MANAGEMENT OF COMPLICATED SCORPION - STING IN CHILDREN
Dr. Sheela Sinha*, Dr. Amit Kr. Mittal**
Associate Professor, Pediatrics, PMCH, Patna *, Junior Resident Pediatrics, PMCH, Patna. **
Introduction: Scorpion sting is an acute life-threatening, time-limiting medical emergency of rural people common in Bihar. The small red scorpion (Mesobuthus Tamulus) most commonly found in gigantic belts of Bihar. Envenomation mainly in wet and summer months, primarily due to accidental contact with scorpion.
Given their small size infant and young children who are stung are at risk for severe autonomic dysfunction, multi organ failure and even death.

Treatment

  • Local:
    • A ligature applied locally to site of sting and released frequently in order to allow small amount of toxin go to circulation which can be detoxified by body easily.
    • Wound should be washed with plain water.
    • Strict bed rest and immobilization of affected part.
    • Alleviate pain, if severe, by NSAIDS (Provide Prolonged Relief), local ice packs, local injection of 2% Xylocaine.
  • Systemic:-
    • Prazosin :- 30 micro gm/kg one dose orally stat, them repeat in same dose at end of 3 hr according to clinical responses and later every 6 hr till extremities are warm dry and peripheral veins are visible. In case of vomiting give it through NG tube.
      Prazosin is regarded as a specific antidote to scorpion venom. A special note that the time lapse between the sting and administration of Prazosin from symptoms of autonomic storm determine the outcome.
      Precaution:
      It should not be given as prophylaxis in children when pain is the only symptoms
      When giving it first dose hypotension may occur so, baby should not be lifted or allowed to sit or stand.
    • Oral hydration and milk feeds must be encouraged. If needed IV maintenance fluids should be given to correct losses due to excessive sweating and vomiting.
    • Diazepam: Given to quieten a child restless after sting dose (0.5-2 mg/kg/dose (Oral, IM or IV).
    • Close monitoring of B.P., Pulse rate, respiration every 30 min for 3 hours, every hour for next.

Now, Considering Different Presentations of Cases
  • Features of Autonomic Storm: C/f of Tachycardia, S3 Gallop, Vomiting, Salivation, Sweating, Priapism T/t :-
    • Prazosin
    • Diazepam - Oral Or IM
    • Nasal O2 - 0.5-2 Lit/min

  • Features of shock and hypotension: Palmoplantar Sweating, Icy cold extremities, Absent or feeble pulse T/t :-
    • Correction of Hypovolemia by N/5 NS, 10 ml/kg
    • Nasal O2 - 0.5-2 lit/min
    • Prazosin
    • IV Dobutamine 5-15 micro gm/kg/min
  • Features of Myocardial dysfunction and Hypertension T/t :-
    • Prazosin
    • Antihypertensive 0 Sodium Nitroprusside (SNP)
    • 0.3-5 micro gm/kg/min for 4-6 hr). If SNP not available then give sub Lingual Isosorbide trinitrate (10 mg every 10 min).
  • Features of Pulmonary Oedema - Most Serious, Basal crepitations, Tachypnea Indicate Development of Pul. Oedema. T/t :-
    • Nasal O2 - 0.5-2 lit/min.
    • Prazosin-given 1 hr before termination of SNP drip
    • IV Dobutamine (5-15 ug/kg/min).
    • Sodium Nitroprusside (SNP) - 0.3-5 micro gm/kg/min. or Nitroglycerin (5 mg/min)
    • MORPHINE-Although used in Pul. Oedema due to other cause it is contraindicated in this situation.
    • Features of Multi-organ Failure
    • Early ventilation-PEEP/IMV/CPAP
    • After load reduction-Sod.Nitroprusside.
    • Careful sedation by diazepam IV.
    • Acid-base correction

  • Children Presenting with convulsion control with
    • Diazepam
    • Midazolam

  • Children Presenting with hyperthermia cold sponging


Unhelpful Treatment:
  • Lytic cocktail (Pethidine + Promethazine + Chlorpromazine)
  • Morphine
  • Steroids
  • Atropine
  • Nifedipine
  • ACE-inhibitor


Signs of Recovery:
  • Warm extremities
  • Palpable peripheral veins
  • Good urine Output
  • Pupil-Normal in size, shape and reaction
  • No Priapism


Criteria for Discharge:
  • No Irritability
  • No Tachycardia
  • No Pulmonary CREPTITIONS
  • Pupil Normal in size, shape & REACTION
  • Adequate food intake
References :
  1. Mahadevan S. Scorpion sting: Indian Pediatr 2000;37:504-514.
  2. Bawaskar HS, Bawaskar PH. Indian red scorpion envenoming Indian J Pediatric 1998;65;383-391.
  3. Bawaskar HS, Bawaskar PH. Management of cardiovascular manifestations of Poisoning by Indian red Scorpion (mesobuthus tamulus). Brit Heart J 1992;68:478-480.
  4. Hasman, Limbird, Goodman and Gilman's. The Pharmacological basis of therapeutics tenth edition. MacGraw-Hill.
  5. HPS Sachdev etc. Principle of Pediatric and Neonatal emergency. 2 nd edition, Jaypee Brothers.
  6. Meharban Singh. Medical emergencies in Children. 3 rd edition, Sagar Publications 571-573.
  7. Behrman, Kliegman, Jenson, Nelson Text book of Pediatrics. 17 th edition.
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Sinha S D, Mittal K A D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=460
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