Scorpion sting

SCORPION STING
GUIDE: DR. REKHA S PATIL
CO-GUIDE: DR. DNYANESH MORKAR
PRESENTER: DR. NIKHIL A CHOUGULE

• Scorpion envenomation is a major public health problem in tropical and
sub-tropical countries, especially in India, Africa, Middle- East, Latin
America. At times it poses a significant life threatening acute time limiting
cardiovascular emergency.
• Irrespective of the understanding of the pathophysiology and management,
the morbidity and fatality remains high in rural areas due to nonexistent
medical facilities and the delay in hospitalisation due to superstitions and
faith in village healers.
• Farmers are more prone to get stung by scorpion during handling debris
and paddy husk in the months of April to early June and September to
October as due to sudden rise in environmental temperature, scorpions
come out of their hides.The sting during these months is more potent and
prone to serious envenomation.
INTRODUCTION
API TEXTBOOK OF MEDICINE 10TH EDITION

SCORPION STING:UPDATE JAPI JAN 2012 VOL.60

• Nearly 1,000 species of scorpion are known worldwide belonging to six
families.
• Buthidae family secretes neurotoxin. Around 86 species of this family are
found in India.
• The Indian red scorpion Mesobuthus tamulus is the most lethal amongst all
the poisonous species of scorpions.
• Except for Hemiscorpius Lepturus, all venomous scorpion species, belong
to the large family Buthidae. The most notorious ones are found in the
genera Buthus (Mediterranean Spain to the Middle East), Parabuthus
(western and southern Africa), Hottentota (South Africa to south east Asia),
Tityus (central America, south America and the Caribbean), Leiurus
(northern Africa and middle East), Androctonus (northern Africa to
southeast Asia), Centruroides (southern united states, Mexico, central
America and Caribbean) and Mesobuthus (throughout Asia)
SCORPION

• M. tamulus, an Indian red scorpion, is venomous and its envenomation is
fatal if not treated in time. Its claws are red coloured, but tail, legs and body
is covered with khaki coloured cuticles. It is 2.5 to 4 inches in length. The
tail consists of stout segments with terminal bulb containing pair of telson
venom secreting salivary glands. It actively secretes venom at the time of
sting by a sharp semi-curved stinger.The stinger is 2 to 4 mm in size.
SCORPION

• The black scorpion Palmaneus gravimanus is less poisonous.It is seen in
Kerala, Vidharbha and Marathwada region of India. It is bigger in size as
compared to red scorpion. It inflicts severe and excruciating painful sting.
Its claws are broad and thick and strong while tail consists of thin
segments.
SCORPION

• 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 cell membrane; in addition, it also inhibits the
deactivation of sodium channels).
• Neurotoxins cause delayed activation of sodium neuronal channels leading
to massive release of endogenous catecholamines.
• Charybdotoxin (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.
SCORPION VENOM

• Clinical effects of the envenomation depends upon the species of scorpion
and lethality and dose of venom injected at the time of sting. Severe effects
is seen in first victim than envenomed by same scorpion to subsequent
victim.
• Severity of envenoming is related to age, size of scorpion and the season
of the sting and time lapsed between sting and hospitalization.
• Early / Premonitory Symptoms: vomiting, profuse sweating all over the
body, priapism, cold extremities and mild tolerable pain.
• Local Manifestations: Severe pain radiates along the corresponding
dermatomes. Local oedema, urticaria, fasciculation and spasm of
underlying muscles are seen at the site of sting due to persistent
stimulation of pain conducting receptors and the liberated serotonin.
Sudden tap at the site of sting induces severe pain and sudden withdrawal
of the part called ‘tap sign’.
CLINICAL MANIFESTATIONS

• Systemic Manifestations:
Characterised by initial parasympathetic stimulation
clinically detected in form of vomiting once or twice, profuse sweating all over
the body(skin diarrhoea), ropy salivation, priapism, bradycardia, hypotension,
transient premature ventricular beats.
Prolonged Sympathetic stimulation is characterised by
propped eyes, puffy and anxious facies, oculogyric crisis, chest discomfort, at
times tingling and numbness all over body and cool extremities. Skin over
hands, feet, palm and sole resemble washer-man hands as they appear finely
wrinkled and cold.
• The major manifestation includes hypertensive crisis and pulmonary
oedema which may be fatal if not treated timely.

• Hypertension: Patient may present with agitated look, confusion,
generalised convulsion, transient hemiplegia, oculogyric crisis, bilateral
extensor plantar response, propped up eyes and a puffy face suggestive of
hypertensive crisis.
Transient initial hypotension is due to hypovolaemia secondary to
acetylcholine excess, it is further aggravated by hot climatic conditions in
summer months of the tropics.
• Pulmonary Edema: PE develops within 30 minutes to maximum 36 hours.
Clinically PE can be suspected when respiratory rate is >24 per minute,
orthopnoea, intractable cough, low volume fast thready pulse, narrow pulse
pressure, summation gallops, systolic murmur and moist basal rales,
central cyanosis.

• Disseminated intravascular coagulation, coma, convulsion, hemiplegia,
aphasia, cerebral infarction and subdural hematoma have been reported
during pre-prazosin era.
• Acute renal failure due to scorpion sting is rare. However, ill-treated,
delayed reporting of a case may result in death due to multi-system organ
failure and acute respiratory distress syndrome.
• After 20 to 30 hours of recovery from autonomic storm, the victim develops
asymptomatic warm extremities, accompanied with bradycardia,
hypotension. He may look exhausted. Patient usually recovers within 72 to
96 hours without any intervention. This phenomenon does not occur if
victim receives scorpion antivenom and prazosin simultaneously.

• Grade 1: Severe, excruciating local pain at the sting site radiating along
with corresponding dermatomes, mild local oedema with sweating at the
sting site, without systemic involvement.
• Grade 2: Signs and symptoms of autonomic storm characterised by
acetylcholine excess or parasympathetic stimulation (vomiting, profuse
sweating from all over body, ropy salivation, bradycardia, premature
ventricular contraction, hypotension, priapism in men) and sympathetic
stimulation (hypertension with blood pressure >140/90, tachycardia with
heart rate >120 per minute, cold extremities, transient systolic murmur).
• Grade 3: Cold extremities, tachycardia, hypotension or hypertension with
pulmonary oedema (respiratory rate >24 per minute, basal rales or
crackles in lungs).
• Grade 4: Tachycardia, hypotension with or without pulmonary oedema with
warm extremities (warm shock).
Clinical grade of scorpion sting on arrival
SCORPION STING:UPDATE JAPI JAN 2012 VOL.60

• 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 radiograph may reveal unilateral or bilateral batwing or patchy PE.
INVESTIGATIONS

• ECG: Sinus bradycardia 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
nonsustained ventricular tachycardia 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 marked tented T waves may be the other common findings. The tall T
waves may mimic acute myocardial infarction.Severity of ECG changes do
not correlate with clinical condition.
• Echocardiography: Shows poor global 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.
INVESTIGATIONS

• 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 venom, the clinical manifestations of the over stimulated ANS and
after effects of excessive catecholamine and correction of hypovolaemia.
• The incision at the sting site or tourniquet is not advisable and patients who
come for medical care after 4 hours of sting and do not show signs of
systemic envenomation can be treated symptomatically without prazosin or
scorpion antivenom.
MANAGEMENT

LOCAL ENVENOMATION
• Mild pain can be abolished by application of ice packs over the site of sting.
Severe excruciating pain can be transiently relieved by local anaesthesia
• Oral diazepam and nonsteroidal anti-inflammatory drugs (NSAIDs) with
first initial dose of lignocaine can give prolonged relief from pain. At times,
severe intolerable pain patient tossing in bed without signs of autonomic
storm injectable opoid (pentazocin) can be used.
MANAGEMENT

SYSTEMIC ENVENOMATION
• Dehydration leading to hypovolaemia is due to vomiting, excessive
salivation and profuse sweating. It should be corrected by oral rehydration.
• Intravenous crystalloids or hydration by nasogastric tube may be
necessary in a confused and agitated victim.
• Electrolyte imbalance should also be corrected.
MANAGEMENT

PRAZOSIN
• A competitive post synaptic α-1 adrenergic receptor antagonist, it reduces
preload, left ventricular impedance without causing tachycardia.
• It reverses the metabolic syndrome evoked due to excessive
catecholamines release.
• Prazosin is a pharmacological and physiological antidote to scorpion
venom actions. It also inhibits sympathetic outflow in CNS. It inhibits
phosphodiesterase, thereby enhancing cGMP level which is one of the
mediators of nitric oxide synthesis. It enhances insulin secretion which is
inhibited by venom.
• Thus, its pharmacological properties can antagonise the haemodynamic,
hormonal and metabolic effects of scorpion venom.
• Administered orally in a dose of 250 to 500 μg/Kg in children and 500 to
1000 μg/kg in adults and should be repeated every 3 hourly until the signs
of clinical improvement appear or till dry and cool extremities persist.
MANAGEMENT

PRAZOSIN
MANAGEMENT

SCORPION ANTIVENOM
• Ongoing cholinergic phenomenon is suggestive of free circulating scorpion
venom, which can be neutralised by antivenom.
• Scorpion antivenom is more effective if a victim is brought in a stage of
acetylcholine excess that is early stages of scorpion sting. Early use of
scorpion antivenom in addition to prazosin hastens the recovery.
MANAGEMENT

SUPPORTIVE THERAPY
• PE should be treated with propped up position, nasal oxygen, intravenous
loop diuretics, oral prazosin. Massive PE may also require immediate oral
nitroglycerin (NTG) spray to reduce the pulmonary congestion and
intravenous NTG drip or if available sodium nitroprusside 4 to 5
μg/kg/minute.
• Blood pressure should be closely monitored and maintained at the level of
systolic 80 to 90 mm Hg. Inotropic support with dopamine and dobutamine
5 to 15 mg/kg/minute is advocated for 36 to 48 hours in warm hypotensive
shock patients. Unconscious patients with cardio-respiratory failure may
also require invasive or non-invasive mechanical ventilatory support.
MANAGEMENT

Step-wise Management
MANAGEMENT

PREVENTION
• Scorpions are killed by organophosphorous pesticides. A false ceiling of
plastic sheet should be put under the roof of hut to prevent scorpions falling
in bed from loose tiles of roof.
• Shoes and clothes should be checked before wearing. Shoes should be
packed with paper or cloth so as to prevent the entry of scorpion in night.
Hand gloves made of thick rubber should be worn while harvesting fire
wood, dry cow dung, lifting paddy, jowar (sorghum) and sugar cane husk.
• Children should not be allowed to go outside in early darkness without
shoes. Simple sandal or slipper did not prevent the sting.
• One should not put hand blindly in crevices, doors or old storage material
during night hours and bedding or cot should kept at distance from mud
house wall and one should not backrest on mud wall.
MANAGEMENT

• API TEXTBOOK OF MEDICINE 10TH EDITION
• SCORPION STING: UPDATE JAPI JAN 2012 VOL.60
• SCORPION ENVENOMATION: WHAT IS NEW? MEDICINE UPDATE: 2013
REFERENCES

Scorpion sting

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Scorpion sting