Hyperthermia Revisited James Knochel, MD Clinical Grand Rounds: September 14, 2005.

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Presentation transcript:

Hyperthermia Revisited James Knochel, MD Clinical Grand Rounds: September 14, 2005

Case: 42 yo Woman Psychiatric patient, possibly schizophrenic 1-day: irritable, hyperactive, belligerent, change in sensorium, ? Hallucinations

Timeline 1505-EMS arrived. Temp high 90’s FLOP in parking lot - in shade Unresponsive. Skin hot and dry IV saline, O2, 80/30, 135, R 8 (x2) PHD ER °, Pupils dilated,  response Flaccid Ice to groin/axillae, saline T probe 107.6° (Foley) Ice to whole body, fan, dopamine ° ° ° Cooling stopped ° Levophed ° Warm blanket ° BP normal

Medications Effexor (SNRI)Hyperkinesis, sweating Trazadone (SRI)Hypotension Loxapine (Phenothiazine) Anticholinergic, risk of NMS, dyskinesia Benztropine (Cogentin)Anticholinergic Lithium (Serotonin receptor agonist) Dehydration (polyuria)

Poisoning with Anticholinergics Dry as a bone Hot as a poker Mad as a hatter Red as a beet

Diagnostic Criteria for Heat Stroke Hyperthermia (>104.5º) CNS Alteration n Confusion n Bizarre Behavior n Mania n Seizure n Coma

Causes of Hyperthermia Heat Stroke (Classic v. Exertional) Sympathomimetic poisoning syndrome (cocaine, amphetamine, ecstasy, ephedrine) Malignant Hyperthermia Neuroleptic Malignant Syndrome Serotonin syndrome Sepsis/Bacteremia, CNS infection Infections in patients with stroke/myelopathy CNS hemorrhage Thyroid Storm Pheochromocytoma Storm Addisonian Crisis Post resection of insulinoma Exercise without heatstroke Drug Reaction (PTU, Dilantin)

Treatment of Heat Stroke Recognition Out of sun Remove clothing EMERGENCY!

Methods of Cooling Effective: Ice water immersion Wet, frozen sheets Tepid water spray Fans, A/C Room Ice to face and neck Ineffective: Cold room alone Ice packs to axilla and groin Ice water gavage Dantrolene Antipyretics

Complication of Heat Stroke CNS damage Shock (lactic acidosis) DIC Rhabdomyolysis Hepatic Injury Acute Renal Failure SIRS Myocardial Injury Intestinal Infarction

New Experimental Information CNS cooling (CNS blood flow, hypoxia) Activated Protein C Beta-3-adrenergic receptors in muscle n Activate UCP-3 n ATP futile cycle n Carvedilol