ACMT Toxicology Visual Pearls: Painful Hand

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.