Scorpion envenomation: Difference between revisions
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[[File:Bbasgen-bark-scorpion.jpg|thumb|Arizona Bark Scorpion, (''Centruroides sculpturatus'')]] | [[File:Bbasgen-bark-scorpion.jpg|thumb|Arizona Bark Scorpion, (''Centruroides sculpturatus'')]] | ||
*Most scorpion stings in North America result only in local pain. | *Most scorpion stings in North America result only in local pain. | ||
*Arizona Bark Scorpion, ''Centruroides sculpturatus'', found in AZ, NM, TX, and CA, can cause systemic toxicity. | *Arizona Bark Scorpion, ''Centruroides sculpturatus'', found in AZ, NV, NM, TX, and CA, is the only neurotoxic species found in North America and can cause systemic toxicity.<ref name="Boyer" /> | ||
==Clinical Features== | ==Clinical Features== | ||
===Local reaction=== | ===Local reaction=== | ||
* | *Pain and paresthesias near envenomation site. | ||
** "Tap" test: severe local tenderness when affected area is lightly tapped | ** "Tap" test: severe local tenderness when affected area is lightly tapped | ||
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*Uncommon but can be severe, particularly in children | *Uncommon but can be severe, particularly in children | ||
*Cranial nerve and somatic motor dysfunction can develop: | *Cranial nerve and somatic motor dysfunction can develop: | ||
**Abnormal roving eye movements | **Abnormal roving eye movements, blurred vision, pharyngeal muscle incoordination | ||
** | **Hypersalivation, noncardiac pulmonary edema (can → respiratory distress/failure) | ||
*Tachycardia and severe agitation can also be present | **Tongue fasciculations and uncoordinated motor agitation (flailing or jerking extremities) | ||
*Tachycardia, other dysautonomias, and severe agitation can also be present | |||
*Without antivenom, symptoms typically last 24-48 hrs | *Without antivenom, symptoms typically last 24-48 hrs | ||
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*Grade 1 - Local pain and/or paresthesias at site of envenomation | *Grade 1 - Local pain and/or paresthesias at site of envenomation | ||
*Grade 2 - Pain and/or paresthesias remote from the site of the sting, in addition to local findings | *Grade 2 - Pain and/or paresthesias remote from the site of the sting, in addition to local findings | ||
*Grade 3 - Either cranial nerve/autonomic dysfunction or somatic skeletal neuromuscular dysfunction | *Grade 3 - Either cranial nerve/autonomic dysfunction '''or''' somatic skeletal neuromuscular dysfunction | ||
**Cranial nerve dysfunction - Blurred vision, roving eye movements, hypersalivation, tongue fasciculations, dysphagia, dysphonia, problems with upper airway | **Cranial nerve dysfunction - Blurred vision, roving eye movements, hypersalivation, tongue fasciculations, dysphagia, dysphonia, problems with upper airway | ||
**Somatic skeletal neuromuscular dysfunction - Restlessness, severe involuntary shaking or jerking of the extremities that may be mistaken for a seizure | **Somatic skeletal neuromuscular dysfunction - Restlessness, severe involuntary shaking or jerking of the extremities that may be mistaken for a seizure | ||
*Grade 4 - Combined cranial nerve/autonomic dysfunction and somatic | *Grade 4 - Combined cranial nerve/autonomic dysfunction '''and''' somatic skeletal neuromuscular dysfunction | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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==Diagnosis== | ==Diagnosis== | ||
* | *Generally clinical diagnosis | ||
**Be aware that a discrete scorpion bite site may not be clinically apparent. | |||
==Treatment== | ==Treatment== | ||
# | #Supportive care | ||
#*Cold compress to area of sting | |||
#*Analgesic and anti-inflammatory medications | |||
#*Benzodiazepines may help with agitation and muscle spasm | |||
#[[Atropine]] | #[[Atropine]] | ||
#*May be given for hypersalivation and respiratory distress caused | #*May be given for hypersalivation and respiratory distress caused | ||
#**Contraindicated for foreign scorpion stings because may exacerbate adrenergic effects | #**Contraindicated for foreign scorpion stings because may exacerbate adrenergic effects | ||
#Anascorp Antivenom<ref>http://www.anascorp-us.com</ref> - Only available in Arizona, Nevada, and Utah | #Anascorp Antivenom<ref>http://www.anascorp-us.com</ref> (Centruroides immune Fab) - Only available in Arizona, Nevada, and Utah | ||
#*Resolves clinical syndrome within 4hr<ref>http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm266515.htm</ref> | #*Resolves clinical syndrome within 4hr<ref>http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm266515.htm</ref><ref name="Boyer">Boyer LV, Theodorou AA, Berg RA, Arizona Envenomation Investigators, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May 14;360(20):2090-8.</ref> | ||
#*Common side effects: vomiting, pyrexia, rash, nausea, and pruritus | #*Common side effects: vomiting, pyrexia, rash, nausea, and pruritus | ||
#*Serious side effects: anaphylaxis | #*Serious side effects: anaphylaxis | ||
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==Disposition== | ==Disposition== | ||
*Grade I or II envenomation may generally be discharged after 6 hours of observation in the ED without progression of symptoms. | |||
*Grade III or IV envenomation likely requires antivenom administration and/or admission. | |||
==See Also== | ==See Also== | ||
Revision as of 21:52, 3 August 2015
Background
- Most scorpion stings in North America result only in local pain.
- Arizona Bark Scorpion, Centruroides sculpturatus, found in AZ, NV, NM, TX, and CA, is the only neurotoxic species found in North America and can cause systemic toxicity.[1]
Clinical Features
Local reaction
- Pain and paresthesias near envenomation site.
- "Tap" test: severe local tenderness when affected area is lightly tapped
Systemic reaction
- Uncommon but can be severe, particularly in children
- Cranial nerve and somatic motor dysfunction can develop:
- Abnormal roving eye movements, blurred vision, pharyngeal muscle incoordination
- Hypersalivation, noncardiac pulmonary edema (can → respiratory distress/failure)
- Tongue fasciculations and uncoordinated motor agitation (flailing or jerking extremities)
- Tachycardia, other dysautonomias, and severe agitation can also be present
- Without antivenom, symptoms typically last 24-48 hrs
Grades of Centruroides envenomation
- Grade 1 - Local pain and/or paresthesias at site of envenomation
- Grade 2 - Pain and/or paresthesias remote from the site of the sting, in addition to local findings
- Grade 3 - Either cranial nerve/autonomic dysfunction or somatic skeletal neuromuscular dysfunction
- Cranial nerve dysfunction - Blurred vision, roving eye movements, hypersalivation, tongue fasciculations, dysphagia, dysphonia, problems with upper airway
- Somatic skeletal neuromuscular dysfunction - Restlessness, severe involuntary shaking or jerking of the extremities that may be mistaken for a seizure
- Grade 4 - Combined cranial nerve/autonomic dysfunction and somatic skeletal neuromuscular dysfunction
Differential Diagnosis
Envenomations, bites and stings
- Hymenoptera stings (bees, wasps, ants)
- Mammalian bites
- Closed fist infection (Fight bite)
- Dog bite
- Marine toxins and envenomations
- Toxins (ciguatera, neurotoxic shellfish poisoning, paralytic shellfish poisoning, scombroid, tetrodotoxin
- Stingers (stingray injury)
- Venomous fish (catfish, zebrafish, scorpion fish, stonefish, cone shells, lionfish, sea urchins)
- Nematocysts (coral reef, fire coral, box jellyfish, sea wasp, portuguese man-of-war, sea anemones)
- Phylum porifera (sponges)
- Bites (alligator/crocodile, octopus, shark)
- Scorpion envenomation
- Reptile envenomation
- Spider bites
Diagnosis
- Generally clinical diagnosis
- Be aware that a discrete scorpion bite site may not be clinically apparent.
Treatment
- Supportive care
- Cold compress to area of sting
- Analgesic and anti-inflammatory medications
- Benzodiazepines may help with agitation and muscle spasm
- Atropine
- May be given for hypersalivation and respiratory distress caused
- Contraindicated for foreign scorpion stings because may exacerbate adrenergic effects
- May be given for hypersalivation and respiratory distress caused
- Anascorp Antivenom[2] (Centruroides immune Fab) - Only available in Arizona, Nevada, and Utah
Disposition
- Grade I or II envenomation may generally be discharged after 6 hours of observation in the ED without progression of symptoms.
- Grade III or IV envenomation likely requires antivenom administration and/or admission.
See Also
References
- ↑ 1.0 1.1 Boyer LV, Theodorou AA, Berg RA, Arizona Envenomation Investigators, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May 14;360(20):2090-8.
- ↑ http://www.anascorp-us.com
- ↑ http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm266515.htm
- ↑ http://www.azcentral.com/news/articles/2011/11/10/20111110scorpion-drug-cost.html