scorpion envenomation in children
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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.