VAPAGuide - Flowcharts

Emergency & clinical flowcharts

Signs and symptoms¹	First aid	Emergency medical treatment	Possible cause	Antivenom²

Local signs of a sting (see below) plus nausea, vomiting, abdominal pain, diarrhoea, urticaria, angio-oedema, bronchospasm, arterial hypotension (see Diagnosis & Treatment: First aid / lay people)		Treatment of immediate-type allergic reactions, including anaphylactic shock	All cnidarians

Unberable local pain; skin lesions with typical ladder-like "cross-hatching pattern" (see Fig. 4.11); cardiac dysfunction (arrhythmias, arterial hypotension), respiratory insufficiency; cardiopulmonary failure within minutes possible (see Chironex fleckeri)	Vinegar (4–6% acetic acid³), see Diagnosis & Treatment: First aid / lay people	Oxygen; commence or continue reanimation; pain: pethidine 1–2 mg/kg body weight, repeat as needed; respiratory insufficiency: endotracheal intubation and artificial respiration (see Diagnosis & Treatment: Hospital	Chironex fleckeri Chiropsalmus quadrigatus	MAVIN Antivenom index

Pain; linear urticarial or papular skin lesions (see Fig. 4.11); cardiac dysfunction (arrhythmias, arterial hypotension), respiratory insufficiency; cardiopulmonary failure within minutes possible (see Physalia physalis); haemolysis			Physalia sp.

Pain, may be minimal; local erythema, may be minimal (see Fig. 4.11); "Irukandji syndrome" (can occur after a delay of up to several hours): cramping abdominal pain, back pain, limb pain, vomiting, state of anxiety, cardiac arrhythmias, arterial hypertension, pulmonary oedema, heart failure (see Carukia barnesi)	Vinegar (4–6% acetic acid³), see Diagnosis & Treatment: First aid / lay people	Oxygen; pain: pethidine; anxiety: diazepam; arterial hypertension: phentolamine 5 mg initially (see Diagnosis & Treatment: Hospital)	Carukia barnesi and various other species

Extremities: acute regional vascular insufficiency distal to the sting (see Diagnosis & Treatment: Hospital)		see Diagnosis & Treatment: Hospital	Various cnidarians (see Diagnosis & Treatment: Hospital)

Extremities: mononeuritis multiplex distal to the sting (see Diagnosis & Treatment: Hospital)		see Diagnosis & Treatment: Hospital	Various cnidarians (see Diagnosis & Treatment: Hospital)

Eyes: pain, conjunctivitis, corneal oedema, iridocyclitis (see Diagnosis & Treatment: Hospital)		see Diagnosis & Treatment: Hospital	Various cnidarians (see Diagnosis & Treatment: Hospital)

Local in the region of the sting: acute (within minutes), painful linear or blotchy urticarial or papulovesicular skin lesions, erythema, (necrosis, ulceration)		Treatment of pain: ice packs (see Diagnosis & Treatment: First aid / lay people); Chironex fleckeri/Chiropsalmus quadrigatus, Physalia sp., Carukia barnesi, see above	All cnidarians

1	See also the Clinical flowchart as a guide to the dynamics of envenoming.
2	See "Essentials of the management of envenoming and poisoning: 9. How is the appropriate antivenom chosen? When is it administered?". If clinical information regarding the efficacy of an antivenom is available, it is presented in the relevant Biomedical database entry.
3	E.g. household vinegar.