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Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
Scorpion envenomation
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Scorpion envenomation

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Scorpion envenomation

Scorpion envenomation

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  • 1. Scorpion envenomation Antonio Souto acasouto@bol.com.br Médico coordenador Unidade de Medicina Intensiva Pediátrica Unidade de Medicina Intensiva Neonatal Hospital Padre Albino Professor de Pediatria nível II Faculdades Integradas Padre Albino Catanduva / SP
  • 2. UTI Pediátrica & Neonatal Hospital Padre Albino Important public health hazard in tropical and sub-tropical regions The annual number of scorpion stings cases exceeds 1.23 million, of which over 32250 may be fatal Brazil: •8.000 /year •3 /100.000 habitants •50% Minas Gerais e São Paulo Dr. Antonio Souto acasouto@terra.com.br 2013
  • 3. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 4. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 5. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 6. UTI Pediátrica & Neonatal Hospital Padre Albino •60s and 70s, cases fatality rate of up to 30% •Since the advent of vasodilators prazosin, captopril, nifedipine, sodium nitroprusside, hydrazine, scorpion antivenom and intensive care management the fatality is dropped to <2-4%. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 7. UTI Pediátrica & Neonatal Hospital Padre Albino •Tityus serrulatus scorpion venom has shown to be more deleterious to children than to adults •This effect is suggested to be body weight dependent. •The children would have higher venom concentration in their body liquids. •More severe systemic symptoms, including higher lethality. •Buthidae species can result a life threatening systemic effects Dr. Antonio Souto acasouto@terra.com.br 2013
  • 8. UTI Pediátrica & Neonatal Hospital Padre Albino T. serrulatus T. stigmurus Dr. Antonio Souto T. bahiensis T. metuendus acasouto@terra.com.br T. obscurus 2013
  • 9. UTI Pediátrica & Neonatal Hospital Padre Albino Familia Buthidae (Hemiscorpius Lepturus) Genero •Buthus (Mediterranean Spain to the Middle East) •Parabuthus (western and southern Africa) •Hottentotta (South Africa to south east Asia) •Leiurus (northern Africa and middle East) •Androctonus (northern Africa to southeast Asia) •Centruroides (southern united states, Mexico, central America and Caribbean) •Mesobuthus (through out the Asia) Tityus (central America, south America and the Caribbean) Dr. Antonio Souto acasouto@terra.com.br 2013
  • 10. UTI Pediátrica & Neonatal Hospital Padre Albino •Arthropods in the class Arachnid •Viviparous and cannibalistic Scorpion have been able to survive in heat, drought, freezing conditions for weeks, desert condition and starvation for months and total immersion of water for days. Survival independent of ecological condition Dr. Antonio Souto acasouto@terra.com.br 2013
  • 11. UTI Pediátrica & Neonatal Hospital Padre Albino Scorpion Venom Dr. Antonio Souto acasouto@terra.com.br 2013
  • 12. UTI Pediátrica & Neonatal Hospital Padre Albino Scorpion Venom Cocktail •Low molecular weight basic proteins, neurotoxins, nucleotides, aminoacids, oligopeptides, cardipotoxins, nephrotoxin, hemolytic toxins, phosphodiesterase, phospholipase A, hyaluroinidase. •Acetylcholineesterase, glycosaminoglycans, histamine, serotonin. 5-hydroxyptamine and proteins that inhibit protease, angiotensinase and succinate –dehydrogenese, ribonuclease, 5- nucleotidase. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 13. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 14. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 15. UTI Pediátrica & Neonatal Hospital Padre Albino Scorpion Venom The lethality varies with species •Venom almost complete absorption would occur in 7-8 hours •70% of maximum concentration in the blood within 15 minutes •Half life of intravenously injected venom is between 4 to 7 minutes •Takes 4.2 to 13.4 hours for elimination from blood. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 16. UTI Pediátrica & Neonatal Hospital Padre Albino Regulating venom ejections This ability explains the variation of intensity of symptoms and existence of “dry” sting without envenoming. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 17. UTI Pediátrica & Neonatal Hospital Padre Albino Scorpion Venom Neurotoxins Highly lethal than neurotoxin of snake venom. The LD50 of some neurotoxins 10 fold more potent than cyanide Act mainly on excitable cells of nerves and muscles Intense and persistent depolarization of autonomic nerves with massive release of autonomic neuromuscular neurotransmitter. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 18. UTI Pediátrica & Neonatal Hospital Padre Albino “autonomic storm” Clinical laboratory data reporting increased catecholamine metabolite excretion and elevated plasma renin and aldosterone are consistent with the stimulatory effects of the venom on the autonomic nervous system. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 19. UTI Pediátrica & Neonatal Hospital Padre Albino Clinical effects •depends upon the species of scorpion •dose of venom injected Severity •Age •Time between sting and hospitalization •Children with 3.9-10% fatality irrespective of intensive care management from Israel, Turkey and India Clinically “autonomic storm” releasing massive amounts of catecholamines Dr. Antonio Souto acasouto@terra.com.br 2013
  • 20. UTI Pediátrica & Neonatal Hospital Padre Albino Transient parasympathetic stimulation vomiting, profuse sweating, ropy salivation, bradycardia, ventricular pre mature contraction, priapism in male, hypotension Prolonged sympathetic stimulation cold extremities, hypertension, tachycardia, pulmonary edema and shock Dr. Antonio Souto acasouto@terra.com.br 2013
  • 21. UTI Pediátrica & Neonatal Hospital Padre Albino Clinical manifestations/ severity 4 grades Grade 1: severe excruciating local pain radiating along with corresponding dermatomes, mild local oedema, without systemic involvement. Grade 2: signs and symptoms of autonomic storm characterized by acetyl choline excess or parasympathetic stimulation and sympathetic stimulation Grade 3: cold extremities, tachycardia, hypotension or hypertension with pulmonary edema (Respiratory rate > 24 per minute, basal rales or crackles in lungs). Grade 4: tachycardia, hypotension with or without pulmonary edema with warm extremities (warm shock). Dr. Antonio Souto acasouto@terra.com.br 2013
  • 22. UTI Pediátrica & Neonatal Hospital Padre Albino Sixteen scientists (Algeria, Argentina, Bolivia, Egypt, India, Israel, Mexico, Morocco, Saudi Arabia, Tunisia and Turkey). 2009 consensus was reached Class I : Local manifestations Class II : Systemic involvement Class III : Cardiogenic failure, hypotension, ventricular arrhythmia, bradycardia, cardiovascular collapse, Respiratory failure- cyanosis, dyspnoea, pulmonary edema, neurological failure Glasgow score < 6 (in absence of sedation), paralysis. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 23. UTI Pediátrica & Neonatal Hospital Padre Albino Local Manifestations •Soon after sting •Severe radiating pain •Inconsolable, incessant crying in a child due to pain there is transient tachycardia, rise in blood pressure, mild sweating but extremities are warm. Severe pain without systemic involvement suggestive of benign or dry sting by venomous species. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 24. UTI Pediátrica & Neonatal Hospital Padre Albino Systemic Manifestations Vomiting : due to autonomic storm often is due to serotonic content of venom Profuse sweating : sweat literally flows all over body Clinically it is called “skin diarrhea”, persist for 3-17 hours. Salivation : Thick ropy salivation due to stimulation of bronchial mucus glands, contributing factors for respiratory failure, occurs soon after sting and it persists for 2-4 hours. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 25. UTI Pediátrica & Neonatal Hospital Padre Albino Priapism : seen in almost all victims of pediatric age Priapism is diagnostic of venomous envenoming but its absence or disappearance did not correlate the outcome. It persists for 5-16 hours. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 26. UTI Pediátrica & Neonatal Hospital Padre Albino Vomiting, sweating, salivation, priapism a diagnostic cardiac signs and symptoms of scorpion sting suggestive of free circulating venom in the blood, can be accessible to antivenin therapy. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 27. UTI Pediátrica & Neonatal Hospital Padre Albino Cardiovascular system mostly affected by venomous sting. Clinical manifestations depends upon the duration of envenoming. Hypertension, cardiac arrhythmias, tachybradycardia, pulmonary edema, hypotension and shock are not the different syndromes but of one process of ongoing autonomic storm. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 28. UTI Pediátrica & Neonatal Hospital Padre Albino Tityus serrulatus The cardiovascular manifestations Arterial hypertension or hypotension, heart failure, pulmonary edema, shock and electrocardiographic changes. “acute myocardial infarction-like pattern.” The American Journal of Cardiology, 67:7; 655-657 Dr. Antonio Souto acasouto@terra.com.br 2013
  • 29. UTI Pediátrica & Neonatal Hospital Padre Albino Tityus serrulatus The cardiovascular manifestations Myocardial damage and depressed left ventricular systolic function. Pulmonary edema attributed to left ventricular failure or to increased pulmonary vascular permeability. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 30. UTI Pediátrica & Neonatal Hospital Padre Albino Hypertension : Hyper-renemia and sympathetic stimulation rapid and significant increase level of epinephrine, norepinephrine, endothelin, atrial nitriuretic peptide. Accumulation of angiotensin II accelerate the myocardial injury and oxygen demand. Alpha receptors stimulation. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 31. UTI Pediátrica & Neonatal Hospital Padre Albino Hypertension : 45-70% within 30 minutes to 8 hours with Bradycardia Main complaints are headache, chest discomfort, suffocation and per oral parasthesia. Children look agitated confused and have propped up eyes, oculogyric phenomenon, puffy face, decreased level of consciousness and convulsions; If untreated the hypertensive effect is long lasting and result in development of myocardial failure and pulmonary dema Dr. Antonio Souto acasouto@terra.com.br 2013
  • 32. UTI Pediátrica & Neonatal Hospital Padre Albino Tachycardia : Raised level of circulating catecholamines by toxin on beta adrenergic receptors 5-20% after 6-7 hours supraventricular tachycardia (heart rate 110-240 per minute) Sudden onset of tachycardia occurs in a recovering hospitalized patient Impaired left ventricular filling, reduction in cardiac out put due to mark tachycardia particularly in children result in delirium and convulsion due to anoxia to the brain Dr. Antonio Souto acasouto@terra.com.br 2013
  • 33. UTI Pediátrica & Neonatal Hospital Padre Albino Hypotension : Hypovolemia and cardiac arrhythmias. Reduction in systemic vascular resistance a hypokinetic phase accompanied by raised heart rate, hypotension with shock reflecting an alter left ventricular contractility. Depletion of catecholamines from nerve terminals because of autonomic storm. Venom inhibits kinase II enzyme and lead to accumulation of bradykinin a neuromuscular agent incriminated for development of pulmonary edema and hypotension Dr. Antonio Souto acasouto@terra.com.br 2013
  • 34. UTI Pediátrica & Neonatal Hospital Padre Albino Pulmonary edema Develop within 30 minutes with severe hypertension and may develop after 36 hours of sting with hypotension and tachycardia. Acute onset of tachydyspnoea, tachycardia, summation gallop, systolic murmur, cold extremities, sudden onset of intractable cough, bilateral moist rales and low volume fast thready pulse. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 35. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 36. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 37. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 38. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 39. UTI Pediátrica & Neonatal Hospital Padre Albino Management Fluid loss vomiting, sweating and salivation correct the fluid balance Dr. Antonio Souto acasouto@terra.com.br 2013
  • 40. UTI Pediátrica & Neonatal Hospital Padre Albino Management Scorpion antivenom (SAV) : Without skin test, Administered as early as possible and through venous route •SAV is specific treatment of scorpion sting’s therapy •Randomized controlled trials •Antivenom resolved the neurological manifestations within four hours. •SAV reduced the levels of circulating unbound venom. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 41. UTI Pediátrica & Neonatal Hospital Padre Albino Management Prazosin Alpha receptors stimulation plays an important role in the pathogenesis of scorpion sting. Phosphodisterase inhibitor, it reduces preload and left ventricular impedance without raising heart rate. Prazosin is a physiological antidote to scorpion venom actions Dr. Antonio Souto acasouto@terra.com.br 2013
  • 42. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 43. UTI Pediátrica & Neonatal Hospital Padre Albino Management Angiotensin converting enzyme inhibitor captopril improves the pulmonary edema and cardiogenic shock due to scorpion sting. Victims who presented in hypokinetic phase due to both ventricular dysfunction, clinically characterized by hypotension, shock, tachycardia, delirium with or without pulmonary edema and warm extremities, Dobutamine infusion 5-20 microgram /kg/min. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 44. UTI Pediátrica & Neonatal Hospital Padre Albino Management Nitroglycerine (NTG) drip 0.5 to 5 microgram /kg/min by improving heart dysfunction and reduction in pulmonary congestion. Venodilator action of NTG reduces the preload of the heart and it improves the intrapulmonary shunting and also relaxes the epicardial coronary arteries and its collaterals. Amiodarone improves the survival by reduction of serum nor-epinephrine level in four children with scorpion sting Dr. Antonio Souto acasouto@terra.com.br 2013
  • 45. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 46. UTI Pediátrica & Neonatal Hospital Padre Albino antivenin therapy antivenin therapy 4-5 ampoules (moderate) 8-10 ampoules (severe) Dr. Antonio Souto acasouto@terra.com.br 2013
  • 47. UTI Pediátrica & Neonatal Dr. Antonio Souto Hospital Padre Albino acasouto@terra.com.br 2013
  • 48. UTI Pediátrica & Neonatal Hospital Padre Albino •Tityus species of scorpions are endemic to South America, particularly Brazil. An F(ab)2 for Tityus serrulatus antivenom is available from Fundação Ezequiel Dias (FUNED), in Belo Horizonte, Brazil. •T. serrulatus envenomation treated with antivenom, vomiting and local pain decreased within 1 hour, and cardiorespiratory manifestations disappeared within 6 to 24 hours in all patients except the 2/18 who presented with acute lung injury. 16/18 patients recovered completely by 24 hours. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 49. UTI Pediátrica & Neonatal Hospital Padre Albino Antivenom therapy must be applied as soon as possible after envenoming. Antivenom preparations •higher purity, greater potency and minimal (or absent) side-efects •widely shared among clinicians in charge of scorpion envenoming, that antivenom therapy is the most efective specific treatment of severe cases. Its use is still justified on the basis of observations both empiric clinical and in experimental models. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 50. UTI Pediátrica & Neonatal Hospital Padre Albino Keep in your mind: when in a endemic region, we must allways think about scorpion envenomation when we have a child crying, vomiting, with profuse sweating, salivation and arterial hypertension without a cause. Dr. Antonio Souto acasouto@terra.com.br 2013
  • 51. UTI Pediátrica & Neonatal Hospital Padre Albino Thank you! Dr. Antonio Souto acasouto@terra.com.br 2013

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