What is the recommended treatment for a patient with this hand injury following a sting by the marine creature shown?

  1. Acetic acid (vinegar)
  2. Antivenom
  3. Cold water
  4. Hot water
  5. Hydrogen peroxide

Answer: 4

Hot water

Lionfish envenomation

The pictured creature is a lionfish. The lionfish, which belongs to the subfamily Scorpaenidae, is native to the Indo-pacific coastal waters, but is a common resident of home aquariums [1]. Most lionfish envenomations are sustained by aquatic fish tank handlers and account for most poison center calls regarding marine envenomation [2]. Injuries commonly occur when fish are transferred, caught, or hand-fed [3]. The lionfish population in US waters has grown due to the release of these predatory fish in nonindigenous environments [4]. Lionfish spines cover a venom-producing integumentary sheath, which releases venom when disrupted [3,5].

What is the clinical presentation of Lionfish envenomation [1,2]?

  • Immediate burning pain and swelling
  • Pain and swelling peak at 30-90 minutes and then resolve over 6-12 hours.
  • Systemic symptoms such as nausea, vomiting, headache, diaphoresis, hypotension, and syncope are rare but can occur.
  • Tissue necrosis is not typical unless there is an associated secondary infection.

How do you manage Lionfish envenomation [2,5,6]?

  • Hot water (42-45◦C) immersion for 30-90 min to inactivate heat-labile component of venom
  • Do not exceed 90 minutes of immersion, particularly if local/regional anesthesia is used
  • Pain management
  • Local wound care and tetanus prophylaxis
  • Inspection for retained spines/foreign body
  • Prophylactic antibiotics may be considered if a concern for retained foreign body exists.

Bedside Pearls

  • Lionfish envenomations present with immediate, severe pain and swelling at the puncture site.
  • Systemic symptoms are rare.
  • Hot water immersion therapy is the gold standard for treatment.
  • Treatment includes local wound care with irrigation, foreign body removal, and tetanus update.

This post was expert peer reviewed on behalf of ACMT by Dr Bryan Judge, Dr Louise Kao, and Dr Andrew Stolbach


  1. Rensch G, Murphy-Lavoie HM. Lionfish, Scorpionfish, and Stonefish Toxicity. 2019 Mar 25. StatPearls. Treasure Island (FL): StatPearls Publishing; 2019 Jan. PMID: 29489204.
  1. Kizer KW, McKinney HE, Auerbach PS. Scorpaenidae envenomation. A five-year poison center experience. JAMA 1985; 253; 807-10. PMID 3968819
  1. K Balhara, A Stolbach; Marine Envenomations. Emergency Medicine Clinics of North America. 2014 Feb;32(1):223-43. PMID: 24275176.
  1. L Cearnal: Red lionfish and ciguatoxin: menace spreading through western hemisphere. Ann Emerg Med. 60 (1):21A-22A 2012. PMID: 22908370.
  1. Atkinson PRT, Boyle A, Hartin D, McAuley D: Is hot water immersion an effective treatment for marine envenomation? Emerg Med J 23: 503, 2006. PMID: 16794088.
  1. Isbister GK. Marine envenomation and poisoning. In: Dart, RC (Ed), Medical Toxicology, 3rd edition. Philadelphia, PA. Lippincott Williams & Wilkins. 2004. P.1621-1632.
Angela Rombola, MD

Angela Rombola, MD

Emergency Medicine Resident
Carolinas Medical Center, Charlotte, NC
Angela Rombola, MD

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Kathryn T. Kopec, DO

Kathryn T. Kopec, DO

Emergency Medicine and Medical Toxicology Faculty
Carolinas Medical Center, Charlotte, NC