scorpion envenomation copy

SCORPION STING

Dr. Hanan Fathy AbdelazizConsultant of Clinical Toxicology

Qassim Poison Control Center

SCORPIONS IN KSA

Clinical Presentation

Overview

Clinical Presentation SystemicLocal

Local Manifestations

O Intense local pain.

O Numbness.

O Tender regional lymph nodes.

O Erythema, local edema and sting marks

are not common.

The victim may present only by pain with or

without other manifestations.

Systemic Manifestations

General and metabolic manifestations:

• Fever, conjunctival congestion, sweating, dehydration, peripheral cyanosis and cold extremities (2ry to peripheral vasospasm caused by catecholamine) and priapism.

• Metabolic effects: Hyperkalaemia , hypocalcaemia, stress hyperglycemia and metabolic acidosis.

Main affected organs: 4 organs

Cardiovascular manifestations:

O Hypertension (severe and very characteristic).

O Arrhythmias, acute heart failure and shock in

severe cases.

Respiratory manifestations:

O Tachypnea, respiratory distress, wheezes and

crepitations.

O Acute pulmonary edema ,either cardiogenic (due

to sudden severe after load effect) or non-

cardiogenic (due to chemical mediators liberation).

Neurological manifestations:

Cranial nerve dysfunction:

• Blurred vision , disturbed eye movement and

constricted pupils.

• Dysphagia and excessive salivation.

• Tinnitus and slurred speech.

Other neurologic dysfunction:

• Involuntary movements.

• Agitation, restlessness, and confusion.

• Malignant hyperthermia.

Gastrointestinal manifestations:

O Excessive salivation.

O Vomiting, diarrhea.

O Acute erosive gastritis that may lead to

hematemesis.

The following may carry poor outcome:

• Rapid onset of symptoms (within half an hour).

• Altered conscious level.

• Shock or hypotension.

• ECG changes.

• Pulmonary edema.

• Malignant hyperthermia.

Risk factors (high risk group): • Extremes of age (< 5 years and > 60 years).

• Central location (e,g neck) or more than one sting.

• patients with cardiovascular, pulmonary disease

,hypertension or diabetes.

Management of Scorpion StingsI. Investigations

The following investigations should be performed

in all symptomatic patients (especially the high risk group):

• C.B.C.

• Serum electrolytes (Na+, K+, Cl-, HCO3-, etc…)

• A.B.G.

• BUN & serum creatinine.

• Serum enzymes (C.P.K., A.S.T., A.L.T., ..... etc.).

• ECG and continuous cardiac monitoring.

• Chest X ray.

II. Treatment

O Protocol of six hours surveillance in the

emergency department (12 hours for high risk

group).

O Only risk group patients and patients develop

systemic manifestations should be hospitalized.

O Treatment depends on:

First aid management (pre hospital – hospital).

Specific management (antivenom).

Symptomatic and local wound treatment.

First aid management

(As Important As The Anti Venom)

I. Pre hospital management:

Ø Moving the patient away from the scorpion

area.

Ø Reassure the patient (very important).

Ø Use ice bags to reduce pain and to slow the

absorption of venom (most effective during the

first 2 hours).

Ø Immobilize the affected part in a functional

position below the level of the heart.

Ø Oral extraction of poison is contraindicated.

II. Hospital management:

O Stabilize vital signs (respiration and blood pressure)

and manage the major clinical problems:

Convulsions.

Shock.

Pulmonary edema and cardiac or respiratory failure.

Hyperthermia.

O Local wound care (cleaning, topical antibiotic and local

anesthetic agent).

O Tetanus prophylaxis.

O Systemic antibiotics (controversial).

Four Questions About Anti Scorpion

Venom

O Indications?

OWhen to give ?

OHow to give?

OWhat are the adverse reactions?

Four Questions About Anti Scorpion

Venom

Indication?

O It is given to all high risk group patients as well

as all patients with any of the systemic

manifestations.

When to give?

O It is best given in the first 4 hours but can still

be given as late as 24 hours.

Four Questions About Anti Scorpion

Venom

How to give?

Ø Three to five (3-5) ampoules as initial

dose are given by slow IV or IM route.

Ø It can be repeated after 30 minutes (if no

improvement).

Ø Skin test (hypersensitivity) must be

performed before administration.

Ø Dose of anti scorpion anti venom is not

related to body weight.

What are the adverse reactions?

Ø Allergic reaction in the form of rashes, urticaria

,wheezing & increased bronchial secretion.

Ø It has good response to steroid.

Management of Unknown

Stings

You have to exclude

scorpion sting

How?

Remember

“Surveillance protocol in the emergency

department

(6-12 hours)”

Unknown Sting (proved not scorpion)

Symptomatic cases

Local Reaction

Systemic

Asymptomatic

cases

Cases need consultation

Symptomatic cases

Systemic reaction

AnaphylaxisAnaphylactic

shock

Local reaction

Mild -Moderate

Severe

Local Reaction

Mild -Moderate

Severe

Systemic Reaction

AnaphylaxisAnaphylactic

shock

Systemic reactionAnaphylaxis Anaphylactic shock

O Reassurance (very important)

O No tourniquet and No oral

treatment.

O Initial I.M 0.3-0.5 mL of

1:1000 epinephrine. may be

repeated.

O A bolus of IV epinephrine

(1:10,000) in severe cases.

O Antihistamines and steroids.

O Admit the patient for

observation.

Same management of

anaphylaxis in addition to:

O Admit the patient is ICU.

O Endotracheal intubation

and ventilatory support.

O Management of shock.

Cases need specific consultation

O Infectious disease specialist consultation is

needed in cases of potential vector-borne

disease transmission.

O If the case is associated with travel to or

coming from tropical region, consider

consultation of a tropical medicine specialist

(i.e. symptoms appear after sting or bite in

tropical area).

Asymptomatic cases

O Asymptomatic cases should be observed for 6-12

hours to exclude scorpion sting (12 hours for high

risk group). If clinical manifestations of scorpion

stings appear i.e vomiting, hypertension, sweating

etc….manage as discussed before.

O If the case become symptomatic manage according

to type of reaction previously discussed.

O If still asymptomatic for 12 hours , it can be

discharged.

Observe for 6 hours

12 hours for high risk group

Symptoms of scorpion sting

e.g. vomiting -hypertension

Manage accordingly

Symptoms of allergic

reaction (local or systemic)

Manage accordingly

Still Asymptomatic

Discharge

Thank you