Beruflich Dokumente
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ARTICLE
Department of Emergency Medicine, Chang-Gung Memorial Hospital, Taoyuan, Taiwan, Republic of China
2
Department of Emergency Medicine, Chang-Gung Memorial Hospital, Keelung, Taiwan, Republic of China
3
College of Medicine, Chang-Gung University, Taoyuan, Taiwan, Republic of China
Objective. To compare the effectiveness of ice packs and hot water immersion for the treatment of centipede envenomations. Methods.
Sixty patients envenomated by centipedes were randomized into three groups and were treated with ice packs, hot water immersion, or
analgesia injection. The visual analog score (VAS) for pain was measured before the treatment and 15 min afterward. Demographic data
and data on local and systemic effects after centipede bites were collected. The VAS scores and the pain decrease ( VAS) were compared
between the three groups. Results. All patients suffered from pain at the affected sites; other local effects included redness (n = 49, 81.7%),
swelling (n = 32, 53.3%), heat (n = 14, 23.3%), itchiness (n = 5, 8.3), and bullae formation (n = 3, 5.0%). Rare systemic effects were
reported. All three groups had similar VAS scores before and after treatment. They also had similar effectiveness in reducing pain caused
by centipedes bites ( VAS = 2.55 ± 1.88, 2.33 ± 1.78, and 1.55 ± 1.68, with ice packs, analgesia, and hot water immersion, respectively, p
= 0.165). Conclusion. Ice packs, hot water immersion, and analgesics all improved the pain from centipede envenomation. Ice pack
treatment is a safe, inexpensive, and non-invasive method for pre-hospital management in patients with centipede envenomation.
standardized question forms. whereas his electrocardiogram showed normal sinus rhythm,
Except for the interventions mentioned above, all patients two patients had generalized urticaria, and three patients expe-
received a 0.5 mL tetanus toxoid intramuscular injection, a rienced dizziness without significant neurological deficit. There
diphenhydramine 30 mg intramuscular injection, proper wound was no headache, fever, or hypotension. There was no statistical
care, and take-home medications, including analgesics if their pain difference in the estimated length of the centipedes, the
was not completely diminished. Patients who were still in severe symptom onset time, or time of arrival in the ED.
pain after the above interventions could receive further treatments Table 2 describes the VAS1, VAS2, and VAS scores. There
as needed and decided upon by the duty ED physician. All patients were no statistically significant differences in VAS1 (p = 0.679)
were followed up after 1 week for complications of the disease and VAS2 (p = 0.885) between the three groups. The VAS
and/or adverse effects of the above interventions. scores were 2.55 ± 1.88, 2.33 ± 1.78, and 1.55 ± 1.68 in the ice
All the data were analyzed using SPSS (Version 14). The first packing, analgesia, and hot water immersion groups,
and second VAS scores (VAS1, VAS2, respectively) of each respectively (p = 0.165). All three groups had their VAS reach
group were compared using a paired t-test. One-way analysis of statistical significance. However, there seemed to be a wider
variance (ANOVA) was used to analyze VAS scores and range of effects in the hot water immersion group. Some
differences in VAS1 and VAS2 ( VAS) between groups.
patients experienced dramatic improvement, whereas many of
the others showed no improvement. As a result, the coefficient
of variance (CV) of the pain decreased was bigger in the hot
Results
water immersion group (1.08) than in the ice pack group or the
From April 2007 to September 2007, the data on 69 consecu- analgesia group (0.73 and 0.76, respectively). Furthermore, one
tive patients who experienced centipede bites were recorded. patient in the hot water immersion group experienced
progression of local swelling and redness with a slight
improvement in pain after immersion, and two patients
Clinical Toxicology
Hot water
Ice packs Analgesia immersion Total
(n = 20) (n = 18) (n = 22) (n = 60)
Gender (%)
Male 10 (50) 9 (50) 11 (50) 30(50)
Female 10 (50) 9 (50) 11 (50) 30(50)
Age 43.4 ± 20.4 53.3 ± 21.4 41.4 ± 18.7 36.1 ± 17.9
Symptoms onset time (min) 2.08 ± 2.30 5.63 ± 9.45 1.66 ± 1.41 2.97 ± 5.53
Time arrive in ED (min) 44.4 ± 59.4 53.4 ± 56.4 33.0 ± 36.6 42.8 ± 51.05
Size of centipede (cm) 11.05 ± 8.17 9.60 ± 3.70 11.23 ± 5.71 10.74 ± 6.23
Local effects (%)
Pain 20 (100.0) 18(100.0) 22 (100.0) 60 (100.0)
Redness 15 (75.0) 14(77.8) 20 (90.9) 49 (81.7)
Heat 3 (15.0) 5 (27.8) 6 (27.3) 14 (23.3)
Vesiculation 0 2 (11.1) 1 (4.5) 3 (5.0)
Swelling 8 (40.0) 12(66.7) 12 (54.5) 32 (53.3)
Itchiness 1 (5.0) 1 (5.6) 3 (13.6) 5 (8.3)
ED, emergency department.
Clinical Toxicology vol. 47 no. 7 2009
A prospective centipedes study in Taiwan 661
Table 2. One-way analysis of variance (ANOVA) of VAS scores and differences in VAS1 and VAS2 ( VAS)
between groups
Hot water
All Ice pack Analgesia immersion p (ANOVA)
VAS1 5.99 ± 2.60 6.35 ± 2.89 6.03 ± 2.53 5.64 ± 2.44 0.679
VAS2 3.88 ± 2.61 3.80 ± 2.80 3.69 ± 2.30 4.09 ± 2.78 0.885
VAS 2.12 ± 1.80 2.55 ± 1.88 2.33 ± 1.78 1.55 ± 1.68 0.165
experienced even more pain (VAS scores 8–9.5 and 7–8) of pain intensity in clinical studies, mostly due to its ease of
after hot water immersion. On the other hand, the ice pack use and convenience for statistics. However, a significant
group had no adverse effects reported. decrease in VAS scores dose not necessarily bring a mean-
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With regard to inadequacy of treatment, there were two ingful pain relief. Jensen et al. in a recent study suggested
patients in the hot water immersion group and the ice pack that a clinically important improvement in pain required a
group who each received a 30 mg ketorolac injection after 13
33% decrease in VAS. According to this criterion, the
the intervention. One patient from analgesia group received a decline in VAS in the ice pack group (40.2%) and the
6 mg morphine injection before leaving the hospital. analgesia group (38.6%) were significant, whereas that in the
During the follow-up period, five patients had ED re-visits. hot water immersion group (27.5%) was not. The hot water
Three of them (two in the ice pack group and one in the anal- immersion group also had the largest CV for VAS. Thus, we
gesia group) came back due to progression of symptoms believe that hot water immersion has the most unpredictable
(swelling, redness, and pain). Each of these three patients was effects among these three methods. Furthermore, the hot
given oral antibiotics under the diagnostic impression of water immersion group had one patient who experienced
cellulitis. They were discharged without any complications or progression of local swelling and redness, and two patients
sequelae. Two other patients came back for unrelated issues. who experi-enced even more pain after hot water immersion.
Among all the patients, one reported local pain for longer than 1 Decisions about clinical application of hot immersion should
week and four reported itchiness for longer than 1 week. take its pro-inflammatory effect into account.
The mechanism of analgesia produced by hot water
immersion has not yet been clarified. Nevertheless, denaturing
Discussion of the heat-labile toxin appears to be the most likely mecha-
14–17
nism. Centipede venom has a complex list of ingredients.
Centipedes (order scolopendromorpha, class chilopoda) are Even though the culprit for the pain is still not yet known, many
fast-moving, predatory, venomous arthropods found mostly of the ingredients such as polypeptides, enzymes, hista-mines,
18
in tropical climates but are also widely distributed in temper- and toxin S are heat labile. Menez et al. boiled centi-pede
ate zones. In Taiwan, centipedes are active during the early venom and found that its lethality in moths was inactivated.
19
5
spring and summertime, and mostly during the night. Similar effects have been clearly demonstrated in box jellyfish
Centipedes belong to five genuses (Scolopendra, 20,21
sting patients. Significant pain relief after local heat
Otostigmus, Rhysida, Cryptops, and Scolopocryptops) and application was found in two centipedes stings in the case series
6 1
16 species in Taiwan. In our study, the estimated centipede of Bush et al. Interestingly, some fishermen in Keelung harbor
length ranged from 3 to 30 cm, with an average of 10 cm. used to apply local heat after centipede envenomation, just as
Centipede stings usually cause no serious morbidity or they did after jellyfish stings.
7,8 Ice pack therapy has long been used for various injuries and
mortality. Local pain (95.8%) and edema (52.1%) were the
3 pains, particularly those related to the musculoskeletal system. It
most common findings in a previous study, which is similar reversibly cools cutaneous and subcutaneous superfi-cial tissues
to our results. Other local effects include redness, bleeding, 22
and bullae formation. Itchiness is less frequent initially, but and causes vasoconstriction, which reduces edema. The
becomes more prominent after pain subsides and may persist mechanism also involves elevating the pain threshold through
longer. Paresis was documented previously without its anti-nociceptive effect on the gate con-trol system and a
9 23
significant neurological deficit. Most of the local effects decrease in nerve conduction. The effec-tiveness of ice pack
occurred within 5 min. Although serious complica- therapy has recently been prospectively
tions were reported in previous studies, most of the sys-temic validated in reducing labor pain, neuropathic pain, and pain
7,10–12 24–27
effects were relatively mild. In our series, this caused by surgery or toxins. In our study, ice pack ther-
was also true. apy showed an effectiveness equivalent to analgesia. How-ever,
All three groups in this study showed decreased VAS there were no adverse effects observed in this group, and no
scores with statistical significance after treatment. The VAS patient refused to receive it. Due to its effectiveness, ease of
score has become a widely used method for measurement application, non-invasiveness, and low cost, we suggest
Clinical Toxicology vol. 47 no. 7 2009
that ice packs should be part of the treatment for centipede 7. Ozsarac M, Karcioglu O, Ayrik C, Somuncu F, Gumrukcu S. Acute
envenomation in ED and pre-hospital settings. coronary ischemia following centipede envenomation: case report and
Systemic analgesics along with antihistamines, tetanus review of the literature. Wilderness Environ Med 2004; 15(2):109–112.
toxoid, and proper wound management have also been used 8. Lin TJ, Yang CC, Yang GY, Ger J, Tsai WJ, Deng JF. Features of cen-
1,28 tipede bites in Taiwan. Trop Geogr Med 1995; 47(6):300–302.
widely before. In our study, the analgesia group serves as 9. Mohri S, Sugiyama A, Saito K, Nakajima H. Centipede bites in Japan.
an active control (best-available-treatment control) group for Cutis 1991; 47(3):189–190.
pain relief. There is not a placebo control group because we 10. Remington CL. The bite and habits of a giant centipede (Scolopendra
presumed that the local pain would not improve much within subspinipes) in the Philippine Islands. Am J Trop Med Hyg 1950;
15 min if the patient was left to be observed, and also 30(3):453–455.
because this is unethical. Two patients initially randomized 11. Supakthanasiri P, Ruxrungtham K, Klaewsongkram J, Chantaphakul H.
to the analgesia group refused intervention and were Anaphylaxis to centipede bite. J Allergy Clin Immunol 2004;
excluded. Patients are still more willing to receive non- 113(2):S244.
invasive and non-pharmacological treatments despite 12. Logan JL, Ogden DA. Rhabdomyolysis and acute renal failure
following the bite of the giant desert centipede Scolopendra heros.
progress in medical effectiveness and safety.
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