Stepwise Management of Scorpion Stings
The proposed stepwise approach of immobilization, analgesia, prazosin, antivenom, and cardiorespiratory monitoring is partially correct but requires important modifications: immobilization and analgesia are appropriate first steps, but prazosin is not routinely indicated, antivenom should be reserved for severe systemic envenomation, and cardiorespiratory monitoring is essential for all patients with systemic symptoms.
Step 1: Immediate First Aid and Immobilization
- Immobilize the affected limb to slow venom dissemination through the lymphatic system 1
- Thoroughly irrigate the wound with copious amounts of warm or room temperature water until no foreign matter remains 2
- Do NOT apply suction to the sting site as this is ineffective and potentially harmful 2
- Remove rings and constricting objects from the affected extremity immediately, as swelling may occur 3
Step 2: Pain Management (Analgesia)
- Over-the-counter acetaminophen or NSAIDs are first-line for local pain relief 2
- Apply ice to the sting site with a clean barrier between ice and skin for additional local pain relief 2
- Topical lidocaine 5% can be applied if the skin is intact, which has shown significant pain reduction 2
- For severe pain unresponsive to oral analgesics, intravenous opioids (such as meperidine) may be required 4
Step 3: Assessment for Systemic Envenomation
Call emergency services immediately if systemic symptoms develop, including 2:
- Difficulty breathing or respiratory distress
- Muscle rigidity or fasciculations
- Dizziness or confusion
- Cardiovascular instability (hypotension, tachycardia, arrhythmias)
Critical Pitfall: Prazosin Is Not Standard First-Line Therapy
- Prazosin is not mentioned in current American Heart Association guidelines for scorpion sting management 5, 2
- The evidence base does not support routine prazosin administration as a standard step in scorpion envenomation management
- Vasopressors (not alpha-blockers like prazosin) are indicated for cardiogenic shock and hypotension secondary to severe envenomation 6, 7
Step 4: Antivenom Administration (When Indicated)
Antivenom should be administered for severe systemic envenomation, particularly in children who are at higher risk 8:
- Severe systemic symptoms including cardiovascular or respiratory compromise
- Progressive neuromuscular symptoms
- Pediatric patients with any systemic symptoms, as they have higher mortality risk 8
Important timing consideration: Patients with severe toxicity often present after a longer delay than those with mild symptoms, making early hospital presentation critical 8
Step 5: Intensive Cardiorespiratory Monitoring
All patients with systemic symptoms require intensive care unit monitoring with 8, 7:
- Continuous cardiac monitoring to detect arrhythmias, as scorpion venom can cause myocarditis and ECG changes mimicking myocardial infarction 6, 7
- Vital signs monitoring for early detection of cardiovascular collapse
- Respiratory monitoring, as acute pulmonary edema and ARDS can develop 6
- Non-invasive ventilation may be required for respiratory compromise 6, 7
- Vasopressor support (not prazosin) for cardiogenic shock and hypotension 6, 7
Pathophysiology Context
The cardiovascular and respiratory manifestations result from 7:
- Venom-induced sympathetic nervous system activation
- Massive catecholamine release from adrenal glands
- Direct toxic effects of venom on myocardium
Step 6: Supportive Care and Monitoring
- Most patients with local symptoms only recover completely within 24-48 hours 2
- Continue pain management with over-the-counter medications as needed for several days 2
- Monitor for signs of secondary infection (progressive erythema, purulent discharge, fever), though antibiotics are NOT routinely indicated as swelling is from mediator release, not infection 2