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Deadly Spider Bites

Deadly Spider Bites

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Published by draculavanhelsing
The funnel web and common spider bites
The funnel web and common spider bites

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Published by: draculavanhelsing on Nov 06, 2010
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12/31/2012

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244
Reprinted from Australian Family Physician Vol. 33, No. 4, April 2004
CLINICALPRACTICEEnvenomation
BACKGROUND
The funnel web spiders, encompassedwithin the genera
Atrax 
and
Hadronyche 
,are the most dangerous spiders in theworld. Although the incidence of envenomation is low, funnel web spidersremain a cause of considerable publicconcern. However, most common spiderbites produce only minor effects requiringonly symptomatic treatment.
OBJECTIVE
This article describes the clinical featuresand treatment of the funnel web spiderand that of its close relative, the mousespiders. It also covers the question of necrotising arachnidism as well as bitesfrom other common species of spiders.
DISCUSSION
Appropriate first aid combined with theadministration of specific antivenom can belife saving for funnel web spider bites. Truenecrotising arachnidism appears to be rare.If suspected, clinicians must first considerthe very wide differential diagnoses.
S
pider bites are one of the commonesttypes of bites or stings presenting for man-agement in general practice and emergencymedicine departments. While in most casesthe responsible species is not identified andthe effects self limited, certain species caninflict life threatening bites.
Funnel web spiders
More than 30 species of the highly danger-ous funnel web spiders are found on theeastern seaboard of Australia including partsof South Australia and Tasmania (
Figure 1
).The venom appears to be particularly harmfulto primates, whereas other mammals are rel-atively unaffected. While many of thesespiders remain unnamed and the venomunstudied, all funnel web spiders belongeither to the genera
Atrax 
or
Hadronyche 
.Identification and classification of funnel webspiders is often difficult – with some speciesresembling the less dangerous trapdoorspiders. Any suspicious spider that hasinflicted even an apparently minor injurywithin the geographic distribution of thesespiders should be treated as if it were afunnel web spider. If the spider is captured orkilled, formal identification is encouraged –even a badly damaged spider can often besuccessfully identified by arachnologists.
Sydney funnel web spider
The spider responsible for the most signifi-cant bites is the Sydney funnel web spider(
Atrax robustus 
), a species geographicallylimited to an area within 160 km radius ofthe Sydney (New South Wales) central busi-ness district.
1
The Sydney funnel webspider is a large spider with a glossy blackcephalothorax and a dark abdomen. Thefemale is larger and more robust than themale (
Figure 2 
). The male has a spur on itssecond leg and the spinnerets (from whichthe spider produces silk) of both sexes arelong and obvious, especially the terminalspinneret. Both sexes of this species arevery aggressive. When disturbed, they willrear up ready to strike with their large,downward pointing fangs. The femalespider constructs a burrow that may be 30cm or more deep. Some use crevices inrocks or around house foundations andcolonies may contain as many as 100spiders. The male spiders tend to roam andoften enter houses, particularly during thesummer months and in wet weather. Bitesmay occur when the spider has taken uptemporary residence in bedding, clothing orfootwear, or when it is trodden on.Most bites occur in the warmer months,and are predominantly sustained on the
B Nimorakiotakis,
MBBS, FACEM, is Staff Specialist, Epworth Hospital andSunshine Hospital, and Fellow, The Australian Venom Research Unit, Departmentof Pharmacology, the University of Melbourne, Victoria.
KD Winkel,
MBBS, BMedSc, PhD, FACTM, is Director, The Australian VenomResearch Unit, Department of Pharmacology, the University of Melbourne, Victoria,and President-Elect, the Australasian College of Tropical Medicine.
The funnel web andcommon spider bites
 
Clinical practice:
The funnel web and common spider bites
Reprinted from Australian Family Physician Vol. 33, No. 4, April 2004
245
extremities. Children are especially at riskdue to their lower body weight and thepotential for multiple bites to occur if spidersare handled. However, considering the largepopulation at risk, effective envenomation isvery uncommon. The male species is consid-ered to be the most venomous, and all13 funnel web spider fatalities documentedbefore the introduction of antivenom in 1980have been attributed to the male spider.
1
Sydney funnel web spiders are usually easilyidentifiable to the trained eye, but any largedark spider found in the geographic distribu-tion area should be treated with suspicion.
Other funnel web spiders
There are 12 described species and at least20 unnamed species in the more widely dis-tributed genus Hadronyche.
2,3
They are alsoaggressive spiders with at least six speciesdescribed as having a similar envenomationsyndrome to the Sydney funnel web spider.
4
As the potency of
Hadronyche spp 
venomappears variable in relationship to sex, size,health, feeding habits and geographical dis-tribution, all bites from these spiders shouldbe managed as for the Sydney funnelweb spider.
Pathogenesis
Although most funnel web spider bites arethought to be ineffective or ‘dry’, the clini-cal syndrome can be devastating and hasbeen lethal in both adults and children.While the causative venom is multicompo-nent, the key neurotoxins are the
Ç 
-atracotoxins (
Ç 
-ACTXs). The
Ç 
-ACTXs actby slowing sodium current inactivationresulting in spontaneous repetitive firing ofaction potentials.
7
This triggers the releaseof excessive – and eventual exhaustion of –predominantly sympathetic neurotransmit-ters leading to the characteristic biphasicclinical syndrome.
Symptoms and signs of envenomation
The initial bite is usually painful and fangmarks are generally seen. The envenomationsyndrome is generally characterised by twophases: the first begins within minutes of thebite, and the second when the secretionssubside – typically many hours later.
1
Historically deaths have occurred in eitherphase of envenomation.Phase 1 is characterised by:
Local effects:
bite site may be painful for days to weeksbecause of direct trauma and acidity of venombut no local necrosis has been recordedlocal swelling, erythema and occasionallysweating.
General effects:
numbness around the mouth and spasms/ fasciculation of the tonguenausea and vomiting, abdominal pain,acute gastric dilatationprofuse sweating, salivation, lacrimation,piloerectionsevere dyspnoea as a result of noncardio-genic pulmonary oedemamental status can rapidly progress fromconfusion to irrationality or comahypertension, tachycardia and vasocon-striction (hypotension may occur later)local and generalised muscle fasciculationand spasm which may be prolonged andviolent (facial, tongue or intercostalmuscles, trismus) and difficult to manage.Phase 2 is characterised by:hypotensionhypoventilation and apnoeacontinuing acute noncardiogenic pul-monary oedemacoma, and, finallyirreversible cardiac arrest.
First aid and treatment
A summary of the recommended first aid andmedical treatment for funnel web spider biteis presented in
Figure 4 
. The key points are:ensure airway, breathing and circulation(ABCs) are maintainedprompt application of pressure immobilisa-tion bandage (PIB) to the affected limbtransfer to hospital, ideally whereantivenom, resuscitation equipment andmonitoring is availableintravenous access should be obtainedPIB should be removed only in an areawere appropriate resuscitation can occurand antivenom is available. (If PIB hasbeen removed and the patient deterio-rates it should be re-applied)local tissue enzymes may inactivate thevenom, therefore the use of PIB may notonly be helpful in delaying the onset ofsymptoms, but may allow for a degree ofinactivation of the venomadminister antivenom as per protocol in
Figure 1. Geographical distribution of funnel webspidersFigure 3. Female Northern funnel web spider
Photo courtesy Vern Daffin
Figure 2. Comparison of size and appearance of male (left) and female (right) Sydney funnel webspiders
Photo courtesy Vern Daffin
 
246
Reprinted from Australian Family Physician Vol. 33, No. 4, April 2004
Clinical practice:
The funnel web and common spider bites
Figure 4 
if systemic signs of envenoma-tion are presentuntil antivenom is available supportive careof the envenomed patient may include:supplemental oxygenatropine (0.6 mg initial dose for an adult)to reduce salivation and bronchorrhoeanasogastric aspiration because ofgastric dilatationmuscle relaxants and sedatives to facil-itate mechanical ventilation and controlintracranial pressureintubation and ventilation for respiratoryfailure and to reduce intracranial pressure(note: entotracheal intubation can be diffi-cult as a result of excessive salivarysecretions and violent fasciculations)fluid resuscitation should be used withcaution in the event of hypotensionbecause of noncardiogenic pulmonaryoedemarelapse is possible and may manifestas dyspnoea secondary to noncardio-genic oedema which usually respondsto further antivenom (this should notbe confused with iatrogenic pulmonaryoedema as a result of intravenousoverload, particularly in children)if no symptoms or signs of envenomationhave started 4 hours after the removal of firstaid measures or postbite, the patient may bedischarged (most patients presenting to hos-pital will not have been envenomed)tetanus status should be assessed andprophylaxis provided if indicated.Since the introduction of funnel web spiderantivenom in 1980, there have been no deathsreported and time required in hospital has dra-matically decreased from an average of 14 days
8
to less than 2 days.
1
Moreover, the antivenom isextremely safe – no cases of anaphylaxis havebeen reported and only one case of serum sick-ness has been associated with the antivenom.
9
Mouse spiders
Mouse spiders (
Missulena spp 
) are mediumsized and robust spiders found throughoutmainland Australia. Currently there are11 recognised species. They possess largepowerful fangs and produce copiousamounts of venom, but systemic envenoma-tion has rarely been reported and bites aregenerally minor. The most severe case ofmouse spider envenomation presented simi-
Figure 4. Management of potential funnel web spider bite
Should be considered in all cases of envenomation by a suspected funnel web or mouse spider
Apply pressure immobilisation bandage (PIB) to affected limb ASAP
PIB is not to be removed until intravenous access is established and appropriate monitoring and antivenom is available
Note: Antivenom should only be given if full facilities for treating an anaphylactic reaction, including resuscitation and monitoring equipment, are available
Administer 240 units (two ampoules) of funnel web spider antivenom intravenously if systemic signs of envenomation.If the patient has severe signs and symptoms of envenomation four ampoules should be administered intravenously.
2
Adrenaline should be ready in case of anaphylaxis (although it has never been reported)Once antivenom is givenand patient has improvedremove PIBObserve the patient for atleast 12 hours preferably inintensive careTitrate further antivenomdosage against signs andsymptoms. Discharge homeif clinically better with theadvice to return if:1. Symptoms of envenomation recur2. Symptoms of serumsickness occurEnsure tetanus status is upto datePatient does not respond, or onlypartially responds, to antivenom within15 minutesKeep PIB on or re-apply PIB if removedAdminister two further vials antivenomReconsider the diagnosis but be aware that severe envenomation may require multipleampoules – in such a case administer two further vials of antivenom (more than eight vialsmay be required)Admit patient to intensive care for closer monitoring
Note: If symptoms recur postremoval of PIB, it should be reapplied until further antivenom has been given.Endotracheal intubation may be difficult as a result of excessive salivation and fasciculations
Good responsePoor response

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