Clinic: Scorpions

Examine for venom effects

Autopharmacological effects

• Nausea, vomiting,
• Sweating,
• Urticaria, angioedema,
• Generalized oedema,
• Arterial hypotension / hypovolaemic shock (transient, recurrent),
• Diarrhoea,
• Bronchospasm.

Local Effects

• Local pain is the dominant symptom, often severe
• Redness; oedema; numbness,
• Tender local (spreading) swelling,
• Blistering,
• Lymphangiopathy and lymphadenopathy,
• Necrotic soft tissue; can include muscle locally.

Haematological effects

Clotting disturbances (Nebo hierochonticus)
Localizing neurological signs, meningism, coma (intracranial bleeding!)
Systemic bleeding: retinal haemorrhages; cranial CT features of cerebellar and cerebral and cerebellar haemorrhages.

Microangiopathic haemolysis (Hemiscorpius lepturus)

Neurological effects

Neurological effects 
(Neuromuscular and autonomic nervous system effects)
Neuromuscular dysfunction
Cranial nerves: Ptosis, "wandering" eye movements, dysphagia (inhalation of vomitus!), dysarthria, pharyngeal reflex absent;
Skeletal musculature: involuntary movements, restlessness, reduced grip and pinch strength; muscle spasms.
Descending flaccid paralysis(rarely progresses to involve respiratory muscles)
Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway, by the paralysed tongue or inhaled vomitus. 
Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.
Autonomic nervous system
Within hours:
Transient cholinergic effects
Vomiting, increased peristalsis, diarrhoea, abdominal pain; profuse sweating; pupil constriction.Bradycardia, arterial hypotension, shock. Hypersalivation; increased bronchial secretion, bronchospasm, respiratory failure. Priapism.
Longer-lasting adrenergic effects
Pupil dilatation.
Tachycardia, arrhythmia, arterial hypertension, myocardial failure, pulmonary oedema (cardiogenic + ?non-cardiogenic component), cardiac ischaemia, shock.
Hyperglycaemia (most likely due to hypercatecholaminaemia) 
Acute pancreatitis (also associated with hyperglycaemia)
Hypertensive encephalopathy.

Species-specific envenoming pattern
The assessment of the envenoming pattern is based on the data from publication in which the identification of the snakes is clearly specified and in accordance with accepted criteria.

Other effect
Autopharmacological effects
Experimental and clinical observations suggest that the major systemic effects of envenoming are caused by endogenous catecholamines and acetylcholine, which are released in response to scorpion venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt with in the section "Neurological effects".
However, scorpion venoms are also believed to lead to other indirect effects that are caused by the release of autopharmacologically active substances (such as kinins, prostaglandins and slow-reacting substances). The pathophysiological effects of these substances overlap to a great extent. This makes it difficult to be certain about aetiology. In particular with regard to pulmonary oedema, there has been discussion concerning the effects of mediators on vascular permeability, which might constitute a non-cardiac component of the pulmonary oedema. Peripheral blood pressure regulation is also responsive to a variety of different mediators that might be released.

The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems. The resulting clinical symptoms of envenoming are, therefore, dealt within the section "Neurological effects".

IMPORTANT
Cardial and pulmonary effects
Secondary to autonomic nervous system effects (see neurological effects below).

Common features of medically important scorpion envenoming

¹Local effect

Within minutes:
Local pain is the dominant symptom, often severe; redness; oedema; numbness.

²Systemic effects

The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems. The resulting clinical symptoms of envenoming are, therefore, dealt within the section "Neurological effects":

Neuromuscular and autonomic nervous system dysfunction

• Neuromuscular dysfunction

Cranial nerves: Ptosis, "wandering" eye movements, dysphagia (inhalation of vomitus!), dysarthria, pharyngeal reflex absent;
Skeletal musculature: involuntary movements, restlessness, reduced grip and pinch strength; muscle spasms.
Descending flaccid paralysis(rarely progresses to involve respiratory muscles)
Cyanosis, shallow breathing, respiratory arrest (respiratory paralysis); respiratory arrest may be precipitated by obstruction of the upper airway, by the paralysed tongue or inhaled vomitus. 
Loss of consciousness and generalized convulsions caused by hypoxaemia in patients who have respiratory paralysis.

• Autonomic nervous system effects

Within hours:
Transient cholinergic effects
Vomiting, increased peristalsis, diarrhoea, abdominal pain; profuse sweating; pupil constriction.Bradycardia, arterial hypotension, shock. Hypersalivation; increased bronchial secretion, bronchospasm, respiratory failure. Priapism.
Longer-lasting adrenergic effects
Pupil dilatation.
Tachycardia, arrhythmia, arterial hypertension, myocardial failure, pulmonary oedema (cardiogenic + ?non-cardiogenic component), cardiac ischaemia, shock.
Hyperglycaemia (most likely due to hypercatecholaminaemia) 
Acute pancreatitis (also associated with hyperglycaemia)
Hypertensive encephalopathy.

Ryan et al. (2021), however, argue that “Akin to scorpion envenomation, the symptoms of IS cannot be wholly attributed to sympathetic hyperstimulation” citing Reis et al. (2019). “Also akin to scorpionism, generalised IS symptoms resemble those of CRS.”
IS=Irukandji Syndrome; CRS=Cytokine Release Syndrome

Time course of systemic effects

May develop within minutes but may be delayed for as much as 24 hours (Warrell 2023). 

^A  Androctonus sp. 

Local effect
Within minutes:
Local pain is the dominant symptom, often severe; redness; oedema; numbness.
Neurological effects
Neuromuscular and autonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above).

Secondary cardiovascular effects are particularly prominent following stings by Androctonus.

For treatment: see section 'CLINICAL MANAGEMENT' below.

^B  Buthus sp.

Neuromuscular andautonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above).

For treatment: see section 'CLINICAL MANAGEMENT' below.

^C  Centruroides sp.

Stings cause “local pain and paraesthesia;” in severe envenoming “motor hyperactivity (fasciculation, head jerking, opsoclonus, muscle spasms that can be misinterpreted as tonic-clonic convulsive movements), tachycardia, hypertension, hypersalivation, sweating, respiratory distress with stridor and hypoxaemia requiring assisted ventilation, vomiting and fever” (Warrell 2023).

For treatment: see section 'CLINICAL MANAGEMENT' below.

^D  Hemiscorpius lepturus

Local effects
The sting is often painless, local blistering, necrosis (Warrell 2023 citing; Chadha and Leviav 1979; Radmanesh 1998)
Microangiopathic haemolysis 
Severe microangiopathic haemolysis causing early haemoglobinuria and leading to a HUS-like presentation with AKI that requiresrenal replacement therapy (Warrell 2023).

For treatment: see section 'CLINICAL MANAGEMENT' below.

^E  Hottentotta tamulus (= Mesobuthus tamulus)

Neurological effects
Neuromuscular and autonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above). 

Secondary cardiovascular effects are particularly prominent following stings by Hottentotta tamulus.

“Seizures and strokes causing hemiparesis, hemiplegia and coma are described. Brain CT/MRI shows ischaemic or haemorrhagic strokes (single or multiple infarcts), posterior reversible encephalopathy syndrome (PRES) and transtentorial herniation.“ (Warrell 2023)

For treatment: see section 'CLINICAL MANAGEMENT' below.

^F  Leiurus sp.

Neurological effects
Neuromuscular and autonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above). 
 
Secondary cardiovascular effects are particularly prominent following stings by Leiurus quinquestriatus.

For treatment: see section 'CLINICAL MANAGEMENT' below.

^G  Nebo hierochonticus

Neurological effects
Neuromuscular andautonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above). 
Hematological effects
Bleeding 
Systemic bleeding: retinal haemorrhages; Cranial CT features of cerebellar and cerebral and cerebellar haemorrhages. (Annobil et al. 1991; Annobil 1993).
Coagulopathy
Type of haemostatic defect
Venom-Induced Consumption Coagulopathy (VICC)
Haemostatic parameters
Hypofibrinogenaemia, prolonged aPTT; normal prothrombin and thrombin times (Amr et al. 2021; Annobil et al. 1991; Annobil 1993). 

“Seizures and strokes causing hemiparesis, hemiplegia and coma are described. Brain CT/MRI shows ischaemic or haemorrhagic strokes (single or multiple infarcts), posterior reversible encephalopathy syndrome (PRES) and transtentorial herniation.“ (Warrell 2023)

For treatment: see section 'CLINICAL MANAGEMENT' below.

^H  Parabuthus sp.

The venom appears to cause mainly neuromuscular effects in contrast to Antroctonus, Hottentotta, Leiurus and Tityus venoms. Also in contrast to Antroctonus, Hottentotta, Leiurus and Tityus stings, pulmonary oedema and myocardial damage do not seem to be characteristic for Parabuthus stings. The same is true for priapism (Müller 1993).

For treatment: see section 'CLINICAL MANAGEMENT' below.

^I  Tityus sp.

Neurological effects
Neuromuscular and autonomic nervous system dysfunction (transient cholinergic effects and longer-lasting adrenergic effects) 
The major systemic effects of envenoming are caused by endogenous catecholamines, which are released in response to the venom. As these are transmitters in the sympathetic, parasympathetic and somatic nervous systems, the resulting clinical symptoms of envenoming are dealt within the section "Neurological effects" (see footnote 2 above). 

Secondary cardiovascular effects are particularly prominent following stings by Tityus sp.

“Seizures and strokes causing hemiparesis, hemiplegia and coma are described. Brain CT/MRI shows ischaemic or haemorrhagic strokes (single or multiple infarcts), posterior reversible encephalopathy syndrome (PRES) and transtentorial herniation.“ (Warrell 2023)

T. obscurus/cambridgei
“Envenoming by T. obscurus/cambridgei in Brazil, Guyana and other Latin American countries causes distinctive neurotoxic features including generalised paresthesia, ataxia, dysarthria, myoclonus, dysmetria, electric shock-like sensations throughout the body andrhabdomyolysis” (Pardal et al. 2014; Warrell 2023)

Tityus trinitatis
“Hypercatecholaminaemia could explain hyperglycaemia and glycosuria but envenoming by many species, notably Trinidadian black scorpions (T. trinitatis), causes acute pancreatitis.” (Warrell 2023). Also, species found in the Middle East and Latin America (Wilkins et al. 2025).

Leiurus quinquestriatus
Acute pancreatitis in children (Sofer et al. 1991). 

For treatment: see section 'CLINICAL MANAGEMENT' below. 

Publications reporting broadly on scorpion envenoming
Abroug et al. (2020); Chippaux and Goyffon (2008); Chippaux (2012); Isbister and Bawaskar (2014); Maddy et al. (2021); Wilkins et al. (2025). 

For the Arab Countries of the Middle East
Amr et al. (2021). 

Species-specific publications: see ‘References’ at the end of the file.

Clinical management

See also Clinical Management: scorpions

for advice on post-First Aid measures, diagnosis (clinical, laboratory) and treatment (supportive, antivenom).

First aid

Immobilization of the stung limb. There is no evidence for the use of pressure bandage immobilisation (Wilkins et al. 2025).
Initiation of symptoms: May develop within minutes but may be delayed for as much as 24 hours (Warrell 2023).
Monitoring of patients: at least 4 hours. Late deterioration up to 12 hours can occur (Maddy et al. 2021; Wilkins et al. 2025). Observation up to 24 hours recommended by Warrell (2023).
Severe envenoming is more likely in children and pregnant women most commonly manifesting as hypertensive crisis (Wilkins et al. 2025). 

Local treatment

• Pain control

• Pain may last as long as 10–15 h, sometimes even longer (up to 24 h). In the majority of cases, pain is the only clinical sign and persists during the first 2 h following the sting (Chippaux and Goyffon 2008).
• With pain as the dominant symptom, pain control is in most cases the priority. Initially, ice packs and simple analgesics can be tried (Wilkins et al. 2025). Topical lidocaine appears to be superior to paracetamol and ice packs,and ice packs proved as efficient as parenteral paracetamol (Aksel et al. 2015).
• Local infiltration of 1% lidocaine or xylocaine is very effective using digital block for stings on digits or regional nerve block. Parenteral opiate analgesics such as pethidine and morphine may be required (Warrell 2023). They may, however, worsen autonomic effects (Chippaux 2012).
• In children, signs and symptoms resulting from severe pain can mimic systemic envenoming.

• Tetanus prophylaxis
• Standard wound care (complicating infection is rare) (WHO 2010). 

Systemic supportive treatment

A general understanding of emergency medicine is required, or can be found in emergency medicine guidelines, e.g. ABCDE approach, WHO-ICRC Basic Emergency Care.

Follow SAMPLE & ABCDE approach

• Comprehensive ABCDE approach

• ICRC Basic Emergency Care: approach to the acutely ill and injured (SAMPLE  and ABCDE approach: first module)

Obey Scorpion - specific features

see 'Species-specific envenoming pattern' above.

Key issues

Diagnostics
Laboratory abnormalities

Neutrophil leucocytosis, metabolic acidosis, hypo- or hyperkalaemia, and increased troponin, natriuretic peptide (either BNP or NT- proBNP), and transaminases. Raised serum amylase, lipase and immunoreactive cationic trypsin indicate acute pancreatitis. Hyperglycaemia and glycosuria are explicable by hypercatecholaminaemia causing increased glucagon and cortisol levels, and either decreased insulin levels or insulin resistance.(Amr et al. 2021; Bahloul et al. 2018; Sofer et al. 1991)

Hemiscorpius lepturus (microangiopathic haemolysis)
Blood films (schistocytes > 1% is diagnostic of microangiopathic haemolytic anaemia), free haemoglobin in the plasma and urine, haptoglobin.

Nebo hierochonticus (coagulopathy)
Hypofibrinogenaemia, prolonged aPTT; normal prothrombin and thrombin times.

ECG, imaging

Catecholamine-induced myocardial effects: ECG, echocardiography and other forms of cardiac imaging. Impaired systolic emptying: Early and repeated echocardiography has proved useful in clinical management (Amr et al. 2021; Kumar et al. 1992; Abdel-Baseer et al. 2021; Patil et al. 2021).

Major clinical features and treatment

Hypertension

In patients with hypertension, pain and agitation should be managed first, and, particularly in children, this alone may be sufficient to control hypertension and tachycardia (Wilkins et al. 2025, citing Sofer and Gueron 1990).
Optimization of pain management, particularly in children. Consideration of Benodiazepines; however, caution regarding side effects!

Adrenergic effects

Hypertensive crisis
Titratable intravenous antihypertensives
No good quality trial data exist comparing antihypertensives. The most widely recommended drug for hypertensive crisis is prazosin (Wilkins et al. 2025, citing Isbister and Bawaskar 2014; Chippaux 2012 and Abrough et al. 2020).
For patients with cardiovascular symptoms (hypertension, bradycardia and early pulmonary oedema) α₁-blocker prazosin (Bawaskar and Bawaskar 1996).
In Tunisia, in patients with severe cardiovascular dysfunction, including shock and pulmonary oedema, dobutamine proved safe and effective (Bouaziz et al. 2020), and in India it was effective in prazosin-refractory cases. (Warrell 2023).
In patients with cardiogenic shock and heart failure, there is limited evidence supporting the use of dopamine (Wilkins et al. 2025, citing Abroug et al. 2015; Elatrous et al. 1999).
One proposed treatment algorithm: Prazosin first line in the early stage: Dopamine added for those who develop left ventricular failure (Wilkins et al. 2025, citing Patil 2009).
Cardiac glycosides andβ-blockers are not recommended! (Warrell 2023).
Pulmonary oedema
See above
Antihypertensives, doputamin (see above).
Non-invasive / invasive ventilation as indicated.
Cardiogenic shock
See ‘Hypertensive crisis‘ above. 
Dobutamine (see above).

Cholinergic effects 

Cholinergic syndrome
Consideration of atropine in patients with life-threatening sinus bradycardia; however, caution regarding side effects! (Warrell 2023).

Neuromuscular dysfunction

Neuromuscular excitation, agitation, anxiety
Consideration of Benodiazepines; however, caution regarding side effects!
Paralysis
Non-invasive / invasive ventilation as indicated. 

Nebo hierochonticus
Coagulopathy/Bleeding 
Systemic bleeding: retinal haemorrhages; Cranial CT features of cerebellar and cerebral and cerebellar haemorrhages. (Annobil et al. 1991; Annobil 1993). 

Hemiscorpius lepturus
Microangiopathic haemolysis 
Severe microangiopathic haemolysis causing early haemoglobinuria and leading to a HUS-like presentation with AKI that requiresrenal replacement therapy (Warrell 2023). 

Specific treatment (antivenoms)

Early antivenom treatment is recommended, however, supportive evidence is poor (Amr et al. 2021; Wilkins et al. 2025, Warrell 2023).
Two systematic reviews and metanalyses performed in 2011 and 2017 found only for Centruroides sp. in Mexico and USA (Boyer et al. 2009) and Hottentotta tamulus in India (more rapid resolution than prazosin alone; Natu et al. 2010; Bawaskar and Bawaskar 2011) limited evidence of faster resolution of signs and symptoms of envenoming (Abrough et al. 2011; Rodrigo et al. 2017).
In a trial in Tunesia (patients likely to have been stung by Androctonus australis or Buthus occitanus) antivenom did not show a benefit. However, only 18% of patients were envenomed (Abrough et al. 1999; Amr et al. 2021).

ANTIVENOMS

Indication and selection of antivenom need to be based on the evidence available in the respective region where the envenoming occurs.

References

• Abdel Baseer KA, Aboelela MG, Qubaisy HM. Echocardiographic Evaluation of the Response to Prazosin Treatment in Scorpion Sting. J Trop Pediatr. 2021 Jul 2;67(3):fmaa063. PMID: 33005956. https://doi.org/10.1093/tropej/fmaa063

• Abroug F, ElAtrous S, Nouira S, Haguiga H, Touzi N, Bouchoucha S. Serotherapy in scorpion envenomation: a randomised controlled trial. Lancet. 1999 Sep 11;354(9182):906-9. PMID: 10489950. https://doi.org/10.1016/s0140-6736(98)12083-4

• Abroug F, Ouanes-Besbes L, Ouanes I, Dachraoui F, Hassen MF, Haguiga H, Elatrous S, Brun-Buisson C. Meta-analysis of controlled studies on immunotherapy in severe scorpion envenomation. Emerg Med J. 2011 Nov;28(11):963-9. Epub 2011 May 11. PMID: 21561982. https://doi.org/10.1136/emj.2010.104158

• Abroug F, Souheil E, Ouanes I, Dachraoui F, Fekih-Hassen M, Ouanes Besbes L. Scorpion-related cardiomyopathy: Clinical characteristics, pathophysiology, and treatment. Clin Toxicol (Phila). 2015 Jul;53(6):511-8Epub 2015 Apr 8. PMID: 25851549. https://doi.org/10.3109/15563650.2015.1030676

• Abroug F, Ouanes-Besbes L, Tilouche N, Elatrous S. Scorpion envenomation: state of the art. Intensive Care Med. 2020 Mar;46(3):401-410. Epub 2020 Mar 3. PMID: 32125457. https://doi.org/10.1007/s00134-020-05924-8

• Aksel G, Güler S, Doğan NÖ, Çorbacioğlu ŞK. A randomized trial comparing intravenous paracetamol, topical lidocaine, and ice application for treatment of pain associated with scorpion stings. Hum Exp Toxicol. 2015 Jun;34(6):662-7. Epub 2014 Oct 10. PMID: 25304965. https://doi.org/10.1177/0960327114551394

• Amr ZS, Abu Baker MA, Al-Saraireh M, Warrell DA. Scorpions and scorpion sting envenoming (scorpionism) in the Arab Countries of the Middle East. Toxicon. 2021 Feb;191:83-103. Epub 2020 Dec 31. PMID: 33387549. https://doi.org/10.1016/j.toxicon.2020.12.017

• Annobil SH, Omojola MF, Vijayakumar E. Intracranial haemorrhages after Nebo hierochonticus scorpion sting. Ann Trop Paediatr. 1991;11(4):377-80. PMID: 1721798. https://doi.org/10.1080/02724936.1991.11747533

• Annobil SH. Scorpion stings in children in the Asir Province of Saudi Arabia. Journal of Wilderness Medicine. 1993;4(3):241-251. doi:10.1580/0953-9859-4.3.241

• Bahloul M, Turki O, Chaari A, Bouaziz M. Incidence, mechanisms and impact outcome of hyperglycaemia in severe scorpion-envenomed patients. Ther Adv Endocrinol Metab. 2018 Jul;9(7):199-208. Epub 2018 May 3. PMID: 29977498; PMCID: PMC6022972. https://doi.org/10.1177/2042018818772779

• Bawaskar HS, Bawaskar PH. Severe envenoming by the Indian red scorpion Mesobuthus tamulus: the use of prazosin therapy. QJM. 1996 Sep;89(9):701-4. PMID: 8917746. https://doi.org/10.1093/qjmed/89.9.701

• 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. 2011 Jan 5;342:c7136. PMID: 21209062; PMCID: PMC3016167. https://doi.org/10.1136/bmj.c7136 

• Bouaziz M, Ben Hamida C, Chelly H, Bahloul M, Kallel H. Dobutamine in the treatment of severe scorpion envenoming. Toxicon. 2020 Jul 30;182:54-58. Epub 2020 May 16. PMID: 32428515. https://doi.org/10.1016/j.toxicon.2020.05.007

• Boyer LV, Theodorou AA, Berg RA, Mallie J; Arizona Envenomation Investigators; Chávez-Méndez A, García-Ubbelohde W, Hardiman S, Alagón A. Antivenom for critically ill children with neurotoxicity from scorpion stings. N Engl J Med. 2009 May 14;360(20):2090-8. PMID: 19439743. https://doi.org/10.1056/nejmoa0808455

• Chadha JS, Leviav A. Hemolysis, renal failure, and local necrosis following scorpion sting. JAMA. 1979 Mar 9;241(10):1038. PMID: 762742. doi:10.1001/jama.1979.03290360054029

• Chippaux JP, Goyffon M. Epidemiology of scorpionism: a global appraisal. Acta Trop. 2008 Aug;107(2):71-9. Epub 2008 Jun 5. PMID: 18579104.

• https://doi.org/10.1016/j.actatropica.2008.05.021

• Chippaux JP. Emerging options for the management of scorpion stings. Drug Des Devel Ther. 2012;6:165-73. Epub 2012 Jul 5. PMID: 22826633; PMCID: PMC3401053. https://doi.org/10.2147/dddt.s24754

• Elatrous S, Nouira S, Besbes-Ouanes L, Boussarsar M, Boukef R, Marghli S, Abroug F. Dobutamine in severe scorpion envenomation: effects on standard hemodynamics, right ventricular performance, and tissue oxygenation. Chest. 1999 Sep;116(3):748-53. PMID: 10492282. https://doi.org/10.1378/chest.116.3.748

• Isbister GK, Bawaskar HS. Scorpion envenomation. N Engl J Med. 2014 Jul 31;371(5):457-63. PMID: 25075837. https://doi.org/10.1056/nejmra1401108

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• Maddy JK, Ng PC, Hall A et al. Global Spider and scorpion envenomation management.joint trauma system clinical practice guideline. 2021 https://jts.health.mil/assets/docs/cpgs/Global_Spider_and_Scorpion_Envenomation_Management_09_Feb_2021_ID84.pdf

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• Natu VS, Kamerkar SB, Geeta K, Vidya K, Natu V, Sane S, Kushte R, Thatte S, Uchil DA, Rege NN, Bapat RD. Efficacy of anti-scorpion venom serum over prazosin in the management of severe scorpion envenomation. J Postgrad Med. 2010 Oct-Dec;56(4):275-80 https://doi.org/10.4103/0022-3859.70938

• Erratum in: J Postgrad Med. 2011 Jan-Mar;57(1):60. Kamerkar, S B [added]; Geeta, K [added]; Vidya, K [added]; Natu, V [added]; Sane, S [added]; Kushte, R [added]; Thatte, S [added]; Uchil, D A [added]; Rege, N N [added]; Bapat, R D [added]. PMID: 20935398.

• Pardal PP, Ishikawa EA, Vieira JL, Coelho JS, Dórea RC, Abati PA, Quiroga MM, Chalkidis HM. Clinical aspects of envenomation caused by Tityus obscurus (Gervais, 1843) in two distinct regions of Pará state, Brazilian Amazon basin: a prospective case series. J Venom Anim Toxins Incl Trop Dis. 2014 Feb 11;20(1):3. PMID: 24517181; PMCID: PMC3923241. https://doi.org/10.1186/1678-9199-20-3

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• Patil SN, Shamraj P, Deshpande J. Retrospective Analysis of Cardiotoxic Scorpion Envenomation in Konkan Region of Western India with Special Reference to Echocardiography. J Clin of Diagn Res. 2021; 15(10):LC20-LC23. https://doi.org/10.7860/JCDR/2021/50682.15559

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• Reis MB, Zoccal KF, Gardinassi LG, Faccioli LH.Scorpion envenomation and inflammation: Beyond neurotoxic effects. Toxicon. 2019 Sep;167:174-179. Epub 2019 Jun 20. PMID: 31228480. https://doi.org/10.1016/j.toxicon.2019.06.219

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• Sofer S, Gueron M. Vasodilators and hypertensive encephalopathy following scorpion envenomation in children. Chest. 1990 Jan;97(1):118-20. PMID: 2295229. https://doi.org/10.1378/chest.97.1.118

• Sofer S, Shalev H, Weizman Z, Shahak E, Gueron M. Acute pancreatitis in children following envenomation by the yellow scorpion Leiurus quinquestriatus. Toxicon. 1991;29(1):125-8. PMID: 2028471. https://doi.org/10.1016/0041-0101(91)90045-s

• Warrell DA. Venomous and poisonous animals.In: Farrar J, Garcia PJ, Hotez T, Junghanss T, Kang G, Laloo D (eds.). Manson’s tropical diseases. 24th ed. Elsevier; 2023.

• WHO ABCDE Approach. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2

• WHO-ICRC Basic Emergency Care: approach to the acutely ill and injured. https://www.who.int/publications-detail-redirect/basic-emergency-care-approach-to-the-acutely-ill-and-injured. https://cdn.who.int/media/docs/default-source/integrated-health-services-(ihs)/csy/bec-quick-cards/becp-edu29-pdf-en-finl.pdf?sfvrsn=2532d61b_2

• WHO (2010) Wound and lymphoedema management. WHO/HTM/NTD/GBUI/20101 I. 2010. https://www.who.int/publications/i/item/9789241599139

• Wilkins D RAMC, Jc Pallett S, Potter J, Woolley SD, Holden G, Chapman K, Kew A, Warrell DA, Lalloo D, Lamb L. Scorpion sting: a narrative review and proposed guidelines for contemporary UK armed forces operations. BMJ Mil Health. 2025 Oct 20:military-2025-003107. Epub ahead of print. PMID: 41120179. https://doi.org/10.1136/military-2025-003107

Species-specific evidence

With scorpion stings, identification of the scorpion that caused the sting is particularly difficult.
If the scorpion is not brought in for identification, then identification on the basis of the patient's description is highly questionable. If the scorpion is available for identification, it is possible in most cases to achieve a conclusive result if identification is performed by an expert. Clinical data from the literature cannot be related to a conclusively identified species in many cases. The clinical information available comes from stings caused by various scorpion species, and it may be that the individual specimens were reliably identified, identified according to unclear criteria or not identified at all. Indirect criteria, such as a course of envenoming considered typical for a particular species of scorpion, and geographical criteria are often used to aid in identification.
The published studies mirror the limitations, however, still provide a valuable picture of scorpion envenoming in the various parts of the world.

Androctonus sp.

Arabian countries and the Middle East

A. amoreuxi, A. australis, A. bicolor, A. crassicauda

• Amr et al. (2021)

Tunisia

Androctonus australis (Androctonus aeneas)

• Goyffon et al. (1982)
  27 patients hospitalised with scorpion stings from a total of 717 accidents. Identification: in the cases where the patient brought the scorpion to the hospital,

Androctonus australis and Buthus occitanus

• Abroug et al. (1999)
  825 patients with scorpion stings. Identification: positive history of scorpion sting, with the scorpion being seen or captured with

Morocco

Androctonus mauretanicus mauretanicus and Buthus occitanus 

• Ghalim et al. (2000)
  275 patients with scorpion stings. Identification: by the patient or the physician. Prevalent in the area: Buthus occitanus and Androctonus mauretanicus mauretanicus; venom serum levels were quantified using an ELISA. Severity scale (Krifi et al. 1998) : Grade I (only local symptoms, local pain and a burning sensation) (247/275); grade II (local and systemic symptoms) (28/275); grade III (local and systemic symptoms with cardiovascular shock, respiratory failure, acute pulmonary oedema, priapism, convulsions) (0/275).

Buthus sp.

Tunisia

Buthus occitanus and Androctonus australis

• Abroug et al. (1999) 
  825 patients with scorpion stings. Identification: positive history of scorpion sting, with the scorpion being seen or captured with A. australis and B. occitanus being the two most common species in the area.

Morocco

Buthus occitanus and Androctonus mauretanicus mauretanicus

• Ghalim et al. (2000) 
  275 patients with scorpion stings. Identification: by the patient or the physician. Prevalent in the area: Buthus occitanus and Androctonus mauretanicus mauretanicus; venom serum levels were quantified using an ELISA. Severity scale (Krifi et al. 1998): Grade I (only local symptoms, local pain and a burning sensation) (247/275); grade II (local and systemic symptoms) (28/275); grade III (local and systemic symptoms with cardiovascular shock, respiratory failure, acute pulmonary oedema, priapism, convulsions) (0/275).

Spain

Buthus occitanus

• Gonzales (1980) 
  100 scorpion stings. Identification: B. occitanus was identified in 50% of cases; criteria not given.

•  Casal and Luque (1985) 

  400 scorpion stings. Identification: the retrospectively analysed cases were attributed to B. occitanus; criteria not given.

Centruroides sp.

USA (Arizona)

Centruroides exilicauda (= C. sculpturatus)

• Curry et al. (1983) 
  673 scorpion stings. Identification: identification of scorpions brought in by the victims; indirect criteria, e.g. clinical picture consistent with signs and symptoms of C. exilicauda stings; grade 1 envenoming (see below) may be caused by other scorpions than C. exilicauda in Arizona, but grades 2, 3 and 4 (see below) only by C. exilicauda.
  Classification:
  Grade 1: local pain and/or local paraesthesias.
  Grade 2: grade 1 plus pain and/or paraesthesias distant from the site of the sting. 
  Grade 3: either neuromuscular dysfunction of the cranial nerves or neuromuscular dysfunction of the skeletal muscles.
  Cranial nerve dysfunction: blurred vision, "wandering" eye movements, hypersalivation, difficulty in swallowing, tongue fasciculations, problems with the upper respiratory tract, slurred speech.
  Neuromuscular dysfunction of the skeletal muscles: jerking of the skeletal muscles, restlessness, involuntary movements that may be mistaken for cerebral seizures. 
  Grade 4: both neuromuscular dysfunction of the cranial nerves and neuromuscular dysfunction of the skeletal muscles (there were cases of serious envenoming in all age groups, but it was more common in children <10 years old).

• Gateau et al. (1992) 
  151 scorpion stings. Identification: stings were attributed to C. exilicauda.

• Likes et al. (1984) 
  438 scorpion stings. Identification: stings were attributed to C. exilicauda.

• Rimsza et al. (1980) 24 scorpion stings (80% of stings in children <10 years old, 40% in children <4 years old). Identification: stings were attributed to C. exilicauda.

Mexico (Leon, Guanajuato State)

C. infamatus infamatus

• Dehaesa and Possani (1994) 
  38,068 scorpion stings. Identification: the majority of the stings were attributed to C. infamatus infamatus; criteria: epidemiological.

Outside the natural areas of distribution of these scorpions

Centruroides hentzi and C. exilicauda

• Trestrail (1981)

3 Centruroides sp. stings. Identification: C. hentzi 2/3 and C. exilicauda 1/3; in all 3 cases the scorpion was available for identification; the stings occurred outside the natural areas of distribution of these scorpions.

Nebo hierochonticus

Arabian countries and the Middle East

Nebo hierochonticus

Amr et al. (2021)

Saudi Arabia

Nebo hierochonticus

• Annobil (1993) 
  47 scorpion stings in children. Identification of scorpions brought in by patients: Leiurus quinquestriatus 18/47, Nebo hierochonticus 2/47, Androctonus crassicauda 1/47, Scorpio maurus 1/47, Compsobuthus werberi 1/47, not identified 24/47; prospective study.

• Annobil et al. (1991)
  1 scorpion sting in a 3 year-old child.

Israel

Nebo hierochonticus

• Rosin (1969)
  2 N. hierochonticus stings in volunteers.

Hemiscorpius sp.

Arabian countries and the Middle East

H. acanthocercus, Hemiscorpius lepturus

Amr et al. (2021)

Iran

• Chadha and Leviav (1979)

•  Radmanesh (1998) 

Hottentotta sp. (=Mesobuthus sp.)

Arabian countries and the Middle East

Hottentotta saulcyi, Hottentotta schach, Hottentotta jayakari.

Amr et al. (2021)

India

• Bawaskar and Bawaskar (1987) 
  12 Mesobuthus tamulus (=Hottentotta tamulus) stings. Identification: no criteria given; all had acute pulmonary oedema; time between sting and hospitalisation 1–12 h (mean 4.25 h).

• Bawaskar and Bawaskar (1989) 
  33 Mesobuthus tamulus (=Hottentotta tamulus) stings (identification: no criteria given).
  Classification:
  Local envenoming:
  
  • local pain 3/33; time between sting and hospitalisation <1 h.
  Systemic envenoming:
  
  • arterial hypertension 10/33; time between sting and hospitalisation 2–4.3 h (mean 3.1 h).
  • tachycardia 11/33; time between sting and hospitalisation 3 h–11 days (mean 8.3 h).
  • pulmonary oedema 7/33; time between sting and hospitalisation 2.3–20 h (mean 7.2 h).
  • fatal 2/33; time between sting and hospitalisation 44 and 6 h.

• Bawaskar and Bawaskar (1992) 
  62 Mesobuthus tamulus (=Hottentotta tamulus) stings. Identification: no criteria given.
  Classification:
  Local envenoming:
  
  • local pain 18/62
  Systemic envenoming:
  
  • arterial hypertension 18/62; time between sting and hospitalisation 1.5–65 h (mean 3 h).
  • supraventricular tachycardia 15/62; time between sting and hospitalisation 1–24 h (mean 5.7 h)
  • pulmonary oedema 11/62; time between sting and hospitalisation 2–52 h (mean 11.6 h).
  fatal 1/62.

• Bawaskar and Bawaskar (1994) 
  163 Mesobuthus tamulus (=Hottentotta tamulus) stings. Identification: no criteria given.
  Classification:
  Local envenoming:
  
  • local pain 78/163.
  Systemic envenoming:
  
  • hypertension and bradycardia 42/163; age 6–85 years (mean 30 years); time between sting and hospitalisation 1.5–8 h (mean 2.5 h).
  • hypertension and tachycardia 17/163; age 3–72 years (mean 16 years); time between sting and hospitalisation 1.5–5.5 h (mean 3 h).
  • pulmonary oedema 14/163; time between sting and hospitalisation 4–17 h (mean 11.5 h).
  • hypotension 3/163; age 35, 60, 65 years; time between sting and hospitalisation 1, 4, 6 h.
  • tachycardia 8/163; time between sting and hospitalisation 4–16 h (mean 10 h).
  • fatal 1/163; age 3.5 years; time between sting and hospitalisation 12 h.

• Bawaskar and Bawaskar (1994) 
  46 patients with severe scorpion (Mesobuthus tamulus = Hottentotta tamulus) envenoming treated with prazosin compared with earlier patients treated with conventional therapy (n = 45) and nifepidine (n = 28). Criteria of identification not given.

• Karnad (1998)  
  5 Mesobuthus tamulus (=Hottentotta tamulus) stings. Identification: no criteria given; time between sting and hospitalisation 4–12 h.

Leiurus sp.

Arabian countries and the Middle East

Leiurus abdullahbayrami, L. hebraeus, Leiurus quinquestriatus

• Amr et al. (2021)
  With scorpion stings, identification of the scorpion that caused the sting is particularly difficult. The majority of victims are small children. If the scorpion is not brought in for identification, then identification on the basis of the patient's description is highly questionable. If the scorpion is available for identification, it is possible in most cases to achieve a conclusive result if identification is performed by an expert. Clinical data from the literature cannot be related to a conclusively identified species in many cases. The clinical information available comes from stings caused by various scorpion species, and it may be that the individual specimens were reliably identified, identified according to unclear criteria or not identified at all. Indirect criteria, such as a course of envenoming considered typical for a particular species of scorpion, and geographical criteria are often used to aid in identification. 
  Because of these factors, the following species are also discussed in this section:
  Nebo hierochonticus
  Androctonus crassicauda
  Scorpio maurus
  Compsobuthus werneri
  Buthotus judaicus.

Israel

• Gueron and Yaron (1979) 
  34 L. quinquestriatus? L. hebraeus ? stings. Identification: "identified as yellow scorpions"; no criteria given.
  Classification according to systemic signs of envenoming: 
  
  • Arterial hypertension 14/34; time between sting and hospitalisation <3 h.
  • Shock but without prior arterial hypertension 9/34; time between sting and hospitalisation <3 h.
  • Cardiac insufficiency, or pulmonary oedema 11/34; time between sting and hospitalisation <3 h.

• Sofer and Gueron (1988) 
  61 L. quinquestriatus stings in children. Identification: "identification of the scorpions" (criteria not given) 7/9; "typical clinical picture" 2/9.
  Classification according to the course of envenoming:
  
  • Uncomplicated course. These children improved rapidly and were able to leave the intensive care unit within 24 h, 52/61.
  • Complicated course 9/61.
  • Respiratory failure 5/9.
  • Severe cardiorespiratory impairment 4/9.

• Sofer et al. (1991a) 
  32 scorpion stings in children. Identification: L. quinquestriatus 25/32, Buthotus judaicus 1/32; "typical clinical picture" 6/32.
  Classification:
  
  • Asymptomatic 5/32.
  • Systemic envenoming 27/32.

• Sofer et al. (1991b) 
  15 patients: 14 stung by the yellow scorpion L. quinquestriatus and one by the black scorpion Buthotus judaicus (criteria not given).

Saudi Arabia

• Annobil (1993) 47 scorpion stings in children. Identification of scorpions brought in by the patients: L. quinquestriatus (possibly L. jordanensis?) 18/47, Nebo hierochonticus 2/47, Androctonus crassicauda 1/47, Scorpio maurus 1/47, Compsobuthus werneri 1/4, not identified 24/47. Prospective study.
  Classification:
  • Severe local pain without systemic signs of envenoming 31/47
  • Severe local pain and mild systemic signs of envenoming, such as vomiting, hypersalivation and sweating 11/47
  • Severe systemic signs of envenoming, such as pulmonary oedema with or without central nervous signs and symptoms, such as restlessness, cerebral seizures, priapism and coma with or without generalised symptoms of paralysis 5/47:

• Amitai et al. (1985) 
  51 scorpion stings in children. Identification: L. quinquestriatus (possibly L. jordanensis?) 32/51, Buthus judaicus 2/51, not identified 17/51; identification criteria not given; it is noted that in the region in which the patients were stung, L. quinquestriatus is the most important species medically.
  Classification:
  
  • Mild to moderately severe envenoming (mild signs and symptoms of systemic envenoming or only local signs of envenoming, such as local erythema or local swelling) 36/51.
  • Severe systemic envenoming (one or more of the following signs and symptoms: coma, cerebral seizures, cardiac arrhythmia, pulmonary oedema) 15/51.

• El-Amin (1992) 96 scorpion stings in children. Identification: on the basis of descriptions by the parents and the scorpions brought in for identification, the following distribution was determined: Leiurus sp. 54/96, Androctonus sp. 23/96, not identified 19/96.

Odontobuthus sp.

Arabian countries and the Middle East

Odontobuthus doriae

• Amr et al. (2021)

Parabuthus sp.

Arabian countries and the Middle East

Parabuthus liosoma

• Amr et al. (2021) 

Botswana

P. granulosus (=P. granulatus)

• Petersen (1987) 
  1 scorpion sting with a severe course of envenoming. Identification: P. granulosus.

South Africa

Western Cape Province

P. granulatus and P. capensis

• Müller (1993) 

  42 scorpion stings with a severe course of envenoming. Identification: 15 of the scorpions that caused the stings were brought in for identification: P. granulatus 14/15, P. capensis 1/15; children <13 years 19/42; patients ≥13 years 23/42.

Cape Province

Parabuthus sp.

• Smith et al. (1983) 
  1 scorpion sting with a severe course of envenoming. Identification: Parabuthus sp.

Zimbabwe

Parabuthus transvaalicus

• Bergman (1997a, b) 

  17 P. transvaalicus stings with a severe course of envenoming. Identification: all scorpions were brought to the hospital and morpholoically identified.

Tityus sp.

Brazil

Tityus serrulatus

• Amarla et al. (1991) 
  5 T. serrulatus stings in children between 3 and 9 years. Identification: scorpions available for identification. Time between sting and antivenom administration 0.5–13 h; time between sting and admission to an intensive care unit 2–32 h, all patients survived.
• Amaral et al. (1993) 
  6 T. serrulatus stings in children between 2 and 9 years; 3 of the children are the same as 3 of those reported by Amaral et al. 1991, above. Identification: scorpions available for identification. Time between sting and antivenom administration 0.5–13 h; time between sting and admission to an intensive care unit 3–32 h, 2 children died.

• Campos et al. (1980) 
  40 scorpion stings in children. Identification: T. serrulatus according to statements of the patients or their relatives; only cases of severe envenoming were included in this retrospective study. A total of 1,173 stings were recorded at the Toxicological Centre of the Joao XXIII Hospital, Belo Horizonte, Brazil, from January 1972 to December 1978; 323 were children <12 years. In adults the course of envenoming was always benign; all cases of severe envenoming involved children (the reported cases are included in the larger study population of Freire-Maia and Campos 1989, see below).

• Nishioka et al. (1992) 
  1 case. Identification: T. serrulatus.

• Hering et al. (1993) 
  2 T. serrulatus stings in patients between 4 and 18 years. Identification: scorpions available for identification. Time between sting and hospitalisation 15 min–6.5 h. All patients received antivenom immediately after hospitalisation. No patient died.

Tityus obscurus

• Paradal et al. (2014) 
  48 patients (34 patients from eastern Pará state and 14 patients from the western part). “Identification of the specimens provided to the medical staff as T. obscurus.

Tityus sp.

• Freire-Maia et al. (1989) 68 scorpion stings in children. Identification: Tityus sp., mostly T. serrulatus; however, identification criteria not specified. Only severe cases were included in this retrospective study. A total of 3,860 stings were recorded at the Toxicological Centre of the Joao XXIII Hospital, Belo Horizonte, Brazil, from January 1972 to December 1987; 1,038 were children <14 years. In adults the symptoms normally consisted of local pain. All cases of severe envenoming and all fatalities occurred in children.

Trinidad

Tityus trinitatis

• Bartholomew (1970) 
  30 scorpion stings. Identification: stings attributed to T. trinitatis. 6 of the patients brought in the scorpion that had caused the sting.
• POON-KING (1963) 
  45 scorpion stings. Identification: stings attributed to T. trinitatis. However, none of the patients brought in the scorpion that had caused the sting and only one patient saw the scorpion by which he/she had been stung.
• Waterman (1938)

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