Whether the melt-water from ice applied directly to the skin can stimulate the discharge of nematocysts has
not been determined. Applications of hot packs or gentle rinses with hot water are not recommended because
they may worsen the pain of the envenomation.
2. Acetic acid 5% (vinegar) is the treatment of choice to inactivate Chironex fleckeri toxin. Vinegar will not
alleviate the pain from a Chironex sting but interrupts the envenomation. It may not be extremely effective
against Chrysaora or Cyanea. The detoxicant should be applied continuously for at least 30 minutes or until
the pain is relieved. A sting from the Australian Physalia physalis, a relatively recently-differentiated species,
should not be doused with vinegar, as this may cause discharge of up to 30% of nematocysts.
For a sting from Chironex fleckeri, if the pressure-immobilization technique for venom sequestration is going
to be used, the bandage should be applied as soon as possible (see below). If vinegar is immediately available,
a liberal dousing should occur and at least 30 seconds should pass before removing the tentacles. After the
tentacles are removed, proceed at once with pressure-immobilization. If vinegar is not available, remove the
tentacles before applying pressure-immobilization. A venolymphatic occlusive tourniquet should be
considered only if a topical detoxicant and pressure-immobilization is unavailable, the victim suffers from a
severe systemic reaction, and transport to definitive care is delayed.
For stings from other species, there are substances that may be more specific and therefore, more effective.
Depending on the species, these include isopropyl alcohol (40% to 70%), dilute ammonium hydroxide,
sodium bicarbonate (particularly for stings of the sea nettle Chrysaora quinquecirrha), olive oil, sugar, urine,
and papain (papaya latex [juice] or unseasoned meat tenderizer powdered or in solution). The last is supposed
to work by cleaving active polypeptides into nontoxic amino acids. Ammonia has been noted to be relatively
ineffective for stings of Carybdea marsupialis in the Adriatic Sea.
Perfume, aftershave lotion, and high-proof liquor are not particularly efficacious and may be detrimental.
Other substances mentioned to be effective at one time or another, but which are to be condemned on the
basis of inefficacy and toxicity, are organic solvents such as formalin, ether, and gasoline.
There is recent evidence that alcohol may stimulate the discharge of nematocysts in vitro; the clinical
significance is as yet undetermined. The rescuer must remember that pain relief may not equate with
nematocyst inhibition.
A commercial aqueous solution of aluminum sulfate 20% and 11% anionic surfactant in aqueous solution
(Stingose) has sometimes been mentioned as effective on the basis that the aluminum ion interacts with
proteins and long-chain polysaccharide components to denature and inactivate venom. Prior treatment with
topical alcohol or methylated spirits reduces the effectiveness of aluminum sulfate solution. This product
seems to have fallen out of favor with clinician jellyfish experts in Australia.
3. No systemic drugs (other than antivenom for a Chironex envenomation) are of verifiable use.
Ephedrine, atropine, calcium, methysergide, and hydrocortisone have all been touted at one time or another,
but no proof exists that they help. Antihistamines may be useful if there is a significant allergic component.
The administration of epinephrine is appropriate only in the setting of anaphylaxis.
4. Immersing the area in hot water is generally not recommended; the hypotonic solution causes
nematocysts to discharge.
5. Once the wound has been soaked with a decontaminant (eg, vinegar), remaining (and often
"invisible") nematocysts must be removed. The easiest way to do this is to apply shaving cream or a paste of
baking soda, flour, or talc and to shave the area with a razor or similar tool. If sophisticated facilities are not
available, the nematocysts should be removed by making a sand or mud paste with seawater and using this to
help scrape the victim's skin with a sharp-edged shell or piece of wood. The rescuer must take care not to
become envenomed; bare hands must be rinsed frequently. If a scrub brush or pad has been used to treat the
envenomation, this step may not result in as much, if any, clinical improvement.
6. A topical anesthetic ointment (lidocaine, 2.5%) or spray (benzocaine, 14%), antihistaminic cream
(diphenhydramine or tripelennamine), or mild steroid lotion (hydrocortisone, 1%) may be soothing. These are
used after the toxin is inactivated. Paradoxical reactions to benzocaine are rarely noted.
7. Victims should receive standard antitetanus prophylaxis.
8. Prophylactic antibiotics are not automatically indicated. Each wound should be checked at 3 and 7
days after injury for infection. Any ulcerating lesion should be cleaned three times a
