In the vast majority of brown recluse envenomations, the history will be simple and routine. As I have said, most of these patients are aware that they have been bitten by something even if they do not know it was a brown recluse. In these cases an AMPLE history is sufficient, although a few additional questions may be necessary to attempt to confirm the type of spider. As I have said, most of these patients seek help soon after envenomation and since the systemic symptoms may take a while to develop the majority of these transports will be uneventful.

Since this is the case I am going to spend a considerable amount of time talking about what amounts to a very small percentage of brown recluse victims. This small percentage however, is most at risk and is the most likely to be misdiagnosed in the field (and often by hospital personnel).

In effect, brown recluse bites are poisonings and general principles concerning poisoning will apply. Apart from narcotic overdoses such as heroin, or benzodiazapines such as Valium, we in EMS can not do a lot to attack injected poisons. We can provide supportive care and assist the patients vital body systems but we can't "fix" the real problem. In fact, about the only type of poisoning that we can "fix" so to speak is in the arena of ingested poisons, and then only if we can act within a very narrow time frame.

With that in mind, we must note that poisonings can produce very strange signs and symptoms that, as I have said, will often differ from patient to patient. I bring up this only to remind you that in a small percentage of calls involving adults who have been bitten by the brown recluse, and even more commonly with children, the chief complaint will be symptoms that the patient or the parent can not explain. Recall that often the bite of the brown recluse is unnoticed. It is for this reason that we must remember a general principle of patient assessment: Any time you are confronted with a patient showing odd, or divergent signs and symptoms that are out of character with the patients overall health picture and that do not fit any "normal" pathology, think poison of some type. This is especially true with children.

For example, you are called to a patient who is having seizures. The patient has no history of seizures, no sign of trauma, and has so serious medical history. Blood sugar is within normal limits. You notice a rash on the patient. These signs appear to be unrelated or divergent since seizures do not cause rashes and rashes do not cause seizures. Taking in to account the patients lack of significant medical history, and the fact that his signs and symptoms do not fit the expected pathology of "normal" illnesses that would cause seizures (i.e. head injury, epilepsy, hypoglycemia etc.), poisoning of some type is a safe and logical consideration. There are other possibilities of course, and I should say that it is entirely possible that the divergent signs and symptoms may be unrelated, but it warrants investigation. A history of events leading up the onset of seizures is necessary assuming there is someone on the scene who can provide this information.

Taking a history in cases such as the one I have just described may be critical. If poisoning from some source is suspected, identifying the poison may mean the difference between receiving rapid treatment and making a speedy recovery or having to identify the toxin at the hospital by way of an often slow process of elimination. Most toxins introduced into a patient by way of envenomation can be treated effectively if they are identified early after the envenomation and treatment is began in a prompt manner.

The history should be brief but thorough and focused on events that lead up to the onset of symptoms. The specific questions that you ask will depend on whether you are questioning the patient or a family member, but the goal will be the same. Here are some important questions to ask after you have attained an idea of the patients' normal health status and past medical history.

These six questions may provide clues as to what the patient has been exposed to. There are probably more that you might ask depending on the specific circumstances but be mindful that if the patient has been poisoned, time is of the essence.

If you suspect envenomation, or if you suspect poison but can not determine the cause, do not waste time playing detective. If your examination and the six questions above do not give you an idea of what type of poison may be attacking your patient, it is doubtful that further questions will.

Other than the history, direct assessment of the patient may help you determine the cause of the poison. If your patient is a child, undress the child and look for possible bites after you have addressed life-sustaining concerns. In some cases it may be worth while to do this with adults as well. This is best done during transport because even if you find a bite site there is little you can do to stop the toxin.