Case history

Рatient – I.U 30 years old

Complaints: Scorpion bite on the foot approximately 25min ago. Intense pain on the right foot, salivation,
tearing, visual disturbances. After some minutes, patient felt paralysis of right foot, diarrhea, inability to speak
correctly, drop of eyelids. Progressive difficulty breathing, general weakness.
Previously diseases and operations: no
Accompanying diseases: no
Allergic background: no
Blood transfusion and hormonal therapy: no
Harmful habits: smoking: yes/no, alcohol abuse: yes/no

Objective status:
General status: Weak
Consciousness – Weakening of consciousness
Physical status: passive
Body weight 60 kg, height 165cm.
Skin: sign of the bite in the left foot. Sting mark, hyperemia around sting.

Breathing is rhythmic (yes/no), free (yes/no), respiratory rate 14 bpm, rales (yes/no).
Cardiovascular system: sinus rhythm, murmurs absent
BP 150/900 mmHg, pulse 150/min.
ECG: sinus rhythm, tachycardia.
Organs of abdominal cavity: abdomen is soft: yes/no, bloating: yes/no, liver is palpated: yes/no
Neuro-psychological status: ptosis, vertigo, blurred vision.
Pathology of veins of lower extremities: (yes/ no) - Inflammation and edema of affected area (bite).
Primary diagnosis: Poisoning by scorpion bite.
Planned methods of investigations: Complete blood count, ECG, coagulogram (eg, TP, TTP and fibrinogen),
measurement of serum fibrinogen and fibrin degradation products, urine, chest X-ray, measurement of serum
electrolytes, blood urea nitrogen and creatinine, also blood typing and cross reaction.

Results of laboratory and instrumental investigations: Coagulopathy, metabolic acidosis. Tachycardia on ECG,
reduced rate of proteins, albumins, ALP, ESR. Normal chest X-ray. Blood type A, RhD positive (A+).
Clinical diagnosis: Poisoning by scorpion bite ( Centruroides alayoni)
Treatment:
Antielapidic Serum (Bivalent) + Heterologous Immunoglobulin Against Centruroides alayoni 
(active substance): 10 ampoules diluted in 0.9% saline or 5% glucose solution in a 1: 2 ratio. Infusing at a speed of 10
mL / min.
Morphine 10mg/ml injection.
Oxygen therapy. Cannula
Clean and apply bandages on the area, place the affected limb in an elevated position.
After 2 days of the bite, it is necessary to evaluate joint movement, muscle strength, sensitivity and waist
measurement.
DATE 13/07/2021
Manushee Henadeera

Prescription list and dynamics of the main indicators of the patient's condition
in the intensive care unit with a diagnosis poisoning by scorpion bite. 13/07/2021 г.

Hours 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
RR 12 15 15 17 17 17 18 18 18 18 18 18 18 18 18 18 18 18 18 19 19 19 19 19
Pulse 13 11 10 90 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 78 78 78 78
0 0 0
HR 13 11 10 90 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80
0 0 0
BP systol. 10 11 12 13 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14 14
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
BP diastol. 60 70 70 70 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80 80
BP mean 73 83 86 90 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10 10
.3 .3 .6 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
SpO2 93 95 96 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98 98
diuresis - - 60 75 78 79 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78 78
stul 30
0
ml
aspiration
(tubes)
drainages
temperature 37 37 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36 36
,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5 ,5

red blood
cells
Hemoglobin
hematocrit(% 38 42
)
white blood 11 11
cells .0 .0
× ×
10 10
9
/L 9
/L
) )
platelets 45 45
0, 0,
00 00
0 0
sedimentation 10 10
rate of
erythrocytes
(mm/h)
partially
thromboplasti
n activated
time
international
normalized
ratio
pH 6. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7. 7.
8 3 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35 35
pCO2 48 46 45 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40 40
(mmHg)
pO2 (mmHg) 70 75 80 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85 85
BE(mmol/l) 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2, 2,
0 1 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
lactate
general. 7. 7.
Protein (/dL) 10 40
urea
creatinine(mg 0. 0.
/dl) 93 86
bilirubin
AST (U/L) 53 60
ALT (U/L) 52 54
.0
4
ALP (U/L) 60 85
troponin
D-dimer

Appointed prescribing medications, instrumental methods of diagnosis and treatment

Hours 8 9 1 1 12 13 14 15 16 17 18 19 20 21 22 23 24 1 2 3 4 5 6 7
antielapidic
serum (vials)
Morphine
Oxygen therapy
Blood analysis
ECG
 Algorithm perform practical skills

Open cricothyroidotomy
Steps in the procedure are as follows:
 Assemble and prepare equipment
 Position the patient supine, with the neck in a neutral position
 Clean the patient’s neck in a sterile fashion using antiseptic swabs
 Anesthetize the area locally, if time allows
 Locate the cricothyroid membrane anteriorly between the thyroid and the cricoid cartilage
 Stabilize the trachea with the left hand until the trachea is intubated
 Make a 2- to 3-cm midline vertical incision through the skin from the caudal end of the thyroid cartilage to the
cephalic end of the cricoid cartilage
 Make a 1- to 2-cm transverse incision through the cricothyroid membrane
 Insert the scalpel handle into the incision and rotate 90° (a hemostat may also be used to open the airway)
  Insert a tracheal hook into the opening, hooking the caudal end of the opening, and lift, allowing for passage of
an appropriately sized cuffed endotracheal or tracheostomy tube (usually No. 5 or No. 6), directing the tube
distally.
 One alternative to the preceding step is to insert the tube through the opening produced by the opened hemostat;
a second alternative is to hold the handle of the scalpel straight down in the opening, slide the handle
cephalically, insert the tube straight down along the handle until it hits the back of the trachea, angle the tube
caudally, and advance the tube
 Inflate the cuff; observe and check for chest rise
 Secure the airway
 Take care not to cut the thyroid or the cricoid cartilage

Nasogastric tube insertion

1. Gather equipment
 Nasogastric tube (fine bore)
 Disposable gloves
 Lubricant and gauze: to lubricate the tip of the NG tube.
 Disposable bowl: to be used in the event of vomiting.
 Paper towels: to allow the patient to wipe around their mouth if needed.
 Large syringe: to obtain an aspirate from the NG tube.
 pH testing strips: to assess the pH of the aspirate.
 Dressing: to secure the NG tube.
 A glass of water for the patient (if swallow is deemed safe).
 Local anaesthetic spray: to numb the oropharynx.
2. Measurement of the insertion length
1. Position the patient sitting upright with their head in a neutral position.
2. Don a pair of non-sterile gloves.
3. Estimate how far the NG tube will need to be inserted: measure from the bridge of the nose to the ear lobe and
then down to 5cm below the xiphisternum.
3. Insertion of the NG tube
1. Lubricate the tip of the NG tube.
2. If available, a local anaesthetic should be sprayed towards the back of the patient’s throat.
3. Warn the patient you are about to insert the NG tube.
4. Insert the NG tube through one of the patient’s nostrils.
5. Gently advance the NG tube through the nasopharynx:
This is often the most uncomfortable part for the patient.
If resistance is met, rotating the NG tube can aid insertion. Avoid forcing the NG tube if significant resistance is
encountered.
If the patient becomes distressed, pause to give them some time to recover.
Intermittently inspect the patient’s mouth to ensure the NG tube isn’t coiling within the oral cavity.
 6. Continue to advance the NG tube down the oesophagus: ask the patient to take some sips of water and then
swallow as this can facilitate the advancement of the NG tube. Avoid giving patients a drink if their swallow is
deemed unsafe, due to the risk of aspiration.
7. Once you reach the desired nasogastric tube insertion length, fix the NG tube to the nose with a dressing.
4. Aspiration of the NG tube
1. Attempt to aspirate gastric contents:
If aspiration is successful, test the pH: a value of <4 suggests correct placement.
If aspiration is unsuccessful or the pH is >4 the patient will require a chest x-ray (CXR).
Some hospitals require a CXR regardless of pH, so check your local guidelines.
Acceptable pH ranges also vary between hospitals, so always check your local guidelines.
2. Once the NG tube is deemed safe for use, the radiopaque guidewire can be removed.
3. Dispose of the used clinical equipment into a clinical waste bin.
4. Wash your hands.

To complete the procedue

Explain to the patient that the procedure is now complete and reassure them that the NG tube will become more
comfortable over the next few hours.
Thank the patient for their time.
Offer the patient paper towels to clean their face and nose.
Let the nursing staff know if the NG tube is currently safe to use.
Document the details of the procedure in the patient’s notes.

Gastric lavage through a nasogastric tube

1. Insert the nasogastric tube into the stomach, then confirm placement. A fully awake patient should be placed in the
left lateral decubitus position. An intubated patient may lie supine. 
2. Introduce 200 to 300 mL of water at body temperature into the tube and then lower the tube into the bucket below
the level of the stomach before water disappears from the funnel. This will cause the water to return (siphon
phenomenon). Repeat until clear (watery) outflow is seen.
3. A single dose of activated charcoal (1 g/kg) can be administered into the stomach after completing gastric lavage as
indicated. Exceptions include substances that are not adsorbed by activated charcoal (alcohols, mercury, lead, iron,
caustics, and hydrocarbons).
Consider administration of repeated doses of activated charcoal (starting from 1 g/kg and followed by 0.5-1 g/kg
every 2-4 hours) in patients who ingested life-threatening doses of quinine, dapsone, phenobarbital, carbamazepine,
or theophylline.