What is the appropriate management of a scorpion sting?

Management of Scorpion Stings

For most scorpion stings in North America, provide local wound care with ice application, over-the-counter pain medications (acetaminophen or NSAIDs), and topical lidocaine if skin is intact, while observing for systemic symptoms that require emergency care. 1

Immediate Assessment and When to Call Emergency Services

Call emergency services immediately if any of these systemic symptoms develop: 2, 1

• Difficulty breathing or bronchospasm
• Muscle rigidity or severe cramping
• Dizziness, confusion, or altered mental status
• Signs of shock (hypotension, syncope)
• Severe pain uncontrolled by over-the-counter medications

Most scorpion stings in North America cause only local symptoms, but bark scorpion (Centruroides) stings can cause severe systemic neuromuscular and autonomic dysfunction. 2, 1 Children are at particularly high risk for severe complications due to smaller body surface area. 3, 4

First Aid and Pain Management

Immediate Local Care

• Thoroughly irrigate the wound with copious amounts of water to clean the area 1
• Apply ice to the sting site (with a clean barrier between ice and skin) for local pain relief 1
• Remove any rings or constricting objects immediately 5

Pain Control Options

• Over-the-counter acetaminophen or NSAIDs are first-line for pain management 1
• Topical lidocaine 5% can be applied if skin is intact, which has shown significant pain reduction in clinical studies 1
• Continue pain management as needed for several days 1

What NOT to Do - Critical Pitfalls

Do not apply suction devices to the sting site - this is ineffective and may cause additional harm 1

Do not apply tourniquets or pressure-immobilization bandages - these can worsen tissue injury and are not supported by evidence for North American scorpion envenomation 2, 1

Do not routinely prescribe antibiotics - swelling in the first 24-48 hours is caused by allergic inflammation and mediator release, not infection 2, 1 Antibiotics are only indicated if signs of secondary infection develop (progressive erythema beyond initial site, purulent discharge, fever, or elevated white blood cell count). 1

Advanced Medical Management for Severe Envenomation

Antivenom Administration

Antivenom should be administered for severe systemic envenomation, particularly in pediatric patients with cardiovascular or respiratory compromise. 1 Early administration in children with severe toxicity is associated with improved outcomes. 3 However, one matched-pair study found that systematic administration of scorpion antivenom regardless of clinical severity did not alter clinical course, and carries risk of anaphylactic shock. 6

Prazosin for Sympathetic Symptoms

While not mentioned in current American Heart Association guidelines as standard first-line therapy 1, prazosin (an alpha-blocker) has evidence supporting its use in severe envenomations with significant sympathetic symptoms, particularly in children. 7, 8 Prazosin at 30 mcg/kg/dose every 6 hours until recovery, combined with aggressive management of acute pulmonary edema, significantly reduced mortality in protocol-guided therapy. 7

Cardiovascular Support

For severe cases with cardiovascular complications: 7, 4

• Dobutamine and sodium nitroprusside for acute pulmonary edema
• Vasodilators or adrenergic antagonists for hypertensive phase
• Inotropic agents for hypotension
• Antiarrhythmics (such as lidocaine) as needed
• Continuous cardiac monitoring in intensive care setting 3

Follow-Up and Recovery

Most patients with local symptoms only recover completely within 24-48 hours. 1 Continue over-the-counter pain medications as needed during this period. 1

Seek medical attention if: 1

• Pain extends beyond the sting site
• An open wound develops
• Any systemic symptoms appear
• Signs of secondary infection develop

Special Population Considerations

Patients with hypertension, cardiac arrhythmias, or those on β-adrenergic blocking agents require special attention but have no contraindication to epinephrine if anaphylaxis develops. 1 The very young, very old, and those with underlying health conditions are at higher risk for severe reactions. 9

Time to medical care is critical - patients with severe toxicity who arrived at the hospital after longer delays had worse outcomes compared to those who presented early. 3