The diagnosis is essentially clinical. Due to the quick and intense local pain, the scorpion is often noticed. Yet the typical victim is someone who is usually stung at night in the foot, outdoors, possibly when he/she has moved a stone or some wood. People are also stung in the morning when they try to put on a shoe in which a scorpion is hiding. Occasionally in North Africa men are stung in the genitalia when they urinate against an object while squatting. The laboratory often shows leukocytosis, hyperglycaemia and a transient increase of the pancreatic and cardiac enzymes. The ECG can display temporary ischaemic deviations.

Patients with systemic symptoms (grades 3 and 4) must be hospitalised for 24-48 hours, preferably in an intensive care unit. Cardiac arrhythmia, hypertension and respiratory problems must be monitored. The airways must be kept open. Administration of oxygen and artificial respiration can be necessary.

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Pain relief with a powerful analgesic is often required. Local application of ice can reduce the pain, but may not be tolerated due to hyperaesthesia of the skin. Opiates should be avoided because of the danger of respiratory depression. Sometimes simple infiltration of the sting site with 2% xylocaine (i.e. lidocaine without adrenalin) can reduce the pain. Intravenous administration of 10 ml of a 10% solution of calcium gluconate over 10-20 minutes can decrease muscle pain and cramps for a short time (30´).

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The general management is aimed at neutralising the effects of the overstimulation of the autonomous nervous system. Steroids and antihistamines are not routinely required. Hypertension is counteracted by giving nifedipine (calcium-antagonist, Adalat®) or prazocin (alpha-blocker, Minipress®). In case of cardiac arrhythmia, xylocaine (lidocaine) may be given IV. Atropine is sometimes used as a parasympatholytic agent, but can aggravate orthosympathic symptoms. It is not systematically recommended. In case of convulsions diazepam IV should be given. Inotropic drugs and diuretics (furosemide) are indicated if there is heart failure. Hyperthermia requires cooling and salicylates.

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Most cases improve without antiserum within 9-30 hours (except for pain and paraesthesias). In the event of severe envenomation, death frequently occurs within 6 hours after the sting. The therapeutic role of antiserum is somewhat controversial. There are clear geographical differences in effectiveness. With degree 3 or 4 symptoms, IV antiserum is recommended. It should be diluted and administered in an IV infusion over 20-30 minutes. The dose is not age-dependent (e.g. 4-6 ml for Leiurus quinquestriatus). Some types of antiserum are also active against other scorpion species. The antiserum against L. quinquestriatus will also improve the symptoms of Androctonus crassicauda stings. However, this does not apply for all situations. Antisera are good for neutralising neuromuscular effects but have little effect on pain or paraesthesias. A type III hypersensitivity reaction can develop after administering the antiserum (horse, donkey or goat serum) (see treatment of snakebites). Type I reaction (anaphylaxis) is exceptional. Steroids, antihistamines and adrenaline must be on hand. If signs of acute hypersensitivity develop, the infusion must be stopped immediately. The effect of the antiserum is generally noticeable rather quickly. One hour’s observation must be allowed before deciding whether to administer a second ampoule. Tetanus vaccination must be checked. Currently F(ab´)₂-based antisera are being developed against several species of Centruroides.

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