Scorpion Sting

Ameer Saadallah M.B.Ch.B. (Mosul, 2017)

1st edition 13-11-2018
Medscape
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Summary:

 Poisonous scorpions tend to have thick tails.

 Children present with more severe and protracted symptoms.
 The signs occur within a few minutes after the sting and usually progress to a
maximum severity within 5 hours. The symptoms generally persist for 10-48 hours.

Clinical Manifestations:
Local signs:
 Pain, paresthesia, and swelling.
 Cytotoxic local effects: Papule, plaque, necrosis.
 Lymphangitis (due to the transfer of the venom through the lymphatic vessels)

Neurological manifestations:
 Autonomic disturbances
 Somatic effects
 Cranial nerve palsies
 Respiratory arrest and loss of protective airway reflexes
 Cerebral infarction, cerebral thrombosis, and acute hypertensive encephalopathy
have been described with a variety of Buthidae scorpion envenomations.

Anaphylaxis

Multisystem organ failure

Laboratory Studies
 CBC
 Clotting screen
 RBS
 Electrolytes
 Others as needed

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Management:
 ABC
 Frequent patient monitoring: In some species onset of systemic symptoms may be
delayed up to 24 hours.
 Calm the patient
 Local treatment:
o Use ice bags or, alternatively, hot water immersion.
Immobilize the affected part in a functional position below the level of the
heart.
o For medical delay secondary to remoteness, consider applying a lymphatic-
venous compression wrap 1 inch proximal to the sting. Only remove this
wrap when the provider is ready to administer systemic support.
o Apply a topical or local anesthetic agent.
o Local wound care & post-exposure prophylaxis of tetanus.

 Specific treatment:
o Antivenin is indicated for symptomatic patients only.

 Supportive treatment:
o Analgesia
o If anaphylaxis: treat as required. The use of antihistamines is more effective
in preventing a histamine response than in reversing it.
o Others as needed

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Subject in details:

Introduction:

Out of 1500 scorpion species, 50 are dangerous to humans.

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.

Poisonous scorpions also tend to have weak-

looking pincers, thin bodies, and thick tails, as
opposed to the strong heavy pincers, thick
bodies, and thin tails seen in nonlethal
scorpions.

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Clinical manifestations:
It ranges from minor local tenderness to multisystem failure followed by death, but
envenomation from most scorpions results in a simple, painful, local reaction that
can be treated with analgesics, antihistamines, and symptomatic/supportive care.
Nonlethal scorpion species tend to produce local reactions similar to a
hymenopteran (bees, wasps, ants) sting, while lethal scorpion species tend to
produce systemic symptoms.
Children present with the same symptoms and signs as adults, except their
symptoms are more severe and protracted. Furthermore, they may display a
restlessness that is out of proportion when compared to any other disease. A child's
symptoms have been described as inconsolable crying; uncontrollable jerking of the
extremities; and chaotic thrashing, flailing, and writhing combined with contorted
facial grimaces. The symptoms mimic a centrally mediated seizure, but the patient is
awake and alert the entire time.
The signs occur within a few minutes after the sting and usually progress to a
maximum severity within 5 hours. The symptoms generally persist for 10-48 hours.

Local signs:
 Pain, paresthesia, and swelling.
This paresthesia feels like an electric current, persists for several weeks, and is the
last symptom to resolve before the victim recovers.
 Cytotoxic local effects: Papule, plaque, necrosis.
 Lymphangitis (due to the transfer of the venom through the lymphatic vessels)

Neurological manifestations:
 Autonomic effects include the following:
o Sympathetic symptoms: tachycardia, hypertension, hyperthermia, and
pulmonary edema (due to increased capillary permeability).
o Parasympathetic symptoms: hypotension, bradycardia, bronchospasm,
salivation, lacrimation, urination, defecation, and gastric emptying.

 Somatic effects include the following:

Muscle spasm that can be mistaken for seizures have been described.
Seizures.

 Cranial nerve effects include the following:

Classic roving or rotary eye movements, blurred vision, tongue fasciculations, and
loss of pharyngeal muscle control may be observed.
Difficulty swallowing combined with excessive salivary secretions may lead to
respiratory difficulty.

 Respiratory arrest and loss of protective airway reflexes

 Cerebral infarction, cerebral thrombosis, and acute hypertensive encephalopathy

have been described with a variety of Buthidae scorpion envenomations.

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Anaphylaxis:
Death can occur from toxicity or from anaphylaxis. These are two separate things,
and many “nonlethal” species can cause anaphylaxis.

Nonneurologic systemic signs:

 Myocarditis
 Acute pancreatitis
 Toxic hepatitis
 Acute tubular necrosis
 Rhabdomyolysis
 Priapism (due to cholinergic stimulation)
 DIC
 Hemolysis
 Pregnancy complications: toxin-induced uterine contraction, eclampsia

Laboratory Studies
 CBC (hemolysis)
 Clotting screen (DIC)
 RBS (liver or pancreases dysfunction)
 Electrolytes (electrolytes disturbances due to GIT symptoms secondary to
autonomic effects)
 Cardiac enzymes (myocarditits)
 Creatine kinase & urinalysis (rhabdomyolysis)
 Obtain amylase/lipase (pancreatitis)
 LFT (hepatitis)
 ABG (respiratory failure)

Other Tests:
 Obtain a chest radiograph in cases of respiratory difficulty.
 Echocardiography is more sensitive than electrocardiography and creatine kinase
assays for assessing myocardial compromise. Findings show a diffuse global
biventricular hypokinesis with a decreased left and right ventricular ejection
fraction.
 Electrocardiography, if indicated, should be performed. ECG changes persist for 10-
12 days before normalizing. Note the following:
o Sinus tachycardia - Most common rhythm
o First-degree block - 10.2%
o Bundle-branch block - 12.8%
o Ventricular repolarization abnormalities - 15%
o ST changes - 39%
o T-wave inversion - 39%
o QTc prolongation - 53%
 Perform serial spirometry measurements to help detect impending venom-induced
diaphragmatic failure.

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Emergency Department Care
 Primary assessment of airway, breathing, and circulation takes precedence.
 The utility of negative pressure extraction devices has not been evaluated for
scorpion stings.
 Frequent patient monitoring allows earlier recognition of the life-threatening
problems of scorpion envenomation.

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.
Alternatively, hot water immersion has been described as a first aid treatment for
scorpion bites in Australia and in Taiwan.
 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.
 Administer local wound care.
 Post-exposure prophylaxis of tetanus.

Specific treatment:
Antivenin is indicated for symptomatic patients only.

Supportive treatment:
 Analgesia may be indicated. Caution when using narcotics for a patient with an
unsecured airway because respiratory depressive effects may be synergistic with
some scorpion venoms.
 If anaphylaxis: treat as required. The use of antihistamines is more effective in
preventing a histamine response than in reversing it.
 If hypoxic: oxygen
 If respiratory failure: mechanical ventilation
 If hypodynamic circulation: fluids for hypovolemia. Dopamine aggravates the
myocardial damage through catecholaminelike actions. Dobutamine may be a
better choice for the inotropic effect. Finally, a pressor such as norepinephrine can
be used as a last resort to correct hypotension refractory to fluid therapy.
 If hyperdynamic circulation: administration 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.
Labetalol blocks beta1-adrenergic, alpha-adrenergic, and beta2-adrenergic receptor
sites, decreasing blood pressure.

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 In particular, the use of the alpha-blocking agent prazosin has been used and
recommended.
Also, nitrates can be used for hypertension and myocardial ischemia.
 If parasympathetic activation: Atropine is used mainly to treat symptomatic
bradycardias. Treatment of excess respiratory secretions has been warned against
because of atropine’s potential adverse cardiopulmonary effects.
 If pulmonary edema: 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.
 Severe excessive motor activity: Administer barbiturates and/or a benzodiazepine
continuous infusion.
Be aware that meperidine and morphine may potentiate the venom.
 The use of steroids to decrease shock and edema is of unproven benefit.
Corticosteroids have not been shown useful in treating venom toxicity.
 Administer systemic antibiotics if signs of secondary infection occur. Prophylactic
antibiotic therapy is not required.

Scorpion Antivenin Polyvalent (Equine) Leaflet

Importedby Iraqi MOH (produced by Razi Vaccine & Serum research institute)

It is obtained from equine (horse) hyperimmune serum, and neutralizes the venom
of Andoroctonus crassicauda, Buthotus saulcyi, Buthotus schach, Odontobothus
doriae, Mesobuthus eupeus, & Hemiscorpius leptorus.
 Most victims should recover after receiving 1 or 2 ampoules of the antivenin, but
some may need very large doses.
 The more severe the case (especially if delayed treatment) the greater amount of
the antivenin will be required.
 For an average case, IM route is used using any large muscle mass.
 For rapid action needed in treating severe cases, slow IV infusion is used. The
antivenin is diluted 1:5 or 1:10 in normal saline.
 The patient should be observed for 1 hour after administration of the antivenin.
 Be prepared for anaphylaxis due to the antivenin.
 Reactions to the antivenin are considered less likely if the antivenin was infused
slowly.
 Reactions may be lessened if an antihistamine is given prior to the antivenin.
 Steroids should never be used for the prevention or for treatment, except in the
case of known allergy.

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Anascorp (Centruroides Scorpions anti-venin):
 It is indicated for symptomatic patients only.
 The best result occurs when antivenin is administered as early as possible
(preferably within the first 2 h after the sting).
 Initiate treatment as soon as possible in patients who develop clinically important
signs of scorpion envenomation, including but not limited to loss of muscle control,
roving or abnormal eye movements, slurred speech, respiratory distress, excessive
salivation, frothing at the mouth, and vomiting.
 A total of 22 types of scorpion antivenom are present in American Zoo and
Aquarium Association Antivenom Index.
 One species' antivenom will have limited effect on another scorpion species'
venom. Thus, correct scorpion species identification is a prerequisite for proper
antivenom treatment.
 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.
 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.
 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.
 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.
Note: Centruroides is a genus of scorpions belonging to the family Buthidae.

IV Preparation:
 Initial dose:
Using 3 vials, reconstitute contents of each vial with 5 mL of sterile normal saline and
mix by continuous gentle swirling. Add the contents of the three reconstituted vials
to sterile normal saline to have a total volume of 50 mL.
Initial dose: Infuse contents of 3 vials IV over 10 minutes monitor for up to 60
minutes after completing infusion to determine if symptoms are resolved

 Additional doses (one vial at 30-60 minutes intervals if needed): dilute

reconstituted vial to total volume of 50 mL with sterile normal saline, and give it IV
over 10 minutes.

 Inspect solution visually for particulate matter and discoloration prior to

administration; do not use if turbid

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Warnings
 Severe hypersensitivity reactions, including anaphylaxis, are possible; prepare for
monitoring and management of allergic reactions.
 Delayed allergic reactions (serum sickness, 0.5% incidence) may occur; monitor
with follow-up visit
 Made from equine plasma and may contain infectious agents (eg, viruses)
 Localized reactions and generalized myalgias reported with cresol, as an injectable
excipient contained in Anascorp

Pregnancy & Lactation

 Pregnancy Category: C; No human or animal data exist; use only if clearly needed
 Lactation: Unknown whether distributed in breast milk; caution advised

Storage
 Store at room temperature (up to 25 ºC [77 ºF])
 Temperature excursions are permitted up to 40 ºC (104ºF)
 Do not freeze
 Discard partially used vials

Long-Term Monitoring
Patients displaying local non-ascending 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.
In some species 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.

Prognosis:
The signs last for 24-72 hours and do not have an apparent sequence. Furthermore,
a false recovery followed by a total relapse is common.
Most patients recover fully after scorpion envenomation.
If the victim survives the first few hours without severe cardiorespiratory or
neurologic symptoms, the prognosis is usually good. Furthermore, surviving the first
24 hours after a scorpion sting also carries a good prognosis.
Young children may not recover as quickly as adults after scorpion envenomation
and are more likely to require observation.

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Serum Sickness:
It is a combination of fever, skin eruptions (mainly urticaria), joint pain, and
lymphadenopathy in regions draining the site of injection after patients were given
antitoxin in the form of horse serum. [1] Certain medications (eg, penicillin,
nonsteroidal anti-inflammatory drugs [NSAIDs]) have also been associated with
serum sickness–like reactions. These reactions typically occur 1 to 3 weeks after
exposure to the drug, but may occur as early as 1 to 24 hours afterward.
Treatment: steroids and antihistamines.

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