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Critical Decisions: Spider and Insect Envenomation

By ACEP Now | on June 1, 2013 | 0 Comment
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From the EM Model
6.0 Environmental Disorders
6.1 Bites and Envenomations

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ACEP News: Vol 32 – No 06 – June 2013

Objectives

On completion of this lesson, you should be able to:

  1. List the medically important spider and insect species in the United States.
  2. Describe common presentations of spider bites and adequately manage potential complications.
  3. Discuss the advantages and disadvantages of potential treatments of spider bites.
  4. Describe potential treatments for patients with insect envenomation.
  5. Rapidly assess and appropriately manage anaphylaxis resulting from insect envenomation.

Among the nearly 40,000 spider species and more than 100,000 species of insects, very few species are responsible for any morbidity and mortality in humans. Anaphylaxis is the most common reason for morbidity and mortality from Hymenoptera (wasps, bees, and ants) envenomation; it is estimated to occur in between 0.4% and 5% of the general population, with approximately 40 to 100 Americans dying because of it yearly, although these figures probably grossly underestimate the true numbers.1 Emergency physicians should be able to recognize, evaluate, and manage spider and insect envenomations.

Case Presentation

A 45-year-old man presents complaining of chest pain and difficulty breathing; he had been mowing his lawn. His vital signs are blood pressure 85/42, pulse rate 52, respiratory rate 24, temperature 37.7° C (99.9° F), and oxygen saturation 88% on room air. Physical examination reveals an obese man who appears pale and is diaphoretic. He has dry mucous membranes. An S1 and S2 are noted, and pulmonary auscultation reveals expiratory wheezing bilaterally. Bowel sounds are diminished, and his abdomen is nontender. A diffuse urticarial rash is noted on his chest, back, arms, and legs. On further questioning, he says that a bee stung him while he was mowing.

Table 1. Signs and symptoms of a widow spider bite3-6

  • Agitation
  • Diaphoresis – local, generalized
  • Headache
  • Hypertension
  • Muscular spasm and rigidity beginning at the bite site and spreading proximally to the face and abdomen
  • Nausea/vomiting
  • Pain – local, radiating, generalized
  • Paralysis
  • Paresthesia
  • Priapism
  • Ptosis
  • Restlessness
  • Rhinorrhea
  • Salivation
  • Shortness of breath
  • Tachycardia

Arthropod Envenomations

Widow

Five species of widow spiders are found in North America, Latrodectus bishopi, Latrodectus geometricus, Latrodectus hesperus, Latrodectus variolus, and Latrodectus mactans, with L. mactans being the most common. They are distributed across the continental United States and range into the southern Canadian provinces.2 Many species are a shiny black with red markings, although both the color and markings can vary. The female spider is primarily responsible for clinically significant envenomations because the male’s fangs are not large enough to penetrate human skin. Widow spiders are generally not aggressive and only bite defensively.3

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Topics: CardiovascularCMECritical CareEmergency MedicineEmergency PhysicianPainTrauma and Injury

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