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correspondence

Indian Pediatr 2013;50: 613-614

Management of Severe Scorpion Sting at a Rural Hospital


Santosh Govind Rathod and Sejal Bhanudas Tambat

Cottage Hospital Mangaon, Morba Road, Dist. Raigad, Maharashtra 402 104, India.
Email: [email protected]
 



Severe scorpion sting is a life threatening accident not uncommon in Western Maharashtra [1]. Scorpion venom delays closing of sodium neuronal channel resulting in liberation of endogenous catecholamines into circulation, manifesting as "autonomic storm" [2]. In the past, upto 30% fatality due to refractory heart failure due to Mesobuthus tamulus envenoming has been reported. Since the advent of prazosin, a postsynaptic alpha blocker, the fatality due to refractory heart failure has reduced to less than 4-8% in pediatric age group [3].

Cottage Hospital is a public health institute situated on Mumbai-Goa highway. The mono specific scorpion antivenom against the Mesobuthaus tumulus is prepared at Haffkine Institute, Mumbai has been available at our Institution since 2010. We retrospectively analyzed details of 12 children who suffered autonomic storm due to scorpion sting (Table I). Of these, six (2 males) had received scorpion antivenom plus prazosin and the remaining (3 males) received only scorpion antivenom. All gave history of scorpion sting and relatives brought the killed specimen.

TABLE I	Characteristics of Children with Autonomic Storm (N=12)
Treatment Anti-scorpion AScV + 
venom (AScV) Prazosin
Age (y) 9 (7-12) 8.8 (3-13)
Time between sting to    
 hospitalization (hours) 2.41 (1-3.5) 1.5 (1-2.5)
Blood pressure ( mm Hg)    
  Systolic 140 (80-190) 123 (90-170)
  Diastolic 80 (60-100) 80 (70-100)
Pulse rate (per min.) 89 (68-110) 89 (84-100)
AScV dose* 2.33 ((2-5)vial) 1.33 ((1.2)vial)
Pulmonary edema 3 0
Recovery 3 6
Time for recovery (h) 7.1 (4-8) 3.75 (2-5)
*1 vial=10 mL; Values in mean (range); Ascv-Anti-Scorpion  venom.

Alpha receptor stimulation plays important role in the pathogenesis of acute pulmonary edema. Prazosin, by blocking alpha receptors corrects the abnormal hemodynamic, and metabolic effects of circulating catecholamines [3,4]. Patients treated with prazosin alone are reported to recover in 10-24 hours, till the venom is metabolized by body. In such situation victims needs close monitoring in intensive care [8]. 10-20% of children, irrespective of oral prazosin, were found to develop tachycardia, hypotension and pulmonary edema [8]. Scorpion antivenom neutralizes the circulating venom and it has no action in reverseing the effects of already raised catecholamine and tissue-bound venom [5]. Cold extremities occur due to alpha receptor stimulation as a result of vasoconstriction, and delay the venom absorption in circulation from site of sting, which acts as depot. Simultaneous use of oral prazosin, which antagonizes the catecholamine actions and improves the peripheral circulation and rapid absorption of venom in circulation that becomes accessible to already circulating antivenom, thus recovery is shortened in prazosin pluse antivenom group as compared to scorpion anti venom grop alone [5]. Rapid recovery of victims treated with prazosin and antivenom prevent the extra load of these cases to intensive care unit, which is beyond the reach of poor people.

References

1. Santhannakrishnan BR, Ranganathan G, Anaantha-subramanian P, Balagopal Raju V. Cardiovascular manifestations of scorpion sting in children. Indian Pediatr. 1977;14:353-6.

2. Gwee MCE, Nirthanan S, Khoo H, Gopalkrishnakone P, Kini MR, Cheath LS. Autonomic effects of same scorpion venoms an toxins. Clin Experim Pharmacol Physiol. 2002;29:795-801.

3. Mahadevan S. Scorpion sting. Indian Pediatr. 2000;37:504-14.

4. Bawaskar HS, Bawaskar PH. Indian red scorpion envenoming. Indian J Pediatr. 1998;65:383-91.

5. Bawaskar HS. Efficacy and safety of scorpion antivenom plus prazosin compared with prazosin alone for venomous, scorpion (Mesobuthus tamulus)_ sting:_randomized open lable clinical trial. BMJ.2010;341:C7136.

 

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