scorpion envenomation copy
TRANSCRIPT
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