Myocardial necrosis after envenoming by the scorpion. feeding on neurotoxic prey (Centruroides spp. A combination of both approaches should be considered, based on local resources and constraints. Apply ice or a cold compress to the area. Application and evaluation. Hypertension is constant at the beginning of systemic envenoming and sometimes has a severe cardiac and respiratory impact. Sofer S, Gueron M, White R, Lifshitz M, Apte R. Interleukin-6 release following scorpion sting in children. This venom vesicle is surrounded by a striated muscular layer facilitating and regulating the ejection of venom. It is only when the symptoms are severe, you may need a medical care. Antivenom should be administered as earlier as possible, and intravenously for better diffusion and to facilitate complexation with the venom. Petricevich VL. This ebook is not only an inspiring read but also offers great advice and insight that can change your life for the better! However, you can call the poison control center for guidance. of sever scorpion sting are received at endemic areas western Maharashtra, Karnataka, Andhra Pradesh, Sauraahtra and Tamil nadu (Figure 2). There are so many books related to this theme like the Scorpion Sting Management book. If you're experiencing numbness, trouble breathing or swallowing, slurred speech or any other unusual health issues, seek immediate medical assistance so a doctor can administer antivenom. Scorpion venom is composed of toxins and enzymes with neurological tropism acting on ion channels of excitable cells. The median amount of midazolam resulting in the first recorded decrease in agitation and involuntary motor activity was 0.30 mg/kg (range, 0.03 to 1.76 mg/kg). The bark scorpion, Centruroides sculpturatus, is the only native scorpion capable of producing a life-threatening envenomation. Check your shoes before you put them on (shake them). Hammoudi-Triki D, Ferquel E, Robbe-Vincent A, Bon C, Choumet V, Laraba-Djebari F. Epidemiological data, clinical admission gradation and biological quantification by ELISA of scorpion envenomings in Algeria: effect of immunotherapy. Some scorpion stings can be life-threatening. Fluid management: Lost because of profuse sweating and vomiting. Abstract. The diagnosis of insect and scorpion stings is clinical. Patients should take . to scorpion sting (Table I). Role of atropine in management of cardiovascular manifestations of scorpion envenoming in humans. Therefore, each vital organ can be affected and endangered by envenoming, treatment of which becomes a priority. They are shy creatures, active at night during the hot season, but often live in houses or near inhabited areas, which explains the high incidence of scorpion stings involving children in many parts of the world. For these reasons, it is essential to administer antivenom as soon as possible after the sting. Bawaskar HS, Bawaskar PH. The ePub format is best viewed in the iBooks reader. However, there is no doubt that their therapeutic value is significant, even taking into account the risk of side effects. Treatment of venomous Centruroides stings consists of bed rest, benzodiazepines for muscle spasms, and IV drugs as needed to control hypertension, agitation, and pain. Academia.edu uses cookies to personalize content, tailor ads and improve the user experience. Objective: To compare the efficacy of Dobutamine and Prazosin in the management of cases with scorpion sting. Management of scorpion envenomation is based on clinical severity. Chippaux JP. Scorpion venom and the inflammatory response. Rodrguez de la Vega RC, Possani LD. Use of antivenoms requires that they are of the highest quality, both in terms of efficacy and safety, and for optimal efficacy, that they are administered early to remove the venom as soon as possible. The incidence of scorpion stings and treatment by antivenom were studied. Ismail M. The scorpion envenoming syndrome. They are associated with biological disorders, the most frequent of which are leukocytosis, hyperglycemia, and lactic acidosis. A scorpion has a flattened elongated body and can easily hide in cracks. From attaining a certificate in marketing to earning an MBA, we have all you need. Immunotherapy: dose depending on antivenom titer, Midazolam 0.050.2 mg/kg orally or IV (or diazepam 0.5 mg/kg IV or rectally) every 12 hours, scorpion, envenoming, treatment, antivenom. The choice between the various available drugs is difficult because the indications and dosages differ depending on: venom composition, which varies according to species and even individuals; the amount of venom injected; complications related to progression of envenoming, including delay in consultation; side effects of the drug; and modalities of drug administration, especially in peripheral health centers where there is often no doctor present. Magalhes MM, Pereira ME, Amaral CFS, et al. Scorpion does not always inject venom when it stings since it can control its ejacula-tion; thus the sting is total, partial or non-existent. Clinical score of scorpion envenoming and corresponding treatment. Efficacy and safety of scorpion antivenom plus prazosin compared with prazosin alone for venomous scorpion (, Local pain (sometime associated with local paresthesia, erythema, ecchymosis, blisters), Mild systemic envenoming: Idem grade I + hyperthermia + Cardiovascular and respiratory symptoms: tachycardia, arrhythmia, dyspnea, hypertension/hypotension, electrocardiographic abnormalities, priapism Hypersecretory syndrome (salivation, sweating, bronchorrhea, nausea, vomiting, diarrhea, urination), Life-threatening envenoming: idem grade II + multivisceral failure, National Antivenom and Vaccine Production Center, Saudi Arabia, South African Vaccine Producers, South Africa, Razi Serum and Vaccine Research Institute, Iran, Haffkine Biopharmaceutical Corporation, India. These cause blockage of sweating, which is essential for temperature regulation, especially in children, and potentiate the adrenergic effects of scorpion venom, increasing hypertension and ischemic complications.16,18,47,48 However, these drugs can be useful in cases of severe bradycardia or complete atrioventricular block, which are sometimes observed. There is also a strong inflammatory response that worsens symptoms, including those of a respiratory nature. This may help reduce pain. Pain Management; View all topics; . Academia.edu no longer supports Internet Explorer. ), Cubozoan Envenomations: Clinical Features, Pathophysiology and Management, Clinical and Epidemiological Aspects of Scorpionism in the World: A Systematic Review, Scorpion Sting Syndrome in Libya. Apply ice. Don't consume food or liquids if you're having difficulty swallowing. The systemic manifestations of scorpion envenoming occur in less than a third of victims of scorpion stings. Pain is present in more than 95% of cases of envenoming and may be associated with edema and erythema (in 20% of cases), more rarely small blisters. Tan PT, Veeramani A, Srinivasan KN, Ranganathan S, Brusic V. SCORPION2: a database for structure-function analysis of scorpion toxins. Rapid aberrant eye movements are likely to be more frequent during envenoming by Centruroides, found in North and Central America. Sorry, preview is currently unavailable. Movements are bilateral and symmetrical, horizontal or rotary, suggesting a peripheral origin, which some authors have attributed to cerebral edema, potentially due to vasoconstriction of brain capillaries, including those in the thalamus.34 The convulsive forms sometimes attributed to hyperthermia and dehydration in very young children could be of the same origin. The author has a strong voice and tells an engaging story that will keep you reading for hours. A scorpion sting may make your skin look red and slightly swollen. Pathophysiology of Scorpion Venom Scorpion venom is a water-soluble, heterogeneous mixture7. 2. The scorpion seeks cool, dark environments and commonly enters homes. 216.444.2538 We sought to describe the effects of continuous intravenous midazolam infusion as therapy for severe bark scorpion (Centruroides exilicauda) envenomation. Most scorpion stings in the United States are painful but harmless. An epidemiological and biological survey of scorpion envenomation was conducted in Algeria. But minor order also has a whiff of neglect. Scorpion stings and envenomation In most cases, the sting causes local effects including: pain, oedema, erythema. Gibly R, Williams M, Walter FG, McNally J, Conroy C, Berg RA. Meves H, Simard JM, Watt DD. Immunotherapy might be repeated after two hours if cure is not obtained on the first attempt. Illinois Sting . You can typically treat a sting at home with ice, elevation, pain medication and antihistamines. If severe pain : NSAIDS Local ice packs, xylocaine, dehydroemetine (counter irritant), streptomycin (NM blockade) 6. Myocardial perfusion scintigraphy study. This is a consequence of greater consideration given to envenoming by health authorities.2,5 The epidemiology of envenoming, including the incidence and circumstances of scorpion stings, has promoted better allocation of resources, appropriate training of health personnel, and implementation of management strategies for accidents.7. Pediatr Oncall J. Most scorpion stings arent dangerous. When heart failure is confirmed, many practitioners use dobutamine alone or in combination with diuretics or antiarrhythmics. Scorpions are more active at night, but people can get stung at any time. If you think one has stung you, call your doctor or go to the emergency room. The venom contains a complex mix of toxins that affect the nervous system (neurotoxins). It has 4 pairs of legs, a pair of claws, and a segmented tail that has a venomous spike at the end. CITE THIS ARTICLE . In addition, the release of inflammatory substances or vasodilators (kinins, prostaglandins) reinforces and exacerbates some symptoms (fever, dyspnea, visceral infarction) which can become dominant. The median duration of infusion was 9. It can be useful to administer analgesics with an anti-inflammatory action, such as salicylates, mindful that use of salicylates could trigger Lyells syndrome or Reyes syndrome, the latter occurring mostly in children during viral infections treated by salicylates.37 The incidence of Reyes syndrome, the symptoms of which can be confused with worsening of envenoming, is low at about 0.8 cases per million children,38 but is often fatal. Management includes strict rest, wound cleansing, analgesics PO, and tetanus prophylaxis (see Tetanus, Chapter 7). Bosmans F, Tytgat J. Voltage-gated sodium channel modulation by scorpion a-toxins. Chippaux JP, Stock RP, Massougbodji A. This first evidence of clinical improvement was recorded as 1.00 hour (median), with a range of 0.00 to 3.75 hours. 7 captopril (an ace inhibitor) has a similar action resulting in hypotension resistant to dopamine agonists. Most patients were treated with antivenom by the intramuscular route. Have you always wanted to read Scorpion Sting Management online completely free? Admit the victim immediately. These neurotransmitters will cause a strong and complex response taking the form, simultaneously or sequentially, of an adrenergic or cholinergic syndrome associated, especially in the case of Tityus and paleotropical scorpion envenoming, with an inflammatory response (see the comprehensive reviews by Freire-Maia et al and Ismail).1618 Symptoms develop rapidly, within a few hours, leading to a range of clinical pictures according to the species of scorpion. . Save my name, email, and website in this browser for the next time I comment. In: Ownby CL, Odell GV, editors. This combines a hypersecretion syndrome (salivation, sweating, vomiting, urinary incontinence, bronchial hypersecretion, and diarrhea), abdominal pain, miosis, bronchospasm, bradycardia with hypotension and, in the male, priapism. Most people dont need to see a healthcare provider for a scorpion sting. Midazolam is the most widely used, particularly in North America.45,46 Elsewhere, particularly in Africa and the Middle East, diazepam is used extensively.39 In addition, benzodiazepines are beneficial in the treatment of hypertension and could be the initial drug of choice in the treatment of scorpion envenoming. Systemic envenoming (grade II and III) requires immunotherapy in addition to administration of salicylates. Ghalim N, El-Hafny B, Sebti F, et al. A good correlation was observed between the grade of envenomation on admission and the blood venom concentrations measured by ELISA. Abdel-Haleem AA, Meki AMA, Noaman HA, Mohamed ZT. While camping, avoid sleeping directly on the ground. Scorpion stings are primarily due to accidental contact with scorpion. Any swelling and redness will usually appear within five minutes. This is a great book to begin reading if youre trying to get back on track after falling out of the loops with your writing. Children are overrepresented among the victims of envenomation. To browse Academia.edu and the wider internet faster and more securely, please take a few seconds toupgrade your browser. B. Poisoning in Children 2013 try to formulate the first attempt of management protocol for scorpion sting syndrome in Libya. Furthermore . Depending on the type of scorpion, the venom can cause pain or, much more rarely, affect your nervous system and cause other serious health problems. 1 annually, scorpion stings. Journal of the Egyptian Society of Parasitology. Children are particularly sensitive to scorpion envenoming. The first group represents about 70% of patients, the second 20%, and the third less than 10%. The Editorial Team at Infolearners.com is dedicated to providing the best information on learning. CHAPTER 37 ENVENOMATION SYNDROMES In: 1. As a consequence, efficacy and safety are significantly increased. 9 a total of 300,000 cases of scorpion sting are reported annually in mexico. Meki AR, Mohey El-Dean ZM. Management of insect stings includes cleansing the wound, antihistamines and pain relievers, and treatment for anaphylaxis. Approximately 1,400 species of the Scorpion are found worldwide. Medical intensive care remains the exclusive domain of a minority of specialists. Use of analgesics, even if they are not the most essential drugs in envenoming, is still important because pain is frequent and intense. However, the cholinergic excess or the neuromuscular excitation can provo Spider bites are uncommon medical events, since there are limited number of spiders world-wide with fangs strong enough to pierce human skin, and most spiders bite humans only as a final defense when being crushed between skin and another object. Full PDF Package Download Full PDF Package. How to Catch a Scorpion ACNH How to capture scorpions Scorpions only appear between May and October, and they'll only spawn between 7 PM and 4 AM. Additionally, we conducted a survey of ED physicians regarding their management of scorpion stings in three different EDs including SQUH. Apply a cool compress to the affected area. Children are at greater risk of developing severe cardiac, respiratory, and neurological complications because of their low body weight. Furthermore, black widow spider bites result in localized diaphoresis and possibly lymphangitis. Pulmonary edema following scorpion envenoming: Mechanisms, clinical manifestations, diagnosis and treatment. Scorpion stings cause an estimated 3000 deaths per annum worldwide. SCORPION STING IN AUTONOMIC STORM MEDICINE 4th UNIT 19-03-2014 1. Moreover, this should be made known to the public and implies organizational logistics (distribution and stock management in peripheral health centers, health staff training). Daisley H, Alexander D, Pitt-Miller P. Acute myocarditis following. However, this could be due to the particular circumstances or scorpion species involved, given that heart failure is a late complication of scorpion envenoming. The symptoms of more severe scorpion stings can continue to develop for 24 hours. You may feel a mild tingling or burning sensation. When the sting is fatal, the mechanism of death is often related to cardiotoxicity with terminal pulmonary edema. Scorpion envenoming and sero-therapy in Morocco. However, the cholinergic excess or the neuromuscular excitation can provo Spider bites are uncommon medical events, since there are limited number of spiders world-wide with fangs strong enough to pierce human skin, and most spiders bite humans only as a final defense when being crushed between skin and another object. They're more likely to be seen during the warmer seasons and when. It is a comprehensive directory of online programs, and MOOC Programs. Gmar-Bouraoui S, Ben Dhia N, Frih A, Skhiri H, Achour A, el May M. Scorpion sting and acute interstitial nephropathy: Apropos of 1 case. You may notice problems with There are 19 known families of scorpions and more than 2200 species, of which about 50 from the families of Buthidae, Hemiscorpiidae and Scorpionidae are harmful to humans. If you can, bring the scorpion with you. Arrival at the health center may be delayed by up to 12 hours after the sting because of an initial preference for traditional medicine, the health center being remote, or the patient having been referred from a health center lacking appropriate health care resources.1,4 First aid is usually administered by health staff with limited appropriate training. New antivenoms are highly purified immunoglobulin fragments, the efficacy and safety of which are excellent. You can lessen your risk by wearing long sleeves, pants and gloves when youre outside in areas where scorpions live. Chebanse, IL. Journal of Venomous Animals and Toxins including Tropical Diseases. Passive immunotherapy, discovered in 1894, is the only etiological treatment of snakebite or scorpion envenoming.49 Immunotherapy is based on administration of antibodies produced by an animal that has been previously hyperimmunized against the venom of the corresponding or a very close species. the display of certain parts of an article in other eReaders. OverviewThe pain you feel after a scorpion sting is instantaneous and extreme. A total incidence of 1.87% was found for the 15-month period. However, all these toxins can have a synergistic action on clinical symptoms, resulting in paradoxical syndromes or severe complications. Adi-Bessalem S, Hammoudi-Triki D, Laraba-Djebari F. Pathophysiological effects of. This chapter describes the animals, their toxins or poisons, the injuries which they cause, and outlines treatment appropriate for each. The venom of the same scorpion can have multiple toxins that may interact with each other, modulating the response of the ion channels involved and leading to complex and rapidly progressive symptoms.9, Toxins binding to the sodium channel are most important, at least with regard to mammals, particularly humans.911 Among the categories currently described, two main types can be distinguished, ie, toxins- and toxins-. 9500 Euclid Avenue, Cleveland, Ohio 44195 |, (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4397632/), (https://www.cdc.gov/niosh/topics/insects/scorpions.html), (https://medlineplus.gov/ency/article/002850.htm), (https://www.merckmanuals.com/home/injuries-and-poisoning/bites-and-stings/scorpion-stings), (https://www.poison.org/articles/tarantula-scorpion-bite-sting-treatment-181), (https://www.ncbi.nlm.nih.gov/books/NBK430928/), (https://www.fs.usda.gov/detail/r8/recreation/safety-ethics/?cid=fsbdev3_066388), Visitation, mask requirements and COVID-19 information. However, poorly refined antivenoms may induce severe adverse reactions, such as shock or anaphylaxis, which necessitate rapid administration of adrenaline. You can typically treat a sting at home with ice, elevation, pain medication and antihistamines. However, it should be borne in mind that the main origin of these symptoms is the increase in vascular resistance caused by peripheral vasoconstriction as a result of the action of catecholamines. Scorpion Sting Management PDF Book Details About the Author of Scorpion Sting Management PDF Free Download Book The book, Scorpion Sting Management , is a compelling novel that will draw you in to the story. This has been confirmed both experimentally and clinically.46,5052. These symptoms may include difficulty breathing, extreme swelling, vomiting and shock. Hall SM, Plaster PA, Glasgow JF, Hancock P. Preadmission antipyretics in Reyes syndrome. 8 mexico has the highest rate of scorpion sting and mortalities. Systemic symptoms can accompany envenomation of widow; funnel web, and Phoneutria spiders, and less often, those of recluse spiders. Scorpions often hide in firewood, clothes, bed linen, shoes, and garbage pails, so care should be taken when handling these things. Chippaux JP, Goyffon M. Venoms, antivenoms and immunotherapy. Symptomatic treatment without the use of antivenom was successful in the management of 205 cases of scorpion stings in Riyadh, Saudi Arabia, without any deaths [6]. As we have seen, experimental studies have shown that many biological markers of inflammation are involved in scorpion envenoming, and have been confirmed in the clinic. Bawaskar H. SCORPION STING: CURRENT MANAGEMENT. By using our site, you agree to our collection of information through the use of cookies. Policy. Scorpion stings are usually more dangerous to children than adults. Fortunately, assessment of severity using a scoring system can largely resolve this problem, enabling treatment to fit the grade of envenoming (Table 1). Romero NO, Hernndez TJM. Plus, you may get other good stuff online like how to access the Scorpion Sting Management online. Do you know you could get the most detailed guide on Scorpion Sting Management online right now? This is due to a greater prevalence of more toxic species. SCORPION STING: CURRENT MANAGEMENT . Soulaymani R, Faraj Z, Semlali I. Epidemiological aspects of scorpion stings in Morocco. Its important to get immediate medical help if you have severe symptoms after a scorpion sting. Introduction Scorpion envenomation is a significant problem in the southwestern United States and throughout Mexico. Vasconcelos F, Lanchote VL, Bendhack LM, Giglio JR, Sampaio SV, Arantes EC. 36 Full PDFs related to this paper. iological characteristics of scorpion envenomation and update the primary care health workers regarding the latest management practices of scorpion envenomation. Subjects: Forty-two children with scorpion sting. Open Access Full Text Article Review Emerging options for the management of scorpion stings Jean-Philippe Chippaux Abstract: Scorpion stings are common in many tropical countries. 2 Get to the ER Dobutamine should be considered (infusion of 10 g/kg/minute until normalization of left ventricular ejection fraction, then 5 g/kg every 12 hours). Receptor stimulation plays an important role in the pathogenesis of scorpion stings resulting in an inotropic (hypertension) phase, which, if not treated, progresses to a hypokinetic (pulmonary oedema, hypotension, tachycardia, and shock) phase. 50 hours (range, 4.25 to 20.50 hours). Scorpion stings are common in many tropical countries. The bark scorpion can cause more severe symptoms. Abroug F, Elatrous S, Nouira S, Haguiga H, Touzi N, Bouchoucha S. Serotherapy in scorpion envenomation: a randomised controlled trial. Serum levels of IL-6 and its soluble receptor, TNF- and chemokine RANTES in scorpion envenomed children: their relation to scorpion envenomation outcome. Once you've spotted one, be careful. Serum levels of cytokines in patients envenomed by. Toxins- (known as potential-dependent) present in the venom of paleotropical scorpions have a binding affinity for their receptor proportional to the intensity of the polarization of the membrane. The study was adjudged for Kerala Ayurveda Research Award 2007. Scorpion sting. Then put the body in a storage. Although most scorpion stings cause only localized pain without life-threatening envenoming, about one third of stings cause systemic envenoming which can result in death. Indeed, most treatments, including those used in clinical trials, used antivenoms with a neutralizing titer of about 10 ED50 (ie, 1 mL of antivenom neutralized an amount of venom corresponding to 10 LD50), while the current antivenoms show a neutralizing titer of more than 50 ED50 (Table 2), ie, are 35 times more effective. Emerging options for the management of scorpion stings, Autopsy Findings in Case of Fatal Scorpion Sting: A Systematic Review of the Literature, Intervention Program for Nursing Staff Regarding Approach to a Patient with Spider Phobia And/Or Bite, Scorpion envenoming in two regions of Colombia: clinical, epidemiological and therapeutic aspects, Scorpion Envenomation Among Children: Clinical Manifestations and Outcome (Analysis of 685 Cases), Perspectives and recommendations towards evidence-based health care for scorpion sting envenoming in the Brazilian Amazon: A comprehensive review, Pulmonary edema following scorpion envenomation: Mechanisms, clinical manifestations, diagnosis and treatment, Epidemiological data, clinical admission gradation and biological quantification by ELISA of scorpion envenomations in Algeria: effect of immunotherapy, SCORPION ENVENOMATION AND SEROTHERAPY IN MOROCCO, Cubozoan Envenomations: Clinical Features, Pathophysiology and Management, Scorpion Sting Envenomation in Children in Southeast Turkey, Antivenom for Critically Ill Children with Neurotoxicity from Scorpion Stings, Comments on Environmental and Sanitary Aspects of the Scorpionism by Tityus trivittatus in Buenos Aires City, Argentina, Cardiac Sarcolemmal Defects in Acute Myocarditis Due to Scorpion Envenoming Syndrome, Antivenom use in cases of bites and stings presenting to a public hospital, A review of epidemiological, clinical and in vitro physiological studies of envenomation by the scorpion Hemiscorpius lepturus (Hemiscorpiidae) in Iran, Epidemiological, Clinical Characteristics and Outcomes of Scorpion Sting in Southeastern Region of Turkey, Continuous Intravenous Midazolam Infusion for Centruroides exilicauda Scorpion Envenomation, Methodology of clinical studies dealing with the treatment of envenomation, Efficacy of scorpion antivenom plus prazosin versus prazosin alone for Mesobuthus tamulus scorpion sting envenomation in children: a randomised controlled trial, Envenomation by the Scorpion Tityus breweri in the Guayana Shield, Venezuela: Report of a Case, Efficacy and Reactivity of Antivenom, and Proposal for a Toxinological Partitioning of the Venezuelan Scorpion Fauna, Epidemiology of scorpion envenomation in the Southeast of Turkey, Clinical Aspects and Emergent Management of Snake Bites Presented to Emergency Department, Hemiscorpius lepturus envenomation: Manifestations and management with specific antivenom, Unusual presentations of scorpion envenomation, Evaluation of the neutralizing capacity of Androctonus crassicauda (Olivier, 1807) antivenom against Leiurus quinquestriatus (Ehrenberg, 1928) venom (Scorpiones: Buthidae), Scorpion envenomation in the region of Marrakesh Tensift Alhaouz (Morocco): epidemiological characterization and therapeutic approaches, Scorpionism in Central America, with special reference to the case of Panama, Epidemiological, clinical characteristics and outcome of scorpion envenomation in Batman, Turkey: An analysis of 120 cases, The neutralizing capacity of Androctonus crassicauda antivenom against Mesobuthus eupeus scorpion venom, Scorpion Sting Syndrome in Libya. Chippaux JP, Goyffon M. Epidemiology of scorpionism: a global appraisal. Abstract. Arterial oxygen saturation (SaO2) is likely to be less than 90%. 1-25, 1-26, 1-27. Dont handle scorpions with your bare hands. Evidence of myocardial ischaemia in severe scorpion envenoming. Finally, clinical trials performed in order to confirm the efficacy of antivenoms have been very few in number and often biased.55 However, a randomized placebo-controlled, blinded clinical trial carried out by Boyer et al46 showed that: antivenom removed the venom from the plasma compartment in less than one hour (versus more than 4 hours on average for the placebo group); the benzodiazepine dose needed was significantly lower in the group treated by antivenom; and cure was achieved in less than 4 hours in all patients treated with antivenom (versus only 15% in the control group).
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