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Centipede Envenomation: Treatment & Medication
Updated: Nov 19, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Prehospital Care
No specific first aid measures are available for centipede stings. Seek medical care if pain persists or systemic symptoms occur. Local application of ice may reduce some of the discomfort; however, others have anecdotally found that local heat application or immersion in hot (nonscalding) water is more comforting.
Emergency Department Care
Management of centipede stings is entirely supportive.
- Pain may be managed with systemic analgesics, as necessary.
- Pain may be managed with local injectable anesthetics (eg, lidocaine, bupivacaine). These can be injected locally or used in performing a regional nerve block. A standard text should be consulted regarding techniques of regional anesthesia.
- Tetanus status should be updated.
- Prophylactic antibiotics are not necessary, but secondary infections should be cultured and treated with appropriate antibiotics (to cover gram-positive bacteria).
- Following initial care, examine the wound for any signs of secondary infection or necrosis.
- Patients should be observed for approximately 4 hours for evidence of systemic toxicity.
Consultations
In the rare case of severe swelling of a stung extremity where a possible developing compartment syndrome is a concern, surgical consultation for compartmental pressure testing should be obtained.
Medication
Analgesics and local anesthetics are used to ameliorate the pain associated with these stings. No antivenoms exist for centipede stings.
Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort and have sedating properties, which are beneficial for patients who have sustained centipede envenomations.
Acetaminophen (Tylenol, Panadol, Aspirin Free Anacin)
DOC to treat pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
325-650 mg PO q4-6h or 1000 mg tid/qid; not to exceed 4 g/d
Pediatric
<12 years: 10-15 mg/kg/dose PO q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO q4h; not to exceed 5 doses in 24 h
Rifampin can reduce analgesic effects; coadministration of barbiturates, carbamazepine, hydantoins, or isoniazid may increase acetaminophen hepatotoxicity
Documented hypersensitivity; known G-6-PD deficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Hepatotoxicity possible in chronic alcoholism following various dose levels of acetaminophen; severe or recurrent pain or high or continued fever may indicate serious illness
Acetaminophen with codeine (Tylenol #3)
Indicated for treatment of mild to moderate pain.
Adult
30-60 mg/dose PO (based on codeine content) q4-6h or 1-2 tab PO q4h; not to exceed 12 tab/d
Pediatric
0.5-1 mg/kg/dose PO based on codeine content q4-6h; 0-15 mg/kg/dose PO based on acetaminophen content; not to exceed 2.6 g/d acetaminophen
Increased toxicity when coadministered with CNS depressants or TCAs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
May result in acute opiate withdrawal symptoms in patients dependent on opiates; caution in severe renal or hepatic dysfunction
Acetaminophen with hydrocodone (Vicodin)
Indicated for relief of moderate to severe pain.
Adult
1-2 tab or cap PO q4-6h prn pain
Pediatric
<12 years: 10-15 mg/kg/dose PO acetaminophen q4-6h prn; not to exceed 2.6 g/d acetaminophen
>12 years: 750 mg acetaminophen PO q4h; not to exceed 10 mg hydrocodone bitartrate per dose; not to exceed 5 doses in 24 h
Toxicity increases when administered concurrently with CNS depressants or TCAs
Documented hypersensitivity, patients with high altitude cerebral edema or elevated intracranial pressure
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Tabs contain metabisulfite, which may cause allergic reactions; upon discontinuation, may result in acute opiate-withdrawal symptoms in patients dependent on opiates; caution in severe renal or hepatic dysfunction
Immunizations
Tetanus immunization should be instituted following a centipede envenomation.
Diphtheria-tetanus toxoid (dT)
Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.
Adult
Prophylaxis: 250-500 Units IM in opposite extremity to tetanus toxoid
Clinical tetanus: 3000-10,000 Units IM
Pediatric
Prophylaxis: 250 Units IM in opposite extremity as tetanus toxoid
Clinical tetanus: Administer as in adults
Patients receiving immunosuppressants, including corticosteroids or radiation therapy, may remain susceptible despite immunization because of poor immune response; cimetidine may enhance or augment delayed-hypersensitivity responses to skin-test antigens; avoid concurrent use of medication with systemic chloramphenicol because it may impair amnestic response to tetanus toxoid; concurrent use of tetanus immune globulin may delay development of active immunity by several days (interaction is nevertheless clinically insignificant and does not preclude concurrent use)
Documented hypersensitivity; history of any type of neurologic symptoms or signs following administration of this product; FDA recommends that elective tetanus immunization be deferred during any outbreak of poliomyelitis because tetanus toxoid injections are an important cause of provocative poliomyelitis
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Do not use to treat actual tetanus infections or for immediate prophylaxis of unimmunized individuals (instead, use tetanus antitoxin, preferably human tetanus immune globulin); diminished antibody response to active immunization may be observed in patients receiving immunosuppressive therapy; better to defer primary diphtheria immunization until immunosuppressive therapy discontinued; routine immunization of symptomatic and asymptomatic HIV-infected persons is recommended
Persons with isolated IgA deficiency have potential for developing antibodies to IgA and could have anaphylactic reactions to subsequent administration of blood products that contain IgA
Do not perform skin testing because intradermal injection of concentrated gamma globulin may cause localized area of inflammation that can be misinterpreted as a positive allergic reaction when it is actually a localized chemical tissue irritation; true allergic responses to human gamma globulin given in the prescribed IM manner are extremely rare; do not admix with other medications (usually incompatible)
Anesthetics
Indicated for pain relief. Stabilize the neuronal membrane and prevent initiation and transmission of nerve impulses, thereby producing local anesthetic action.
Lidocaine (Xylocaine)
Inhibits depolarization of type C sensory neurons by blocking sodium channels.
Epinephrine prolongs effect and enhances hemostasis (maximum epinephrine dose 4.5-7 mg/kg).
Adult
Plain: 4.5 mg/kg injected locally
With epinephrine: 7 mg/kg injected locally
Pediatric
Not established
Coadministration with cimetidine or beta-blockers increases toxicity of lidocaine; coadministration with procainamide and tocainide may result in additive cardiodepressant action; may increase effects of succinylcholine
Documented hypersensitivity; avoid in Adams-Stokes syndrome and Wolff-Parkinson-White syndrome; avoid in severe sinoatrial, AV, or intraventricular block if artificial pacemaker not in place
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Use solution without preservatives; caution in heart failure, hepatic disease, hypoxia, hypovolemia or shock, respiratory depression, and bradycardia; may increase risk of CNS and cardiac adverse effects in elderly patients; high plasma concentrations can cause seizures, heart block, and AV conduction abnormalities
Bupivacaine (Marcaine, Sensorcaine)
May reduce pain by slowing nerve impulse propagation and reducing action potential, which in turn prevents initiation and conduction of nerve impulses.
Epinephrine prolongs effect and enhances hemostasis (maximum epinephrine dose 4.5-7 mg/kg).
Adult
Plain: 2 mg/kg injected locally
With epinephrine: 3 mg/kg injected locally
Pediatric
Not established
May enhance effects of CNS depressants; coadministration may increase toxicity of MAOIs, TCAs, beta-blockers, vasopressors, and phenothiazines
Documented hypersensitivity; septicemia; spinal deformities; severe hypertension; existing neurologic disease
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Test a dose and monitor for CNS toxicity and cardiovascular toxicity; caution with inflammation or sepsis in region of proposed injection; monitor patient's state of consciousness after each injection; caution in hypertension, cerebral vascular insufficiency, peripheral vascular disease or heart block, and arteriosclerotic heart disease
Nonsteroidal anti-inflammatory drugs (NSAIDs)
NSAIDs are most commonly used to relieve mild to moderate pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include fenoprofen, flurbiprofen, mefenamic acid, ketoprofen, indomethacin, and piroxicam.
Ibuprofen (Ibuprin, Advil, Motrin)
Usually DOC for treatment of mild to moderate pain if no contraindications exist.
Inhibits inflammatory reactions and pain, probably by decreasing prostaglandin synthesis.
Adult
200-400 mg PO q4-6h while symptoms persist; not to exceed 3.2 g/d
Pediatric
<6 months: Not established
6 months to 12 years: 20-40 mg/kg/d PO divided tid/qid
>12 years: Administer as in adults
May decrease effects of loop diuretics when coadministered; concurrent administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity; avoid in patients with peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution with congestive heart failure, hypertension, and decreased renal and hepatic function
Ketoprofen (Oruvail, Orudis, Actron)
For relief of mild to moderate pain and inflammation. Small dosages are initially indicated in small or elderly patients and in those with renal or liver disease. Doses >75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe patient for response.
Adult
25-50 mg PO q6-8h prn; not to exceed 300 mg/d
Pediatric
<3 months: Not established
3 months to 12 years: 0.1-1 mg/kg PO q6-8h
>12 years: Administer as in adults
May decrease effects of loop diuretics when coadministered; concurrent administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with GI disease, cardiovascular disease, renal or hepatic impairment, and in those taking anticoagulants
Flurbiprofen (Ansaid)
May inhibit cyclooxygenase, causing inhibition of prostaglandin biosynthesis. These effects may result in analgesic, antipyretic, and anti-inflammatory activities.
Adult
200-300 mg/d PO divided bid/qid
Pediatric
Not established
May decrease effects of loop diuretics when coadministered; concurrent administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in decrease of prostaglandin synthesis.
Adult
500 mg PO; follow with 250 mg q6-8h; not to exceed 1.25 g/d
Pediatric
<2 years: Not established
>2 years: 2.5 mg/kg/dose PO; not to exceed 10 mg/kg/d
May decrease effects of loop diuretics when coadministered; concurrent administration with anticoagulants may increase PT (monitor and watch for signs of bleeding); may increase serum lithium levels and risk of methotrexate and phenytoin toxicity; probenecid may increase toxicity of NSAIDs
Documented hypersensitivity; avoid in peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Mefenamic acid (Ponstel)
Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
500 mg PO initially; follow with 250 mg PO q4h prn
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency, and high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May have adverse effects in fetus; caution in congestive heart failure, hypertension, and decreased renal and hepatic function; caution in anticoagulation abnormalities or during anticoagulant therapy
Indomethacin (Indocin)
Rapidly absorbed. Metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis.
Adult
25-50 mg PO bid/tid
75 mg SR PO bid; not to exceed 200 mg/d
Pediatric
1-2 mg/kg/d divided PO bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and possibly toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; GI bleeding or renal insufficiency
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)
Piroxicam (Feldene)
Decreases activity of cyclooxygenase, which, in turn, inhibits prostaglandin synthesis. These effects decrease formation of inflammatory mediators.
Adult
10-20 mg/d PO qd
Pediatric
0.2-0.3 mg/kg/d PO qd; not to exceed 15 mg/d
Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; active GI bleeding
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur (discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia)
Osmotic diuretics
In the setting of documented compartment syndrome, osmotic diuretics such as mannitol may, when combined with elevation of the extremity, obviate the need for fasciotomy if pressures respond rapidly.
Mannitol (Osmitrol, Resectisol)
An osmotic diuretic. Inhibits tubular reabsorption of electrolytes by increasing osmotic pressure of glomerular filtrate. Increases urinary output.
Adult
0.25-0.5 g/kg/dose IV; limit to bid for no more than 2 d to avoid resistance
Pediatric
Administer as in adults
May decrease serum lithium levels
Documented hypersensitivity; anuria, severe pulmonary congestion, progressive renal damage, severe dehydration, active intracranial bleeding, and progressive heart failure; hypotension
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Carefully evaluate cardiovascular status before rapid administration of mannitol since a sudden increase in extracellular fluid may lead to fulminating CHF; avoid pseudoagglutination, when blood given simultaneously, add at least 20 mEq of sodium chloride to each liter of mannitol solution; do not give electrolyte-free mannitol solutions with blood
More on Centipede Envenomation |
| Overview: Centipede Envenomation |
| Differential Diagnoses & Workup: Centipede Envenomation |
 Treatment & Medication: Centipede Envenomation |
| Follow-up: Centipede Envenomation |
| Multimedia: Centipede Envenomation |
| References |
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References
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Ozsarac M, Karcioglu O, Ayrik C, et al. Acute coronary ischemia following centipede envenomation: case report and review of the literature. Wilderness Environ Med. 2004;15(2):109-12. [Medline].
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Langley RL. Animal-related fatalities in the United States-an update. Wilderness Environ Med. 2005;16(2):67-74. [Medline]. [Full Text].
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Bush SP, King BO, Norris RL, Stockwell SA. Centipede envenomation. Wilderness Environ Med. 2001;12(2):93-9. [Medline].
Hare T. Poisonous Dwellers of the Desert. Southwest Parks & Monuments Association; 1995:1-32.
Hasan S, Hassan K. Proteinuria associated with centipede bite. Pediatr Nephrol. Apr 2005;20(4):550-1. [Medline].
McFee RB, Caraccio TR, Mofenson HC, McGuigan MA. Envenomation by the Vietnamese centipede in a Long Island pet store. J Toxicol Clin Toxicol. 2002;40(5):573-4. [Medline].
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Further Reading
Keywords
centipede envenomations, centipede sting, Scolopendra species, Scolopendra, Scolopendra gigantea, Scolopendra heros, Scolopendra subspinipes, Otostigmus species, Otostigmus, Chilopoda, Arthropoda, centipede venom
