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TREATMENT
Prehospital Care
Primary assessment of airway, breathing, and circulation takes precedence.
The utility of negative pressure extraction devices has not been evaluated for scorpion stings.
Priapism: +3
Vomiting: +2
SBP >160: +2
Corticosteroid PTA: +2
Temperature >38ºC: +1
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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.
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]
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 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.
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.
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:
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.
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]
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.
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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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.
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.
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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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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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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Author
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
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
Ramy Yakobi, MD, MBA Medical Director, Department of Emergency Medicine, Beth Israel
10 de 12 30/11/2017 14:18
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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
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
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
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
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
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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