Any person, 16 years and over, presenting with a bite or sting – excludes snake (sea and land) and spider bites.
For snake and spider bites, switch to snake or spider bite protocol.
This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.
- Apply first aid.
- Complete rapid clinical assessment.
- If signs of envenomation, seek advice from the Poisons Information Centre 13 11 26 or a local clinical toxicologist.
- Risk of anaphylaxis is possible in bites or stings. If signs of anaphylaxis, switch to anaphylaxis or allergic reactions protocol.
History prompts, signs and symptoms
These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.
History prompts
- Presenting complaint
- Onset of symptoms
- Events surrounding presentation
- Type of bite or sting if known
- Time of bite or sting
- Number of bites or stings
- Location and size
- Pain assessment – PQRST
- Pre-hospital treatment, including time and type of first aid applied
- Past admissions
- Medical and surgical history
- Known allergies
- Current medications
Signs and symptoms
- Localised rash or bite mark
- Generalised pain or localised pain
- Swelling
- Erythema
- Itch
Red flags
Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.
Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.
Historical
- Delay in first aid
- Known anaphylaxis to bite or sting
Clinical
- Signs of anaphylaxis, switch to anaphylaxis or allergic reactions protocol
- Signs of envenomation:
- Confusion
- Collapse
- Visual disturbances
- Drooping eyelids (ptosis)
- Difficulty speaking, swallowing or breathing
- Seizure
- Weakness or paralysis
- Respiratory weakness or arrest
- Anxiety, restlessness or feelings of impending doom
- Numbness to lips and tongue (blue-ringed octopus)
- Backache and/or headache
- Shooting pain to affected limb, chest or abdomen
- Nausea, vomiting and/or abdominal pain
- Swollen or tender lymphatic glands at the groin or axilla of the bitten limb
Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.
Clinical assessment and specified intervention (A to G)
If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.
Position
| Assessment | Intervention |
|---|---|
General appearance/first impressions | Position of comfort Pressure immobilisation is required for blue-ringed octopus bites and cone snail/shell stings. Apply promptly or leave in situ if already placed and lay patient flat |
Airway
| Assessment | Intervention |
|---|---|
Patency of airway | Maintain airway patency Consider airway opening manoeuvres and positioning |
Breathing
| Assessment | Intervention |
|---|---|
Respiratory rate and effort Auscultate chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation, as clinically indicated Consider oxygen if dyspnoeic. Titrate oxygen to maintain SpO2 over 93% Patients at risk of hypercapnia, maintain SpO2 at 88–92% Signs of envenomation include respiratory abnormalities |
Circulation
| Assessment | Intervention |
|---|---|
Perfusion (capillary refill, skin warmth and colour) Pulse Blood pressure Cardiac rhythm | Assess circulation Attach cardiac monitor if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern Consider 12 lead ECG |
| IVC and/or pathology | Insert IV cannula, if trained and clinically indicated If unable to obtain IV access, consider intraosseous, if trained |
Signs of shock: tachycardia and CRT 3 seconds and over and/or abnormal skin perfusion and/or hypotension | If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved |
Treating anaphylaxis is a clinical priority. If symptoms are present, switch to anaphylaxis or allergic reactions protocol.
Disability
| Assessment | Intervention |
|---|---|
| ACVPU | If ACVPU shows reduced level of consciousness, continue to GCS, pupillary response and limb strength |
GCS, pupillary response and limb strength | Obtain baseline and repeat assessment as clinically indicated Assess for signs of envenomation or neurotoxic paralysis, such as:
|
| Pain | Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment Sea urchin, jellyfish, bluebottle, stingray or stonefish: immerse the affected area in tolerably hot water, 45°C, for up to 20 minutes. Remove for a short time. If symptoms persist repeat until the pain subsides |
Exposure
| Assessment | Intervention |
|---|---|
| Temperature | Measure temperature |
| Skin inspection, including posterior surfaces | See specific treatment section for further information Check and document any abnormalities If a limb is affected, conduct a full set of neurovascular observations |
Fluids
| Assessment | Intervention |
|---|---|
| Hydration status: last ate, drank, bowels opened, passed urine or vomited | Commence fluid balance chart, as required |
| Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
| Assessment | Intervention |
|---|---|
BGL | Measure BGL, if clinically indicated If less than 4 mmol/L, consider hypoglycaemia protocol |
Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.
Focused assessment
No specific focused assessment. Use clinical judgement and A to G assessment to determine focused assessment.
Precautions and notes
- Insect and marine bites and stings have the potential to cause an anaphylactic reaction. Treatment of anaphylaxis is a clinical priority.
- Symptoms of envenomation may not be immediately present, and may develop over 60 minutes to several hours.
- Severe envenomation may cause stomach pain, nausea, vomiting, headache, muscle pain, weakness, drowsiness, difficulty breathing, cardiac arrhythmias and cardiac arrest.
- The treatment for most bites and stings is symptomatic. Antihistamines may provide some relief from itch.
- Ticks can be present in clothing for hours before attaching. Inspect the clothing thoroughly and instruct the patient to wash the clothing in hot water to kill any remaining ticks.
- The Australian paralysis tick can cause ataxia and an ascending flaccid paralysis similar to Guillain-Barre syndrome. Cranial nerve palsies may also occur causing ophthalmoplegia or facial paralysis similar to Bell’s palsy.
- Symptoms may progress after removal of the tick for 24–48 hours.
- Other tick bite symptoms may include: arthralgia, fever, lethargy, anorexia, a generalised rash and a delayed mammalian tick allergy.
- Bluebottle jellyfish stings are painful but usually self-limiting. They cause inflammation of the skin, e.g. erythema and swelling.
Interventions and diagnostics
Specific treatment
Venomous bites and stings
For all venomous and unfamiliar insect bites and marine stings, or if clinically concerned, consult with the Poisons Information Centre 13 11 26 or a local clinical toxicologist.
Monitor for signs of envenomation or shock.
Select:
Blue-ringed octopus and cone snail (cone shell)
- Apply pressure bandage with immobilisation.
- Use a broad 15 cm elasticised bandage. The bandage is applied over the bite site and then distally to proximally, covering the whole limb.
- Leave the bandage in situ if already placed, or reinforce it if the current bandage is inadequate.
Stonefish
- For pain relief, immerse the affected area in tolerably hot water, or shower, 45°C, for up to 20 minutes.
- Observe for signs of shock.
Box jellyfish
- The box jellyfish, including the Irukandji, can be found in NSW waters. If a box jellyfish sting is suspected the area should be rinsed with vinegar and the tentacles removed.
- Monitor for signs of envenomation.
Non-venomous bites and stings
Non-venomous bites and stings have the potential to cause anaphylaxis and/or severe pain. Switch to anaphylaxis or allergic reactions protocol if suspected.
If clinically concerned, consult the Poisons Information Centre 13 11 26 or a local clinical toxicologist.
Select:
Sea urchins, jellyfish, bluebottle or stingray
- Sea urchins: remove visible spines, which may be segmented and fall apart. Do not attempt to remove deeply penetrated spines. Local or regional anaesthesia may be required.
- Jellyfish and bluebottle: wash off any remaining tentacles.
- Stingray: superficial barb can be removed, if safe to do so. For any barbs penetrating the chest or abdomen, or deeply penetrating, escalate as per local CERS protocol.
Immerse the affected area in tolerably hot water, 45°C, for up to 20 minutes. Remove for a short time. If symptoms persist, repeat until the pain subsides.
Insect bites or stings, excluding tick bites
- Remove the sting by pulling it out or scraping it away if in situ.
- Wash the area with water and keep the area clean and dry.
- Apply a cold pack at 20–minute intervals, alternating off and on, to the bite site, for pain relief and to reduce swelling.
- Provide analgesia.
- For itch, give loratadine 10 mg orally once daily.
Tick bite
- If the patient has a history of allergic reactions to tick bites, the tick should only be removed where resuscitation facilities are readily available.
- Cover the tick with an ether-containing spray or permethrin cream.
- Do not attempt to remove the tick with tweezers as the head can pull off and remain embedded.
- Wait approximately 10 minutes for the tick to die, then carefully brush off.
- Assess patients for additional ticks, particularly scalp and flexures.
- Check patient clothing for ticks.
Urticarial rash
- For isolated urticaria provide symptomatic relief, e.g. analgesia or cold pack.
- Give loratadine 10 mg orally once daily.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
Pain score 4–6 (moderate)
Give:
oxycodone (immediate release):
- 16–65 years: 5 mg orally and, if required, repeat once after 30 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg orally and, if required, repeat once after 30 minutes, maximum dose 5 mg
and/or paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
Pain score 7–10 (severe)
Give one of:
Fentanyl intranasal
- 16–65 years: 50 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 100 microg. Dose to be divided between nostrils
- 65 years and over: 25 microg intranasally and, if required, repeat once after 5 minutes, maximum dose 50 microg. Dose to be divided between nostrils
Note: ensure an extra 0.1 mL is drawn up for the first dose to account for the dead space in the mucosal atomiser device
Fentanyl IV
- 16–65 years: 50 microg IV and, if required, repeat once after 5 minutes, maximum dose 100 microg
- 65 years and over: 25 microg IV and, if required, repeat once after 5 minutes, maximum dose 50 microg
Morphine IV
- 16–65 years: 5 mg IV and, if required, repeat once after 5 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IV and, if required, repeat once after 5 minutes, maximum dose 5 mg
Morphine IM
- 16–65 years: 5 mg IM and, if required, repeat once after 60 minutes, maximum dose 10 mg
- 65 years and over: 2.5 mg IM and, if required, repeat once after 60 minutes, maximum dose 5 mg
Methoxyflurane
- Using a 3 mL self-administered device, instruct the patient to inhale through the mouthpiece and take a couple of gentle breaths to get used to the fruity smell and taste; then take 6–8 deep breaths once only
and/or paracetamol 1000 mg orally once only
and/or ibuprofen 400 mg orally once only
If pain does not improve with medication, escalate as per local CERS protocol.
Nausea and/or vomiting
If nausea and/or vomiting is present, give:
- metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
- or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
- or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only
Choice of antiemetic should be determined by cause of symptoms.
Tetanus
If patient has a ‘tetanus-prone’ wound, consider giving a tetanus booster vaccine.
- Diphtheria and tetanus (ADT booster) vaccine should be given as per the Australian Immunisation Handbook Guide for tetanus prophylaxis in wound management.
- If ADT booster is not available then diphtheria/tetanus/pertussis (Boostrix) vaccine can be used.
- If no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine: refer to medical or nurse practitioner or nurse immuniser.
- If pregnant or breastfeeding: dTpa vaccine (diphtheria-tetanus-acellular pertussis) is recommended. Refer to medical or nurse practitioner or nurse immuniser.
Radiology
Radiology will depend on the working diagnosis. It needs to be requested by a medical or nurse practitioner. If there is concern for urgent radiology, escalate as per local CERS protocol.
Pathology
- Seriously unwell person: FBC, UEC, troponin
Medications
The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.
Drag the table right to view more columns or turn your phone to landscape
| Drug | Dose | Route | Frequency |
|---|---|---|---|
0.5 mL | IM | Once only | |
OR | |||
0.5 mL | IM | Where ADT booster not available Once only | |
Fentanyl H, R | 16–65 years: 65 years and over: | IV/intranasal | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Ibuprofen H, R | 400 mg | Oral | Pain score 1–10
Once only |
10 mg | Oral | Once daily | |
3 mL via self–administered device | Inhalation | Pain score 7–10 Once only | |
Over 20 years: | Oral/IV/IM | Once only | |
Morphine H, R | 16–65 years:
65 years and over: | Pain score 7–10 | |
| IV | Repeat once if required after 5 minutes | ||
| IM | Repeat once if required after 60 minutes | ||
4 mg Maximum dose 8 mg | Oral/IV/IM | Repeat once if required after 60 minutes | |
16–65 years:
65 years and over: | Oral | Pain score 4–6 Repeat once if required after 30 minutes to maximum dose | |
Oxygen | 2–15 L/min, device dependent | Inhalation | Continuous |
1000 mg | Oral | Pain score 1–10 Once only | |
Apply directly onto tick | Topical | Once only | |
5 mg | Oral | Once only | |
OR | |||
12.5 mg | IV/IM | Once only | |
250 mL Maximum dose 1000 mL | IV/intraosseous | Bolus Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved | |
Medications with contraindications or requiring dose adjustment are marked:
- H for patients with known hepatic impairment
- R for patients with known renal impairment.
Escalate to medical or nurse practitioner.
References
- Australian Resuscitation Council. ANZCOR Guideline 9.4.3 – Envenomation from Tick Bites and Bee, Wasp and Ant Stings. Melbourne, Australia: Australian Resuscitation Council; 2021 [cited 16 February 2023]. Available from: https://www.resus.org.nz/assets/Uploads/ANZCOR-Guideline-9.4.3-Envenomation-from-Tick-Bites-and-Bee-Wasp-and-Ant-Stings-Nov-2021.pdf
- Beasley R, Chien J, Douglas J, et al. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: ‘Swimming between the flags’. Respirology. 2015 Nov;20(8):1182-91. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26486092
- de Shazo RD, Williams DF, Goddard J, et al. Stings of imported fire ants: clinical manifestations, diagnosis, and treatment. UpToDate, Waltham, MA (Accessed on 4 Mar 2016). 2013.
- MIMS Australia. Clinical Resources. Australia: MIMS Australia Pty Ltd; 2022 [cited 2 Feb 2023]. Available from: https://www.mimsonline.com.au.acs.hcn.com.au/Search/Search.aspx
- Emergency Care Institute and Agency for Clinical Innovation. Bites and stings. NSW, Australia: Agency for Clinical Innovation; 2023 [cited 15 February 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/bites-and-stings
- Needham GR. Evaluation of five popular methods for tick removal. Pediatrics. 1985 Jun;75(6):997-1002. Available from: https://www.ncbi.nlm.nih.gov/pubmed/4000801
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 13 Apr 2022]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- NSW Health. Ticks. NSW, Australia: NSW Government; 2022 [cited 16 February 2023]. Available from: https://www.health.nsw.gov.au/environment/pests/parasites/Pages/ticks.aspx
- NSW Poisons Information Centre. Bites and Stings. Australia: NSW Government; 2023 [cited 16 February 2023]. Available from: https://www.poisonsinfo.nsw.gov.au/
- Pitches DW. Removal of ticks: a review of the literature. Weekly releases (1997–2007). 2006 Aug 17;11(33):3027. Available from: https://www.eurosurveillance.org/content/10.2807/esw.11.33.03027-en
- Therapeutic Guidelines Ltd. Removal of Ticks. Australia: eTG; 2022 [cited 21 June 2023]. Available from: https://tgldcdp.tg.org.au.acs.hcn.com.au/viewTopic?etgAccess=true&guidelinePage=Wilderness%20Medicine&topicfile=altitude-illness&guidelinename=auto§ionId=c_WMG_Tick_bite_topic_4#c_WMG_Tick_bite_topic_4
| Evidence informed |
Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process. |
| Collaboration |
This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol. |
| Currency | Due for review: Jan 2026. Based on a regular review cycle. |
| Feedback | Email ACI-ECIs@health.nsw.gov.au |
Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/insect-bites-marine-stings