J Emerg Med
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Case Reports
Variation in Clinical Presentations and Outcomes of Heat Stroke Victims in the Mass-Casualty Setting.
Immigrants crossing the Southern U.S. border are particularly susceptible to heat illness. We review 3 patients from a heat-related mass-casualty incident with variations in heat stroke presentation, course, and outcome. ⋯ On July 23, 2017, emergency medical services responded to a trafficking-related mass-casualty incident in San Antonio, Texas, involving 39 migrants found inside an abandoned tractor trailer without air conditioning who had been trafficked from Laredo, Texas. Three victims exhibiting heat stroke symptoms were taken to the ED of a large academic teaching hospital. Patient 1 was a 42-year-old man who presented with seizing, vomiting, and a core temperature of 38.8°C (101.8°F). His 54-day hospital course was notable for 2 cardiac arrests, disseminated intravascular coagulation, prolonged lactic acidosis, and residual kidney disease. Patient 2 was a 32-year-old man who presented to the emergency department intubated in the field with a core temperature of 40.7°C (105.3°F). His 60-day hospital course was notable for disseminated intravascular coagulation, severely elevated troponin, prolonged lactic acidosis, and stroke. Patient 3 was a 20-year-old man who presented with seizing and decorticate posturing, with a core temperature of 40.5°C (104.9°F). His 6-day hospital course was notable for rapid clinical improvement and full recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians will encounter heat stroke victims. Our patients were exposed to an identical environment, and while each patient was otherwise healthy and differed significantly only in age, they exhibited a diversity of heat stroke presentations and sequelae. Treatment prioritizes cooling, but rapid deterioration requires intensive treatment of multiorgan failure.
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Early thoracotomy (ET) is a procedure performed on patients in extremis. Identifying factors associated with ET survival may allow for optimization of guidelines and improved patient selection. ⋯ ETs performed at Level I TCs were associated with 40% greater odds of survival compared with ETs at non-Level I TCs. This demonstrates that factors extrinsic to the patient may play a role in survival of severely injured patients.
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Idarucizumab is a humanized, monoclonal antibody fragment used specifically to reverse the anticoagulant effects of dabigatran. ⋯ We discuss 4 cases of patients who were treated with idarucizumab to reverse dabigatran before early/emergency surgery. Two of the patients had subdural hematomas, 1 had a splenic laceration, and 1 had Fournier gangrene. All patients received 5 g of idarucizumab before surgery. Intraoperative blood loss in all patients was normal, no adverse events were reported, and the patients recovered normally. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The case reports presented provide detailed, practical, real-world experience beyond that reported in other case reports and the Reversal Effects of Idarucizumab on Active Dabigatran study. This can help guide clinicians on how idarucizumab can reverse the anticoagulant effect of dabigatran in emergency situations, including patients with subdural hematoma. Our experience suggests that idarucizumab may be a safe and effective antidote to the effects of dabigatran in real-life bleeding situations involving early or emergency surgeries.
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Observational Study
Postcontrast Acute Kidney Injury After Computed Tomography Pulmonary Angiography for Acute Pulmonary Embolism.
Despite the widespread use of computed tomography pulmonary angiography with contrast media for the diagnosis of acute pulmonary embolism, high-quality evidence on risk factors for postcontrast acute kidney injury related to its use is lacking. ⋯ Our study findings could serve as useful reference for physicians who are concerned about performing computed tomography pulmonary angiography for fear of renal function deterioration.
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Heat stroke is a life-threatening syndrome that is characterized by its severe clinical symptoms, rapid progression, and high rate of mortality. Recently, research has indicated that a dysfunctional intestinal epithelia barrier plays an important role in the pathophysiology of heat stroke. Protecting the intestines from heat stress had been identified as a potentially effective treatment for patients with heat stroke and may reduce the innate immune response caused by endotoxins in circulation. ⋯ A more detailed pathogenesis of heat stroke needs to be elucidated so that potentially effective means of treatment and prevention of heat stroke can be developed and studied.