From, Date: 8-10-2012
DR.MAMATHA.V, Bellary
Post Graduate Student in M.D. Pediatrics,
Department of Pediatrics,
VIMS, Bellary.
To,
The Principal,
Vijayanagara Institute of Medical Sciences,
Bellary.
THROUGH PROPER CHANNEL
Respected Sir,
Subject: Acceptance of registration and forwarding of synopsis.
In reference with the above cited subject, I the undersigned, studying Post Graduate course in M.D Pediatrics have been allotted the dissertation topic “COMPLICATIONS, TREATMENT AND OUTCOME OF SCORPION STING.” under the guidance of
Dr. VEERA SHANKAR. M, Professor and Head, Department of Pediatrics, VIMS, Bellary.
I request you to kindly forward the synopsis in the prescribed form to the University for approval.
Thanking you,
Yours faithfully,
(Dr .Mamatha.V)
Post Graduate Student in M.D,
Signature of the Guide Department of Pediatrics,
VIMS, Bellary.
Dr. Veera Shankar. M,
Professor and Head,
Department of Pediatrics,
VIMS, Bellary.
From, Date: 8-10-2012
The Professor and Head, Bellary.
Department of Pediatrics,
VIMS, Bellary.
To,
The Registrar,
Rajiv Gandhi University of Health Sciences,
Bangalore.
THROUGH PROPER CHANNEL
Respected Sir,
Sub: Submission of synopsis for registration and forwarding.
As per the regulations of the University for registration of dissertation topic, the following Post Graduate student in M.D. Pediatrics has been allotted the dissertation topic as follows by the official registration committee of all qualified and eligible guides of the department of Pediatrics.
NAME / TOPIC / GUIDEDR. MAMATHA.V,
Post Graduate Student in M.D,
Dept. of Pediatrics,
VIMS, Bellary. / “COMPLICATIONS, TREATMENT AND OUTCOME OF SCORPION STING ”. / Dr. VEERA SHANKAR.M ,
Professor and Head,
Department of Pediatrics,
VIMS, Bellary.
Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to the PG students at an early date.
Thanking you,
Yours faithfully,
(Dr. Veera Shankar. M)
Professor and Head,
Signature of the Guide Department of Pediatrics ,
VIMS, Bellary.
Dr. Veera Shankar. M,
Professor and Head,
Department of Pediatrics,
VIMS, Bellary
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA, BANGALORE.
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / Name of the candidate andaddress / DR.MAMATHA .V
POST GRADUATE IN M.D. PEDIATRICS,
DEPARTMENT OF PEDIATRICS,
VIMS, BELLARY.
2 / Name of the Institution / VIJAYANAGARA INSTITUTE OF
MEDICAL SCIENCES, BELLARY.
3 / Course of the study and subject / MD IN PEDIATRICS.
4 / Date of admission to the course / 31 .05.2012
5 / Title of the topic / COMPLICATIONS, TREATMENT AND OUTCOME OF SCORPION STING .
6
7
8 / BRIEF RESUME OF INTENDED WORK
6.1. Need for study
Scorpion sting envenomation are real threats in children of tropical and subtropical zones of world including India. It may be life threatening in children, if left untreated. The annual number of scorpion stings exceeds 1.2 million with 2.3 billion population at risk.1
Children are at greater risk of developing severe envenomation. Clinical manifestations include vomiting, profuse sweating, pulmonary and death.2
Furthermore the specific treatment that is scorpion antivenom is not available in this region indicating the seriousness of the problem. If not managed early and appropriately, can lead to high mortality.
Hence the present study is taken up to study various complications of scorpion sting, its management and outcome.
6.2 Review of Literature.
Scorpion sting is a major public health problem in many tropical and subtropical countries. The severity of scorpion sting varies with the scorpion species, age and size and is much greater in children owing to their lesser BSA.
HISTORY AND EXAMINATION 3
The following features are commonly seen:
Ø Local tissue effects like edema, redness, tenderness, ascending hyperesthesia.
Ø Signs of parasympathetic dysfunction included hypotension , bradycardia, excessive sweating, salivation, lacrimation, urination, defecation, priapism and gastric emptying . Sweating and salivation persists for 6- 13 hours.
Ø Signs of sympathetic dysfunction include tachycardia, S3 gallop, arrhythmias, hypertension, hyperthermia, features of pulmonary edema. Cold extremities which persist for 24 – 72 hours.
Ø Pulmonary edema may develop within 30 minutes to 3 hours after a sting due to myocardial dysfunction secondary to intense vasoconstriction or probable direct injury. Children appear pale with clammy skin and have tachycardia with elevated blood pressure, retractions, nasal flaring and grunting with tachypnea and intractable cough. Pink frothy sputum is not always seen as in adults. Death can occur within 30 minutes in some children due to ventricular arrhythmias.4
Ø Cranial nerve effects such as difficulty in swallowing, nystagmus, blurring of vision and fasciculations.
Ø Restlessness and involuntary movements, seizures, altered sensorium, cerebral thrombosis, thalamus induced systemic paraesthesia, hemiplegia and aphasia.
INVESTIGATIONS:
Ø Hb, TC, DC, ESR
Ø Blood urea, Serum Creatinine
Ø RBS, Serum electrolytes
Ø Urine routine- to look for rhabdomyolysis
Ø Chest x ray- if features of pulmonary edema are present
Ø ECG
MANAGEMENT 3:
General measures
Ø Maintain airway, assess breathing and circulation .Keep the child in propped up position and administer oxygen if needed. Intubation and ventilator support should be given to deliver required PEEP if severe features of pulmonary edema are present.
Ø Local treatment for pain by using ice packs, local anaesthetics like xylocaine, oral diazepam 0 .1- 0.3mg per kg per dose, NSAIDS.
Ø Monitor heart rate, respiratory rate, blood pressure, look for S3 gallop, basal crepitations every half hourly for first three hours, every hourly for next four hours and then every four hours till improvement is seen.
Ø Ensure administration of adequate oral fluids to the child. Give maintainance intravenous fluids (N/5) is needed to prevent hypovolemia due to vomiting or diarrhea, sweating, hypersalivation and insensible water loss.
Specific pharmacotherapy:
Ø Management of pulmonary edema: Patient should be given propped up position. Intravenous aminophylline 5mg/kg diluted in dextrose given as slow bolus to counter the associated bronchospasm. If available isosorbide buccal spray is useful or powder of nitroglycerine should be rubbed on gums and intravenous furosemide 10 to 20 mg should be given to reduce pre load and pulmonary congestion. In case of massive pulmonary edema intravenous sodium nitroprusside drip 3 to 5 micro grams/kg/min can be started and dose should be raised according to patients response and blood pressure. In case of shock or hypotension early administration of dobutamine 5 to 15micro grams/kg/min along with sodium nitroprusside drip is life saving.
Ø Prazosin : In children with features of autonomic storm , prazosin is the main stay of treatment which is alpha-1 adreno receptor antagonist. It should be given as early as possible to reduce gap between sting and 1st dose of prazosin which determines the outcome. Dose is 30 micro gm/kg/dose oral. Dose should be repeated after 3 hours and then 6th hourly till signs of improvement are seen like warm extremities and reduced tachycardia.
Ø Scorpion antivenin: Monospecific F(ab)2 antivenom serum prepared by immunized horse is available for clinical use from Haffkine biopharma Mumbai since 2002. 2 randomised controlled trials have shown that it is useful in critically ill children with neurotoxicity and fast recovery occurs when given along with prazosin.
Rajniti Prasad et al in their study at Varanasi included 90 children admitted with scorpion sting envenomation over a period of four and half year. Grading of severity was done on the basis of local or systemic involvement, and management protocol was followed as per hospital guidelines. All patients had perspiration and cold extremities.Most of them had sting over extremities except two, having over the trunk. Shock was present in 48(53.3%), whereas myocarditis, encephalopathy, pulmonary edema and priapism were present in 38(42.2%), 32(35.5%), 34(37.8%), and 28(31.1%) children, respectively. Eight (8.9%) children had died. The mean value of blood pressure, sodium and potassium among survivors and non-survivors was insignificant. Mortality was significantly higher in children presented after 6 hours of bite. Patients, who had metaboloic acidosis, tachpnea, myocarditis, APE, encephalopathy and priapism had significantly higher mortality (p<0.05).5
In Bawaskar and Bawaskar study they included 12 consecutive children less than 15 years of age admitted between January 2002 to January 2003 to general Hospital, Mahad with the diagnosis of scorpion envenomation. The age of the children (6 males and 6 females) ranged from 3.5 years to 15 years. Steroids were used in all eleven cases at PHCs while antihistaminic (Pheniramine) was used in eight cases. Antiscorpion venom (ASV) and prazosin was used in four patients each while five were given furosemide. Two children (aged 6 years and 10 years) died of massive pulmonary edema and hypotension despite use of dopamine and nitroprusside infusion.6
In the study conducted by Bosnak M in turkey, the mean age of the patients were 6.1 +/- 4.1 years ranging between 4 month and 15 years. Male to female ratio was 1.8. Thirty-three (71.1%) cases of scorpion stings came from rural areas. Twenty-six (57.8%) of the patients were stung by Androctonus crassicauda. The most common sting localization was the foot-leg (55.6%). The mean duration from the scorpion sting to hospital admission was 4.5 +/- 2.6 hours. The most common findings at presentation were cold extremities (95.5%), excessive sweating (91.1%) and tachycardia (77.7%). The mean leukocyte count, and serum levels of glucose, lactate dehydrogenase, creatine phosphokinase and international normalized ratio were found above the normal ranges. Prazosin was used in all patients, dopamine in 11 (24.4%) and Na-nitroprusside in 4 (8.8%) patients. Two children died (4.4%) due to pulmonary oedema. These children, in poor clinical status at hospital admission, needed mechanical ventilation, and death occurred despite use of antivenin and prazosin in both of them.7
In the study by Narayanan P, Mahadevan S, Serane V in JIPMER Pondicherry to know the effect of nitroglycerine infusion in children hospitalized for scorpion sting with severe myocardial dysfunction and decompensated shock they concluded that nitroglycerine therapy could bring about significant improvement in myocardial function and hemodynamic parameters with a potential for improved survival.8
6.3. OBJECTIVES OF THE STUDY
Ø To study the complications and management of scorpion sting.
Ø To evaluate the outcome of scorpion sting.
MATERIALS AND METHODS
7.1. SOURCE OF DATA
All scorpion sting cases admitted in pediatric emergency ward in VIMS, Bellary during the time period of 18 months i.e., from December 2012 to July 2014 with a sample size of 50.
7.2. a) METHOD OF COLLECTION OF DATA
Children below the age of 15 years admitted with history of scorpion sting in pediatric emergency ward will be included in the study . Each patient will undergo-
Ø Detailed history and clinical evaluation
Ø Relevant investigations
Ø Management will be done under the strict guidance of my guide and outcome will be assessed.
INCLUSION CRITERIA
Ø All cases of definite scorpion sting in children upto 15 years of age in which a scorpion is seen in the vicinity either by patient or the parents immediately after the sting.
Ø Children with history of sting coupled with classic clinical manifestations of scorpion.
EXCLUSION CRITERIA
Ø Cases of scorpion sting in patients more than 15 years of age.
Ø Unknown bites and cases where the clinical manifestations are not compatible with scorpion sting.
7.3. DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER
HUMANS OR ANIMALS?
Ø Haemoglobin , TC ,DC ,ESR
Ø Random blood sugar, Serum electrolytes
Ø Blood urea, Serum creatinine
Ø Urine routine
Ø Chest x ray
Ø Electrocardiography
7.4. HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION?
Yes. Ethical Clearance has been obtained from Institutional Ethical Committee (IEC) of VIMS, Bellary.
LIST OF REFERENCES:
1. Chippaux JP,Goyffon M. Epidemiology of Scorpionism:a global appraisal.Acta Trop.2008;107:71-9.
2. Bawaskar HS,Bawaskar PH,Cardiovascular manifestations of severe scorpion sting in India(Review of 34 children).Ann Trop Pediatric 1991;11:381-387.
3.Meharban Singh.Medical Emergencies in Children.5th edition 2012;758-760.
4.Panna Choudhary,Avind Bagga,Krishnan Chugh,Siddarth Ramji,Piyush Gupta.Principles of Pediatric and Neonatal Emergencies.3rd edition.2011;445-453.
5. Rajniti Prasad & Om Prakash Mishra & Nisha Pandey &Tej Bali Singh. Scorpion Sting Envenomation in Children: Factors Affecting the Outcome. Indian J Pediatr (May 2011) 78(5):544–548.
6. Himmatrao S. Bawaskar and Promodini H. Bawaskar. Clinical Profile of Severe Scorpion Envenomation in Children at Rural Setting. Indian Pediatrics 2003; 40:1072-1081.
7. Bosnak M, Levent Yilmaz H, Ece A, Yildizdas D, Yolbas I, Kocamaz H, Kaplan M, Bosnak V. Department of Pediatrics, Pediatric Intensive Care Unit, Dicle University Medical School, Diyarbakir, Turkey.Severe scorpion envenomation in children: Management in pediatric intensive care unit.Hum Exp Toxicol. 2009 Nov;28(11):721-8.
8. Narayanan P, Mahadevan S, Serane VT.Department of Pediatrics, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER),Pondicherry 605 006, India. Nitroglycerine in scorpion sting with decompensated shock. Indian Pediatr. 2006 Jul;43(7):613-7.
9 / Signature of the candidate
10 / Remarks of the guide
11 / 11.1. Name and designation of the guide / Dr. VEERA SHANKAR. M,
PROFESSOR AND HEAD,
DEPARTMENT OF PEDIATRICS,
VIMS, BELLARY.
11.2. Signature
11.3. Head of the Department / Dr. VEERA SHANKAR. M,
PROFESSOR AND HEAD,
DEPARTMENT OF PEDIATRICS,
VIMS, BELLARY.
11.4. Signature
12 / 12.1. Remarks of the Chairman
and Principal
12.2. Signature.