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.

Functional independence after major abdominal surgery in the elderly.

BACKGROUND: Elders undergo approximately 40% of more than 1 million major abdominal operations annually. Yet evidence about recovery to preoperative levels of functional independence is limited. This study details course and predictors of functional recovery after elective major abdominal operations in the elderly. STUDY DESIGN: This was a prospective cohort of 372 consecutive patients, 60 years old or more, enrolled from surgeons in private practice and two university-affiliated hospitals, assessed preoperatively and postoperatively at 1, 3, and 6 weeks, 3 and 6 months, using self-report and performance-based measures (Activities of Daily Living [ADL], Instrumental Activities of Daily Living [IADL], Medical Outcomes Study Short Form-36 Physical Component and Mental Component Scales [PCS, MCS], Geriatric Depression Scale [GDS], Folstein Mini-Mental State Exam [MMSE], timed walk, functional reach, hand grip strength). RESULTS: Mean age was 69 +/- 6 years with 56% men, 47% nonHispanic Caucasian, and 42% Mexican American; hospital distribution was 49% private, 51% university-affiliated. Maximum functional declines (95% CI) occurred 1 week postoperatively: ADL, 2.8 points (2.4 to 3.2); IADL, 7.6 points (7 to 8.3); SF-36 PCS, 6.5 points (5.4 to 7.6); Mini-Mental State Exam, 0.5 points (0.2 to 0.7); timed walk, 6.8 seconds (5.2 to 8.4); functional reach, 1.7 inches (1.2 to 2.2); grip strength, 2 kilograms (1.3 to 2.7) (p < 0.001 for all). SF-36 mental component scale and Geriatric Depression Scale scores did not worsen. Mean recovery times were: Mini-Mental State Exam, 3 weeks; timed walk, 6 weeks; ADL, SF-36 PCS, and functional reach, 3 months; and IADL, 6 months. Mean grip strength did not return to preoperative status by 6 months. The incidence of persistent disability at 6 months, compared with preoperative status, was: ADL, 9%; IADL, 19%; PCS, 16%; mental component scale, 17%; timed walk, 39%; functional reach, 58%; and grip strength, 52%. Potentially modifiable independent predictors of ADL and IADL recovery were preoperative physical conditioning and depression plus serious postoperative complications. CONCLUSIONS: The clinical course of functional recovery varied across different measures. Protracted disability at 6 months after operation was substantial. Several potentially modifiable factors consistently predicted recovery.

Higher Hb level is associated with better early functional recovery after hip fracture repair.

BACKGROUND: The benefits and indications for blood transfusion are controversial. One possible reason to transfuse is to improve functional recovery after major surgery. However, the data linking improved function with higher Hb concentration are limited. STUDY DESIGN AND METHODS: A: retrospective cohort study was performed in 5793 patients at least 60 years old undergoing hip fracture repair at 20 academic and community hospitals. The primary outcome was distance walked at the time of discharge from the hospital. The mean postoperative Hb concentration was the main exposure variable and was defined as the average value from Day 1 after surgery to discharge. We used robust regression to assess the association between postoperative Hb level with distance walked, controlling for other preoperative variables that could influence functional recovery. RESULTS: On bivariate analysis, the predicted distance walked at discharge in feet (95% CI) increased with higher Hb levels (7 g/dL, 56 feet [42-70]; 8 g/dL, 61 feet [54-68]; 9 g/dL, 67 feet [64-70]; 10 g/dL, 74 feet [72-77]; 11 g/dL, 83 feet [80-85]; 12 g/dL, 92 feet [87-96]). After adjustment for other factors associated with ability to walk, higher average postoperative Hb level was independently associated with walking greater distance (p < 0.001). CONCLUSIONS: Higher postoperative Hb level may improve functional recovery after hip fracture repair. If confirmed with clinical trials, this finding would provide a rationale to maintain higher Hb concentrations in elderly patients recovering from surgery.