1. Lionfish Stings: Treatment and Prevention Derek B. Covington, M.D. Resident Physician – PGY2 Department of Anesthesiology Technical Diving International - Instructor Candidate

2. Why should I Care? Painful

3. Why Should I Care? Deadly

4. Why Should I Care? Tasty

5. Objectives and Outline To properly identify lionfish To recognize symptoms of an envenomation To treat an envenomation in the field To prevent an envenomation

6. Lionfish Belong to family of fish called Scorpaenidae –3 genus: categorized based on venom organ structure and toxicity Pterois –Long, slender spines w/ least potent sting –Lionfish Scorpaena –Shorter, thicker spines w/ more potent sting –Scorpionfish Synanceia –Stout, powerful spines w/ most potent sting –Stonefish

7. Scorpaenidae PteroisSynanceiaScorpaena www.stinapa.orgwww.stinapa.org, http://www.scubatravel.co.uk/e_Scorpion_fish_26_06.html, http://www.jamesfreeanimals.com/2012/04/stone-fish-what-do-you-know-about-this.html,http://www.scubatravel.co.uk/e_Scorpion_fish_26_06.html http://www.jamesfreeanimals.com/2012/04/stone-fish-what-do-you-know-about-this.html

8. Scorpaenidae Spines –Number and location 12-13 dorsal spines 2 pelvic spines 3 anal spines Pectoral spines vary in number and are innocuous –Each spine associated with pair of venom glands –Integumentary sheath surrounds spine and is pushed downwards onto venom glands to stimulate venom during a sting

9. Lionfish http://rollingharbour.com/tag/pterois-miles/

10. Venom Toxicity secondary to proteins –Proteins Antigenic  stimulate the immune system Large  high molecular weight Heat labile  denatures at high temperatures

11. Lionfish Scientific name: Pterois volitans Venomous marine fish native to Indo- Pacific Characterized by red, white, and black bands with extravagant pectoral fins and dorsal spines Measure 6 to 4cm in length Weigh up to 500 grams

12. Lionfish Lifespan: 5 – 15 years Prey: small fish, invertebrates, and mollusks Predators: few natural predators include moray eels, large fish (Tiger groupers), and sharks.

13. Epidemiology Number of envenomations unknown –>100 in medical literature from aquarists –Typically involve divers, fisherman, and others involved in marine activies

14. Mortality and Morbidity Severity of envenomations increase from Pterois to Scorpaena to Synanceia Lionfish –Typically local wound –May progress to tissue necrosis –Rare case reports of death

15. Symptoms Immediate, excruciating to incapacitating, local wound pain –Pain may spread to involved entire limb Peaks at 60-90 minutes and lasts up to 12 hours Mild subsequent pain may last up to weeks Edema, erythema, tissue necrosis Systemic symptoms –Hypotension, pyrexia, chills, nausea, muscle twitching, dyspnea, convulsions, dizziness, diaphoresis, and anaphylaxis

16. Signs Single or multiple puncture wounds –Surrounding ring of blue-cyanotic tissue –Subsequent edema, erythema, and warmth may involved entire limb –Vesicle formation (often in hands) may progress to rapid tissue sloughing, cellulitis, and surrounding hyperesthesia.

17. Prehospital Care Gentle removal of visible spines Direct pressure to control bleeding Administration of analgesia Immerse wound in hot water (<114F/45C) Transport for definitive medical evaluation

18. Hospital Care Tetanus prophylaxis Removal of retained spines Resusitation with IV fluids IV analgesia Antibiotic prophylaxis Antivenom available, but rarely indicated

19. Prevention Avoidance If not avoidance, use proper precautions: –Kevlar gloves –Shears to trim spines –Knife to remove fish from spear –Properly lined catch bag

20. Quiz! An open water diver comes back to the boat complaining of being attacked by a “frilly” striped fish. As you examine the wound, you notice a single puncture wound on the dorsum of his hand with surrounding erythema. He is complaining of substantial pain. What do you do next?

21. What did we learn today?

22. Summary Lionfish stings are increasing due to increased interaction with people in the Atlantic and Carribean oceans Wounds appears as Field treatment should include immediate removal of spines, analgesia, and immersion in hot water

23. Summary Best prevention is avoidance. However, those wishing to get close should utilize proper equipment (kevlar gloves, knifes, and appropriate catch bag). Lionfish can be tasty!

24. Continuing Education Divers Alert Network –www.DAN.orgwww.DAN.org Undersea and Hyperbaric Medicine Society –http://membership.uhms.orghttp://membership.uhms.org Annals of Emergency Medicine Emedicine/Medscape –http://emedicine.medscape.com/article/77076 4-overviewhttp://emedicine.medscape.com/article/77076 4-overview

25. Additional Information Lionfish Cookbook

26. Any Questions ?