Hypertension with tachycardia
Seventeen patients (12 M, 5 F), aged 3–72 (average 16) years, reported 1.5–5.5/hr (average 3) after the sting. Their blood pressures were between 130/104 and 140/110 mm Hg, and heart rates between 116 and 180 (average 124) beats per min. Eight victims had grade 2/6 systolic murmur, suggesting papillary muscle dysfunctions, loud diastolic gallops and ice–cold extremities, and they looked pale.

Pulmonary edema
Fourteen patients (6 M, 8 F) who reported 4–17hr (average 11.5) after the sting were orthopnoeic and cyanosed, and had a frost–bitten appearance to their extremities, they were ice–cold and had fast thready low volume pulses. Eight were hypertensive (average BP 140/90 mm Hg). Five hypertensive and two hypotensive patients had tracheal death rattle sounds and were expectorating brick red blood with froth.

Hypotension
The blood pressure of three patients (60 F, 35 F, 65 M) who reported 1, 4 and 6 hr after the sting were 90/80, 98/90 and 40 mm Hg. In the 35 year old female the blood pressure rose to 130/110 at 1 hr after oral prazosin administration. Heart rates on admission were 68,100 and 108 beats per min.

Tachycardia
Eight patients (6 M, 2 F) who reported 4–16 hr (average 10) after the sting had supraventricular tachycardia, their heart rates were 110–160 (average 128) beats per min, and they appeared hypovolaemic and had ice–cold extremities.

Fatal
A three and a half year old female child was brought in unconscious and moribund 12 hr after being stung. On examination she had marked tachycardia, no peripheral pulse was palpable, and her pupils were pinpoints and did not react to light. She was gasping, cyanosed and had bilateral moist rales all over the chest. Despite oxygen inhalation, intravenous insulin, glucose, aminophylline and sodium bicarbonate, she died after a cardiac arrest.

Management
A combination of 5 mg nifedipine plus prazosin (250 ug in children and 500 ug in adults) with prazosin repeated 6 hourly was given to 18 patients presenting with hypertension with bradycardia. The remaining patients were given prazosin alone. The pulmonary edema group were propped up, and were given I.V. aminophylline and oxygen, in addition to prazosin. Eight hospitalized victims with hypertension and tachycardia developed acute pulmonary edema with marked supraventricular tachycardia, although their blood pressure was controlled with a single dose of prazosin for recovery. They took 18 to 28 hr (average 22) for clinical improvement. The remaining ten from this group recovered within 12 hr with oral prazosin alone. Five victims had massive life threatening pulmonary edema, but they recovered with I.V. sodium nitroprusside drip. Patients in the hypotension with pulmonary edema group recovered with prazosin alone. Patients in the hypotension and tachycardia group recovered with oral prazosin and oral rehydration solution. One female suffering from hypotension subsequently had hypertension that necessitated sublingual nifedipine administration to reduce raised blood pressure. She had no signs of impending myocardial failure. A prolonged QTC interval associated with bradycardia and hypotension appeared 48–96 hr after envenoming, persisted for 3–4 days with normal vital function, and regressed without any active intervention.

S. Bawaskar & P. H. Bawaskar
Bawaskar Hospital and Research Center,
Prabhat Colony, Savitri Marg, Mahad,
Raigad 402 301, Maharashtra, India.