Variation in Clinical Presentations and Outcomes of Heat Stroke Victims in the Mass-Casualty Setting.

BACKGROUND: 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. CASE REPORT: 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.

Appalachian Trail hikers' ability to recognize Lyme disease by visual stimulus photographs.

BACKGROUND: Lyme disease is the most common vector-borne infectious disease in North America. With nearly 2,500 Appalachian Trail (AT) hikers entering the endemic area for as long as 6 months, exposure to the disease is likely. The characteristic exanthem of erythema migrans (EM) should be a trigger for seeking medical treatment, and its recognition in this relatively isolated environment is important. OBJECTIVE: The purpose of this study was to determine the ability of AT hikers to identify EM, the exanthem of Lyme disease. METHODS: Hikers were administered a photographic stimulus in this Internal Review Board-approved pilot study. Historical hiking data, basic demographics, and self-reported treatment and diagnosis were collected. RESULTS: In all, 379 responses were collected by 4 researchers at 3 geographically separate locations at or proximate to the AT from June 2011 to May 2012. Fifty-four percent of respondents (206 of 379) were able to recognize the photographs of EM/Lyme disease; 46% could not. Of those who did recognize EM, 23 (6%) had seen it either on themselves or on another hiker while on the AT. A total of 37 hikers stated that they had been diagnosed with Lyme disease while hiking, and of these, 89% were treated with antibiotics. Thirteen of these 37 hikers (35%) diagnosed with Lyme disease had visualized an embedded tick. Nine percent of all respondents reported they had been diagnosed with Lyme disease by a healthcare practitioner, whether from EM, symptomatology, or by titer. CONCLUSIONS: This study suggests that hikers are poorly able to recognize the characteristic exanthem of Lyme disease but have a high exposure risk.

Mesorchial testicular torsion: case report and a review of the literature.

Testicular torsion can be extravaginal, intravaginal, or mesorchial. Mesorchial torsion is less well defined and has an atypical presentation. Here we present the case of a 13-year-old with severe, intermittent right scrotal pain, erythema, and a large hydrocele. Color Doppler ultrasound examination showed epididymal enlargement and normal flow. Weeks after presentation, serial color Doppler ultrasound examinations showed epididymal enlargement and decreased perfusion. A literature review for testicular torsion etiology and clinical and radiologic findings documents this as the only recorded case of mesorchial testicular torsion with clinical and radiologic findings. Atypical pain, if persistent, requires careful reassessment, radiologic studies, and surgical exploration.