Hyperthermia Mehrdad Esmailian MD. Assistant professor of Emergency Medicine Definition ► Elevation of core body temperature above the normal diurnal range of 36ºC to 37.5ºC due to failure of thermoregulation ► Hyperthermia is not synonymous with the more common sign of fever, which is induced by cytokine activation during inflammation, and regulated at the level of the hypothalamus Hyperthermia ► The most important causes of severe hyperthermia (greater than 40ºC or 104ºF) caused by failure of thermoregulation are: Heat stroke Neuroleptic malignant syndrome Malignant hyperthermia Physiology ► Body temperature is maintained within a narrow range by balancing heat load with heat dissipation ► Body's heat load results from both metabolic processes and absorption of heat from the environment ► As core temperature rises, the preoptic nucleus of the anterior hypothalamus stimulates efferent fibers of the ANS to produce sweating and cutaneous vasodilation Physiology ► Evaporation is the principal mechanism of heat loss in a hot environment, but this becomes ineffective above a relative humidity of 75% ► Other methods of heat dissipation Radiation- emission of infrared electromagnetic energy Conduction- direct transfer of heat to an adjacent, cooler object Convection-direct transfer of heat to convective air currents ► These methods cannot efficiently transfer heat when environmental temperature exceeds skin temperature Physiology ► Temperature elevation ↑ O2 consumption and metabolic rate hyperpnea and tachycardia ► Above 42ºC (108ºF), oxidative phosphorylation becomes uncoupled, and a variety of enzymes cease to function ► Hepatocytes, vascular endothelium, and neural tissue are most sensitive to these effects, but all organs may be involved ► As a result, these patients are at risk of multiorgan system failure Heat Regulation ► The regulation of body temperature involves three distinct functions: Thermosensors Central integrative area Thermoregulatory effectors Thermosensors ► Temperature-sensitive structures are located both peripherally in the skin and centrally in the body ► Skin temperature changes, correlate poorly with changes in the rate of heat loss ► Thermosensitive neurons are in the preoptic area of the anterior hypothalamus. They are activated when the temperature of the blood circulating through that area exceeds a certain “set point” ► The skin temperature affects heat loss, since a person resting in a warm environment initiates sweating, even though the core temperature remains constant ► In contrast, changes in core temperature are more potent in producing heat-dissipating responses Central Integrative Area ► The CNS interprets information received from the thermosensors to properly instruct thermoregulatory effectors ► The concept of a central thermostat by which an alteration shifts effector thresholds in the same direction fits a variety of clinical situations ► For example, fever, the circadian rhythm of temperature variation, and the 0.5° C difference in rectal temperature after ovulation can be explained by variation of a thermal setpoint Thermoregulatory Effectors ► Sweating and peripheral vasodilation are the major mechanisms by which heat loss can be accelerated ► In a warm environment, evaporation of sweat from the skin is the most important mechanism of heat dissipation ► Heat loss from the skin by convection and radiation is maximized by increased skin blood flow to facilitate sweating ► Humans possess apocrine and eccrine sweat glands ► Apocrine glands are concentrated in the axillae and produce milky sweat rich in carbohydrate and protein. They are adrenergically innervated and respond to emotional stress as well as to heat ► Most glands producing “thermal sweat” are eccrine glands. These are cholinergically innervated and distributed over the entire body, with the largest number on the palms and soles. Eccrine sweat is colorless, odorless, and devoid of protein ► Individuals exercising in hot environments commonly lose 1 to 2 L/hr of sweat; loss of 4 L/hr for short periods is possible ► Cooling is best achieved by evaporation from the body surface; sweat that drips from the skin does not cool the body, and sweat evaporated from clothing is considerably less efficient ► Each liter of completely evaporated sweat consumes 580 kcal of heat ► The ability of the environment to evaporate sweat is termed atmospheric cooling power and varies primarily with humidity, but also with wind velocity ► As humidity approaches 100%, evaporative heat loss ceases ► The vascular response to heat stress is cutaneous vasodilation and compensatory vasoconstriction of splanchnic and renal beds ► These vascular changes are under neurogenic control and allow heat to be dissipated quickly and efficiently, but they place a tremendous burden on the heart ► To maintain blood pressure, cardiac output must increase dramatically. For this reason, saunas and hot tubs may be dangerous for patients with cardiac disease ► Cardiovascular and baroreceptor reflexes also affect skin blood flow. Reduced forearm sweating and vasodilation are observed in severely dehydrated subjects exercising in a warm environment Acclimatization ► Definition : constellation of physiologic adaptations that appear in a normal person as the result of repeated exposures to heat stress ► Daily exposure to work and heat for 100 min/day results in near-maximal acclimatization in 7 to 14 days. This is characterized by an earlier onset of sweating (at a lower core temperature), increased sweat volume, and lowered sweat electrolyte concentration ► Acclimatization is hastened by modest salt deprivation and delayed by high dietary salt intake ► As acclimatization proceeds, the sweat sodium concentration drops while the volume increases ► The cardiovascular system plays a major role in both acclimatization and endurance training, largely resulting from an expansion of plasma volume ► Heart rate is lower and associated with a higher stroke volume ► Other physiologic changes include : ► Earlier release of aldosterone, although acclimatized individuals generate lower plasma levels of aldosterone during exercise heat stress ► Total body potassium depletion of up to 20% (500 mEq) by the second week of acclimatization can occur as a result of sweat and urine losses coupled with inadequate repletion ► The well-conditioned athlete is not necessarily heat acclimatized ► To maintain heat and exercise-induced adaptive responses, heat exposure needs to continue intermittently at least on 4-day intervals ► Plasma volume decreases considerably within 1 week in the absence of heat stress Predisposing Factors ► Elderly patients or those with chronic diseases who are taking medications predisposing to heat illness are prone to classic heatstroke during periods of high ambient heat and humidity. Adequate fluid intake is essential. ► Elderly patients sometimes dress inappropriately for hot weather; heat loss is maximized by light, loose-fitting garments ► Exertional heatstroke is most likely to occur in young, healthy people involved in strenuous physical activity, especially if they have not acclimatized ► Fluid intake is the most critical variable. Dehydration can be minimized by education on work-rest cycles and fluid consumption and through provision of cool, pleasantly flavored fluids ► The goal is to maximize voluntary fluid intake and gastric emptying so that fluid can rapidly enter the small intestine, where it is absorbed ► Gastric emptying is accelerated to 25 mL/min by large fluid volumes (500-600 mL) and cool temperatures (10° C to 15.8° C) ► High osmolality inhibits gastric emptying; osmolality of less than 200 mOsm/L is optimal ► Hydration can be monitored by measuring body weight before and after training or athletic competition ► An athlete with a loss of 2% to 3% body weight (1.5-2 L in a 70-kg man) should drink extra fluid and be permitted to compete only when within 0.5 to 1 kg (1-2 pounds) of the starting weight on the previous day ►A weight loss of 5% to 6% represents a moderately severe deficit and usually is associated with intense thirst, scanty urine, tachycardia, and an increase in rectal temperature of about 2° C. Such athletes should be restricted to light workouts after hydration to their normal weight ►A loss of 7% or more of body weight represents severe water depletion; the athlete should not participate in sports until examined by a physician. Wrestlers frequently fast, restrict food and fluid intake, and exercise vigorously wearing vapor-impermeable clothing to lose weight quickly so that they can compete in a lower weight class ► The administration of salt tablets during strenuous exercise can cause delayed gastric emptying, osmotic fluid shifts into the gut, gastric mucosal damage, and hypernatremic dehydration ► A 6-g sodium diet is sufficient for successful adaptation for work in the heat, with sweat losses averaging 7 L/day ► Excessively high salt intake in relation to salt losses in sweat during initial heat exposure can impair acclimatization because of inhibition of aldosterone secretion ► Excessive salt ingestion can also exacerbate potassium depletion ► Evaporative cooling can be lost when clothing inhibits air convection and evaporation ► Loose-fitting clothing or ventilated fishnet jerseys allow efficient evaporation ► Light-colored clothing reflects rather than absorbs light ► Water evaporated from clothing is much less efficient for body cooling than is water evaporated from the skin ► The body's heat dissipation mechanisms are analogous to the cooling system of an automobile : Coolant (blood) is circulated by a pump (heart) from the hot inner core to a radiator (skin surface cooled by the evaporation of sweat). Temperature is sensed by a thermostat (CNS), which alters coolant flow by a system of pipes, valves, and reservoirs (vasculature) MINOR HEAT ILLNESS ► Heat Cramps ► Heat Edema ► Heat Syncope ► Prickly Heat MAJOR HEAT ILLNESS ► HEAT EXHAUSTION ► HEATSTROKE Classic Exertional Heat Cramps ► Brief, intermittent, and often severe muscular cramps occurring typically in muscles that are fatigued by heavy work ► Heat cramps occur most commonly during the first days of work in a hot environment and develop in persons who produce large amounts of thermal sweat and subsequently drink copious amounts of hypotonic fluid ► Heat cramps appear to be related to salt deficiency ► The most commonly victims : athletes, roofers, steel workers, coal miners, field workers, and boiler operators ► Heat cramps tend to occur after exercise when the victim has stopped working and is relaxing. In this respect, they differ from the cramps experienced by athletes during exercise, which tend to last for several minutes, are relieved by massage, and resolve spontaneously ► Essentials of Diagnosis : Cramps of most worked muscles Usually occur after exertion Copious sweating during exertion Copious hypotonic fluid replacement during exertion Hyperventilation not present in cool environment ► DDs : hyperventilation tetany ► Heat cramp victims exhibit hyponatremia, hypochloremia, and low serum sodium and chloride levels ► Rhabdomyolysis or resultant renal damage is not present with isolated heat cramps Management ► Mild cases without concurrent dehydration may be treated orally with 0.1% to 0.2% salt solution (two to four 10-grain salt tablets [56 to 112 mEq] or ¼ to ½ teaspoon table salt dissolved in a quart of water), which is the general limit of palatability ► Severe cases respond rapidly to intravenous isotonic solution (0.9% NaCl) ► Salt tablets are gastric irritants and are not recommended Heat Edema ► Swollen feet and ankles are often reported by nonacclimatized individuals, especially the elderly, who encounter climatic stresses of tropical and semitropical area ► Such individuals often have no underlying cardiac, hepatic, venous, or lymphatic disease. They commonly have assumed rigorous schedules with long periods of sitting or standing ► The edema is usually minimal, not accompanied by any significant impairment in function, and often resolves after several days of acclimatization ► It is presumed that hydrostatic pressure and vasodilation of cutaneous vessels, combined with some degree of orthostatic pooling, lead to vascular leak and accumulation of interstitial fluid in the lower extremities ► Aldosterone increases in response to the heat stress and perceived central volume deficit ► Awareness of this clinical presentation prevents overly vigorous diagnostic and therapeutic intervention ► Brief diagnostic evaluation to rule out thrombophlebitis, lymphedema, or congestive heart failure is appropriate, but invasive diagnostic techniques or vigorous pharmacologic therapy is not indicated Management ► No evidence exists that diuretic therapy is effective ► Leg elevation or thigh-high support hose ► In most individuals, the problem resolves either through adequate acclimatization or with the individual's return to a home climate Heat Syncope ► The elderly have a special predilection for this disorder ► Individuals adapt to a hot, humid environment by dilation of cutaneous vessels to deliver heat to the body surface. Thus, an increased portion of the intravascular pool is located in the periphery at any given time ► Increasing blood flow to compliant cutaneous veins raises skin vascular volume at the expense of thoracic blood volume. Individuals who stand for protracted periods tend to pool blood in the lower extremities ► Combined with volume loss and peripheral vasodilation, this pooling can result in inadequate central venous return, a concomitant drop in cardiac output, and a cerebral perfusion inadequate to maintain consciousness Management ► The disorder is self-limited, because assumption of a horizontal position is the cure ► Individuals at risk for heat syncope should be warned to move often, flex leg muscles repeatedly when standing stationary, avoid protracted standing in hot environments, and assume a sitting or horizontal position when prodromal warning signs or symptoms occur ► prodromal warning signs or symptoms : scintillating scotomata tunnel vision Vertigo Nausea Diaphoresis weakness Adequate education prevents many serious injuries Prickly Heat ► Prickly heat, also known as miliaria rubra, lichen tropicus, and heat rash, is an acute inflammatory disorder of the skin that occurs in tropical climates ► It is the result of blockage of sweat gland pores by macerated stratum corneum and secondary staphylococcal infection ► The acute phase is characterized by vesicles in the malpighian layer of the skin caused by dilation and rupture of the obstructed sweat gland ducts ► Clinically, this initially produces intensely pruritic vesicles on an erythematous base. The rash is confined to clothed areas, and the affected area is often completely anhidrotic ► Over the next week or so, a keratin plug arises and fills these vesicles, causing a deeper obstruction of the sweat gland duct. The obstructed duct then ruptures a second time, producing a deeper vesicle within the dermis. This is known as the profunda stage, and it can persist for weeks. Profunda vesicles are not pruritic and closely resemble the white papules of piloerection ► Chronic dermatitis is a common complication Management ► Chlorhexidine in a light cream or lotion is the antibacterial treatment of choice during the acute phase ► Salicylic acid, 1%, can be applied three times daily to localized, affected areas to assist in desquamation, but it should not be used over large areas because of possible salicylate intoxication ► For diffuse or pustular rashes, erythromycin can be helpful ► Prickly heat can be prevented by wearing light, loose-fitting, clean clothing and avoiding situations that produce continuous sweating ► Routine use of talcum or baby powder should be avoided ► Spending 8 to 12 hours a day in an airconditioned environment is helpful Heat Exhaustion ► Volume depletion that occurs under conditions of heat stress ► Types: water depletion / salt depletion ► Water depletion heat exhaustion results from inadequate fluid replacement by individuals working in a hot environment ► This “voluntary dehydration” results in progressive hypovolemia ► Salt depletion heat exhaustion takes longer to develop than the water depletion form. It occurs when large volumes of thermal sweat are replaced by water with too little salt ► It differs from heat cramps in that systemic symptoms occur ► This syndrome is characterized by hyponatremia, hypochloremia, and low urinary sodium and chloride concentrations ► Body temperature usually remains near normal Clinical Features Weakness Fatigue frontal headache impaired judgment Vertigo nausea and vomiting muscle cramps Orthostatic dizziness and syncope ► The core temperature is only moderately elevated, usually less than 40° C, and signs of severe CNS dysfunction are not present Diagnosis ► Vague malaise, fatigue, headache ► Core temperature often normal; if elevated, less than 40° C (104° F) ► Mental function essentially intact; no coma or seizures ► Tachycardia, orthostatic hypotension, clinical dehydration (may occur) ► Other major illness ruled out ► If in doubt, treat as heat stroke ► Elevations of hepatic transaminases to several thousand units can be seen in patients with heat exhaustion or healthy runners after a marathon, whereas in patients with heatstroke, such levels are usually in the tens of thousands after 24 hours Management ► Heat exhaustion is primarily a volume depletion problem, and rapid recovery generally follows fluid administration ► Decisions regarding the type of fluid and electrolyte replacements should be based on serum electrolyte measurements and the estimation of hydration status by clinical and laboratory parameters ► In mild cases, rest in a cool environment and an oral electrolyte solution, such as 0.1% saline, may suffice ► Patients with significant volume depletion or electrolyte abnormalities generally require intravenous fluids ► If the patient is orthostatic, normal saline should be administered until the patient is hemodynamically stable ► Free water deficits should be replaced slowly over 48 hours so as not to decrease serum osmolality more than 2 mOsm/hr ► Overly rapid correction of hypernatremia is associated with seizures caused by cerebral edema Disposition ► Young, otherwise healthy patients who do not have significant laboratory abnormalities and who respond rapidly to treatment do not require hospitalization. These patients can be discharged with instructions to drink plenty of fluids and avoid heat stress for 24 to 48 hours. ► Older patients, particularly those with cardiovascular disease or other predisposing factors, require more cautious fluid and electrolyte replacement and frequent reassessment ► Admission if patient is elderly, has significant electrolyte abnormalities, or would be at risk for recurrence if discharged Treatment Rest Cool environment Assess volume status (orthostatic changes, BUN, hematocrit, serum sodium) Fluid replacement: normal saline to replete volume if patient orthostatic, replace free water deficits slowly to avoid cerebral edema Heat Stroke ► Body temperature rises with fails in homeostatic thermoregulatory mechanisms ► This failure results in elevation of body temperature to extreme levels, usually greater than 40.5° C (105° F), producing multisystem tissue damage and organ dysfunction ► Core body temperature > 40.5ºC (105ºF) with associated CNS dysfunction in the setting of a large environmental heat load that cannot be dissipated ► Complications include: ARDS DIC Renal or hepatic failure Hypoglycemia Rhabdomyolysis Seizures ► The resultant damage to tissues depend on : Body temperature Exposure time Work load Tissue perfusion Individual factors ► Neurologic dysfunction is a hallmark of heatstroke, and cerebral edema is common ► Other pathologic changes include : petechiae in the walls of the third and fourth ventricles marked cerebellar Purkinje cell damage The hypothalamus, the predominant site of central thermoregulatory control, is usually not damaged ► Heat stress creates tremendous demands on the cardiovascular system, and signs of circulatory failure, increases in skin blood flow (peripheral vasodilation) and a reduction of the thermal gradient between the core and the skin ► Compensatory vasoconstriction of the splanchnic and renal vasculature. The resulting splanchnic and renal ischemia may explain the nausea, vomiting, and diarrhea observed in postmarathon runners ► Hepatic damage : centrilobular necrosis with extensive cholestasis ► Failure to perfuse the skin with heated blood from the core results in a dramatically increased rate of heat storage. This produces RICP, which, in combination with a reduction in MAP caused by failure of compensatory splanchnic vasoconstriction, conspires to produce a fall in cerebral blood flow; this results in the major CNS dysfunction characteristic of heatstroke Diagnosis Exposure to heat stress, endogenous or exogenous Signs of severe CNS dysfunction (coma,seizures, delirium) Core temperature usually above 40.5° C (105° F), but may be lower Dry, hot skin common, but sweating may persist Marked elevation of hepatic transaminases Classic (nonexertional) heat stroke ► Affects individuals with underlying chronic medical conditions that either impair thermoregulation or prevent removal from a hot environment. ► Conditions include: Cardiovascular disease Neurologic or psychiatric disorders Obesity Anhidrosis Extremes of age Anticholinergic agents or diuretics ► Occurs during periods of sustained high ambient temperatures and humidity, as during summer heat waves ► Victims are often elderly and poor and live in underventilated dwellings without air conditioning ► Debilitated patients who have limited access to oral fluids may develop water-depletion heat exhaustion, which progresses to heatstroke if untreated ► Victims of CHS commonly suffer from chronic diseases, alcoholism, or schizophrenia, which predispose to heat illness. Such patients are often prescribed medications (e.g., diuretics, antihypertensives, neuroleptics, and anticholinergics) that impair the ability to tolerate heat stress ► Sweating is totally absent in the majority of CHS patients ► Poor outcome critria : Advanced age Hypotension Altered coagulation status The necessity for endotracheal intubation on arrival at the emergency department Exertional heat stroke ► Occurs in young, otherwise healthy individuals engaged in heavy exercise during periods of high ambient temperature and humidity ► Findings include : cutaneous vasodilation, tachypnea, rales due to noncardiogenic pulmonary edema, excessive bleeding due to DIC, altered mentation or seizures ► Labs: coagulopathy, ARF, elevated LFTs due to acute hepatic necrosis, respiratory alkalosis, and a leukocytosis as high as 30,000 to 40,000/mm3 ► Rhabdomyolysis and ARF, rarely seen in patients with CHS, are common in patients with EHS ► Sweating is present in half the cases of EHS ► Hypoglycemia ► Coagulopathy ► Hyponatremia with serum sodium levels less than 130 mmol/L (neurologic symptoms or seizures) ► Delirium or coma is characteristic, but virtually any neurologic abnormality, including bizarre behavior, opisthotonus, hallucinations, decerebrate rigidity, oculogyric crisis, and cerebellar dysfunction, can be seen ► Convulsions occur in up to 75% of patients and can be precipitated by therapeutic maneuvers (such as ice water immersion) ► Profound muscle rigidity with tonic contractions, coarse tremor, and dystonic movements can mimic seizures ► Pupils may be fixed and dilated, and the electroencephalogram may be isoelectric ► All these changes are potentially reversible, although permanent damage, including cerebellar deficits, hemiplegia, dementia, and personality changes, is common in severe cases ► Patients with heatstroke usually have hyperdynamic cardiovascular systems with low peripheral vascular resistance, tachycardia (up to 180 beats/min), and an elevated cardiac index. These changes are expected because skin blood vessels dilate to dissipate heat; however, this low peripheral vascular resistance has persisted in patients treated with ice water immersion and reduction of body temperature to near normal ► CVP is usually elevated ► The combination of elevated CVP with rightsided cardiac dilation suggests right-sided cardiac failure, which is also seen after shock or sepsis ► Respiratory alkalosis is a physiologic response to active or passive heating and may be severe enough to produce tetany ► Although most patients with CHS have respiratory alkalosis, those with EHS usually have a relatively pure lactic acidosis ► Lactic acidosis is associated with a poor prognosis in cases of CHS but not necessarily in cases of EHS ► Aberrations in coagulation are common in patients with severe heatstroke, and their presence is a poor prognostic sign ► Abnormal hemostasis is manifested clinically by purpura, conjunctival hemorrhage, melena, bloody diarrhea, hemoptysis, hematuria, myocardial bleeding, or hemorrhage into the CNS ► Hepatic injury is evidenced by markedly elevated levels of hepatic aminotransferases (serum aspartate transaminase and alanine transaminase) ► Jaundice typically appears 24 to 72 hours after the onset of severe heatstroke and gradually recedes if the victim survives ► Survivors generally have no permanent impairment of liver function ► Hypoglycemia with a serum glucose level less than 65 mg/dL is common in cases of exertional heatstroke ► Renal damage is common. The initial urine specimen, usually obtained by catheterization, is a scanty, brownish, turbid fluid resembling machine oil ► Microscopic examination reveals proteinuria with abundant granular casts and red blood cells ► Acute oliguric renal failure complicates 25% to 30% of EHS cases and 5% of CHS cases ► Glomerular filtration rate, renal plasma flow, urine flow, and sodium excretion diminish markedly during exercise ► Heavy physical exertion in hot climates produces acidic and maximally concentrated urine, which can result in acute oliguric renal failure when combined with hypotension and myoglobinuria ► Cocaine use is also associated with rhabdomyolysis and hyperthermia ► Diarrhea, probably caused by intense splanchnic vasoconstriction, is commonly seen ► Cooling aggravates the diarrhea, creating an unpleasant treatment problem ► Pancreatitis is described with elevated serum amylase and lipase levels Diagnosis ► Thermometry : Oral thermometry is affected by mouth breathing and is a poor approximation of the core Rectal thermometry is less variable but responds to changes in core temperature slowly Thermistors that are inserted 15 cm into the rectum offer continuous monitoring of temperature and less variability Although slower to respond to changes in core temperature than tympanic temperature readings, rectal measurements are not biased by head skin temperature An esophageal thermistor positioned adjacent to the heart is another option Placement of a tympanic temperature sensor directly on the tympanic membrane may be difficult and is not used clinically Commercially available infrared thermometers do not physically contact the tympanic membrane and are unreliable in detecting hyperthermia If a patient is being monitored with a catheter, pulmonary arterial temperature can be measured precisely with a thermistor catheter Management ► Ensure ABCs, complications initiate rapid cooling, tx Management Cooling ► Immediate cooling is the cornerstone of treatment ► Cooling must be initiated as soon as possible, in conjunction with the initiation of stabilizing treatment ► Mortality increases significantly when cooling is delayed ► In the prehospital setting, cooling should be initiated by removing the patient from the hot environment and fanning ► When the patient arrives at the hospital, clothes should be removed, a thermistor probe should be inserted, and the temperature should be continuously monitored ► The ideal method of evaporative cooling uses a body cooling unit on which the patient lies suspended on a net surface while being sprayed with atomized 15° C water from above and below ► Air warmed to 45° C to 48° C is blown over the skin surface at 3 m/min. The unit, not widely available, maximizes evaporative cooling by maintaining cutaneous vasodilation and avoiding heat generation caused by shivering ► Evaporative cooling is the most widely used cooling method ► The combination of atomized tepid water at 40° C from a spray bottle and standing fans cool at rates comparable to both body cooling unit and immersion ► Other evaporative techniques, including the use of downdraft from a helicopter ► Immersion in ice water results in a rapid reduction of core temperature to less than 39° C within 10 to 40 minutes ► When the body temperature reaches 39° C, cooling measures should be discontinued to avoid hypothermic overshoot ► Continuous monitoring is necessary to maintain the core temperature at 37° C to 38° C ► Cooling modalities other than evaporation and immersion should be considered adjunctive treatments ► Application of ice packs to high heat transfer areas (neck, groin, axillae) is commonly used ► Cooling blankets may be a useful adjunct but will not produce rapid cooling if used exclusively ► Cardiopulmonary bypass with a heat exchanger has been successful in the treatment of malignant hyperthermia ► Peritoneal dialysis with cold fluids, although successful in a canine model, remains untested in humans ► Cold-irrigant gastric or rectal lavage will not provide significant heat exchange if used as the primary cooling modality Resuscitation ► Aspiration and seizures are common in patients with heatstroke, and airway control is essential ► Hypoxemia may occur because of aspiration, pneumonitis and pulmonary infarction, hemorrhage, or edema ► Metabolic demands are high, and normal pulmonary ventilation may be inadequate in this setting ► Circulatory fluid requirements are modest in some cases, averaging 1200 mL of isotonic crystalloid solution in the first 4 hours ► Pulmonary edema occurs in patients with heatstroke and can be exacerbated by overzealous fluid administration ► The use of a CVP catheter to monitor fluid resuscitation may be deceptive ► Most patients have a hyperdynamic circulation with high cardiac index, low peripheral vascular resistance, and elevated CVP as a result of right-sided heart failure. These patients may require only modest intravenous fluids because cooling produces vasoconstriction and increases blood pressure ► Hypotension is common in patients with heatstroke and is usually caused by peripheral vasodilation resulting in high-output cardiac failure, in addition to dehydration ► Blood pressure usually rises with cooling ► If the patient has a low central venous or pulmonary capillary wedge pressure, a fluid challenge of 250 to 500 mL of 0.9% saline should be given rapidly while blood pressure, pulse, and urine output are monitored ► If the blood pressure rises, further fluids are given with careful monitoring of the CVP. Aggressive fluid replacement is continued until the blood pressure reaches 90/60 mm Hg or the CVP exceeds 12 mL H2O ► Occasionally, patients exhibit hypodynamic responses with low cardiac index, elevated CVP, and hypotension. These patients may be cyanotic, whereas patients with hyperdynamic circulation are initially pink ► This clinical observation can be helpful in identifying patients who may respond to catecholamines ►A variety of tachyarrhythmias commonly occur during heatstroke. These usually resolve with cooling, and electrical cardioversion should be avoided until the myocardium is cooled ► The use of p -adrenergic agents such as norepinephrine is not recommended because they promote vasoconstriction without improving cardiac output or perfusion, decrease cutaneous heat exchange, and may enhance ischemic renal and hepatic damage ► Atropine and other anticholinergic drugs that inhibit sweating should be avoided ► Antipyretics such as aspirin and acetaminophen are not indicated and may be harmful ► Salicylates, particularly in large doses, can worsen hyperthermia by uncoupling oxidative phosphorylation and aggravate coagulopathies ► Large doses of acetaminophen can result in further hepatic damage ► The efficacy of dantrolene is not established ► After volume repletion, administration of mannitol in an initial intravenous dose of 12.5 g, followed by 12.5 g mannitol per liter of intravenous fluid increases renal blood flow and minimizes damage from myoglobinuria secondary to rhabdomyolysis ► If myoglobinuria is documented, maintenance of urine output of at least 50 mL/hr and urinary alkalinization are indicated ► Dextran is contraindicated because of its propensity to coat platelets and impair coagulation ► Persistent anuria, uremia, or hyperkalemia is an indication for consideration of hemodialysis ► Hematologic evaluation ABG CBC and platelet counts Electrolytes BUN/Cr Glucose AST/ALT LDH, CPK Cric and lactic acid Calcium levels PT/PTT/INR FDP : ► Acidosis is common, especially in patients with exertional heatstroke ► Lactate levels are usually elevated; this may persist or even worsen with improved extremity perfusion ► Cooling modalities that drastically lower skin temperature may induce violent shivering; this increases metabolic heat production and may impede cooling ► In this situation, chlorpromazine (25 mg IV) can be efficacious. Chlorpromazine has anticholinergic properties that can interfere with sweating and cause hypotension or, rarely, precipitate seizures ► Many patients are agitated during the initial cooling period. Short-acting benzodiazepines can be used for sedation and to control seizures ► Barbiturates are less desirable for treatment of seizures, since metabolism is altered by hepatic dysfunction ► Coagulopathies can occur during the first day of illness but are more common on the second and third days. Initial treatment should include replacement therapy with FFP and platelets ► The clinician should monitor the laboratory signs of DIC (hypofibrinogenemia, elevated fibrin split products, prolonged prothrombin time, and thrombocytopenia) ► The bleeding diathesis in patients with heatstroke may be the result of fibrinolysis. Although amino caproic acid can impede fibrinolysis, administration of this compound is associated with rhabdomyolysis and its use is not recommended in patients with heatstroke DDs ► When a history of collapse under conditions of heat stress is present, rapid improvement in mental status and blood pressure with cooling eliminates alternative diagnoses ► If the temperature does not respond and the patient does not recover neurologically, other causes of fever and coma must be considered Shaking chills suggest fever with an altered hypothalamic set point rather than heat illness (Meningitis and encephalitis) In patients with heatstroke, the spinal fluid should be crystal clear, with occasional lymphocytic pleocytosis and elevated protein levels Cerebral falciparum malaria, which presents a clinical picture of high fever and encephalitis, is seen in tropical areas In patients with thyroid storm, the clinical symptoms resemble those of heatstroke It should be suspected if the thyroid gland is enlarged or nodular, but a normal thyroid gland does not exclude the diagnosis Thyroid function test results are elevated, but these are not available on an emergency basis Thyroid storm is rare, and some critical aspects of treatment, such as rapid cooling, coincide with those for heatstroke Drug-induced heat illness is an important consideration, particularly anticholinergic poisoning Differentiation may be difficult because both heatstroke and anticholinergic poisoning produce hyperpyrexia, hot and dry skin, tachycardia, and abnormal mental status Constricted pupils are present in many heatstroke patients Mydriasis should be present in patients with anticholinergic poisoning, and its absence argues strongly against this diagnosis Typhoid fever, typhus, delirium tremens, and hypothalamic hemorrhage Malignant Hyperthermia ► Rare genetic disorder manifests after administration of anesthetic agents: succinylcholine and halothane ► Onset is usually in 1 hour of the administration of anesthesia, rarely delayed up to 10 hours ► ½ of cases are inherited in as AD; Rest are inherited in different patterns ► Early clinical findings in malignant hyperthermia include : muscle rigidity (especially masseter stiffness), sinus tachycardia, increased CO2 production, and skin cyanosis with mottling ► Marked hyperthermia (up to 45ºC [113ºF]) occurs minutes to hours later; core body temperature tends to rise 1ºC every 5 to 60 minutes Malignant Hyperthermia ► Hypotension, complex dysrhythmias, rhabdomyolysis, electrolyte abnormalities, DIC and mixed acidosis accompany the elevated temperatur ► Rarely, biochemically-proven malignant hyperthermia may present solely with rhabdomyolysis in the absence of hyperthermia Neuroleptic malignant syndrome ► Idiosyncratic reaction to antipsychotic agents ► IN addition to hyperthermia, NMS is also characterized by "lead pipe" muscle rigidity, altered mental status, choreoathetosis, tremors, and evidence of autonomic dysfunction, such as diaphoresis, labile blood pressure, and dysrhythmias Diagnostic Evaluation ► Get a rectal temperature; abnormal VS include sinus tachycardia, tachypnea, widened pulse pressure, hypotension ► CXR may demonstrate pulmonary edema ► ECG may reveal dysrhythmias, conduction disturbances, nonspecific ST-T wave changes, or heat-related myocardial ischemia or infarction ► Labs: CBC CCP, Coagulation Studies, creatine kinase, and check for hyperphosphatemia, myoglobinuria ► Myoglobinuria should be suspected in a patient who has a brown urine supernatant that is heme-positive, and clear plasma. ► Toxicologic screening may be indicated if a medication effect is suspected. ► Head CT and lumbar puncture if CNS etiologies suspected ► Diagnosis confirmed by in vitro muscle contracture test following recovery from the acute hyperthermic episode ► Abnormal augmentation of in vitro muscle contraction following treatment with halothane or caffeine is diagnostic of the disorder ► However, this test is expensive, not widely available, and frequently not covered by insurance ► Genetic testing for the more than 40 known mutations of the SKM ryanodine receptor (RyR1) can be used in conjunction with the in vitro muscle contracture test to evaluate individual susceptibility in patients from families with a history of malignant hyperthermia Malignant hyperthermia Management: ► Dantrolene administration is the mainstay of treatment of malignant hyperthermia, and should be initiated as soon as the possible ► With dantrolene administration, the mortality of the fulminant syndrome has fallen from %70 to less than %10 ► Dantrolene is a nonspecific SKM relaxant that acts by blocking the release of calcium from the SR decreases the myoplasmic concentration of free calcium and diminishes the myocyte hypermetabolism that causes clinical symptoms ►A 2 mg/kg IV bolus is given and should be repeated every 5 minutes until symptoms abate up to a maximum dose of 10 mg/kg ► This may be repeated every 10 to 15 hours. After an initial response, the drug should be continued orally at a dose of 4 to 8 mg/kg per day, in four divided doses, for three days