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Hyperthermia Revisited

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. - EMS arrived. Temp high 90’s

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Hyperthermia Revisited

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  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 - 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

  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 • Confusion • Bizarre Behavior • Mania • Seizure • 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. 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 Methods of Cooling

  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 • Activate UCP-3 • ATP futile cycle • Carvedilol

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