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    5 views6 pages

    Black Widow

    Uploaded by

    afan
    Lalala

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    © All Rights Reserved
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    ORIGINAL CONTRIBUTION ‘ensonomation, black linical Presentation and Treatment of Black Widow Spider Envenomation: A Review of 163 Cases cdo spider From the Department of Medical Richard Flak, MO ‘Tosicology, Cood Samaritan ‘Susan Wethern-Kestnr, BN Regional Medical Centr, ‘Michael V Vance, MD Phornis, Arizona. Richard Gerkin, MO Revive for publication June 10,1991. Revi Decomber 2, 1001. Accepted for publication Decomber 17,1991, mn recived Provented et the Society for Academic Emergency Medicine Annual Meeting in Washington, DC, May 1991 Auer 1962. 21.7 ANNALS OF EMERGENCY MEDICINE Study objective: To review cases of black widow spider envenoma- tion to describe the clinical presentation and evaluat the efficacy of treatment Design: Retrospective chart review, Setting: An urban toxicology referral contr. ‘Type of participants: Al patients attended by the toxicology ser- vice and discharged from our hospital between January 1982 and December 1990 with a diagnosis of black widow spider envenamation Interventions: Inclusion criteria wore site 2 positive black widow spidor identification ra visible envenomation sie "targa lesion”) Depending on the clinical presentation, pationts were categorized as grace 1,2, orn severity. The eicacy and side effects of treatment altomatives were evaluate. Measurements and main results: One hundted shty:tivee patients met the inclusion criteria, The most common sites of envenc- mation were the upper and lowes exemites. The mast camon pe- senting complaint was generalized abdominal back, nd eg pain One hundred eighteen patents italy presented to our insttion, and 45 were transfers. Pain elit of grade 2 and 3 envenomations was achioved most effectively wit either black widow spder- specific antivenn alone or combination of W opioids and muscle relaxants. Fity-eight patents received antivenin wit complete resolution of symtoms ina mean time of 31 £26.7 minutes. Of the 118 patients iialy sen at our institution, the mean total dation of symptoms was 9++227 hous in patients reelvng antvenin ard 22 +249 hous inpatients not receiving ativenin, Fity-two percent of patients not ‘eceivingantiveninrequited hospitalization, whereas only 12% of those receiving antvenin wer admitted, One patient died of severe bron- chospasm after receiving antverin,Caleium gluconate was not effoc- tivein providing symptomatic eli inthis series, with 95% of the ade 2 and 3 envenomation treated italy with calcium gluconate ‘quiring the ation of V opioid o other analgesics for symptomatic tli. ity-five percent of patients intalyeciving WY morphine and 70% of those italy receiving both V morphine and benzodiazepines obtained symptomatic relief without atonal medication ENVENOMATION lark eal Conclusion: One hundred sity-three envenomation by black widow riders were reviewed and graded according to severty wit treatment ‘modalities evaluated. Although calcium gluconate usually has bean con- sidered the ist-lne treatment of severe envenomation by black widow spiders, we found itineffecive for pain rei compeed with a combina- tion of V opioids and benzodiazepines. The use of antiverin significantly shortened the duration of symotams in severe envenomations. [Clark FF, Wether-KestnerS, Vance MN, Gorn: Clinical presentation ‘and treatment of black widow spider envenomation: A review of 163, cases, Ann Emerg Mod July 1982:21:782-787,] INTRODUCTION Superstitions surrounding spiders were reported in Greek mythology. when the jealous goddess Aphrodite transformed Arachne into a spider. In the 17th eentury, southern Europe: experienced a panic over the bite of a spider that is thought to have been a type of wolf spider, Lycosa tarantula, and a dance ealled a “tarantella” was devised to protect bite victims. “Much of the folklore concerning bites by large hairy spiders (most of which are harmless) originated from this era. Medical reports of spider bites during this period proclaimed to be from tarantulas more likely were from Latrodectus tredecim- _guttatus, a European species related to the North American Dlack widow. Black widow spiders (Latrodectus sp) produce one of the ‘most potent known venoms by volume.? The venom is chiefly a ncurotoxin in human beings, with symptoms most often ranifested as severe skeletal muscle pain and cramping’ and autonomic disturbances such as diaphoresis and hyperten- ion.3 A variety of treatments have heen tried for sever Latrodectus cavenomations. Muscle relaxants, TV ealeium eluconate, opioids, and Latrodectus-specilie antivenin hay heen used with reported suecess.?7 Small studies have been, undertaken to assess the efficacy of therapy.# but the gue ‘Typical target lesion, demonstrotng the contrl puncte ste of envenomation, @ surrounding are of aching, andthe outer erythematous ring poyvea authors could draw no conclusions. We retrospectively reviewed 163 eases of envenomations by black widow spiders to deserihe the elinical presentation and evaluate the efficacy of treatment. MATERIALS AND METHODS ‘The charts of 172 consecutive patients with a diagnosis of black widow spider envenomation directly managed by the toxicology service of an urban hospital and regional toxicology referral center from January 1982 through December 1990 were reviewed retrospectively. The species of black widow found in Arizona is Latrodectus hesperus (LH), bites of which are clinically similar to those reported with the more ubiqui- tous Latrodectus mactans and Latrodectus variolus.? Venom from Latrodectus mactans and Latrodectus hesperus are s0 structurally similar that cnvenomations by each would be expected to respond similarly to various treatment regimens 10.1 Inclusion eriteria for entry into the study were either & positive Lil identification by the patient (or hospital staff when the spider was brought to the emergency department) or the presence of an erythematous envenomation site or “target lesion” (Figure 1) on physical examination associated with characteristic symptoms of envenomation. We have found the target lesion a reliable sign of LH envenomation, 12 Each chart was reviewed for data pertaining to patient age, “anatomic location of the bite, time and circumstances of the bite, vital signs, presenting complaint, physical examination finaings, total duration of symptoms, laboratory results, transfer data from referral facilites, and treatment includ- ing outcome and adverse reactions. “Relief of symptoms” ‘was defined as subjective pain relief as recorded in each, patient's medical record for 30 minutes or longer after treat- ment administration, We divided study patients into grade Tabi Grading ele often and symptoms flowing Latrodectas envenomatons rade __Descripden Tatlin Series (3) 1 Asymptomatic 0) cal sin at envenomation ste Nova sane 2 Musa pin in rvononstog avery Emanion of muscular paint abdomen ‘envenomatd on lover aan, renee envanomated 0 oper amity Local daphoress of enerometon site or Inte extremity Nomal va sgne in a Generalized muscle pain in back, abdomen, nd chest Diphorsiaremote om enverarnon ste Abnormal vel sis ypartnsion sto lead prssure> 10mm Hp (aso ood pressure» arm Ho ‘Techyardia (pase >100) ses an vrtig Headache 89 ANNALS OF EMERGENCY MEDICINE 21:7. SULY 1982 ENVENOMATION Clark eeat was based on the remai Retrospective follow-up information concerning delayed hypersensitivity reactions was sought on all patients receiv ing antivenin. All patients receiving antivenin at ou tion are educated extensively eon i associated with delayed hypersensitivity reactions such rashes, myalgias, pruritus, and fever. Each patient (o ‘accompanying parent for children) was requested to notify the poison center if signs or symptoms of delayed hypersensi- tivity reactions were observed so that the patient could be re-evaluated or preseriptions ordered if needed. Follove-up data concerning these reactions were recorded by the poison center, and these data were reviewed on paticnts treated since 1986 for any observed and reported delayed hypersen- sitivity reactions, In addition, telephone follow-up was aitempted to all patients who received antivenin. Sued analy wan performed using Stade tse and 2 analysi ing criteria RESULTS One hundred seventy-two charts with the widow spider envenomation” were reviewed inclusion eiteria. Ninety-nine patients (61%) were male Ninety-four patients (58%) were bitten at their residence, and 24 (159%) were bitten by a spider Uhat was in thei eloth- ing or shoes as thoy dressed. Sixteen pationts (6%) were bit ten in bed. The average age ofall patients was 31.6 years, with an age range of 8 months to 88 years. The stuly group included 18 pediatric patients. A positive identification of the spider was recorded in 117 charts (7296), whereas a target lesion was mentioned among the recorded physical examination in 79 patients (4896). Patients most often were hitten on the lower extremity (Figure 2). The average time from envenomation until onset of symptoms was 1.15 £ 1.64 hours (ranging from immediately to [2 hours). The average time from onset of symptoms until presentation to a health eare facility for all patients wax 6,157.83 hours (range, 30 minutes to 48 hours). liagnosis of “black ind 163 met Fowe2 Lectons of Latredet hesperus ncenmaton No.of Paionts JULY 1882. 21:7. ANNALS OF EMERGENCY MEDICINE ‘The most common presenting complaint was genes ‘muscular abdominal, back, and leg pain, altho of complaints were recorded (Figure 3). Thirty (22%) were diaphoretc on presentation, Most adult vietims presented with normal vital signs, but 45 (31%) were hyper- tensive (systolic blood pressure, 140 mm Hg, er diastolic (10%) presented with tachycardia (pulse 100). ‘The majority of all envonomations were grade 2 (87%) and 3 (5496) in severity (Table 1). Kighty-nine male vietims (90%) and 59 female victims (92%) were grade 2 or 3 envenoma- tions. Eighty grade 2 or 3 patients (54%) were 31 years old or younger. ‘Twenty-two patients (149) in this series initially were sent home after evaluation in an ED or physician's office but returned to an ED with recurring pain. One hundred eighteen patients (72%) in the study initially were seen at our institu- tion. Forty-five patients (28%) were transferred to our insti- tution from another facility due to treatment failures of rade 2 or 3 envenomations. Of the 45 transferred patients, 15 (88% of those transferred) had reeeived either ealeium eluconate alone or in combination with a muscle relaxant such, asmethocarbamol. Only six (139) had received a trial of TV ‘or IM opioids. The remainder of patients had received some combination of oral analgesics, TV muscle relaxants, or other therapies. None had received antivenin. Laboratory testing was performed on some severe enveno- ‘mations (Table 2). Twenty-one of 54 patients with laboratory ‘work performed had abnormal laboratory findings, the mast ‘common being leukocytosis. Although 38 patients with severe and cramping were evaluated with total ereatine evels, only seven were found to have elevat ced values (highest, 1,350; mean, 718 IU/L). Myoglobinuria aluated gure Common signs and symptoms asscated i = se

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