The fi rst aid currently recommended is based around the mnemonic ‘R.I.G.H.T’. The
details provided earlier in Table no.6 is again furnished below for easy reading.
Table No. 6: Currently recommended First aid
• R = Reassure the patient.
• I = Immobilisation of the limb in the same way as a fractural limb helps to
prevent rapid absorption of the venom into the circulation. (Use bandages
or cloth to hold the splints, not to block the blood supply or apply
pressure. Do not apply any compression in the form of tight ligatures,
they don’t work and can be dangerous!).
• G. H. = Get to Hospital Immediately. (Traditional remedies have NO PROVEN
benefi t in treating scorpion sting).
• T = Tell the doctor all that happened from the time of scorpion sting along
with symptoms that developed till reaching (or arrival) the hospital.
This method will get the victim to the hospital quickly, without recourse to
traditional medical approaches which can delay effective treatment.
Traditional methods
The traditional methods such as application of counter irritants, herbal materials
or paste over the site of sting or tight tourniquet (it may intensify local effects of
venom), or hot fomentation should be avoided as they may enhance the effects of
venom. Also avoid cutting and suction (oral extraction of venom from the site), or
cutting and letting out the blood, or washing the wound with chemicals or alcohol or
other methods as they facilitate the absorption of toxin. In view of the consequences
noticed, these traditional methods have to be discarded.
However, local application of ice bags (one of the traditional methods) to reduce
the pain is acceptable for some time if not contraindicated. This method slows down
the absorption of venom via vasoconstriction. This is the most effective one during the
fi rst 2 hours following the scorpion sting. One should not cause freezing injury, while
using ice cubes / bag.
While dealing a case of scorpion sting consider mnemonic ‘RASI’.
• Remember principles
• Address the problems – clinical and social
• Seek help from others when required and
• Inform the patient and / or care givers on the status of illness, clinical course,
management, outcome, welfare measures and follow up clearly with empathy.
Principles involved in the management of scorpion sting
The principles envisaged to treat scorpion sting at all Health Centres / Hospitals
irrespective of the status (Government or Private) are given below (the same given
under snake bite) under “12 As”.
Table No. 7: Principles involved in the management
1. Admit the victim immediately.
2. Ask effectively.
3. Assess quickly.
4. Act swiftly.
5. Administer medication meticulously.
6. Address to the wound properly.
7. Anticipate complications keenly.
8. Avoid errors carefully.
9. Ascertain the status repeatedly.
10. Amicable with patients and care givers and show empathy.
11. Advise on follow up accordingly.
12. Arrange for referral early.
1) Admit all victims of scorpion sting & keep the victims under observation for
24 to 48 hrs. (If scorpion is brought try to identify the colour and size of it).
2) a) Ask for the details of scorpion sting and never be carried away with the sting
marks either for diagnosis or for assessment of severity.
• Time of sting
• Number of stings
• Nature of the incident
• Depth of the sting
• Site of envenomation-close to head & torso [results in quicker venom
absorption & onset of symptoms in the former]
b] Ask for the time interval between the sting and arrival at the hospital.
c] Ask for the details of traditional medicines or household remedies used, as it
may sometimes cause confusing symptoms or interfere with other drugs to be
administered.
d] Ask for clinical symptoms and correlate with the progression of symptoms and
signs due to scorpion sting [provided in page vide supra]
3] Assess the following quickly.
a] Airway, Breathing and Circulation
b] Vitals HR, RR, BP and Pulse oximetry (if required)
c] Site of sting and the probable route of envenomation – (Intravenous have
immediate effects, while subcutaneous and intramuscular routes take several
minutes to hours to cause effect)
d] Chest expansion
e] Clinically from head to foot as well as back
f] For associted co-morbid illness[es]
g] For consuming any medication[s]
h] Status of envenomation – mild, moderate and severe
[in view of neurotoxic, cardiotoxic, hemotoxic, myotoxic or a combination of them]
4] Act swiftly
a] To support Airway, Breathing and Circulation
b] To start IV line [fl uid for children – refer Annexure II Table No.29]
c] To provide supportive measures depending upon the requirements
d] To connect ventilator if there is a need
5] Administer medication meticulously
a] Tetanus Toxoid injection intramuscularly
b] Topical anaestetic agent to the site of sting to decrease paraesthesia.
c] Injection lignocaine 1% without adrenaline; 2ml as local infi ltration
(after test dose for lignocaine) (0.1 to 0.2mg/kg body weight for children)
d] Oral rehydration solution to hydrate the patient if not contraindicted.
e] Tab. Paracetamol 10mg/kg body weight to reduce pain
f] Tab. Prazosin [plain 1mg]
Pharmacological aspects of Prazosin
Prazosin is an alpha blocker. It counteracts scorpion induced adrenergic
cardiovascular effects and reduces pulmonary edema through vasodilatory effect,
Usually it is started with small dose using plain tablet but not exceeding 5mg/day.
For children the dose preferred is 30 microgram / kg body weight. Though pediatric
requirement has not been established, it is started with small dose. Prazosin can be
given irrespective of blood pressure, provided there is no hypovolemia
It should be avoided, if the patient is hypersensitive to prazosin. Always exercise
caution if patient has renal insuffi ciency and hypertension. Users must remember that
it interacts with beta blocker and causes hypotension. Also, verapamil may increase
serum levels of prazosin and increase patient’s sensitivity to prazosin and cause
postural hypotension. Interestingly, prazosin decreases the anti hypertensive effect of
clonidine. Safety in pregnancy has not been established. Also, users are informed to
follow standard measures while using prazosin (Refer Table No.21).
Table No. 21: Measures to be adopted while using Prazosin
• Prazosin should not be given as prophylactic dose when pain is the only
symptom.
• Give Prazosin through nasogastric tube, if baby has vomiting.
• Keep the patient in lying posture for about 3 hours (even while examining
the case) in order to prevent ‘fi rst dose phenomenon’ (hypotension) due to
Prazosin.
• Monitor pulse, BP, and respiration every 30 minutes for 3 hours.
• Reassess for warmth and return of pain at the site of sting.
• Continue monitoring of pulse, BP, and respiration every 60 minutes for next
6 hours.
• Recheck the same every 4 hours till improvement is visible.
• Repeat Tab. Prazosin in the same dose at the end of 3 hours according to
clinical response and later every 6 hours till extremities are warm, dry and
peripheral veins are visible easily.
* Alternative to Tab. Prazosin is Nifi dipine, Nitroprusside, Nitroglycerine, Isosorbide
di-nitrate, Hydralazine or Angiotensin converting enzyme inhibitors (ACEIs).
However, users have to remember the constraints while prescribing such drugs.
g] Beta-blockers in small doses along with alpha blockers if needed and if not
contraindicated.
h] Nitrates if patient has hypertension and myocardial ischemia
i] Ionotropics such as digitalis (has little effect), or dobutamine (refer snake bite
section for details). Avoid Dopamine as it aggravates the myocardial damage.
j] Nor-epinephrine as IV drip to correct hypotension refractory to fl uid therapy.
k] Antimicrobials if infection is suspected
l] Inj. Atropine (required at times) to counter venom induced parasympathetic
effects.
m] Inj. Insulin has been shown to prevent multiorgan failure (especially cardiopulmonary)
in animal experiments.
n] Barbiturate and / or benzodiazepine as continuous infusion for severe /
excessive motor activity
o] Steroids to decrease shock and edema is of unproven benefi t.
p] Antivenom for scorpion sting is not used commonly in India (as species specifi c
antivenom is not available and usage has not demonstrated any benefi t)
q] Vaccine – not available (tried in experimental animals).
r] IV fl uids as per need [fl uid for children- refer Annexure II Table No.29].
s] Other supportive medications such as sodium nitroprusside (0.3 –0.5 mcg/
kg/min with upward titration), or nitroglycerine as per need (usually in
pulmonary edema)
Though Inj. Morphine is used as a standard therapy for pulmonary edema, it should
be avoided in scorpion sting since narcotics worsen dysrhythmias in children
6] Address to the wound properly
The details of wound care are provided below. However, one should also remember
the other surgical issues described vide Table 11 in the snake bite section.
a] Wound following scorpion sting may show sting marks with or without local
manifestations.
b] Sometimes venom may penetrate deep and hence deeper tissues may be
damaged which may not be visible during initial examination (rare).
c] At the site of the sting a bleb or vesicle may develop and end in the form of non
specifi c ulcer. (Non-specifi c ulcers are defi ned as ulcers due to infection of
wounds, physical or chemical agents or due to local irritation).
d] Consider the following while managing the wound / ulcer (uncommon in
scorpion sting).
• Minimize unnecessary blood loss.
• Initiate adequate cleaning with normal saline or tap water, and edema
control.
• Remove debris and necrotic tissue, irrigate gently with water / normal
saline.
• Expose viable tissues, excise eschar after controlling hemotoxic
complications.
• Use topical antibacterial agents.
• Apply dressings after complete debridement.
• Maintain proper wound environment and prevent ischemia.
• Keep the bacterial count as low as possible.
• Facilitate healing of acute wound by applying non adherent dressing to
ensure adequate epithelialization and to prevent contamination of the
wound.
• Keep wounds clean and dry.
• Avoid soaking or scrubbing the wound.
• Teach & explain the care of wound to the patients and / or care givers.
• Educate on good personal hygiene and nutrition.
• Control diabetes if identifi ed.
7] Anticipate complications keenly.
a] Examine the victims at regular intervals for alterations in symptoms and signs
b] Anticipate dysrhythmias during the fi rst 24 to 48 hours after sting
c] Start tapering prazosin after the clinical improvement begins to manifest
d] Observe for drug related systemic changes and drug toxicity, and treat them
accordingly.
8] Avoid errors carefully while assessing the case, investigating the victims,
administering medications, following the case at hospital, undertaking any
procedures for the patient, referring to other specialists or hospitals, communicating
with patients / and care givers, planning for discharge, preparing reports, fi lling up
the forms, reviewing the data and conducting the audit.
9] Ascertain the status repeatedly and provide supportive measures, as these cases
may develop covert signs during hospital stay while on treatment.
10] Amicably interact with patient and care givers and show empathy to them in
view of the socio clinical aspects related to scorpion sting.
11] Advise on follow up accordingly in view of the systemic toxicity. Patients may
also be motivated to attend to the nearest Health Centre / Hospital for follow up
care. Follow-up checks are required for assessment of long term effects on different
organs / systems and for appropriate management wherever required / needed.
12. Arrange for referral early – One should also remember the criteria for referral and
provide clear instructions while referring the case. The details on referral aspects
are provided in Table 24.