- Email: [email protected]
Wound assessment of the Loxosceles reclusa spider bite
Wound assessment of the Loxosceles reclusa spider bite A u t h o r : Terri D a w n C l o w e r s , RN, BSN, MNSc, Little Rock, A r k a n s a s
Objective The p u r p o s e of this s t u d y w a s to d e t e r m i n e the d a t a t h a t are m o s t i m p o r t a n t for n u r s e s to recognize in t h e a s s e s s m e n t of a Loxosceles reclusa ( b r o w n recluse) spider bite. G i v e n such a s s e s s m e n t elem e n t s , it m a y b e possible to d e c r e a s e the severity of complications a n d complexity of care b y providing t h e m o s t appropriate therapy. Methods This s t u d y involved a retrospective review of 39 identified p a t i e n t charts. A s p e c t s t h a t w e r e exami n e d i n c l u d e d demographics, w o u n d a s s e s s m e n t s , a n d o u t c o m e data. P a t i e n t s w h o came to the s t u d y facility w i t h i n 48 hours of the bite a n d w h o s e diagnosis w a s a p r o b a b l e or possible b r o w n spider bite m e t inclusion criteria. Results Data analysis r e v e a l e d t h a t the majority of p a t i e n t s s u s t a i n e d b i t e s on t h e extremities a n d t h a t t h o s e bites p r o d u c e d the m o s t c o m m o n l y n o t e d symptoms. This is the first s t u d y in w h i c h specific local and systemic symptoms have been quantified and r e l a t e d to the w o u n d area. B e c a u s e of varied treatm e n t a n d limited follow-up, d e t e r m i n i n g t h e relationship b e t w e e n w o u n d a s s e s s m e n t a n d o u t c o m e w a s problematic. Discussion O n g o i n g studies, in c o n t r a s t to retrospective review, are n e e d e d to r e d u c e the limitations of this study, s u c h as the loss of p a t i e n t s to follow-up. Areas for further r e s e a r c h i n c l u d e the replication of this s t u d y a n d detailed analysis of t r e a t m e n t variables in relation to w o u n d outcome. (J Emerg Nurs 1996;22:283-7) ' o r t h A m e r i c a n l o x o s c e l i s m is a c o n d i t i o n c a u s e d b y e n v e n o m a t i o n of the L o x o s c e l e s reclusa (brown recluse) spider (Figure 1). The first recognized, d o c u m e n t e d c a s e of North A m e r i c a n loxo s c e l i s m w a s p u b l i s h e d in 1957.1 Spiders of the g e n u s L e x o s c e l e s are f o u n d in South, Central, a n d
N
Terri Clowers is an instructor in the Department of Nursing, University of Central Arkansas, and a staff nurse, emergency department and Med-Flight, Baptist Medical Center, Little Rock, Arkansas. For reprints, write Terri Clowers, RN, 515 Trumpler,Little Rock, AR 72211. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/1/75829
North America, a n d in several other parts of the world. The m o s t a b u n d a n t l y i n f e s t e d s t a t e s are Arkansas, Missouri, Kansas, a n d Oklahoma. 2 Reclusa m e a n s recluse or t h e s e c l u d e d one. The b r o w n recluse spider avoids s u n l i g h t a n d areas of activity a n d rarely b i t e s u n l e s s t h r e a t e n e d . The living q u a r t e r s are typically o u t d o o r s in w o o d p i l e s or garages, or i n s i d e the h o m e in closets, b a s e m e n t s , a n d attics. The v e n o m of the b r o w n recluse is comp o s e d of alkaline p h o s p h a t a s e , lipase, protease, hyaluronidase, a n d s p h i n g o m y e l i n a s e D. It s e e m s likely t h a t the s p h i n g o m y e l i n a s e D triggers a n enzym a t i c reaction t h a t d a m a g e s t h e s t r u c t u r e of the erythrocyte a n d c a u s e s hemolysis. Purified v e n o m has b e e n d e m o n s t r a t e d to c a u s e n e c r o s i s of skin, b u t the exact c o m p o u n d r e s p o n s i b l e for this r e a c t i o n is u n k n o w n . Purified v e n o m has also b e e n s h o w n to act directly on t h e cell wall c a u s i n g i m m e d i a t e d e s t r u c tion. Small capillaries that are t o u c h e d b y this v e n o m s h o w i m m e d i a t e c o a g u l a t i o n a n d occlusion, w h i c h occur hours before visible e v i d e n c e of t i s s u e necrosis is noted. 2 As c o a g u l a t i o n b e g i n s , large n u m b e r s of platelets are t r a p p e d at t h e site of e n v e n o m a t i o n a n d the c o a g u l a t i o n is w o r s e n e d b y the m e c h a n i c a l d a m a g e to the red cells i n s i d e t h e clots.
Clinical presentation and treatment The clinical p r e s e n t a t i o n of a p a t i e n t with L. reclusa e n v e n o m a t i o n r a n g e s from mild, local e r y t h e m a (Figure 2) to severe s y s t e m i c complications. Death h a s occasionally b e e n reported. As is typical of all injuries, children a n d older adults are more prone to severe reactions a n d mortality, However, s y s t e m i c r e a c t i o n s have n o t b e e n n o t e d to b e proportional to the local r e a c t i o n a n d vice versa. A variety of local s y m p t o m s h a v e b e e n widely reported in the literature. T h e s e i n c l u d e itching, pain, erythema, macule, eschar, ulceration, a n d i n d u r a t i o n . The s y s t e m i c s y m p t o m s reported in the literature i n c l u d e fever, chills, m a l a i s e , n a u s e a a n d v o m i t i n g , m y a l g i a s , t h r o m b o c y t o p e n i a , a n d d i s s e m i n a t e d intravascular coagulation. There have b e e n no previous reports in t h e literature to q u a n t i f y the f r e q u e n c y with w h i c h local or s y s t e m i c s y m p t o m s o c c u r or to relate t h e m to a n a t o m i c regions of the body. Only A n d e r s o n s, 4 a t t e m p t e d to relate a local f i n d i n g (a macule) to w o u n d outcome. He b e l i e v e d a m a c u l e w a s e v i d e n c e
August 1996 283
JOURNAL OF EMERGENCY NURSING/Clowers
Figure 1 L o x o s c e l e s reclusa (brown recluse) spider. (Courtesy
Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
Figure 2 Early bite wound; macule surrounded by erythema. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
of s u b s t a n t i a l e n v e n o m a t i o n if p r e s e n t less t h a n 24 h o u r s from t h e t i m e of t h e bite. T h e l i t e r a t u r e h a s f o c u s e d e x t e n s i v e l y on t r e a t m e n t , b u t t h e r e a p p e a r s to b e no t r e a t m e n t of choice.
284
Volume 22, Number 4
Figure 3 Necrotic bite wound. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
A l t h o u g h local w o u n d c a r e a n d a p p r o p r i a t e t e t a n u s p r o p h y l a x i s are t y p i c a l l y u n c h a l l e n g e d , other regimens are more controversial. These treatments i n c l u d e a n t i v e n o m , steroids, l e u k o c y t e inhibitors,
C l o w e r s / J O U R N A L O F EMERGENCY NURSING
Table 1 Erythema
comparison
None N %
Area of bite Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
1
2:6
1
2.6
2
5.1
Erythema 2.5-4.9 cm 5.0-7.4 cm N % N %
<2.5 cm N % 1
2.6
1
2.6
3 1 6
7.7 2.6 15.4
1 1
2.6 2.6
1 1 3
2.6 2.6 7.7
7
17,9
1
2.6
1 1 -1 4
2.6 2.6 -2.6 10.3
Table 2 Pain comparison
7.5-9.9 em N %
10-15 cm N %
1
2.6
2
5.1
1
2.6
2
5.1
2
5.1
Size unknown N % 2 -1 1 1 4 4 1 2 16
N
5.1 -2.6 2.6 2.6 10.3 10,3 2.6 5.1 41.0
Total %
5 2 1 1 1 8 6 11 4 39
12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
Table 3 Macule comparison Pain
Macule Yes
No Area of bite
N
%
N
%
Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
2 ----1 3 4 2 12
5.1 ----2.6 7.7 10.3 5.1 30.8
3 2 1 1 1 7 3 7 2 27
7.7 5.1 2.6 2.6 2.6 17.9 7.7 17.9 5.1 69.2
Total N % 5 2 1 1 1 8 6 11 4 39
No
12,8 5,1 2,6 2,6 2.6 20,5 15.4 28.2 10.3 100.0
Yes
Area of bite
N
%
N
%
N
Head/neck Chest Abdomen Perineum Back Arms/axiUa Hands/wrist Legs/hips Feet/ankles Total
5 2 1 1 -5 3 8 3 28
12.8 5.1 2.6 2.6 -12.8 7.7 20.5 7.7 71.8
----1 3 3 3 1 11
----2.6 7.7 7.7 7.7 2.6 28.2
5 2 1 1 1 8 6 11 4 39
Total % 12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
Table 4 Fever comparison Fever 98.7~ N
None Area of bite
N
%
Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
3 1 1 1 -4 5 5 2 22
7.7 2.6 2.6 2.6 -10.3 12.8 12.8 5.1 56.4
antibiotics, Antivenom, would (Figure
and
surgical
if administered
decrease 3), b u t
excision within
the
lesion
the
antivenom
size
and
2 1 --1 3 1 3 2 13
and the
prevent
is not
grafting.
first 24 hours, necrosis
commercially
~F %
N
5.1 2.6 --2.6 7.7 2.6 7.7 5.1 33.3
-----1 -3 -4
available. nisone mixed
> 100.0 ~ F %
5 Treatment or
-----2.6 -7.7 -10.3
with
dexamethasone
results
preventing
in both
hemolysis.
Total
animal
N
%
5 2 1 1 1 8 6 11 4 39
12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
steroids
such
(Decadron) and
5-7 L e u k o c y t e
as
has
human
predshown
studies
inhibitors
August
1996
in
such
285
JOURNAL OF EMERGENCYNURSING/Clowers
Figure 4 Healing bite wound; well demarcated. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
as d a p s o n e are t h o u g h t to prevent infiltration of the w o u n d by leukocytes (decreasing erythema, induration, and necrosis) b u t have severe effects such as hepatitis, hemolytic anemia, and cholestatic jaundice. 7 Antibiotics have traditionally b e e n recomm e n d e d only for s e c o n d a r y infections incurred from s c r a t c h i n g t h e wounds. Early surgical excision is contraindicated. Venom s p r e a d s rapidly throughout the wound in the first 1 to 2 weeks, and d e m a r c a t i o n lines often do not a p p e a r until at least 4 weeks after the bite occurs. Therefore early excision would be u n n e c e s s a r y a n d ineffective. If required, delayed surgical excision and grafting (6 to 8 weeks) has b e e n shown to be more appropriate. 6 Hyperbaric oxygen t h e r a p y and the use of transdermal nitroglycerin p a t c h e s have h a d some a n e c d o t a l success, s, 9
Methods Two objectives were identified for this study. First, the author w a s i n t e r e s t e d in delineating specific a s s e s s m e n t d a t a that were m o s t important for the nurse to recognize in the initial evaluation of a brown recluse s p i d e r bite. These initial d a t a not only guide the s u b s e q u e n t nursing care b u t also are often instrum e n t a l in d e t e r m i n i n g the m e d i c a l t r e a t m e n t plan. Second, if initial w o u n d a s s e s s m e n t and wound outcome can be correlated, p e r h a p s more appropriate decisions can be m a d e in the allocation of resources.
286 Volume 22, Number 4
The s t u d y u s e d a r e t r o s p e c t i v e , d e s c r i p t i v e d e s i g n to d o c u m e n t the early postbite (less than 48 hours) w o u n d characteristics of the brown recluse spider a n d the history surrounding the bite. Data collection w a s a c c o m p l i s h e d through a chart review of appropriate patients, defined as those s e e k i n g medical attention in the study hospital within 48 hours of the bite and who h a d a d i a g n o s i s of either a probable or possible brown spider bite. A s a m p l e of conven i e n c e identified 39 p a t i e n t s in a 6-year period for inclusion in the study. Descriptive statistics were u s e d in the final analysis of data. Because of both the small s a m p l e and small ceil size, statistical tests such as t tests and chi-square tests were not appropriate. An i n s t r u m e n t developed by the author was u s e d to collect the data. This i n s t r u m e n t c o m b i n e d d e m o g r a p h i c data s u c h as a g e and sex with the chart r e v i e w information. P a t i e n t c h a r t information included wound characteristics identified in the initial a s s e s s m e n t , the initial diagnosis, e m e r g e n c y care, and r e c o m m e n d e d treatment. The i n s t r u m e n t also d o c u m e n t e d the course of wound healing and any complications t h a t n e c e s s i t a t e d altered or continuing treatment. Final diagnosis a n d w o u n d outcome c o m p l e t e d the information d o c u m e n t e d on the tool. A p h y s i c i a n expert in the area of brown spider bites r e v i e w e d the tool for face validity. For ease of review, the following anatomic regions of the b o d y were used: head/neck, chest, abdomen, perineum, back, arms/axilla, hands/wrist, legs/hips, and the feet/ankles.
Results Of the 39 patients who m e t the s t u d y criteria, 17 (43.6%) were male and 22 (56.4%) were female. The ages of the subjects r a n g e d from 3 to 68 years of age, with the majority (69.2%) b e t w e e n the a g e s of 16 and 45 years. Of the regions listed in the methodology, male subjects reported bites in five different regions and female subjects reported bites in all nine different regions, with the legs/hips b e i n g the most commonly reported area (28.2%) in both sexes. When the four categories comprising the total area of the extremities are combined, 74.3% of all bites occur in these areas. Swelling, rash, red streaks, and cellulitis were identified through chart review and are local symptoms not previously reported in the literature. The three m o s t commonly noted local s y m p t o m s on the initial evaluation were e r y t h e m a in 37 of 39 cases (94.9%), pain in 27 of 39 cases (69.2%), and a macule in 11 of 39 cases (28.2%). All three of these local s y m p t o m s occurred m u c h more frequently on the extremities (as a group) than on any other anatomic
Clowers/JOURNAL OF EMERGENCYNURSING
area. For b i t e s on t h e extremities, positive r e s p o n s e s for e r y t h e m a were n o t e d in 28 of 37 c a s e s (75.6%), p a i n in 19 of 27 c a s e s (70.3%), a n d a m a c u l e in 10 of 11 c a s e s (90.9%) (Tables 1, 2, a n d 3). In a d d i t i o n to t h e s y s t e m i c s y m p t o m s identified d u r i n g the clinical p r e s e n t a t i o n section, a d e n o p a t h y w a s also identified as a s y s t e m i c s y m p t o m d u r i n g chart review. T h e m o s t frequently identified s y s t e m i c s y m p t o m w a s a t e m p e r a t u r e v a r i a n c e in 17 of 39 c a s e s (43.5%). In t h e majority of t h e s e p a t i e n t s , oral t e m p e r a t u r e s r a n g e d from 98.7 ~ to 100.0 ~ F, b u t 4 of the 17 p a t i e n t s (23.6%) h a d t e m p e r a t u r e s in e x c e s s of 100.0 ~F, w i t h the highe s t d o c u m e n t e d at 103.0 ~ F. Of the p a t i e n t s w i t h fever, 13 of 17 c a s e s (76.4%) h a d b i t e s on extremities. D o c u m e n t e d t e m p e r a t u r e s in e x c e s s of 100.0 ~ F w e r e f o u n d only w i t h e x t r e m i t y b i t e s (four cases; Table 4). T h e s y s t e m i c s y m p t o m s of chills, malaise, n a u s e a a n d vomiting, myalgias, a n d a d e n o p a t h y were also n o t e d exclusively in e x t r e m i t y bites. T h u s it s e e m s t h a t not only are b r o w n recluse spider b i t e s to t h e e x t r e m i t i e s more c o m m o n , b u t also more severe. Of the 39 p a t i e n t s , 14 (35.9%) were lost to followup. Of the 25 w h o r e c e i v e d follow-up, only 6 p a t i e n t s h a d d o c u m e n t e d h e a l i n g of their w o u n d , w h e r e a s 19 h a d w o u n d s in various s t a g e s of repair. No p a t i e n t h a d d o c u m e n t e d w o r s e n i n g of the w o u n d (Figure 4).
strate no correlation b e t w e e n initial w o u n d a s s e s s m e n t a n d w o u n d outcome. However, s o m e interesti n g a n e c d o t a l o b s e r v a t i o n s w e r e made. Of the 24 p a t i e n t s t r e a t e d w i t h antibiotics, 18 (75%) h a d bites on the extremities. Of t h e 12 p a t i e n t s t r e a t e d with steroids, 7 (58%) h a d b i t e s on t h e extremities. Of the p a t i e n t s initially t r e a t e d w i t h h y p e r b a r i c oxygen, 13 of 16 (81%) h a d e x t r e m i t y bites. Of the p a t i e n t s w h o were a d m i t t e d to the hospital, 9 of 11 (82%) h a d bites on the extremities. The c o m m o n a l i t y of t h e s e initial t r e a t m e n t s is s i g n i f i c a n t e v e n t h o u g h the literature d o c u m e n t s n o c o n s i s t e n t f o u n d a t i o n for t h e s e treatm e n t s . T h e s e n u m b e r s d e m o n s t r a t e a more aggressive a p p r o a c h to e x t r e m i t y b i t e s b u t a very r a n d o m ized, i n c o n s i s t e n t t r e a t m e n t pattern. M a n y of t h e s e t r e a t m e n t s w e r e c o m b i n e d , further c o m p l i c a t i n g a n y a t t e m p t to correlate a s s e s s m e n t , t r e a t m e n t , a n d outcome. A prospective, o n g o i n g s t u d y of p a t i e n t s from e n t r y into t h e h e a l t h care s y s t e m to w o u n d h e a l i n g would possibly correlate initial w o u n d a s s e s s m e n t w i t h w o u n d o u t c o m e . A d d i t i o n a l a v e n u e s for future r e s e a r c h are s t u d i e s involving t r e a t m e n t variables to d e t e r m i n e t h e t r e a t m e n t of choice, g i v e n certain wound assessments.
References Discussion E r y t h e m a , pain, a n d a m a c u l e at the area of the b i t e a r e t h e m o s t c o m m o n l o c a l s y m p t o m s of a L. reclusa spider bite, a n d fever is the m o s t c o m m o n s y s t e m i c s y m p t o m . All four of t h e s e s y m p t o m s o c c u r r e d w i t h the g r e a t e s t f r e q u e n c y in b i t e s on the extremities. This f i n d i n g h a d not b e e n d o c u m e n t e d specifically in the literature before this study. T h e s e f i n d i n g s s u g g e s t the theory that e x t r e m i t y b i t e s are more c o m m o n a n d more severe, p e r h a p s n e c e s s i t a t i n g a s t a n d a r d i z e d , s t r e a m l i n e d a p p r o a c h to care. This h a s n o t b e e n d o c u m e n t e d as specifically in previous r e s e a r c h as it w a s in this study. Data o n t h e c o n d i t i o n of the w o u n d at t h e termin a t i o n of t r e a t m e n t w e r e difficult to collect a n d interpret. B e c a u s e of the e x t e n s i v e c o m b i n a t i o n s of s y m p t o m s , t r e a t m e n t s , a n d the large n u m b e r of p a t i e n t s lost to follow-up, this s t u d y could d e m o n -
1. Dillaha C, Jansen G, Honeycutt W, Hayden C. North American loxoscelism. JAMA 1964;188:33-6. 2. Wasserman G, Anderson R Loxoscelism and necrotic arachnidism. J Toxicol Clin Toxicol 1983:21:451-72. 3. Anderson P. Treatment of severe loxoscelism. J Me State Med Assoc 1971;68:609-11,618. 4. Anderson R Brown recluse spider bites: an update. J Ky Med Assoc 1978;76:172-3. 5. Gendron B. Loxosceles reclusa envenomation. Am J Emerg Med 1990;8:51-4. 6. Gutowicz M, Fritz R, Sonoga A. Brown recluse spider bite. J Am Podiatr Med Assoc 1989;79:142-6. 7. Hobbs G, Harrell R. Brown recluse spider bites: a common cause of necrotic arachnidism. Am J Emerg Med 1989;7:309-12. 8. Svendsen F. Treatment of clinically diagnosed brown recluse spider bites with hyperbaric oxygen: a clinical observation. J Ark Med Soc 1986;83:199-204. 9. Burton K. Nitroglycerine patches for brown recluse spider bites. Am Fam Physician 1995;51:1401.
August 1996 287
Objective The p u r p o s e of this s t u d y w a s to d e t e r m i n e the d a t a t h a t are m o s t i m p o r t a n t for n u r s e s to recognize in t h e a s s e s s m e n t of a Loxosceles reclusa ( b r o w n recluse) spider bite. G i v e n such a s s e s s m e n t elem e n t s , it m a y b e possible to d e c r e a s e the severity of complications a n d complexity of care b y providing t h e m o s t appropriate therapy. Methods This s t u d y involved a retrospective review of 39 identified p a t i e n t charts. A s p e c t s t h a t w e r e exami n e d i n c l u d e d demographics, w o u n d a s s e s s m e n t s , a n d o u t c o m e data. P a t i e n t s w h o came to the s t u d y facility w i t h i n 48 hours of the bite a n d w h o s e diagnosis w a s a p r o b a b l e or possible b r o w n spider bite m e t inclusion criteria. Results Data analysis r e v e a l e d t h a t the majority of p a t i e n t s s u s t a i n e d b i t e s on t h e extremities a n d t h a t t h o s e bites p r o d u c e d the m o s t c o m m o n l y n o t e d symptoms. This is the first s t u d y in w h i c h specific local and systemic symptoms have been quantified and r e l a t e d to the w o u n d area. B e c a u s e of varied treatm e n t a n d limited follow-up, d e t e r m i n i n g t h e relationship b e t w e e n w o u n d a s s e s s m e n t a n d o u t c o m e w a s problematic. Discussion O n g o i n g studies, in c o n t r a s t to retrospective review, are n e e d e d to r e d u c e the limitations of this study, s u c h as the loss of p a t i e n t s to follow-up. Areas for further r e s e a r c h i n c l u d e the replication of this s t u d y a n d detailed analysis of t r e a t m e n t variables in relation to w o u n d outcome. (J Emerg Nurs 1996;22:283-7) ' o r t h A m e r i c a n l o x o s c e l i s m is a c o n d i t i o n c a u s e d b y e n v e n o m a t i o n of the L o x o s c e l e s reclusa (brown recluse) spider (Figure 1). The first recognized, d o c u m e n t e d c a s e of North A m e r i c a n loxo s c e l i s m w a s p u b l i s h e d in 1957.1 Spiders of the g e n u s L e x o s c e l e s are f o u n d in South, Central, a n d
N
Terri Clowers is an instructor in the Department of Nursing, University of Central Arkansas, and a staff nurse, emergency department and Med-Flight, Baptist Medical Center, Little Rock, Arkansas. For reprints, write Terri Clowers, RN, 515 Trumpler,Little Rock, AR 72211. Copyright 9 1996 by the Emergency Nurses Association. 0099-1767/96 $5.00 + 0 18/1/75829
North America, a n d in several other parts of the world. The m o s t a b u n d a n t l y i n f e s t e d s t a t e s are Arkansas, Missouri, Kansas, a n d Oklahoma. 2 Reclusa m e a n s recluse or t h e s e c l u d e d one. The b r o w n recluse spider avoids s u n l i g h t a n d areas of activity a n d rarely b i t e s u n l e s s t h r e a t e n e d . The living q u a r t e r s are typically o u t d o o r s in w o o d p i l e s or garages, or i n s i d e the h o m e in closets, b a s e m e n t s , a n d attics. The v e n o m of the b r o w n recluse is comp o s e d of alkaline p h o s p h a t a s e , lipase, protease, hyaluronidase, a n d s p h i n g o m y e l i n a s e D. It s e e m s likely t h a t the s p h i n g o m y e l i n a s e D triggers a n enzym a t i c reaction t h a t d a m a g e s t h e s t r u c t u r e of the erythrocyte a n d c a u s e s hemolysis. Purified v e n o m has b e e n d e m o n s t r a t e d to c a u s e n e c r o s i s of skin, b u t the exact c o m p o u n d r e s p o n s i b l e for this r e a c t i o n is u n k n o w n . Purified v e n o m has also b e e n s h o w n to act directly on t h e cell wall c a u s i n g i m m e d i a t e d e s t r u c tion. Small capillaries that are t o u c h e d b y this v e n o m s h o w i m m e d i a t e c o a g u l a t i o n a n d occlusion, w h i c h occur hours before visible e v i d e n c e of t i s s u e necrosis is noted. 2 As c o a g u l a t i o n b e g i n s , large n u m b e r s of platelets are t r a p p e d at t h e site of e n v e n o m a t i o n a n d the c o a g u l a t i o n is w o r s e n e d b y the m e c h a n i c a l d a m a g e to the red cells i n s i d e t h e clots.
Clinical presentation and treatment The clinical p r e s e n t a t i o n of a p a t i e n t with L. reclusa e n v e n o m a t i o n r a n g e s from mild, local e r y t h e m a (Figure 2) to severe s y s t e m i c complications. Death h a s occasionally b e e n reported. As is typical of all injuries, children a n d older adults are more prone to severe reactions a n d mortality, However, s y s t e m i c r e a c t i o n s have n o t b e e n n o t e d to b e proportional to the local r e a c t i o n a n d vice versa. A variety of local s y m p t o m s h a v e b e e n widely reported in the literature. T h e s e i n c l u d e itching, pain, erythema, macule, eschar, ulceration, a n d i n d u r a t i o n . The s y s t e m i c s y m p t o m s reported in the literature i n c l u d e fever, chills, m a l a i s e , n a u s e a a n d v o m i t i n g , m y a l g i a s , t h r o m b o c y t o p e n i a , a n d d i s s e m i n a t e d intravascular coagulation. There have b e e n no previous reports in t h e literature to q u a n t i f y the f r e q u e n c y with w h i c h local or s y s t e m i c s y m p t o m s o c c u r or to relate t h e m to a n a t o m i c regions of the body. Only A n d e r s o n s, 4 a t t e m p t e d to relate a local f i n d i n g (a macule) to w o u n d outcome. He b e l i e v e d a m a c u l e w a s e v i d e n c e
August 1996 283
JOURNAL OF EMERGENCY NURSING/Clowers
Figure 1 L o x o s c e l e s reclusa (brown recluse) spider. (Courtesy
Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
Figure 2 Early bite wound; macule surrounded by erythema. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
of s u b s t a n t i a l e n v e n o m a t i o n if p r e s e n t less t h a n 24 h o u r s from t h e t i m e of t h e bite. T h e l i t e r a t u r e h a s f o c u s e d e x t e n s i v e l y on t r e a t m e n t , b u t t h e r e a p p e a r s to b e no t r e a t m e n t of choice.
284
Volume 22, Number 4
Figure 3 Necrotic bite wound. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
A l t h o u g h local w o u n d c a r e a n d a p p r o p r i a t e t e t a n u s p r o p h y l a x i s are t y p i c a l l y u n c h a l l e n g e d , other regimens are more controversial. These treatments i n c l u d e a n t i v e n o m , steroids, l e u k o c y t e inhibitors,
C l o w e r s / J O U R N A L O F EMERGENCY NURSING
Table 1 Erythema
comparison
None N %
Area of bite Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
1
2:6
1
2.6
2
5.1
Erythema 2.5-4.9 cm 5.0-7.4 cm N % N %
<2.5 cm N % 1
2.6
1
2.6
3 1 6
7.7 2.6 15.4
1 1
2.6 2.6
1 1 3
2.6 2.6 7.7
7
17,9
1
2.6
1 1 -1 4
2.6 2.6 -2.6 10.3
Table 2 Pain comparison
7.5-9.9 em N %
10-15 cm N %
1
2.6
2
5.1
1
2.6
2
5.1
2
5.1
Size unknown N % 2 -1 1 1 4 4 1 2 16
N
5.1 -2.6 2.6 2.6 10.3 10,3 2.6 5.1 41.0
Total %
5 2 1 1 1 8 6 11 4 39
12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
Table 3 Macule comparison Pain
Macule Yes
No Area of bite
N
%
N
%
Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
2 ----1 3 4 2 12
5.1 ----2.6 7.7 10.3 5.1 30.8
3 2 1 1 1 7 3 7 2 27
7.7 5.1 2.6 2.6 2.6 17.9 7.7 17.9 5.1 69.2
Total N % 5 2 1 1 1 8 6 11 4 39
No
12,8 5,1 2,6 2,6 2.6 20,5 15.4 28.2 10.3 100.0
Yes
Area of bite
N
%
N
%
N
Head/neck Chest Abdomen Perineum Back Arms/axiUa Hands/wrist Legs/hips Feet/ankles Total
5 2 1 1 -5 3 8 3 28
12.8 5.1 2.6 2.6 -12.8 7.7 20.5 7.7 71.8
----1 3 3 3 1 11
----2.6 7.7 7.7 7.7 2.6 28.2
5 2 1 1 1 8 6 11 4 39
Total % 12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
Table 4 Fever comparison Fever 98.7~ N
None Area of bite
N
%
Head/neck Chest Abdomen Perineum Back Arms/axilla Hands/wrists Legs/hips Feet/ankles Total
3 1 1 1 -4 5 5 2 22
7.7 2.6 2.6 2.6 -10.3 12.8 12.8 5.1 56.4
antibiotics, Antivenom, would (Figure
and
surgical
if administered
decrease 3), b u t
excision within
the
lesion
the
antivenom
size
and
2 1 --1 3 1 3 2 13
and the
prevent
is not
grafting.
first 24 hours, necrosis
commercially
~F %
N
5.1 2.6 --2.6 7.7 2.6 7.7 5.1 33.3
-----1 -3 -4
available. nisone mixed
> 100.0 ~ F %
5 Treatment or
-----2.6 -7.7 -10.3
with
dexamethasone
results
preventing
in both
hemolysis.
Total
animal
N
%
5 2 1 1 1 8 6 11 4 39
12.8 5.1 2.6 2.6 2.6 20.5 15.4 28.2 10.3 100.0
steroids
such
(Decadron) and
5-7 L e u k o c y t e
as
has
human
predshown
studies
inhibitors
August
1996
in
such
285
JOURNAL OF EMERGENCYNURSING/Clowers
Figure 4 Healing bite wound; well demarcated. (Courtesy Arkansas Hyperbaric Associates, Little Rock, Arkansas.)
as d a p s o n e are t h o u g h t to prevent infiltration of the w o u n d by leukocytes (decreasing erythema, induration, and necrosis) b u t have severe effects such as hepatitis, hemolytic anemia, and cholestatic jaundice. 7 Antibiotics have traditionally b e e n recomm e n d e d only for s e c o n d a r y infections incurred from s c r a t c h i n g t h e wounds. Early surgical excision is contraindicated. Venom s p r e a d s rapidly throughout the wound in the first 1 to 2 weeks, and d e m a r c a t i o n lines often do not a p p e a r until at least 4 weeks after the bite occurs. Therefore early excision would be u n n e c e s s a r y a n d ineffective. If required, delayed surgical excision and grafting (6 to 8 weeks) has b e e n shown to be more appropriate. 6 Hyperbaric oxygen t h e r a p y and the use of transdermal nitroglycerin p a t c h e s have h a d some a n e c d o t a l success, s, 9
Methods Two objectives were identified for this study. First, the author w a s i n t e r e s t e d in delineating specific a s s e s s m e n t d a t a that were m o s t important for the nurse to recognize in the initial evaluation of a brown recluse s p i d e r bite. These initial d a t a not only guide the s u b s e q u e n t nursing care b u t also are often instrum e n t a l in d e t e r m i n i n g the m e d i c a l t r e a t m e n t plan. Second, if initial w o u n d a s s e s s m e n t and wound outcome can be correlated, p e r h a p s more appropriate decisions can be m a d e in the allocation of resources.
286 Volume 22, Number 4
The s t u d y u s e d a r e t r o s p e c t i v e , d e s c r i p t i v e d e s i g n to d o c u m e n t the early postbite (less than 48 hours) w o u n d characteristics of the brown recluse spider a n d the history surrounding the bite. Data collection w a s a c c o m p l i s h e d through a chart review of appropriate patients, defined as those s e e k i n g medical attention in the study hospital within 48 hours of the bite and who h a d a d i a g n o s i s of either a probable or possible brown spider bite. A s a m p l e of conven i e n c e identified 39 p a t i e n t s in a 6-year period for inclusion in the study. Descriptive statistics were u s e d in the final analysis of data. Because of both the small s a m p l e and small ceil size, statistical tests such as t tests and chi-square tests were not appropriate. An i n s t r u m e n t developed by the author was u s e d to collect the data. This i n s t r u m e n t c o m b i n e d d e m o g r a p h i c data s u c h as a g e and sex with the chart r e v i e w information. P a t i e n t c h a r t information included wound characteristics identified in the initial a s s e s s m e n t , the initial diagnosis, e m e r g e n c y care, and r e c o m m e n d e d treatment. The i n s t r u m e n t also d o c u m e n t e d the course of wound healing and any complications t h a t n e c e s s i t a t e d altered or continuing treatment. Final diagnosis a n d w o u n d outcome c o m p l e t e d the information d o c u m e n t e d on the tool. A p h y s i c i a n expert in the area of brown spider bites r e v i e w e d the tool for face validity. For ease of review, the following anatomic regions of the b o d y were used: head/neck, chest, abdomen, perineum, back, arms/axilla, hands/wrist, legs/hips, and the feet/ankles.
Results Of the 39 patients who m e t the s t u d y criteria, 17 (43.6%) were male and 22 (56.4%) were female. The ages of the subjects r a n g e d from 3 to 68 years of age, with the majority (69.2%) b e t w e e n the a g e s of 16 and 45 years. Of the regions listed in the methodology, male subjects reported bites in five different regions and female subjects reported bites in all nine different regions, with the legs/hips b e i n g the most commonly reported area (28.2%) in both sexes. When the four categories comprising the total area of the extremities are combined, 74.3% of all bites occur in these areas. Swelling, rash, red streaks, and cellulitis were identified through chart review and are local symptoms not previously reported in the literature. The three m o s t commonly noted local s y m p t o m s on the initial evaluation were e r y t h e m a in 37 of 39 cases (94.9%), pain in 27 of 39 cases (69.2%), and a macule in 11 of 39 cases (28.2%). All three of these local s y m p t o m s occurred m u c h more frequently on the extremities (as a group) than on any other anatomic
Clowers/JOURNAL OF EMERGENCYNURSING
area. For b i t e s on t h e extremities, positive r e s p o n s e s for e r y t h e m a were n o t e d in 28 of 37 c a s e s (75.6%), p a i n in 19 of 27 c a s e s (70.3%), a n d a m a c u l e in 10 of 11 c a s e s (90.9%) (Tables 1, 2, a n d 3). In a d d i t i o n to t h e s y s t e m i c s y m p t o m s identified d u r i n g the clinical p r e s e n t a t i o n section, a d e n o p a t h y w a s also identified as a s y s t e m i c s y m p t o m d u r i n g chart review. T h e m o s t frequently identified s y s t e m i c s y m p t o m w a s a t e m p e r a t u r e v a r i a n c e in 17 of 39 c a s e s (43.5%). In t h e majority of t h e s e p a t i e n t s , oral t e m p e r a t u r e s r a n g e d from 98.7 ~ to 100.0 ~ F, b u t 4 of the 17 p a t i e n t s (23.6%) h a d t e m p e r a t u r e s in e x c e s s of 100.0 ~F, w i t h the highe s t d o c u m e n t e d at 103.0 ~ F. Of the p a t i e n t s w i t h fever, 13 of 17 c a s e s (76.4%) h a d b i t e s on extremities. D o c u m e n t e d t e m p e r a t u r e s in e x c e s s of 100.0 ~ F w e r e f o u n d only w i t h e x t r e m i t y b i t e s (four cases; Table 4). T h e s y s t e m i c s y m p t o m s of chills, malaise, n a u s e a a n d vomiting, myalgias, a n d a d e n o p a t h y were also n o t e d exclusively in e x t r e m i t y bites. T h u s it s e e m s t h a t not only are b r o w n recluse spider b i t e s to t h e e x t r e m i t i e s more c o m m o n , b u t also more severe. Of the 39 p a t i e n t s , 14 (35.9%) were lost to followup. Of the 25 w h o r e c e i v e d follow-up, only 6 p a t i e n t s h a d d o c u m e n t e d h e a l i n g of their w o u n d , w h e r e a s 19 h a d w o u n d s in various s t a g e s of repair. No p a t i e n t h a d d o c u m e n t e d w o r s e n i n g of the w o u n d (Figure 4).
strate no correlation b e t w e e n initial w o u n d a s s e s s m e n t a n d w o u n d outcome. However, s o m e interesti n g a n e c d o t a l o b s e r v a t i o n s w e r e made. Of the 24 p a t i e n t s t r e a t e d w i t h antibiotics, 18 (75%) h a d bites on the extremities. Of t h e 12 p a t i e n t s t r e a t e d with steroids, 7 (58%) h a d b i t e s on t h e extremities. Of the p a t i e n t s initially t r e a t e d w i t h h y p e r b a r i c oxygen, 13 of 16 (81%) h a d e x t r e m i t y bites. Of the p a t i e n t s w h o were a d m i t t e d to the hospital, 9 of 11 (82%) h a d bites on the extremities. The c o m m o n a l i t y of t h e s e initial t r e a t m e n t s is s i g n i f i c a n t e v e n t h o u g h the literature d o c u m e n t s n o c o n s i s t e n t f o u n d a t i o n for t h e s e treatm e n t s . T h e s e n u m b e r s d e m o n s t r a t e a more aggressive a p p r o a c h to e x t r e m i t y b i t e s b u t a very r a n d o m ized, i n c o n s i s t e n t t r e a t m e n t pattern. M a n y of t h e s e t r e a t m e n t s w e r e c o m b i n e d , further c o m p l i c a t i n g a n y a t t e m p t to correlate a s s e s s m e n t , t r e a t m e n t , a n d outcome. A prospective, o n g o i n g s t u d y of p a t i e n t s from e n t r y into t h e h e a l t h care s y s t e m to w o u n d h e a l i n g would possibly correlate initial w o u n d a s s e s s m e n t w i t h w o u n d o u t c o m e . A d d i t i o n a l a v e n u e s for future r e s e a r c h are s t u d i e s involving t r e a t m e n t variables to d e t e r m i n e t h e t r e a t m e n t of choice, g i v e n certain wound assessments.
References Discussion E r y t h e m a , pain, a n d a m a c u l e at the area of the b i t e a r e t h e m o s t c o m m o n l o c a l s y m p t o m s of a L. reclusa spider bite, a n d fever is the m o s t c o m m o n s y s t e m i c s y m p t o m . All four of t h e s e s y m p t o m s o c c u r r e d w i t h the g r e a t e s t f r e q u e n c y in b i t e s on the extremities. This f i n d i n g h a d not b e e n d o c u m e n t e d specifically in the literature before this study. T h e s e f i n d i n g s s u g g e s t the theory that e x t r e m i t y b i t e s are more c o m m o n a n d more severe, p e r h a p s n e c e s s i t a t i n g a s t a n d a r d i z e d , s t r e a m l i n e d a p p r o a c h to care. This h a s n o t b e e n d o c u m e n t e d as specifically in previous r e s e a r c h as it w a s in this study. Data o n t h e c o n d i t i o n of the w o u n d at t h e termin a t i o n of t r e a t m e n t w e r e difficult to collect a n d interpret. B e c a u s e of the e x t e n s i v e c o m b i n a t i o n s of s y m p t o m s , t r e a t m e n t s , a n d the large n u m b e r of p a t i e n t s lost to follow-up, this s t u d y could d e m o n -
1. Dillaha C, Jansen G, Honeycutt W, Hayden C. North American loxoscelism. JAMA 1964;188:33-6. 2. Wasserman G, Anderson R Loxoscelism and necrotic arachnidism. J Toxicol Clin Toxicol 1983:21:451-72. 3. Anderson P. Treatment of severe loxoscelism. J Me State Med Assoc 1971;68:609-11,618. 4. Anderson R Brown recluse spider bites: an update. J Ky Med Assoc 1978;76:172-3. 5. Gendron B. Loxosceles reclusa envenomation. Am J Emerg Med 1990;8:51-4. 6. Gutowicz M, Fritz R, Sonoga A. Brown recluse spider bite. J Am Podiatr Med Assoc 1989;79:142-6. 7. Hobbs G, Harrell R. Brown recluse spider bites: a common cause of necrotic arachnidism. Am J Emerg Med 1989;7:309-12. 8. Svendsen F. Treatment of clinically diagnosed brown recluse spider bites with hyperbaric oxygen: a clinical observation. J Ark Med Soc 1986;83:199-204. 9. Burton K. Nitroglycerine patches for brown recluse spider bites. Am Fam Physician 1995;51:1401.
August 1996 287