PEDIATRIC PHARMACOLOGY

AND THERAPEUTICS

Scorpion envenomation and antivenom

therapy
Shaul Sofer, MD, Eliezer S h a h a k , MD, a n d M o s h e G u e r o n , MD
From the Pediatric Intensive Care Unit and Department of Cardiology, Soroka University Med-
ical Center, and t h e Faculty of Health Sciences, Ben-Gurion University of the Negev,
Beer-Sheva, Israel

The clinical course and o u t c o m e of scorpion envenomation in 52 children

treated in a pediatric intensive care unit without specific antivenom were retro-
spectively e v a l u a t e d and c o m p a r e d with those of scorpion envenomation in
the 52 preceding cases treated with specific scorpion antivenom. The d e m o -
graphic, clinical, and laboratory features on hospital arrival were similar in the
two groups. The lengths of stay in the pediatric intensive care unit and in the pe-
diatric wards were c o m p a r a b l e . Hypotension with pulmonary e d e m a devel-
o p e d in four of the children who did not receive antivenom and in one child who
did receive antivenom as a complication of the envenomation; all c o m p l e t e l y
recovered. Cardiogenic shock occurred in one child who did not receive
antivenom, but who recovered completely, and in three children who received
antivenom, of whom two died and one survived with a major deficit. Our study
did not demonstrate any beneficial effect of therapy with a n t i v e n o m for scor-
pion envenomation in children. However, our "control" group (i.e:, the treated
group) was a historical one; thus a prospective, randomized study appears to
be warranted. Such a study m a y define specific subgroups that m a y benefit from
treatment with antivenom. (J PEDIATR1994;124:973-8)

Scorpion envenomation is not an uncommon event in var-
ious parts of the world.l"5 Severe autonomic and central
nervous system symptoms and cardiac, respiratory, and
pancreatic dysfunction may Occur, leading to multisystem
organ failure and death, especially among children. 61~ The
mortality rate after envenomation has declined markedly in
some centers during the last few decades. 4,5, 8, 11-19 This
improvement has been attributed to treatment in an inten-
sive care setting, 4, 5, 8, 11, !3, 15-17 treatment of symptoms
with drugs,4,5,11,! 4 and specific antivenom administra-
tion.4,,5, 11, 13 However, there is no convincing evidence of
the value of serotherapy in human beings envenomated by
scorpions. 1,2~ MoreOver, AV may cause acute allergic
Submitted for publication July 16, 1993; accepted Dec. 20, 1993.
Reprint requests: Shaul Sofer, MD, Division of Pediatrics, Soroka
Medical Center, PO Box 151, Beer-Sheva 84101, Israel.
Copyright | 1994 by Mosby-Year Book, Inc.
0022-3476/94/$3.00 + 0 9/25/53824
reactions, including anaphylaxis 4, 6 and the delayed onset of
rash and symptoms of serum sickness, 18 and it is expensive.
In the United States, AV has not been subjected to U.S.
Food and Drug Administration testing, and its use is not
federally approved. At present, AV is available only within
the state of Arizona by special action of the Arizona State
Board of Pharmacy, 1618 and its use is controversial. For
AV Antivenom
ED Emergency department
NAV No antivenom
PICU Pediatric intensive care unit
these reasons and on the basis of our experience, we have
discontinued the use of AV in children with scorpion
envenomation since 1989. In this study, we compared the
outcome of scorpion envenomation in children treated in a
pediatric intensive care unit with specific AV before 1989,
with that in children admitted to the P I C U after 1989, who
were similarly treated but did not receive AV.

973
974 Sofer, Shahak, and Gueron
METHODS
The Soroka University Hospital is located in the city of
Beer-Sheva and serves a population of about 350,000,
including 80,000 Bedouin, seminomadic Moslem inhabit-
ants of the Negev desert. The Soroka PICU is the only one
in the region, and practically all children who have been
stung by scorpions are initially admitted to this unit. The
medical records of all children admitted with signs of
intoxication after scorpion sting between July 1, 1989, and
Dec. 31, 1992, were retrospectively evaluated.
Fifty-two such children who received no AV were iden-
tified and were compared with a group consisting of the 52
preceding patients with scorpion envenomation who were
treated with AV and admitted to the PICU before July 1,
1989 (from July 10, 1985, to July 1, 1989). Demographic,
clinical, and laboratory data were collected from the files,
as well as duration of stay in the PICU, duration of hospi-
talization, rate and type of complications, number of deaths,
and long-term morbidity.
Specific AV against the venom of the yellow scorpion,
Leiurus quinquestriatus (the most prevalent and most toxic
scorpion in the Negev desert), was prepared in donkeys by
the Hebrew University Department of Entomology and
Venomous Animals, in Jerusalem. According to the pa-
tient's age, 5 to 15 ml AV diluted in 5% dextrose and 0.33%
sodium chloride solution was administered intravenously
shortly after arrival. According to the manufacturer, in 20
gm mice, 1 ml AV neutralizes at least 80% of a 50% lethal
dose of the venom. Therapy to relieve symptoms included
intravenous fluid replacement in all cases. Analgesics, sed-
atives, or both were given to agitated children. Antihyper-
tensive drugs (hydralazine, 0.2 m g / k g per dose adminis-
tered intravenously, or sublingually administered nife-
dipine, 0.5 mg/kg per dose, or both) were given to children
with severe or significant hypertension who did not respond
to administration of analgesics and sedatives. 23 Treatment
with nifedipine was introduced in our PICU in 1988.
Supportive therapy did not change substantially between
the two study periods with a few minor exceptions. Since
1987, we have become less reluctant to use more potent an-
algesics such as meperidine, despite some experimental data
suggesting that use of narcotics may enhance venom toxic-
ity. 24 In the same year we also started to use antihyperten-
sive drugs more frequently on the basis of our experience
with hypertensive encephalopathy. 23 In addition, we re-
placed diazepam with midazolam for sedation in 1989.
RESULTS
The groups were similar regarding ethnic origin, sex, and"
time interval between envenomation and arrival in the
emergency department (Table I). Children in the NAV
group were slightly older than those in the AV group and
The Journal of Pediatrics
June 1994
consequently somewhat heavier (average weight, 15.1 kg vs
13.4 kg, respectively). The site of the sting could not be
identified in 14 (27%) of the children in the AV group and
in 20 (38%) of children in the NAV group. Of the children
in the AV group, 34 (65%) were stung on a limb, in com-
parison with 27 (52%) of the N A V children. Head or neck
sting occurred in one child in the AV group and in two chil-
dren in the N A V group.
The clinical presentation and laboratory results on arrival
were similar and, if anything, to the disadvantage of the
NAV group (Table I). Clinical findings such as hypother-
mia (rectal temperature of 34.1 ~ C to 35.0 ~ C), restlessness,
excessive secretions and salivation, and priapism in male
patients were similar.
Tachycardia was slightly more prevalent in the AV
group; bradycardia was slightly more common in the N A V
group. Decreased level of consciousness, miosis or mydria-
sis, and vomiting were more frequent in the NAV group.
Hypertension, an important sign of scorpion envenoma-
tion,23, 25 is not included in Table I because meticulous, se-
rial measurements of blood pressure with an electronic de-
vice were introduced to our PICU in 1987, thus making
comparison of this measurement impossible. However, sig-
nificant or severe hypertension was similar in the two
groups; hypertension occurred in 79% of the entire AV
group and in 77% of N A V children admitted between 1987
and June 1989.
Fifteen children had severe respiratory failure on arrival,
including two patients who had tracheal tubes inserted be-
fore arrival. Indications for intubation were severe inspira-
tory stridor as a result of subglottic edema in 2 children and
gasping type of breathing with coma in the 13 other
patients. Duration of intubation ranged from 1 to 8 hours.
Rapid extubation was possible because the respiratory fail-
ure was a result of severe central nervous system depression
and muscle spasm and not of primary lung abnormalities,
and because the central nervous system and neuromuscular
dysfunction resolved quickly after endotracheal intubation
and initiation of treatment with fluids, sedatives, and anal-
gesics. Of the 13 children with coma and gasping respira-
tions, nine had severe hypertension with blood pressure
measurements that ranged between 150/100 and 170/120
mm Hg. The level of consciousness and respiratory func-
tions of these children markedly improved when normal
blood pressure was achieved with administration of antihy-
pertensive agents (usually one or two doses of hydralazine
or nifedipine, or both). Three of the thirteen cases have been
previously reported. 23 All 15 children with respiratory fail-
ure eventually recovered completely, and neither heart fail-
ure nor any other significant complications developed; all
patients left the PICU after 16 to 67 hours of hospitaliza-
tion. There were no significant differences regarding out-
The Journal of Pediatrics Sofer, Shahak, and Gueron 975
Volume 124, Number 6

Table I. Demographic, clinical, and laboratory features of children with envenomation on admission

A V g r o u p (n = 52) N A V g r o u p (n = 52)

Male subjects 30 (58) 29 (56)

Bedouins/Jews 49/3 51/ 1
Age
Range 22 days-14 yr 30 days-15 yr
Median 3 yr 4 yr
Time interval from sting to ED arrival (hr)
Range 0.25-4 0.3-4
Mean 1.56 1.53
Hypothermia (<36 ~ C) 16 (31) 17 (33)
Restlessness 45 (86) 48 (92)
Excessive secretions and sweating 50 (96) 49 (94)
Tachycardia 38 (73) 31 (60)
Bradycardia 4 (8) 10 (19)
Decreased level of consciousness 15 (29) 22 (42)
Miosis or mydriasis 13 (25)* 24 (46)*
Vomiting 32 (61)t 42 (81)t
Priapism~: 25/30 (83) 28/29 (96)
Respiratory failure
Coma with gasping 5 (10) 8 (15)
Obstructive subglottic edema 1 (2) 1 (2)
Laboratory findings
Electrocardiographic changes 24 (46) 23 (44)
Arterial pH (units)
Range 6.9-7.4 7.0-7.4
Mean 7.29 7.28
Blood glucose (mmol/L [mg/dl])
Range 4.7-27.8 (85-500) 4.7-33.3 (84-600)
Mean 10.4 (188) 12.4 (224)
Values in parentheses (except bloodglucosevalues)are percentages.
*p <0.05.
tP = 0.05.
1:Inmate subjects.

come, duration of intubation, and duration of PICU stay
between the six children in the AV group and the nine chil-
dren in the NAV group. However, the median age of the 15
children with respiratory failure was lower than that of all
children in both groups: 2 versus 3 years, respectively. The
site of sting was not identified in nine of the children with
respiratory failure and involved the limbs in the six other
children. Arterial pH was slightly lower in children in the
NAV group, and the blood glucose level was slightly higher
in the NAV group. The frequency of electrocardiographic
changes, including ST elevations and high T waves, was
similar in both groups.
Major complications of envenomation that were mani-
fested after arrival consisted mainly of cardiovascular dys-
function (Table II). Abnormalities were noted in five chil-
dren in the NAV group, including one with cardiogenic
shock, and in four of the children in the AV group, includ-
ing three who had cardiogenic shock. All children in the
NAV group survived without sequelae; two of the children
in the AV group died. A 3-year-old girl died of shock, se-
vere metabolic acidosis, right and left heart failure, and
pulmonary edema. An 8-year-old boy remained brain dead
after resuscitation from shock and severe ventricular ar-
rhythmias including ventricular fibrillation. A 13-year-old
boy in the AV group survived but remained handicapped by
aphasia and leg amputation; he had cardiogenic shock, left
heart failure with pulmonary edema and ventricular ar-
rhythmias, and multiple brain infarcts, as shown by com-
puted tomography. On the seventh day of hospitalization
the patient had signs of right popliteal artery occlusion that
eventually led to amputation. This patient and the first of
the two patients who died have been reported elsewhere. 8
All four children in the AV group who had severe cardio-
vascular complications received the maximum dose of an-
tivenom (15 ml intravenously) promptly on arrival, several
hours before the onset of complications. The median age of
the children with cardiovascular dysfunction, in both the
treated and the nontreated groups, was significantly higher
than the median age of all children (12 years vs 3 years, re-
spectively; range, 3 to 15 years). Eight of the nine children
976 Sofer, Shahak, and Gueron
T a b l e II. Severe complications of envenomation during
hospitalization and outcome
AV group NAV group
Complications and outcome (n = 52) (n = 52)
Pulmonary edema with hypotension 1 (2) 4 (7.7)
Cardiogenic shock 3 (5.8) 1 (2) 0
Death 2 (3.8) 0 (0)
Full recovery 49 (94) 52 (100)
9Noncardiovascular complications* 1 (2) 0 (0)
Values in parentheses are percentages.
*Limb amputation and aphasia in one patient.
with cardiovascular dysfunction, in both groups, were stung
on a limb; the site of the sting was not detected in the ninth
child. All nine children arrived in the ED between 1 and 3
hours after envenomation.
When all children in the AV group were compared with
the NAV group, there were no significant differences for
either PICU or total hospital stay (Table III).
Hundreds of children and adults who were seen in the ED
after a scorpion sting without signs of general intoxication
were not included in this study. Most of them had local pain,
were treated with analgesics, and were discharged. A few
children were admitted for observation. All these patients,
as well as other sting victims treated at local clinics, were
not given specific AV. We are not aware of any complica-
tions among these victims.
DISCUSSION
General intoxication does not develop in most human
victims of scorpion sting, but victims do experience local
pain or a mild burning sensation at the site of the sting.
Those with signs of general intoxication have impressive but
usually transient and self-limited manifestations. However,
in some victims, especially children, respiratory failure and
death may occur as a result of upper airway obstruction,
severe hypertensive encephalopathy, or heart failure. 8, 23
Although our study deals with an Israeli population, the
situation is not unique to Israel. Hundreds of victims are
reported to be stung annually by the American scorpion
Centruroides sculpturatus, particularly in Arizona and in
parts of California, Texas, Nevada, and New Mexico. 17, 19
The in vitro effects of the venom of the American scorpion
are similar to those of the venom of the Israeli and North
African scorpion L. quinquestriatus, which is the subject of
our study. Both species cause activation of neuronal sodium
channels, resulting in excessive firing of neurons,26, 27 and
both induce similar increases i n blood pressure and in
plasma renin levels in rats. 2s However, the clinical mani-
festations of envenomation in U.S. patients are dissimilar.
American patients with severe envenomation, mostly in-
fants and young children, seem to manifest central nervous
The Journal of Pediatrics
June 1994
T a b l e III. Duration of stay in PICU and duration of
hospitalization
Duration AV NAV
of stay group group p*
PICU (hr)
Range 4-108 3-88 --
Mean 20.9 21. I 0.89
Hospitalization (days)
Range 1-4t 1-6
Mean 2.75 2.83 0.89
*The p values were determined by the multiresponse permutation proce-
dure. 43
]'One patient hospitalized for 88 days was excluded.
system and neuromuscular dysfunction comparable to that
in the Israeli victims. However, cardiovascular dysfunction,
the main hazard of the Israeli-North African scorpion, as
well as of the Indian scorpion (Buthus tamulus) and the
Brazilian scorpion (Tityus serrulatus), has not been re-
ported after envenomation by the American scorpion, at
least in the past decade.
Severe cardiovascular dysfunction, including shock and
pulmonary edema, occurred in 9% of our patients, prima-
rily in "older" children. We have no explanation for the
higher incidence of cardiac abnormalities among older
children, but our observation is in accord with those of oth-
ers who reported a single patient younger than 1 year among
34 sting victims with cardiovascular dysfunction (aged 9
months to 60 years). 3' 7, 29, 30 In addition, only 2 patients
younger than 1 year of age were among 32 patients aged 8
months to 34 years who died of scorpion sting.3, ~, 7, 29, 30
The death rate from scorpion envenomation dropped sig-
nificantly in the United States between 1940 and 1970. 31
(The last mortality figures available to us are for 1968.19)
The decrease in the mortality rate was attributed to good
scorpion control and eradication, and to improved thera-
peutic practices including immediate airway control and
intensive care. 15-19
Specific AV against many toxic scorpion species is now
commercially available. This therapeutic modality has been
advocated since 1953 as the only specific treatment of scor-
pion sting. 3234 Uncontrolled studies have shown that chil-
dren treated with AV shortly after E D arrival recover faster
than those who are not treated. 16-18Bond 18 was able to dis-
charge from the ED some children with envenomation af-
ter AV administration, thus saving money and use of PICU
facilities. However, allergic reactions (rash or serum sick-
ness) developed in 58% of his patients. Bond's approach may
be appropriate for Arizona, but we believe that it should not
be adopted in other regions where envenomation is associ-
ated with severe cardiovascular dysfunction and death.
Cardiovascular dysfunction may develop hours after en-
The Journal of Pediatrics
Volume 124, Number 6
venomation, and its occurrence is unpredictable; all victims
arriving in the ED with signs of systemic intoxication should
be admitted to the hospital, preferably to an intensive care
unit.
The pathogenesis of cardiac dysfunction is not clear. It
has been suggested that hypokinesia and diminished myo-
cardial performance are the result of increased catechola-
mine production, causing increased myocardial oxygen de-
mand in excess of oxygen supply. 7, 35-39 Antivenom given
before intoxication may prevent catecholamine excretion
but cannot abolish its effect once excreted; this might
explain its apparent ineffectiveness in human victims, as
shown in our study. Animal studies have shown that it is
possible to prevent intoxication and death when AV is ad-
ministered before, or concomitantly with, the venom. 3234
This situation obviously does not apply to human victims.
Cardiac dysfunction develops hours after ED arrival and
thus seems to be potentially preventable. However, our
study shows that the frequency of significant cardiovascu-
lar abnormalities was similar in children treated with A V
and in untreated children, and children treated with AV had
a more difficult course. Although we do not believe that the
apparently higher mortality rate in the AV group is caus-
ally related to AV administration, our data demonstrate the
ineffectiveness of the AV. In addition, 15% of our patients
were already in a state of severe respiratory failure on ar-
rival at the hospital; AV therapy could not be preventive in
such cases. In fact, the postintubation course of the children
in our study who were treated with specific A V did not dif-
fer from the course of the children who did not receive AV.
Thus, despite almost 40 years of use, there is no convinc-
ing evidence that AV is effective in the treatment of human
envenomation. Moreover, no quantitative studies have
compared A V dosage, route of administration, time-effec-
tiveness relation, and titer of the A V used. 29, 40
We believe that the marked decrease in the mortality rate
in our institution is the result of the introduction of inten-
sive care and treatment of symptoms 8'41, 42 rather than
therapy with AV. Similar results have been reported for the
Mahad region of India, where the mortality rate decreased
from 30% in the 1970s to 2% to 3% in the 1980s without the
use of AV but with intensive care and treatment of symp-
toms.4,14 These data emphasize the need to reconsider
therapy with AV in human victims of scorpion stings and
the need for a control study regarding its efficacy. Such a
study may define specific subgroups that may benefit from
therapy with AV.
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international subscribers, for Vol. 124 (January-June) and Vol. 125 (July-December), shipping
charges included. Each bound volume contains subject and author indexes, and all advertising is
removed. Copies are shipped within 60 days after publication of the last issue in the volume. The
binding is durable buckram, with the Journal name, volume number, and year stamped in gold
on the spine. Payment must accompany all orders. Contact M o s b y - Y e a r Book, Inc., Subscrip-
tion Services, 11830 Westline Industrial Dr., St. Louis, M O 63146-3318, USA/800-453-4351, or
314-453-4351.
Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular
Journal subscription.