Overview of Scorpion Envenoming - emergpa.net · Genus Buthus At least Buthus (occitanus) tunetatus and B. occitanus (Fig. 4) may cause medically signif-icant stings [15, 16, 22,

Overview of Scorpion Envenoming

Julian White

ContentsTaxonomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

The Anatomy of Scorpions is Distinctive . . . . . . . . . . 3Family Buthidae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Family Hemiscorpiidae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Family Scorpionidae . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Scorpion Venoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Clinical Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Scorpion Antivenoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Non-antivenom treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Grading System for Levels of Evidence SupportingRecommendations in Critical Care Toxicology,2nd Edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Scorpions are the second most globally importantcause of envenoming, after snakebite and in someregions are more important than snakebite. Esti-mates have been made of the incidence of medi-cally significant scorpion stings (Table 1)[1]. Scorpion sting is a significant problem prin-cipally in regions within the two tropics, notablyin more arid areas (Fig. 1) [1]. All scorpions arevenomous, with a sting structure in the “tail”(telson) [1–4]. However, only a minority of scor-pion species are known to cause medically signif-icant envenoming in humans, and virtually all ofthese are found in a single family, Buthidae, andcause systemic envenoming that can prove lethal,particularly in children [1–4]. There is an impor-tant outlier, the Iranian species Hemiscorpiuslepturus, family Hemiscorpiidae (formerly infamily Scorpionidae), which has a very differentclinical envenoming profile [5–7]. At least twoother genera of scorpions have occasionally beenreported as causing medically significant stings:Heterometrus spp. and Nebo spp., familyScorpionidae (Nebo is placed within family Di-plocentridae by some taxonomists) [8–11]. Withthe exception of Hemiscorpius and a few otherspecies, scorpion stings cause immediate pain,often severe, occasionally nonspecific systemicsymptoms, and, in the case of medically importantspecies, a variable syndrome of neuroexcitatorysystemic envenoming. This latter group has gen-erally been considered homogenous in clinicalpresentation, but as more detail is collected onthe effect of stings by individual species, it is

J. White (*)Toxinology Department, Women’s and Children’sHospital, North Adelaide, SA, Australiae-mail: [email protected]

# Springer International Publishing AG 2016J. Brent et al. (eds.), Critical Care Toxicology,DOI 10.1007/978-3-319-20790-2_147-1

1

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becoming apparent that there are distinctenvenoming syndromes associated with eachgroup, sometimes even species, of scorpion.

Taxonomy

Scorpions are invertebrates, arthropods, with fourpairs of legs, the distinctive chelicerae (front “pin-cers” or “claws”), multiple eyes, and the defining“tail” with the terminal segment containing thevenom gland and sting [4]. As a general rule,

scorpions with bulky pincers (chelicerae) usethese to help capture and subdue prey and relyless on potent venom, so that for humans, theirsting, though generally painful, is less likely toresult in significant envenoming [12]. Conversely,those scorpions with comparatively delicate pin-cers often rely more on potent venom, so aremore commonly associated with significant en-venoming in humans [12].

There are approximately 18 families of scor-pions (Table 2), with approximately 2,000described species at last count, with numerous

Table 1 Epidemiology of scorpion stings globally according to Chippaux and Goyffon [1]

RegionEstimated totalstings

Estimated totaldeaths

Incidence per100,000

Mortality per100/000

North Africa 350,000 810 222.93 0.52

Sub-Saharan Africa 61,500 570 37.96 0.35

East/South Africa 79,000 245 94.05 0.29

Near and MiddleEast

146,500 796 77.15 0.42

Asia 250,000 645 19.76 0.05

Mexico 250,000 75 233.64 0.07

Amazonian basin 17,500 20 22.15 0.03

South America 36,000 110 16.36 0.05

Total 1.19 million 3271 52.59 0.14

Fig. 1 Map of approximate range of “scorpionism,” thoseareas where scorpion stings represent a significant prob-lem, modified from Chippaux and Goyffon [1]. Thoseareas highlighted in light red represent regions where the

approximate incidence of stings is 1 to 100/100,000 pop-ulation. Those areas in dark red approximate incidence ofstings >100/100,000 population (Figure copyright #Julian White 2016)

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new species being described each year, reflectinga concerted effort by scorpion taxonomists tocatch up with the backlog of undescribed, butknown, species, although there is significant con-troversy surrounding scorpion taxonomy [13]. Allmedically important species fall within just fourfamilies, Buthidae, Hemiscorpiidae (Scorpionidae),Diplocentridae (subsumed within Scorpionidaeby some taxonomists), and Scorpionidae, thoughmany other species of scorpion can deliverdistressing locally painful stings, but without sig-nificant systemic effects.

The Anatomy of Scorpions isDistinctive

Family Buthidae

While the vast majority of medically importantscorpions are in family Buthidae, they are foundin only some genera (Table 2), and there arenumerous Buthid scorpions which have not beenreported as causing medically significant stings(Fig. 2) [1, 2]. Some of the most medically impor-tant genera include:

Genus AndroctonusThese scorpions, found predominantly in NorthAfrica through to the Middle East, include severalspecies of knownmedical significance (A. australis,A. bicolor, A. crassicauda, A. mauritanicus), andit is possible other Androctonus spp. may causemedically significant stings [1, 2]. Recent taxo-nomic studies have indicated that even withincurrently defined species, such as A. australis(Fig. 3), there may be several distinct populations,and the implications of this for venom toxicity andclinical profile are unclear [14]. In Morocco itappears Androctonus spp. are responsible formany, possibly a majority of medically significantstings, with 30–50,000 cases reported to theMoroccan Poison Information Center (PIC) annu-ally, of which about 1,000 are severe, with 10–100fatalities/year [1]. However, the Moroccan PICdata includes stings by other species, and amongthese, Buthus occitanus is of major significance. Itshould be noted that appropriate anti-scorpionantivenom is generally not available in Morocco,so it is unclear if ready availability of antivenommight reduce the number of fatalities. Past studiesin Morocco reported that A. mauritanicus was theprincipal species involved and clinical

Table 2 An approximate higher-level taxonomy for scorpions

Family Subfamily Medically significant genera

Bothriuridae –

Buthidae Androctonus, Buthus, Centruroides, Hottentotta, Leiurus, Mesobuthus,Odontobuthus, Parabuthus, Tityus

Chactidae –

Chaerilidae –

Diplocentridae Diplocentrinae –

Nebinae Nebo

Euscorpiidae –

Hemiscorpiidae Hemiscorpius

Heteroscorpionidae –

Iuridae –

Liochelidae –

Microcharmidae –

Pseudochactidae –

Scorpionidae Heterometrus

Scorpiopidae –

Superstitioniidae –

Urodacidae –

Vaejovidae –

Overview of Scorpion Envenoming 3

improvement was noted with specific antivenomtreatment, compared to patients not given anti-venom, but in a nonclinical trial study [15, 16]. InAlgeria A. australis is reported to cause 70 % ofmedically significant stings [17]. In LibyaA. australis, A. bicolor, and A. amoreuxi all occur,but it is unclear if all cause medically significantstings [18]. In Saudi Arabia A. crassicauda,

together with Leiurus quinquestriatus, is consid-ered the mostmedically important scorpion [19]. InTurkey A. crassicada is responsible for most med-ically significant scorpion stings, >50 % in oneseries [20]. In Iran A. crassicauda is consideredof major medical significance, second only toHemiscorpius lepturus in severity and lethal poten-tial [21].

Fig. 2 Diagrammatic representation of some principalmorphological features of scorpions of taxonomic rele-vance. (a) shows the dorsal (upper) side of the scorpion.

(b) shows the ventral (underside) of the scorpion(Figures copyright # Julian White 2016)

Fig. 3 Androctonusaustralis from North Africa(Figure copyright # JulianWhite 2016)

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Genus ButhusAt least Buthus (occitanus) tunetatus andB. occitanus (Fig. 4) may cause medically signif-icant stings [15, 16, 22, 23]. The latter species,widely distributed in parts of MediterraneanEurope and North Africa, appears to have distinctdifferences in venom and clinical severity withinthe geographic range [1, 24]. While most stingsmay be painful, significant or severe systemicenvenoming appears largely restricted to someNorth African populations such as those inMorocco.

Genus CentruroidesIt is likely many species of Centruroides scor-pions may cause medically significant stings, par-ticularly in children, though only a limited rangeof species are clearly hazardous (C. sculpturatus(Fig. 5), C. noxius, C. suffusus, C. infamatus,C. limpidus) [1–3, 25–27].

Genus HottentottaThese scorpions range from Africa to the Indiansubcontinent and include at least several speciesof major medical significance (H. alticola,H. hottentotta, H. tamulus (note H. tamulus waspreviously named Mesobuthus tamulus)) [1, 2,28]. The taxonomy of this group of scorpionshas been the subject of revision [29]. While the

medical importance of stings in Africa appears tobe minor, in the Indian subcontinent H. tamulus isarguably the most medically important Indianscorpion [1, 28, 30].

Genus LeiurusPossibly all Leiurus spp. scorpions are medicallyimportant, not just the well-recognized and fearedL. quinquestriatus (Fig. 6) [1, 2, 31]. While prin-cipally recognized from North Africa through tothe Middle East, it is also reported as present andcausing major envenoming in sub-Saharan Africa[31]. While the majority of stings are non-lifethreatening, in children severe and potentiallyfatal envenoming can occur and is occasionallyreported in adults [1, 31–34]. In at least part ofthe range of L. quinquestriatus, it is reported tocommonly cause acute pancreatitis in children[35].

Genus MesobuthusThe medical importance ofMesobuthus spp. scor-pions is less clear since the known importantspecies, M. tamulus, was shifted to genusHottentotta, as H. tamulus [1, 28–30].

Genus OdontobuthusThe medical importance of this genus and specif-ically O. doriae remains unclear, but limited clin-ical case experience in Iran indicates this speciescan cause, in addition to moderate to marked localpain, some systemic effects including tachycardiaand pulmonary edema [21].

Genus ParabuthusThese sub-Saharan African scorpions includeseveral species of medical significance(P. transvaalicus, P. granulatus, possiblyP. liosoma, P. mossambicensis) (Fig. 7) [1, 2,36–39].

Genus TityusArguably the most medically important genus ofSouth American scorpions, Tityus, includes anumber of species causing major envenomingfrequently in parts on the continent, notably, butnot exclusively, Brazil (Tityus serrulatus,T. bahiensis, T. pachyurus, T. zulianus,

Fig. 4 Buthus occitanus from North Africa(Figure copyright # Julian White 2016)


T. confluens, T. asthenes, T. breweri, T. stigmurus,T. obscurus, T. trivittatus, T. neoespartanus,T. trinitatis) [1, 2, 40–54]. At least one species,T. serrulatus, is parthenogenetic (Fig. 8) [55].

Family Hemiscorpiidae

Genus HemiscorpiusH. lepturus is clearly associated with medicallyimportant stings in southwestern Iran, where it is aleading cause of severe and lethal envenoming [1,5–7, 21, 56–63]. It is also reported from Iraq,Yemen, and Pakistan, but it is unclear if it causessignificant human envenoming in these locations.As mentioned earlier, the envenoming profile isvery distinct from that caused by Buthid scorpionsand is more closely clinically aligned with thenecrotic arachnidism resulting from bites bybrown recluse spiders, Loxosceles spp. [64].

Fig. 7 Parabuthus transvaalicus from Southern Africa(Figure copyright # Julian White 2016)

Fig. 5 Centruroidessculpturatus from Arizona,North America(Figure copyright # JulianWhite 2016)

Fig. 6 Leiurusquinquestriatus from theMiddle East(Figure copyright # JulianWhite 2016)

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Family Scorpionidae

Genus NeboNebo hierichonticus has been reported to causemedically significant envenoming, more closelyrelated to Hemiscorpius lepturus envenomingthan Buthid-type envenoming, but few casereports are available to properly define theenvenoming syndrome, and the epidemiologicimportance of these scorpions remains uncertain[8]. A single case report documented intracranialand retinal hemorrhages in a child, which resolvedwithout residual deficit [11].

Themedical significance of stings by the widelydistributed Asian scorpion genus Heterometrusremains unclear [8], though venom studies indicateat least some species have neurotoxic venoms(H. longimanus, H. spinifer; direct agonist actionson postjunctional muscarinic M3 cholinoceptorsand alpha-adrenoceptors) [65]. However, there isno clear evidence to verify any species causingmedically significant stings.

Scorpion Venoms

Venom research into scorpions has concentratedon Buthid venoms which have proved a richsource of highly potent and often very specificion channel toxins, particularly potassium channeltoxins [3, 4]. These diverse small peptide toxins

can target just a few, sometimes just one type ofion channel and so have proven instrumental inunderstanding the molecular basis of neural sig-naling pathways [4, 66, 67]. Scorpion toxins aredivided into two broad classes of short chainpeptides by some authors [4]:

1. The “long toxins,” with about 60 AA, targetprincipally Na+ channels and are considered asdominant in causing clinical envenoming inhumans and divided into two subgroups.Alpha-type toxins found principally inPaleotropical species inhibit the inactivationphase of the nerve action potential, binding tosite 3 on the Na+ channel. Beta-type toxins arefound in Neotropical species and reduce theexcitability threshold of excitable cell mem-branes acting at site 4 of the Na+ channel. Forthe most medically important scorpions offamily Buthidae, usually only one type oflong toxin is found, alpha or beta.

2. The “short toxins,” with about 30–40 AA, tar-get principally K+ or Cl+ channels and are oftenpresent in only small quantities in scorpionvenom. They occur across all types of scor-pions. The K+ channel short toxins can besubdivided into voltage-dependent andligand-dependent types, and all have 3–4 disul-fide bridges with a CSab motif and are of mostimportance as pharmacologic tools. They aregenerally nontoxic in mammals, except ifinjected intracerebrally.

In contrast to snake venoms, most scorpionvenoms and specifically Buthid venoms are richlyendowed with polypeptide toxins, but generallyhave few or no enzymatic toxins [4].

The toxins involved in the local necrotic andsystemic hemolytic and organ destructive effectsof Hemiscorpius lepturus venom have been lesswell defined, in part because this species has avery limited geographic range, mostly in westernIran, and venom may be less easy to obtain forstudy. In vivo studies of whole venom in miceindicated it is highly cytotoxic, damaging themyocardium and renal tubules by 3 hpostinjection, followed by intestinal damage by6 h, with elevated creatine kinase and lactate

Fig. 8 Tityus serrulatus from Brazil, South America(Figure copyright # Julian White 2016)


dehydrogenase, but no observed effects on thelungs or liver [68]. The venom can induce theimmune system to produce interleukin-12[69]. Envenoming is associated with ADAMTS13deficiency and ADAMTS13 autoantibody inhuman cases, and it has been suggested that thismay play a role in venom-induced coagulopathyand development of both DIC- and an HUS-likesyndrome [70]. The role of a sphingomyelinase-D-like toxin, Heminecrolysin, has been empha-sized in some studies, interestingly given a similartoxin that is considered a major factor in reclusespider, Loxosceles spp., venom-induced localnecrosis. Indeed there are significant similaritiesbetween Hemiscorpius lepturus envenoming andLoxosceles envenoming (loxoscelism) [71, 72].Heminecrolysin has potent lysophospholipase-Dactivity, and this may play an important rolein intravascular hemolysis in envenomedpatients [73].

Scorpionidae scorpion toxins have also beenexamined for a limited range of species, notablyfrom the two genera of possibly medically signif-icant scorpions, Nebo and Heterometrus [65,74–76]. The latter, in at least some species, con-tains a variety of components including peripheralmuscarinic agonist toxins, ion channel toxins,phospholipase A2 toxins, antibacterial toxins,and anti-osteoporosis agents [65, 76].

Clinical Presentation

Some key groups of scorpions will be covered indetail in subsequent chapters. As discussed ear-lier, most medically important scorpions causepredominantly neuroexcitatory envenoming, inaddition to local pain [3, 4]. A summary of clinicalfeatures is listed in Table 2.

There are two broad types of clinical syn-dromes associated with scorpion envenoming:

1. Neuroexcitatory envenoming characterized byan initially painful sting, often severely pain-ful, followed by development of systemicenvenoming in patients where sufficientvenom has been injected. Because of smaller

body mass, children are more likely to developsevere or life-threatening envenoming. As withany other type of envenoming, not all patientswill suffer significant envenoming, and inadults, for most scorpion species, envenomingis an unpleasant but time-limited and surviv-able illness. Neuroexcitatory envenoming byscorpions is predominantly a feature ofselected Buthid (family Buthidae) scorpions.Many other scorpion species may cause signif-icant, usually short-lived local pain, but with-out specific neuroexcitatory envenoming.Within this broad group there are clinical fea-tures specific for particular species groups,though delineation of such syndromes is gen-erally rudimentary or incomplete in most casesat this time. Features common across manyButhid species groups include autonomic stim-ulation (a catecholamine-storm-like effect;hypertension, tachycardia, piloerection, sweat-ing, salivation, etc.), cardiac dysfunction(reduced output, cardiac failure, raised tropo-nins, cardiogenic pulmonary edema), neuro-logic effects (collapse, in some casesconvulsions, coma, or athetoid movements oflimbs or nystagmus), and nonspecific effectssuch as abdominal pain, headache, nausea, andvomiting [3, 4].

2. Dermonecrotic envenoming with systemiccytotoxic effects. This type of envenoming israre for scorpion stings and is mostly seen withIranian Hemiscorpius lepturus envenoming,particularly in the Khuzestan region of SWIran [5–7, 21, 56–63]. The sting may not bepainful and can go unnoticed, with later devel-opment of local skin necrosis and a systemicillness which, in severe cases, includes intra-vascular hemolysis, anemia, thrombocytope-nia, disseminated intravascular coagulation,acute kidney injury (AKI) and renal failure,multi-organ failure, and death [5–7]. As forneuroexcitatory scorpion envenoming, chil-dren are at highest risk [6]. In a study ofenvenomed children with hemolysis andhematuria, 23 % had AKI, 6.7 % developedDIC, and 10 % developed a hemolyticuremic-like syndrome, and within this entire

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pediatric patient group, 98 % had detectableanti-ADAMTS13 antibody, and 92 % haddecreased levels of ADAMTS13 [70].H. acanthocercus has recently been reportedas causing similar envenoming in Iran, with aconfirmed fatality. It is unclear howmany otherHemiscorpius spp. may be medicallysignificant [63].

A group named the Scorpion ConsensusExpert Group has proposed a unified clinical clas-sification of scorpion envenoming, although thisclassification ignores dermonecrotic envenoming,concentrating on just neuroexcitatory enveno-ming, and the group is dominated by membersfrom Morocco and France [77]. The “final pro-posed classification” of severity of scorpionstings, essentially a grading system, is presentedin Table 3.

Treatment

The treatment of scorpion stings and of cases withsignificant envenoming remains controversialglobally, with two distinctly different approachesadvocated by groups of clinicians.

The intensive care and pharmacologicapproach:

This approach is based on the assumption thatantivenom, as a specific antidote, is ineffectivein scorpion envenoming and that supportivecare and standard pharmaceuticals are moreeffective. This view has been prominent acrossparts of North Africa, the Middle East, and theIndian subcontinent and is applicable only toclassic neuroexcitatory scorpion envenoming;it has not been proposed for dermonecroticenvenoming [78–87].

The use of ICU and life-supportive measuressuch as inotropes, IV fluids, intubation, andventilation, all where indicated, has beenreported as effective in treating severe scor-pion stings in both Israel and India and morerecently in parts of North Africa includingMorocco, Algeria, and Tunisia [78–87]. The

latter three countries, at least, had previouslyrelied on use of antivenom, and it is unclearthe validity of studies suggesting antivenomwas less effective [84–86]. In India the adventof a specific scorpion antivenom has seem-ingly modified this approach, so that anti-venom is now the preferred treatment inmost centers [88–93].

The antivenom-centric approach:

Globally this is the predominant preferred treat-ment. There is ample published evidence thatwhen used appropriately it results in better out-comes for patients and reduced mortality [17,22, 23, 88–110]. In Mexico alone, with about300,000 hospitalizations per year for scorpionsting, the advent of antivenom has dramaticallyreduced mortality in the prime risk group, chil-dren [95, 97].

The dose of antivenom will depend on the type ofantivenom and the degree of envenoming, notthe size of the patient. Scorpion venoms canrapidly distribute throughout the body, andsystemic envenoming can develop rapidly;therefore antivenom should be given veryearly to have maximum benefit, with signifi-cant decreasing value as the time from sting toadministration increases [17, 23, 101,104]. (Grade IIa recommendation) It is unclearat what point giving antivenom is no longerappropriate, but certainly after 24 h it is likelyto be much less effective. Nevertheless, in apatient with life-threatening envenoming,where other treatment modalities are also prov-ing of limited effectiveness, active consider-ation to giving appropriate antivenom at ahigh dose is appropriate.

As in any other situation where antivenom is used,there is a risk of adverse reactions, and appro-priate precautions should be taken, includinghaving adrenaline (epinephrine) drawn upready to give, if required, plus having resusci-tation equipment immediately to hand.

It is important to note that for dermonecrotic scor-pion envenoming by Hemiscorpius lepturus,antivenom is the current cornerstone of


treatment, and there is no apparent dissent fromits use in patients with this form of envenoming[21, 56–60]. The previously discussednon-antivenom approach to treatment of scor-pion stings is entirely inappropriate for thisform of envenoming. Studies have demon-strated effectiveness of the antivenom in an

in vivo rat model, even when administered2 h post-venom [56]. Experimentally, a cam-elid nanobody antibody fragment-based anti-dote has been successfully developed againstHemiscorpius venom, but the role of this infuture clinical use is untested [111].

Table 3 A grading system for neuroexcitatory scorpion envenoming prosed by the “Scorpion Consensus Expert Group”[77]

Class I: localmanifestations

Class II: minor manifestations(non-life threatening)

Class III: severe manifestations (life threatening). Presence ofat least one of the following signs

Bullous eruptionBurningsensationEcchymosisErythemaHyperesthesiaItchingNecrosisparesthesiaPainPurpura/petechiaSwellingTingling

Abdominal distensionAgitation/restlessness/excitementAnisocoriaArthralgiaAtaxiaConfusionConvulsionDiarrheaDry mouthDystoniaEncephalopathyFasciculationGastrointestinal hemorrhageHematuriaHeadacheHypertensionHyperthermiaHypothermiaLacrimationLocal muscular crampsMiosisMydriasisMyocloniaNauseaNystagmusOdynophagiaPallorPancreatitisGeneral paresthesiaPriapismProstrationPtosisRhinorrheaSalivationSomnolence/lethargy/drowsinessStridorSweatingTachycardiaThirstUrinary retentionVomitingWheezing

Cardiogenic failureHypotensionVentricular arrhythmiaBradycardiaCardiovascular collapseRespiratory failureCyanosisDyspneaPulmonary edemaNeurological failureGlasgow score �6 (in absence of sedation)Paralysis

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Scorpion Antivenoms

A number of antivenoms against particular scor-pion venoms are produced in South and CentralAmerica, Africa, the Middle East, Europe, andIndia [112]. In a number of regions/countries,Mexico being a good example, the introductionof scorpion antivenom has been associated with adramatic improvement in outcomes [3, 27]. How-ever, in certain regions and countries, there hasbeen a move away from antivenom as a treatmentchoice, and the literature is replete with argumentsin favor, or against, the use of antivenom, as notedearlier [17, 22, 78–80, 84–86, 98, 101, 103–105].

However, the availability of an effective anti-venom may not equate with advocacy for routineuse in envenomed patients because other factors,notably cost, may negatively influence the cost/benefit equation, a situation recently discussed inrelation to treating scorpion envenoming in theUSA [110].

Non-antivenom treatments

As noted earlier, non-antivenom treatment ofscorpion stings has been advocated by a numberof groups, mainly in North Africa, through theMiddle East, to India, but in at least some ofthese places, notably India, now antivenom isavailable, the same authors who earlier advocatednon-antivenom treatment now advocate use ofantivenom [78–93].This needs to be consideredwhen perusing the often confusing literature onmanagement of scorpion envenoming.

However, it is clear that treatments such as theuse of prazosin can be effective in managing scor-pion envenoming and should be considered whenantivenom is not readily available [87–92].Equally, such pharmacologic approaches mayhave a useful adjunctive role in treatment.

Conclusion

Scorpion stings are an important cause of injuryfrom venomous animals globally and representthe second most important impact, after snakebite.

In some regions scorpion sting is more importantthan snakebite in impact on the health system. Onlya small minority of scorpions can cause significantenvenoming, andmost of these are Buthid scorpionscausing systemic and potentially lethal neuro-excitatory envenoming, in addition to marked localpain. An important outlier is the Iranian scorpion,Hemiscorpius lepturus, which causes delayed localnecrosis and a potentially fatal cellulolytic systemicsyndrome of hemolysis, DIC, and multi-organ fail-ure, similar to loxoscelism caused by recluse spi-ders. Despite ongoing controversy, the availableevidence, globally, favors the use of specific anti-venom as the most effective treatment for systemicscorpion envenoming, but this is most effectivewhen given early.

Grading System for Levels of EvidenceSupporting Recommendationsin Critical Care Toxicology, 2nd Edition

I. Evidence obtained from at least one properlyrandomized controlled trial.

II-1. Evidence obtained from well-designed con-trolled trials without randomization.

II-2. Evidence obtained from well-designedcohort or case–control analytic studies, pref-erably frommore than one center or researchgroup.

II-3. Evidence obtained from multiple time serieswith or without the intervention. Dramaticresults in uncontrolled experiments (such asthe results of the introduction of penicillintreatment in the 1940s) could also beregarded as this type of evidence.

III. Opinions of respected authorities, based onclinical experience, descriptive studies andcase reports, or reports of expert committees.

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Overview of Scorpion Envenoming - emergpa.net · Genus Buthus At least Buthus (occitanus) tunetatus and B. occitanus (Fig. 4) may cause medically signif-icant stings [15, 16, 22,