Scorpion Poisoning - Rivin

Scorpions are a common arthropod found all over the world.
If threatened, a scorpion may use its long, flexible tail to sting a potential predator.
Frequently, people unknowingly come into contact with these species and experience the painful sensation of envenomation

1. Scorpion Poisoning Tharuka Fernando Karen Wickremasekara Rivindu Wickramanayake

2. Introduction Scorpions are a common arthropod found all over the world. If threatened, a scorpion may use its long, flexible tail to sting a potential predator. Frequently , people unknowingly come into contact with these species and experience the painful sensation of envenomation.

3. Re d & Black Scorpi on

4. 93 Scorpion Bite 2 Types of Scorpion Black – 99% -- Pain is severe ,but not fatal . Red Scorpion – found in Guhagar,Chiplun , Kokan area of Maharashtra state of India,Pondechari This bite can be Fatal

5. Etiology While there are thought to be about 1750 species of scorpions in the world, only 25 are considered to be lethal to humans. In most cases, the sting of a scorpion causes pain but is relatively harmless to a healthy adult. Species found in Asia, Africa, and South America may need medical attention due to the potential toxic effects of their venom.

6. Epidemiology The effect of the scorpion sting is highly dependent on the species. S pecies like Centruroides and Parabuthus cause neuromuscular issues, Buthus , Mesobuthus , & Androctonus exhibit life-threatening cardiovascular effects. These worrisome effects are mostly seen in the elderly and even more so in infants and young children.

7. Pathophysiology Grade 1: Local pain and paresthesias at the sting site. The puncture wound may not be noticeable in this grade. The "tap test" may confirm a provider's suspicion by distracting the patient and tapping on the area of the sting, causing increased pain. This does not occur with other species. Care is limited to analgesia . Grade 2: Local pain and paresthesias at the sting site as well as proximally. Recommended care again includes analgesia with optional anxiolytics if needed.

8. CONT.. Grade 3: Grade 2 with added cranial nerve (increased oral secretions, blurry vision, rapid tongue movement, nystagmus) or skeletal neuromuscular dysfunction (flailing of the extremities and tetanus-like arching of the back). These patients require analgesia and anxiolytics as well as anti - venom. Grade 4: Unlike grade 3 envenomation where the patient will experience either cranial nerve or skeletal muscle dysfunction, grade 4 envenomation include both. This can cause hyperthermia, rhabdomyolysis , pulmonary edema, and multiple organ failures. Again, anti - venom is critical in this situation.

9. Sym ptom s o f S corpion B ite Local – more severe than snake bite – pain , oedema & reddening Systemic – Nausea , vomiting, restlessness, fever ,convul s ions, coma, cyanosis The site of the bite is i dentified as – Pinpoint puncture spot ,local sweating & oedema 97

10. Toxicokinetics L ess than 10% of scorpion stings cause systemic symptoms & can be serious. Neurotoxins are the mainstay of symptomatology in envenomation. The venom of some species can cause prolonged depolarization by causing incomplete inactivation of sodium channels resulting in a slow influx of sodium. This then leads to membrane hyper - excitability and unregulated axon firing.

11. History and Physical Most scorpion stings cause a local inflammatory reaction and pain. S eizure-like activity in the patient . M otor hyperactivity of the pharyngeal muscles and uncontrolled diaphragmatic and intercostal neuromuscular activity may be seen. C ardiopulmonary effect T achycardia P ulmonary edema, C ardiogenic shock

12. Evaluation History and physical most commonly diagnose scorpion stings. Usually, the patient can visualize the scorpion, and the practitioner will observe an erythematous area on the skin with local inflammation. Numbness and weakness at the site may also be seen . CBC, CMP, PT/INR, PTT, and lipase . Laboratory studies are usually reserved for patients with severe (grade 3 to 4) envenomations .

13. Management Most stings only require supportive therapy including ibuprofen, cleaning of the sting area, and tetanus prophylaxis. Patients should be observed for at least 4 hours, but the onset of life-threatening symptoms occurs much quicker in children, with an average of 14 minutes. In patients with severe envenomation displaying symptoms such as hypersalivation , clonus, rapid eye movements, or restlessness, immediate intervention is critical. These patients may need endotracheal intubation due to the possibility of rapid onset severe pulmonary edema. As cardiogenic shock can complicate this, administration of dobutamine has been shown to be helpful.

14. CONT.. Intravenous benzodiazepines may be used if the patient displays muscle spasticity. Antivenom is reserved for patients displaying skeletal muscle or cranial nerve dysfunction who are stung by Centruroides scorpions. It is available in the United Staes , under the name Anascorp , which is intravenous scorpion-specific F( ab ’)2 equine antivenom . The recommended dose is three vials, followed by an additional two if symptoms continue. Complications are low and comprise mostly serum sickness (0.5%). Anascorp is considered much safer than the previous antivenom , which was marketed in 1965 and taken off shelves in 2001 due to its high rates of anaphylaxis (3.4%). .

15. If a patient is observed for 4 hours and is determined to have a mild sting, is tolerating oral intake, and has adequate pain control, the patient may be safely discharged home with return precautions.

16. Thank You! Rivin ..®