Adult ECAT protocol

Insect bites or marine stings

A6.1 Published: December 2023. Printed on 20 Jun 2024.

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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

AssessmentIntervention

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

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

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

AssessmentIntervention

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

See pathology section

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

AssessmentIntervention
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:

  • drooping of eyelids (ptosis)
  • decrease or paralysis of eye movements (ophthalmoplegia)
  • limb weakness
  • ataxia
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

AssessmentIntervention
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

AssessmentIntervention
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

AssessmentIntervention

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

16–65 years
50 microg
Maximum dose 100 microg

65 years and over:
25 microg
Maximum dose 50 microg

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

Loratadine

10 mg

Oral

Once daily

3 mL via self–administered device

Inhalation

Pain score 7–10

Once only

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

16–65 years
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Pain score 7–10

IV Repeat once if required after 5 minutes
IM Repeat once if required after 60 minutes

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

16–65 years:
5 mg
Maximum dose 10 mg

65 years and over:
2.5 mg
Maximum dose 5 mg

Oral

Pain score 4–6

Repeat once if required after 30 minutes to maximum dose

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

Permethrin cream

Apply directly onto tick

Topical

Once only

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

Sodium chloride 0.9%

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

Hide references

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

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