Difference between revisions of "Heat stroke"
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==Background== | ==Background== | ||
| − | * | + | *Severe end of heat-related illness spectrum characterized by severe hyperthermia and neurologic dysfunction |
| − | *Types | + | *True emergency - universally fatal if left untreated |
| − | + | **Mortality approaches 30% even with treatment<ref name="Gaudio">Gaudio FG, Grissom CK. Cooling Methods in Heat Stroke. J Emerg Med. 2015 Oct 31.</ref> | |
| − | + | *Hallmark is multisystem organ dysfunction from heat-induced damage resulting in systemic inflammatory response | |
| − | **Exertional | + | |
| − | + | ===Types=== | |
| + | *Classic (nonexertional) - insidious development over days | ||
| + | **Seen in children and elderly | ||
| + | **During the time of [[heat wave]] | ||
| + | *Exertional - rapid onset during exercise or other exertion | ||
| + | **Seen in otherwise young, healthy individuals | ||
==Clinical Features== | ==Clinical Features== | ||
| − | *Heat | + | *Symptoms<ref name="Becker">Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011 Jun 1;83(11):1325-30.</ref> |
| − | ** | + | **Elevated temperature >40°C (104°F) '''PLUS''' |
| − | **Confusion | + | **CNS neurologic abnormalities (e.g. inappropriate behavior, [[Confusion]], [[dysarthria|slurred speech]], [[Delirium]], [[Ataxia]], [[Coma]], [[Seizures]]) |
| − | |||
| − | |||
| − | |||
| − | |||
*Anhidrosis is frequently present; however, its absence does NOT rule out heat stroke | *Anhidrosis is frequently present; however, its absence does NOT rule out heat stroke | ||
| − | * | + | *May have massive [[rectal bleeding|hematochezia]] secondary to decreased intestinal perfusion and ischemia<ref>Lambert GP. Intestinal barrier dysfunction, endotoxemia, and gastrointestinal symptoms: the 'canary in the coal mine' during exercise-heat stress? Med Sport Sci. 2008;53:61-73.</ref> |
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| − | |||
{{Template:Heat Emergencies}} | {{Template:Heat Emergencies}} | ||
===Non-Environmental=== | ===Non-Environmental=== | ||
*Infectious | *Infectious | ||
| − | **[[Sepsis]] | + | **[[Sepsis (Main)|Sepsis]] |
**[[Meningitis]] | **[[Meningitis]] | ||
**[[Encephalitis]] | **[[Encephalitis]] | ||
| Line 31: | Line 31: | ||
**[[Tetanus]] | **[[Tetanus]] | ||
*Endocrine | *Endocrine | ||
| − | **[[Thyroid | + | **[[Thyroid storm]] |
**[[Pheochromocytoma]] | **[[Pheochromocytoma]] | ||
| − | **[[DKA]] | + | **[[Diabetic ketoacidosis|DKA]] |
*Neurologic | *Neurologic | ||
| − | **Hypothalamic bleeding or infarct | + | **Hypothalamic [[ICH|bleeding]] or [[stroke|infarct]] |
| − | **[[CVA]] | + | **[[Stroke (main)|CVA]] |
**[[Status epilepticus]] | **[[Status epilepticus]] | ||
*Toxicologic | *Toxicologic | ||
| − | **Anticholinergic toxidrome | + | **[[Anticholinergic toxicity|Anticholinergic toxidrome]] |
| − | **[[Sympathomimetic | + | **[[Sympathomimetic toxicity]] |
| − | **[[Salicylate | + | **[[Salicylate toxicity]] |
**[[Serotonin syndrome]] | **[[Serotonin syndrome]] | ||
**[[Malignant hyperthermia]] | **[[Malignant hyperthermia]] | ||
| − | **[[Neuroleptic | + | **[[Neuroleptic malignant syndrome]] |
| − | **Withdrawal (ETOH, | + | **Withdrawal (e.g. [[ETOH withdrawal|ETOH]], [[benzodiazepine withdrawal|benzodiazepines]]) |
{{AMS and fever DDX}} | {{AMS and fever DDX}} | ||
| − | == | + | ==Evaluation== |
| − | *Blood | + | ===Workup=== |
| + | *[[ECG]]<ref>Mimish L. Electrocardiographic findings in heat stroke and exhaustion: A study on Makkah pilgrims. J Saudi Heart Assoc. 2012 Jan; 24(1): 35–39.</ref> | ||
| + | **Most often sinus tachycardia, self-limited | ||
| + | **Less frequently ischemic changes including ST depressions, TWIs | ||
| + | *Core temperature (continuous monitoring is ideal, e.g. with bladder temperature monitor) | ||
| + | *Blood glucose | ||
*CBC | *CBC | ||
| − | * | + | *Metabolic panel |
| − | * | + | *[[LFTs]] |
| − | * | + | *Blood gas |
| − | * | + | *[[Lactate]] |
| − | * | + | *Coagulation studies ([[DIC (Disseminated Intravascular Coagulation)|DIC]]) |
| − | * | + | *Creatine phosphokinase and myoglobin ([[Rhabdomyolysis]]) |
| − | + | *[[Urinalysis]] | |
| − | *[[ | + | *[[CXR]] |
| − | *CXR | + | *[[CT brain]] (± [[LP]]), if indicated (Cerebral Edema) |
| − | * | ||
| − | == | + | ===Evaluation=== |
| − | + | *Clinical diagnosis | |
| − | * | + | *Exposure to hot environment and high index of suspicion. |
| − | * | ||
| − | == | + | ==Management== |
| − | * | + | *Address ABCs |
| − | * | + | *Rapid cooling (see below) - mainstay of treatment |
| − | * | + | **Reduces morbidity/mortality, should be started in prehospital setting if no other life-threats exist<ref name="Becker" /> |
| − | * | + | *Remove from environment |
| − | + | *[[IVF]] (for renal protection and avoiding rhabdomyolysis) | |
| − | + | **Bolus if hypotensive | |
| − | * | + | **Infusion titrated to UOP (goal 2-3ml/kg/hr) |
| − | ** | + | |
| − | *** | + | ===Rapid Cooling=== |
| − | *** | + | *Cooling end point should be ~39°C (102.2°F) - no good data for this goal<ref name="Gaudio" /> |
| − | ** | + | *No role for: antipyretics or dantrolene |
| − | *** | + | *Combination of methods, or adjuncts such as cool IVF may increase efficacy of individual methods |
| − | ** | + | ====Techniques==== |
| − | ** | + | *Cool water immersion - treatment of choice<ref name="Becker" /><ref name="Pryor" /> |
| − | *** | + | **Immersion of body to level of torso or neck in cool or ice-water |
| − | ** | + | **Best for exertional heat stroke in young/healthy patients, but benefit shown in elderly patients as well |
| − | ** | + | **Diffuse application of ice or cold packs to entire body may provide similar benefit (but less data) |
| − | ** | + | ***Applying ice packs only to neck, axillae, groin provides only minimal cooling<ref name="Gaudio" /> |
| − | ** | + | **Benefits: most rapid decrease in temperature, some studies have shown 100% survival (esp when started within 30 minutes of collapse)<ref name="Gaudio" /><ref name="Becker" /><ref name="Pryor">Pryor RR, Roth RN, Suyama J, Hostler D. Exertional heat illness: emerging concepts and advances in prehospital care. Prehosp Disaster Med. 2015 Jun;30(3):297-305.</ref> |
| − | + | **Disadvantages: requires special equipment (may not be immediately available), poorly tolerated, unable to provide defibrillation or many other resuscitative measures | |
| + | *Evaporative/Convective Cooling | ||
| + | **Spray cool water (15°C / 59°F) on patient while directing fans at patient | ||
| + | **Benefits: Easier to apply in ED and while performing other interventions | ||
| + | **Disadvantages: Slower cooling (than immersion) with slightly higher morbidity/mortality | ||
| + | *Invasive Techniques (limited data <ref name="Gaudio" />) | ||
| + | **Bladder Lavage | ||
| + | **Gastric Lavage | ||
| + | **Thoracic Lavage with chest tubes | ||
| + | **Cardiopulmonary bypass/ECMO | ||
==Complications== | ==Complications== | ||
*[[Hypotension]] | *[[Hypotension]] | ||
| − | ** | + | **Usually responds to small fluid bolus (500cc) and body cooling |
| − | + | **If no response to fluids → consider [[vasopressors]] (dopamine or dobutamine) | |
| + | ***Avoid peripheral vasoconstriction (e.g. norepinephrine), which may redirect blood flow away from skin and diminish cooling | ||
*[[Electrolyte abnormalities]] | *[[Electrolyte abnormalities]] | ||
| − | **Variable: hypokalemia and hyper or hyponatremia may be seen | + | **Variable: [[hypokalemia]] and [[hypernatremia|hyper]] or [[hyponatremia]] may be seen |
| − | *Hematologic | + | *Hematologic - [[DIC]] or abnormal bleeding |
| − | + | *[[hepatic failure|Hepatic injury]] - almost always reversible | |
| − | *Renal failure | + | *[[Renal failure]] |
*[[ARDS]] | *[[ARDS]] | ||
| − | *[[Seizure]] | + | *[[Seizure]] - treat with [[Benzodiazepines]] |
| − | ** | + | *[[focal neuro deficits|Neurologic deficit]] |
| + | **Persistent in 20%, associated with high mortality | ||
| + | |||
| + | ==Disposition== | ||
| + | *All patients require admission | ||
==See Also== | ==See Also== | ||
| − | *[[Heat | + | *[[Heat emergencies]] |
| − | *[[Heat | + | *[[Heat exhaustion]] |
| − | *[[Acute | + | *[[Acute fever]] |
==References== | ==References== | ||
| + | <references/> | ||
| − | [[Category: | + | [[Category:Environmental]] |
Latest revision as of 03:02, 2 March 2020
Contents
Background
- Severe end of heat-related illness spectrum characterized by severe hyperthermia and neurologic dysfunction
- True emergency - universally fatal if left untreated
- Mortality approaches 30% even with treatment[1]
- Hallmark is multisystem organ dysfunction from heat-induced damage resulting in systemic inflammatory response
Types
- Classic (nonexertional) - insidious development over days
- Seen in children and elderly
- During the time of heat wave
- Exertional - rapid onset during exercise or other exertion
- Seen in otherwise young, healthy individuals
Clinical Features
- Symptoms[2]
- Anhidrosis is frequently present; however, its absence does NOT rule out heat stroke
- May have massive hematochezia secondary to decreased intestinal perfusion and ischemia[3]
Differential Diagnosis
Environmental heat diagnoses
Non-Environmental
- Infectious
- Endocrine
- Neurologic
- Hypothalamic bleeding or infarct
- CVA
- Status epilepticus
- Toxicologic
Altered mental status and fever
- Infectious
- Sepsis
- Meningitis
- Encephalitis
- Cerebral malaria
- Brain abscess
- Other
Evaluation
Workup
- ECG[4]
- Most often sinus tachycardia, self-limited
- Less frequently ischemic changes including ST depressions, TWIs
- Core temperature (continuous monitoring is ideal, e.g. with bladder temperature monitor)
- Blood glucose
- CBC
- Metabolic panel
- LFTs
- Blood gas
- Lactate
- Coagulation studies (DIC)
- Creatine phosphokinase and myoglobin (Rhabdomyolysis)
- Urinalysis
- CXR
- CT brain (± LP), if indicated (Cerebral Edema)
Evaluation
- Clinical diagnosis
- Exposure to hot environment and high index of suspicion.
Management
- Address ABCs
- Rapid cooling (see below) - mainstay of treatment
- Reduces morbidity/mortality, should be started in prehospital setting if no other life-threats exist[2]
- Remove from environment
- IVF (for renal protection and avoiding rhabdomyolysis)
- Bolus if hypotensive
- Infusion titrated to UOP (goal 2-3ml/kg/hr)
Rapid Cooling
- Cooling end point should be ~39°C (102.2°F) - no good data for this goal[1]
- No role for: antipyretics or dantrolene
- Combination of methods, or adjuncts such as cool IVF may increase efficacy of individual methods
Techniques
- Cool water immersion - treatment of choice[2][5]
- Immersion of body to level of torso or neck in cool or ice-water
- Best for exertional heat stroke in young/healthy patients, but benefit shown in elderly patients as well
- Diffuse application of ice or cold packs to entire body may provide similar benefit (but less data)
- Applying ice packs only to neck, axillae, groin provides only minimal cooling[1]
- Benefits: most rapid decrease in temperature, some studies have shown 100% survival (esp when started within 30 minutes of collapse)[1][2][5]
- Disadvantages: requires special equipment (may not be immediately available), poorly tolerated, unable to provide defibrillation or many other resuscitative measures
- Evaporative/Convective Cooling
- Spray cool water (15°C / 59°F) on patient while directing fans at patient
- Benefits: Easier to apply in ED and while performing other interventions
- Disadvantages: Slower cooling (than immersion) with slightly higher morbidity/mortality
- Invasive Techniques (limited data [1])
- Bladder Lavage
- Gastric Lavage
- Thoracic Lavage with chest tubes
- Cardiopulmonary bypass/ECMO
Complications
- Hypotension
- Usually responds to small fluid bolus (500cc) and body cooling
- If no response to fluids → consider vasopressors (dopamine or dobutamine)
- Avoid peripheral vasoconstriction (e.g. norepinephrine), which may redirect blood flow away from skin and diminish cooling
- Electrolyte abnormalities
- Variable: hypokalemia and hyper or hyponatremia may be seen
- Hematologic - DIC or abnormal bleeding
- Hepatic injury - almost always reversible
- Renal failure
- ARDS
- Seizure - treat with Benzodiazepines
- Neurologic deficit
- Persistent in 20%, associated with high mortality
Disposition
- All patients require admission
See Also
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Gaudio FG, Grissom CK. Cooling Methods in Heat Stroke. J Emerg Med. 2015 Oct 31.
- ↑ 2.0 2.1 2.2 2.3 Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011 Jun 1;83(11):1325-30.
- ↑ Lambert GP. Intestinal barrier dysfunction, endotoxemia, and gastrointestinal symptoms: the 'canary in the coal mine' during exercise-heat stress? Med Sport Sci. 2008;53:61-73.
- ↑ Mimish L. Electrocardiographic findings in heat stroke and exhaustion: A study on Makkah pilgrims. J Saudi Heart Assoc. 2012 Jan; 24(1): 35–39.
- ↑ 5.0 5.1 Pryor RR, Roth RN, Suyama J, Hostler D. Exertional heat illness: emerging concepts and advances in prehospital care. Prehosp Disaster Med. 2015 Jun;30(3):297-305.