1/57. Efficacy of blood purification therapy for heat stroke presenting rapid progress of multiple organ dysfunction syndrome: a comparison of five cases. Five patients were admitted to our hospital because of classical heat stroke during the heat waves which attacked our country in the summers 1994 and 1995. The clinical and laboratory findings of all patients suggested the rapid progress of multiple organ dysfunction syndrome (MODS). Blood purification (BP) therapy, in addition to conventional treatment, was performed in three of the patients. Despite their disastrous general condition, all completely recovered or recovered sufficiently to be transferred to a rehabilitation hospital. Two additional patients were treated with conventional treatment only and both died in 1-3 days after admission.Clinical characteristics and laboratory findings on admission showed no differences between the cases receiving BP therapy and those not receiving BP therapy. These findings suggest that, in heat stroke patients, additional BP therapy may provide a better prognosis than conventional therapy only. These beneficial effects of BP may have been due mainly to the removal of proinflammatory cytokines related to heat stroke. ( info) |
2/57. Disseminated zygomycosis due to rhizopus schipperae after heatstroke. A 21-year-old woman suffered heatstroke and developed diarrhea while trekking across south texas. The heatstroke was complicated by seizures, rhabdomyolysis, pneumonia, renal failure, and disseminated intravascular coagulation. The patient's stool and blood cultures grew campylobacter jejuni. The patient subsequently developed paranasal and gastrointestinal zygomycosis and required surgical debridement and a prolonged course of amphotericin b. The zygomycete cultured was rhizopus schipperae. This is only the second isolate of R. schipperae that has been described. R. schipperae is characterized by the production of clusters of up to 10 sporangiophores arising from simple but well-developed rhizoids. These asexual reproductive propagules are produced on Czapek Dox agar but are absent on routine mycology media, where only chlamydospores are observed. Despite multiorgan failure, bacteremia, and disseminated zygomycosis, the patient survived and had a good neurological outcome. Heatstroke has not been previously described as a risk factor for the development of disseminated zygomycosis. ( info) |
| Exertional heat stroke usually occurs in warm climates. Increased serum levels of liver enzymes is a common finding in this condition, whereas liver failure is a more rare event that carries a poor prognosis. liver transplantation has been recommended as treatment in cases of severe liver failure, but no long-term survival after this procedure in exertional heat stroke has been described. We report the case of a 31-year-old man who had a heat stroke after running 5 km at 21 degrees C. He developed severe liver damage, with serum alanine aminotransferase (ALAT) activities increasing to 16,410 U/l (reference values, 10-50 U/l) after 48 h, concomitantly with a pronounced coagulation disturbance, with Normotest (NT) decreasing to 12% (international normalized ratio (INR) = 4.2) (reference values, 70%-130% for NT and 0.8-1.2 for INR). A liver biopsy on the 5th day after the incident showed extensive liver cell necrosis. The patient was referred to be considered for liver transplantation but recovered completely on conservative treatment. We conclude that exertional heat stroke is a diagnostic possibility also in temperate climates and that severe liver failure may ensue. The liver injury is reversible, and the indications for liver transplantation in this situation have not been clarified. ( info) |
4/57. Neuropsychological sequelae of heat stroke: report of three cases and discussion. heat stroke includes neurologic impairment as a person's body temperature reaches 40.5 degrees C (105 degrees F) as a result of a failure of thermoregulation. The physiologic complications of heat stroke are well described in the literature. The domains of cognitive functioning affected and the severity of impairment resulting from heat stroke can vary from mild deficits in attention and memory to severe global dementia. There can also be changes in affect and personality that are equally debilitating. This article presents the neuropsychological test results of three active duty soldiers who suffered heat stroke and were tested within 2.5 months of injury. ( info) |
| A 16-year-old man developed heat stroke during football practice when the temperature was 33.8 degrees C (heat index, 44.4 degrees C). resuscitation with ice water lavage, external cooling, and intravenous fluids was initially successful, but the patient again became obtunded. Liver chemistry tests and the prothrombin time and serum ammonia increased markedly, and rhabdomyolysis and renal failure became evident, necessitating hemodialysis. He underwent liver transplantation for fulminant hepatic failure approximately 72 hours after admission. rhabdomyolysis with renal failure and severe electrolyte disturbances continued despite aggressive hemodialysis and the patient had a cardiopulmonary arrest and died 10 days after transplantation. This case shows that liver transplantation cannot always overcome the generalized toxic effects of heat stroke. More aggressive hemodialysis or combined liver/kidney transplantation might result in a positive outcome in selected cases. ( info) |
6/57. Sudden death during jungle trekking: a case of heat stroke. heat stroke, which is also known as "sun stroke," is a medical emergency, and fatalities can occur unless it is diagnosed early and treated efficiently. heat stroke may manifest quite suddenly, giving little time to differentiate it from extreme physical exhaustion in collapsed subjects. It is also known to lead to serious disseminated intravascular coagulation. Sudden death in a young female is presented who collapsed after trekking in a hilly, jungle area in malaysia on a warm, humid day. She had joined a weight reduction programme a few weeks earlier. She was found collapsed and in a semiconscious state in the jungle by her groupmates and was taken to hospital. On admission she was unconscious, hyperpyrexic, with rapid, thready pulse and a low blood pressure. Biochemical studies revealed metabolic acidosis, elevated liver and cardiac enzymes and impairment of renal function. Her coagulation profile was found to be impaired and she started bleeding through the mouth and nostrils. She also developed watery diarrhoea and initially a septicaemic condition, including acute enteritis was suspected. Despite active treatment, her condition deteriorated and she died eight hours after admission. autopsy confirmed a generalised bleeding tendency, with pulmonary, oesophageal and gastrointestinal mucosal haemorrhages. Flame-shaped subendocardial shock haemorrhages were seen in the interventricular septum on the left side of the heart. The findings support a diagnosis of heat stroke. Various aspects related to heat stroke, the autopsy diagnosis and its prevention are discussed. ( info) |
7/57. Exertional heat stroke--the prevention of a medical emergency. In most cases, exertional heat stroke (EHS) can be prevented in the military setting. The actions taken by the israel Defense Forces (IDF) and their outcome prove this well. Unfortunately, despite the available information, there are still incidents of failure of command in conducting physical exercise, leading to EHS. In our experience, most incidences are a consequence of disregarding safety regulations. The application of simple and reasonable measures will not only prevent accidents from happening, but will also result in better trained soldiers. ( info) |
8/57. Entrapment in small, enclosed spaces: a case report and points to consider regarding the mechanism of death. The mechanism of death due to confinement in an enclosed space is usually ascribed to asphyxia from oxygen deprivation. We report the case of the decomposed remains of a 23-year-old man discovered in an unused industrial size refrigerator in which the mechanism of death is heatstroke. The investigation of the death indicates the subject most likely voluntarily entered the refrigerator and for unknown reasons, closed the door. Injuries identified at autopsy and damage to the inside of the structure indicate he struggled to exit the cabinet. The autopsy shows no significant natural disease processes and toxicology studies were negative. The diagnosis of heat stroke typically rests on the evaluation of multiple features, including the age and size of the decedent, the ambient temperature, the medical history of the decedent, whole body hydration, body fat content, alcohol and drug use, medication history, general physical condition, and many other factors. The diagnosis of heatstroke due to confinement in an enclosed container requires evaluation of the heat stress of the container, the heat strain experienced by the individual, autopsy findings suggesting signs of a struggle to exit the container, and other factors. In all such cases, a careful death investigation with correlation of autopsy findings is required to accurately determine the mechanism and cause of death. We suggest that for all such deaths, physiological and environmental factors promoting hyperthermia and heatstroke be considered as a possible mechanism of death, along with those associated with the more obvious danger of asphyxiation. ( info) |
9/57. An analysis of factors contributing to a series of deaths caused by exposure to high environmental temperatures. autopsy reports at the Forensic science Centre, Adelaide, south australia, were reviewed for the 8 years from January 1991 to December 1998 for cases with unusual features in which deaths had been attributed to exposure to high environmental temperatures. amphetamine-related hyperpyrexial deaths, anesthetic deaths caused by malignant hyperpyrexia, deaths of elderly incapacitated individuals during heat waves, and deaths of children trapped in the back of cars were excluded from the study. In 9 cases, where heat-related deaths had occurred (age range 21 to 77 years; M:F = 8:1). Predisposing factors included lack of familiarity with Australian environmental conditions, excessive clothing, prolonged sun exposure, acute alcohol intoxication, obesity, benztropine and trifluoperazine medication, and underlying dementia, alcoholic liver disease, and possibly epilepsy. ( info) |
10/57. Hyperpyrexia in the emergency department. The differential diagnosis of the hyperpyrexic patient in the emergency department is extensive. It includes sepsis, heat illness including heat stroke, neuroleptic malignant syndrome, malignant hyperthermia, serotonin syndrome and thyroid storm. Each of these possible diagnoses has distinguishing features that may help to differentiate one from another. However, establishing the correct diagnosis is a challenge in the setting of the obtunded emergency patient who gives no history and where there may be limited access to any past medical or drug history. This paper presents such a case and reviews the features of the differential diagnoses and management of the hyperpyrexic patient. ( info) |