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Scorpion envenomation
1. Scorpion envenomation
Antonio Souto
acasouto@bol.com.br
MĂŠdico coordenador
Unidade de Medicina Intensiva PediĂĄtrica
Unidade de Medicina Intensiva Neonatal
Hospital Padre Albino
Professor de Pediatria nĂvel II
Faculdades Integradas Padre Albino
Catanduva / SP
2. UTI PediĂĄtrica & 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:
â˘8.000 /year
â˘3 /100.000 habitants
â˘50% Minas Gerais e SĂŁo Paulo
Dr. Antonio Souto
acasouto@terra.com.br
2013
3. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
4. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
5. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
6. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
â˘60s and 70s, cases fatality rate of up to 30%
â˘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 PediĂĄtrica & Neonatal
Hospital Padre Albino
â˘Tityus serrulatus scorpion venom has shown to be
more deleterious to children than to adults
â˘This effect is suggested to be body weight dependent.
â˘The children would have higher venom concentration in
their body liquids.
â˘More severe systemic symptoms, including higher
lethality.
â˘Buthidae species can result a life threatening systemic
effects
Dr. Antonio Souto
acasouto@terra.com.br
2013
8. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
T. serrulatus
T. stigmurus
Dr. Antonio Souto
T. bahiensis
T. metuendus
acasouto@terra.com.br
T. obscurus
2013
9. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
Familia Buthidae (Hemiscorpius Lepturus)
Genero
â˘Buthus (Mediterranean Spain to the Middle East)
â˘Parabuthus (western and southern Africa)
â˘Hottentotta (South Africa to south east Asia)
â˘Leiurus (northern Africa and middle East)
â˘Androctonus (northern Africa to southeast Asia)
â˘Centruroides (southern united states, Mexico, central
America and Caribbean)
â˘Mesobuthus (through out the Asia)
Tityus (central America, south America
and the Caribbean)
Dr. Antonio Souto
acasouto@terra.com.br
2013
10. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
â˘Arthropods in the class Arachnid
â˘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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Scorpion Venom
Dr. Antonio Souto
acasouto@terra.com.br
2013
12. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
Scorpion Venom
Cocktail
â˘Low molecular weight basic proteins, neurotoxins,
nucleotides, aminoacids, oligopeptides, cardipotoxins,
nephrotoxin, hemolytic toxins, phosphodiesterase,
phospholipase A, hyaluroinidase.
â˘Acetylcholineesterase, glycosaminoglycans, histamine,
serotonin. 5-hydroxyptamine and proteins that inhibit
protease, angiotensinase and succinate âdehydrogenese,
ribonuclease, 5- nucleotidase.
Dr. Antonio Souto
acasouto@terra.com.br
2013
13. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
14. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
15. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
Scorpion Venom
The lethality varies with species
â˘Venom almost complete absorption would occur in 7-8
hours
â˘70% of maximum concentration in the blood within 15
minutes
â˘Half life of intravenously injected venom is between 4 to 7
minutes
â˘Takes 4.2 to 13.4 hours for elimination from blood.
Dr. Antonio Souto
acasouto@terra.com.br
2013
16. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
Regulating venom ejections
This ability explains the variation of
intensity of symptoms and existence of
âdryâ sting without envenoming.
Dr. Antonio Souto
acasouto@terra.com.br
2013
17. UTI PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Hospital Padre Albino
âautonomic stormâ
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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Clinical effects
â˘depends upon the species of scorpion
â˘dose of venom injected
Severity
â˘Age
â˘Time between sting and hospitalization
â˘Children with 3.9-10% fatality irrespective of
intensive care management from Israel, Turkey
and India
Clinically âautonomic stormâ
releasing massive amounts of catecholamines
Dr. Antonio Souto
acasouto@terra.com.br
2013
20. UTI PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Local Manifestations
â˘Soon after sting
â˘Severe radiating pain
â˘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 PediĂĄtrica & 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 âskin diarrheaâ, 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Tityus serrulatus
The cardiovascular manifestations
Arterial hypertension or hypotension, heart failure,
pulmonary edema, shock and electrocardiographic
changes.
âacute myocardial infarction-like
pattern.â
The American Journal of Cardiology, 67:7; 655-657
Dr. Antonio Souto
acasouto@terra.com.br
2013
29. UTI PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
36. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
37. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
38. UTI PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
39. UTI PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Management
Scorpion antivenom (SAV) :
Without skin test,
Administered as early as possible and through venous
route
â˘SAV is specific treatment of scorpion stingâs therapy
â˘Randomized controlled trials
â˘Antivenom resolved the neurological manifestations
within four hours.
â˘SAV reduced the levels of circulating unbound venom.
Dr. Antonio Souto
acasouto@terra.com.br
2013
41. UTI PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
43. UTI PediĂĄtrica & 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 PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
46. UTI PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Dr. Antonio Souto
Hospital Padre Albino
acasouto@terra.com.br
2013
48. UTI PediĂĄtrica & Neonatal
Hospital Padre Albino
â˘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.
â˘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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Antivenom therapy must be applied as soon as possible
after envenoming.
Antivenom preparations
â˘higher purity, greater potency and minimal (or absent)
side-efects
â˘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 PediĂĄtrica & 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 PediĂĄtrica & Neonatal
Hospital Padre Albino
Thank you!
Dr. Antonio Souto
acasouto@terra.com.br
2013