Neobook — clinical reference

Scope and Purpose
Clinical Question: Concise statement describing the clinical dilemma
Structured PICO
Evidence Synthesis Approach
Summary of Evidence and Contextual Considerations
- Risk Stratification and Severity Grading
- Role of the Poisons Information Helpline in Species Identification
- Limitations of Existing Severity Scoring Systems
- Differences in Clinical Presentation: Adults vs Children
- Contextual Relevance
Clinical Presentation and Management by Severity Grade
- Grade 1: Localised Envenomation
- Grades 2–4: Systemic Envenomation
- Management Principles for Grades 2–4
Scorpion Envenomation: Graded Management Summary Table
Disposition and Referral
- Grade 0–1 (Localised Envenomation Only)
- Grade ≥2 (Systemic Envenomation)
Contextual considerations
Summary of Recommendations
Endorsement and Approval
References

Date of Report: 09 June 2025
Prepared By: Christopher Straeuli, Patricia Leighton, Heike Geduld, Heinri Zaayman, Sa’ad Lahri, Clint Hendrikse
Request Origin: PTC

Scope and Purpose

These clinical practice recommendations provide focused guidance on the management of scorpion envenomation in the Western Cape, specifically in the context of the current unavailability of scorpion antivenom. This document is not intended as a comprehensive guideline on scorpionism, but rather addresses a critical evidence gap by offering practical, evidence-informed recommendations for frontline clinicians. The guidance reflects local epidemiology and resource constraints and was developed through a rapid evidence review and expert consensus process. Supportive care remains the cornerstone of management in the absence of antivenom. Clinicians are advised to refer to the AfriTox¹ database or contact the Poisons Information Helpline (0861 555 777) for case-specific toxicology advice.

Summary of key recommendations

Contact the Poisons Information Helpline (0861 555 777) for assistance in identifying the scorpion species. If a photo is available, share it for expert review.
Use the severity grading system to guide management decisions.
In children, restlessness or hyperactivity may be a primary sign of systemic envenomation.
Provide adequate pain control at all severity levels.
Monitor for respiratory depression, especially when considering pharmacological interventions.
In children with Grade 3 or higher envenomation, early airway management decisions are critical.
Use the severity grading system in all referral communications and involve appropriate tertiary centres for Grade ≥2 cases

1. Clinical Question: Concise Statement describing the Clinical Dilemma

Scorpion envenomation is an uncommon but potentially life-threatening condition in South Africa. Over a 10-year period, the Tygerberg Poisons Information Centre recorded 740 cases, with nearly 20% classified as serious envenomations.² Of these, 90% received antivenom. Most incidents occurred in the Western Cape and predominantly affected adults, although severe outcomes are more likely in children.²

It is important to note that this dataset likely reflects a referral bias: most reports are made by clinicians seeking guidance in moderate to severe cases, while mild stings or those managed outside the formal health system are less likely to be captured. As a result, the true incidence of serious scorpion envenomation may be lower than these figures suggest.

In Southern Africa, serious systemic toxicity is primarily caused by two Parabuthus species: P. granulatus and P. transvaalicus.³ These stings can result in fatal outcomes, particularly in younger patients.⁴ While national and international guidelines recommend antivenom for Grade 3–4 systemic envenomation, a recent national shortage—linked to production interruptions at the South African Vaccine Producers (SAVP)—has rendered antivenom inaccessible.

In this context, supportive care remains the cornerstone of management. Although the current antivenom shortage has prompted renewed focus on non-pharmacological interventions, it is important to emphasise that supportive care is essential regardless of antivenom availability. Antivenom has a delayed onset of action and may not prevent early complications, such as respiratory failure - particularly in paediatric patients. These practice recommendations aim to provide structured, evidence-informed guidance on supportive care that remains relevant both in the current context and when antivenom access is restored.

2. Structured PICO

Component	Description
Population	People who sustained a scorpion sting, including all adults and children who access health care (via EMS or facility-based care)
Intervention	Standard care, which includes supportive management but WITHOUT scorpion antivenom
Comparator	Standard care, which includes supportive management AND scorpion antivenom
Outcomes(s)	Primary – mortality; Secondary outcomes – hospital length of stay, need for ventilatory support, ICU/HCU admission and length of stay

3. Evidence Synthesis Approach

These recommendations were developed using a tiered evidence synthesis process:

Rapid literature review: A focused search was conducted to identify relevant studies and existing guidance. Findings were pragmatically appraised for relevance and quality.
Expert consensus: In the absence of sufficient high-certainty evidence, a structured consensus process was undertaken with a multidisciplinary group of clinicians and toxicology experts.
Contextual adaptation: Recommendations were informed by expert clinical judgement and tailored to reflect local epidemiology, resource availability, and system-level constraints.

Consensus meeting date: 08/05/2025

Participants (Name/Role):

Heike Geduld – Emergency Medicine, ECSS (Provincial Emergency Medicine)
Carine Marks – Pharmacist and director of Tygerberg Poisons Information Centre
Clint Hendrikse – Emergency Medicine, UCT, Head of Division
Sa’ad Lahri – Emergency Medicine, SU, Head of Division
Waseela Khan – Emergency Medicine, UCT
Heinri Zaayman – Emergency Medicine, SU
Pat Leighton - Emergency Medicine, UCT
Thasveer Gansen – Emergency Medicine, SU
Mignon Du Toit – Emergency Medicine, SU
Chris Straeuli – Emergency Medicine, UCT

Reviewed by:

Bradley Browne – Paediatrician, Director: Poisons Information Centre, Red Cross Hospital
Kate Balme – Poisons Information Centre. Red Cross Hospital

4. Summary of Evidence and Contextual Considerations

These practice recommendations are based on a rapid review of the available literature, structured consensus among emergency medicine and toxicology experts, and contextual adaptation to the South African health system. Key issues considered are outlined below.

4.1 Risk Stratification and Severity Grading

Early recognition of systemic envenomation is critical to reducing morbidity and mortality.
The routine use of a severity grading system is recommended to aid risk stratification, identify patients requiring close observation or escalation of care, and facilitate communication between healthcare providers and poison centres.
The adopted grading system is based on a contextual adaptation of the UpToDate⁵ classification and is preferred over the Poisoning Severity Score⁶ (PSS), which may under classify systemic toxicity in scorpion stings.

Severity Grades (Adapted)

Grade 0: No signs or symptoms of envenomation
Grade 1: Localised pain and/or paraesthesia at the sting site
Grade 2: Pain or paraesthesia extending beyond the sting site
Grade 3: Any of the above, plus cranial nerve dysfunction or somatic/autonomic neuromuscular signs
Grade 4: All features of Grade 3 combined
Use of the grading system enables early triage, helps prioritise transfer to higher levels of care (e.g. TBH, GSH, RXH), and promotes consistent documentation across sites.

4.2 Role of the Poisons Information Helpline in Species Identification

If a photo of the scorpion is available, clinicians are strongly encouraged to consult the Poisons Information Helpline (0861 555 777) for expert review.
Accurate identification is essential for risk assessment, particularly in distinguishing medically important species such as Parabuthus. While species-level identification may be challenging, simple morphological cues can assist: scorpions with thick tails and small pincers are more likely to be Parabuthus, whereas thin-tailed scorpions with large pincers are typically of lower medical significance.
If the scorpion species is confirmed to be of low medical importance—i.e. unlikely to cause systemic envenomation—then the patient may be safely discharged with analgesia and appropriate follow-up advice.

4.3 Limitations of Existing Severity Scoring Systems

The Poisoning Severity Score (PSS) may not adequately capture systemic toxicity from scorpion envenomation. In particular, patients with paraesthesia or systemic symptoms may still be classified as Grade 1 using PSS⁶ .
The adapted UpToDate⁵ grading system allows for earlier detection of Grade 2 or higher severity and is more appropriate in the South African context, where delayed recognition and transport are major contributors to adverse outcomes.

4.4 Differences in Clinical Presentation: Adults vs Children

Although most scorpion stings occur in adults (71% in local data), children are disproportionately affected by severe outcomes and mortality. ⁴
Children under 13 years may present with distinct features, even in early systemic envenomation. These include:
- Excessive salivation
- Marked anxiety or hyperactivity
- Dyspnoea and early respiratory distress
- Autonomic dysfunction (e.g. tachycardia, hypertension)
Unique behavioural features seen in paediatric systemic envenomation include:
- Agitation, restlessness, uncontrolled thrashing and flailing
- Crying, screaming, jerking movements
- Inability to remain still or be restrained
- Facial grimacing, lip-smacking, chewing-like motions
These signs are highly abnormal and are often misinterpreted but should be viewed as clear indicators of Grade 3 or higher envenomation, requiring urgent escalation.

4.5 Contextual Relevance

Local mortality is often related not to the direct effects of venom alone, but to delays in transport, missed early signs, and inadequate early resuscitation.
As such, a structured and proactive approach to risk assessment—especially in children—is essential to reducing preventable deaths.
The use of the adapted severity grading system facilitates:
- Triage and disposition planning
- Clear communication between referring and receiving facilities
- Decision-making regarding transfer to tertiary care centres

5. Clinical Presentation and Management by Severity Grade

Management of scorpion envenomation should be guided by clinical severity, informed by the adapted grading system. The approach is stratified below by grade, with specific attention to differences in adult and paediatric presentations.

5.1 Grade 1: Localised Envenomation

Clinical Features

Pain localised to the sting site
No remote symptoms or systemic signs

Management

Analgesia:
- Administer oral paracetamol
- If applied early, local cooling with ice packs may help reduce pain and slow venom absorption. This is most effective when administered before the onset of severe hyperalgesia
- If pain is not controlled with oral analgesia, consider local anaesthetic infiltration (e.g. lignocaine without adrenaline, 3–5 mg/kg).
- Consider regional anaesthesia with longer-acting agents if expertise is available and pain is severe
Supportive care:
- Irrigate wound if needed
- Provide tetanus prophylaxis as indicated
- NSAIDs may be used for analgesia if clinically appropriate and no contraindications exist (e.g., suspected renal impairment, active bleeding).
Observation:
- Observe for 12–24 hours
- Discharge if no systemic symptoms develop
- If expert identification confirms a scorpion species of low medical significance, early discharge may be considered

5.2 Grades 2–4: Systemic Envenomation

Clinical Features
Symptoms may develop within 1–4 hours post-sting (up to 8 hours)

Grade 2:
- Remote pain and/or paraesthesia
- Anxiety, hyperaesthesia
- Muscle cramps
Grade 3:
- Cranial nerve dysfunction (dysphagia, drooling, dysarthria)
- Respiratory distress or failure
- Autonomic instability (tachycardia, hypertension, fever, sweating)
- Neuromuscular dysfunction (ataxic gait, weakness, myoclonic jerks, other involuntary movements)
Grade 4:
- Combined features of Grade 3

Paediatric-Specific Presentation (Grade 3 and higher)

Unexplained crying, restlessness, or agitation
Abnormal movements: jerking, writhing, posturing
Facial grimacing, lip-smacking, chewing-like motions
Severe hypersalivation
Early respiratory failure
These features may mimic seizures or toxidromes and should trigger urgent escalation

5.3 Management Principles for Grades 2–4

Pain Management

Continue Grade 1 analgesia strategies
Add fentanyl (intranasal or IV) if available and clinically indicated
Morphine is not preferred due to increased histamine release

Airway Management

Respiratory depression is the leading cause of mortality, especially in children
Clinicians must anticipate airway deterioration and act early
Prepare for intubation in all Grade 3 or 4 cases, particularly in agitated children

Intubation Strategy

Premedication: Consider short-acting benzodiazepine (e.g., midazolam) to permit preoxygenation in extremely restless patients
Induction:
- Preferred: Etomidate (0.2-0.3 mg/kg)
- Alternative: Ketamine (2 mg/kg)
- Alternative: Propofol (if operator expertise is available)
Muscle Relaxant:
- Preferred: Rocuronium (0.9–1.2 mg/kg)
- Alternative: Suxamethonium (less effective theoretically due to neuromuscular pathophysiology)
Ketamine is a reasonable and safe first-line induction agent in children, particularly where clinicians are familiar with its use. Although ketamine can increase secretions, this is generally manageable and should not preclude its use. In the presence of bulbar dysfunction⁴ , however, excessive salivation may complicate airway management. Clinicians should be aware of this possibility and prepare accordingly.

Ventilation Strategy

Volume-controlled mode with lung-protective strategy (tidal volume 6–8 mL/kg)
Initial PEEP: 5–6 cm H_₂O
Titrate FiO₂ and PEEP based on oxygenation and evidence of pulmonary oedema
Consult a specialist if the clinician is not experienced with ventilated patients

Circulatory Support

Monitor for autonomic instability (tachycardia, hypertension)
Treat with sedation and analgesia
If persistent, consider labetalol infusion—but only under senior guidance

Neuromuscular Symptoms / Muscle Cramps

Consider a slow IV infusion of 10% calcium gluconate (10 mL over 5–10 minutes)
- Adults: 10 mL over 5–10 minutes
  Children: 0.5 mL/kg (maximum 10 mL) over 5–10 minutes
- Duration of effect: ~20–30 minutes
- Maximum of one repeat dose

Bronchospasm

Administer inhaled β2-agonist therapy (e.g., salbutamol) if bronchospasm is present

Sedation Prior to and After Intubation

Before intubation:
- Children: Midazolam may be required to facilitate intubation
- Adults: If agitation persists despite analgesia, titrated midazolam is recommended
After intubation:
- Midazolam and morphine infusion
- Alternatively, propofol/morphine combination if available

Scorpion Envenomation: Graded Management Summary Table

Click on the image to enlarge.

Unlike in cytotoxic snakebites, NSAIDs are not contraindicated in scorpion envenomation. They may be used for pain control provided there are no individual contraindications (e.g., renal impairment, active bleeding). Concerns raised in snakebite literature regarding NSAID-associated complications are not directly applicable to neurotoxic scorpion stings.

6. Disposition and Referral

Clinical disposition should be guided by the severity grading, available resources, and proximity to a higher-level facility. All patients with systemic signs of envenomation (Grade 2 and above) require early discussion with a referral centre.

6.1 Grade 0–1 (Localised Envenomation Only) Disposition:

Observe at the base facility for 12–24 hours post-sting.
If no systemic symptoms develop, discharge with analgesia and clear return instructions.
If the scorpion has been positively identified by an expert as being of low medical significance, the patient may be discharged earlier, provided pain is controlled.

Safety Netting:

Advise the caregiver/patient to return immediately if symptoms progress (e.g., agitation, difficulty breathing, excessive salivation, or weakness).

6.2 Grade ≥2 (Systemic Envenomation)

Disposition:

All patients with Grade 2 or higher severity must be discussed with a referral centre (e.g., Tygerberg Hospital, Groote Schuur Hospital, Red Cross War Memorial Children’s Hospital).
Transfer to a tertiary facility should be arranged for patients with:
- Bulbar or respiratory symptoms
- Autonomic instability
- Severe agitation or behavioural disturbance (particularly in children)
- Anticipated need for ventilatory or intensive care support

Stabilisation Prior to Transfer:

Move the patient to a high acuity/resuscitation area.
Secure airway, breathing, and circulation (ABCs).
If transfer is delayed and intubation is required, ensure continuous sedation and ventilation support on route.
Contact the Poisons Information Helpline at 0861 555 777 for further guidance and support with ongoing management or triage decisions.

Referral Communication:

Use the adapted severity grading system in all referrals to facilitate consistent and rapid clinical handover.

7. Contextual Considerations

These recommendations were developed in response to a critical gap in guidance during a period of national antivenom shortage. They reflect the realities of the South African health system and aim to support safe, feasible, and equitable care for patients with scorpion envenomation.

Factor	Consideration
Risk–Benefit	The absence of antivenom increases the risk of adverse outcomes in severe cases. These recommendations aim to mitigate harm by standardising supportive care and early escalation.
Feasibility	All recommendations are designed to be implementable within the existing provincial emergency care system, using available medications, equipment, and personnel.
Cost and Resources	No additional direct costs are anticipated. Dissemination will be supported via EMGuidance and existing platforms without requiring new infrastructure.
Acceptability	A multidisciplinary group of emergency medicine and toxicology experts contributed to these recommendations, ensuring broad clinical relevance and alignment with frontline practice.
Equity	By standardising clinical care, these guidelines aim to improve outcomes in rural and under-resourced settings, where delayed transport and limited specialist access increase risk.
Practice Variation	In the absence of high-certainty evidence, some variation in practice is expected. These recommendations aim to reduce unwarranted variation by providing structured clinical pathways.
Urgency	The nationwide shortage of scorpion antivenom creates an urgent need for interim guidance. These recommendations provide timely support to clinicians during this high-risk period.
Guideline Alignment	These recommendations are aligned with national Standard Treatment Guidelines (STGs)⁷ , AfriTox¹ , and UpToDate⁵. They provide contextualised advice in the absence of locally specific Western Cape guidance.

8. Summary of Recommendations

These clinical practice recommendations provide structured, context-specific guidance for the management of scorpion envenomation in the absence of antivenom. They are intended to support safe, standardised care, improve early recognition, and guide appropriate escalation.

8.1 Species identification should be attempted via the Poisons Information Helpline (0861 555 777). Early expert confirmation of scorpions species of low medical significance allows for safe discharge with symptomatic care.

8.2 Use a standardised severity grading system (adapted from UpToDate⁵) to guide triage, treatment, and inter-facility communication. This system is preferred over the Poisoning Severity Score in this context.

8.3 Grade 1 (localised envenomation) can be managed with analgesia, wound care, and observation. NSAIDs may be used for pain control if no contraindications are present. Discharge may be considered after 12–24 hours if no systemic symptoms develop.

8.4 Grade 2–4 (systemic envenomation) requires escalation of care. Early recognition and referral are critical. Anticipate the need for airway protection, particularly in paediatric patients.

8.5 In children, restlessness, agitation, and abnormal movements (e.g., flailing, grimacing, lip-smacking) may indicate severe systemic involvement. These are not behavioural signs, but markers of Grade ≥3 envenomation.

8.6 Intubation should be considered early in patients with bulbar symptoms, respiratory distress, or severe agitation. Etomidate and rocuronium are the preferred agents. Avoid ketamine.

8.7 Ventilation should follow lung-protective strategies. Monitor closely for pulmonary oedema. Sedation post-intubation should include midazolam ± morphine or propofol.

8.8 All cases of Grade ≥2 must be discussed with a referral centre. Use the severity grading system to structure referrals and ensure consistent communication.

These recommendations are conditional, based on expert consensus and low-certainty evidence. They are intended as interim guidance during the current antivenom shortage.

9. Endorsement and Approval

These recommendations were developed by a multidisciplinary panel of clinicians and toxicology experts through a structured consensus process. They are formally endorsed by the academic heads of Emergency Medicine at Stellenbosch University and the University of Cape Town.

Name	Position	Affiliation	Date
A/Prof Sa’ad Lahri	Head of Division: Emergency Medicine	Stellenbosch University	09 June 2025
A/Prof Clint Hendrikse	Head of Division: Emergency Medicine	University of Cape Town	09 June 2025

For queries related to these recommendations, contact:
Poisons Information Helpline – 0861 555 777
AfriTox Database – www.afritox.co.za

10. References

Poisons Information Centre RCCH. AfriTox [Internet]. [cited 2025 Jun 2]. Available from: https://www.afritox.co.za/
Marks CJ, Muller GJ, Sachno D, Reuter H, Wium CA, Du Plessis CE, et al. The epidemiology and severity of scorpion envenoming in South Africa as managed by the Tygerberg Poisons Information Centre over a 10 year period. Afr J Emerg Med Rev Afr Med Urgence. 2019 Mar;9(1):21–4.
Müller GJ, Modler H, Wium CA, Veale DJH. Scorpion sting in southern Africa: diagnosis and management. Contin Med Educ [Internet]. 2012 [cited 2025 Jun 2];30(10). Available from: https://www.ajol.info/index.php/cme/article/view/83136
Müller GJ. Scorpionism in South Africa. A report of 42 serious scorpion envenomations. South Afr Med J Suid-Afr Tydskr Vir Geneeskd. 1993 Jun;83(6):405–11.
LoVecchio F. Scorpion envenomation causing neuromuscular toxicity (United States, Mexico, Central America, and Southern Africa) [Internet]. [cited 2025 Jun 2]. Available from: https://sniv3r2.github.io/d/topic.htm?path=scorpion-envenomation-causing-neuromuscular-toxi city-united-states-mexico-central-america-and-southern-africa
Persson HE, Sjöberg GK, Haines JA, Pronczuk de Garbino J. Poisoning severity score. Grading of acute poisoning. J Toxicol Clin Toxicol. 1998;36(3):205–13.
NHI – EDP – STGs and EML – National Department of Health [Internet]. [cited 2025 Jun 2]. Available from: https://www.health.gov.za/nhi-edp-stgs-eml/

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Emergency Medicine Cape Town, Clinical Practice Recommendations (EM-CPR)_Scorpion Stings Practice Recommendations_Practice Recommendations for Scorpion Envenomation (in the Absence of Antivenom)_Version Control: 1.2_Review Date: 12 June 2025

Practice Recommendations for Sorpion Envenomation (in the Absence of Antivenom)