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Scorpion envenomation in children

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Scorpion envenomation in children

  1. 1. CLINICOPATHOLOGICAL PROFILE OF SCORPION ENVENOMATION INCHILDREN OF CHHATTISGARH REGIONMEETA SACHDEVG.MALINIDEPTT. OF PEDIATRICSJLN HOSPITAL & RESEARCH CENTRE; BHILAI
  2. 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. 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. 4. TAXONOMY• Arthropod ,Class- Arachnida.• Lethal scorpions:- Family-Buthidae.• 1-20 cm in length.
  5. 5. HABITAT• Terrestrial habitat.• Nocturnal behavior.• Crevices, burrows, under logs/debris, paddy husk, fields.• Luggage & cargo.
  6. 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. 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. 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. 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. 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. 11. SUBJECT & METHODSDemographic parametersClinical symptoms & signsInvestigationsDetails of treatment & outcome.
  12. 12. OBSERVATIONS
  13. 13. AGE DISTRIBUTION 16% <=5Y 20% 6Y - 10Y 64% 11Y - 15yVariable N Mean SD Minimum Maximum AGE 25 5.8000 3.8864 1.0000 14.000
  14. 14. SEX DISTRIBUTION 32% F M68% MALE : FEMALE = 2.1 : 1
  15. 15. MONTH DISTRIBUTION 8% 8% JAN 4% 4% FEB 8% MAR 8% APR 4% MAY 0% JUNE JULY16% AUG 16% SEPT OCT NOV 12% 12% DEC 56 % OF CASES – JUN - SEP 82.3 %
  16. 16. RURAL / URBAN DISTRIBUTION 16% RURAL URBAN 84%
  17. 17. INDOOR / OUTDOOR INCIDENCE INDOOR48% 52% OUTDOOR
  18. 18. TIME DISTRIBUTION 8% 8% 0-6 AM 6 AM-12 NOON48% 12 NOON -6 PM 36% 6 PM-12 MN MAX. CASES :- 6PM – 12MN
  19. 19. STING SITE DISTRIBUTION 4%16% LOWER LIMB UPPER LIMB FACE 80%
  20. 20. ONSET OF SYMPTOMS 8% <=30 MIN >30 MIN - 2 HRS 92%
  21. 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 SIDE X 2 RI PH YL LI NE 1 PR AZ O SI N 1 TREATMENT HISTORY
  22. 22. TIME LAPSE 8% 32% <3 HRS24% 3-6 HRS 6-12 HRS >12 HRS 36%Variable Mean SD Minimum MaximumTime Lapse 5.9800 5.6374 0.5000 27.000
  23. 23. % OF PATIENTSLO 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. 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. 25. SEVERITY 80.8 % GRADE-1: ISOLATED PAIN80% 72% GRADE-260% (SYSTEMIC MANIFESTATIONS) 19.2 % HYPERTENSION40% SWEATING VOMITING 20% PRIAPISM FEVER ,SHIVERING20% 8% GRADE-30% (LIFE-THREATENING MANIFESTATIONS) GRADE-1 GRADE-2 GRADE-3 CARDIOGENIC SHOCK PULMONARY EDEMA ALTERED CONSCIOUSNESS
  26. 26. INVESTIGATIONS
  27. 27. HEMATOLOGICAL PARAMETERS120% 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. 28. BIOCHEMICAL PARAMETERS120% 100%100% 100% HYPERGLYCEMIA100% 39 % 76% ^ LIVER ENZ 80% 68% RFT 60% 60% ELETROLYTES 40% ^ CK 16% ^ CKMB 20% ^ LDH 0%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
  29. 29. ECG FINDINGS I II IIIaVR aVL aVF V1 V2 V3 V4 V5 V6
  30. 30. 5 yr Male
  31. 31. 12 yr Male
  32. 32. 5 yr Female
  33. 33. 2.5 yr Male
  34. 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, shockfluids 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. 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. 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. 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. 38. NO. OF PATIENTS 10 15 20 25 30 0 5 PR AZ O SI N 25 IV FL UI DS 23DO BU TA M IN E 16 DO PA M IN E 5 MANAGEMENT LA SI X 7VE N TI LA TI O N 2
  39. 39. HOSPITAL STAY 18 16 16NO. 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. 40. NO MORTALITY
  41. 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. 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. 43. THANKS
  44. 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. 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. 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. 47. CRITICAL CARE ISSUES RESPIRATORY FAILURE• Bronchorrhoea & bronchoconstriction.• Hypertension.• Upper airway dysfunction.• Convulsions, cerebral haemorrhage, central respiratory failure.• ARDS
  48. 48. UNHELPFUL TREATMENT• Lytic cocktail ( pethidine + promethazine + chlorpromazine )• Morphine (worsens dysarrhythmias).• Steroids (enhance necrotizing effects of excessive catecholamines ).• Atropine (potentiates tachycardia & sustained hypertension ).
  49. 49. UNHELPFUL TREATMENT• Nifedipine (reflex tachycardia & negative ionotropic effect).• ACE inhibitors (aggravate hyperkalemia & inhibit breakdown of bradykinin).• Insulin glucose potassium drip.• Scorpion antivenom.

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