Snake or spider bite

Any person, 4 weeks to 15 years, presenting with a suspected or confirmed bite from a snake or spider.

Escalate immediately as per local CERS protocol for all snake and suspected funnel-web spider bites.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

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.

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 Keep immobile

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning If airway adjuncts are required, insert gently and consider the potential for bleeding

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Consider auscultation of chest (breath sounds) Oxygen saturation (SpO2)	Assist ventilation as clinically indicated Apply oxygen to maintain SpO2 over 93%

Circulation

Assessment	Intervention
Snake or funnel-web spider bite	Apply pressure bandage with immobilisation (PBI) 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 bandage in situ if already placed, or reinforce if current bandage is inadequate Hourly neurovascular observations of the affected limb to ensure perfusion is maintained Include assessment of sensation, motor function and perfusion, i.e. pulses, colour, temperature, swelling and capillary refill
Redback spider bite	A pressure bandage is not recommended, and will only make the pain worse Cold packs or heat packs may help relieve pain
Bleeding	Look for bleeding from the bite site, cannulation site and occult sites, e.g. gastrointestinal, urinary or intracranial sites Consider as a sign of envenomation
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 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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
GCS, pupillary response and limb strength	Obtain baseline and repeat assessment as clinically indicated Consider altered conscious state as a sign of envenomation
Pain	Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

Assessment	Intervention
Temperature	Measure temperature
Head-to-toe inspection, including posterior surfaces	Look for bite sites, but do not remove pressure bandage Palpate lymph nodes for tenderness

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
Nausea and/or vomiting	If present, consider envenomation and see nausea and/or vomiting section Antivenom takes precedence over symptom management

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): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete a cardiovascular focused assessment.

Complete a neurological focused assessment.

Precautions and notes

• See NSW Health Snake and Spider Bite Clinical Management Guidelines.
• Do not remove pressure bandage with immobilisation (PBI) until:
  • antivenom is readily available
  • a medical review has occurred
  • there are no clinical signs of envenomation
  • laboratory investigations have occurred and bloods have returned to normal.
• Risk of anaphylaxis with antivenom is highest in the first hour post administration.

Snake bite

• A snake bite observation chart is recommended for recording specific signs associated with snake bites or envenomation.
• Snake bite victims with significant coagulopathy: IM injections should usually be avoided, except for Boostrix or ADT booster.
• Point of care testing (PoCT) devices are inaccurate in testing for INR, aPTT and D-dimer in snake bite and should not be used.
• Patients with a suspected snake bite must be transferred to a hospital with formal laboratory facilities unless an INR can be done locally with a result available within 2 hours. However, if systemic envenomation is evident, antivenom should be given before transfer. Be prepared to manage anaphylaxis and discuss with the Poisons Information Centre 13 11 26 or local clinical toxicologist if this occurs.

Interventions and diagnostics

Specific treatment

• Treatment is focused on determining if patient is envenomed and what treatment is required. This is done in consultation with a local medical practitioner and the Poisons Information Centre 13 11 26 or local clinical toxicologist.
• Identification of the snake should only be done by experts. Snake handlers may be able to assist in the identification of snakes. However, Australian snakes have overlapping shapes, sizes and colours and non-expert identification is generally incorrect.
• Systemic envenomation: prepare for administration of antivenom.
• Venom-induced consumptive coagulopathy (VICC) – life-threatening bleed: consider early administration of fresh frozen plasma (FFP) if actively bleeding, in consultation with a medical practitioner and local clinical toxicologist.
• Funnel-web spider envenomation: prepare for administration of antivenom.
• Redback spider envenomation: provide effective analgesia.
• Antivenom administration: if patient proceeds to antivenom administration, prepare equipment to manage anaphylaxis. Consider anaphylaxis or allergic reaction protocol.

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Analgesia

Select pain score:

• 1–3 (mild)
• 4–6 (moderate)
• 7–10 (severe)

Consider non-pharmacological pain relief (appendix).

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Nausea and/or vomiting

If nausea and/or vomiting is present and over 6 months give:

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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.

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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.

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Radiology

Not usually indicated. If there is concern for urgent radiology, escalate care as per local CERS protocol.

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Pathology

Snake bite

• Point of care cannot be used. Formal laboratory testing is needed.
• FBC, UEC, CK
• Coags including INR, aPTT, fibrinogen and d-Dimer
• Urinalysis: collect and check for blood which may indicate myoglobinuria or haemoglobinuria

Funnel-web spider bite

• Experiencing extreme hypertension or is hypotensive: 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.

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.

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