Dangers of Prehospital Cooling: A Case Report of Afterdrop in a Patient with Exertional Heat Stroke.

BACKGROUND: Exertional heat stroke is a potentially life-threatening disease with varying clinical presentations and severity. Given the severe morbidity that can accompany the disease, the immediate management often begins in the prehospital setting. It is important to have not only a comprehensive understanding of the prehospital cooling methods in addition to hospital management strategies, but an understanding of their potential complications as well. CASE REPORT: A 32-year-old male presented to a San Antonio hospital in March 2014 with progressive confusion, nausea, nonbloody emesis, and ataxia. Initial presentation was concerning for exertional heat stroke, as the patient was recorded in the field to have a temperature of 42.1°C (106.2°F). The patient, on arrival to the emergency department, was found to have a core body temperature of 38.1°C (100.6°F). All active cooling measures were terminated and active rewarming was initiated. Despite adequate resuscitation and rapid identification of the patient's overcorrection in core body temperature, the lowest recorded temperature was 36.0°C (96.8°F). Why Should an Emergency Physician Be Aware of This? This case represents the dangers associated with exertional heat stroke, overcorrection of core body temperature, and the potentially lethal complication of afterdrop. It also represents the need for immediate recognition of the condition and initiation of appropriate medical care. Although this patient's clinical outcome was good, the event could have caused serious morbidity or could have potentially been fatal.

Sixteen-year-old athlete with chest pain and shortness of breath due to pulmonary emboli.

BACKGROUND: Pulmonary embolism (PE) is a life-threatening condition that is extremely uncommon in the healthy pediatric population. OBJECTIVE: Because pediatric PE is rarely on the Emergency Physician's differential diagnosis, with this case we hope to increase the clinical suspicion for PE in children who present to the Emergency Department (ED). CASE REPORT: This is a case of bilateral pulmonary embolism in a 16-year-old basketball player whose only risk factor is oral contraceptive medication. Initial vital signs demonstrated a temperature of 37.1°C (98.8°F), blood pressure 124/74 mm Hg, heart rate 74 beats/min, respiratory rate 16 breaths/min, and oxygen saturation 100% on room air. Subsequent vital signs, physical examination, chest radiograph, electrocardiogram, and laboratory assessments were all within normal limits. Using clinician gestalt in combination with the patient's Wells score of 0, a D-dimer was obtained and returned at 1916 ng/mL. The computed tomography scan with PE protocol detected a total of seven pulmonary emboli bilaterally. The patient was anticoagulated with Lovenox (Sanofi US, Bridgewater, NJ) in the ED and admitted to the pediatric intensive care unit. Complete thrombophilia work-up was negative. The patient was discharged with Lovenox and was transitioned to warfarin. CONCLUSIONS: Emergency Physicians may be inclined to discharge a pediatric patient at low pre-test probability for PE with outpatient follow-up if the work-up is non-contributory. But the current adult PE clinical criteria are not as sensitive or specific in the pediatric population. This case demonstrates that the clinician's gestalt should play a major role in combination with the Wells score and PERC (pulmonary embolism rule-out criteria) rule to exclude PE until clinical decision rules specific for the pediatric population are established.

The "flat cava" sign revisited: what is its significance in patients without trauma?

OBJECTIVE: The purpose of this study was to evaluate the clinical significance of the "flat cava" sign on abdominal CT scans in hospitalized patients without trauma. MATERIALS AND METHODS: CT scans of the abdomen of 500 inpatients imaged for a wide variety of nontraumatic indications were retrospectively reviewed for a flat cava sign. Two radiologists measured the maximal anteroposterior and transverse diameters of the inferior vena cava at four predetermined levels. The medical records of the subset of patients with a flat cava sign--defined as a maximal transverse-to-anteroposterior ratio of 3:1 or greater at one or more of the four levels--were reviewed for evidence of hypovolemia or hypotension. RESULTS: Seventy patients (14%; 48 women, 22 men) had a flat inferior vena cava present on at least one of the four levels. Of these 70 patients, 21 had definite and three had possible clinical evidence of hypotension or hypovolemia. A flat cava sign isolated to only one level was seen in 22 of the 70 patients, most commonly at the level just below the renal veins, and only four of these 22 patients had evidence of hypotension or hypovolemia. CONCLUSION: Of the 500 inpatients, 14% had a flat cava sign on at least one of the four levels examined on abdominal CT scans. The majority of these patients with a flat cava sign did not have hypotension or evidence of hypovolemia, but a minority (30%) did.