Transcript Stone fish injury

A painful swollen thumb
Dr. Law chi yin
PYNEH A&E
A painful swollen thumb
A lady age around 60
Sudden severe thumb pain for one hour
after stung by a fish spine while preparing
the fish for dinner
The fish was caught by her son in the
nearby pier
Her son said that the fish was a stonefish
A painful swollen thumb
Would you believe him?
Could he catch a stonefish near a pier in
Hong Kong?
Was the severe thumb pain due to
stonefish envenomation?
A painful swollen thumb
On examination:
– Blood pressure and pulse were stable
– Marked swelling of her left thumb and hand
noted
– Mild redness and hot only
– No foreign body found in the wound
The lady’s injury hand
The lady’s injury hand
The lady’s injury hand
Treatment given in A&E
ATT
Analgesic injection
Warm water bath
Kept in observation ward
– Symptoms
– Vital signs
– Monitoring size of swelling
Asked her son to bring back the fish body
for examination
A painful swollen thumb
Two hours later
The fish body was brought to A&E
The size was just as the length of a tongue
depressor
The fish body looked like a stone
The secret fish
The secret fish
The secret fish
The color was brown and grey
Mouth and eyes point upward
The dorsal spines were cut by the lady
What was the secret fish?
stonefish
Identification Guide to
Fishes in the Live
Seafood Trade of the
Asia-Pacific Region.
Published by
– WWF Hong Kong
– Agriculture, Fisheries and
Conservation Department.
Hong Kong
stonefish stung injury
Swelling and pain persisting despite warm
water bath
Skin blister found near puncture site
Swelling extend up to forearm
no muscle weakness, dyspnea and
hypotension
stonefish stung injury
Blister was clear, no pus
Aspiration done in observation,
Oral ciprofloxacin started
stonefish stung injury
Pros and cons of Stonefish antivenom
discussed
She refused antivenom for fear of possible
allergic reaction
stonefish stung injury
Pain and swelling static during observation
She was discharged with oral antibiotic
Follow up 3 days later
stonefish stung injury
She came back 10 hours later after
leaving A&E
pain and size of bulla increasing
No evidence of tendinosynovitis
Distal pulse and capillary circulation was
good
She was admitted to orthopedic ward for
puncture site cellulitis
stonefish stung injury
Management in orthopedic ward
– Wound dressing
– IV antibiotic
– Patch of superficial skin necrosis noted on
day 3, no debridement done
– Pain and swelling subsided with conservative
treatment
– No antivenom given
What is stonefish and its
venom?
Venomous marine fish
Family Scorpaenidae
– Pterois - lionfish
– Scorpaena – scorpionfish
– Synanceia - stonefish
stonefish
The most venomous
fish in the world
13 dorsal spines
contains venom.
The severity of the
envenomation
depends on the depth
and number of
penetration
stonefish
stonefish envenomation killed many
Pacific and Indian Ocean islanders in preantivenom period.
1st antivenom developed in 1959
stonefish venom
3 deaths reported in the literature
1 case direct intravascular envenomation
(Mozambique, 1957)
2 other deaths occurring days or months
after envenomation, ? wound infection or
tetanus
stonefish venom
The venom heat-labile proteins
4 biologically active factors:
1.
2.
3.
4.
hyaluronidase fraction
capillary permeability factor
a toxic or lethal fraction (Stonustoxin)
pain producing factor
The 1&2 factors cause edema
The Stonustoxin is myo- and neurotoxic
and cause shock
What are the clinical features of
stonefish envenomation and
treatment?
Symptoms of envenomation
Systemic effects
– Nausea
– muscle weakness
– Dyspnea
– hypotension
Symptoms of envenomation
Pain
– Immediately localized pain
– spread to involve limb in 90 minutes
– lasting up to 12 hours if untreated
– Mild subsequent pain may persist for days to
weeks.
Signs of envenomed wound
Discolored by a surrounding ring of bluish
cyanotic tissue
Subsequent edema, erythema, and
warmth may involve the entire limb
tissue necrosis in the absence of
secondary infection (rarely)
Vesicle formation (hands) may be followed
by rapid tissue sloughing and cellulitis
Tissue reaction of envenomation
Patel and Wells describe 3 grades of tissue
reaction in Lionfish envenomation (Pterosis
volitans, Family Scorpaenidae)
– erythematous reaction
– blister formation
– dermal necrosis
They have recommended early blister excision
to prevent tissue necrosis
The blister fluid contain residual active venom
Goal of treatment
Control pain
– Warm water bath
– Analgesic
– Local anesthesia
– Antivenom
Goal of treatment
Wound management
– Removal of foreign bodies
– Debridement
Prevent infections in high-risk wounds
– ATT
– IV or oral board spectrum antibiotics
Singapore experience
8 cases of stonefish (Synanceia sp.)
envenomation in 1.25 years time
– Ann Acad Med Singapore 2004;33:515-20
50% cases fish was identify by direct
visualization (fish body was brought to
A&E )
Caused severe pain and gross edema
of the affected limb
Singapore experience
Treatment given
– hot water (45ºC) bath
– analgesia
– tetanus prophylaxis
– broad-spectrum antibiotics
– Specific antivenom is available but not
used
– Surgical debridement
Singapore experience
Length of hospital stay averaged 3.9
days
no deaths or systemic morbidity
1 case required surgical debridement
for local necrosis
Average time for complete resolution
was 8.2 days
Singapore experience
Conclusions
– majority of stonefish envenomations do
not result in significant or protracted
morbidity
– supportive treatment is adequate
– Systemic morbidity and mortalities are
rare.
Is antivenom useful?
Stonefish antivenom
Has beneficial effect in relieving the pain
of envenomation
40 years of unpublished experience and
cases report
Effect of stonefish antivenom other
venomous fish sting remains uncertain
J Toxicol Clin Toxicol. 2003;41(3):301-8
Australia's Commonwealth Serum
Laboratories (CSL Ltd)
The sole manufacturer of antivenoms for
human use in Australia.
Australian antivenoms are amongst the
best in the world, in terms of purity and
adverse reaction rate
stonefish antivenom
It produced by immunizing horses against
the stonefish venom
The horse’s serum antibodies is purified
and fragmented by a series of digestion
and processing steps
It neutralise the effects of the stonefish
envenomation
– http://www.pharmacology.unimelb.edu.au/avru
web/Venoms.htm
Ingredients of the antivenom
It contains 2,000 units of antivenom in 1.5
to 3 mL of liquid.
It also contains
– phenol as a preservative
– sodium chloride
– substances found in horse blood.
Indications for antivenom
Severe pain
Systemic features
– Shock, weakness, paralysis
large amount of venom
– multiple punctures
Contra-indication for
antivenom
those who have no serious effects of
envenomation
Severe allergy reaction to skin test or
horse serum product
Dosage of antivenom
same for both adults and children
It depends on the number of puncture sites from
the spines on the stonefish:
– 1 - 2 punctures the dose is 1 vial (2,000 units)
– 3 - 4 punctures the dose is 2 vials (4,000 units)
– 5 or more punctures the dose is 3 vials (6,000 units).
Dosage of antivenom
The injection is intramuscularly and can be
repeated if necessary.
It is occasionally diluted and injected into a
vein.
Adverse reaction
Anaphylaxis
Serum sickness
Serum sickness of antivenom
Clinical features
– Rash
– swollen glands
– joint pains
– fever may
occur anytime in the first 2 weeks after
injection
2 cases had been reported after stonefish
antivenom
Prevention of serum sickness
Pretreatment is advocated
– Adrenaline SC/IMI
– Antihistamine
– Corticosteroid
Skin testing for allergy to antivenom is not
recommended, as it is unreliable and may
delay urgent therapy
Prevention of serum sickness
Corticosteroids delay both the incidence
and severity of serum sickness
should be considered if a large volume of
antivenom given
Marine wound infections
All marine injuries are at risk of secondary
infection, antibiotics are recommended
High risk wound
– deep puncture wounds
– grossly contaminated wounds,
– hand and foot (high incidence of ulceration
necrosis)
– persons who are chronically ill or
immunocompromised
Marine wound infections
Common bacteria
– erysipelothrix rhusiopathiae
– mycoplasma marinum
– vibrio and aeromonas
Erysipelothrix rhusiopathiae
(紅斑丹毒絲菌 )
Fish handler's disease
acquired through skin abrasion and minor
wound while handling marine animals
especially fish and shellfish
It appears as a well-demarcated cellulitis
characterized by erythema, edema, and warmth.
Erythromycin, cephalexin, and penicillin VK are
all referenced as appropriate first-line treatment
Mycoplasma marinum
(海魚分枝桿菌 )
Present with chronic suppurative and
granulomatous lesions
After contact contaminated seawater
Local debridement, adequate drainage,
and a prolonged antibiotic course
(doxycycline, clotrimazole) are essential
Vibrio and Aeromonas species
Vibrio species
– Vulnificus
– Parahaemolyticus
– damsela
Aeromonas species
– Parahaemolyticus
– alginolyticus
Vibrio and Aeromonas species
The most serious marine infections
may result in the loss of a limb or death
– Necrotizing fasciitis
– Cellulitis
– Myositis
– gas gangrene
– Sepsis
Vibrio and Aeromonas species
Vibrio vulnificus septicemia has a 20-50%
mortality
Require IV antibiotic and ICU care
Aeromonas infections may mimic
clostridial gangrene.
Antibiotic therapy should be guided by
wound swab culture results
Stonefish sting:
an occupational hazard in
Hong Kong
Chan TY, Tam LS, Chan LY
Department of Clinical Pharmacology, CUHK
–Ann Trop Med Parasitol. 1996 Dec;90(6):675-6.
Reference websites
http://www.emedicine.com/emerg/topic300.htm
http://annals.edu.sg/pdf200408/V33N4p515.pdf
http://www.wwf.org.hk/eng/pdf/conservation/wl_trade/idm
_popularfish/idm19_S_verrucosa.pdf
http://www.csl.com.au/
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retri
eve&db=PubMed&dopt=Abstract&list_uids=22691281
http://www.pharmacology.unimelb.edu.au/avruweb/Veno
ms.htm
http://www.pharmacology.unimelb.edu.au/avruweb/creat
able.html