A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings

Wilderness Medical Society Clinical Practice Guidelines for the Treatment of Acute Pain in Austere Environments: 2024 Update

The Wilderness Medical Society (WMS) convened an expert panel to develop evidence-based guidelines for the management of pain in austere environments. Recommendations are graded based on the quality of supporting evidence as defined by criteria put forth by the American College of Chest Physicians. This is an update of the 2014 version of the "WMS Practice Guidelines for the Treatment of Acute Pain in Remote Environments" published in Wilderness & Environmental Medicine 2014; 25:41-49.

Parenteral, Non-Intravenous Analgesia in Acute Traumatic Pain-A Narrative Review Based on a Systematic Literature Search

Traumatic pain is frequently encountered in emergency care and requires immediate analgesia. Unfortunately, most trauma patients report sustained pain upon arrival at and discharge from the Emergency Department. Obtaining intravenous access to administer analgesics can be time-consuming, leading to treatment delay. This review provides an overview of analgesics with both fast onset and parenteral, non-intravenous routes of administration, and also indicates areas where more research is required.

Scorpion Stings in Minas Gerais (Brazil): A Monocentric Retrospective Study Evaluating All Envenoming Cases of Local Scorpionism

INTRODUCTION

We aim to provide better insights into the demographic, epidemiological, and seasonal characteristics of scorpion envenomation reported in the Rio Doce Valley, Brazil.

METHODS

We conducted this monocentric retrospective descriptive study with data on Investigation Forms of Accidents by Venomous Animals, only envenoming cases of scorpion stings, between January 1, 2017 and December 31, 2020, belonging to the compulsory notification system of the Municipal Hospital of Governador Valadares.

RESULTS

There were 3032 accidents, and the male-to-female ratio was 1.17:1 (male, 54%; females, 46%). Accidents occurred every month, but there was an increase in June, July, and October to January. In most cases, the time between the scorpion sting and medical care was between 1 and 3 h (n=1304; 43%). The most frequent clinical and systemic manifestations were pain at the bite site (94%) and vagal symptoms (7%). Cases were mild (n=2750, 91%), moderate (n=221, 7%), and severe (n=56, 2%). Children younger than 10 y constituted the most cases, 522 (17%). There was a significant difference between clinical severity and age (P<0.01). Ten patients developed acute pulmonary edema. Two 4-y-old children died. All severely envenomated patients as well as 74% and 2% of mild and moderately envenomated patients, respectively, received specific scorpion antivenoms.

CONCLUSIONS

Scorpion envenomation is of greater severity in children aged <10 y. The clinical presentation includes mainly local pain associated with vagal symptoms. Accidents occur every month, but there was an increase in June, July, and October to January.

Prospecting Local Treatments Used in Conjunction with Antivenom Administration Following Envenomation Caused by Animals: A Systematic Review

Envenomation caused by venomous animals may trigger significant local complications such as pain, edema, localized hemorrhage, and tissue necrosis, in addition to complications such as dermonecrosis, myonecrosis, and even amputations. This systematic review aims to evaluate scientific evidence on therapies used to target local effects caused by envenomation. The PubMed, MEDLINE, and LILACS databases were used to perform a literature search on the topic. The review was based on studies that cited procedures performed on local injuries following envenomation with the aim of being an adjuvant therapeutic strategy. The literature regarding local treatments used following envenomation reports the use of several alternative methods and/or therapies. The venomous animals found in the search were snakes (82.05%), insects (2.56%), spiders (2.56%), scorpions (2.56%), and others (jellyfish, centipede, sea urchin-10.26%). In regard to the treatments, the use of tourniquets, corticosteroids, antihistamines, and cryotherapy is questionable, as well as the use of plants and oils. Low-intensity lasers stand out as a possible therapeutic tool for these injuries. Local complications can progress to serious conditions and may result in physical disabilities and sequelae. This study compiled information on adjuvant therapeutic measures and underscores the importance of more robust scientific evidence for recommendations that act on local effects together with the antivenom.

Epidemiological, toxicological and physiopathological characteristics of scorpion stings and their management in Morocco: A literature review

All around the world, scorpion envenomation represents a public health issue. In Morocco, it represents the first cause of poisoning. The aim of this review is to highlight the epidemiological, toxicological and physiopathological characteristics of scorpion stings and envenomation in Morocco as well as their management. According to the bibliography, the most areas affected by scorpion stings and envenomation are those in the center and south of Morocco. Lethality rate is more important in children than adult. Age, admission class, season, serum venom concentration, and the time elapsed between the scorpion sting and medical intervention are risk factors for a poor prognosis. Until now, we have only known the LD50 of 14 scorpion species from three genera: Androctonus, Buthus and Hottentota, and only 6 species, out of 61 moroccan scorpions, have been assessed for their venom toxicity on mice organs. The venom of harmful moroccan scorpions induces several histopathological changes in the myocardium, brain, liver, pulmonary alveoli, and kidneys in rats, as well as severe consequences in the lungs with intra-alveolar hemorrhage. There was also a significant increase in serum enzyme levels of aspartate transaminase (AST), alanine transaminase (ALT), creatine phosphokinase (CPK), and lactate dehydrogenase (LDH), as well as high levels of plasma albumin, creatine and glucose. In the absence of a specific treatment, the management of scorpion envenomation is based only on symptomatic therapy. We noted a widely use of traditional remedies. Despite the magnitude of the scorpion problem in Morocco, it remains understudied and continues to claim lives, particularly given the lack of an efficient etiological cure.

Comparison of Intravenous Paracetamol, Dexketoprofen Trometamol, or Topical Lidocaine Use for Pain Relief in Scorpion Stings: A Placebo-Controlled, Randomized Study

INTRODUCTION

After a scorpion sting, patients commonly present to hospitals with pain. Our study sought to compare the analgesic efficacy of IV paracetamol, IV dexketoprofen trometamol, topical lidocaine, and placebo in patients reporting pain after presenting with a history of scorpion sting.

METHODS

This double-blind, randomized, placebo-controlled study was conducted in the emergency department of a tertiary hospital. Adult patients who presented with the complaint of pain after a scorpion sting and did not have systemic findings were randomly assigned to 1 of the following 4 groups: IV paracetamol, IV dexketoprofen trometamol, topical lidocaine, and placebo. The visual analog scale scores were measured at the time of presentation to the emergency department and at 30 and 60 min to determine the pain intensity.

RESULTS

The study included 106 patients, of whom 30 were in the paracetamol group, 26 in the dexketoprofen trometamol group, 25 in the topical lidocaine group, and 25 in the placebo group. We did not find a different analgesic effect among the groups in the first 30 min (P=0.185). IV paracetamol, dexketoprofen trometamol, and topical lidocaine did not show different analgesic effects in the first 60 min (P>0.05). IV paracetamol and dexketoprofen trometamol were found to provide a more effective analgesia than the placebo at 60 min (P<0.05). The analgesic effects of topical lidocaine and placebo did not differ (P=0.330).

CONCLUSIONS

IV paracetamol and IV dexketoprofen trometamol provided analgesia in the first 60 min, similar to topical lidocaine but superior to placebo.

Scorpion Venom: Detriments and Benefits

Scorpion venom may cause severe medical complications and untimely death if injected into the human body. Neurotoxins are the main components of scorpion venom that are known to be responsible for the pathological manifestations of envenoming. Besides neurotoxins, a wide range of other bioactive molecules can be found in scorpion venoms. Advances in separation, characterization, and biotechnological approaches have enabled not only the development of more effective treatments against scorpion envenomings, but have also led to the discovery of several scorpion venom peptides with interesting therapeutic properties. Thus, scorpion venom may not only be a medical threat to human health, but could prove to be a valuable source of bioactive molecules that may serve as leads for the development of new therapies against current and emerging diseases. This review presents both the detrimental and beneficial properties of scorpion venom toxins and discusses the newest advances within the development of novel therapies against scorpion envenoming and the therapeutic perspectives for scorpion toxins in drug discovery.

Randomized Clinical Trial of Intravenous Acetaminophen as an Analgesic Adjunct for Older Adults With Acute Severe Pain

OBJECTIVES

Older adults are at risk for undertreatment of pain. We examined intravenous (IV) acetaminophen as an analgesic adjunct to IV opioids in the care of older emergency department (ED) patients with acute severe pain.

METHODS

This was a randomized clinical trial conducted in two EDs in the Bronx, New York. Eligible adults aged 65 years and older with acute severe pain were randomized to 0.5 mg of IV hydromorphone and 1 g of IV acetaminophen or 0.5 mg of IV hydromorphone and 100 mL of normal saline placebo. The primary outcome was the between group difference in improvement of numerical rating scale (NRS) pain scores at 60 minutes. Secondary outcomes were the between-group differences in the proportion of patients who chose to forgo additional pain medications at 60 minutes; the proportion who developed side effects; the proportion who required rescue analgesia; and between-group differences in NRS pain scores at 5, 15, 30, and 45 minutes.

RESULTS

Eighty-one patients were allocated to each arm. Eighty patients in the IV acetaminophen arm and 79 patients in the placebo arm had sufficient data for analysis. At 60 minutes, patients in the hydromorphone + IV acetaminophen group improved by 5.7 NRS units while those in the hydromorphone + placebo group improved by 5.2 NRS units, for a difference of 0.6 NRS units (95% confidence interval [CI] = -0.4 to 1.5). A total of 28.7% of patients in the hydromorphone + IV acetaminophen group wanted more analgesia at 60 minutes versus 29.1% in the hydromorphone + placebo group, for a difference of -0.4% (95% CI = -14.3% to 13.5%). These differences were neither clinically nor statistically significant. Safety profiles were similar in both groups.

CONCLUSION

In this randomized clinical trial, the addition of IV acetaminophen to IV hydromorphone as an adjunctive analgesic for acute, severe, pain in older adults provided neither clinically nor statistically superior pain relief when compared to hydromorphone alone within the first hour of treatment.

Scorpion Sting Management at Tertiary and Secondary Care Emergency Departments

Objectives

We sought to review the management of scorpion stings in tertiary and secondary care emergency departments in Oman and determine physician’s knowledge of management protocols.

Methods

We conducted a retrospective study of all scorpion stings cases seen in Sultan Qaboos University Hospital (SQUH) emergency department (ED) from March 2016 to July 2017. Additionally, we conducted a survey of ED physicians regarding their management of scorpion stings in three different EDs including SQUH.

Results

The total number of scorpion stings seen at SQUH during the study period was 128. Localized pain was seen in 97.7% (n = 125), swelling in 14.8% (n = 19), and local redness in 7.0% (n = 9) of patients. Around 13.0% (n = 17) of patients were found to have systemic symptoms with tachycardia being the most common. Bedside clotting test was done for 11.7% (n = 15) of patients. The most commonly used treatment was local anesthesia (54.7%, n = 70). No patient received scorpion antivenom. In the 89 surveyed physicians the main management method used was analgesia (88.8%, n = 71) followed by local anesthesia (81.1%, n = 65). Most physicians (80.0%, n = 64) believed that local anesthesia was the most effective management. However, 32.5% (n = 26) ordered a whole blood bedside clotting test, 69.2% (n = 18) of which were junior doctors.

Conclusions

Most scorpion sting cases managed in SQUH had local symptoms. Tachycardia was the most common systemic manifestation. Bedside clotting test was not commonly ordered and mainly requested by junior doctors. Local anesthesia infiltration is the recommended management for scorpion sting. Analgesia was the main management followed by local anesthesia.

Management of scorpion envenoming: a systematic review and meta-analysis of controlled clinical trials

BACKGROUND

Scorpion stings cause an estimated 3000 deaths per annum worldwide. We conducted a systematic review of all controlled clinical trials related to scorpion sting management.

METHODS

We searched PubMed, EMBASE, Scopus, Web of Science and CINAHL and included controlled prospective clinical trials (randomized or non-randomized). The following interventions were assessed: adults and children with scorpion stings treated with (a) steroids vs. placebo, (b) different methods of pain relief, (c) antivenom vs. supportive treatment, (d) prazosin vs. supportive treatment, (e) antivenom vs. prazosin and (f) antivenom plus prazosin vs. prazosin alone. When trials had comparative outcomes, they were combined in a meta-analysis. Data was analysed with Review Manager 5. Dichotomous data were compared with relative risk (RR), and continuous data were compared with mean differences using a fixed effect model. There is no PROSPERO registration number for this study.

RESULTS

Antivenom against Centruroides sp. are effective in reversing the clinical syndrome faster than no antivenom treatment in children (RR, 0.02; 95% CI, 0.01 to 0.06; 322 participants; three trials). Antivenom (against Mesobuthus tamulus) and prazosin combination is better than prazosin alone for faster resolution of symptoms (mean difference, -12.59 h; 95% CI, -14.01 to -11.17; 173 participants; three trials).

CONCLUSIONS

The polyvalent antivenom against Centruroides sp. in USA/Mexico and the monovalent antivenom against M. tamulus in India are effective for rapid resolution of symptoms. Prazosin is useful as an add-on therapy for M. tamulus stings.

The Use of Intravenous Acetaminophen for Acute Pain in the Emergency Department

OBJECTIVES

Acetaminophen (APAP) is a mainstay for pain management worldwide. The intravenous (IV) formulation has been widely used in Europe for more than 20 years in adults and children. In the United States, IV APAP obtained full approval from the Food and Drug Administration in 2010. There is emerging literature to suggest the use of IV APAP for pain reduction in the emergency department (ED). This evidence-based review examines the evidence pertaining to the use of IV APAP for acute pain control in the ED.

METHODS

The MEDLINE and EMBASE databases were searched. Randomized controlled trials (RCTs) that described or evaluated the use of IV APAP for acute pain in the ED were included. Duplicate articles, unpublished reports, abstracts, review articles, and non-English literature were excluded. The primary outcome of interest in this review was the difference in pain score between IV APAP and active comparator or placebo from baseline to a cutoff time specified in the original trials. Secondary outcome measures were the incidence of adverse events and reduction in the amount of adjuvant analgesics consumed by patients who received IV APAP. Methodologic quality of the trials was assessed using the Grading of Recommendations Assessment, Development, and Evaluation criteria.

RESULTS

Fourteen RCTs with various methodologic flaws, which enrolled a total of 1,472 patients, met the inclusion criteria. The level of evidence for the individual trials ranged from very low to moderate. In three of the 14 trials, a significant reduction in pain scores was observed in patients who received IV APAP. The first trial found a significant reduction in mean pain scores when IV APAP was compared to IV morphine at 30 minutes after drug administration (4.7 ± 2.3 vs. 2.9 ± 2.2). In the second trial, patients who received IV APAP reported of lower pain scores (31.7 ± 18 mm, 95% confidence interval [CI] = 8.2 to 25.2 mm) compared to those who received IV morphine (48.3 ± 14.1 mm, 95% CI = 8.2 to 25.2 mm), 15 minutes after drug administration. A third trial found a significant reduction (p = 0.005) in the mean pain scores when IV APAP was compared to intramuscular piroxicam at 90 minutes after drug administration. In the remaining eight trials, pain scores were not statistically different when IV APAP was compared to other pain medications. The incidence of side effects associated with IV APAP was very low.

CONCLUSIONS

Fourteen RCTs with various methodologic flaws provided limited evidence to support the use of IV APAP as the primary analgesic for acute pain control in patients who present to the ED.