What is the initial management of a scorpion sting?

Initial Management of Scorpion Stings

For most scorpion stings, immediate first aid consists of wound irrigation, ice application for pain relief, and over-the-counter analgesics, with emergency services called only if systemic symptoms develop. 1

Immediate First Aid Measures

Wound Care

• Thoroughly irrigate the sting site with copious amounts of water to clean the area and remove any foreign matter 1
• Apply a clean occlusive dressing after irrigation to improve healing and reduce infection risk 1

Pain Management

• Apply ice to the sting site with a clean barrier between ice and skin for local pain relief 1
• Administer over-the-counter acetaminophen or NSAIDs to alleviate local pain 1
• Apply topical lidocaine (5%) if the skin is intact, which has demonstrated significant pain reduction in clinical studies 1

Remove Constricting Objects

• Remove rings and other constricting items from the affected extremity, as swelling may develop 2

When to Call Emergency Services

Systemic Symptoms Requiring Immediate Emergency Response

• Call emergency services immediately if the patient develops:
  • Difficulty breathing 1
  • Muscle rigidity 1
  • Dizziness or confusion 1
  • Cardiovascular or respiratory compromise 1

Indications for Medical Evaluation (Non-Emergency)

• Seek medical care if pain extends beyond the sting site or becomes severe 1
• Seek medical care if pain is not controlled by over-the-counter medications 1
• Seek medical care if an open wound develops 1
• Seek medical care if systemic symptoms appear 1

Critical Actions to AVOID

Contraindicated Interventions

• 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 1
• Do NOT cut the wound or attempt to suck out venom 3

Antibiotic Considerations

When Antibiotics Are NOT Needed

• Do not assume antibiotics are needed for swelling around the sting site - swelling is typically caused by mediator release, not infection 1
• Universal prophylactic antibiotics are not recommended 1

Signs of Secondary Infection Requiring Antibiotics

• Progressive erythema extending beyond the initial sting site 1
• Purulent discharge 1
• Systemic signs of infection such as fever or elevated white blood cell count 1

Special Populations and Severe Cases

Pediatric Patients

• Children are at higher risk for severe systemic envenomation and require closer monitoring 1, 4
• Early presentation to the hospital (within 4 hours) is associated with better outcomes, as delayed presentation correlates with more severe toxicity 4, 5

Antivenom Administration

• Antivenom should be administered for severe systemic envenomation, particularly in pediatric patients with cardiovascular or respiratory compromise 1
• The evidence for antivenom efficacy is mixed - one matched-pair study showed no difference in clinical course between antivenom-treated and untreated patients for mild-to-moderate cases 6, but it remains the standard for severe envenomation with life-threatening complications 4

Patients with Cardiac Comorbidities

• 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

Expected Clinical Course

Recovery Timeline

• Most patients with local symptoms only will recover completely within 24-48 hours 1
• Continued pain management with over-the-counter medications may be needed for several days 1

Monitoring

• Close surveillance with vital signs and continuous cardiac monitoring is essential for patients with systemic symptoms, enabling early detection of life-threatening complications such as cardiac and respiratory failure, convulsions, or hypertension 4

Common Pitfalls

• Most scorpion stings in North America cause only local symptoms, but severe reactions can occur, especially with bark scorpion (Centruroides) stings 1
• Oral corticosteroids lack definitive proof of efficacy through controlled studies and are not specifically recommended for scorpion stings 1
• Prazosin is not mentioned in current American Heart Association guidelines as a standard first-line therapy, though some older research protocols used it for severe pediatric cases 1, 5