Scorpion Stings In Jordanian Children
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Eman A Rawabdeh, Hussein A Bataineh

From Department of Pediatrics and pharmacy at Prince Rashed Hospital (PRH) 2001-2005.
Pediatrician email: Bataineh_Hussein@yahoo.com.
P.O. Box 260 Aidoun, 21166, Irbid, Jordan.

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ABSTRACT Objective: To determine which scorpion stings need treatment with antivenom. Material: This review study was based on analysing cases of scorpion stings in children seen during 2001 to 2005 at (PRH) which is a referral hospital in north of Jordan. Results: In our series of 386 cases, 201 (52%) were asymptomatic and 185 (48%) were showing some local or general symptoms of envenomation at the time of arrival to the hospital emergency department. Of these 185 symptomatic cases, 169 had developed symptoms within two hours of the sting and all 185 by four hours. Conclusion: Completely asymptomatic cases which remain so during observation need not be given antiscorpion serum, which should be avoided if possible.

Keywords: scorpion, antivenom.
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Scorpion envenomation is common in tropical and subtropical regions, especially in North Africa, Latin America, India, and the Middle East, where it is seen as a public-health problem.1, 2

The current therapeutic strategies rely partly on supportive symptomatic treatments.2 Scorpion antivenom is, however, the only specific treatment and is widely used in many countries such as Brazil and Saudi Arabia.2, 3-5
So the suggested treatment regimes are:
1) no antivenom serum, 6symptomatic treatment only;
2) 1 mL antivenom intramuscularly;7 and
3) 5 mL intravenous antivenom in all cases.

This study was based on scorpion sting cases in children seen during 2001 to 2005 in Prince Rashed hospital which is a referral hospital in north of Jordan. The total number of cases seen was 386, with ages varying from one year to 12 years, the youngest of which was a baby of 10 months. The patients comprised 237 males and 149 females. Fifty-three of them were below two years, 125 were between two to five years, and 208 were between five and 12 years of age.

Management Protocol
The treatment of scorpion envenomation consists of nonspecific or supportive care and specific treatment with scorpion antivenom, which should be species-specific. We gave 5 mL antivenom intravenously in all cases.

Patients with a history of reactions to antivenom were excluded. We gave 10 mL antivenom in moderate systemic affection and 15-20 mL in severely affected cases showing signs of myocarditis or central nervous system (CNS) affection. The antivenom used was purified polyvalent anti-scorpion serum produced by the Egyptian Organisation for Biological Vaccine Production in Cairo, Egypt. The serum was prepared from the purified plasma of healthy horses immunized with venoms of Leiurus quinquestriatus, and Androctonus amoreuxi, and capable of neutralizing venoms of L. quinquestriatus, A. amorexi, A. crassicauda, and A. Aeneas and Buthus occitanus.

Non-specific (supportive) treatment consisted mainly of chlorpromazine (largactil) 0.5 to 2 mg/kg, repeated once or twice, and sometimes promethazine (phenergan) 0.25 to 1mg/kg was adequate to control autonomic symptoms and agitation.

For convulsions, diazepam 0.1 to 0.5 mg/kg was used, and occasionally had to be repeated. For cardiac complications like pulmonary edema, myocarditis and heart failure, frusemide 1 to 3 mg/kg, and ACE inhibitors like captopril were used.

For cerebral edema, appropriate therapy, such as mannitol, dexamethazone, hyperventilation, etc., were used. Cases which showed marked respiratory distress or impending respiratory failure were put on mechanical ventilation.

In our series of 386 cases, 201 (52%) were asymptomatic and 185 (48%) were showing some local or general symptoms of envenomation at the time of arrival at the hospital. Of these 185 symptomatic cases, 169 had developed symptoms within two hours of the sting and all 185 by four hours.
Twenty-nine (7.5%) had local symptoms like pain, swelling, redness, and itching lasting for between two and four hours. Systemic involvement was seen in 156 cases (40%). General symptoms such as salivation, sweating, extreme irritability, agitation and excessive crying were present in 132 cases (32%). Priapism was present in 52 affected male children (22%). The symptom wise presentation, laboratory and radiological abnormalities are listed in Table 1.

Cardiovascular and neurological complications cause the most morbidity and are major causes of mortality in scorpion envenomation. Neurological complications were the next most common feature, and were seen in 51 cases (13%). The main neurological complications were extreme agitation and disorientation, muscular spasms, seizures, coma and cerebral edema, which is the most dreaded complication. A girl of four years who presented to hospital in a comatose condition after about six hours of envenomation died of cerebral edema.

A total of 182 patients (163 symptomatic and 19 asymptomatic) were given 5 mL antivenom intravenously. Reactions were seen in 25 patients (13.7%), with minor transient skin reactions in 23 (12.6%) of them. In two patients (1%), the reactions were more serious, such as severe urticaria, periorbital edema, cough, breathlessness, severe hypotension and heart failure. One symptomatic patient who was given serum intravenously started showing signs of anaphylactoid reaction within minutes, and had to be sent to ICU, where the patient eventually recovered.

None of the asymptomatic cases developed any symptoms during the 24 hours of observation. In the 163 symptomatic cases, antiscorpion venom serum was given. In the remaining 22 cases, it could not be given because of non-availability or hypersensitivity to serum. Those affected children who were given serum had fewer complications, and shorter hospital stay, and there were no deaths in the group.

The hospital stay in the group that was given serum was between 3 to 7. For those who were not given serum, it was between 7 to 13 days.