scorpion sting management

1. SCORPION STING IN AUTONOMIC STORM
MEDICINE 4th UNIT
19-03-2014
1

2. CASE SCENARIO
14 year old boy,without any premorbid illness
presented to our emergency depatrment at 7pm with
history of unknown bite on right lower limb-just above
the medial malleolus around 5.30pm on the same day.
He complained of upper abdominal pain,
slurring of speech,increased salivation,excessive
sweating,blurring of vision,painful penile erection,
nausea and 2 episodes of vomiting following the bite
No history of any bleeding manifestations
2

3. O/E,
• Conscious,oriented Diaphoresis+
Extrimities cold and clammy
Priapism+
No ptosis,no perioral numbness
No bleeding manifestaions
Vitals:
Pulse-98/min regular
BP=160/100mmhg Right upperarm supine position
RR-16/’regular abdomino thoracic,SPO2-97% in room air
Systems: CVS-s1 s2 +
RS –NVBS,bilateral scattered rhonchi+
P/A-soft BS+,epigastric tenderness+
CNS-no FND,Pupils bilateral 3mm briskly reacting to light
Local examination-no bite mark,no tenderness,no oozing of
blood no local lymphadenopathy 3

4. The 20 WBCT at admission was < 20 minutes.
A provisional Diagnosis of Scorpion sting in autonomic storm
was made and Patient was transferred to IMCU for intensive
care.
He was given T.Prazosin 1mg stat InjAvil,Hydrocortisone,lasix
along with other supportive measures and frequent monitoring
of O2 saturation.
At 9.30pm,sudden drop in Spo2 was noted to 90%
O/E, patient conscious,oriented,tachypneic,Pulse-100 bpm
RR-32 per min,BP-120/100,extrimities warm
CVS-s1 s2 +
RS-bilateral extensive crackles+
P/A-soft epigastric tenderness+
CNS-no FND 4

5. • Patient was intubated with COETT 7 connected to
mechanical ventillator ACMV-VC mode
• He was on mechanical ventillatory support for 20
hours and later extubated .
• His general condition stabilised and was shifted to
ward on Day4.
• In ward he did not go in for any other complications
and was hence discharged in a stable condition on
6th day following the bite with final diagnosis as:
SCORPION STING IN AUTONOMIC STORM
WITH ARDS
5

6. Investigations:
CBC(9/2/14)
Hb:12.8
13/2/14
12.6
RBS:192
FBS-
77,PPBS-110
RBS-102
Tc:6400 6400 B.urea:33 38
DC-
P59L40E01
P59L39E02 S,.Creatinine
-
1.0S.bilirubin
(T)0.9
0.9
ESR:4mm 1st
hr
5mm 1st hr AST/ALT-
24/16
Rbc:4.2
million/mm3
4.3 t.protein:6.7
PCV:42 40 Sodium- 138 142
PLC:2.4 lakh 2.5 Potassium-
5.2
4.8
6

7. ECG:
Normal standardisation,
SR @ 105bpm,axis+60 degree
P,QRS duration and morphology normal
PR interval-0.10 sec
QTC-0.45 sec
Tall peaked T waves in
lead 2,3, aVF
CXR-PA view:NAD
Cardiology opinion:clinicaly normal heart.
7

8. 8

9. Discussion:
In many tropical and subtropical regions of the world
scorpions-crab like arachnids- are the most important
venomous animals after snakes.
• Scorpions are eight-legged arthropods; order
Scorpionida and class Arachnida.
• The terminal segment, called the telson (bulb containing
a pair of venom secreting salivary glands), contains two
venom glands connecting with the curved needle sharp
sting that is used either for defense or to obtain food.
• The length of adult scorpions varies from under 2 cm to
about 20 cm but the length does not relate to its toxicity
(some of the most dangerous scorpions are only 2–4 cm
long).
9

10. • The toxicity of scorpion venom is worse than that of the
snakes but only a small quantity is injected.
• In spite of advances in pathophysiology and therapy the
mortality remains high in rural areas due to lack of access
to medicare.
• Since the advent of scorpion antivenom (SAV), prazosin,
dobutamine and intensive care facilities the fatality due to
scorpion sting has been significantly reduced.
10

11. Biology of scorpion venom:
• The scorpion venom is a mixture of various active
substances namely polypeptides and enzymes.
• Venom consists of: (1) neurotoxin, which acts on the
respiratory, vasomotor centers, nerve terminals and end plates
of both striped and unstriped muscles
(2) hemolysins, agglutinin
hemorrhagins, leukocytolysins, coagulins, lecithin,
cholesterin,cardiotoxins, nephrotoxins, hyaluronidases, 11

12. phosphodiesterases,phopholipases, glycosaminoglycans,
histamine,tryptophan and cytokine releasers.
• Also, a number of free amino acids and serotonin are
isolated from the venom.
• Of the scorpion venom toxins, neurotoxins are the most
important and they contain peptides that block the
sodium channels (beta-toxins).
12

13. • There is massive release of endogenous
catecholamines into the circulation due to delayed
activation of sodium neuronal channels by the venom.
• The main molecular targets of scorpion neurotoxins
are the voltage gated sodium channels and potassium
channels including calcium activated potassium
channels.
• Iberiotoxin and tamulotoxin content of the scorpion
(Mesobuthus tamulus) venom are the only selective
inhibitors of potassium channel. 13

14. • Sodium and potassium channel blocking toxins of
scorpion venom mediate synergistic effects responsible
for intense and persistent depolarization of autonomic
nerves with massive release of autonomic
neurotransmitters evokes an “autonomic storm”
response
14

15. • The stimulation of nitrergic nerves supplying penile
smooth muscles may explain the priapism observed in severe
scorpion envenoming (these nerves run from brain to spinal
cord in independent pathway to supply penile smooth muscle
for vasodilation, i.e. other than sympathetic and
parasympathetic tracts pathway).
• Scorpion venom contains serotonin, which may cause
local pain at the site of sting.
15

16. • Multiple toxins may be present in the venom of a single
species of scorpion capable of producing potent synergistic
effects in victim.
• Venom of Tityus trinitatis in Trinidad is pancreotoxic
responsible for development of acute pancreatitis-edematous
or hemorrhagic pancreatitis with development of pancreatic
pseudocysts
16

17. Epidemiology:
• Out of 1,500 scorpion species known to exist, about 30 are
of medical importance.
• Although a variety of different scorpion species exist,
majority of them produce similar effects.
• Most scorpion species produce venom, which causes only
minor local reactions in humans,but in certain parts of
world including certain parts of India scorpion stings are
a serious (sometimes fatal) health hazard.
• Scorpions capable of inflicting fatal stings are all
members of the families Buthidae and Scorpionidae.
Examples of some most deadly species are Androctonus
australis (NorthAfrica and Middle East), Androctonus
crassicauda (Turkey, MiddleEast and North Africa), Buthus
occitanus (countries borderingMediterranean and Middle
East),and Mesobuthus tamulus (India). 17

18. • Painful scorpionstings are a common event
throughout the tropics; however, fatal envenoming is
frequent only in parts of Latin America, North
Africa,Middle East and India.
• In India, 86 species of scorpions have been identified;
two types of poisonous species are important namely
the small red Buthus tamulus and the large black
Palamneus gravimanus; of the two Buthus tamulus is
more toxic.
• Mesobuthus tamulus (the Indian red scorpion) is the
most lethal amongst all poisonous species of
scorpions in India with fatalities in adults and
children. 18

19. • M.tamulus actively secretes venom rich in
neurotoxin and massive release of endogenous
catecholamines causes hypertensive crisis,
arrhythmias, pulmonary edema and myocardial
damage.
• Mesobuthus tamulus scorpion is common in western
Maharashtra, Saurashtra ,Kerala,AndhraPradesh,
TamilNadu and Karnataka states where morbidity and
mortality due to scorpion stinging have been reported
• Another Indian scorpion, Palamneus gravimanus
inflicts severe and excruciating painful sting..
19

20. Clinical features:
• Venom is deposited deep to subcutaneous tissue after sting;
almost complete absorption of the venom from sting site
would occur in 7–8 hours (70% of maximum concentration of
venom in the blood reached within 15 minutes of sting).
• The severity of envenoming is related to age (high fatality
is seen in children and 50% mortality in less than 4 years
old in the past), size of scorpion and the season of sting
(April to early June and September to October). 20

21. • Clinical presentation can be divided into local
manifestations and systemic manifestations.
1)Local Manifestations
• Severe excruciating local pain is the only clinical
manifestation seen in 35% of cases ,radiating along the
corresponding dermatomes.
• Local signs such as swelling, redness, heat and regional
lymph node involvement are never extensive.
21

22. • Stings typically do not produce a visible skin lesion,
although on rare occasion a small red mark is noted
• Local edema, urticaria, fasciculation and spasm of
underlying muscles are rarely seen at the site of sting due
to persistent stimulation of pain receptors and the liberated
serotonin.
• Positive tap test is present (on tapping increase in
paresthesia occurs) in some patients. 22

23. • Due to pain there is transient bradycardia,
transient rise in blood pressure and sweating with
warm extremities.
• Most scorpion stings are minor, producing severe
local pain and paresthesias without systemic
involvement (benign or dry sting).
23

24. 2)Systemic Manifestations
• Scorpion venom delays the closing of neuronal sodium
channels,resulting in “autonomic storm” owing to sudden
outpouring of endogenous catecholamines into the circulation.
Systemic symptoms may develop within minutes, but may be
delayed as much as 24 hours.
• Features of autonomic nervous system excitation are
transient cholinergic and prolonged adrenergic stimulation.
24

25. • Initial parasympathetic excitation is characterized by
- vomiting once or twice,
- profuse sweating (skin diarrhea for 3–17 hours)
- ice cold extremities,
- hypersalivation and
-thick mucus secretion due to stimulation of
bronchial mucus glands,
- lacrimation,
-pin-point pupils,
-diarrhea,
-abdominal distension,
-priapism,
-bradycardia and hypotension.
25

26. • Prolonged massive release of catecholamines, as in
pheochromocytoma, later produces
-restlessness,
-piloerection,
-marked tachycardia,
-mydriasis,
-hyperglycemia,
-hypertension,
-toxic myocarditis,
-cardiac failure and pulmonary edema.
26

27. • All forms of electrocardiogram (ECG)abnormalities
are noted and include sinus tachycardia, ventricular
premature beats, couplets, transient nonsustained
ventricular tachycardia, rarely fatal arrhythmias and
ST-T changes closely resemble congenital QT interval
syndrome.
27

28. • The major manifestation include hypertensive crisis and
life-threatening pulmonary edema, which may be fatal if not
treated timely.
• Endogenous hypercatecholemia could also explain
hyperglycemia and glycosuria in some cases.
• Hemiplegia and other neurological lesions have been
attributed to fibrin deposition resulting from disseminated
intravascular coagulation (DIC).
28

29. On basis of clinical manifestations scorpion
envenomation is graded into four grades in India:
• Grade 1: Severe excruciating local pain radiating
along corresponding dermatomes, mild local edema at
the site of sting without systemic involvement.
• Grade 2:features of autonomic storm characterized
by parasympathetic and sympathetic stimulation.
• Grade 3: Cold extremities, tachycardia, hypotension
or hypertension with pulmonary edema.
• Grade 4: Tachycardia, hypotension with or without
pulmonary edema with warm extremities (warm shock).
29

30. MANAGEMENT
• No scorpion sting should be taken as benign unless
observed for 24 hours irrespective of species involved.
• On the basis of pathophysiology, therapeutic effort should
be directed against the venom, overstimulated autonomic
nervous system and correction of hypovolemia.
Local treatment:
• Mild pain -ice packs over the site of sting.
• Severe excruciating local pain -lignocaine (without
adrenaline in digital block)
30

31. • Oral diazepam and nonsteroidal anti-inflammatory drugs
(NSAIDs)with lignocaine block can give prolonged relief from
pain.
• Incision at the site of sting or tourniquet application is not
advisable at all. Patients suspected of envenomation should
be hospitalized for at least 12 hours and observed for
cardiovascular and neurological sequelae.
31

32. Treatment of shock
Treatments of shock are:
(1) Foot end of bed to be elevated to
maintain cerebral circulation in cases of peripheral circulatory
failure; but if left ventricular failure is present back rest is
advised,
(2) Dehydration, electrolyte imbalance
due to vomiting, excessive salivation and profuse sweating
should be corrected by oral and parenteral fluids. Intravenous
glucose, normal saline to be given in sufficient volume
judiciously as there will be heart failure in some cases
(3) Hydrocortisone 100 mg IV repeated
every 4 hours helps to tide over the shock and decreases edema
of conductive tissues in toxic myocarditis in scorpion sting.
32

33. Treatment with prazosin:
• Prazosin is pharmacological and physiological
antidote to scorpion venom actions; a competitive
postsynaptic alpha-1 adrenoreceptor antagonist.
• Prazosin has 1,000 fold affinity to alpha receptors
(alpha receptors stimulation plays a major role in the
evolution of myocardial dysfunction and acute
pulmonary edema,tachycardia. )
• It totally reverses the metabolic and hormonal effects
of alpha receptor stimulation 33

34. • Prazosin inhibits phosphodiesterase, thereby
enhancing cyclic guanosine monophosphate (cGMP)
level, which is one of the mediators of nitric oxide
synthesis.
• It also enhances insulin secretion that is inhibited by
scorpion venom by which it counters hyperglycemia
and hyperkalemia.
• This alfa-1 adrenergic receptor blocker reduces
preload, left ventricular impedance without causing
decrease in cardiac contractility.
• Prazosin (plain tablet not sustained release form) is
administered orally as 1 mg in adults (children 30
μg/kg).
34

35. • Prazosin should be given through a nasogastric tube if the
patient is vomiting and the patient should be kept in lying
posture for about 3 hours (even during examination) in
order to prevent the “first dose hypotension phenomenon”.
• Repeat prazosin in the same dose after 3 hours depending
on the clinical response and later every 6 hours (not
exceeding 5 mg total in a day) till the extremities are warm,
dry and the peripheral veins are visible easily.
• Prazosin can be given irrespective of blood pressure
provided there is no hypovolemia.
• Since the advent of prazosin, the fatality due to scorpion
sting has been reduced to less than 1%.
• Prazosin is a cellular and pharmacologic antidote to the
actions of scorpion venom and it is also cardioprotective35

36. • It should be the first line of treatment for severe scorpion
stings. Prazosin is a poor man’s scorpion anti venom.
• The time lapse between the sting and administration of
prazosin for symptoms of autonomic storm determines the
outcome.
• Cardiac arrhythmias are many times self-limiting.
Tachyarrhythmias -intravenous metoprolol or esmolol and
bradyarrhythmias - atropine.
• Hypertension and pulmonary edema-
nifedipine,nitroprusside, hydralazine, or prazosin.
• Defibrination syndrome -conservatively or with heparin,
fresh blood transfusion or fibrinogen infusions.
• Captopril, glucose insulin-potassium drip, lytic cocktail
(pethidine-chlorpromazine promethazine) have also been
tried to alleviate the venom effects but did not stand the test
of time 36

37. ADVANCED SUPPORTIVE MANAGEMENT
• Close attention to airway is required. Intubation and
mechanical ventilation are sometimes necessary owing to
venom effects and respiratory depression from the
medications to control symptoms.
• Pulmonary edema is the most important cause of mortality
and should be treated with propped up position, nasal
oxygen,intravenous loop diuretics and prazosin.
• Inotropic support with dopamine and dobutamine 5–15
mg/kg per minute is advocated for 36–48 hours in warm
hypotensive shock patients.
37

38. Scorpion Anti Venom(SAV)
Scorpion antivenom -specific treatment-matter of
debate and controversy during last 5 years; several previous
studies have shown that SAV does not alleviate hemodynamic
changes or cardiogenic pulmonary edema, or prevent death
and the outcome was the same for victims treated with
antivenom and without antivenom.
But recent randomized controlled trials have overcome
the controversy regarding beneficial effects of early
administration of SAV. Commercially prepared antivenins are
available in several countries for some of the most dangerous
species; however, SAV is expensive and always in short supply.
In the opinion of most authorities administration of antivenom
is the only specific measure for severe scorpion sting poisoning.
38

39. • Scorpion antivenom is effective if a victim is brought at an
early stage of scorpion sting (in a stage of acetyl choline
excess) ongoing cholinergic phenomenon is suggestive of
free circulating scorpion venom, which can be neutralized
by SAV.
• Intravenous administration of antivenom rapidly reverses
systemic toxicity features but not pain and paresthesia. No
test dose is required as there are high circulating
catecholamines and anaphylaxis is very rare.
• Addition of SAV to prazosin enhances recovery time and
shortens hospital stay in patients with grade 2–4
Mesobuthus tamulus envenomation in India.
39

40. Other Studies
1)Administration of oral L-carnitine in a dose 1980 mg/day in
three divided doses till the left ventricular function normalized
is found beneficial (a study from emergency service of a
tertiary care center in Andhra Pradesh showed no mortality
and got benefited irrespective of severity of the sting).
2)Prophylactic immunization with scorpion venom toxoid has
been considered in Mexico
40

41. In our patient,high index of suspicion,promt diagnosis and
adequate and meticulous management with prazosin and other
drugs along with mechanical ventillatroy support, even
without SAV,proved to be life saving though he presented with
features of Grade3 envenomation.
41

42. REFERENCES
1)Harrison’s principles of Internal Medicine 18th edition
2)API textbook of medicine 9th edition
3)japi.org
4)medscape.com
5)nejm.org
42

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