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Lionfish and Stonefish Envenomation Treatment & Management

  • Author: Scott A Gallagher, MD, FACEP; Chief Editor: Joe Alcock, MD, MS  more...
Updated: Oct 29, 2015

Prehospital Care

Prehospital care should address recognition of the injury as a potential envenomation, gentle removal of visible spines, direct pressure to control bleeding, administration of analgesia, and transport for definitive medical evaluation.

Recognition of serious systemic symptoms and prompt institution of appropriate life-saving procedures, such as cardiopulmonary resuscitation (CPR) and treatment for anaphylaxis, should be paramount in the prehospital care setting.


Emergency Department Care

Emergency department (ED) management of Scorpaenidae envenomations involves addressing the venom exposure as well as the accompanying inflicted trauma. General rules of therapy include prompt analgesia, wound management, antivenom administration, and supportive treatment for significant envenomations.

CPR and advanced cardiac life support (ACLS) procedures are rarely indicated but always take absolute precedence.

Wound debridement

Gentle manual removal of obviously protruding spines prevents further penetration or breakage.

With proper anesthesia, surgical removal of embedded spines is indicated when they are in proximity to joints, nerves, or vessels.

Weight-bearing surfaces may require removal of spines to prevent chronic pain.

Always irrigate copiously after adequate anesthesia.

Hot water immersion technique

Heat treatment is widely recommended as effective initial treatment for envenomations by Scorpaenidae, as well as echinoderms, stingrays, and other venomous spine injuries.

The affected limb should be immersed in water no warmer than 114 degrees Fahrenheit, or 45 degrees Celsius.

Be careful not to inflict thermal burns by placing an insensate limb (as a result of local anesthesia or decreased sensitivity as a result of pain) into scalding water.

Local or regional anesthesia, if available, is a suggested means of adjunctive analgesia.


Methods of recommended analgesia vary depending upon the reference cited and range from immersion techniques to local or regional anesthesia to parenteral analgesics.

Most references recommend that initial therapy consist of immersion in nonscalding hot water (upper limit of 114 degrees Fahrenheit or 45 degrees Celsius) after removal of visible spines and sheath, in order to inactivate the thermolabile components of the venom that might otherwise cause a severe systemic reaction.

Adjunctive regional or local anesthesia offers several benefits that are not conferred by immersion techniques with analgesia. In addition to the absence of the risk of thermal injury, reliable, prompt, and prolonged analgesia allows for simultaneous debridement of the wound.

Parenteral analgesics and/or sedatives may be needed for patients who have wounds that are difficult to immerse or anesthetize, or for persons exhibiting significant anxiety reactions to the envenomation.

Wound management principles

Wound management principles include identification of foreign material, adequate debridement, tetanus prophylaxis, and appropriate referral for retained fragments that are not easily accessible in the ED.

Although the spines rarely break off into the skin, debridement of loose spines should be undertaken promptly, because retained spines continue to envenomate. Embedded structures should be pulled straight out with forceps to avoid breaking them.

Ultrasound and plain radiography may help locate retained fragments, many of which require referral for consideration of operative removal (eg, proximity to nerves, vessels, joints, weight-bearing surfaces). Retained fragments act as foreign bodies, causing inflammation and eventually becoming encapsulated into granulomata, which may lead to delayed healing and secondary infection.

Tetanus prophylaxis is indicated in all patients who have experienced traumatic marine injury and who have insufficient or uncertain immunization histories.

Severe to life-threatening systemic symptoms of envenomation most commonly result from envenomations by the Synanceia genus and only rarely result from envenomations by other genera of the Scorpaenidae family.

Stonefish antivenom

Stonefish antivenom from Australia's Commonwealth Serum Laboratories (CSL) is recommended only for predilution intramuscular usage. However, for serious envenomations, this route may not be ideal because of erratic absorption. Following dilution, a slow intravenous administration may be preferable: 1 ampule (2000 U) for every 1-2 punctures, up to 3 ampules for more than 4 punctures. It should be diluted in 50-100 mL of isotonic sodium chloride solution and run through at least 20 minutes.

As this is a hyperimmunized equine antisera, there are risks of allergic reaction and serum sickness in the recipient. Skin testing and/or pretreatment should precede administration. Rather than skin testing, Australian sources tend to recommend pretreatment with subcutaneous epinephrine and an intramuscular antihistamine, adding an intramuscular corticosteroid for known hypersensitivity.



Consultation with an appropriate surgical specialist is advised for all complicated puncture wounds, including those in proximity to articular and neurovascular structures.

Spine extraction is best performed acutely with an operating microscope in the surgical suite.

Plantar puncture wounds are a potentially complicated injury, and they may require consultation or referral for foreign material that is not easily extracted in the ED.

Consultation and admission to a general internist for supportive care may be warranted when symptoms of serious envenomation are present.

Protracted pain, nausea, muscular weakness, respiratory distress, and hypotension are a few systemic symptoms that indicate the need for admission.

Additionally, in the rare case of Vibrio or Aeromonas sepsis, a coordinated multispecialty effort is needed to address wound debridement, antibiosis, and critical care support.

Contributor Information and Disclosures

Scott A Gallagher, MD, FACEP Department of Emergency Medicine, Aspen Valley Hospital; Senior Clinical Instructor, Department of Surgery, School of Medicine, University of Colorado Health Sciences Center

Scott A Gallagher, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

John T VanDeVoort, PharmD Regional Director of Pharmacy, Sacred Heart and St Joseph's Hospitals

John T VanDeVoort, PharmD is a member of the following medical societies: American Society of Health-System Pharmacists

Disclosure: Nothing to disclose.

James Steven Walker, DO, MS Clinical Professor of Surgery, Department of Surgery, University of Oklahoma College of Medicine

James Steven Walker, DO, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Robert L Norris, MD Professor, Department of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, International Society of Toxinology, American Medical Association, California Medical Association, Wilderness Medical Society

Disclosure: Nothing to disclose.

  1. Williamson, JA, Fenner, PJ, Burnett, JW. Venomous and Poisonous Marine Animals: Medical and Biological Handbook. Sydney, Australia: U New South Wales P. 1996: 106-117, 374-387, 418-422.

  2. Aldred B, Erickson T, Lipscomb J. Lionfish envenomations in an urban wilderness. Wilderness Environ Med. 1996 Nov. 7(4):291-6. [Medline].

  3. Auerbach PS. Marine envenomations. N Engl J Med. 1991 Aug 15. 325(7):486-93. [Medline].

  4. Auerbach PS. Medical Guide to Hazardous Marine Life. 2nd ed. Flagstaff, Az: Best Pub; 1991. 17-19.

  5. Auerbach PS. Wilderness Medicine: Management of Wilderness and Environmental Emergencies. 4th ed. 2001. 1492-1497.

  6. Bove AA. Bove and Davis' Diving Medicine. 3rd ed. Philadelphia, Pa: WB Saunders; 1997. 310-311.

  7. Burnett JW. Aquatic adversaries: stonefish. Cutis. 1998 Dec. 62(6):269-70. [Medline].

  8. Chan TY, Tam LS, Chan LY. Stonefish sting: an occupational hazard in Hong Kong. Ann Trop Med Parasitol. 1996 Dec. 90(6):675-6. [Medline].

  9. Cunningham, P, Goetz, P. Pisces Guide to Venomous & Toxic Marine Life of the World. Houston, Tex: Pisces Books; 1996. 102-114.

  10. Currie BJ. Marine antivenoms. J Toxicol Clin Toxicol. 2003. 41(3):301-8. [Medline].

  11. Edmonds C. Dangerous Marine Creatures: Field Guide for Medical Treatment. 2nd ed. 1995. 63-68, 75-79, 239-249.

  12. Garyfallou GT, Madden JF. Lionfish envenomation. Ann Emerg Med. 1996 Oct. 28(4):456-7. [Medline].

  13. Gwee MC, Gopalakrishnakone P, Yuen R, et al. A review of stonefish venoms and toxins. Pharmacol Ther. 1994. 64(3):509-28. [Medline].

  14. Habif TP. Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 3rd ed. St Louis, Mo: Mosby; 1996. 488-490.

  15. Haddad V Jr. Injuries caused by scorpionfishes (Scorpaena plumieri Bloch, 1789 and Scorpaena brasiliensis Cuvier, 1829) in the Southwestern Atlantic Ocean (Brazilian coast): epidemiologic, clinic and therapeutic aspects of 23 stings in humans. Toxicon. 2003 Jul. 42(1):79-83. [Medline].

  16. Halstead BW, Auerbach PS. Dangerous Aquatic Animals of the World: A Color Atlas: With Prevention, First Aid, and Treatment. St Louis, Mo: Mosby; 1992. 85-88.

  17. Hare JA, Whitfield PE. An integrated assessment of the introduction of lionfish (Pterois volitans/miles) to the western Atlantic Ocean. NOAA Technical Memorandum NOS NCCOS 2. Silver Spring, Md: NOAA/NOS/NCCOS; 2003. 21.

  18. Hodgson WC. Pharmacological action of Australian animal venoms. Clin Exp Pharmacol Physiol. 1997 Jan. 24(1):10-7. [Medline].

  19. Isbister GK. Venomous fish stings in tropical northern Australia. Am J Emerg Med. 2001 Nov. 19(7):561-5. [Medline].

  20. Kizer KW. Marine envenomations. J Toxicol Clin Toxicol. 1983-84. 21(4-5):527-55. [Medline].

  21. Kizer KW. Scorpaenidae envenomation. A five-year poison center experience. JAMA. 1985. 253 (6):807-10. [Medline].

  22. Lyon RM. Stonefish poisoning. Wilderness Environ Med. 2004. 15 (4):284-8. [Medline].

  23. Meir J, White J. Clinical Toxicology of Animal Venoms and Poisons. Boca Raton, Fla: CRC Press; 1995. 2-5, 141-151.

  24. Patel MR, Wells S. Lionfish envenomation of the hand. J Hand Surg [Am]. 1993 May. 18(3):523-5. [Medline].

  25. Perkins RA, Morgan SS. Poisoning, envenomation, and trauma from marine creatures. Am Fam Physician. 2004 Feb 15. 69(4):885-90. [Medline].

  26. Singletary EH, Adam SR, Bodmer JCA. Envenomations. Med Clin North Am. 2005. 89(6):1195-1224.

  27. Soppe GG. Marine envenomations and aquatic dermatology. Am Fam Physician. 1989 Aug. 40(2):97-106. [Medline].

  28. Sutherland SK. Antivenom use in Australia. Premedication, adverse reactions and the use of venom detection kits. Med J Aust. 1992 Dec 7-21. 157(11-12):734-9. [Medline].

  29. Taylor DM. An analysis of marine animal injuries presenting to emergency departments in Victoria, Australia. Wilderness Environ Med. 2002. 13(2:106-12. [Medline].

  30. Trott AT. Wounds and Lacerations: Emergency Care and Closure. 2nd ed. St Louis, Mo: Mosby; 1997. 285-295.

Lionfish (Pterois volitans) have long, slender spines with small venom glands, and they have the least potent sting of the Scorpaenidae family. Courtesy Dee Scarr.
Scorpionfish (genus Scorpaena) have shorter, thicker spines with larger venom glands than lionfish do, and they have a more potent sting. Courtesy Dee Scarr.
Stonefish (genus Synanceia) have short, stout spines with highly developed venom glands, and they have a potentially fatal sting. Courtesy Paul S. Auerbach, MD.
Members of the genera Scorpaena, such as these scorpionfish, and Synanceia, such as the stonefish, usually are found well camouflaged on the sandy bottom of the sea or amongst rocks. Shoes or booties may provide some protection; however, it is best to avoid touching the sea bottom or to use a shuffling gait while wading. Courtesy Dee Scarr.
Members of the genus Pterois, such as this lionfish, are usually free-swimming or hovering in small caves or crevices for protection. Provoking these fish by handling or cornering them may result in a painful envenomation. Courtesy Dee Scarr.
In defense of the animals, envenomations and injury generally occur in response to a perceived threat, usually handling or stepping on the animals. Photo by Scott A Gallagher, MD.
A 45-year-old diver was taking photographs in Australia at a depth of 60 feet. He suddenly noticed an excruciating pain in his left foot after resting his foot on a large stonefish. Photo courtesy John Williamson, MD and Surf Lifesaving Queensland.
Top, Brown rockfish of the Scorpaenidae family. Lateral view of the left pelvic spine in articulation with the pelvic girdle. Middle, Anterior view of left pelvic spine (proximal portion) of the brown rockfish. Bottom, Lionfish spine.
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