Respiratory Failure and Cardiovascular Dysfunction Following Scorpion Sting in Children. Shaul Sofer M.D. Pediatric Intensive Care Unit

Transcription

1 Respiratory Failure and Cardiovascular Dysfunction Following Scorpion Sting in Children Shaul Sofer M.D Pediatric Intensive Care Unit Soroka Medical Center, Faculty of Health Sciences Ben-Gurion University of the Negev Beer-Sheva, Israel Budapest, March 20th, 2015

2 Epidemiology

3 The Scorpion Dance

4 The Families of Scorpions Bothriuridae Scorpionidae Buthidae Vejovidae Diplocentridae Chactidae

5 Buthidae: toxic species Centruroides suffusus (Mexico) Tityus serrulatus (Brazil) Leiurus quinquestriatus (North Africa, Israel) Buthotus tamulus (India)

6 Yellow Scorpion: Leiurus quinquestriatus Hebraeus

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8 Composition of Scorpion Venom Mucopolysaccharides Hyaluronidase Phospholipase Serotonin or histamine Protease inhibitors Histamine releasers Neurotoxins

9 Pharmacological effects Adrenergic Cholinergic Inflammation Modification of sodium channel (influx of Na + and Ca 2+ ) Inhibition of Ca 2+ - activated K + channels (neuromuscular transmission)

10 Severity of Intoxication Amount of venom (number of stings) Composition of the venom Different species Age Nutritional state Season Geographical area Integrity of the stinger Age (size) of the victim Site of injection Susceptibility?

11 Hershkovich et al. Toxicon 1985

12 Hershkovich et al. Toxicon 1985

13 Hershkovich et al. Toxicon 1985

14 Acute pancreatitis in children following envenomation by the yellow scorpion Leiurus Quinquestriatus Sofer, Shalev, Weizman, Shahak and Gueron Toxicon 1991

15 Scorpion Stings among Children Total - 61 Respiratory failure - 9 (15%) (8 Bedouins, 1 Jew) Sofer and Gueron, Toxicon 1988

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19 Respiratory Rate and Pattern on Arrival Patient N o Age (years) /365 Respiratory rate (minute) Bradypnea, stridor Gasping Gasping Gasping 60, Dyspnea

20 Vital Signs on Arrival Patient # Age (yrs) R.R (min) H.R (min) B.P (mm Hg) Consciousness /50 Confused, agitated / / /50 Stupor

21 Physical Findings during Clinical Deterioration Patient # Hours after arrival R.R (min) H.R (min) B.P (mm Hg) Consciousn ess 1 1 Cardio respiratory arrest 2 14 (50) 80 (40) 130 (140/90) 90/45 Agitated, confused 3 4 (16) 52 (70) 150 (100/60) 70/50 Coma 4 14 (22) 60 (85) 180 (90/50) 50/20 Coma

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23 Arterial Blood Gases Patient # PO 2 PCO 2 ph 1 Cardio respiratory arrest

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25 Hemodynamic Data During Deterioration Patient # B.P (mm Hg) C.V.P (mm Hg) P.C.W.P (mm Hg) P.A.P (mm Hg) 1 Cardio respiratory arrest 2 90/45 ND / /50 10 ND ND 4 50/ /20

26 Patients 6-9 on Arrival Pts. No Age (yrs) R.R (min) H.R (min) B.P (mm Hg) CNS ECG Chest X- ray 6 2 Hypopnea /125 stupor P interstitial P.E. 7 1 Hypopnea /110 stupor P interstitial P.E. 8 1 Hypopnea /120 stupor P normal 9 22 D /60 stupor normal interstitial P.E.

27 Sofer and Gueron. Chest 1990

28 BP and Therapy in Eight Children Case Age (yrs) Initial BP Peak BP Antihypertensive Drugs BP after Therapy / /130 Hydralazine 105/59 (N) /87 113/100 Hydralazine 96/45 (N) / /120 Hydralazine 125/68 (N) / /112 Hydralazine 107/65 (N) / /110 Hydralazine 120/79 (N) /90 150/100 Nifedipine 110/45 (N) /87 136/87 Nifedipine 116/63 (N) / /100 Nifedipine 120/80 (N)

29 Vasodilators and hypertensive encephalopathy following scorpion envenomation in children Shaul Sofer and Mosche Gueron Chest 1990

30 Renin and Aldosterone Levels Age (years) Renin (ng/ml) Aldosterone (pg/ml) B.P (mm Hg) 6 7/ / > / > / > / > / 90 Renin: normal Aldosterone: normal Gueron, Ilia, Shahak and Sofer. Toxicon 1993

31 Echocardiographic Changes following Scorpion Sting Patient No A B A B A B A B A B A B A B Fractional shortening (%) Mitral regurgitation Abnormal global wall motion A = On admission. B = On discharge. Normal values for fractional shortening 29-42% Gueron, Margulis and Sofer. Toxicon 1990

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34 Radionuclide Angiography following scorpion sting

35 Radionuclide Angiography on recovery from envenomation

36 Isotopic Thallium Imaging Margulis, Sofer, Zalstein, Zucker, Ilia and Gueron: Toxicon 1994

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41 CNS dysfunction Hypoxia, Hypercarbia, Acidosis Depressed respiratory center, Neurogenic P.E Respiratory failure Hypertensive encephalopathy Low pressure P.E Bradypnea Airway obstruction Hypertension Scorpion venom (catecholamines, inflammatory cascade) P.E Hypoxia Acidosis Pulmonary hypertension R.V failure Cardiogenic shock

42 PAOP, mm Hg 23 (4) 15 (6) CI, l/min/m (0.6) 3.6 (0.7) Elatrous et al. Chest 1999

43 Elatrous et al. Chest 1999

44 Elatrous et al. Chest 1999

45 Early bedside echo in children with scorpion envenomation children 19 children: Abnormal echo upon arrival 16 treated with Inotropic support (dobutamine) 9 required mechanical ventilation None of the patients with normal echo had subsequent heart failure None of the children younger than 2 years had heart failure Sofer et al, Toxicon 2012

46 E.C.G, Troponin and NTproBNP in relation to Echo results S-T changes on arrival E.C.G Arrival elevated Troponin Abnormal Echo n=19 7 (37%) 6 (31%) Elevated Troponin on 24 h measurement 16 (84%) Arrival elevated NTproBNP 13/18 (72%) Elevated NTproBNP on 24 h measurement 16/16 (100%)

47 Mechanical Ventilation Normal Echo n=74 Abnormal Echo n=19 P Value Number children 5 (7%) 9 (47%) < Age, distribution (y) < Age, mean (years) < Duration (hours) (Mean ± SD) 8.2 ±3.8 44±10.4 < 0.001

48 Management and Therapy First aid measures (I.V line, cryotheraphy, local lidocaine. No ligations!) Infants and children should be given analgesics and sedatives first Symptomatic patients should be admitted to the PICU Patients with respiratory failure, cardiogenic shock and tachyarrhythmias should be treated conventionally

49 Theraphy Fluid balance Hydralazine Nifedipine Diuretics? Atropine? Adrenergic blockers? Nitric oxide? Serotherapy?

50 Antivenom Therapy Sofer et al. Scorpion-envenomation and antivenom therapy. J. Pediatrics. 124: ; Abroug et al. Serotherapy in scorpion envenomation: a randomize control trial. Lancet 354:906-9; 1999 Boyer et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. New England Journal of Medicine 360:290-8; 2009 Sofer et al. Antivenom for children with neurotoxicity from scorpion stings. New England Journal of Medicine (letter) 361: ; 2009 Abroug et al. Meta-analysis of controlled studies on immunotherapy in severe scorpion envenomation. Emergency Medical Journal 28: ; 2011

51 Summary and conclusions Scorpion sting is a common medical hazard worldwide causing morbidity and mortality Children are especially at risk and should be rushed to the hospital Babies and infants may suffer from hypopnea or apneic episodes required immediate mechanical ventilation

52 Summary and conclusions Older children may suffer from heart failure and cardiogenic shock required inotropic support and mechanical ventilation Early bedside echocardiography is of utmost important. It has 100% sensitivity and specificity detecting cardiac dysfunction Troponin level in early stage has poor correlation with echo results and it s not helpful

53 Summary and conclusions The outcome of envenomated children arriving short after the sting to a medical center comprising modern ED and PICU facilities, are excellent

54 Thank You!

55 Tarasiuk, Khvatskin, Sofer. Toxicon 1998

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58 MRI

59 Respiratory Failure Following Scorpion Envenomation Hypopnea and apneic episodes due to direct effect of the venom on the CNS Allergic (and non allergic?) subglottic edema and bronchospasm Cardiogenic pulmonary edema ARDS muscle rigidity

60 Myocardial injury observed in 13/27 (48%) patients 1. Elevated CPK 2. Elevated MB CK 3. MB CK/CPK > 6%

61 Myocardial injury without heart failure following envenomation by the scorpion Leiurus Quinquestriatus in children Shaul Sofer, Eliezer Shahak, Ariela Slonim and Mosche Gueron Toxicon 1991

62 Signs and Symptoms on Arrival C.N.S. (Lethargy, agitation, stupor) Excessive sweating and salivation Vomiting Brady or tachycardia Hypertension Hyper-or Hypothermia