Scorpion Envenomation - Current Treatment recommendations

A local retired nurse just emailed me asking me  for the following information. Seems to be a lot of "Cures" that the local folks recommend. My grandma even recommended drinking milk straight from the cow as a cure, LOL ! Anyway, here are the current AAFP recommendations and the sources are noted at the bottom.
These are the current recommendations and standards of care for Scoprion envenomation.


●Pain management with oral medications (eg, ibuprofen 10 mg/kg; maximum single dose 800 mg), cleansing of the sting site, and tetanus prophylaxis typically suffice in these patients. These patients should be observed for four hours to ensure no further progression of symptoms.

●Prior to discharge the patient should tolerate oral intake, have no progression of symptoms, and their pain should be adequately controlled with oral medications. (See 'Asymptomatic or mild envenomation' above.)



These patient's should be handled by a trained healthcare provider in adequate settings. So, get them to your local emergency care facility.

●Victims with severe systemic symptoms (eg, restlessness, muscle fasciculations, hypersalivation, cranial nerve dysfunction, roving eye movements) are at heightened risk for respiratory compromise, myocardial infarction (adults with coronary artery disease), hyperthermia, rhabdomyolysis, and multiple organ failure and warrant close monitoring for these complications. Key supportive interventions in these patients encompass:

•Frequent suctioning of oral secretions.

•Endotracheal intubation in patients unable to maintain their airway or who develop pulmonary edema.

•Intravenous administration of fentanyl 1 mcg/kg. Fentanyl is preferred if antivenom administration is planned because, unlike morphine, fentanyl does not cause histamine release.

●Intravenous administration of benzodiazepines (eg, midazolam infusion titrated to effect) for sedation and to treat muscle spasticity. The use of benzodiazepines should be limited or avoided if antivenom administration is planned.

●We suggest that patients in the United States or Mexico with Grade III or IV symptoms (table 1) after Centruroides scorpion envenomation (skeletal muscle and/or cranial nerve dysfunction) receive intravenous scorpion-specific F(ab')2 equine antivenom (Grade 2B). (See 'Centruroides antivenom' .)

There is ONLY 1 institution in Guadalajara that has the ANTIVENOM for this and many other Toxins. The contact info is the following :

Cruz Verde de Guadalajara - Ayuntamiento de Guadalajara
Centro Regional de Información y Atención Toxicológica CRIAT
Av. Los Angeles, esq. Analco
Unidad Administrativa Reforma, Col. Las Conchas
C.P. 44460, Guadalajara, Jalisco
México
Contacto Institucional
Dr. Alberto Iram Villa Manzano
Tel. Directo (333) 669.1338
Tel. Conmutador (333) 669.1320 al 25, Ext. 1338
Email: criatguadalajara@usa.net
Hrs: 24 hrs per day /365 days of the year
Personal:  1 medical director and 5 doctors


REFERENCES
Klauber LM. Rattlesnakes: Their Habits, Life Histories, and Influence on Mankind, University of California Press, Berkeley 1997. Vol 1, p.838.
LoVecchio F, McBride C. Scorpion envenomations in young children in central Arizona. J Toxicol Clin Toxicol 2003; 41:937.
Gambhir IS, Singh DS, Pattnaik DN. Stroke in a young woman. Postgrad Med J 1998; 74:555.
Boyer LV, Theodorou AA, Berg RA, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med 2009; 360:2090.
Curry, SC, Vance, MV, Ryan, PJ, et al. Envenomation by the scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol 1983-1984; 21:417.
Russell FE. Venomous arthropods. Vet Hum Toxicol 1991; 33:505.
Krifi MN, el Ayeb M, Ben Lasfar Z, et al. Improvement and standardization of antivenoms sera. Arch Inst Pasteur Tunis 1992; 69:253.
Hutt MJ, Houghton PJ. A survey from the literature of plants used to treat scorpion stings. J Ethnopharmacol 1998; 60:97.
LoVecchio F, Welch S, Klemens J, et al. Incidence of immediate and delayed hypersensitivity to Centruroides antivenom. Ann Emerg Med 1999; 34:615.
Stipetic ME, Lugo A, Brown B, et al. A prospective analysis of 558 common striped scorpion (Centruroides vittatus) envenomations in Texas during 1997 (meeting abstract). J Toxicol Clin Toxicol 1998; 36:461.
Sofer S. Scorpion envenomation. Intensive Care Med 1995; 21:626.
Vatanpour H, Rowan EG, Harvey AL. Effects of scorpion (Buthus tamulus) venom on neuromuscular transmission in vitro. Toxicon 1993; 31:1373.
Garcia ML, Hanner M, Kaczorowski GJ. Scorpion toxins: tools for studying K+ channels. Toxicon 1998; 36:1641.
Arie-Saadia G, Sofer S, Zlotkin E, Shainberg A. Effect of Leiurus quinquestriatus hebreus venom on calcium and deoxyglucose uptake in cultured cardiac cells. Toxicon 1996; 34:435.
Boyer L, Heubner K, McNally J, Buchanan P. Death from Centruroides scorpion sting allergy. J Toxicol Clin Toxicol 2001; 39:561.
Dehesa-Dávila M, Possani LD. Scorpionism and serotherapy in Mexico. Toxicon 1994; 32:1015.
Clark RF, Selden BS, Kunkel DB, Frost MD. Abnormal eye movements encountered following severe envenomations by Centruroides sculpturatus. Neurology 1991; 41:604.
Berg RA, Tarantino MD. Envenomation by the scorpion Centruroides exilicauda (C sculpturatus): severe and unusual manifestations. Pediatrics 1991; 87:930.
Annobil SH. Scorpion stings in children in the Asir Province of Saudi Arabia. J Wilderness Med 1993; 4:241.
Amaral CF, Rezende NA. Both cardiogenic and non-cardiogenic factors are involved in the pathogenesis of pulmonary oedema after scorpion envenoming. Toxicon 1997; 35:997.
Kolecki P. Inadvertent methamphetamine poisoning in pediatric patients. Pediatr Emerg Care 1998; 14:385.
Approval letter - Anascorp. US Food and Drug Administration. http://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/FractionatedPlasmaProducts/ucm266726.htm (Accessed on August 04, 2011).
Ramsey JM, Salgado L, Cruz-Celis A, et al. Domestic scorpion control with pyrethroid insecticides in Mexico. Med Vet Entomol 2002; 16:356.

Two things to note relative to Chapala:

In Chapala, most scopions are Vaejovis, which are far less toxic than centruroides.

While CRIAT usually has many more different antidotes,
The faboterapico scorpion antidote is availalbe at:
- IMSS (when they have a doctor working - usually before 9pm).
- Centro de Salud (but only if stung between 8am and 3pm)
- Chapala Municipal clinic (24 hours)
- Cruz Roja (24 hours)

Got hit by an alacran/scorpion on the knee about a week ago.  It was a small, very light brown almost transparent one. This happened at 10PM....drank a liter of milk and had a burning/numbing sort of pain until 3AM, fell asleep then and the next day had no problem or pain, except for the loss of sleep.
It wasn't fun but it wasn't fatal.  

slainte39 wrote:Got hit by an alacran/scorpion on the knee about a week ago.  It was a small, very light brown almost transparent one. This happened at 10PM....drank a liter of milk and had a burning/numbing sort of pain until 3AM, fell asleep then and the next day had no problem or pain, except for the loss of sleep.
It wasn't fun but it wasn't fatal.  

Aside from the nocturnal trips to the toilet, what other noticeable effect did the milk have? My wife almost stepped on a scorpion a few days age that was just as you described: small, almost transparent. We spray our doorways and windows with cynoff and the bug seemed to be a little worse for wear for it. In fact in just under a year here it is only the second live scorpion we've had in the house.

Anyway, good to here the symptoms were not too severe.

It seems different people have different reactions to scorpion venom, so one size doesn't fit all.  Being (for a while), a septuagenarian, you always hear, "we" are in more danger....but who knows?''...probably so.
The milk is an old wives tale home remedy that a very intelligent younger member of the family believes in, so that's what I did.
Avoidance and prevention  are the best policies to start with.

a former maid swears by the milk thing. they even give it to toddlers when they get stung and it works she says.
the small clear ones give you a nastier whack than the bigger brown ones.

Centro de Salud here on the coast must have only one anti-venom. Gringo neighbor got stung on the hand while taking clothes off the line ..... but she never saw it.  Could have been a bee or wasp but she got a shot of anti-venom because she was afraid

Pedro wrote:a former maid swears by the milk thing. they even give it to toddlers when they get stung and it works she says.
the small clear ones give you a nastier whack than the bigger brown ones.

I've seen other people agonizing and in pain for days with scorpion stings so I have to go with the milk thing in my case. 
Would I have been different without the milk?....who knows"...and I'm not going to find out for the sake of about 12 pesos worth of milk.

What about intravenous liquids to flush the toxins?
My husband was in terrible pain for days after a sting from one of the small brown scorpions - went to Cruz Roja but they wouldn't administer the anti-venom because he wasn't having allergic reactions, tried pain killers and an antihistamine, topical analgesics, everything we could think of. Finally our local doctor sent us to a clinic by the bus station in Chapala where they hooked him up to an IV, and after several hours of that the pain had diminished somewhat. I don't know what was in the IV however.

Sounds like a tequila IV.....works everytime.

CanuckBob wrote:Sounds like a tequila IV.....works everytime.

<<snork>>

For a more layman style of advice from someone who has spent a lot of time in the Sierras, it is true most scorpions around here do not cause a reaction  other than pain and fear, but why take a chance? If you do not know what kind of a reaction you will have the list provided above is critical to understand.

If you have any of the symptoms of severe reaction, you may only have 30 minutes or less to get treatment before dropping dead. Lots of factors are involved so I don't want to alarm, just advise. Do not be a stoic with the home remedies, be safe and over react yourself to a clinic..
It is always smarter to err on the side of caution if you get stung, especially for the first time, but anytime makes sense. You never know when a bad one gotcha. As a survivor of more than my share of stings, I can say this from experience.
Get yourself to one of the clinics mentioned above and wait it out. They will only treat the severe reaction and will just keep you sitting around until they say "go home, you're ok". So you lose a few hours waiting. Its worth the risk.
Nevertheless, even if after going home from the clinic, if hyper-salivation (excess water in the mouth) occurs any time after that, numbing of the tongue or any other symptom, get thee back to the clinic post haste. Some people have been known to have delayed reactions depending on the site of the bite and other factors (like size).
We were once counseled during our Mexico specific first aide courses to keep two antihistamines on site at all times. This was a red cross course of its day and is admittedly outdated by a decade so I don't know if they still recommend it. Anyway, at the time, they recommended:
1. Avapena is your number one pill to take after sting, then,
2. if your reaction is looking to be severe and you think you may not get to a clinic in time, take a benedryl.
Someone with an inside at the Red Cross could maybe verify that advice? It is what they recommend in states like Guerrero and it has served me well.

BTW don't be surprised if 10 days or so after any sting if you get the "hormigas". Feels like ants running around the stung site and following the nerves upwards. Scorpion venom attacks the nerves and this is a known side effect. It will pass and is nothing to be alarmed about. Do your own research and due diligence on this. Google it if you want more info.

Avapena is a brand name for a first-generation antihistamine very similar to Benadryl (diphenhydramine). Many doctors, and even more laymen will tell you to take it. Do not take it unless you have a real allergic reaction (very rare with a scorpion sting).

Before the mid 90s in Mexico, the best treatment was serum, which looked like this snake antidote serum. It was the leftover clear fluid in blood when the red and white cells are removed. It had many extra proteins that could cause a very serious allergic reaction. Thus pretreatment with a strong antihistamine was needed and done before giving the serum. Many doctors remember or learn processes but may not know the reason. Thus the antihistamine protocol still remains for many.  

The treatment used now is not serum. It is made from serum, but is just the pure antibodies. They are also modified so that the antibody tail is cut off, leaving only  a very small, and effective part to deactivate the toxin. No antihistamine is needed with it.

Antihistamines affect the nerves, and so does the toxin. Adding the two together is not making anything better. It makes it worse. Here in a brain activity scan showing the use of antihistamines, and showing the decrease in neural function on the right with a first-generation antihistamine similar to Avapena or Benadryl

holdrja wrote:What about intravenous liquids to flush the toxins?
My husband was in terrible pain for days after a sting from one of the small brown scorpions - went to Cruz Roja but they wouldn't administer the anti-venom because he wasn't having allergic reactions, tried pain killers and an antihistamine, topical analgesics, everything we could think of.  Finally our local doctor sent us to a clinic by the bus station in Chapala where they hooked him up to an IV, and after several hours of that the pain had diminished somewhat.  I don't know what was in the IV however.

Intravenous administration of fentanyl 1 mcg/kg. Fentanyl is preferred if antivenom administration is planned because, unlike morphine, fentanyl does not cause histamine release.


This is the current STANDARD OF CARE for pain management. It is somewhat expensive but works.