Scorpion Envenomation Workup

  • Author: David Cheng, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 9, 2011
 

Laboratory Studies

Scorpion envenomation cases vary from those requiring no laboratory tests to scenarios requiring extensive hematologic, electrolyte, and respiratory analysis.

  • Obtain a CBC count for leukocytosis and hemolysis in patients with stings from the Hemiscorpius species. Hemiscorpius lepturus has been shown to cause severe hemolysis.
  • Electrolyte evaluation is warranted in patients with venom-induced salivation, vomiting, and diarrhea.
  • Coagulation parameters should be measured for venom-induced defibrination because, at high concentrations, the venom is an anticoagulant. Defibrination syndrome has been reported following Mesobuthus tamulus stings.
  • Glucose levels should be measured to evaluate for hyperglycemia from liver and pancreas dysfunction.
  • Creatine kinase and urinalysis help evaluate for venom-induced excessive motor rhabdomyolysis. Renal failure may occur secondary to hemoglobinuria from hemolysis (after H lepturus sting) or myoglobinuria from rhabdomyolysis
  • Obtain amylase/lipase values to assess for pancreatitis, which is common, from Tityus trinitatis stings.
  • Patients may have increased aspartate aminotransferase and alanine aminotransferase levels from venom-induced liver cell destruction.
  • Increased catecholamine, aldosterone, renin angiotensin, and antidiuretic hormone levels are detected a few hours after the sting. The increased levels persist for 6 hours, after which a gradual decline occurs.
  • Interleukin (IL)–1 levels are elevated in all envenomations.
  • High levels of IL-6, interferon-gamma, and granulocyte-macrophage colony-stimulating factor are present in severe envenomations.
  • Radiolabeled antibodies or immunoenzymatic assays help quantify the serum venom level because an association exists between the clinical signs of envenomation and this level.
  • Obtain arterial blood gas (ABG) measurements as indicated for respiratory distress or to determine acid/base status.
Next

Imaging Studies

  • Obtain a chest radiograph in cases of respiratory difficulty. Unilateral pulmonary edema may be seen on chest x-ray films because of the venom effect on pulmonary vascular permeability.
  • Echocardiography findings are discussed as follows:
    • Echocardiography is more sensitive than electrocardiography and creatine kinase assays for assessing myocardial compromise after a scorpion sting.
    • Findings show a diffuse global biventricular hypokinesis with a decreased left and right ventricular ejection fraction of approximately 0.14-0.38. This dysfunction can appear just a few hours after the sting and usually normalizes within 4-8 days.
    • Serial echocardiography findings show that the return of left ventricular function to a normal state correlates to clinical cardiorespiratory improvement.
  • Color-flow Doppler study findings show mitral incompetence, probably secondary to venom-induced dilated cardiomyopathy.
  • Myocardial perfusion scintigraphy can also be used to investigate the contractility and perfusion of the cardiac tissue.[11]
Previous
Next

Other Tests

  • Arterial blood gas determinations show a decrease in arterial oxygenation tension and an increase in PCO2 within 15 minutes of the envenomation, findings consistent with mild metabolic acidosis.
  • Pulmonary artery catheterization findings may include the following:
    • Elevated systemic vascular resistance occurs up to 4 times the normal level, with elevated mean arterial pressure (MAP) of 203 mm Hg.
    • Left ventricular failure produces a MAP of 57-69 mm Hg.
    • Biventricular failure produces a MAP of 47 mm Hg.
    • Low cardiac index occurs with elevated filling pressures.
  • Perform serial spirometry measurements to help detect impending venom-induced diaphragmatic failure.
  • Electrocardiography, if indicated
    • ECG changes persist for 10-12 days before normalizing.
    • ECG changes are observed in 63% of children who have been envenomated.
    • Rhythm disturbances are not dose-dependent but are related to the venom composition.
      • Sinus tachycardia - Most common rhythm
      • QTc prolongation - 53%
      • ST changes - 39%
      • T-wave inversion - 39%
      • Ventricular repolarization abnormalities - 15%
      • Bundle-branch block - 12.8%
      • First-degree block - 10.2%
    • A possible sequence of ECG changes has been noted. This sequence starts with bizarre, broad-notched, biphasic, peaked T waves with a beat-to-beat variation. This bizarre T wave is followed by the appearance of tiny Q waves and then atrioventricular dissociation with an accelerated junctional rhythm.
Previous
Next

Procedures

Cerebrospinal fluid pleocytosis is evident on spinal tap studies.

Previous
Next

Histologic Findings

The local sting site shows mixed inflammatory cell infiltrates with eosinophils scattered among collagen bundles in an edematous dermis. Myocardial changes, which are most prominent at the papillary muscle and subendocardial region, include focal myocardial necrosis; myofibril destruction, especially at the I band; fine fatty deposits in the cardiac muscle fibers; interstitial edema; and increased cellularity, mainly lymphocytes and monocytes. Changes resemble interstitial hypoxia-induced myocarditis caused by large doses of catecholamines.

Previous
Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

David Cheng, MD  Associate Professor of Emergency Medicine, Education Director, Associate Emergency Medicine Residency Director, Case Medical Center

David Cheng, MD is a member of the following medical societies: American College of Emergency Physicians, American Heart Association, Council of Emergency Medicine Residency Directors, International Society for Mountain Medicine, National Association of EMS Physicians, Society for Academic Emergency Medicine, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Judith A Dattaro, MD, FACEP  Assistant Professor of Emergency Medicine in Surgery, Cornell University Medical College; Consulting Staff, Department of Emergency Medicine, Weill-Cornell University Medical Center, New York Presbyterian Hospital

Judith A Dattaro, MD, FACEP is a member of the following medical societies: American Association of Women Emergency Physicians, American College of Emergency Physicians, American Medical Association, Chicago Medical Society, Illinois State Medical Society, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Ramy Yakobi, MD, MBA  Medical Director, Department of Emergency Medicine, Beth Israel Medical Center

Ramy Yakobi, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Sean P Bush, MD, FACEP  Professor of Emergency Medicine, Loma Linda University School of Medicine; Consulting Staff, Envenomation Specialist, Department of Emergency Medicine, Loma Linda University Medical Center

Sean P Bush, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, International Society on Toxicology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Protherics Consulting fee Consulting; Nycomed (formerly Fougera) Grant/research funds Speaking and teaching; Rare Disease Therapeutics Grant/research funds Research; Bioclon Grant/research funds Research

Charles J Gerardo, MD, FACEP  Associate Professor, Department of Surgery, Division of Emergency Medicine, Duke University School of Medicine; Director of Clinical Affairs, Division of Emergency Medicine, Duke University Medical Center

Charles J Gerardo, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Hispanic Medical Association, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Lisa Kirkland, MD, FACP, CNSP, MSHA  Assistant Professor, Department of Internal Medicine, Division of Hospital Medicine, Mayo Clinic; ANW Intensivists, Abbott Northwestern Hospital

Lisa Kirkland, MD, FACP, CNSP, MSHA is a member of the following medical societies: American College of Physicians, Society of Critical Care Medicine, and Society of Hospital Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

References

  1. Chippaux JP, Goyffon M. Epidemiology of scorpionism: a global apprasial. Acta Trop. 2010/08;107:71-9.

  2. Jahan S, Mohammed Al Saigul A, Abdul Rahim Hamed S. Scorpion stings in Qassim, Saudi Arabia--a 5-year surveillance report. Toxicon. Aug 2007;50(2):302-5. [Medline].

  3. Shahbazzadeh D, Amirkhani A, Djadid ND, Bigdeli S, Akbari A, Ahari H. Epidemiological and clinical survey of scorpionism in Khuzestan province, Iran. Toxicon. Mar 15 2009;53(4):454-9. [Medline].

  4. Langley RL, Morrow WE. Deaths resulting from animal attacks in the United States. Wilderness Environ Med. Feb 1997;8(1):8-16. [Medline].

  5. Boyer L, Heubner K, McNally J, Buchanan P. Death from Centruroides scorpion sting allergy [abstract]. J Toxicol Clin Toxicol. 2001;39:561-562.

  6. Bosnak M, Ece A, Yolbas I, Bosnak V, Kaplan M, Gurkan F. Scorpion sting envenomation in children in southeast Turkey. Wilderness Environ Med. Summer 2009;20(2):118-24. [Medline].

  7. Parma JA, Palladino CM. [Scorpion envenomation in Argentina]. Arch Argent Pediatr. Apr 2010;108(2):161-7. [Medline].

  8. Freire-Maia L, Pinto GI, Franco I. Mechanism of the cardiovascular effects produced by purified scorpion toxin in the rat. J Pharmacol Exp Ther. Jan 1974;188(1):207-13. [Medline].

  9. Pinto MC, Borboleta LR, Melo MB, Labarrére CR, Melo MM. Tityus fasciolatus envenomation induced cardio-respiratory alterations in rats. Toxicon. Jun 1 2010;55(6):1132-7. [Medline].

  10. Bawaskar HS. Diagnostic cardiac premonitory signs and symptoms of red scorpion sting. Lancet. Mar 6 1982;1(8271):552-4. [Medline].

  11. Figueiredo AB, Cupo P, Pintya AO, Caligaris F, Marin-Neto JA, Hering SE. [Assessment of myocardial perfusion and function in victims of scorpion envenomation using gated-SPECT]. Arq Bras Cardiol. Apr 2010;94(4):444-51. [Medline].

  12. [Best Evidence] Boyer LV, Theodorou AA, Berg RA, et al. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. May 14 2009;360(20):2090-8. [Medline]. [Full Text].

  13. Natu VS, Kamerkar SB, Geeta K, Vidya K, Natu V, Sane S, et al. Efficacy of anti-scorpion venom serum over prazosin in the management of severe scorpion envenomation. J Postgrad Med. Oct-Dec 2010;56(4):275-80. [Medline].

  14. Bawaskar HS, Bawaskar PH. Efficacy and safety of scorpion antivenom plus prazosin compared with prazosin alone for venomous scorpion (Mesobuthus tamulus) sting: randomised open label clinical trial. BMJ. Jan 5 2011;342:c7136. [Medline]. [Full Text].

  15. Gupta BD, Parakh M, Purohit A. Management of scorpion sting: prazosin or dobutamine. J Trop Pediatr. Apr 2010;56(2):115-8. [Medline].

  16. Patil SN. A retrospective analysis of a rural set up experience with special reference to dobutamine in prazosin-resistant scorpion sting cases. J Assoc Physicians India. Apr 2009;57:301-4. [Medline].

  17. Centruroides (Scorpion) Immune F(ab')2 (Equine). Prescribing information. Accessed August 9, 2011. [Full Text].

  18. Bouaziz M, Bahloul M, Kallel H, Samet M, Ksibi H, Dammak H, et al. Epidemiological, clinical characteristics and outcome of severe scorpion envenomation in South Tunisia: multivariate analysis of 951 cases. Toxicon. Dec 15 2008;52(8):918-26. [Medline].

  19. Guerra CM, Carvalho LF, Colosimo EA, Freire HB. Analysis of variables related to fatal outcomes of scorpion envenomation in children and adolescents in the state of Minas Gerais, Brazil, from 2001 to 2005. J Pediatr (Rio J). Nov-Dec 2008;84(6):509-15. [Medline].

  20. Abroug F, Ayari M, Nouira S, et al. Assessment of left ventricular function in severe scorpion envenomation: combined hemodynamic and echo-Doppler study. Intensive Care Med. Aug 1995;21(8):629-35. [Medline].

  21. Amaral CF, Dias MB, Campolina D, Proietti FA, de Rezende NA. Children with adrenergic manifestations of envenomation after Tityus serrulatus scorpion sting are protected from early anaphylactic antivenom reactions. Toxicon. Feb 1994;32(2):211-5. [Medline].

  22. Amaral CF, Lopes JA, Magalhaes RA, de Rezende NA. Electrocardiographic, enzymatic and echocardiographic evidence of myocardial damage after Tityus serrulatus scorpion poisoning. Am J Cardiol. Mar 15 1991;67(7):655-7. [Medline].

  23. Amaral CF, Rezende NA. Treatment of scorpion envenoming should include both a potent specific antivenom and support of vital functions. Toxicon. Aug 2000;38(8):1005-7. [Medline].

  24. Amitai Y, Mines Y, Aker M, Goitein K. Scorpion sting in children. A review of 51 cases. Clin Pediatr (Phila). Mar 1985;24(3):136-40. [Medline].

  25. Bahloul M, Ben Hamida C, Chtourou K, et al. Evidence of myocardial ischaemia in severe scorpion envenomation. Myocardial perfusion scintigraphy study. Intensive Care Med. Mar 2004;30(3):461-7. [Medline].

  26. Bawaskar HS, Bawaskar PH. Clinical profile of severe scorpion envenomation in children at rural setting. Indian Pediatr. Nov 2003;40(11):1072-5. [Medline].

  27. Bawaskar HS, Bawaskar PH. Severe envenoming by the Indian red scorpion Mesobuthus tamulus: the use of prazosin therapy. QJM. Sep 1996;89(9):701-4. [Medline].

  28. Bergman NJ. Scorpion sting in Zimbabwe. S Afr Med J. Feb 1997;87(2):163-7. [Medline].

  29. Bharani AK, Sepaha GC. Myelopathy after scorpion sting. Arch Neurol. Nov 1984;41(11):1130. [Medline].

  30. Biswal N, Mathai B, Bhatia BD. Scorpion sting envenomation: complications and management. Indian Pediatr. Aug 1993;30(8):1055-9. [Medline].

  31. Bond GR. Antivenin administration for Centruroides scorpion sting: risks and benefits. Ann Emerg Med. Jul 1992;21(7):788-91. [Medline].

  32. Brand A, Keren A, Kerem E, Reifen RM, Branski D. Myocardial damage after a scorpion sting: long-term echocardiographic follow-up. Pediatr Cardiol. 1988;9(1):59-61. [Medline].

  33. Carbonaro PA, Janniger CK, Schwartz RA. Scorpion sting reactions. Cutis. Mar 1996;57(3):139-41. [Medline].

  34. Cupo P, Jurca M, Azeedo-Marques MM, Oliveira JS, Hering SE. Severe scorpion envenomation in Brazil. Clinical, laboratory and anatomopathological aspects. Rev Inst Med Trop Sao Paulo. Jan-Feb 1994;36(1):67-76. [Medline].

  35. Curry SC, Vance MV, Ryan PJ, Kunkel DB, Northey WT. Envenomation by the scorpion Centruroides sculpturatus. J Toxicol Clin Toxicol. 1983-1984;21(4-5):417-49. [Medline].

  36. Das S, Nalini P, Ananthakrishnan S, Sethuraman KR, Balachander J, Srinivasan S. Cardiac involvement and scorpion envenomation in children. J Trop Pediatr. Dec 1995;41(6):338-40. [Medline].

  37. De Rezende NA, Dias MB, Campolina D, Chavez-Olortegui C, Diniz CR, Amaral CF. Efficacy of antivenom therapy for neutralizing circulating venom antigens in patients stung by Tityus serrulatus scorpions. Am J Trop Med Hyg. Mar 1995;52(3):277-80. [Medline].

  38. Devi CS, Reddy CN, Devi SL, et al. Defibrination syndrome due to scorpion venom poisoning. Br Med J. Feb 7 1970;1(5692):345-7. [Medline].

  39. el-Amin EO. Issues in management of scorpion sting in children. Toxicon. Jan 1992;30(1):111-5. [Medline].

  40. Freire-Maia L, Campos JA, Amaral CF. Approaches to the treatment of scorpion envenoming. Toxicon. Sep 1994;32(9):1009-14. [Medline].

  41. Gateau T, Bloom M, Clark R. Response to specific Centruroides sculpturatus antivenom in 151 cases of scorpion stings. J Toxicol Clin Toxicol. 1994;32(2):165-71. [Medline].

  42. Ghalim N, El-Hafny B, Sebti F, et al. Scorpion envenomation and serotherapy in Morocco. Am J Trop Med Hyg. Feb 2000;62(2):277-83. [Medline].

  43. Gibly R, Williams M, Walter FG, McNally J, Conroy C, Berg RA. Continuous intravenous midazolam infusion for Centruroides exilicauda scorpion envenomation. Ann Emerg Med. Nov 1999;34(5):620-5. [Medline].

  44. Goyffon M, Vachon M, Broglio N. Epidemiological and clinical characteristics of the scorpion envenomation in Tunisia. Toxicon. 1982;20(1):337-44. [Medline].

  45. Gueron M, Ilia R, Sofer S. The cardiovascular system after scorpion envenomation. A review. J Toxicol Clin Toxicol. 1992;30(2):245-58. [Medline].

  46. Gueron M, Margulis G, Ilia R, Sofer S. The management of scorpion envenomation 1993. Toxicon. Sep 1993;31(9):1071-83. [Medline].

  47. Gueron M, Weizmann S. Catecholamine excretion in scorpion sting. Isr J Med Sci. Jul-Aug 1969;5(4):855-7. [Medline].

  48. Ismail M. The scorpion envenoming syndrome. Toxicon. Jul 1995;33(7):825-58. [Medline].

  49. Karnad DR. Haemodynamic patterns in patients with scorpion envenomation. Heart. May 1998;79(5):485-9. [Medline].

  50. Kric-Dautovic S, Begovic B. Acute renal insuffiency & toxic hepatitis folowing scorpion sting. Med arh. Feb 2007;61:123-4.

  51. Krifi MN, Kharrat H, Zghal K, et al. Development of an ELISA for the detection of scorpion venoms in sera of humans envenomed by Androctonus australis garzonii (Aag) and Buthus occitanus tunetanus (Bot): correlation with clinical severity of envenoming in Tunisia. Toxicon. Jun 1998;36(6):887-900. [Medline].

  52. Magalhaes MM, Pereira ME, Amaral CF, et al. Serum levels of cytokines in patients envenomed by Tityus serrulatus scorpion sting. Toxicon. Aug 1999;37(8):1155-64. [Medline].

  53. Malhotra KK, Mirdehghan CM, Tandon HD. Acute renal failure following scorpion sting. Am J Trop Med Hyg. May 1978;27(3):623-6. [Medline].

  54. Muller GJ. Scorpionism in South Africa. A report of 42 serious scorpion envenomations. S Afr Med J. Jun 1993;83(6):405-11. [Medline].

  55. Murthy KR, Hase NK. Scorpion envenoming and the role of insulin. Toxicon. Sep 1994;32(9):1041-4. [Medline].

  56. Naqvi R, Naqvi A, Akhtar F, Rizvi A. Acute renal failure developing after a scorpion sting. Br J Urol. Aug 1998;82(2):295. [Medline].

  57. Nouira S, Boukef R, Nciri N, et al. A clinical score predicting the need for hospitalization in scorpion envenomation. Am J Emerg Med. May 2007;25(4):414-9. [Medline].

  58. Otero R, Navio E, Cespedes FA, et al. Scorpion envenoming in two regions of Colombia: clinical, epidemiological and therapeutic aspects. Trans R Soc Trop Med Hyg. Dec 2004;98(12):742-50. [Medline].

  59. Radmanesh M. Androctonus crassicauda sting and its clinical study in Iran. J Trop Med Hyg. Oct 1990;93(5):323-6. [Medline].

  60. Radmanesh M. Cutaneous manifestations of the Hemiscorpius lepturus sting: a clinical study. Int J Dermatol. Jul 1998;37(7):500-7. [Medline].

  61. Rajarajeswari G, Sivaprakasam S, Viswanathan J. Morbidity and mortality pattern in scorpion stings. (A review of 68 cases). J Indian Med Assoc. Oct 1979;73(7-8):123-6. [Medline].

  62. Reddy CR, Suvarnakumari G, Devi CS, Reddy CN. Pathology of scorpion venom poisoning. J Trop Med Hyg. May 1972;75(5):98-100. [Medline].

  63. Sofer S. Scorpion envenomation. Intensive Care Med. Aug 1995;21(8):626-8. [Medline].

  64. Sundararaman T, Olithselvan M, Sethuraman KR, Narayan KA. Scorpion envenomation as a risk factor for development of dilated cardiomyopathy. J Assoc Physicians India. Nov 1999;47(11):1047-50. [Medline].

  65. Tu A, ed. Handbook of Natural Toxins: Invertebrate Venoms. Vol 2. New York, NY: Marcel Dekker; 1984:513-678.

  66. Velasco-Castrejon O, Lara-Aguilera R, Alatorre H. [Clinical and epidemiological aspects of scorpion sting in a hyperendemic area]. Rev Invest Salud Publica. Apr-Jun 1976;36(2):93-103. [Medline].

 
Previous
Next
 
Centruroides limbatus, identified by Scott Stockwell, PhD. A small barb at the base of the stinger may be helpful in identifying Centruroides or Tityus species, although its presence is variable. Photo by Sean Bush, MD.
Centruroides species. Note the slender pincers generally characteristic of scorpions from the family Buthidae. Photo by Sean Bush, MD.
Scorpions from the family Buthidae (which includes almost all of the potentially lethal scorpions) generally can be identified by the triangular sternal plate. In other families of scorpions, this feature is more square or pentagonal. Photo by Sean Bush, MD.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.