Scorpion envenomation with neuromuscular toxicity: Grading of severity and treatment

For assistance in managing a patient with a suspected scorpion envenomation, contact a regional poison control center (in the United States, call 1-800-222-1222).
Grade	Clinical findings	Treatment
I	Localized pain or paresthesias at site	Pain management (eg, ibuprofen) Local wound care Tetanus prophylaxis
II	Local and remote pain or paresthesias	As above, regional anesthesia (eg, digital block) for severe local pain; intravenous opioids (eg, fentanyl) for severe remote pain
III	As above, and: Cranial nerve dysfunction: Abnormal eye movements, dysphagia, drooling, and/or slurred speech OR Somatic skeletal neuromuscular dysfunction: Undulating and writhing restlessness, fasciculations, extremity shaking and jerking, opisthotonos (arching of the back), and emprosthotonos (tetanic forward body flexion) with preservation of alertness. Autonomic dysfunction: Centruoides: Salivation, vomiting, bronchoconstriction, diaphoresis, and tachycardia most frequent. Parabuthus: Salivation, vomiting, and urinary retention most frequent.	Antivenom, if available* Supportive care: Frequent suctioning of oral secretions Endotracheal intubation if airway compromise or pulmonary edema with hypoxemia Monitor for and treat myocardial ischemia, heart failure, and rhabdomyolysis^¶ Treat pain with intravenous opioids (eg, fentanyl^Δ) If antivenom is not available, treat muscle activity and anxiety with short-acting benzodiazepines (eg, midazolam)^◊ Provide local wound care as above
IV	All above features present

Grading scale and treatment following envenomation with Centruroides species (southwestern United States, Mexico, and Central America) and Parabuthus species (southern Africa). For dosing of scorpion-specific antivenom, refer to UpToDate topics on scorpion envenomation causing neuromuscular toxicity (United States, Mexico, Central America, and southern Africa).

* To obtain antivenom in the United States, contact the nearest regional poison control center at 1-800-222-1222.

¶ Refer to UpToDate topics on the recognition and emergency treatment of myocardial infarction, heart failure, and rhabdomyolysis.

Δ If antivenom administration is planned, fentanyl is preferred because it promotes less antihistamine release than morphine.

◊ Benzodiazepines should be used carefully or avoided if antivenom administration is planned because antivenom reverses the excitatory effects of scorpion venom, and patients who have received high doses of benzodiazepines may develop excessive sedation and respiratory compromise.

Graphic 67046 Version 9.0

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Scorpion envenomation with neuromuscular toxicity: Grading of severity and treatment