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Scorpion Envenomation Treatment &

Management
Updated: Nov 28, 2017
Author: David Cheng, MD; Chief Editor: Joe Alcock, MD, MS more...

TREATMENT

Prehospital Care
Primary assessment of airway, breathing, and circulation takes precedence.

Few studies have evaluated the utility of most first aid.

The utility of negative pressure extraction devices has not been evaluated for scorpion stings.

Perform endotracheal intubation and vascular access as needed.

Emergency Department Care

Supportive care in all cases and antivenom in severe cases are used for the treatment of scorpion
envenomation.

Grades of Centruroides envenomation are as follows:

Grade I - Local pain and/or paresthesias at the site of envenomation

Grade II - Pain and/or paresthesias remote from the site of the sting, in addition to local
findings
Grade III - Either cranial nerve/autonomic dysfunction or somatic skeletal neuromuscular
dysfunction, as follows:
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 IV - Combined cranial nerve/autonomic dysfunction and somatic nerve dysfunction

Androctonus australis Hector Hospitalization Score is as follows (total ≥2 = Hospitalization) [26] :

Priapism: +3
Vomiting: +2
SBP >160: +2
Corticosteroid PTA: +2
Temperature >38ºC: +1

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Heart rate >100 bpm: +1

Although grading and scoring systems have been developed, they are limited due to species
specificity and low-degree symptoms that would lead to hospitalization or therapy.

Medical Care
Because the clinical manifestations and severity of the symptoms vary among patients,
individualize management of scorpion stings. Furthermore, frequent patient monitoring allows
earlier recognition of the life-threatening problems of scorpion envenomation. Treatment generally
consists of moving the patient away from the scorpion and stabilizing the patient's airway and vital
signs, followed by administration of antivenin and institution of symptomatic and local treatment.

Local treatment

Use ice bags to reduce pain and to slow the absorption of venom via vasoconstriction. This is most
effective during the first 2 hours following the sting.

Immobilize the affected part in a functional position below the level of the heart to delay venom
absorption.

Calm the patient to lower the heart rate and blood pressure, thus limiting the spread of the venom.

For medical delay secondary to remoteness, consider applying a lymphatic-venous compression

wrap 1 inch proximal to the sting site to reduce superficial venous and lymphatic flow of the venom
but not to stop the arterial flow. Only remove this wrap when the provider is ready to administer
systemic support. The drawback of this wrap is that it may intensify the local effects of the venom.

Apply a topical or local anesthetic agent to the wound to decrease paresthesia; this tends to be
more effective than opiates and ice application. [27]

Administer local wound care.

Administer tetanus prophylaxis.

Administer systemic antibiotics if signs of secondary infection occur.

Administer muscle relaxants for severe muscle spasms (ie, benzodiazepines.)

Systemic treatment

Systemic treatment is instituted by directing supportive care toward the organ specifically affected
by the venom.

Establish airway, breathing, and circulation (ie, ABCs) to provide adequate airway, ventilation, and
perfusion.

Monitor vital signs (eg, pulse oximetry; heart rate, blood pressure, and respiratory rate monitor).

Use invasive monitoring for patients who are unstable and hemodynamic.

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Administer oxygen.

Administer intravenous fluids to help prevent hypovolemia from vomiting, diarrhea, sweating,
hypersalivation, and insensible water loss from a tropical environment.

Perform intubation and institute mechanical ventilation with end-tidal carbon dioxide monitoring for
patients in respiratory distress.

For hyperdynamic cardiovascular changes, administration of a combination of beta-blockers with

sympathetic alpha-blockers is most effective in reversing this venom-induced effect. Avoid using
beta-blockers alone because this leads to an unopposed alpha-adrenergic effect. Also, nitrates can
be used for hypertension and myocardial ischemia.

For hypodynamic cardiac changes, a titrated monitored fluid infusion with afterload reduction helps
reduce mortality. A diuretic may be used for pulmonary edema in the absence of hypovolemia, but
an afterload reducer, such as prazosin, nifedipine, nitroprusside, hydralazine, or angiotensin-
converting enzyme inhibitors, is better. Inotropic medications, such as digitalis, have little effect,
while dopamine aggravates the myocardial damage through catecholaminelike actions.
Dobutamine may be a better choice for the inotropic effect. [28] Finally, a pressor such as
norepinephrine can be used as a last resort to correct hypotension refractory to fluid therapy.

Administer atropine to counter venom-induced parasympathomimetic effects.

Other treatment

Insulin administration in scorpion envenomation animal experiments has helped the vital organs to
use metabolic substrates more efficiently, thus preventing venom-induced multiorgan failure,
especially cardiopulmonary failure. Unfortunately, no human studies have been conducted.

Administer barbiturates and/or a benzodiazepine continuous infusion for severe excessive motor
activity. In some cases, be aware that meperidine and morphine may potentiate the venom. Also,
the concurrent use of barbiturates and narcotics may add to the respiratory depression in patients
who have been envenomated.

The use of steroids to decrease shock and edema is of unproven benefit.

A vaccine preparation was tried in experimental animals but was not pursued because of the need
to prepare different antigens according to different geographical areas and to different species of
scorpions living in the same area.

Antivenom

Antivenom is the treatment of choice after stabilization and supportive care. Because of the
heterogeneity of venom composition between different scorpion species, one species' antivenom
will have limited effect on another scorpion species' venom. Thus, correct scorpion species
identification is a prerequisite for proper antivenom treatment.

For newer scorpion antivenom, the exact dosing has not been established as animal studies
treatment amount does not translate into human studies treatment amount. In addition, the quantity
to be used is determined by the patient’s clinical severity, symptom evolution, and treatment

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response. Unfortunately, predicting the patient’s response treatment is difficult, which makes exact
antivenom dosing difficult. Furthermore, underdosing will result in limited or no effect, while
overdosing increases the side effects and hypersensitivity reactions. Because the new antivenoms
are highly purified immunoglobulin fragments, adverse reaction is less frequent and tends to be
mild.

The antivenom significantly decreases the level of circulating unbound venom within a few hours.
The persistence of symptoms after the administration of antivenom is due to the inability of the
antivenom to neutralize scorpion toxins already bound to their target receptors. Thus, symptomatic
and supportive treatment is needed with immunotherapy. [28]

General time guidelines for the disappearance of symptoms after antivenom administration are as
follows:

Centruroides antivenom: Severe neurologic symptoms reverse in 15-30 min. Mild-to-

moderate neurologic symptoms reverse in 45-90 min.
Non- Centruroides antivenom: In the first hour, local pain abates. In 6-12 hours, agitation,
sweating, and hyperglycemia abate. In 6-24 hours, cardiorespiratory symptoms abate.

While an anaphylaxis reaction to the antivenom is possible, the patient is at lower risk for this than
with other antivenoms for other poisonous envenomations if there is a scorpion venom—induced
large release of catecholamines. Also, animal-derived antivenom increases the risk of
hypersensitivity reaction compared to human monoclonal-derived antivenom. Finally, the larger the
dose of antivenom, the greater the change for serum sickness.

In a prospective, randomized, double-blind study, Boyer et al compared scorpion-specific F(ab')2

antivenom (Anascorp, Centruroides [scorpion] immune F(ab)2 intravenous [equine], Instituto
Bioclon) (n=8) with placebo (n=7) in children who developed neurotoxic symptoms following
scorpion envenomation. [29] Neuromotor abnormalities were present in all patients at baseline, and
respiratory distress was present in 20%. Beginning 2 hours after treatment, symptom resolution
differed significantly in the antivenom group compared with the placebo group. Plasma venom
concentrations were undetectable and cessation of the neurologic syndrome occurred within 4
hours in 100% of antivenom recipients compared with 1 placebo recipient (p=0.001).

Thus, the Boyer et al study suggests that scorpion-specific F(ab')2 antivenom successfully treated
the clinical syndrome, reducing the need for concomitant sedation and reducing circulating
unbound venom levels for Centruroides envenomation. [29]

For Mesobuthus tamulu envenomations, horse-derived antivenom has been developed. Natu et al
compared the newer antivenom treatment versus the traditional prazosin treatment in their open
label study of 81 envenomated patients and found that antivenom decreased clinical recovery time
to 4.14 hours +/- 1.6 hours compared to prazosin’s clinical recovery time of 19.28 hours +/- 5.03
hours. [30]

Natu et al also found that the antivenom plus prazosin combination group had a recovery time of
3.46 hours +/- 1.1 hours but felt it was comparable to the antivenom group recovery time and
recommended that the combination therapy be reserved for patients presenting with pulmonary
edema with hypertension.

Bawaskar et al compared antivenom plus prazosin versus prazosin in their open label trial of 70

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patients with only grade 2 envenomations (beginning of systemic involvement) and found that
91.4% of the combination treatment group had resolution of their clinical symptoms within the
10-hour mark compared to 22.9% in the prazosin treatment group. [31] Both the Natu and the
Bawaskar studies suggest the utility of the new Mesobuthus tamulus antivenom for systemic
symptoms envenomations.

Kumar et al found that early (<4 h) administration of antivenom with prazosin increases the
percentage of children not developing myocardial dysfunction. [32, 33]

Further inpatient care

Inpatient care is dictated by the severity of the envenomation and consists of stabilizing the patient,
neutralizing the venom, providing supportive therapies, and preventing complications. Patients with
grade III or grade IV Centruroides stings and other severe Buthidae envenomations should be
admitted to the intensive care unit (ICU) and/or treated with antivenom.

Treat all patients with severe systemic symptoms in an intensive care unit (ICU) setting because of
the unpredictability of the symptomology, the risks associated with antivenin administration, and the
need for airway or blood pressure support.

Young children do worse than adults. Young children may not recover as quickly as adults after
scorpion envenomation and are more likely to require observation.

Transfer

Transfer is appropriate if antivenin administration or ICU treatments are not available at the
institution where the patient initially presents.

Consultations
Local poison control centers may assist in management of envenomations.

Contact the American Association of Poison Control Centers (800-222-1222) to be connected to a

local poison control center.

The University of Arizona Poison and Drug Information Center (520-626-6016 from outside Arizona
or 800-362-0101 from Arizona only) has special experience in Centruroides envenomation.

The Antivenom Index, published jointly by the American Association of Poison Control Centers and
the American Zoo and Aquarium Association, lists the locations, amounts, and various types of
antivenom stores.

Activity
Rest and immobilization of the sting site is recommended to prevent rapid absorption of the venom
into the circulation.

Complications

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Complications of scorpion envenomation may include the following:

Cellulitis and abscess formation at sting site [34]

Dilated cardiomyopathy [35, 36]
Ankylosis of small joints if the sting occurs at a joint
Rhabdomyolysis
Persistent paresthesia
Antivenin anaphylaxis and serum sickness [37]
Iatrogenic, high-dose, sedative-hypnotic respiratory arrest
Respiratory arrest
Cardiac arrest
Shock
Seizures
Rhabdomyolysis
Death
Defibrination after M tamulus stings
Hemolysis after H lepturus stings
Pancreatitis after T trinitatis stings
Antivenom-associated reactions
Renal failure

Prevention
Protective clothing, such as shoes or gloves, may prevent some scorpion envenomations. Check
shoes, gloves, clothing, and backpacks for scorpions prior to use.

Keep yards free of debris, which can serve as a place for scorpions to hide.

Make sure windows and doors fit tightly to prevent scorpions from entering the house.

Avoid walking barefoot, especially at night when scorpions are active.

Use a Wood lamp at night because the cuticle of the Centruroides species is fluorescent under
ultraviolet light.

Methods of biological control of scorpions include introducing chickens, ducks, and owls to the
area.

Methods of chemical control of scorpions include using organophosphates, pyrethrins, and

chlorinated hydrocarbons.

Government monitoring of the scorpion public health problem is warranted.

Long-Term Monitoring
Patients displaying local nonascending reactions to the venom may be discharged after 6 hours of
observation, with close follow-up. If the patient was treated with a pressure bandage, the symptoms
may be delayed and inpatient observation is warranted. Patients with grade I or grade II
Centruroides envenomations may be discharged. Discharge of patients with other Buthidae

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envenomations is more problematic because onset of systemic symptoms may be delayed up to 24

hours.

If an antivenin is administered, monitor the patient for serum sickness over next the few weeks.

Inform the patient about the possibility of persistent pain or paresthesia at the sting site.

Instruct patient regarding progression. Discuss symptoms of delayed serum sickness with patients
treated with antivenom.

Medication

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9, 2011. [Full Text].

Media Gallery

Centruroides limbatus, identified by Scott Stockwell, PhD. A small barb at the base of the
stinger may be helpful in identifying Centruroides or Tityus species, although its presence is
variable. Photo by Sean Bush, MD.
Centruroides species. Note the slender pincers generally characteristic of scorpions from the
family Buthidae. Photo by Sean Bush, MD.
Scorpions from the family Buthidae (which includes almost all of the potentially lethal
scorpions) generally can be identified by the triangular sternal plate. In other families of
scorpions, this feature is more square or pentagonal. Photo by Sean Bush, MD.

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Contributor Information and Disclosures

Author

David Cheng, MD Associate Professor of Emergency Medicine, Education Director, Associate

Emergency Medicine Residency Director, Case Medical Center

David Cheng, MD is a member of the following medical societies: American College of Emergency
Physicians, International Society for Mountain Medicine, Council of Emergency Medicine
Residency Directors, American Heart Association, National Association of EMS Physicians, Society
for Academic Emergency Medicine, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Judith A Dattaro, MD, FACEP Assistant Professor of Emergency Medicine in Surgery, Cornell
University Medical College; Consulting Staff, Department of Emergency Medicine, Weill-Cornell
University Medical Center, New York Presbyterian Hospital

Judith A Dattaro, MD, FACEP is a member of the following medical societies: American Association
of Women Emergency Physicians, American College of Emergency Physicians, American Medical
Association, Chicago Medical Society, Illinois State Medical Society, Society for Academic
Emergency Medicine

Disclosure: Nothing to disclose.

Ramy Yakobi, MD, MBA Medical Director, Department of Emergency Medicine, Beth Israel

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Medical Center

Ramy Yakobi, MD, MBA is a member of the following medical societies: American Academy of
Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Sean P Bush, MD, FACEP Professor of Emergency Medicine, The Brody School of Medicine at
East Carolina University

Sean P Bush, MD, FACEP is a member of the following medical societies: American College of
Emergency Physicians, International Society on Toxicology, Society for Academic Emergency
Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Charles J Gerardo, MD, FACEP Associate Professor, Department of Surgery, Division of

Emergency Medicine, Duke University School of Medicine; Vice Chief of Program Development,
Division of Emergency Medicine, Duke University Medical Center

Charles J Gerardo, MD, FACEP is a member of the following medical societies: American College
of Emergency Physicians, Society for Academic Emergency Medicine, Council of Emergency
Medicine Residency Directors, National Hispanic Medical Association

Disclosure: Received research grant from: BTG International Inc.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New
Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of
Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Lisa Kirkland, MD, FACP, FCCM, MSHA Assistant Professor, Department of Internal Medicine,
Division of Hospital Medicine, Mayo Clinic; Vice Chair, Department of Critical Care, ANW
Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, FCCM, MSHA is a member of the following medical societies: American
College of Physicians, Society of Hospital Medicine, Society of Critical Care Medicine

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Disclosure: Nothing to disclose.

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