The TBI discriminant index appears to be a sensitive index of brain function. It may be used to suggest whether or not a patient presenting with altered mental status requires a CT scan. This index may aid in the triage of such patients in the ED. Such an easy to use, automated system may greatly enhance the clinical utility of EEG in the ED.
Controversy exists concerning the lethality of Tasers. These are conducted electrical weapons which incapacitate subjects by delivering an electrical charge that causes diffuse muscle contraction. In North America, over 440 deaths have been reported immediately following Taser use. Taser International has recently suggested that Tasers should not be aimed at the chest, although there is no conclusive proof that a discharge over the heart would cause an arrhythmia. The case history is presented of a young man who was shot in the chest by a Taser and presented to the emergency department in ventricular fibrillation.
Loxoscelism is a systemic inflammatory reaction in response to a brown recluse spider bite (BRSB). In this case we describe a patient with a heightened inflammatory response to a presumed BRSB, with Coomb's positive hemolysis, cytoplasmic antineutrophil cytoplasmic antibody (cANCA) vasculitis, and features of hemophagocytic lymphohistiocytosis (HLH). A 24-y-old female presented with sudden pain and swelling to her lower back, nausea, fever, and tachycardia after a presumed BRSB. Hemolysis began on hospital day 3 (15.9 g$dL -1 ) with a nadir on hospital day 5 (6.3 g$dL -1 ). She had an lactate dehydrogenase of 1415 U$L -1 , ferritin of 15534 ng$mL -1 , persistent fever, and signs of bone marrow suppression despite hemolysis, with thrombocytopenia (100,000 mL -1 ) and an inadequate reticulocyte response (1.7%) suggestive of HLH. The patient's blood was Coomb's and cANCA/antiproteinase 3 positive. She had signs of toxin-induced vasculitis, with respiratory failure requiring bilevel positive airway pressure, radiographs with bilateral pulmonary infiltrates, and a desquamating rash. She received 6 U of packed red blood cells, furosemide for pleural and pericardial effusions, antibiotics, and symptomatic treatment during the acute phase of her illness. Hemolysis improved without glucocorticoids by hospital day 6. The patient demonstrated a dysregulated immunologic and complement-mediated response to the presumed BRSB. The triad of Coomb's positive hemolysis, cANCA vasculitis, and HLH-like reaction associated with a presumed BRSB is described for the first time in the literature and brings up questions for future research regarding the role of immune modulators and complement inhibitors in the treatment of severe loxoscelism as well as the genetic factors that predispose certain individuals to such reactions.
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