Antivenom includes Stonefish CSL antivenom. All doses are recommended to be given intramuscular due to an increased risk of anaphylactoid reaction. One vial is equivalent to 2,000 units and neutralizes 20 mg of venom. Give one vial for one to two puncture wounds, two vials for three to four puncture wounds, and three vials for five or more puncture wounds.²

Caveats: Watch closely for signs of necrotizing fasciitis due to a high risk for Vibrio vulnificus co-infection—give antibiotics early and observe for signs of compartment syndrome.¹⁰

Family: Scorpaenidae (Scorpionfish)

Lionfish (Pterois volitans and Pterois lunulata)

Location: Indo-Pacific Ocean

Appearance: Similar to stonefish, lionfish possess multiple spines that release venom in response to pressure. Their appearance is variable across 12 species in the Pterois genus, but they generally have alternating brown to orange and white stripes or spots.

Pathophysiology and Symptoms: These fish are common to home aquariums and account for the majority of spiny fish-related calls to poison control centers in the United States.¹² Initial symptoms include severe pain that peaks within one to two hours with variable skin changes (eg, erythema versus pallor versus cyanosis). Lesions can progress to hemorrhagic bullae with necrosis. Systemic effects are similar to stonefish (see above).

Management: Management is similar to the approach for stonefish envenomation (see above), with the caveat that there is no antivenom for lionfish.

References

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2. Nelson LS, Howland M, Lewin NA, et al. Goldfrank’s Toxicologic Emergencies, 11e. New York: McGraw-Hill, 2019.
3. Schmidt ME, Abdelbaki YZ, Tu AT. Nephrotoxic action of rattlesnake and sea snake venoms: An electron-microscopic study. J Pathol. 1976 Feb;118(2):75–81.
4. Southcott RV, Coulter JR. The effects of the southern Australian marine stinging sponges, Neofibularia mordens and Lissodendoryx sp. Med J Aust. 1971 Oct 30;2(18):895–901.
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6. Mercer HP, McGill JJ, Ibrahim RA. Envenomation by sea snake in Queensland. Med J Aust. 1981 Feb 7;1(3):130–132.
7. Shiraev TP, Marucci D, McMullin G. Threatened limb from stingray injury. Vascular. 2017 Jun;25(3):326–328.
8. McGoldrick J, Marx JA. Marine envenomations; Part 1: Vertebrates. J Emerg Med. 1991 Nov–Dec;9(6):497–502.
9. Wiener S. Observations on the venom of the stone fish (Synanceja trachynis). Med J Aust. 1959 May 9;46(19):620–627.
10. Tang WM, Fung KK, Cheng VC, et al. Rapidly progressive necrotising fasciitis following a stonefish sting: A report of two cases. J Orthop Surg (Hong Kong). 2006 Apr;14(1):67–70.