Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care

Introduction

Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes.

Methods

A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0.

Results

Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases.

Conclusion

Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital.

•

Non-trauma conditions constitute a third of surgical emergencies and a quarter of deaths in the emergency room.

•

Acute abdomen, urological conditions and malignancies are the leading causes of non-trauma emergencies.

•

Available facilities could provide care for only half of the non-trauma patients requiring emergency room admission.

Hypo and Hyper: Common Pediatric Endocrine and Metabolic Emergencies

The presentation of endocrine and metabolic emergencies represents one of the more challenging clinical scenarios faced by pediatricians and emergency providers. In this review, the authors attempt to describe some of the more common entities that a provider may see and provide a guide for the recognition and management of these difficult-to-assess and often very ill children.

Computed Tomography Pulmonary Angiography for Evaluation of Patients With Suspected Pulmonary Embolism: Use or Overuse

Background:

The use of computed tomography pulmonary angiography (CTPA) has been increased during the last decade.

Objectives:

We studied the adherence to current diagnostic recommendations for evaluation of pulmonary embolism in a teaching hospital of Tehran University of Medical Sciences.

Patients and Methods:

The registered medical records (Wells scores and serum D-dimer level) of all patients whose CTPA was performed with suspicion of pulmonary thromboembolism (PTE) were studied retrospectively. Modified Wells score of each patient was determined without being aware of the CTPA results. The patients were categorized to those with a high (likely) clinical probability (score > 4) and low (unlikely) clinical probability (score≤ 4) of PTE.

Results:

During a 6-month period, 82 patients who underwent CTPA were included. The prevalence of PTE was 62.2% in the group of subjects with a likely clinical risk. In 45 (54.8%) of those patients whose CTPA was requested, the PTE was unlikely based on modified Wells criteria. In the clinically unlikely group, serum D-dimer assay was done in 15 out of 45 (33.3%), while it was inappropriately checked in 10 out of 37 (27.0%) with a clinically likely risk. General adherence rate to diagnostic algorithm of PTE was 43.9%.

Conclusion:

There is still excessive unjustified concern of PTE in less trained physicians leading to excessive diagnostic work-up. Loyalty to the existing guideline for management of suspected PTE in educational hospitals and supervision of attending physicians could prevent overuse of CTPA.

A rare case of gallbladder torsion along the axis of body: a case report

Abnormal attachment of the gallbladder to the liver is the main cause for gallbladder torsion. However, the present study reports a rare case of gallbladder torsion in which a portion of fundus is rotated along the axis of body. So far, very few similar cases have been reported. An 87-year-old woman complaining right upper quadrant abdominal pain for 4 days was admitted. Her body temperature was 38.5℃ with moderate dehydration. A large tender mass was palpated on the right abdomen extending to the right iliac fossa. Computed tomography of abdomen showed a large cavity with a diameter of 15 cm containing a big stone and a small normal looking gallbladder. Ultrasonographic scan showed a twisted portion of the gallbladder torsion. During emergency laparotomy, the middle portion of the gallbladder was found to be twisted counterclockwise with huge gangrenous gallbladder distal. The proximal body of the gallbladder was spared and attached firmly to the liver. Cholecystectomy was performed and the patient was discharged 2 weeks later without postoperative complications. Histological findings of specimen were consistent with operative findings. The current study reports on a rare case of gallbladder torsion by reviewing previous studies.

A four-year cardiovascular risk score for type 2 diabetic inpatients

As cardiovascular risk tables currently in use were constructed using data from the general population, the cardiovascular risk of patients admitted via the hospital emergency department may be underestimated. Accordingly, we constructed a predictive model for the appearance of cardiovascular diseases in patients with type 2 diabetes admitted via the emergency department. We undertook a four-year follow-up of a cohort of 112 adult patients with type 2 diabetes admitted via the emergency department for any cause except patients admitted with acute myocardial infarction, stroke, cancer, or a palliative status. The sample was selected randomly between 2010 and 2012. The primary outcome was time to cardiovascular disease. Other variables (at baseline) were gender, age, heart failure, renal failure, depression, asthma/chronic obstructive pulmonary disease, hypertension, dyslipidaemia, insulin, smoking, admission for cardiovascular causes, pills per day, walking habit, fasting blood glucose and creatinine. A cardiovascular risk table was constructed based on the score to estimate the likelihood of cardiovascular disease. Risk groups were established and the c-statistic was calculated. Over a mean follow-up of 2.31 years, 39 patients had cardiovascular disease (34.8%, 95% CI [26.0-43.6%]). Predictive factors were gender, age, hypertension, renal failure, insulin, admission due to cardiovascular reasons and walking habit. The c-statistic was 0.734 (standard error: 0.049). After validation, this study will provide a tool for the primary health care services to enable the short-term prediction of cardiovascular disease after hospital discharge in patients with type 2 diabetes admitted via the emergency department.

Emergency response team activation in the outpatient clinic of a single dental teaching hospital in Korea: a retrospective study of 10 years' records

BACKGROUND

To prepare for possible emergency situations during dental treatment, it is helpful to know how often and what kinds of emergencies may arise. This study set out to evaluate the incidences, causes, treatments, and outcomes of emergency situations in the outpatient clinic of a dental teaching hospital in Korea.

METHODS

We retrospectively reviewed the records of patients who had experienced an emergency situation and emergency response team activated in a selected outpatient clinic between November 2004 and November 2013. Specific information about the emergency cases was collected, including the patient characteristics and the frequency, types, treatments, and outcomes of the emergency situations.

RESULTS

We identified 35 instances of emergency situations in 2,890,424 patients (incidence = 0.012 per 10,000 outpatients). The number of cases was as follows: 10 (28.6%) in the Department of Periodontics, 10 (28.6%) in the Department of Oral and Maxillofacial Surgery, 6 (17.1%) in the Department of Oral and Maxillofacial Radiology, 4 (11.4%) in the Department of Prosthodontics, 2 (5.7%) in the Department of Conservative Dentistry, 2 (5.7%) in the Department of Pediatric Dentistry, and 1 (2.9%) in the Department of Orthodontics. Three (8.6%) of the emergency situations arose before treatment, 22 (62.9%) during treatment, 7 (20.0%) after treatment, and 2 (5.7%) in a patient's guardian.

CONCLUSIONS

In accordance with the growing elderly population and more aggressive dental procedures, the number of emergency situations may increase in the future. We recommend that clinicians keep in mind airway management and the active control of emergency situations.

Relationship Between Low Back Pain With Quality of Life, Depression, Anxiety and Stress Among Emergency Medical Technicians

Background:

Musculoskeletal disorders have become increasingly common among healthcare providers. They have become the most common cause of work-related disabilities among nurses.

Objectives:

The current cross-sectional study aimed to measure the prevalence of back pains among emergency medical technicians (EMTs), and association of back pain with quality of life, depression, anxiety and stress.

Materials and Methods:

One hundred and eighty registered nurses working as EMTs at the Hamadan Emergency Medical Center were selected by consensus. Data collection tools were Demographic, Perceived Quality-of-Life, Short Form Health Survey (SF-36), and Depression Anxiety Stress Scales (DAS21) and pain scale measurements.

Results:

Data showed that while 50.7% of the participants had an average awareness of the basic principles of back care, the majority (71.8%) had at least one type of back pain. There were associations between the prevalence of pain and depression (P = 0.049), pain and awareness (P = 0.035), and stress and job satisfaction (P = 0.024).

Conclusions:

A large number (about two-thirds) of EMTs had some sort of back pain; it is highly recommended to promote the attitude and motivation of the individuals to take care to prevent back injury and inform them of the principles of back care. Implications for primary prevention and care practice include encouraging EMTs to apply accurate principles of back care.

[Inverted takotsubo cardiomyopathy due to subarachnoid haemorrhage]

We present a case of a 34-year-old woman with cardiogenic shock after successful resuscitation. In the medical history migraine was known. Emergency echocardiography demonstrated left ventricular dysfunction with hypokinetic basal and midventricular segments and hyperkinetic apex. Cerebral computed tomography suggested a massive subarachnoid haemorrhage (SAH) with transtentorial herniation, so that taking into account the clinical history (severe headache) the diagnosis of a SAH-associated inverted takotsubo cardiomyopathy could be made. In the case of subarachnoid haemorrhage it should be noted that extracerebral organ dysfunction, e.g. inverted takotsubo cardiomyopathy, frequently occurs.

Indicators for childhood asthma in Spain, using the Rand method

OBJECTIVE

To develop quality indicators to measure asthma care in primary health care.

METHOD

A modified RAND was used, which included the systematic review of the literature in Embase, Cochrane and Pubmed Quality Agencies and Database. The work group identified the indicators, translated them into Spanish and resolved any duplicates. Each indicator is composed of several dimensions (access to care, clinical effectiveness, patient-centred quality and patient safety). A multidisciplinary panel of 98 professionals from all over Spain were invited to score each indicator using a Likert scale. After calculating the average and median of each indicator, this information was sent to those who responded (n=38) for a second round and further scoring. The agreement percentage for the group was obtained for each indicator.

RESULTS

Of the 105 asthma indicators reviewed, we selected 46 that were presented to the panel of experts. In both Delphi phases, 37.1% of the members of the initial panel of experts responded. Of these, 26 were primary care paediatricians, six were pulmonologists, three were nurses, two were pharmacists and one was an allergist. For 32 indicators, agreement exceeded 70% and seven of those scored highest for the various care aspects for asthmatic children.

CONCLUSION

Quality indicators are presented for the follow-up of asthma and their implementation in primary care, which have undergone a strict selection and agreement process by a multidisciplinary work group.

The impact of an emergency department nursing intervention on continuity of care, self-care capacities and psychological symptoms: secondary outcomes of a randomized controlled trial

BACKGROUND

As yet there is no firm evidence about the types of intervention that can reduce emergency room revisits. However, the literature on emergency room revisits suggests patient difficulties with managing their health problems and treatments after discharge may play a role.

OBJECTIVES

We carried out a randomized trial of an emergency department-based nursing intervention, but results showed no reduction in revisits (primary outcome). This paper describes the secondary outcomes of the trial: patient perceptions of continuity of care, illness perceptions, self-care capacities, psychological symptoms and medication adherence 30 days after emergency room discharge.

DESIGN

Randomized, controlled trial.

SETTINGS

The trial was conducted in the emergency department of a tertiary cardiac hospital in Montreal, Canada between November 2007 and March 2010.

PARTICIPANTS

The study involved 203 patients, including 108 in the experimental group and 95 in the control group.

METHODS

The intervention included one nurse patient encounter before discharge and two phone calls in the 10 days after discharge. Participants provided data 30 days post-discharge on secondary outcomes potentially related to emergency department revisits.

RESULTS

Although, as previously reported, the intervention had no impact on the primary outcome of emergency department revisits, the present study demonstrated a significant positive effect on patients' perceived continuity of care (p=.033), self-care capacities (p=.037), anxiety (p=.007) and depressive symptoms (p=.043), and the illness perceptions treatment control subscale (p=.037). No differences were found for other illness perception subscales or medication adherence (all p's>.05).

CONCLUSION

Although the intervention did not influence emergency department revisits it did improve secondary outcomes, suggesting pathways for future research.

Pediatric emergencies

It is important that pediatric critical care nurses possess a thorough understanding of their patient and be able to provide exceptional care, especially during emergent situations in the operating room. This care is accomplished by assessing the pediatric patient, dosing medications accurately and effectively, and performing effective Pediatric Advanced Life Support. Pediatric patients present with unique anatomy, physiology, and pathophysiology. Emergencies are reviewed according to organ system, with a focus on definition, presentation, pathophysiology, management, and special considerations.

[Ultrasound of the large abdominal vessels]

Ultrasound has recently become an indispensable tool for the family physician, whether exercised in primary care and emergency department; and likewise it has spread to many other specialties: internal medicine, critical care, neurology, pneumology, digestive, etc. and that ultrasound has proven to be a safe diagnostic tool and have great capacity. We firmly believe that ultrasound done to «bedside» the patient by the family doctor, can greatly complement the physical examination and greatly improve clinical effectiveness, allowing the browser an immediate view of the anatomy and physiology of certain structures. It is within this context is particularly relevant ultrasonography of the Aorta and large abdominal vessels, made by the family doctor or the emergency itself, which will develop along this chapter.

Can ambulatory emergency care help to streamline services?

This article discusses four models of ambulatory emergency care (AEC), a form of clinical care that allows practitioners to assess, diagnose, treat and discharge patients on the same days that they present to emergency departments. The article recommends one model in particular, the process model, and sets out four questions practitioners who want to deliver AEC should ask of patients at the point of referral.

An overview of breast emergencies and guide to management by interventional radiologists

A review of breast and emergencies may seem mutually exclusive of one another, but breast interventions beyond pathologic diagnosis are encountered and may be urgent. Acute breast situations that can potentially require interventional techniques to resolve include abscess or complications from percutaneous biopsy or trauma such as hemorrhage or pseudoaneurysm. Acute breast interventions are not commonly seen, but a working knowledge of the various treatment approaches and management is important. These entities can be similar to other areas of the body, but there are some specifics to the breast that can allow for optimal treatment and management.

[Development and effects of a simulation-based education program for newborn emergency care]

PURPOSE

This study was conducted to develop a simulation-based education program for newborn emergency care based on most needed topics found from the needs assessment. This study consisted of two phases: developing the program and evaluating its effectiveness.

METHODS

The effectiveness of the program was tested in July, 2012, with 49 junior nursing students from C Nursing College in Seoul, who did not have any clinical experience in newborn care. The experimental group was given a three-hour lecture, three hours of clinical training, and a two-hour simulation program, whereas the control group only had the three-hour lecture.

RESULTS

There was significant improvement in knowledge in both groups, but no significant differences according to educational methods. The experiment group was more confident of their care (4.32±.29) than the control group (3.60±.29) with the difference being significant (t=8.85, p<.001), and the experimental group was also more satisfied with the program (χ²=4.60, p=.032).

CONCLUSION

As the results indicate 'the neonatal emergency care program' increased learners' knowledge, confidence and satisfaction with the program, it should be integrated into clinical training in pediatric nursing curriculum and in-service programs for nurses. To increase generalization further verification studies with various learner groups are needed.

Wildfire disasters: implications for rural nurses

BACKGROUND

As natural disasters are increasing globally, nursing's role in responding to disasters is evolving. Disaster nursing has emerged as a specialty that focuses on the care of groups and communities during disaster response. The role of rural nurses in disasters is less well defined.

METHODS

A review of peer-reviewed literature combined with the International Council of Nurses framework of Disaster Nursing Competencies was conducted to understand the roles and functions of nurses in rural areas that experience disasters. The authors' findings from investigating the effects of four wildfires in rural Canadian communities are also discussed.

RESULTS

Six major themes derived from our wildfire studies were generated within the context of nursing practice and are useful in the preparation of rural nurses involved in disaster management and recovery. This adds to the current literature which by and large has not addressed nursing in rural catastrophes.

CONCLUSION

Well-prepared and educated rural nurses who combine theoretical knowledge with their understanding of a rural community potentially can reduce the impact of a disaster. Other nursing roles include mentoring nursing students in disaster preparation and assisting in initiatives to address community recovery in the aftermath of a disaster.

[Factors related to dissatisfaction and anger in parents of children treated at paediatric emergency services]

AIM

Anger in patients and relatives is very frequent in health emergency services and is often associated with aggressiveness and emotional alterations. The aim of the present study is to explore anger in parents while their children are receiving care in paediatric emergency services, seeking the specific dimensions of dissatisfaction that may predict the onset of anger in parents.

MATERIALS AND METHODS

A cross-sectional descriptive study using a self-report questionnaire in 711 parents of children seen in paediatric emergency departments. The self-report questionnaires used were the State-Trait Anger Expression Inventory-2 (STAXI-2) and the Satisfaction with Healthcare Services Scale. The statistical analysis included descriptive, correlational, variance and multiple linear regression models.

RESULTS

A total of 53 parents (7,5%) showed a moderate or high anger level. The mean score for satisfaction was 37.12 (SD=7.33). It was found that higher levels of overall satisfaction were significantly associated with lower levels of anger (r=-.29, p=.00). Among the variables studied, dissatisfaction with access to the service (β=-.172, p=.00), with the healthcare staff (β=-.121, p=.01), and perceived severity of the child's health status (β=.157, p=.00) predicted higher levels of anger.

CONCLUSIONS

On the basis of our results, it is important to continue working to substantially improve access for patients and their families to the emergency department, as well as the information and communication process with the healthcare staff should be included in intervention initiatives.

Factors influencing the yield of mesenteric angiography in lower gastrointestinal bleed

AIM: To assess if certain triaging rules could be established to optimize the yield of mesenteric angiography.

METHODS: Medical records of 101 patients were retrospectively reviewed and parameters relating to age, gender, pulse rate, blood pressure, serum hemoglobin, intensive care unit (ICU) admission, and the number of packed red blood cells (PRBC) transfused in the 12 and 24 h prior to the angiography were tabulated in two groups with positive and negative angiography results.

RESULTS: We found no correlation between gender, pulse rate, blood pressure or serum hemoglobin and positivity of the mesenteric angiogram. But patients with positive angiogram were found to be on average 7 years older (73.2 years vs 65.9 years old) (P = 0.02). Angiogram was positive in 39.3 % (11/28) of patients admitted in ICU vs 23.2% (17/73) who were admitted elsewhere in the hospital (P = 0.03). In the 12 and 24 h prior to angiography, patients with a positive angiogram received a mean of 2.7 ± 2.3 and 3.3 ± 2.6 units of PRBC s respectively, while patients with a negative angiogram had a mean of 1.6 ± 1.9 (P = 0.02) and 2.1 ± 2.6 units (P = 0.04) received respectively in the same period.

CONCLUSION: Older age, ICU admission, having received at least 4 units PRBC over 12 h or 5 units over 24 h prior to angiogram are leading indicators for a positive study.

Do obese children experience more severe fractures than nonobese children? A cross-sectional study from a paediatric emergency department

OBJECTIVES

To determine whether there is an association between childhood obesity and severe extremity fractures. Associations between obesity and complications related to the fracture and/or fracture management were also examined.

METHODS

The present study was a retrospective, cross-sectional study conducted at a tertiary care children's emergency department. Eligible cases for review were children (two to 17 years of age) with an extremity fracture. Severe extremity fractures were defined as those requiring manipulation under anesthesia, open operative repair and/or admission to hospital. The primary outcome was the proportion of severe extremity fractures and the secondary outcome was the proportion of complications.

RESULTS

A total of 1340 charts of children who presented with extremity fracture from January 2008 to December 2010 were reviewed. The mean (± SD) age of the study population was 9.1±4.0 years and 62.1% were male. Overall, 19.9% (95% CI 17.8% to 22.0%) were obese and 39.6% (95% CI 36.7% to 39.1%) sustained a severe extremity fracture. The OR of severe extremity fractures among obese versus nonobese children was 1.00 (95% CI 0.76 to 1.32), adjusted for age, sex and mechanism of injury. In addition, the OR of experiencing complications among obese relative to nonobese children was 1.12 (95% CI 0.68 to 1.85).

CONCLUSIONS

The results of the present study demonstrated that in children with extremity fractures, obese children were not at increased risk for sustaining more severe extremity fractures or subsequent complications compared with nonobese children.

Emergency department management of acute exacerbations of chronic obstructive pulmonary disease and factors associated with hospitalization

BACKGROUND

Currently there is a paucity of information about biomarkers that can predict hospitalization for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) patients presenting to the emergency department (ED). There is limited data on the consistency of ED management of AECOPD with local COPD guidelines. The aim of this study was to identify biomarkers associated with hospitalization in AECOPD patients and to determine if the ED management was concordant with local COPD guidelines.

MATERIALS AND METHODS

We performed a retrospective audit of consecutive AECOPD patients presenting to the Gold Coast Hospital ED over a 6-month period.

RESULTS

During the study period, 122 AECOPD patients (51% male, mean age (SE) 71 (±11) years) presented to the ED. Ninety-eight (80%) patients were hospitalized. Univariate analysis identified certain factors associated with hospitalization: Older age, former smokers, home oxygen therapy, weekday presentation, SpO2 < 92%, and raised inflammatory markers (white cell count (WCC) and C-reactive protein (CRP)). After adjustment for multiple variable, increased age was significantly associated with hospitalization (odds ratio (OR) 1.09; 95% confidence interval (CI): 1.00-1.18; P = 0.05). Radiology assessment and pharmacological management was in accordance with COPD guidelines. However, spirometry was performed in 17% of patients and 28% of patients with hypercapneic respiratory failure received noninvasive ventilation (NIV).

CONCLUSION

We identified several factors on univariate analysis that were associated with hospitalization. Further research is required to determine the utility of these biomarkers in clinical practice. Also, while overall adherence to local COPD guidelines was good, there is scope for improvement in performing spirometry and provision of NIV to eligible patients.

[Use of a homemade introducer guide (bougie) for intubation in emergency situation in patients who present with difficult airway: a case series]

BACKGROUND AND OBJECTIVES

The incidence of difficult airway reaches 10% of emergency intubations. Although few studies address the use of handmade introducer guides in emergency and intensive care environment, there are descriptions of handmade guides available on the Internet. We describe a case series on the use of a handmade introducer guide (bougie) for emergency intubation in patients with difficult airway.

CASE REPORT

The handmade introducer guide was used in five consecutive patients with difficult airways, and clinical instability and in the absence of another immediate method to obtain an airway. This technique provided successful intubation and there were no complications.

CONCLUSIONS

The use of the handmade introducer guide can be a useful option for the management of difficult airways.

Acute urticaria presenting in the emergency room of a general hospital

BACKGROUND

Acute urticaria is a common disorder that often prompts patients to seek treatment in the emergency room (ER). There are few data on acute urticaria presenting in ER.

OBJECTIVES

This study aimed to provide demographic and clinical data of patients presenting with acute urticaria at an ER of an Italian general hospital covering an area of about 90,000 inhabitants. The predictive factors of the length of stay in the ER had also been investigated.

METHODS

The database of ER patients was searched for urticaria by ICD-9 code and by keywords in the diagnosis description. All the medical records of the identified patients were reviewed and the length of stay in ER was noted.

RESULTS

A total of 459 patients were admitted to ER with acute urticaria in a 1-year period corresponding to 1.01% of total ER visits and to 1.2 admission per day. Angioedema was present in 139 cases (30.3%), fever in 55 (12%). Twenty-nine patients fulfilled the criteria of anaphylaxis. Triggers could be identified in 193 cases (42%): drugs in 20.7%, insects bites (10.2%), foods (7.4%) and contact urticaria in 3.7%. Anaphylaxis (p<0.001), food (p<0.05) and drugs (p<0.05) as triggers were significant and independent predictive factors of the length of stay in ER.

CONCLUSIONS

Patients with acute urticaria are frequently referred to the emergency room, but only in a few cases urticaria is associated with severe allergic manifestations. Drug and food hypersensitivity, together with anaphylaxis, are the best predictors of the length of stay in ER.

Hernia emergencies

Hernia emergencies are commonly encountered by the acute care surgeon. Although the location and contents may vary, the basic principles are constant: address the life-threatening problem first, then perform the safest and most durable hernia repair possible. Mesh reinforcement provides the most durable long-term results. Underlay positioning is associated with the best outcomes. Components separation is a useful technique to achieve tension-free primary fascial reapproximation. The choice of mesh is dictated by the degree of contamination. Internal herniation is rare, and preoperative diagnosis remains difficult. In all hernia emergencies, morbidity is high, and postoperative wound complications should be anticipated.

[Systemic loxoscelism presented in a pregnant patient]

BACKGROUND

Loxoscelism is a condition caused by the inoculation of a series of proteolytic enzymes through the loxosceles spider bite (violinist). Morbidity and mortality is unknown in our country. The loxoscelism toxi-syndrome of local expression may have a good prognosis; however, viscera-cutaneus or systemic form has a serious and often fatal evolution. We report a case of a systemic variant developed in a pregnant patient.

CLINICAL CASE

We present the first reported case of systemic loxoscelism in a pregnant patient, highlighting the survival of the mother-son, in the presence of viscera-cutaneus behavior. We describe the natural history of clinical expression, highlighting the benefit of current therapeutic antivenom fourth generation and immunoregulation role in supporting the therapeutic approach and the guideline of the surgical approach.

CONCLUSIONS

The appropriate multidisciplinary management coupled with an early use of antivenom limits the severity and the potential development of complications. Clinical suspicion is the cornerstone of therapeutic management of these patients.