A painful swollen thumb Dr. Law chi yin PYNEH A&E.
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Transcript of A painful swollen thumb Dr. Law chi yin PYNEH A&E.
A painful swollen thumbA painful swollen thumb
Dr. Law chi yinDr. Law chi yin
PYNEH A&EPYNEH A&E
A painful swollen thumbA painful swollen thumb
A lady age around 60 A lady age around 60
Sudden severe thumb pain for one hour Sudden severe thumb pain for one hour after stung by a fish spine while preparing after stung by a fish spine while preparing the fish for dinnerthe fish for dinner
The fish was caught by her son in the The fish was caught by her son in the nearby piernearby pier
Her son said that the fish was a stonefishHer son said that the fish was a stonefish
A painful swollen thumbA painful swollen thumb
Would you believe him?Would you believe him?
Could he catch a stonefish near a pier in Could he catch a stonefish near a pier in Hong Kong?Hong Kong?
Was the severe thumb pain due to Was the severe thumb pain due to stonefish envenomation?stonefish envenomation?
A painful swollen thumbA painful swollen thumb
On examination:On examination:– Blood pressure and pulse were stableBlood pressure and pulse were stable– Marked swelling of her left thumb and hand Marked swelling of her left thumb and hand
notednoted– Mild redness and hot onlyMild redness and hot only– No foreign body found in the woundNo foreign body found in the wound
The lady’s injury hand The lady’s injury hand
The lady’s injury handThe lady’s injury hand
The lady’s injury handThe lady’s injury hand
Treatment given in A&ETreatment given in A&E
ATT ATT Analgesic injection Analgesic injection Warm water bath Warm water bath Kept in observation wardKept in observation ward– SymptomsSymptoms– Vital signs Vital signs – Monitoring size of swellingMonitoring size of swelling
Asked her son to bring back the fish body Asked her son to bring back the fish body for examinationfor examination
A painful swollen thumbA painful swollen thumb
Two hours laterTwo hours later
The fish body was brought to A&EThe fish body was brought to A&E
The size was just as the length of a tongue The size was just as the length of a tongue depressordepressor
The fish body looked like a stone The fish body looked like a stone
The secret fishThe secret fish
The secret fishThe secret fish
The secret fishThe secret fish
The color was brown and grey The color was brown and grey
Mouth and eyes point upwardMouth and eyes point upward
The dorsal spines were cut by the ladyThe dorsal spines were cut by the lady
What was the secret fish?What was the secret fish?
stonefishstonefish
Identification Guide to Identification Guide to Fishes in the Live Fishes in the Live Seafood Trade of the Seafood Trade of the Asia-Pacific Region. Asia-Pacific Region.
Published by Published by – WWF Hong KongWWF Hong Kong– Agriculture, Fisheries and Agriculture, Fisheries and
Conservation Department. Conservation Department. Hong KongHong Kong
stonefish stung injurystonefish stung injury
Swelling and pain persisting despite warm Swelling and pain persisting despite warm water bathwater bath
Skin blister found near puncture siteSkin blister found near puncture site
Swelling extend up to forearmSwelling extend up to forearm
no muscle weakness, dyspnea and no muscle weakness, dyspnea and hypotensionhypotension
stonefish stung injurystonefish stung injury
Blister was clear, no pusBlister was clear, no pus
Aspiration done in observation, Aspiration done in observation,
Oral ciprofloxacin started Oral ciprofloxacin started
stonefish stung injurystonefish stung injury
Pros and cons of Stonefish antivenom Pros and cons of Stonefish antivenom discussed discussed
She refused antivenom for fear of possible She refused antivenom for fear of possible allergic reactionallergic reaction
stonefish stung injurystonefish stung injury
Pain and swelling static during observationPain and swelling static during observation
She was discharged with oral antibioticShe was discharged with oral antibiotic
Follow up 3 days laterFollow up 3 days later
stonefish stung injurystonefish stung injury
She came back 10 hours later after She came back 10 hours later after leaving A&Eleaving A&E
pain and size of bulla increasing pain and size of bulla increasing
No evidence of tendinosynovitis No evidence of tendinosynovitis
Distal pulse and capillary circulation was Distal pulse and capillary circulation was goodgood
She was admitted to orthopedic ward for She was admitted to orthopedic ward for puncture site cellulitis puncture site cellulitis
stonefish stung injurystonefish stung injury
Management in orthopedic wardManagement in orthopedic ward– Wound dressingWound dressing– IV antibioticIV antibiotic– Patch of superficial skin necrosis noted on Patch of superficial skin necrosis noted on
day 3, no debridement doneday 3, no debridement done– Pain and swelling subsided with conservative Pain and swelling subsided with conservative
treatmenttreatment– No antivenom givenNo antivenom given
What is stonefish and its What is stonefish and its venom?venom?
Venomous marine fishVenomous marine fish
Family Scorpaenidae Family Scorpaenidae – PteroisPterois - lionfish - lionfish – ScorpaenaScorpaena – scorpionfish – scorpionfish– SynanceiaSynanceia - stonefish - stonefish
stonefishstonefish
The most venomous The most venomous fish in the worldfish in the world
13 dorsal spines 13 dorsal spines contains venom. contains venom.
The severity of the The severity of the envenomation envenomation depends on the depth depends on the depth and number of and number of penetrationpenetration
stonefishstonefish
stonefish envenomation killed many stonefish envenomation killed many Pacific and Indian Ocean islanders in pre-Pacific and Indian Ocean islanders in pre-antivenom period.antivenom period.
1st antivenom developed in 1959 1st antivenom developed in 1959
stonefish venomstonefish venom
3 deaths reported in the literature3 deaths reported in the literature
1 case direct intravascular envenomation 1 case direct intravascular envenomation (Mozambique, 1957) (Mozambique, 1957)
2 other deaths occurring days or months 2 other deaths occurring days or months after envenomation, ? wound infection or after envenomation, ? wound infection or tetanustetanus
stonefish venomstonefish venom
The venom heat-labile proteinsThe venom heat-labile proteins4 biologically active factors: 4 biologically active factors:
1.1. hyaluronidase fraction hyaluronidase fraction 2.2. capillary permeability factorcapillary permeability factor3.3. a toxic or lethal fraction (Stonustoxin)a toxic or lethal fraction (Stonustoxin)4.4. pain producing factorpain producing factor
The 1&2 factors cause edemaThe 1&2 factors cause edemaThe Stonustoxin is myo- and neurotoxic The Stonustoxin is myo- and neurotoxic and cause shock and cause shock
What are the clinical features of What are the clinical features of stonefish envenomation and stonefish envenomation and
treatment?treatment?
Symptoms of envenomationSymptoms of envenomation
Systemic effects Systemic effects – NauseaNausea– muscle weaknessmuscle weakness– DyspneaDyspnea– hypotensionhypotension
Symptoms of envenomationSymptoms of envenomation
PainPain– Immediately localized painImmediately localized pain– spread to involve limb in 90 minutesspread to involve limb in 90 minutes– lasting up to 12 hours if untreatedlasting up to 12 hours if untreated– Mild subsequent pain may persist for days to Mild subsequent pain may persist for days to
weeks.weeks.
Signs of envenomed woundSigns of envenomed wound
Discolored by a surrounding ring of bluish Discolored by a surrounding ring of bluish cyanotic tissuecyanotic tissueSubsequent edema, erythema, and Subsequent edema, erythema, and warmth may involve the entire limbwarmth may involve the entire limbtissue necrosis in the absence of tissue necrosis in the absence of secondary infection (rarely)secondary infection (rarely)Vesicle formation (hands) may be followed Vesicle formation (hands) may be followed by rapid tissue sloughing and cellulitisby rapid tissue sloughing and cellulitis
Tissue reaction of envenomationTissue reaction of envenomation
Patel and Wells describe 3 grades of tissue Patel and Wells describe 3 grades of tissue reaction in Lionfish envenomation (reaction in Lionfish envenomation (Pterosis Pterosis volitansvolitans, Family , Family Scorpaenidae)Scorpaenidae)– erythematous reactionerythematous reaction– blister formation blister formation – dermal necrosisdermal necrosis
They have recommended early blister excision They have recommended early blister excision to prevent tissue necrosis to prevent tissue necrosis The blister fluid contain residual active venomThe blister fluid contain residual active venom
Goal of treatmentGoal of treatment
Control painControl pain– Warm water bathWarm water bath– AnalgesicAnalgesic– Local anesthesiaLocal anesthesia– AntivenomAntivenom
Goal of treatmentGoal of treatment
Wound managementWound management– Removal of foreign bodiesRemoval of foreign bodies– DebridementDebridement
Prevent infections in high-risk woundsPrevent infections in high-risk wounds– ATTATT– IV or oral board spectrum antibioticsIV or oral board spectrum antibiotics
Singapore experienceSingapore experience
8 cases of stonefish (8 cases of stonefish (Synanceia sp.Synanceia sp.) ) envenomation in 1.25 years time envenomation in 1.25 years time – Ann Acad Med Singapore 2004;33:515-20Ann Acad Med Singapore 2004;33:515-20
50% cases fish was identify by direct 50% cases fish was identify by direct visualization (fish body was brought to visualization (fish body was brought to A&E )A&E )
Caused severe pain and gross edema Caused severe pain and gross edema of the affected limb of the affected limb
Singapore experienceSingapore experience
Treatment givenTreatment given– hot water (45ºC) bathhot water (45ºC) bath– analgesiaanalgesia– tetanus prophylaxistetanus prophylaxis– broad-spectrum antibioticsbroad-spectrum antibiotics– Specific antivenom is available but not Specific antivenom is available but not
usedused– Surgical debridementSurgical debridement
Singapore experienceSingapore experience
Length of hospital stay averaged 3.9 Length of hospital stay averaged 3.9 daysdays
no deaths or systemic morbidityno deaths or systemic morbidity
1 case required surgical debridement 1 case required surgical debridement for local necrosis for local necrosis
Average time for complete resolution Average time for complete resolution was 8.2 days was 8.2 days
Singapore experienceSingapore experience
ConclusionsConclusions– majority of stonefish envenomations do majority of stonefish envenomations do
not result in significant or protracted not result in significant or protracted morbidity morbidity
– supportive treatment is adequatesupportive treatment is adequate– Systemic morbidity and mortalities are Systemic morbidity and mortalities are
rare. rare.
Is antivenom useful?Is antivenom useful?
Stonefish antivenomStonefish antivenom
Has beneficial effect in relieving the pain oHas beneficial effect in relieving the pain of envenomation f envenomation
40 years of unpublished experience and c40 years of unpublished experience and cases report ases report
Effect of stonefish antivenom other venomEffect of stonefish antivenom other venomous fish sting remains uncertain ous fish sting remains uncertain
J Toxicol Clin Toxicol. 2003;41(3):301-8J Toxicol Clin Toxicol. 2003;41(3):301-8
Australia's Commonwealth Serum Australia's Commonwealth Serum Laboratories (CSL Ltd)Laboratories (CSL Ltd)
The sole manufacturer of antivenoms for The sole manufacturer of antivenoms for human use in Australia. human use in Australia.
Australian antivenoms are amongst the Australian antivenoms are amongst the best in the world, in terms of purity and best in the world, in terms of purity and adverse reaction rate adverse reaction rate
stonefish antivenomstonefish antivenom
It produced by immunizing horses against It produced by immunizing horses against the stonefish venom the stonefish venom The horse’s serum antibodies is purified The horse’s serum antibodies is purified and fragmented by a series of digestion and fragmented by a series of digestion and processing stepsand processing stepsIt neutralise the effects of the stonefish It neutralise the effects of the stonefish envenomation envenomation – http://www.pharmacology.unimelb.edu.au/http://www.pharmacology.unimelb.edu.au/
avruweb/Venoms.htmavruweb/Venoms.htm
Ingredients of the antivenomIngredients of the antivenom
It contains 2,000 units of antivenom in 1.5 It contains 2,000 units of antivenom in 1.5 to 3 mL of liquid. to 3 mL of liquid.
It also contains It also contains – phenol as a preservativephenol as a preservative– sodium chloridesodium chloride– substances found in horse blood.substances found in horse blood.
IndicationsIndications for antivenom for antivenom
Severe pain Severe pain
Systemic featuresSystemic features– Shock, weakness, paralysisShock, weakness, paralysis
large amount of venom large amount of venom – multiple punctures multiple punctures
Contra-indication for Contra-indication for antivenomantivenom
those who have no serious effects of those who have no serious effects of envenomationenvenomation
Severe allergy reaction to skin test or Severe allergy reaction to skin test or horse serum producthorse serum product
Dosage of antivenomDosage of antivenom
same for both adults and children same for both adults and children
It depends on the number of puncture sites from It depends on the number of puncture sites from the spines on the stonefish:the spines on the stonefish:– 1 - 2 punctures the dose is 1 vial (2,000 units)1 - 2 punctures the dose is 1 vial (2,000 units)– 3 - 4 punctures the dose is 2 vials (4,000 units)3 - 4 punctures the dose is 2 vials (4,000 units)– 5 or more punctures the dose is 3 vials (6,000 units). 5 or more punctures the dose is 3 vials (6,000 units).
Dosage of antivenomDosage of antivenom
The injection is intramuscularly and can be The injection is intramuscularly and can be repeated if necessary. repeated if necessary.
It is occasionally diluted and injected into a It is occasionally diluted and injected into a vein. vein.
Adverse reactionAdverse reaction
Anaphylaxis Anaphylaxis
Serum sicknessSerum sickness
Serum sickness of antivenomSerum sickness of antivenom
Clinical featuresClinical features– RashRash– swollen glandsswollen glands– joint painsjoint pains– fever may fever may
occur anytime in the first 2 weeks after occur anytime in the first 2 weeks after injectioninjection2 cases had been reported after stonefish 2 cases had been reported after stonefish antivenomantivenom
Prevention of serum sicknessPrevention of serum sickness
Pretreatment is advocatedPretreatment is advocated– Adrenaline SC/IMIAdrenaline SC/IMI– AntihistamineAntihistamine– CorticosteroidCorticosteroid
Skin testing for allergy to antivenom is not Skin testing for allergy to antivenom is not recommended, as it is unreliable and may recommended, as it is unreliable and may delay urgent therapy delay urgent therapy
Prevention of serum sicknessPrevention of serum sickness
Corticosteroids delay both the incidence Corticosteroids delay both the incidence and severity of serum sicknessand severity of serum sickness
should be considered if a large volume of should be considered if a large volume of antivenom givenantivenom given
Marine wound infections 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 infectionsMarine wound infections
Common bacteria– erysipelothrix rhusiopathiae – mycoplasma marinum – vibrio and aeromonas
Erysipelothrix rhusiopathiaeErysipelothrix rhusiopathiae(( 紅斑丹毒絲菌 紅斑丹毒絲菌 ))
Fish handler's diseaseFish handler's disease
acquired through skin abrasion and minor wound acquired through skin abrasion and minor wound while handling marine animalswhile handling marine animals
especially fish and shellfishespecially fish and shellfish
It appears as a well-demarcated cellulitis It appears as a well-demarcated cellulitis characterized by erythema, edema, and warmth.characterized by erythema, edema, and warmth.
Erythromycin, cephalexin, and penicillin VK are Erythromycin, cephalexin, and penicillin VK are all referenced as appropriate first-line treatmentall referenced as appropriate first-line treatment
Mycoplasma marinum Mycoplasma marinum (( 海魚分枝桿菌 海魚分枝桿菌 ))
Present with chronic suppurative and Present with chronic suppurative and granulomatous lesions granulomatous lesions
After contact contaminated seawaterAfter contact contaminated seawater
Local debridement, adequate drainage, Local debridement, adequate drainage, and a prolonged antibiotic course and a prolonged antibiotic course (doxycycline, clotrimazole) are essential(doxycycline, clotrimazole) are essential
Vibrio and Aeromonas species
Vibrio Vibrio speciesspecies– VulnificusVulnificus– ParahaemolyticusParahaemolyticus– damseladamsela
AeromonasAeromonas species species– ParahaemolyticusParahaemolyticus– alginolyticusalginolyticus
Vibrio and Aeromonas species
The most serious marine infections The most serious marine infections
may result in the loss of a limb or deathmay result in the loss of a limb or death– Necrotizing fasciitisNecrotizing fasciitis– CellulitisCellulitis– MyositisMyositis– gas gangrenegas gangrene– SepsisSepsis
Vibrio and Aeromonas species
Vibrio vulnificusVibrio vulnificus septicemia has a 20-50% septicemia has a 20-50% mortality mortality
Require IV antibiotic and ICU careRequire IV antibiotic and ICU care
AeromonasAeromonas infections may mimic infections may mimic clostridial gangrene. clostridial gangrene.
Antibiotic therapy should be guided by Antibiotic therapy should be guided by wound swab culture resultswound swab culture results
Stonefish sting: Stonefish sting: an occupational hazard in an occupational hazard in
Hong KongHong Kong
Chan TY, Tam LS, Chan LY Chan TY, Tam LS, Chan LY Department of Clinical Pharmacology, CUHKDepartment of Clinical Pharmacology, CUHK
–Ann Trop Med Parasitol. 1996 Dec;90(6):675-6.Ann Trop Med Parasitol. 1996 Dec;90(6):675-6.
Reference websitesReference websites
http://www.emedicine.com/emerg/topic300.htmhttp://www.emedicine.com/emerg/topic300.htmhttp://annals.edu.sg/pdf200408/V33N4p515.pdfhttp://annals.edu.sg/pdf200408/V33N4p515.pdfhttp://www.wwf.org.hk/eng/pdf/conservation/wl_trade/idmhttp://www.wwf.org.hk/eng/pdf/conservation/wl_trade/idm_popularfish/idm19_S_verrucosa.pdf_popularfish/idm19_S_verrucosa.pdfhttp://www.csl.com.au/http://www.csl.com.au/http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrihttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=22691281eve&db=PubMed&dopt=Abstract&list_uids=22691281http://www.pharmacology.unimelb.edu.au/avruweb/Venohttp://www.pharmacology.unimelb.edu.au/avruweb/Venoms.htmms.htmhttp://www.pharmacology.unimelb.edu.au/avruweb/creathttp://www.pharmacology.unimelb.edu.au/avruweb/creatable.htmlable.html