You are on page 1of 3

SCORPION

STING/ENVENOMATION

Background

Public health hazard, Rural Areas > Urban


Common in tropical and subtropical regions
Underestimated disease, Underreported numbers, Lack of reliable statistics
Scorpion Envenomation is worse than Snake Envenomation
Case Fatality Rate dropped to <1% from 30% with current therapy


Medically important species

About 1400 species, 50 lethal to humans, few important ones are:


1. Large Black scorpion (Palmaneous gravimanus)
2. Small red scorpion (Buthus Tamulus) Toxic
3. Indian Red scorpion (Mesobuthus Tamulus) Most lethal CVS manifestations ++

Pathophysiology of envenomation

Dry sting is possible (but never presume!)


Often mild Local reaction, death possible due to cardiac/neurotoxicity
Venom composed of cocktail of enzymes/neuro/cardiotoxins
Transient Hypotension (Cholinergic/Hypovolemia) prolonged Hypertension
(Catecholamine surge) Hypotension (Cardiogenic/depletion of catecholamines)

Venom blocks the inactivation of Na channels and inhibits the K channels. The stimulated
sodium channels and the inhibited potassium channels, both lead to intense, persistent
stimulation of autonomic nerves, leading to massive release of neurotransmitters from adrenal
medulla, stimulating parasympathetic and sympathetic nerve endings, thus initiating
Autonomic storm
Closer proximity of the sting to the head and torso results in quicker venom absorption into the
central circulation and a quicker onset of symptoms.

Clinical Presentation (Cardiotoxicity, Neurotoxicity, Respiratory dysfunction)


CVS symptoms are predominant in India

Local: Excruciating pain, Paresthesia, Swelling, redness, LN enlargement

Parasympathetic (PNS): Salivation, Sweating (Skin Diarrhea), Vomiting , Bradycardia, VPCs,
Arrythmias, Priapism, hypotension

Sympathetic (SNS): Cold extremities, hypertension, tachycardia, pulmonary edema (Alpha
receptors stimulation plays an important part in the pathogenesis of hypertension and
pulmonary edema due to scorpion sting)

Neurologic Manifestations (common in North America): AMS, Irritability, Restlessness,


Delirium, Seizures. Mesobuthus Tamulus may cause focal neurological presentation include
hemi paresis, hemorrhagic or thrombotic stroke.
Respiratory Manifestations: Cough, Breathlessness, Cyanosis, Wheeze, Tachypnea and
hyperventilation. Pulmonary edema , Respiratory failure.
TAP Sign: Sudden tap on/around the site of sting induces severe pain/withdrawal

Classes of severity:

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

Labs: (Limited role, not for diagnosis but to look for complications)
1.
2.
3.
4.
5.

CBC (expect elevated TLC)


PT/APTT (? toxin induced DIC)
Random Blood Glucose/Fingerstick
Creat, Urea, SE (? Toxin induced ATN, Rhabdo, hyperK)
ECG: Almost all victims with envenomation, have some kind of ECG abnormality (ST-T
changes, arrhythmias, wide QRS, Prolonged Qtc, BBB, Peaked T waves etc)
6. CXR: look for pulmonary edema
7. ECHO (LV Function)
8. Cardiac biomarkers (Myocarditis), Creat Kinase MB
9. Amylase/Lipase (Venom induced pancreatitis Rare in India)
10. Blood Gas
11. U/A

Treatment
1970-80s During s Pre prazosin era Lytic Cocktail(chlorpromazine, promethazine, and
meperidine) was in vogue (not recommended anymore)
1.
2.
3.
4.

ABC (O2, NIV, Intubate, Judicious use of Fluids)


Reassure (Consider low dose benzos/Immobilize to hamper venom absorption)
Pain Relief (Ice packs, NSAIDs, Local Lignocaine)
Prazosin (Dose: 30mcg/Kg) - Sooner the better

Prazosin is widely used for management of Mesobuthus Tamulus sting. It is the physiological
and pharmacological antidote for scorpion envenomation.

Reduces preload withot causing tachycardia


Reverse metabolic syndrome evoked by catecholamines
Blunts myocardial response to sympathetic stimulation

Rectifies Hyperglycemia/HyperK by causing insulin release

5. Antibiotics (if there is suspicion of secondary infection)


6. Tetanus Prophylaxis
7. Scorpion Anti Venom (SAV)
SAV use was controversial in the past, but now most authorities agree that early use of IV SAV
resolves the neurological manifestations within hours, also reduces the requirement for
concomitant sedation with and decreased the levels of circulating unbound venom.
Dose: 30-50ml slow IV (1amp = 10ml = INR 350/6 US $), Sooner the better
Supportive Care: NIV, Dobutamine drip (inotrope of choice, if not in florid shock), IV
NTG/Nitroprusside drip for pulmonary edema, Norepi for refractory hypotension

Avoid- BB, CCB, Antihistaminics, Promethazine
Poor Prognosis if:
1.
2.
3.
4.
5.

Age < 5years, Weight < 25Kgs


Azotemia
Altered Mental status
Delayed presentation
Acidosis and Leucocytosis (>25000)

Further Reading:

1. Kale AA. A Crusade Against Scorpion Sting: Life and Works of Dr. Himmatrao Bawaskar.
2.
3.

4.
5.

Journal of Family Medicine and Primary Care 2012;1(1):52-55. doi:10.4103/2249-


4863.94453.
BAWASKAR HS., BAWASKAR PH. Prazosin in management of cardiovascular
manifestations of scorpion sting. Lancet, 1986, 2, 510-1.
Bawaskar HS, Bawaskar PH. Efficacy and safety of scorpion antivenom plus prazosin
compared with prazosin alone for venomous scorpion (Mesobuthus tamulus) sting:
randomised open label clinical trial. BMJ. 2011;342:c7136.
http://japi.org/january_2012/08_scorpion_sting_update.pdf
http://www.emri.in/images/stories/scorpion_sting.pdf

Questions/Comments/Feedback

Lakshay Chanana
drlakshay_em@yahoo.com
EMDidactic @ Twitter
EM Academy @ Facebook