Clinical Toxicology (2009) 47, 659–662

Copyright © Informa UK, Ltd.

ISSN: 1556-3650 print / 1556-9519 online
DOI: 10.1080/15563650802084821

ARTICLE

Comparisons of ice packs, hot water immersion,

and analgesia injection for the treatment of
centipede envenomations in Taiwan
1,3 2,3 1,3 1,3 1,3
CHUNG-HSIEN CHAOU , CHIAN-KUANG CHEN , JIH-CHANG CHEN , TE-FA CHIU , and CHIH-CHUAN LIN
1
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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.

Keywords Centipedes; Envenomation; Bites and stings; Pain; Ice pack

Introduction The complications of centipede bites and the adverse effects

Centipede bites are reported worldwide, mostly in tropical and
subtropical regions. The majority of cases occur in the residence
1 Material and methods
and usually cause no serious morbidity or mortality. However,
most envenomated patients suffer from some degree of local
effect including pain, swelling, erythema, heat, and itchiness.
Among these symptoms, pain, often excruciating, is the most
unendurable. As a result, pain relief has become the cornerstone
2,3
of treatment in these patients. In a Medline search, there was
only one prospective study on centipede bites. Balit et al.
4 approved by the Investigational Review Board.
reported an interesting finding that both hot and cold
temperatures could actually reduce the pain produced by
envenomation. However, they did not indicate which was more
effective at reducing pain caused by centipede bites. The aim of
this study was to prospectively investigate the effectiveness of
ice packs, hot water immersion, and analgesia injection on pain
relief in centipede-envenomated patients.
Received 20 December 2007; accepted 25 March 2008.
Address correspondence to Chih-Chuan Lin, Department of
Emergency Medicine, Chang-Gung Memorial Hospital, Linko
Medical Center, No. 5, Fu Hsing St., Kuei-Shang County, Taoyuan,
Taiwan. E-mail: bearuncle@yahoo.com
of interventions were also recorded in this study.
This was a prospective randomized study. Emergency
depart-ment (ED) patients who suffered from centipede bites
were enrolled in the study, provided they did not meet the
exclu-sion criteria listed below. The study was reviewed and
The study was conducted at the ED of Keelung Chang-
Gung Memorial Hospital in north Taiwan. The ED has a vol-
ume of 70,000 patient visits per year. Centipedes are active
around Keelung city during the late spring and summertime.
The study period was from April 2007 to September 2007.
All patients older than 6 years who suffered from a witnessed
envenomation by a centipede within the previous 3 h were
included. Patients with unstable vital signs, consciousness dis-
turbance, language or comprehension barriers, and those who
received treatment in any way before visiting the ED were
excluded. After informed and written consent was obtained,
patients were randomly assigned to three groups by drawing
identical envelopes and received one of the following treatments:
 Clinical Toxicology vol. 47 no. 7 2009

660 C.-H. Chaou et

ice packing, hot water immersion, or analgesia injection. The ice
pack group received ice packs on the affected site for 15 min. The
hot water immersion group received hot water immersion of the
affected site for 15 min. We prepared the water with a blood
warmer that had the temperature set at 43–45°C. The patients in the
analgesia group received ketorolac 30 mg (or meperidine 50 mg if
they were previously allergic to ketorolac) via intra-muscular
injection and were observed for 15 min. First and sec-ond visual
analog scale (VAS) scores were measured just before and after the
interventions in all patients. All the above proce-dures were
conducted by one of the four ED nurse specialists. They were
previously trained for this study. Demographic data including age,
gender, onset time, estimated centipede length, local effects, and
systemic effects were collected during the treatment period using
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al.
Seven patients were excluded by criteria (three patients came
after 3 h, and four patients received other treatment at home).
Another two patients in the analgesia group refused to
receive the injection and were excluded. Sixty patients
completed the study. All the patients in the analgesia group
received a ketor-olac intramuscular injection.
The demographic data are shown in Table 1. There were 30
males and 30 females in the study, with an overall mean age of
43.4 ± 20.4 years. All patients complained of pain at the
affected site. 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%). Sys-
temic effects were rare: one patient experienced palpitation

standardized question forms.
Except for the interventions mentioned above, all patients
received a 0.5 mL tetanus toxoid intramuscular injection, a
diphenhydramine 30 mg intramuscular injection, proper wound
care, and take-home medications, including analgesics if their pain
was not completely diminished. Patients who were still in severe
pain after the above interventions could receive further treatments
as needed and decided upon by the duty ED physician. All patients
were followed up after 1 week for complications of the disease
and/or adverse effects of the above interventions.
All the data were analyzed using SPSS (Version 14). The first
and second VAS scores (VAS1, VAS2, respectively) of each
group were compared using a paired t-test. One-way analysis of
variance (ANOVA) was used to analyze VAS scores and
differences in VAS1 and VAS2 ( VAS) between groups.
Results
From April 2007 to September 2007, the data on 69 consecu-
tive patients who experienced centipede bites were recorded.
Clinical Toxicology
whereas his electrocardiogram showed normal sinus rhythm,
two patients had generalized urticaria, and three patients expe-
rienced dizziness without significant neurological deficit. There
was no headache, fever, or hypotension. There was no statistical
difference in the estimated length of the centipedes, the
symptom onset time, or time of arrival in the ED.
Table 2 describes the VAS1, VAS2, and VAS scores. There
were no statistically significant differences in VAS1 (p = 0.679)
and VAS2 (p = 0.885) between the three groups. The VAS
scores were 2.55 ± 1.88, 2.33 ± 1.78, and 1.55 ± 1.68 in the ice
packing, analgesia, and hot water immersion groups,
respectively (p = 0.165). All three groups had their VAS reach
statistical significance. However, there seemed to be a wider
range of effects in the hot water immersion group. Some
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
water immersion group (1.08) than in the ice pack group or the
analgesia group (0.73 and 0.76, respectively). Furthermore, one
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

Table 1. Demographics of patients included in this study

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
Table 2. One-way analysis of variance (ANOVA) of VAS scores and differences in VAS1 and VAS2 ( VAS)
between groups
All Ice pack
VAS1 5.99 ± 2.60 6.35 ± 2.89
VAS2 3.88 ± 2.61 3.80 ± 2.80
VAS 2.12 ± 1.80 2.55 ± 1.88
VAS, visual analog scale.
experienced even more pain (VAS scores 8–9.5 and 7–8)
after hot water immersion. On the other hand, the ice pack
group had no adverse effects reported.
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With regard to inadequacy of treatment, there were two
patients in the hot water immersion group and the ice pack
group who each received a 30 mg ketorolac injection after
the intervention. One patient from analgesia group received a
6 mg morphine injection before leaving the hospital.
During the follow-up period, five patients had ED re-visits.
Three of them (two in the ice pack group and one in the anal-
gesia group) came back due to progression of symptoms
(swelling, redness, and pain). Each of these three patients was
given oral antibiotics under the diagnostic impression of
cellulitis. They were discharged without any complications or
sequelae. Two other patients came back for unrelated issues.
Among all the patients, one reported local pain for longer than 1
week and four reported itchiness for longer than 1 week.
Discussion
Centipedes (order scolopendromorpha, class chilopoda) are
fast-moving, predatory, venomous arthropods found mostly
in tropical climates but are also widely distributed in temper-
ate zones. In Taiwan, centipedes are active during the early
5
spring and summertime, and mostly during the night.
Centipedes belong to five genuses (Scolopendra,
Otostigmus, Rhysida, Cryptops, and Scolopocryptops) and
6 1
16 species in Taiwan. In our study, the estimated centipede
length ranged from 3 to 30 cm, with an average of 10 cm.
Centipede stings usually cause no serious morbidity or
7,8
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
to our results. Other local effects include redness, bleeding,
and bullae formation. Itchiness is less frequent initially, but
becomes more prominent after pain subsides and may persist
longer. Paresis was documented previously without
9 23
significant neurological deficit. Most of the local effects
occurred within 5 min. Although serious complica-
tions were reported in previous studies, most of the sys-temic
7,10–12
effects were relatively mild. In our series, this
was also true.
All three groups in this study showed decreased VAS
scores with statistical significance after treatment. The VAS
score has become a widely used method for measurement
661
Hot water
Analgesia immersion p (ANOVA)
6.03 ± 2.53 5.64 ± 2.44 0.679
3.69 ± 2.30 4.09 ± 2.78 0.885
2.33 ± 1.78 1.55 ± 1.68 0.165
of pain intensity in clinical studies, mostly due to its ease of
use and convenience for statistics. However, a significant
decrease in VAS scores dose not necessarily bring a mean-
ingful pain relief. Jensen et al. in a recent study suggested
that a clinically important improvement in pain required a
13
33% decrease in VAS. According to this criterion, the
decline in VAS in the ice pack group (40.2%) and the
analgesia group (38.6%) were significant, whereas that in the
hot water immersion group (27.5%) was not. The hot water
immersion group also had the largest CV for VAS. Thus, we
believe that hot water immersion has the most unpredictable
effects among these three methods. Furthermore, the hot
water immersion group had one patient who experienced
progression of local swelling and redness, and two patients
who experi-enced even more pain after hot water immersion.
Decisions about clinical application of hot immersion should
take its pro-inflammatory effect into account.
The mechanism of analgesia produced by hot water
immersion has not yet been clarified. Nevertheless, denaturing
of the heat-labile toxin appears to be the most likely mecha-
14–17
nism. Centipede venom has a complex list of ingredients.
Even though the culprit for the pain is still not yet known, many
of the ingredients such as polypeptides, enzymes, hista-mines,
18
and toxin S are heat labile. Menez et al. boiled centi-pede
venom and found that its lethality in moths was inactivated.
19
Similar effects have been clearly demonstrated in box jellyfish
20,21
sting patients. Significant pain relief after local heat
application was found in two centipedes stings in the case series
of Bush et al. Interestingly, some fishermen in Keelung harbor
used to apply local heat after centipede envenomation, just as
they did after jellyfish stings.
Ice pack therapy has long been used for various injuries and
reversibly cools cutaneous and subcutaneous superfi-cial tissues
22
and causes vasoconstriction, which reduces edema. The
mechanism also involves elevating the pain threshold through
its anti-nociceptive effect on the gate con-trol system and a
decrease in nerve conduction. The effec-tiveness of ice pack
therapy has recently been prospectively
validated in reducing labor pain, neuropathic pain, and pain
24–27
caused by surgery or toxins. In our study, ice pack ther-
apy showed an effectiveness equivalent to analgesia. How-ever,
there were no adverse effects observed in this group, and no
patient refused to receive it. Due to its effectiveness, ease of
application, non-invasiveness, and low cost, we suggest

662
that ice packs should be part of the treatment for centipede
envenomation in ED and pre-hospital settings.
Systemic analgesics along with antihistamines, tetanus
toxoid, and proper wound management have also been used
1,28
widely before. In our study, the analgesia group serves as
an active control (best-available-treatment control) group for
pain relief. There is not a placebo control group because we
presumed that the local pain would not improve much within
15 min if the patient was left to be observed, and also
because this is unethical. Two patients initially randomized
to the analgesia group refused intervention and were
excluded. Patients are still more willing to receive non-
invasive and non-pharmacological treatments despite
progress in medical effectiveness and safety.
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There were several limitations to our study. First, this was
a local study and application of these results must take into
account species and/or geographic variations. Second, this
was not a double-blinded study; it is difficult to conduct a
double-blinded study on such a topic, because one cannot
blind the feeling of thermo-sensation. However,
randomization may reduce the placebo effect. Third, the
study included only 60 patients, which might not be
sufficient to detect differ-ences among the three therapies.
Conclusion
Centipede bites produce moderate to severe pains. Both ice
packs and hot water immersion can reduce the pain from
centipede envenomation. Their effects appear to be equiv-
alent to analgesics. However, ice pack treatment has the
advantage of being inexpensive, safe, and non-invasive. Ice
packs may be considered the intervention of choice for ED
and pre-hospital management in patients with centipede
bites.
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