or arch their tail in the direction of the intruder as a defensive maneuver to protect themselves. This drives their spine into the unwanted intruder. The ray’s tail can reach all the way to the front of its head for protection.

People who step on a stingray most frequently are injured on their feet and lower legs. Hands and arms can be injured if a person tries to touch or catch one.

• A fisherman, for example, can be injured removing a stingray from a net or fishing line.
• In rare cases, the stingray's powerful spine has penetrated a person's abdomen or chest causing severe injury.
• Rays found in home aquariums can cause injuries.
• You can prevent injury by shuffling your feet while walking or wading through water to startle and shoo them away. Wearing footwear such as sneakers or dive booties may not help because the spine can penetrate them.
• Don't try to chase or ride a stingray.
• If you have hooked one, cut the line and release it. A seemingly dead ray can whip its tail in defense and cause an injury.
• Certain rays, such as skates and manta rays, do not have a stinger at the base of their tails and are harmless.
• Some rays in marine parks are friendly because they have become used to humans, and you can touch them. These rays are more likely to give you a hickey from the suction action created by their mouths when trying to feed on your hands. Venom is only located in the tail spine.

The stinger, or spine near the base of the tail, is hard and sharp with backward-pointing barbs (retroserrations) that can cause a jagged cut. It can be difficult to remove from a wound because of the back-facing barbs. There can be one to four spines at the base of the ray’s tail depending on the species.

A skin-like covering, the sheath, over the stinger encloses the venom glands. The spine lies in a groove along the tail. Injury from a stingray can damage a person's muscles or tendons in addition to the cut or puncture wound. Part of the sheath and spine can be left in the wound. The venom is composed of many different substances that cause tissue to break down and die as well as cause severe pain.

The toxins contained in the sheath can cause the following symptoms:

• Immediate and severe pain radiating up the limb and lasting up to 48 hours
• Swelling in the wounded area
• Bleeding from the wound
• Color change in the area of injury -- first dusky blue, then red
• Sweating
• Low blood pressure
• Faintness, weakness, dizziness
• Salivation, nausea, vomiting, diarrhea
• Headache
• Shortness of breath
• Seizure
• Muscle cramps and pain, paralysis
• Heart rhythm irregularities
• Death, though rare, has been reported from a puncture of the heart or abdomen and from loss of blood.

Because stingray injuries usually hurt so much, medical attention is definitely needed. Pain management, wound care, a tetanus vaccine update, and antibiotics are the most likely treatments.

• Seek medical care if generalized symptoms, such as faintness or sweating, are felt. These symptoms indicate that venom has been absorbed.
• If the injury does not hurt, but you need a tetanus booster, then medical attention should be sought.
• If you have redness, swelling, infection, or delayed healing, seek medical attention.

In most cases, a stingray injury should be handled in a hospital's emergency department. If the injured person is in severe distress with pain, bleeding, vomiting, and faintness, then 911 should be called for ambulance transport to a medical facility.

• Transport by ambulance, if available, is the best choice so treatment can be started en route. If an ambulance is not available, go by car. If a boat ride is needed to shore, call ahead to arrange an ambulance or car for transportation to a medical facility.
• A tetanus booster is needed if it has been more than 5 years since the last tetanus booster. Tetanus prevention is needed if the person has never had a tetanus vaccination.

Rapid evaluation and entry into the treatment area of the emergency department may be needed, especially if the stinger penetrated the person's head, chest, or abdomen.

Typical steps in diagnosing the extent of the stingray injury are as follows:

• Blood pressure and pulse are checked.
• The doctor performs an initial examination to see if resuscitation (help in breathing) is needed.
• The doctor treats the pain and takes care of the wound.
• Once the injured person is stable, X-rays may be taken if the doctor thinks foreign matter or parts of the stingray's sheath and spine remain in the wound.
• Blood tests are usually not needed.

Care of the injured person begins at the scene and is first directed at safe rescue and removal of the victim from the water.

A stingray injury that does not need to be checked by a doctor is rare.

• Home first aid measures should be started, but a medical evaluation is also warranted.
• Lay the person down.
• If the person is vomiting, position the person on the side so they do not inhale vomit.
• Stop the bleeding by applying direct pressure with a clean cloth or whatever is available such as a beach towel.
• You may attempt to remove the stinger with tweezers to decrease toxin exposure if doing so will not cause further injury. Be careful not to injure yourself with the stinger.
• If there is no pain, then treat it as a puncture wound or laceration by cleaning and disinfecting with soap and water.
• If there is pain, bleeding, or more than a minor wound, and symptoms such as faintness or sweating (which indicate that venom has been absorbed into the body), arrange for transportation to a medical facility.
  • If in a remote area, treat the pain by immersing the injured area in water as hot (but not burning) as the person is able to tolerate (113 F or 45 C) for 30-90 minutes. This neutralizes the painful effects of the venom because the venom is inactivated by heat.
  • Oral pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil) can be given if the person is not vomiting and not allergic to it.
• If you belong to Divers Alert Network (DAN), call their emergency number to obtain medical evacuation assistance and arrange for referral to a medical care facility. Your DAN membership card has details.

Stingray injury care is mainly directed at monitoring the injured person's vital signs, providing pain relief, and treating the wound.

• Vital signs: Treatment for abnormal vital signs is the first step.
  • If blood pressure is low, fluids are given through an IV.
  • Additional medications may be needed to maintain proper blood pressure.
  • Sometimes, hospitalization is required if the person is very ill.
• Pain: There is no antivenom (antidote) to stingray toxin. The venom is a protein and is broken down by heat, so placing the injured area in water as hot as the person can tolerate (113 F or 45 C) for 30-90 minutes can dramatically relieve the pain. A word of caution: Once the area is numb, care must be taken to prevent a burn injury from the hot water.
  • Pain medication, such as narcotics, given through an IV may be needed until the heat has neutralized the toxin.
  • Numbing medications injected into the injured area help to relieve the pain and allow the doctor to explore the wound to look for injuries to structures below without causing further pain.
• Wound care: The doctor cleans the wound, removes foreign matter, and looks for injuries to tendons, nerves, blood vessels, and other body structures. If it has been more than 5 years since the last tetanus booster, one should be given.
  • Antibiotics are usually given because the wound is contaminated with bacteria from the stinger and from the seawater. The doctor needs to consider the specific types of marine organisms that caused the injury when choosing the antibiotics used to treat this wound.
  • The wound might be left open, then closed with stitches a few days later if it has not become infected. If the wound is repaired on the initial visit, it is usually closed loosely to allow any infection to easily drain.
  • If important structures, such as nerves, tendons, or arteries, are damaged, then a surgeon (such as a hand specialist) needs to be consulted to assist in the management of the wound. Cleaning and repair in the operating room may be needed.

Stingray injury wounds usually require re-cleaning on a daily basis with soap and water and then application of an antibiotic ointment and dressing.

• If antibiotics are prescribed, take them as directed.
• If your wound becomes infected, have it rechecked.
• Keep any follow-up appointments that have been scheduled.

To prevent stingray injury, don't purposely harass or handle a stingray. When wading in shallow waters where stingrays may be, wear foot protection and shuffle your feet to scare away any resting rays.

With early medical care, serious symptoms and pain can be relieved. Follow-up is required to check for additional complications. The wound will probably require more than one visit to treat depending on how severe it is.

Referral for reevaluation or to perform a delayed repair may be advised for the following reasons:

• Wounds are often slow to heal.
• Pieces of the spine’s integument (coating) may remain in the wound.
• Additional tissue damage can happen from tissue break down.
• Delayed infections can occur.
• Patience, time, and proper medical care help limit the damage from this injury.

Picture of a spotted eagle ray (stingray)

Stingray spine. It is clear why these can cause either a puncture wound or a slashing laceration. The size of the spine depends on the size and type of the stingray. Toothpick to pencil size is typical. Photo courtesy of Cecil Berry

Picture of stingray spine, photo courtesy of Cecil Berry