Is it an Emergency?

Inquire re

• time of the sting,
• nausea, vomiting.
• Sting
  • Local pain is the dominant symptom, often severe
  • redness; oedema; numbness.
  • Tender local (spreading) swelling,
  • Blistering,
  • Lymphangiopathy and lymphadenopathy,
  • Necrotic soft tissue; can include muscle locally.

Assess

• state of consciousness.

Measure

• blood pressure/pulse,
• breathing (respiratory rate),
• oxygen saturation (pulse oximeter),
• 20WBCT (bedside test) (see Nebo hierochonticus in: Clinical entries: Scorpions).

Observe/investigate

• Sting area
  • Local pain,
  • Tender local (spreading) swelling,
  • Blistering,
  • Lymphangiopathy and lymphadenopathy,
  • Necrotic soft tissue; can include muscle locally.
• Autonomic nervous system
  Within hours:
  Transient cholinergic effects
  Vomiting, increased peristalsis, diarrhoea, abdominal pain; profuse sweating; pupil constriction.Bradycardia, arterial hypotension, shock. Hypersalivation; increased bronchial secretion, bronchospasm, respiratory failure. Priapism.
  Longer-lasting adrenergic effects
  Pupil dilatation.
  Tachycardia, arrhythmia, sarterial hypertension, myocardial failure, pulmonary oedema (cardiogenic + ?non-cardiogenic component), cardiac ischaemia, shock.
  Hyperglycaemia (most likely due to hypercatecholaminaemia) 
  Acute pancreatitis (also associated with hyperglycaemia)
  Hypertensive encephalopathy. 

• Clotting disturbances (see Nebo hierochonticus in:Clinical entries: Scorpions)
  Localizing neurological signs, meningism, coma (intracranial bleeding!)
  Systemic bleeding: retinal haemorrhages; cranial CT features of cerebellar and cerebral and cerebellar haemorrhages.

• Microangiopathic haemolysis (see Hemiscorpius lepturus in:Clinical entries: Scorpions)
  Severe microangiopathic haemolysis causing early haemoglobinuria and leading to a HUS-like presentation with AKI that requires renal replacement therapy (Warrell 2023).

• Neuromuscular dysfunction
  • Cranial nerves: Ptosis, "wandering" eye movements, dysphagia (inhalation of vomitus!), dysarthria, pharyngeal reflex absent;
  • Skeletal musculature: involuntary movements, restlessness, reduced grip and pinch strength; muscle spasms.
  • Descending flaccid paralysis(rarely progresses to involve respiratory muscles)
  • Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway, by the paralysed tongue or inhaled vomitus. 
  • Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis. 

Monitoring for signs and symptoms of local and systemic envenoming (see above).

Symptomatic emergency medical treatment and antivenom treatment are complementary strategies.

Antivenom in those scorpion stings in which antivenom is avaibale, of proven value and indicated, it must be secured as early as possible while emergency medical treatment is running.

The aim of symptomatic emergency medical treatment is the rapid correction of critical parameters (fluid balance, blood pressure, oxygenation etc.) and the maintenance of vital functions (respiratory, cardiovascular).

Symptomatic measures help bridge the gap until specific treatment (antivenom) can be administered and starts being effective. If no antivenom is available or if the required effect is not achieved with antivenom, the goal is to employ symptomatic measures until such time as the venom naturally starts losing its activity.

The aim of antivenom treatment is neutralisation of the venom. The success of antivenom treatment depends on the quality of the antivenom, the specific properties of those venom components relevant to envenoming and the time point at which antivenom is administered (neurotoxic envenoming).