SCORPION

STING
Presenter– Dr. NEELAVENI Moderator – Dr. MRUDHULA
Junior Resident Assistant Professor
Department of Pediatrics Department of Pediatrics
Narayana Medical College and Narayana Medical College and
Hospital, Hospital,
Nellore Nellore
 INTRODUCTION
 Scorpion sting is an acute life-threatening, time-limiting medical emergency. Reliable statistics are
not readily available for this common rural accident.
 There are more than 1,200 species of scorpions worldwide, only a few cause more than a
painful sting
 India has about a 100 species of scorpions of which two are frequently encountered
- common red scorpion : Mesobuthus tumulus
- black scorpion - Palamnaeus swammerdami
 These are nocturnal active creatures
 They inhabit areas with warm, moist climates.
 Dominant clinical effects following the sting vary from species to species. Cardiovascular effects are
particularly prominent following the stings by Indian red scorpion (Mesobuthus tamulus)
PALAMNAEUS
SWAMMERDAMI
 VENOM
 Scorpion toxin is a water-soluble antigen complex containing a mixture of neurotoxin, cardiotoxin,
nephrotoxin, hemolysine, phosphodiesterase, phospholipase, hyaluronidase, histamine, and other
chemicals.
 The clinical signs depend on the dose of poison, patient age, season, and the time between scorpion
bite and admittance to hospital.
 Although pain, heat, edema, and hematoma in 97% of all the cases were observed as local effects,
systemic effects such as hypotension or hypertension, respiratory failure, cardiovascular toxicity,
hemolysis, renal failure, and hemorrhaging can also be seen in 3% of all cases
 The venom contains neurotoxins that alter neural membrane ionic channels,
- inhibit inactivation of voltage gated sodium channels
- blocks calcium activated potassium channels
 This causes an excessive activation of sympathetic and parasympathetic nervous system and a
massive release of catecholamines causing autonomic and cardiovascular dysfunction
 This ‘’AUTONOMIC STORM ” results in tachycardia, increased myocardial oxygen consumption,
hypertension, coronary and systemic vasoconstriction and increased after-load.
 Scorpion venom also suppresses secretion of insulin leading to hyperglycemia, hyperkalemia,
increased free fatty acids and free radical accumulation.
 Most of the deaths due to scorpion sting are attributed to cardio-pulmonary complications such as
myocarditis and acute pulmonary oedema.
 SCORPION VENOM
Neurotoxins are the most important (consist of different small sized proteins with sodium and potassium cations,
which interfere with neurotransmission).
 Beta toxin (Peptide neurotoxin that opens the sodium channels).
Alpha toxin ( Depolarises the polarizes the cell membrane; in addition, it also inhibits the deactivation of sodium
channels ).
Neurotoxins cause delayed activation of sodium neuronal channel leading to massive release of endogeneous
catecholamines.
 Charybdotoxin ( It inhibits the calcium dependent potassium channels.)
 Iberiotoxin inhibits potassium channels.
 Serotonin (Which may cause local pain at the site of the sting).
 Kallikrein inhibitor (Causing raised bradykinin levels)- Tiyus Species.
TOXINS AND MEDIATORS
 EFFECTS OF ENVENOMATION

 Most stings are minor

 The most serious envenomations occurs in children.
 Symptoms develop over 30 min to 6 hours and last for 2 days
 Local effects :
- Pain, swelling, ecchymoses, tissue necrosis
 Systemic effects /Neurological effects :
- “Autonomic storm” begins with profuse perspiration, tachypnoea, tachycardia, excessive salivation,
vomiting, priapism and then progresses to shock.
 A wide variety of neurologic symptoms like agitation, rigidity, tremor, twitching, encephalopathy,
convulsions, cerebral edema and coma.
 Contd …
 Cardiovascular effects :

- The autonomic storm results in intense tachycardia, increased cardiac work, excessive afterload, all of which culminate in
circulatory failure.
- Tachycardia usually persists for few hours and may be an early sign of myocardial injury.
- hypertension usually lasts for 4-6 hours and then cardiogenic shock sets in, characterised by hypotension and cold
peripheries.
 shock if untreated, may lead to multiorgan failure, culminating in death.
 Multiple mechanisms lead to cardiovascular failure.
- Myocardial ischemia ,
- Myocarditis with raised CPK-MB isoenzymes and cardiac troponin I levels
 high vascular resistance in both systemic and pulmonary circulations leading to low cardiac output from excessive afterload
 Pulmonary edema, either cardiogenic or non cardiogenic
 Contd …

 High vascular resistance in both systemic and pulmonary circulations leading to low cardiac output
from excessive afterload
 Pulmonary edema, either cardiogenic or non cardiogenic

 Other effects :
- pancreatitis.
- Metabolic acidosis, hyperglycaemia
- Disseminated intravascular coagulation (DIC)
CLINICAL FEATURES
 INVESTIGATIONS
 Total leucocyte counts are raised to 11,000 to 26,000.
 Cardiac CPK MB is raised.
 Reduction in serum amylase and serum calcium levels may be observed.
 There is raised serum glucose ,potassium and reduction in insulin level.
 Chest radiography may reveal unilateral or bilateral batwing or patchy PE
 INVESTIGATIONS
ECG: Sinus Bradycardiya seen in early hypertensive cases with a heart rate of 42 to 60
per minute, usually persisted for 3 to 4 hours. The other common findings are ventricular
premature contraction, couplets, transient non sustained ventricular tachycaridia and
rarely fatal ventricular arrhythmias. The sinus tachycardia, injury to conducting system in
the form of left anterior hemiblock, bundle branch block, complete heart block and mark
tented T waves may be the other common findings. The tall T waves may mimic acute
Mayocradial infarction. Severity of ECG changes do not correlate with clinical condition.
Echocardiography : Show spur globally contractility 12 to 15 hours after sting with low
ejection fraction decreased systolic ventricular performance and mitral incompetence.
There is good correlation between clinical improvement and return of ventricular function.
The Management is mainly focused on controlling:

Automatic dysfunction

Pain

Fluid management

Pulmonary edema.
 TREATMENT

 Local :

- Clean the wound with antiseptic solution and water

- Local instillation of lignocaine, if pain is severe
- immobilise the limb
- Cold compresses
- Pain relief with oral or parenteral agents (NARCOTICS should be avoided because
they appear to have a synergistic neurotoxic effect with the venom)
MANAGEMENT

 SCORPION ANTIVENIN :
 Approximately 20 different scorpion AVs
are available worldwide, but their use is
controversial because of variable efficacy
and the risk of potential nonallergic
anaphylaxis.
 Since it doesn’t counter act the venom
induced autonomic storm, its use is
questionable.
 It is not routinely used in the practice. If it
were to be used it should be used before30
min of the scorpion sting.
 Contd..

 PRAZOSIN :
 Its an alpha blocker, its an pharmacological antidote to the action of scorpion venom.
 Only used in symptomatic patients within 4-6 hours of scorpion sting.
 Not used in asymptomatic patients.
 CNS sympathetic stimulation is reduced.
- It also increases insulin secretion and may reverse metabolic derangements.
- It should be administered in all children with autonomic storm.
- Recommended dose is 30 mcg /kg/dose . It can be repeated after 3 hours and then every 6th
hourly all autonomic features subside.
 Generally, more than 4 doses may not be required in children.

 Other options and supportive measures :

- Agents with combined alpha and beta blocker blockade such as labetalol.-
- Hydralazine and/or nifedipine may also reduce hypertension,
- For Uncontrollable hypertension vasodilator infusions like sodium nitroprusside, nitroglycerine
.These agents need mandatory invasive arterial monitoring as hypotension may be catastrophic
and profound.
- Fluid intake and output should be optimized.
- Dobutamine and other inodilators may be used if cardiogenic shock is present.
- The patient may need ventilatory support, either non-invasive or invasive.
- intubation may be required in case of respiratory failure or inability to handle secretions
- Tetanus toxoid if not previously immunised
- benzodiazepines in case of seizures
- INSULIN may be required to maintain blood sugar levels
- The child with evidence of systemic toxicity following a scorpion sting should be
admitted for at least 24 hr of monitoring
 POOR PROGNOSTICS FACTORS

 Delay in initiation of prazosin

 Presentation >24 hr after significant envenomation
 Presence of pulmonary oedema
 Presence of arrhythmia
 Myocardial ischemia
 Encephalopathy
 

KEY POINTS

•Scorpion venom is a potent sympathetic stimulator

•Cardiac manifestations are common in Indian red scorpion envenomation

•Alpha receptors stimulation plays a major role in evolution of myocardial dysfunction and acute pulmonary
edema in victims of scorpion sting

•Prazosin–an alpha adrenoreceptor antagonist–is antidote to venom action

•Time lapse between the sting and administration of Prazosin for autonomic storm determines the outcome.

•Scorpion stings can cause death due to toxic effects on the cardiovascular system. Observations for
possible complications from a scorpion sting and the possibility of myocarditis should be kept in mind in
patients admitted to the ED with complaints of a scorpion sting, especially with shortness of breath and poor
general conditions.
THANK YOU