To begin, shuffle the double-faced piranha cards and give each player one, along with five bandage tokens. Place the top card from the draw pile in the middle of the table. On your turn, place your card on the table, either face up, then flip over all other cards of the same color. If ten or more piranhas of the same color are visible, that swarm attacks you, costing you tokens based on the size of the piranha group. Draw a card to end your turn.

When a player runs out of tokens, the game ends, and the player with the most tokens wins.

Piranha Flip includes a cooperative variation.