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’sFLOP in parking lot - in shadeUnresponsive. Skin hot and dryIV saline, O2, 80/30, 135, R 8 (x2)

1535 - PHD ER. 107.6°, Pupils dilated, responseFlaccid

1544 - Ice to groin/axillae, saline1549 - T probe 107.6° (Foley)1550 - Ice to whole body, fan, dopamine1554 - 108.9°1605 - 106.2° 1619 - 103.4° Cooling stopped1647 - 99.3° Levophed1652 - 98.3° Warm blanket1922 - 95.4° 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 Confusion Bizarre Behavior Mania Seizure 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 Activate UCP-3 ATP futile cycle Carvedilol