Mercury rising

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Case 1-April 2005

32 year old bank employee reported feeling unwell to his colleagues and took a nap in the afternoon. Did not wake up. Had traveled extensively on his bike in the morning. No co-morbidities. On admission GCS 5/15, HR 150/min, BP 90/60, Temp 106F, Skin dry. No rash, meningeal signs, localising signs.
Nov 2006 Kishore P. Critical Care Conference 2006

 Diagnosed as heat stroke Aggressive cooling measures, shifted to ICU. Progressive severe vasodilatory shock maximum inotropes within 4 hours Anuric-dialyzed DIC and bleeding product support Progressive severe shock and lactic acidosis-died on day 4
Nov 2006 Kishore P. Critical Care Conference 2006

It does not take long either to boil an egg or to cook neurons.

Hamilton D, Anaesthesia 32:271, 1976

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Kishore P. Critical Care Conference 2006

 Common medical catastrophe during the summer months Failure of thermoregulatory mechanism coupled with an exaggerated acute phase response Heat stroke demands urgent attention because
High mortality Can cause permanent neurological damage

The reason for this presentation

Nov 2006 Kishore P. Critical Care Conference 2006

How common is it?

Largely under diagnosed and under reported No reliable Indian data In this hospital, we see about 30-40 patients per year, of which 12-15 come to the ICU referral bias

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Kishore P. Critical Care Conference 2006

Heat Loss
Conduction Convection Radiation Evaporation Acclimatization
Nov 2006 Kishore P. Critical Care Conference 2006

Copyright 2002 - Tennessee Emergency Management Agency

Heat Injury Predisposition

3 Factors Influencing Heat Production 1. Increased Internal Heat Production.
Physical Activity Febrile illness Pharmacologic agents

2. Increased External Heat Gain

Exposure to high ambient temperature

3. Decreased Ability to Disperse Heat

Pharmacologic agents Humidity
Nov 2006 Kishore P. Critical Care Conference 2006

Heat Injury Predisposition

Elderly Sick in our hospital wards
Poor Infants Institutionalized
Nov 2006 Kishore P. Critical Care Conference 2006

Labourers Medications
Athletes, Military Explorers Non-Acclimated

No one is exempt!

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Kishore P. Critical Care Conference 2006

Spectrum of heat illnesses

Heat cramps

Heat syncope

Heat exhaustion

Heat stroke

Heat cramps
Cramps of most worked muscles After exertion Copious sweating during exertion Copious hypotonic fluid replacement during exertion Hyperventilation not present in cool environment Treat with NS or oral salt water
Nov 2006 Kishore P. Critical Care Conference 2006

Heat Syncope
Results from cumulative effect of peripheral vasodilatation, decreased vasomotor tone and relative volume depletion. Usually occurs in non acclimated pts in early stage of exposure. Dx includes excluding more serious causes of syncope Treatment includes rehydration, removal from heat, and rest
Nov 2006 Kishore P. Critical Care Conference 2006

Heat exhaustion
Vague malaise, fatigue, headache Sensorium normal-poor judgment, vertigo Core temperature < 104F Tachycardia, dehydration Rule out other disease states If in doubt, treat as heat stroke Treat - Rest, cool environment Hydration-IV and oral
Kishore P. Critical Care Conference 2006

Nov 2006

Heat stroke-clinical diagnosis

Core temperature > 105F or 40.6C Severe CNS dysfunction (coma, seizures, delirium) During periods of sustained high ambient temperatures Dry hot skin common but sweating may persist
Nov 2006 Kishore P. Critical Care Conference 2006

Heat Stroke-types
Classic
Summer Heat Waves No sweat in 84-100% of patients More insidious onset Elderly, poor, debilitated patients Rhabdomyolysis and ARF rare
Nov 2006 Kishore P. Critical Care Conference 2006

Heat Stroke-types
Exertional
50% sweat Young, healthy, labourers, athletes, military Rhabdomyolysis and ARF common Usually have predisposing factor

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Cellular level
Denaturation of all proteins Membrane proteins become non functional This process leads to MOSF Endothelial damage - cytokine storm sepsis like syndrome Gut mucosal barrier disruption translocation of GNB contributes to sepsis and MOSF
Nov 2006 Kishore P. Critical Care Conference 2006

Heat stroke-organ dysfunction CNS

CNS
drowsiness, coma delirium, Irritability, bizarre behavior, seizures, Cerebral edema with raised intracranial pressure.

Cerebellum
Highly sensitive to heat Ataxia common

Total breakdown of thermoregulation Any neurological disturbance can occur with heatstroke.
Nov 2006 Kishore P. Critical Care Conference 2006

Remember
In the setting of a heat illness, coma also may be caused by
electrolyte abnormalities, hypoglycemia, hepatic encephalopathy, uremic encephalopathy, acute structural abnormalities, such as intracerebral hemorrhage due to trauma or coagulation disorders.
Nov 2006 Kishore P. Critical Care Conference 2006

Heat stroke-organ dysfunction CVS

Shock states
Hyperdynamic: Low SVRI High CI Tachycardia Wide pulse presure Hypodynamic: High SVRI Low CI Low intravascular volume
Nov 2006 Kishore P. Critical Care Conference 2006

CVS
Cardiogenic pulmonary edema
Myocardial hypofunction Cooling related

Endothelial dysfunction profound capillary leak

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Hepatic
Liver injury SGOT, SGPT > 1000 IU/L Transaminases may not be elevated at presentation Jaundice Fulminant hepatic failure

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Hematological
Thrombocytopenia (aggregation) DIC aPTT, PT prolonged, low fibrinogen (protein denaturation)

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Pulmonary
Type I respiratory failure
ARDS Pulmonary edema

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Musculoskeletal
Rhabdomyolysis

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Renal
Acute renal failure
Volume depletion Decreased cardiac output Direct thermal tubular damage Sepsis syndrome Rhabdomyolysis

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 Heatstroke has been reported to affect almost every organ in the body except for the pancreas.

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Kishore P. Critical Care Conference 2006

Anyone with hyperpyrexia and altered mental state is considered heatstroke until proven otherwise.
Nov 2006 Kishore P. Critical Care Conference 2006

Heat stroke can also be a nosocomial disease!

Nov 2006

Presse Med. 2006 Feb;35(2 Pt 1):196-9 Kishore P. Critical Care Conference 2006

Differential diagnosis
Acute CNS infection Cerebral malaria Severe sepsis Neuroleptic malignant syndrome Malignant hyperthermia Thyroid storm

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Predictors of multi-organ dysfunction in heatstroke

G M Varghese, G John, K Thomas, O C Abraham, D Mathai

28 patients over 3 years Overall mortality 71%

85% in >2 organ failures

Elevated CPK (>1000), liver enzymes > twice normal and metabolic acidosis were predictors of mortality Emerg Med J 2005;22:185187
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The golden hour of heat stroke

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Am J Emerg Med. 1989 Nov;7(6):616-9 Kishore P. Critical Care Conference 2006

Treatment-Cooling methods

Nov 2006

Evaporative Immersion Strategic ice packs Ice cold IV fluids Ice packing Cooling blankets Gastric lavage Peritoneal lavage Cardiac bypass Endovascular cooling catheters
Kishore P. Critical Care Conference 2006

Ice immersion
Most effective method Large quantities of ice should be readily available in a large tub Cumbersome Difficult to resuscitate IV access difficult Vasoconstriction may limit heat exchange

Evaporative

Wet the body and clothes-spray

Precautions
Wet sheets over a patient, without good air flow, will tend to increase temperature and should be avoided Slow down cooling once core temperature is less than 101F

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Cold IV fluids
15 ml/kg of ice cold IV fluids reduces temp by 1-2C Patients need fluid resuscitation as they are usually dehydrated Cooling more effective in air conditioned environment

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Kishore P. Critical Care Conference 2006

Dangers while cooling

Pulmonary edema Overshoot hypothermia

Mil Med. 2003 Aug;168(8):671-3 Resuscitation. 1991 Feb;21(1):33-9

Investigations
CBC PT, aPTT CPK, LFT, creat. ABG, Chest X-Ray, ECG MP X 3 CSF

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Supportive treatment
Fluid resuscitation followed by inotrope and vasopressor therapy Ventilation for ARDS Platelet, FFP and cryoprecipitate support as indicated Dialysis for ARF Manage like sepsis

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Kishore P. Critical Care Conference 2006

Treatment of early complications

Shivering
Chlorpromazine 25-50mgIV only if cooling is not adequate because of shivering

Convulsions
Diazepam, Phenobarbitone, Mannitol to reduce edema

Myoglobinuria
Mannitol and crystalloids
Nov 2006 Kishore P. Critical Care Conference 2006

Late complications
Nosocomial sepsis CIPN, GBS like picture Cerebellar degeneration Bickerstaff brainstem encephalitis

Ann Fr Anesth Reanim. 2006 Jul;25(7):780-3. Epub 2006 May 3 J Neurol Neurosurg Psychiatry. 1999 Mar;66(3):408 Nov 2006 Kishore P. Critical Care Conference 2006

Experimental adjuncts
Activated proein C? MARS, liver transplant Ipsaspirone, ketanserin, L-arginine Human umbilical cord blood cells

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Kishore P. Critical Care Conference 2006

Heat Stroke No-Nos

Aspirin Paracetamol

Alcohol baths
Dantrolene

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Kishore P. Critical Care Conference 2006

Take home
Common and deadly Recognize early
Have a high index of suspicion, even in a hospitalised patient

Early aggressive cooling measures Rule out differentials Aggressive organ supportive therapy
Nov 2006 Kishore P. Critical Care Conference 2006

 Copyright Texas Parks & Wildlife Department

HEAT, HATE I hate to hate, but heat makes me hate. Therefore I hate heat, even though, I repeat, I hate to hate. Ramesh Gandhi