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

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

3. 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) 1535 -PHD ER. 107.6°, Pupils dilated,  response Flaccid 1544 -Ice to groin/axillae, saline 1549 -T probe 107.6° (Foley) 1550 -Ice to whole body, fan, dopamine 1554 -108.9° 1605 -106.2° 1619 -103.4° Cooling stopped 1647 - 99.3° Levophed 1652 - 98.3° Warm blanket 1922 - 95.4° BP normal

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

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

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

7. 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)

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

9. 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

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

11. 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