scorpion envenomation in children

CLINICOPATHOLOGICAL PROFILE OF

SCORPION ENVENOMATION IN

CHILDREN OF CHHATTISGARH REGION

MEETA SACHDEV G.MALINI DEPTT. OF PEDIATRICS JLN HOSPITAL & RESEARCH CENTRE; BHILAI

INTRODUCTION

Scorpion sting: • Acute life-threatening, time-limiting

emergency.• True incidence not known.• Children are frequent victims.• Case fatality:- 3-22 % (hospitalized

children).

INTRODUCTION

• Commonest species :- Mesobuthus tamulus (red scorpion) & Palamneus swammerdam ( black scorpion).

• Clinical picture evolves in 30 minutes to 6 hrs.

• Cardiovascular effects are prominent.

• Pulmonary edema & cardiogenic shock- major causes of death.

TAXONOMY

• Arthropod ,Class-

Arachnida.

• Lethal scorpions:-

Family-Buthidae.

• 1-20 cm in length.

HABITAT

• Terrestrial habitat.

• Nocturnal behavior.

• Crevices, burrows,

under logs/debris,

paddy husk, fields.

• Luggage & cargo.

ABOUT SCORPION VENOM• Neurotoxin, cardiotoxin, nephrotoxin,

hemolytic toxin, phosphodiesterases, phospholipases, hyaluronidases, glycosaminoglycans, histamine, serotonin, tryptophan, cytokine releasers.

• Neurotoxin:- Acts indirectly by stimulation of sodium channels at presynaptic nerve terminal & inhibition of calcium dependant potassium channels -autonomic storm.

AUTONOMIC STORM

• Complex interaction between sympathetic & parasympathetic stimulation.

• Transient cholinergic stimulation:- 1-2 hrs to 6-13 hrs.

• Prolonged sympathetic stimulation:- <4hrs to 24-72 hrs.

• Depletion of catecholamines:- severe myocardial dysfunction.

• Recovery phase:- 48- 72 hrs,replenishment of catecholamine stores.

CLINICAL FEATURES

PARASYMPATHETIC

• Bradycardia• Hypotension• Vomiting • Salivation• Sweating• Priapism• Bronchoconstrictio

n• Bronchorrhoea• Generalised

weakness

SYMPATHETIC• Hyperthermia• Tachycardia• Tachypnoea• Hypertension• Arrhythmia• Hyperkinetic pul.

edema• Hyperglycemia• Piloerection• Restlessness • Hyperexcitability

AIMS & OBJECTIVES

• To evaluate various demographic & clinical parameters.

• To analyze significant factors related to severity.

• To assess efficacy & role of early administration of prazosin.

• To formulate & facilitate the strategy for comprehensive care & management of cases.

SUBJECT & METHODS• TYPE OF STUDY : RETROSPECTIVE

• TIME FRAME : JAN 2008 – SEP 2010

• NO. OF SUBJECTS : 25

• AGE GROUP : UPTO 15 YEARS

• INCLUSION CRITERIA : H/O SCORPION

STING

SUBJECT & METHODS

Demographic parameters

Clinical symptoms & signs

Investigations

Details of treatment & outcome.

OBSERVATIONS

AGE DISTRIBUTION

64%

20%

16%

<=5Y

6Y - 10Y

11Y - 15y

Variable N Mean SD Minimum MaximumAGE 25 5.8000 3.8864 1.0000 14.000

SEX DISTRIBUTION

32%

68%

F

M

MALE : FEMALE = 2.1 : 1

MONTH DISTRIBUTION

8%4%

4%

0%

16%

12%

16%

8%

4%8%

8%

12%

JANFEBMARAPRMAYJUNEJULYAUGSEPTOCTNOVDEC

56 % OF CASES – JUN - SEP 82.3 %

RURAL / URBAN DISTRIBUTION

16%

84%

RURAL

URBAN

INDOOR / OUTDOOR INCIDENCE

48% 52%INDOOR

OUTDOOR

TIME DISTRIBUTION

8%8%

36%

48%

0-6 AM

6 AM-12 NOON

12 NOON -6 PM

6 PM-12 MN

MAX. CASES :- 6PM – 12MN

80%

16%4%

LOWER LIMB

UPPER LIMB

FACE

STING SITE DISTRIBUTION

ONSET OF SYMPTOMS

92%

8%

<=30 MIN

>30 MIN - 2HRS

TREATMENT HISTORY

10

8

2 21 1

0

2

4

6

8

10

12

NO

OF

PA

TIE

NT

S

TIME LAPSE

32%

36%

24%

8%

<3 HRS

3-6 HRS

6-12 HRS

>12 HRS

Variable Mean SD Minimum MaximumTime Lapse 5.9800 5.6374 0.5000 27.000

100%

8%

60%

32%

80%

44%32%

8%

40%

0%

20%

40%

60%

80%

100%

120%

% O

F P

AT

IEN

TS

SIGNS & SYMPTOMS

73.6 % 91.1 %

12%

24%

72%

52%

64%

88%

20%

80%

48%

0%10%20%30%40%50%60%70%80%90%

100%

GCS 9

-12

FEVER

TACHYCARDIA

DYSPNOEA

NORM

OTENSIV

E

HYPOTENSIO

N

HYPERTENSION

COLD P

ERIPHERY

CREPTS

% O

F P

AT

IEN

TS

CLINICAL SIGNS20.5 %

61.5 %

95.5 %

77.7 % 24.5 %29.6 %

38 %

SEVERITY

GRADE-1:ISOLATED PAIN

GRADE-2(SYSTEMIC MANIFESTATIONS)

HYPERTENSIONSWEATINGVOMITINGPRIAPISMFEVER ,SHIVERING

GRADE-3(LIFE-THREATENING MANIFESTATIONS)

CARDIOGENIC SHOCKPULMONARY EDEMAALTERED CONSCIOUSNESS

8%20%

72%

0%

20%

40%

60%

80%

GRADE-1 GRADE-2 GRADE-3

80.8 %

19.2 %

INVESTIGATIONS

HEMATOLOGICAL PARAMETERS

20%

56%

100%

64%

0%

20%

40%

60%

80%

100%

120%

ANEMIA

LEUCOCYTOSIS

NEUTROPHILIA

PLATELETS

Variable Mean SD Minimum MaximumHB 11.380 1.8448 7.4000 15.200TLC 13952 6528.7 6000.0 30000P0LYMORPH 79 % 11.726 55% 94 %PLATELETS 2.5680 0.8775 1.0000 4.5000

80 %

BIOCHEMICAL PARAMETERS

Variable Mean SD Minimum MaximumRBS 154.80 87.329 32.000 397.00CPK 1281.1 3135.8 42.000 16002LDH 921.24 402.83 485.00 2553.0

60%

16%

100%100%

68%76%

100%

0%

20%

40%

60%

80%

100%

120%HYPERGLYCEMIA

LIVER ENZ

RFT

ELETROLYTES

CK

CKMB

LDH

39 %

ECG FINDINGSI II III

aVR aVL aVF

V1 V2 V3

V4 V5 V6

5 yr Male

12 yr Male

5 yr Female

2.5 yr Male

MANAGEMENT

Prazosin: Postsynaptic alpha blocker.Cellular & pharmacological antidote.Reverses both ionotropic & hypokinetic phases.*Reverses metabolic effects caused by

depressed insulin secretion.Has reduced mortality from 25-30% to <1%.**

* Bawaskar HS, Bawaskar PH.Vasodialators:Scorpion envenoming & the heart (An Indian experience).Toxicon 1994;32:1031-1040.

** Bawaskar HS, Bawaskar PH. Indian red scorpion envenoming. Indian J Pediatr 1998;65:383-391

PRAZOSIN

Available as 1mg scored tablet. (Rs-38/10 tab)

Dose :- 30 mcg/kg ; 4-6 hourly.

First dose phenomenon .

Usually 4-6 doses are required.

Given irrespective of blood pressure.

PRAZOSIN THERAPY

6

9

7

3

0123456789

10

NO

. O

F P

AT

IEN

TS

MANAGEMENT

25 23

16

5 72

05

1015202530

NO

. OF

PA

TIE

NTS

HOSPITAL STAY16

7

1 1

6 68

5

02468

1012141618

<2 DAYS >2-3 DAYS >3-4 DAYS >4 DAYS

NO

. OF

PATI

ENTS

ICU STAY

TOTAL STAY

NO MORTALITY

CONCLUSION & RECOMMENDATIONS

• Majority of the children develop severe manifestations of scorpion envenomation.

• Close monitoring is essential.

• Time lapse between sting & administration of prazosin determines outcome.

CONCLUSION & RECOMMENDATIONS

• Prazosin should be given as an immediate measure.

• Most of the cases with myocardial dysfunction respond to dobutamine infusion.

• Ventilatory support in cases of severe pulmonary edema, refractory shock & cerebral involvement may reduce mortality.

THANKS

REFERENCES• Bouaziz m et al. Epidemiological, clinical characteristics and

outcome of severe scorpion envenomation in South Tunisia: multivariate analysis of 951 cases.Toxicon 2008 Dec 15;52(8):918-26.

• Bosnak M et al.Severe scorpion envenomation in children: Management in pediatric intensive care unit. Hum Exp Toxicol. 2009 Nov;28(11):721-8.

• Bawaskar HS,Bawaskar PH.Indian Red Scorpion Envenoming.Indian j Pediatr 1998;65 :383-391.

• Bawaskar HS ,Bawaskar PH.Utility of scorpion antivenin vs Prazosin in the management of severe Mesobuthus tamulus (Indian red scorpion) envenoming at rural setting.J Assoc Physicians India.2007 Jan;55:14-21.

CRITICAL CARE ISSUES

Myocardial dysfunction & blood pressure.

• Dobutamine (5-15 mcg/kg/min).*• Sodium nitroprusside (0.3-5 mcg/kg/min).**• Nitroglycerine (0.5-5mcg/kg/min).***

* Elatrous et al Dobutamine in severe scorpion envenomation. Chest 1999; 116:748-753.

** Bawaskar HS,Bawaskar PH.Prazosin for vasodilator treatment of acute pulmonary edema due to scorpion sting.Ann Trop Med Parasitol 1987;1:719-723.

*** P.Narayan et al.Nitroglycerine in scorpion sting with decompensated shock.Indian Pediatrics 2006;43:613-617.

CRITICAL CARE ISSUES

Pulmonary edema• Decreased intravascular volume can coexist

with pulmonary edema. • Dynamic state.• Diastolic dysfunction of left heart.• Chest X-ray : sensitive & easily available tool.• Clouding of consciousness : indicates shock.• Severe cases may require ventilation.• 30 minutes -3 hrs.

CRITICAL CARE ISSUES

RESPIRATORY FAILURE• Bronchorrhoea & bronchoconstriction.• Hypertension.• Upper airway dysfunction.• Convulsions, cerebral haemorrhage,

central respiratory failure.• ARDS

UNHELPFUL TREATMENT

• Lytic cocktail ( pethidine + promethazine + chlorpromazine )

• Morphine (worsens dysarrhythmias).

• Steroids (enhance necrotizing effects of excessive catecholamines ).

• Atropine (potentiates tachycardia & sustained hypertension ).

UNHELPFUL TREATMENT

• Nifedipine (reflex tachycardia & negative ionotropic effect).

• ACE inhibitors (aggravate hyperkalemia & inhibit breakdown of bradykinin).

• Insulin glucose potassium drip.

• Scorpion antivenom.