Patients who have been bitten by a brown recluse fall into four basic categories for EMS purposes. Note that I have created these categories for illustration purposes and that the medical community does not recognize them. They're are only to make a point.

Category one patients would be those who get bitten and call EMS immediately (or get in the car and head to the emergency department right after the bite). Depending on the area where you work, your response time will probably be such that virtually no physical treatment will be necessary. If the patient reaches the hospital within an hour or so after the bite, no symptoms other than redness (erthmia) around the bite and maybe pain at the site may be noted in this timeframe.

Category two patients will be those who either did not know they were bitten at all, or who did not know what had bitten them. As I was researching this subject, I found case after case of individuals who had absolutely no idea they had been bitten until strange symptoms began to occur. One particular case that I think represents this group of people was the case of a young woman who awoke one morning and noticed what appeared to be pale, watery spots of blood on her sheets. Concerned, she began to search for the source of this blood, and found what appeared to her to be a small burn on her posterior shoulder. The site was red and at its center was a broken blister, which was the source of the bloody discharge. Apparently she had broken this blister in her sleep. Although she had no idea how and when she suffered a burn at this location she thought little more about the wound until later when the site began to hurt. She noted that the injury seemed to be getting larger and much more painful. Within 12 hours of awakening with this mysterious wound, she developed the classic flu-like symptoms and noticed a strange rash spreading over her body. Finally, she was taken to the emergency department where she was informed that she had suffered a brown recluse bite. She recovered but required excision of the site to stop the destruction of tissue.

Our treatment for this group of patients would still be largely supportive. Other than analgesics for pain, there isn't much we can do for them accept take precautionary and supportive measures and be alert for deterioration of the patients condition. Depending on the patients vital signs, this could mean anything from simple emotional support to defensive measures including O2, IV's for vascular access, pulse ox and cardiac monitoring if you find the patients condition warrants. In deciding how much preventive or supportive care to provide, remember that patients reactions to envenomation vary widely and at different speeds.

Personally, I would prefer to be ready for a patient to deteriorate before such an event takes place rather than to wait for it to happen and then have to play catch up. These patients may not go downhill, but remember that I described envenomations as metabolic "time bombs". Unfortunately, since patients responses to envenomation are so diverse, there is no way to tell how long it will take for the metabolic explosion will occur. It can be very rapid once it begins.

The third category of patient is probably the most rare. These would be those patients in the midst of a full blown systemic reaction. I have already stated that we rarely see these in the pre-hospital setting and it is very possible that we could zero in on the symptoms without realizing the cause. For example, the call may be dispatched as "seizures" or "unknown unconscious". Of course we would attack the seizures but may be unable to determine the cause.

The patients' family may only be able to tell you that the patient was "not feeling well" or something to that effect, without knowing that they have suffered a bite. More on assessing these patients in a moment but I will go ahead and tell you that as far as treatment goes, all you can do is treat what you find. If the patient is seizing, then treat the seizures as you would normally do. Take any supportive measures necessary to preserve the patients life. We can't get to the heart of the patients' problem in this case, so rapid transport is a priority.

Category four patients are children. This group is the most likely to die from a brown recluse bite, and the least likely to be able to give you useful information. Brown recluse spiders can be found in a variety of places, many of which are the very places that kids like to play. Closets, old cars, around objects in the yard, in garages, if it's warm and dark, brown recluse spiders will like it and a kid may come into contact with one. The parent or caregiver of the child may have no idea what is wrong with the child and have no idea that a bite has taken place.

A call for assistance by the parent may be delayed due to blaming the child's symptoms on some common malady like the flu (especially in the early stages). Children pick up a lot of common illnesses and the parent may not think to seek assistance until the toxin has produced serious signs and symptoms. Again, with these patients take any necessary actions to preserve life and then expedite transport. A toxicologist and advanced internal medicine are required to definitively treat these patients.