Are we using the correct first aid for jellyfish?

In this issue of the MJA, Isbister and colleagues report that hot water immersion was no more effective than ice packs for treating the pain of stings by the box jellyfish (Chironex fleckeri).1 This finding is surprising, as jellyfish venoms are heat-labile,2 but unsurprising, given that heat treatment for some patients did not begin until 4 hours after the patient was stung. Managing jellyfish stings is generally subject to confusion, and official advice needs revising to make it clear, consistent and effective. The current Australian Resuscitation Council (ARC) guidelines for treating jellyfish envenoming3 encourage this confusion by suggesting that people stung while swimming in temperate waters (south of Bundaberg) should use heat immersion to reduce pain (based on a randomised controlled trial of treatment for bluebottle stings4), but those envenomed in tropical waters (north of Bundaberg) should be treated with ice. The guidelines also advise that vinegar should be used to minimise envenoming only in tropical areas — unless it is clear that the patient has been stung by a bluebottle, in which case vinegar should never be used. Which treatment should you use if you are stung while swimming at Bundaberg? The answer is, at present, uncertain, and urgently requires investigation.