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1. CLINICOPATHOLOGICAL PROFILE OF
SCORPION ENVENOMATION IN
CHILDREN OF CHHATTISGARH REGION
MEETA SACHDEV
G.MALINI
DEPTT. OF PEDIATRICS
JLN HOSPITAL & RESEARCH CENTRE; BHILAI

2. INTRODUCTION
Scorpion sting:
• Acute life-threatening, time-limiting
emergency.
• True incidence not known.
• Children are frequent victims.
• Case fatality:- 3-22 % (hospitalized
children).

3. 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.

4. TAXONOMY
• Arthropod ,Class-
Arachnida.
• Lethal scorpions:-
Family-Buthidae.
• 1-20 cm in length.

5. HABITAT
• Terrestrial habitat.
• Nocturnal behavior.
• Crevices, burrows,
under logs/debris,
paddy husk, fields.
• Luggage & cargo.

6. 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.

7. 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.

8. CLINICAL FEATURES
PARASYMPATHETIC SYMPATHETIC
• Bradycardia • Hyperthermia
• Hypotension • Tachycardia
• Vomiting • Tachypnoea
• Salivation • Hypertension
• Sweating • Arrhythmia
• Priapism • Hyperkinetic pul. edema
• Bronchoconstriction • Hyperglycemia
• Bronchorrhoea • Piloerection
• Generalised • Restlessness
weakness • Hyperexcitability

9. 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.

10. 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

11. SUBJECT & METHODS
Demographic parameters
Clinical symptoms & signs
Investigations
Details of treatment & outcome.

12. OBSERVATIONS

13. AGE DISTRIBUTION
16%
<=5Y
20% 6Y - 10Y
64% 11Y - 15y
Variable N Mean SD Minimum Maximum
AGE 25 5.8000 3.8864 1.0000 14.000

14. SEX DISTRIBUTION
32%
F
M
68%
MALE : FEMALE = 2.1 : 1

15. MONTH DISTRIBUTION
8% 8% JAN
4% 4% FEB
8% MAR
8% APR
4% MAY
0%
JUNE
JULY
16% AUG
16% SEPT
OCT
NOV
12%
12% DEC
56 % OF CASES – JUN - SEP 82.3 %

16. RURAL / URBAN DISTRIBUTION
16%
RURAL
URBAN
84%

17. INDOOR / OUTDOOR INCIDENCE
INDOOR
48% 52%
OUTDOOR

18. TIME DISTRIBUTION
8%
8%
0-6 AM
6 AM-12 NOON
48%
12 NOON -6 PM
36% 6 PM-12 MN
MAX. CASES :- 6PM – 12MN

19. STING SITE DISTRIBUTION
4%
16%
LOWER LIMB
UPPER LIMB
FACE
80%

20. ONSET OF SYMPTOMS
8%
<=30 MIN
>30 MIN - 2
HRS
92%

21. NO OF PATIENTS
ST
10
12
0
2
4
6
8
ER
O
ID
S
AV 10
IL 8
DO
PA
M
IN
E
2
LA
SI
DE X
2
RI
PH
YL
LI
NE
1
PR
AZ
O
SI
N
1
TREATMENT HISTORY

22. TIME LAPSE
8%
32% <3 HRS
24%
3-6 HRS
6-12 HRS
>12 HRS
36%
Variable Mean SD Minimum Maximum
Time Lapse 5.9800 5.6374 0.5000 27.000

23. % OF PATIENTS
LO
C
100%
0%
20%
40%
60%
80%
AL PA
C
HA IN
N
G
120% 100%
VO ES
M
8%
SA ITI
LI NG
DI VA
60%
73.6 %
TI
AP O
H N
O
R
32%
ES
PR IS
IA
80%
PI
91.1 %
AL SM
T.
CO SE
44%
NV N
U S
LS
32%
SIGNS & SYMPTOMS
DY ION
SP
8%
N
EA
40%

24. CLINICAL SIGNS
20.5 % 95.5 %
100% 29.6 % 77.7 % 24.5 %
88%
90% 80%
80% 72%
% OF PATIENTS
64% 61.5 %
70%
60% 52%
48%
50% 38 %
40%
30% 24% 20%
20% 12%
10%
0%
IA
EA
Y
N
R
N
VE
TS
12
ER
O
VE
RD
O
9-
O
EP
SI
SI
SI
PH
FE
N
A
N
CS
N
N
CR
SP
YC
TE
TE
TE
RI
G
DY
CH
PE
O
R
PO
RM
PE
TA
HY
LD
HY
NO
CO

25. SEVERITY
80.8 %
GRADE-1:
ISOLATED PAIN
80% 72%
GRADE-2
60% (SYSTEMIC MANIFESTATIONS)
19.2 % HYPERTENSION
40% SWEATING
VOMITING
20% PRIAPISM
FEVER ,SHIVERING
20% 8%
GRADE-3
0% (LIFE-THREATENING MANIFESTATIONS)
GRADE-1 GRADE-2 GRADE-3 CARDIOGENIC SHOCK
PULMONARY EDEMA
ALTERED CONSCIOUSNESS

26. INVESTIGATIONS

27. HEMATOLOGICAL PARAMETERS
120%
80 % 100%
100%
ANEMIA
80% 64%
56% LEUCOCYTOSIS
60%
NEUTROPHILIA
40%
20% PLATELETS
20%
0%
Variable Mean SD Minimum Maximum
HB 11.380 1.8448 7.4000 15.200
TLC 13952 6528.7 6000.0 30000
P0LYMORPH 79 % 11.726 55% 94 %
PLATELETS 2.5680 0.8775 1.0000 4.5000

28. BIOCHEMICAL PARAMETERS
120%
100%100% 100% HYPERGLYCEMIA
100% 39 %
76% ^ LIVER ENZ
80% 68% RFT
60%
60% ELETROLYTES
40% ^ CK
16% ^ CKMB
20%
^ LDH
0%
Variable Mean SD Minimum Maximum
RBS 154.80 87.329 32.000 397.00
CPK 1281.1 3135.8 42.000 16002
LDH 921.24 402.83 485.00 2553.0

29. ECG FINDINGS
I II III
aVR aVL aVF
V1 V2 V3
V4 V5 V6

30. 5 yr Male

31. 12 yr Male

32. 5 yr Female

33. 2.5 yr Male

34. SCORPION STING
(ICU MANAGEMENT)
Tachycardia, Tachypnea
cool extremities, ,ice cold extremities,
hyper/hypotension, sweating, s3 gallop,
restlessness altered consciousness
Prazosin,
Dyspnea,fatigue,tachycardia Pulmonary edema,
diazepam,
hypertension hypotension, shock
fluids oral/maintenance,
SYSTOLIC DYSFUNCTION DIASTOLIC DYSFUNCTION
NSAIDS, monitoring
Recovery-dry warm
Nasal O2, Nasal O2,IV fluids,
extremities,
maintenance iv fluids, CVP,prazosin,Dobutamine,
peripheral veins dialated,
prazosin,diazepam Dopamine, Lasix, ventilation
no priapism,good UOP
Dobutamine infusion
(5-15 MCG/KG/MIN)

35. 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

36. 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.

37. NO. OF PATIENTS
0
1
2
3
4
5
6
7
8
9
10
<4
8
HR
S
6
<7
2
HR
S
9
<9
6
HR
S
7
>9
6
HR
S
3
PRAZOSIN THERAPY

38. NO. OF PATIENTS
10
15
20
25
30
0
5
PR
AZ
O
SI
N
25
IV
FL
UI
DS
23
DO
BU
TA
M
IN
E
16
DO
PA
M
IN
E
5
MANAGEMENT
LA
SI
X
7
VE
N
TI
LA
TI
O
N
2

39. HOSPITAL STAY
18 16
16
NO. OF PATIENTS
14
12
10 8 ICU STAY
8 7 TOTAL STAY
6 6
6 5
4
2 1 1
0
<2 DAYS >2-3 DAYS >3-4 DAYS >4 DAYS

40. NO MORTALITY

41. 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.

42. 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.

43. THANKS

44. 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.

45. 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.

46. 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.

47. CRITICAL CARE ISSUES
RESPIRATORY FAILURE
• Bronchorrhoea & bronchoconstriction.
• Hypertension.
• Upper airway dysfunction.
• Convulsions, cerebral haemorrhage,
central respiratory failure.
• ARDS

48. UNHELPFUL TREATMENT
• Lytic cocktail ( pethidine + promethazine +
chlorpromazine )
• Morphine (worsens dysarrhythmias).
• Steroids (enhance necrotizing effects of
excessive catecholamines ).
• Atropine (potentiates tachycardia &
sustained hypertension ).

49. UNHELPFUL TREATMENT
• Nifedipine (reflex tachycardia & negative
ionotropic effect).
• ACE inhibitors (aggravate hyperkalemia &
inhibit breakdown of bradykinin).
• Insulin glucose potassium drip.
• Scorpion antivenom.