1. SAQ 18
A 36 year old elite athlete presents after completion of a half marathon. He struggled to finish the race and collapsed soon after crossing the finishing line. The ambient temperature is 36 degrees.
On arrival his vital signs include:
GCS 12 (E3 V4 M5)
HR 130
BP 85/50
Temp 40.7

2. Complete the following table regarding causes of hyperthermia by providing 2 examples for each type listed. (6 marks)
Excessive heat production exertional/MH/NMS/thyrotoxicosis/phaeochromocytoma drugs (sympathomimetic/serotonergic) seizures Diminished heat dissipation heat stroke /dehydration/autonomic dysfunction/NMS/ anticholinergic toxicity Hypothalamic dysfunction CVA/emcephalitis/Trauma/NMS/Gramulomatous diseases Uncontrolled hyperthermia differs from fever -body temp is elevated above the thermoregulatory set point

3.   Besides information already provided List two (2) predisposing factors for Heat stroke in this patient (2 marks)
Demographics
Age(extremes of age)Athletes
Environmental
high ambient temp/humidity/heat waves/poor ventilation
Behaviour
lack of acclimatization/salt & water deprivation
Underlying conditions
dermatologic/psychiatric/chronic diseases
Drugs
anticholinergics/neuropsychiatric/sympathomimetic/diuretics/cardiac
These are all the predisposing categories but those highlighted red already provided in stem so no mark if listed

4.   List four (4) cardinal clinical features (from different systems) that you would expect to find in this patient (4 marks)
Neurological dysfunction
Confusion/ACS/seizure
Hyperthermia
T > 40.??
Lack of sweating
esp in exertion heat stroke
Vasodilatory shock
Complications
ATN/RF
Rhabdomyolysis
Electrolyte abnormalities (hyperglycemia/low phosphate/hyperK)
LFT/coagulation/leukocytosis/myoglobin

5.   State your six (6) ED treatment priorities for this patient (6 marks) Heat stroke with T 40.7 BP 85/50 HR 130 GCS 12
Cooling
1.external
remove clothing/fans/tepid spray/ice packs(axillae/groin) avoid shivering
2. invasive with specified aim or end point ( eg temp 39)
cool IV fluid/lavages/plan for ECMO
3.Resuscitation & ongoing fluids with estimated volume and endpoints (HR/BP)
4.ETT/sedation/paralysis with rationale for this pt
eg aid temp control/prevent shivering-BZDs/worsening obtundation
Treat/prevent most likely complications
5.Rhabdo/RF with U/O aim/hr ie 2-3mls/kg/hr/consider mannitol or frusemide infusion
6.Electrolytes (hypoNa/hyperK)
Treatment of other complications also accepted but only if adequate cooling/ resus/ treatment of most likely complications already addressed
NB Disposition is NOT treatment It is part of “Management” ( refer to ACEM glossary of terms)

6. General themes for poorly scoring answers
Not answering the question (you must be familiar with the ACEM glossary of terms)
Not being specific
Not providing aims or endpoints of specific treatment
Not demonstrating critical thinking