Outcome of scorpion sting envenomation after a protocol guided therapy

Abstract

Scorpion sting (SS) envenomation is a life threatening emergency in children, though not so severe in adults. Attempt to develop protocol using prazosin and dobutamine and few other drugs to treat SS.
Children aged 0-13 years with a history of scorpion sting were studied. Clinical features, complications, drug therapy and outcome of the cases for the period 1992-97(N = 186) was collected by the authors and also from the medical records department (RETROSPECTIVE GROUP). Cases treated during 1997-2000 (N = 198) as per the protocol were recorded as PROSPECTIVE GROUP. All the cases were observed for at least for 24 hours. Cases coming within 4 hours of a sting were given a dose of Prazosin (30 mic.gm/Kg/dose) and were observed. Those who came after 4 hours & were asymptomatic received only symptomatic treatment. Cases with signs of envenomation received Prazosin every 6 hourly till recovery. Cases having acute pulmonary edema (APE) were treated with dobutamine and sodium nitroprusside drip. Complicated cases were monitored in PICU as per the protocol.
Complications associated with excessive parasympathetic and sympathetic stimulation were observed. Myocarditis was observed due to the toxin and excessive catecholamine, which complicated in left ventricular failure (LVF) and APE. Nearly half of the children with acute myocarditis developed APE. Death was mainly due to myocarditis and APE, with or without encephalopathy. Mortality was high in children who received steroid and antihistaminics outside and who came late (> 4 hours).
Complication rate remained almost same in both the groups. There was a significant reduction in overall mortality (P = < 0.0155) and in deaths associated with APE (P = < 0.0001) after the protocol guided therapy. There was also a reduction in mortality in encephalopathy group though not statistically significant. This treatment protocol and aggressive management of APE reduced the mortality due to SS significantly.

Full text

31
Original Article
Outcome of Scorpion Sting Envenomation After A
Protocol Guided Therapy
Niranjan Biswal, Rani A. Bashir, Uday C. Murmu, Betsy Mathai, J. Balachander
1
and
S. Srinivasan
Department of Pediatrics and Cardiology, JIPMER, Pondicherry.
ABSTRACT
Objective. Scorpion sting (SS) envenomation is a life threatening emergency in children, though not so severe in adults.
Attempt to develop protocol using prazosin and dobutamine and few other drugs to treat SS.
Methods. Children aged 0-13 years with a history of scorpion sting were studied. Clinical features, complications, drug therapy
and outcome of the cases for the period 1992-97(N=186) was collected by the authors and also from the medical records
department (RETROSPECTIVE GROUP). Cases treated during 1997-2000 (N=198) as per the protocol were recorded as
PROSPECTIVE GROUP. All the cases were observed for at least for 24 hours. Cases coming within 4 hours of a sting were
given a dose of Prazosin (30 mic.gm/Kg/dose) and were observed. Those who came after 4 hours & were asymptomatic
received only symptomatic treatment. Cases with signs of envenomation received Prazosin every 6 hourly till recovery. Cases
having acute pulmonary edema (APE) were treated with dobutamine and sodium nitroprusside drip. Complicated cases were
monitored in PICU as per the protocol.
Result. Complications associated with excessive parasympathetic and sympathetic stimulation were observed. Myocarditis was
observed due to the toxin and excessive catecholamine, which complicated in left ventricular failure (LVF) and APE. Nearly
half of the children with acute myocarditis developed APE. Death was mainly due to myocarditis and APE, with or without
encephalopathy. Mortality was high in children who received steroid and antihistaminics outside and who came late (>4 hours).
Conclusion. Complication rate remained almost same in both the groups . There was a significant reduction in overall mortality
(P=<0.0155) and in deaths associated with APE (P=<0.0001) after the protocol guided therapy. There was also a reduction
in mortality in encephalopathy group though not statistically significant. This treatment protocol and aggressive management
of APE reduced the mortality due to SS significantly. [Indian J Pediatr 2006; 73 (7) : 577-582]
E-mail : nbiswal@jipmer.edu.
Key words : Scorpion sting; Myocarditis; Acute pulmonary edema (APE); Prazosin; Dobutamine; Sodium nitro prusside (SNP)
Scorpion sting (SS) in children is a life threatening
emergency. Most of the children with severe
envenomation die due to the toxin, whereas it is a
relatively less serious condition in adults. After a sting the
venom enters the circulation very rapidly, with a tissue
distribution half life of 5-6 minutes and peak tissue
concentration is reached in 37 minutes. The excretion
half-life of scorpion toxin is approximately 30 minutes.
1
It
induces complications in almost all the organ systems.
Most of the cases receive various drugs before coming to
a referral centre and many of them in a critical condition.
Different regimens had been tried in the past like
steroid. Adrenaline, cocktail of drugs containing
Correspondence and Reprint requests : Dr. Niranjan Biswal,
Department of Pediatrics, Jipmer, Pondicherry. Pin-605006.
Fax : 0413-2272067
Morphine, Pethidine, phenergan(Promethazine), Avil
(Pheniramine maleate), Largactil., Lasix (frusemide) and
insulin with glucose, large boluses of fluid therapy and
many other drugs, Most of the deaths due to scorpion
sting are attributed to cardiopulmonary complications
like myocarditis and acute pulmonary edema (APE).
2,3,4
Though the antivenin is available, it is species
specific and works only when it is given immediately
after the sting
5,6
Its efficacy is doubtful in the present
situation when cases come late and long after the toxin
’
s
peak tissue concentration time. In the absence of a
consensus on management and non availability of
antivenin as a routine drug in the hospitals, it is necessary
to evolve an alternate strategy to treat this condition.
Prazosin, a post synaptic alpha-1 blocker has the
pharmacological properties that counteracts the effects of
excessive catecholamine and helps in reducing
pulmonary congestion. It had been found to be an
Indian Journal of Pediatrics, Volume 73—July, 2006 577

32
Niranjan Biswal
et al
effective drug for SS in some studies involving adults.
7,8
The present study attempts to develop a protocol using
prazosin and dobutamine and few other drugs to treat SS
envenomation in children.
MATERIALS AND METHODS
This study was conducted at a tertiary care hospital
(JIPMER, PONDICHERRY) during Sep, 1997 to Dec, 2000.
All the cases (0-13 years) presenting to pediatric services
with a history of scorpion sting were either observed or
admitted to the pediatric intensive care unit (PICU). They
were classified into different groups (I-VII)depending on
the complications and symptoms.
Group I PCF
GROUP II PCF + APE
GROUP III PCF + MYOCARDITIS
GROUP IV PCF + APE + MYOCARDITIS
GROUP V PCF + APE+MYOCARDITIS +
ENCEPHALOPATHY
GROUP VI ENCEPHALOPATHY
GROUP VII NO COMPL ICATIONS
Myocarditis was diagnosed on the basis of clinical
features i.e tachycardia, arrhythmia, gallop rhythm,
systolic murmurs, ECG changes, elevated LDH (lactate
dehydrogenase) and echocardiography. APE pulmonary
was diagnosed on the basis of suggestive clinical features
like tachypnoea, pinkish, frothy sputum impaired
percussion note over lung fields, crepitations and
radiological findings, complemented with decreased
oxygen saturation with increased AaDo2. All of them
Protocol For Management Of Scorpion Sting
received a dose of prazosin (30 microgram per Kg body
weight) in supine position with monitoring of blood
pressure (BP), heart rate (HR), respiration rate (RR) and
hydration status. Cases showing signs of neurological,
cardiovascular (CVS), or pulmonary complications were
transferred to PICU .for monitoring and further
management. Subsequent management was based on the
development of complications and assignment to a
particular group in protocol. Children with persistent
irritability or altered sensorium, convulsions, neurologic
deficit were classified as cases of encephalopathy. In the
PICU children were monitored for oxygen saturation, HR,
RR, BP and urine output
Cases with a history of SS who came within 4 hr, were
given paracetamol for pain and a dose of Prazosin (30
microgram per Kg) tablet and were given 6 hourly till all
the symptoms subsided. Asymptomatic cases that came
after 4 hrs of SS, were kept under observation without
prazosin.
All the symptomatic cases were given Prazosin and
supportive care. Central venous pressure (CVP) was
monitored in addition to routine monitoring in ICU in
children who required sodium nitroprusside drip (SNP).
Children with APE were put on SNP drip and
dobutamine along with supportive measures and
ventilated when required. They were tapered off the SNP
drip after they got stabilized hemodynamically and were
given prazosin in intermediate care room. Dobutamine
was tapered and stopped after withdrawing prazosin.
This protocol was passed by the institute research
committee. Informed consent was taken from the parents
before starting the treatment as per the protocol.
(Prospective group) All the cases were observed for a
minimum period of 24 hrs. Cases with complications
were discharged after they were off the drugs for 12 hrs
(Prazosin and dobutamine) and were stable for 24 hrs.
Data regarding the cases for the previous years June,
Clinical Features Treatment
H/O scorpion sting *Paracetamol 15 mg/Kg &
Local pain ± wwelling *< 4 Hrs = Prazosin 30 mic gm/Kg
No systemic signs *>/=4hrs = No prazosin
*Observation for 24 hrs
Sweating, vomiting, cold extremity, *Prazosin. 6 hrly and maintenance
BP Normal or High (PCF) *I.V. Fluids, +/- oral rehydration solution
PCF + APE + Myocarditis **SNP drip 0.3-8 mic. gm/Kg/min
Low BP, Apical murmur, Gallop rhythm, Hemoptysis +/- CCF *Stop prazosin & restart- 30 min before stopping SNP
*Dobutamine 5-15 mic gm/Kg/min
*Dopamine 3-5 mic gm/Kg/min
*Lasix 1 mg/Kg slowly & after stabilisation of B.P.
*Ranitidine
*2/3
rd
of Maintenance - I.V. Fluids & I.C.U. care
Encephalopathy *I.V fluids (normal maintenance)
*Prazosin 6 hrly
*Gadenal and diazepam for seizures
*Ranitidine
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33
Outcome of Scorpion Sting Envenomation After a Protocol Guided Therapy
1992-Aug, 1997 was collected by the authors at the time of
discharge and in few cases from the medical record
division of the hospital (Retrospective group). Analysis
was done in relation to complications, time interval
between the sting and the admission, body weight and
mortality. Fisher's exact test was used to compare the
outcome between the prospective and the retrospective
group. P value of < 0.05 was taken as statistically
significant.
RESULTS
384 children with scorpion sting (SS) were studied over a
period of 9 years. (1992-2000) in this hospital. 186 children
in retrospective group (1992-1997) were treated with a
cocktail of drugs like pethidine, largactil, promethazine
(Lytic cocktail), Avil. (pheniramine maleate) morphine,
decadron (dexamethasone). Lasix (frusemide) and
digoxin was given for myocarditis and APE. Multiple
boluses of normal saline or Ringer’s lactate were
administered for PCF. 198 children with SS were admitted
during 1997-2000. Out of them 56.4% were males and
43.6% females. Most of the cases (85%) were within 1-10
years. More number of boys had scorpion sting in 1–5 yrs
of age group, though an overall both the sexes were
equally affected. 17% of them had no symptoms or
complications. The youngest child who survived was a 37
days old infant with APE. Children who came late were
having features of excessive sympathetic activity
(tachycardia, intense vasoconstriction and carditis). Few
children presenting immediately after the sting (within 20
minutes) had features of parasympathetic hyperactivity
(i.e. sweating, salivation, bronchospasm and vomiting)–
(CHOLINERGIC ACTIVITY). But, none of these children
had bradycardia. All of them responded to therapy
satisfactorily within 30 minutes. 80 of the cases presented
with pain at the site of the sting. 2 children who had no
pain at admission developed pain after 8 hours with had
myocarditis with APE.
Tachycardia in the study cases lasted for 3 to 96 hrs,
whereas bradycardia improved withinin 6 hrs. Nearly
70% of cases had sinus tachycardia. Ventricular ectopics
with tachycardia was noted in some of the fatal cases.
Only 2 out of 6 having sinus bradycardia had APE.
Priapism was noted in nearly 50% of boys, nearly three
fourth had tachycardia and one fourth had hypertension.
Priapism subsided within 8 hrs in all the children except
in two, where it lasted for 24 hrs.
All the children (n=10) weighing 5 Kg or less had
complications; but without any mortality. Its incidence
reduced to 79-86% (n=178) in 6-25 Kg group and only 50%
(n=10) in more than 25 Kg group. 3 cases died in 21-25 Kg
group and 2 cases each in 11-15Kg and 6-10 Kg group. A
37-days-old child was the youngest victim in this study
who survived APE.
Most of the children had come with cold extremities,
sweating and vomiting.12.6% of the children had
hypertension (>95
th
percentile for age) and only 3% had
hypotension (<5
th
percentile) (Table 1). Nearly half of the
cases had neither local pain, sting marks, edema nor
echymosis as evidence of SS. 2 children developed local
pain at sting site, myocarditis and APE after 8 hours of
admission. Their clinical features and associated
complications are outlined (Table 1).
TABLE 1. Clinical Features of the Cases (1992-2000)
Signs /Symptoms 1997-2000
N=198 (%)
Local pain 97 (48.9)
Local reaction 10 (5)
Vomiting 95 (48)
Sweating 117 (59)
Salivation 60 (30.3)
Cold periphery 150 (75.75)
Abdominal pain 7 (3.5)
Altered behavior 55 (27.7)
Tonic posturing 6 (3)
Seizures 6 (3)
PCF 144 (72.7)
Priapism 51 (25.75)
Dilated pupil 6 (3)
Constricted pupil 24 (12)
Tachycardia 131 (67)
Bradycardia 7 (3.5)
Hypertension 25 (12.6)
Hypotension 6 (3)
Tachypnoea 53 (26.7)
Crepitations 32 (60)
S3 60 (30)
APE 59 (30)
Apical murmur(MR) 5 (2.5)
Myocarditis 86 (43)
All the cases with hypertension responded within 4
hours but hypotension took longer and variable period for
recovery 6-44 hrs. Children developed myocarditis and
hypotension under observation even after 12-16 hrs of the
sting and took upto 18 hrs for recovery. Myocarditis was
detected in 20% of cases clinically but could be diagnosed
in 43% of cases after other investigations. 69% of the cases
with PCF showed resolution in 8 hours with warm
periphery. Only one child with myocarditis and PCF took
36 hr for recovery. 78% of cases with priapism recovered
in 8 hours but it lasted upto 24 hr in 2 cases. 16 cases were
seen with APE without clinical or ECG evidence of
myocarditis and 8 of them had echocardiographic
evidence of myocarditis. All but 3 cases with tachypnoea
had APE.
Fresh crepitations appeared in the lungs even after 36
hrs of admission. S3 gallop rhythm appeared even after 41
hrs of admission and lasted for upto 72 hrs. Systolic
murmur at the apex disappeared in 4 hrs in all the cases.
Only in one child with APE with myocarditis the systolic
murmur appeared after 12 hrs of admission and lasted for
24 hrs. Rare features observed were generalized body
weakness with hypotonia, hyperthermia, shivering, extra
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34
Niranjan Biswal
et al
pyramidal symptoms, giddiness, dysarthria and coma.
All the children with encephalopathy presented with
signs and symptoms of encephalopathy at the time of
admission 54.5% of the cases without any complications
had come to the hospital within 1 hr of the sting and only
2 cases had APE within 1-4 hr of the sting. More than 80%
of cases with APE, Myocarditis and Encephalopathy
presented to us after 4 hrs of the sting. All the fatal cases
were seen after 4 hr of the sting (Table 2)
67% of cases did not receive any treatment from
outside and 76.69% of them had complications. Out of 164
complicated cases, 44 had received avil (pheniramine
maleate), decadron (dexamethasone) and 53% of them
developed myocarditis with APE, and 2 cases developed
encephalopathy. These two drugs given along with
prazosin also had higher incidence of complications.
Children admitted within 1 hr of sting had much less
complications than of those who came later. Children
admitted after 4 hrs of scorpion sting had significantly
higher incidence of complications and mortality than of
those who came earlier, (P= 0.0011, 95% C.I=0.5858-
0.6998). Out of the 4 cases with multiple stings, only one
had developed APE. 9 cases had late onset APE even after
1- 24 hrs of admission.
Incidence of complications remained almost same in
both the groups except a slight increase in incidence of
APE cases in the prospective group. The mortality rate
reduced significantly in the prospective group (Table 3).
There were 20 deaths recorded in the retrospective group
out of 186 admissions, whereas only 7 deaths occurred
after the protocol guided therapy. (P=<0.0155, 95%
CI=1.196-1.956). Two children died immediately coming
to the casualty during 1997–2000 before receiving the
management as per the protocol. Therefore, these were
not considered as deaths in the prospective group for
analysis. One of them had come with persistent seizures
in coma and had a cardiac arrest and died immediately.
The other child had severe APE at presentation with pink
frothy sputum and circulatory collapse and had a cardiac
arrest on arrival at the casualty. He could not be
resuscitated.
There was a significant reduction in mortality
associated with APE in the prospective group. 16 out of 20
cases with APE died during 1992-96, whereas 5 out of 59
cases with APE expired after receiving the management
according to the protocol.(P=<0.0001,95% C.I=1.923-4.710)
(Table 3).
TABLE 3. Comparasion of Outcome of Cases in Both the Groups
1992-Aug, 1997 Sept, 1997-2000
N=186 Total cases (n=384) N=198
N=167 (89.8%) Complications N=164 (82.8%)
N=28 (14.14%) Myocarditis N=86 (43.4%)
N=20 (10.7%) Death N=7 (4%)
N=20 (10.7%)16* Ape N=59 (29.8%) 5*
N=6 (3.2%) 4* Encephalopathy N=8 (3.5%) 2*
• *Indicates Death.
• Ape (P=<0.0001)
• Mortality (P=<0.0155)
4 out of 6 cases with encephalopathy expired in the
retrospective group, where as only 2 out of 8 cases with
encephalopathy died in the prospective group. There was
clinically a perceptible reduction in mortality in this
group, though it was not statistically significant (P=0.628).
Children who received steroid and antihistaminics had
a significantly higher mortality than the cases who did
not receive any treatment (P= 0.0012, 95% C.I=0.1924-
0.3212). Even those who received prazosin along with
steroid and antihistaminics had a significantly higher
mortality.(P=0.0135,95% C.I =0.0675-0.1756) than those
who did not receive any drugs before admission (Table 2).
132 cases were treated with prazosin alone and there
was no death. All the 20 cases treated with prazosin
survived. 5 of the 59 cases treated with SNP, prazosin and
dobutamine had expired. Interestingly analysis of these
cases {(1). prazosin alone, (2.) prazosin + dobutamine and
(3). SNP + prazosin+dobutamine)}, revealed that the first
group had significantly lower mortality than the third
group. (P=0.003).
Only one child developed hypotension after the first
dose of prazosin and was resuscitated with normal saline
and had no other complication afterwards. He had come
in less than 4 hr after the sting and was not given any
further dose of prazosin. No serious side effect was
TABLE 2. Outcome in Relation to Time Interval & Treatment Outside. (1997-2000)
I II III IV V VI VII TOTAL
Interval Between Sting <1HR 17 1 5 3 1 1 14 42
and Admission 1-4HR 30 3 24 9 1 0 13 80
>4HR 20 4** 9 29*** 6* 1* 7 76
Treatment Received (a) Avil & Steroids 12 2** 5 19*** 2 1 3 44
Outside (b) Prazosin 0 0 1 3 1 0 0 5
(c) Both 6 0 2 3 4* 1* 0 16
(d) None 49 6 30 16 1 0 31 133
• * indicates death
• 4 hours or less vs >4 hours (p=0.0011)
• (c) vs (d) ---- (P=0.0135)
• (a) vs ( d) — (p=0.0012)
Indian Journal of Pediatrics, Volume 73—July, 2006 580

35
Outcome of Scorpion Sting Envenomation After a Protocol Guided Therapy
documented in any of the cases who received SNP.
On follow-up of 60 cases for a period of 6 months to 2
yr, 2 children (aged 2 yr and 4 yr) had myocardial
dyskinesia and dilatation of cardiac chambers and
reduction of ejection fraction even after 1 year of SS. A 6
year old child continued to have mitral regurgitation
without myocardial involvement or stenosis of mitral
valve even after 24 months of followup and had no
definite history suggestive of rheumatic fever or previous
viral myocarditis. Many of the cases did not come for
follow-up despite repeated postal reminders.
DISCUSSION
Reduction in intensity of local pain at the site of the sting
on development of PCF and reappearance of pain when
the periphery became warm indicates restoration of
circulation after a phase of intense vasoconstriction,
excessive catecholamine activity. Autonomic storm after
scorpion sting had been reported by others also.
8, 9,10
Life
threatening complications (APE, Myocarditis,
Encephalopathy) were common in <5 Kg group similar to
another study.
10
However, the mortality rate was more in
> 25 Kg group contrary to another study.
8
PCF cases with cold extremities were seen in 73% of
cases, similar to 86.3% reported in literature.
8
This is
probably the early stage of compensated shock due to
excessive catecholamine resulting in peripheral
vasoconstriction, but with out significant myocardial
dysfunction. Though profuse sweating was observed only
in 59% of our cases (including some fatal cases also), it
was found in 97 % of cases and was conspicuously absent
in fatal cases in another study.
2
Nearly half of the cases with myocarditis had APE &
many had S3 gallop and apical murmur of mitral
regurgitation similar to tachyarrhythmia myocarditis in 3-
75% of cases and apical murmur in 43.9% of cases in other
studies.
2, 11, 12, 13
Late onset APE could have been due to acute
myocardial injury and LVF caused by the toxin and the
toxin induced autonomic storm. This had been reported in
17%–34.8% cases from Saudi Arabia (SA) and India.
12,8
3
of the present cases had neither acidosis nor other
identifiable cause for tachypnoea similar to 3% of cases
reported from Saudi Arabia and could be due to toxin
induced central hyperventilation.
12
Generalized seizures and tonic posturing was seen in
3% of cases in comparison to 2-13% from India, Israel and
SA. Irritability, excessive sleepiness, excessive crying to
minimal stimulation (i.e. calling by name or gentle caress
by the mother) was found in 28% of present cases whereas
it had been reported in 42% of cases with a very high
incidence of encephalopathy (21.3%) from SA.
12
Time lapsed between the sting and the admission is
probably a key factor for better outcome. Children
admitted within 4 hr of the sting had much less
complications than those came later (P=0.0011).Most of
the cases with APE, encephalopathy and myocarditis
came to us after 4 hr of the sting and had higher mortality
and morbidity. However some studies from India and
Saudi Arabia had observed that most of the fatal cases got
admitted after 30 minutes to 3 hr of sting
2, 8, 12
we believe
that early hospitalization and Prazosin therapy might
have prevented complications and mortality. Usefulness
of Prazosin in preventing cardiopulmonary complications
had been described in adults.
8
Most of the cases who received multiple drugs outside
before coming to the emergency had complications.
Children who received decadron (dexamethasone) and
anti-histaminic (avil) in spite of receiving prazosin had
higher mortality and complications in comparison to
those who did not receive any drug (P=0.0135).There was
also significant statistical difference between the groups
receiving antihistamines and dexamethasone to no
treatment group (p=0.00012) and 4 out of 5 deaths
occurred in this group. Antihistaminics and
dexamethasone alone or in combination are known to
potentiate the effect of catecholamine in CVS and CNS
and worsen encephalopathy.
10
Those who received
multiple drugs also wasted valuable time and came late
with complications in different systems.
Significant reduction in mortality (P=<0.001) was the
key observation in the present study, similar to few
reports from adult studies.
10, 14
Mortality was far less
(p=0.003) in cases treated with prazosin alone in
comparison to others who received either dobutamine,
dopamine or SNP along with prazosin. This could be due
to the protective effect of prazosin on cardiovascular and
respiratory system. This effect was probably not so much
after the onset complications. Though SS had been
suggested to be a contributing factor for cardiomyopathy
in later life, in the present study only 2 cases had
persistent cardiac dysfunction and only one had mitral
regurgitation following the SS.
15
It is difficult to draw any
conclusion from this.
Reduction in mortality associated with encephalopathy
68% to 26% could be due to the usefulness of Prazosin in
neutralizing the adverse effect of catecholamine released
in the brain, as the catecholamine released outside the
brain doesn’t cross the blood brain barrier. Cerebral
infarctions in different areas had been reported on C.T
scan after the scorpion sting.
16
CONCLUSION
In a year 30-50 children with SS are admitted in this
hospital and most of them come with systemic
complications. Delayed hospitalization was associated
with severe life threatening complications. Treatment
with steroid, antihistaminic and sympathomimetic drugs
before admission was associated with poor outcome.
Presence of PCF alone without cardiopulmonary
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36
Niranjan Biswal
et al
compromise carried excellent prognosis with 100%
recovery with treatment. Excellent result was achieved in
cases with APE following the above protocol in children.
Encephalopathy with or without other complications
resulted in higher mortality.
Early medical attention, avoiding conventionally used
harmful drugs like steroid antihistaminic and other
cocktails of sedatives may reduce the complications and
mortality. Many children did not come for follow-up
despite repeated postal reminders and might have been
asymptomatic after discharge. A long term prospective
study may answer the issue of long term complications
following a sting.
Acknowledgement
We are thankful to Dr. H.S. Bawasker, M.D. Physician and Dr M.S.
Ranjit, M.D. Ped. Cardiologist for their suggestions and guidance
during designing of the protocol.
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P, Raju B. Cardiovascular manifestations of scorpion sting in
children. Indian Pediatr 1977; 15 : 353-356.
14. Bawasker HS and Bawasker PH. Severe envenoming by Indian
Red Scorpion (B tamulus). The use of Prazosin therapy. Q J
Med 1996; 89 : 701-704.
15. Sunder Raman T, Olithiselvan M, Sethuraman KR, Narayan
KA. Scorpion envenomation as a risk factor for development
of cardiomyopathy. J Assoc Phys India 1999; 47(11) : 1047-1057.
16. Thaker AK, Lal R, Mishra M. Scorpion bite with multiple
cerebral infarcts. Neurol India 2002; 50 : 100-102.
Indian Journal of Pediatrics, Volume 73—July, 2006 582

37
Notes and News
DOWN SYNDROME – MEDICAL BENEFIT – DONATION
Voluntary contributions and donations are welcome from individuals, philanthropists and organizations,
towards the Down Syndrome Medical Benefit Scheme at the St. John's Medical College, Bangalore. The
cheque or DD may be drawn in favour of “St. John's Medical College”. In the accompanying letter, it may
be mentioned that it is for the purpose of medical benefit to the individuals affected with Down syndrome.
In the instance of availing the IT benefit – 80G, cheque or DD may be drawn in favour of “CBCI Society for
Medical Education”.
The criteria for availing the financial assistance is as follows:
Individuals with Down syndrome admitted in St. John's Medical College Hospital, Bangalore for any major
medical and or surgical intervention whose family is in dire need might apply through Chief of Medical
Services to Associate Director, St. John's Medical College, Bangalore – 34.
Address for correspondence : Dr. Mrs. Sayee Rajangam, Professor & Head, Division of Human Genetics,
Department of Anatomy St. John's Medical College, Sarjapur Road, Bangalore – 560 034. Ph.: 080/22065041,
Fax : 080/2550777, E-mail : sjmcdhg@yahoo.co.in.
RAJ NEOCON – 2006
2-3, September - 2006
Theme – Comprehensive Newborn Care : Today's Investment, Tomorrow's saving. Venue : Global
Hospital, Mount Abu (Distt. Sirohi) Rajasthan, Registration fee : Rs. 700/- for single, Rs. 1000/- for family
up to 15 August 2006. Send only D/D in favour of NNF Rajasthan - Jodhpur, For Details Contact : Dr.
Mukesh Gupta (Organizing Chairman & President); E-22/10, Umaid Hospital Campus, Umaid Hospital,
Jodhpur (Rajasthan). Ph. : 094144-95142, 0291-2430209; E-mail : mukeshg4@yahoo.com
INDO-US EMERGENCY MEDICINE SUMMIT 2006
A Level one International Academic Meeting “Connecting Care Competencies and Culture”27
th
Sept – 1
st
Oct 2006)
Jawaharlal Nehru Auditorium Complex All India Institute of Medical Sciences, New Delhi, India, Visit :
www.indusem2006.com.
Calling for Abstracts : Emergency Medicine Academic Research Competition (EMARC) 2006 (Prizes worth
Rs. 1,00,000) Promoting Emergency Research in India Medical Students, Residents, Nurses, Paramedics and
Faculty (Separate Nursing and Paramedic Competitions)
Supported by : American Association of Physicians of Indian Origin Celebrating APPI Silver Jubilee Year
(2006–2007) and Journal of General Medicine
Hosted by : All India Institute of Medical Sciences, New Delhi, India and University of South Florida,
Tampa, USA.
Correspondence : Dr. Sanjeev Bhoi, Assistant Professor Medicine, Faculty Room, Division of Emergency
Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-110029, Ph.: 91-11-26589029, Fax
: 91-11-26588663. E-mail : indusem2006@hotmail.com; indusem2006@yahoo.co.in
Indian Journal of Pediatrics, Volume 73—July, 2006 583