Paeds · acute-care-resuscitation-and-toxicology
Envenomation and marine bites
Also known as Snake bite · Funnel-web spider bite · Redback spider bite · Box jellyfish sting · Irukandji syndrome · Stingray injury · Pressure-immobilisation bandage
Fellowship guide to envenomation and marine bites in children: pressure-immobilisation first aid for snakes and funnel-web spiders, venom-induced consumption coagulopathy and neurotoxicity, Australian snake antivenom dosing, funnel-web and redback spider envenomation, box jellyfish and Irukandji syndromes, and hot-water first aid for stingray and stonefish injuries.
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Target exams
Red flags
- Child bitten by an Australian elapid snake with any systemic feature or an unrecordable INR — give snake antivenom intravenously and do not wait for full results
- Limb bandaged for a suspected snake or funnel-web bite — keep the pressure-immobilisation bandage in place until envenomation is excluded by repeated blood tests
- Snake or funnel-web bite with drooping eyelids, double vision, or trouble swallowing or breathing — evolving neurotoxicity needing airway support and antivenom
- Tropical child stung at sea with immediate agonising pain and whip-like skin marks — box jellyfish sting; douse with vinegar, call help, prepare for cardiorespiratory collapse
- Minor jellyfish sting followed twenty to forty minutes later by severe back and chest pain, sweating and hypertension — Irukandji syndrome; admit for analgesia and cardiac monitoring
- Child collapse minutes after a coastal sting in northern Australia — assume box jellyfish envenomation and start cardiopulmonary resuscitation while antivenom is given
- Puncture wound to the chest or abdomen from a stingray — penetrating trauma with vascular and cardiac injury; manage as major trauma, not just a sting
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- Recognition and first aid for the envenomed child, including the pressure-immobilisation bandage for snake and funnel-web spider bite
- Safe use of Australian snake and spider antivenoms and the indications for each
- Initial management of jellyfish and marine stings with vinegar and hot water
- Resuscitation of severe neurotoxic and coagulopathic snake envenomation and funnel-web spider bite
- Diagnosis and management of venom-induced consumption coagulopathy, myotoxicity and thrombotic microangiopathy
- Management of box jellyfish cardiorespiratory collapse and Irukandji syndrome
- The four clinical syndromes of Australian elapid envenomation and their defining tests
- Pressure-immobilisation first aid and which creatures it does and does not apply to
- Antivenom indications, dosing, adverse reactions and the limited role of redback antivenom
- Short case: the child with a suspected snake bite and an unrecordable INR
- Communication: explaining antivenom risk and the observation strategy to the family
- Acute care: first aid and hospital management of the envenomed child
- Pharmacology: indications and risks of antivenom therapy
- Public health: prevention of snake, spider and jellyfish envenomation
- The pressure-immobilisation technique and the creatures for which it is indicated
- Venom-induced consumption coagulopathy and its laboratory pattern
- Jellyfish syndromes — box jellyfish, Irukandji and bluebottle — and their first aid
- Resuscitation scenario: funnel-web spider bite with neurotoxicity
- Communication: breaking bad news after a fatal box jellyfish sting
- Management of snake, spider and marine envenomation in children
- Pressure-immobilisation first aid and antivenom indications
- Marine envenomation first aid with vinegar and hot water
- Patient Care: resuscitation of the envenomed child and safe antivenom use
- Medical Knowledge: venom-induced consumption coagulopathy and neurotoxicity
- Systems-Based Practice: retrieval, toxinology and poisons information support in remote regions
- Medical Expert: management of snake, spider and marine envenomation
- Collaborator: retrieval and toxinology referral for the envenomed child
- Health Advocate: prevention and water-safety education in tropical and remote communities
Overview & Definition
A seven-year-old is carried into a country emergency department an hour after stepping on a brown snake in long grass, an armband tight on his bitten forearm and a worried father beside him, and a toddler arrives screaming from a north Queensland beach with angry whip-marks across her legs. These are the two faces of paediatric envenomation, and the first decisions — the right bandage, right fluid, right antidote — decide the outcome. Envenomation is the process by which animal venom causes harmful effects after a bite or sting, and in the Australian and tropical context the creatures that matter are the terrestrial elapid snakes, the funnel-web and redback spiders, the box and Irukandji jellyfish, and the spined marine animals such as the stingray and stonefish. [1] [12]
The uniting principle is that envenomation is a time-dependent, toxin-driven emergency in which a child's smaller body mass means a given venom load reaches effective concentration sooner and at lower volumes than in an adult, so children are often more severely affected. The first-aid manoeuvre must match the creature — a pressure-immobilisation bandage for snakes, funnel-web spiders, blue-ringed octopus and cone snails whose venom travels in lymph, but hot water for the heat-labile venoms of the stingray, stonefish and bluebottle, and vinegar for the box jellyfish whose nematocysts keep discharging. The hospital response then searches for the venom's target organ — coagulation, nerve, muscle, kidney, or heart — and gives antivenom only when there is clinical or laboratory evidence of that injury. [5] [9]
Two ideas carry the whole topic. The first is that antivenom is a specific but hazardous treatment, given for proven envenomation rather than prophylactically, because every antivenom is a foreign protein that can cause immediate hypersensitivity or serum sickness. The second is that the observation strategy is as important as the antidote, because many snake bites are dry or minimally envenomating, and because the coagulopathy, myotoxicity and neurotoxicity declare themselves over hours that must not be cut short. [1] [6]
References12ShowHide
- [1]Johnston CI, Ryan NM, Page CB, et al. The Australian Snakebite Project, 2005-2015 (ASP-20). Med J Aust, 2017.PMID 28764620
- [2]Johnston CI, O'Leary MA, Isbister GK. Australian taipan (Oxyuranus spp.) envenoming: clinical effects and potential benefits of early antivenom therapy - Australian Snakebite Project (ASP-25). Clin Toxicol (Phila), 2017.PMID 27903075
- [3]Johnston CI, Isbister GK. Australian snakebite myotoxicity (ASP-23). Clin Toxicol (Phila), 2021.PMID 33156703
- [4]Abouyannis M, Marriott AE, et al. Handheld Point-of-Care Devices for Snakebite Coagulopathy: A Scoping Review. Thromb Haemost, 2025.PMID 39214143
- [5]Little M. Harm due to the use of pressure bandage immobilisation in patients bitten by snakes in Australia. Clin Toxicol (Phila), 2023.PMID 37668172
- [6]Isbister GK, Fan HW. Spider bite. Lancet, 2011.PMID 21762981
- [7]Isbister GK, Gray MR, et al. Funnel-web spider bite: a systematic review of recorded clinical cases. Med J Aust, 2005.PMID 15850438
- [8]Isbister GK, Page CB, Buckley NA, et al. Randomized controlled trial of intravenous antivenom versus placebo for latrodectism: the second Redback Antivenom Evaluation (RAVE-II) study. Ann Emerg Med, 2014.PMID 24999282
- [9]Currie B. Clinical implications of research on the box-jellyfish Chironex fleckeri. Toxicon, 1994.PMID 7886690
- [10]Nickson CP, Waugh EB, Jacups SP, Currie BJ. Irukandji syndrome case series from Australia's Tropical Northern Territory. Ann Emerg Med, 2009.PMID 19409658
- [11]McGee RG, Webster AC, Lewis SR, et al. Interventions for the symptoms and signs resulting from jellyfish stings. Cochrane Database Syst Rev, 2023.PMID 37272501
- [12]Berling I, Isbister G. Marine envenomations. Aust Fam Physician, 2015.PMID 25688956