Any person, 4 weeks to 15 years, 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 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
- Pre-hospital treatment, including time and type of first aid applied
- Past admissions
- Medical and surgical history
- Known allergies
- Current medications
- Immunisation status
- Current weight
Signs and symptoms
- Localised rash or bite mark
- Generalised 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 protocol
- Signs of envenomation:
- Confusion
- Collapse
- Visual disturbances
- Drooping eyelids (ptosis)
- Difficulty speaking, swallowing or breathing
- Weakness or paralysis
- Respiratory weakness or arrest
- Seizure
- Anxiety, restlessness or feelings of impending doom
- Numbness to lips and tongue (blue-ringed octopus)
- Backache and/or headache
- Shooting pain to the 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 child or adolescent at risk: patient or carer concern, suspected non-accidental injury or neglect, 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 work of breathing Auscultation chest (breath sounds) Oxygen saturation (SpO2) | Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93% Signs of envenomation include respiratory abnormalities |
Circulation
Assessment | Intervention |
---|---|
Perfusion (capillary refill, skin warmth and colour) Heart rate 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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL |
Treating anaphylaxis is a clinical priority. If symptoms are present, switch to anaphylaxis protocol.
Disability
Assessment | Intervention |
---|---|
AVPU | If AVPU shows reduced level of consciousness, continue to assess 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 |
Head-to-toe inspection, including posterior surfaces | See specific treatment section Check and document any abnormalities If a limb is affected, conduct a full set of neurovascular observations |
Fluids
Assessment | Intervention |
---|---|
Hydration status | Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses |
Nausea and/or vomiting | If present, see nausea and/or vomiting section |
Glucose
Assessment | Intervention |
---|---|
BGL |
Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria):
If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose:
|
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 can 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 and 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 the itch.
- Ticks can be present in clothing for hours before attaching. Inspect the clothing thoroughly and instruct the patient's carers 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, generalised rash and a delayed mammalian tick allergy.
- Bluebottle jellyfish stings are painful but usually self-limiting, causing 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 protocol if suspected.
If clinically concerned, consult with 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 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:
- 6 months–1 year: desloratadine 1 mg, orally once daily
- 1–6 years: desloratadine 1.25 mg, orally once daily
- 6–12 years: desloratadine 2.5 mg, orally once daily
- 12 years and over: desloratadine 5 mg, orally once daily or if over 30 kg and can swallow tablets, 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 antihistamine:
- 6 months–1 year: desloratadine 1 mg, orally once daily
- 1–6 years: desloratadine 1.25 mg, orally once daily
- 6–12 years: desloratadine 2.5 mg, orally once daily
- 12 years and over: desloratadine 5 mg, orally once daily or if over 30 kg and can swallow tablets, loratadine 10 mg, orally once daily.
- A cool compress may be applied to the rash to provide symptom relief.
- Avoid topical steroids as they do not alleviate symptoms or reduce the duration of the rash.
Analgesia
Select pain score:
Pain score 1–3 (mild)
Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
Pain score 4–6 (moderate)
Give:
oxycodone (immediate release):
- 1–12 months: 0.05 mg/kg orally once only, maximum dose 0.5 mg
- 12 months and over: 0.1 mg/kg orally once only, maximum dose 5 mg
and/or paracetamol 15 mg/kg, orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
Pain score 7–10 (severe)
Give one of:
Fentanyl intranasal
- 12 months and over: 1.5 microg/kg intranasally, maximum single dose 75 microg and, if required, repeat once after 5 minutes, maximum total dose 3 microg/kg or 150 microg, whichever is less. 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
Morphine IV
- 1–12 months: 0.05 mg/kg IV, maximum single dose 0.5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.1 mg/kg or 1 mg, whichever is less
- 12 months and over: 0.1 mg/kg IV, maximum single dose 5 mg and, if required, repeat once after 5 minutes, maximum total dose 0.2 mg/kg or 10 mg, whichever is less
and/or paracetamol 15 mg/kg orally once only, maximum dose 1000 mg
and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg
If pain does not improve with medication, escalate as per local CERS protocol.
Consider non-pharmacological pain relief (appendix).
Nausea and/or vomiting
If nausea and/or vomiting is present and over 6 months give:
ondansetron:
- 8–15 kg: 2 mg, orally once only
- 15–30 kg: 4 mg, orally once only
- Over 30 kg: 8 mg, orally once only.
Procedural analgesia
For pain relief required during procedures only, not used to replace appropriate analgesia.
Sucrose 24%
- 1–18 months: give 1–2 mL orally per procedure
- Maximum dose:
- 1–3 months: up to 5 mL in 24 hours
- 3–18 months: up to 10 mL in 24 hours.
Repeat as needed up to the maximum dose.
Tetanus
All patients must be considered for a tetanus booster if they have a tetanus-prone wound. Refer to medical or nurse practitioner or nurse immuniser to consider tetanus immunisation requirements.
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: FBC, UEC, troponin
Medications
The patient’s weight is mandatory for calculating fluid and medication doses.
The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.
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 |
---|---|---|---|
6 months–1 year: 1–6 years: 6–12 years: 12 years and over: | Oral | Once daily | |
Fentanyl H, R | 12 months and over: Maximum single dose 75 microg | Intranasal | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Glucose 40% gel | 4 weeks–1 year: 1–5 years: 5 g 6–11 years: 10 g 12 years and over : 15 g | Buccal | Repeat after 15 minutes if required |
Ibuprofen H, R | 3 months and over: Maximum dose 400 mg | Oral | Pain score 1–10 Once only |
12 years and over, can swallow tablets and over 30 kg: | Oral | Once daily | |
Morphine H, R | 1–12 months: 12 months and over: | IV | Pain score 7–10 Repeat once if required after 5 minutes to maximum dose |
Over 6 months and 8–15 kg: 15–30 kg: Over 30 kg: | Oral | Once only | |
1–12 months: 12 months and over: | Oral | Pain score 4–6 Once only | |
0.25–15 L/min, device dependent | Inhalation | Continuous | |
15 mg/kg Maximum dose 1000 mg | Oral | Pain score 1–10 Once only | |
Apply directly onto tick | Topical | Once only | |
20 mL/kg Maximum dose 1000 mL | IV/intraosseous | Bolus Once only | |
1–18 months: Maximum dose 3–18 months: | Oral | Used during procedures only Repeat if required to maximum dose |
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
- Huygelen V, Borra V, De Buck E, et al. Effective methods for tick removal: A systematic review. J Evid Based Med. 2017 Aug;10(3):177-88. DOI: 10.1111/jebm.12257
- Australian Resuscitation Council. The ARC Guidelines. Melbourne, Australia: Australian Resuscitation Council; 2021 [cited 1 Mar 2023]. Available from: https://resus.org.au/the-arc-guidelines/
- 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).2021 [Available from: https://www.uptodate.com/contents/stings-of-imported-fire-ants-clinical-manifestations-diagnosis-and-treatment
- The Sydney Children's Hospital Network. Practice Guidline- Pain Management Australia: NSW Health; 2021 [cited 23 Feb 2023]. Available from: http://webapps.schn.health.nsw.gov.au/epolicy/policy/5610/download
- 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
- Department of Health. Management of tick bites in Australia. Australia: Australia Government 2022 [cited 10 March 2023]. Available from: https://www.health.gov.au/resources/publications/management-of-tick-bites-in-australia?language=en
- NSW Health. Australian Medicines Handbook. Australia: Australian Government, NSW; 2022 [cited 23 Feb 2023]. Available from: https://amhonline.amh.net.au.acs.hcn.com.au/
- NSW Emergency Care Institute. Tick Bite Management. NSW, Australia: NSW Health; 2023 [cited 1 Mar 2023]. Available from: https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-tools/toxicology/tick-bite-management
- NSW Health. AMH Children's Dosing Companion. Australia: Australian Government, NSW; 2023 [cited 23 Feb 2023]. Available from: https://childrens.amh.net.au/auth
- NSW Poisons Information Centre. Pressure Immobilisation. NSW, Australia: NSW Poisons Information Centre; 2023 [cited 1 Mar 2023]. Available from: https://www.poisonsinfo.nsw.gov.au/First-Aid/Pressure-Immobilisation.aspx
- The Sydney Children's Hospital Network. Meds 4 Kids Dosing Guide. Australia: NSW Health; 2023 [cited 23 Feb 2023]. Available from: https://webapps.schn.health.nsw.gov.au/meds4kids/
- 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/paediatric/insect-bites-or-marine-stings