Page 45 - 2026 SMOG

GLOBAL SCORPION ENVENOMATION
Scorpions envenomate humans by stinging them with the telson on their tail. The majority of
medically significant envenomation occurs in the Middle East, the tropics (e.g., Southwest Asia,
India, Central and South America), and North Africa. Scorpions are nocturnal, hibernate in winter,
and are active in the warm seasons. Humans are frequently envenomated by scorpions hiding in
dark, hidden locations such as inside shoes and small crevices.
Antivenom is available for some species; data regarding the benefits and risks of many of these
antivenoms are significantly limited. In patients with moderate to severe symptoms refractory to
analgesics and benzodiazepines, antivenom, if available, may be indicated. Due to the high risk
of immediate or delayed allergic reactions to these antivenoms, administration should be done
at a controlled clinical location, and prehospital treatment should be focused on supportive care.
Intravenous histamine antagonists (i.e., diphenhydramine), steroids, and epinephrine should be
immediately available prior to antivenom administration.
Clinical Grade and Treatment of Scorpion Stings
Grade Effects Treatment
1 Local Effects Only Analgesia
2 Mild/Moderate Autonomic Excitation Benzodiazepines
(i.e., tachycardia, hypertension)
Agitation and Anxiety Benzodiazepines
Pain and Paresthesia Remote to Sting Site Analgesia
3 Pulmonary Edema Antivenom, noninvasive or
mechanical ventilation
Hypotension or Cardiogenic Shock Antivenom, vasopressors
Neuromuscular excitation, somatic neuromuscular Antivenom, benzodiazepines
dysfunction, or cranial nerve dysfunction (associated
with Centruroides species)
4 Multiorgan failure, coma, seizures, endorgan damage Antivenom, vasopressors,
secondary to hypotension, somatic neuromuscular sedation (benzodiazepines,
dysfunction, and cranial nerve dysfunction propofol, phenobarbital),
(associated with Centruroides species) mechanical ventilation
**Notes/Pearls**
• Treat anaphylactic reactions as soon as they are recognized.
• For clinically significant envenomation, management is supportive and focused on the patient’s
symptoms and graded 1–4.
• Patients graded 3&4 will require antivenom and evacuation to an MTF able to administer
antivenom.
• Administer Benzodiazepines aggressively to ensure symptom control
• For significant neuromuscular spasm, oral secretions, sedation, or other threats to the patient’s
airway, perform endotracheal intubation to prevent aspiration and ensure adequate ventilation.
• Manage pulmonary edema with noninvasive or invasive ventilation in combination with
optimization of cardiac output.
• Use directacting vasopressors (epinephrine and norepinephrine) to treat bradycardia and
hypotension.
• DO NOT cut, suck, electrocute, cauterize, or use chemicals on the envenomation site.
Reference: CPG ID #84 (Global Spider and Scorpion Envenomation Management)

2026 Standard Medical Operating Guidelines (SMOG) • 37