Emergency Flowchart

Signs and symptoms¹	First aid²	Emergency medical treatment³	Possible culprit	Antivenom⁴


Local signs of a sting (see below) plus nausea, vomiting, abdominal pain, diarrhoea, urticaria, angio-oedema, bronchospasm, arterial hypotension.	ANZOR Guidelines Other regional / national guidelines	Treatment of immediate-type allergic reactions, including anaphylactic shock	All cnidarians

Unberable local pain; Skin lesions with typical ladder-like "cross-hatching pattern". Cardiac dysfunction (arrhythmias, arterial hypertension), Respiratory insufficiency; Cardiopulmonary failure within minutes possible. Clinical entries: Chironex sp., Chiropslamus sp.		Oxygen; Pain control; Commence or continue reanimation; Endotracheal intubation and artificial respiration. ANZCOR Guidelines Other regional / national guidelines	Chironex fleckeri Chiropsalmus quadrigatus	BOX JELLYFISH ANTIVENOM (Australia).

Pain; Linear urticarial or papular skin lesions; Cardiac dysfunction / respiratory insufficiency; Haemolysis Rhabdomyolysis (?) Clinical entries: Physalia sp.		Oxygen; Pain control; Commence or continue reanimation; Endotracheal intubation and artificial respiration. ANZCOR Guidelines Other regional / national guidelines	Physalia sp.

Pain, may be minimal; Local erythema, may be minimal; "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. Clinical entries: Carukia sp.⁵		Oxygen; Pain control; Anxiety control; Treatment of (severe) arterial hypertension and related complications. ANZCOR Guidelines Other regional / national guidelines	Carukia barnesi and various other species

Extremities: acute regional vascular insufficiency distal to the sting.		General principles of treatemnt of regional vascular insufficiency	Various cnidarians

Eyes: pain, conjunctivitis, corneal oedema, iridocyclitis.		General principles of treatemnt of eye lesions	Various cnidarians

Local effects in the region of the sting: acute (within minutes), painful linear or blotchy urticarial or papulovesicular skin lesions, erythema, (necrosis, ulceration)		Pain control alone in non-systemic envenoming. In jelyyfish causing systemic envenoming see above.	All cnidarians

1	See also Clinical flowchart as a guide to the dynamics of envenoming.
2+3	Due to the high regional diversity of jellyfish, the unpredictable dynamics caused by global warming and the uncertainty of the evidence base for the various recommendations, we refer to regional/national guidelines. We recommend to follow-up developments of the evidence carefully.
4	Follow up changes regarding indication and new products
5	Other species carybdeid jellyfish that may cause Irukandji syndrome (Gershwin et al 2013: “Table 1.2 Summary of ecology and syndrome characteristics of species known or believed to cause Irukandji syndrome”; Tibballs et al 2012; Debate: Little et al 2006, Gershwin 2006, Fenner 2006): Alatina mordens, Carukia shinju, Carybdea alata, Carybdea rastonii, Carybdea xaymacana, Malo maxima, Malo kingi, Alatina mordens, Gerongia rifkinae, and Morbakka fenneri