Heightened Immune Response to Presumed Loxosceles reclusa Envenomation.

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 µL-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.

Automated electroencephalogram identifies abnormalities in the ED.

BACKGROUND: Advances in analysis of electrical signals have now made it possible to create a handheld electroencephalogram (EEG). METHODS: The BrainScope device, currently under development by BrainScope Co, Inc, Washington, DC, was used to assess 153 patients who presented to a tertiary referral hospital with headache or altered mental status. A limited array of 8 adhesive electrodes, similar to electrocardiographic leads, was applied to the forehead of the subjects. The data were analyzed, and the result given by the algorithm was compared with the clinical diagnosis given to the patient. RESULTS: One hundred fifty-three patients were enrolled. The patient was determined to be normal or abnormal using the algorithm in the device, and blinded clinicians determined whether this was accurate. The sensitivity of the device was 96% and the specificity was 87% for detecting abnormality. CONCLUSIONS: The automated EEG device may be a useful tool for identifying brain abnormality in the emergency department.

Use of brain electrical activity to quantify traumatic brain injury in the emergency department.

PRIMARY OBJECTIVE: To validate a QEEG algorithm on traumatic brain injury in an Emergency Department (ED) setting. METHODS AND PROCEDURES: EEG data were collected from 105 patients with head injury (53 CT+ and 52 CT-) and 50 ED controls. Ten minutes of eyes closed resting EEG was collected from five frontal locations. A discriminant index of the probability of belonging to the TBI CT+ group was computed. Analysis of variance was computed comparing this index across the three patient groups. Using ROC curves, the p < 0.05 confidence level was determined to compute sensitivity and specificity for the TBI CT+ population. RESULTS: CT+ patients had a mean TBI discriminant index of 80.4, CT- patients 38.9 and controls 24.5; F = 70.2, p < 0.0001. Sensitivity was 92.45% for the CT+ group and specificity was 90.00% for the control group. CONCLUSIONS: 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.

Ventricular fibrillation in a man shot with a Taser.

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.

Transcervical Foley catheter with and without extraamniotic saline infusion for labor induction: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of transcervical Foley catheter alone (Foley) to transcervical Foley catheter with extraamniotic saline infusion for labor induction and cervical ripening in women with an unfavorable cervix. METHODS: This was a multicenter, randomized, controlled trial of women presenting for labor induction with a singleton, cephalic fetus, intact membranes, and unfavorable cervix (Bishop score 6 or less). Eligible women were randomly assigned to receive either Foley catheter alone or Foley catheter with extraamniotic saline infusion. All women received concurrent oxytocin administration. The primary study outcome was the induction-to-delivery interval. Secondary outcomes included cesarean delivery, maternal infectious outcomes, and immediate neonatal outcomes. Analysis was by intent to treat. RESULTS: One hundred eighty-eight women met eligibility criteria and were randomly assigned (Foley plus extraamniotic saline infusion, n=97; Foley, n=91). Baseline demographic characteristics, including parity, gestational age, and Bishop score were similar between the study groups. The median induction-to-delivery interval in the extraamniotic saline infusion arm (12.6 hours, interquartile range 9.3-18.8 hours) was similar to that in the Foley arm (13.4 hours, interquartile range 9.6-17.5 hours) (P=. 70). The proportion of women delivered by 24 hours was comparable between groups (delivery 24 hours, extraamniotic saline infusion 89.7%, Foley 87.9%, P=.70), as was the rate of cesarean delivery (Foley 18.7%, extraamniotic saline infusion 27.8%, P=.14). No significant differences were noted between the study groups with respect to rate of chorioamnionitis, endometritis, or immediate birth outcomes. CONCLUSION: In women with an unfavorable cervix, the addition of extraamniotic saline infusion to a transcervical Foley catheter does not improve efficacy for labor induction. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00442663 LEVEL OF EVIDENCE: I.