Difference between revisions of "Heat stroke"

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==Clinical Features==
 
==Clinical Features==
*Heat exposure + elevated temperature >40C (>104F) + neurologic abnormalities:
+
*Symptoms<ref name="Becker">Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011 Jun 1;83(11):1325-30.</ref>
**Inappropriate behavior
+
**Elevated temperature >40°C (104°F) '''PLUS'''
**[[Confusion]]
+
**CNS neurologic abnormalities (e.g. Inappropriate behavior, [[Confusion]], [[Delirium]], [[Ataxia]], [[Coma]], [[Seizures]])
**[[Delirium]]
+
*Anhidrosis is frequently present; however, its absence does NOT rule out heat stroke
**[[Ataxia]]
 
**[[Coma]]
 
**[[Seizures]]
 
*Anhidrosis is frequently present; however, its absence does '''NOT''' rule out heat stroke
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Management==
 
==Management==
===General===
+
*Address ABCs
#Remove from environment
+
*Rapid cooling (see below) - mainstay of treatment
#Address airway, breathing and circulation
+
**Reduces morbidity, should be started in prehospital setting if no other life-threats exist<ref name="Becker" />
#IV normal saline
+
*Remove from environment
#*Bolus if hypotensive
+
*IVF (for renal protection and avoiding rhabdomyolysis)
#*Titrate to urine output, start at 250mL/hour
+
**Bolus if hypotensive
#*Avoid aggressive IV fluid resuscitation unless severely dehydrated
+
**Infusion titrated to UOP (goal 250mL/hour)
  
===Cooling===
+
===Rapid Cooling===
*Mainstay of treatment
 
 
*Goal is to reduce temp to 39C (102.2F) and then stop to avoid overshoot hypothermia
 
*Goal is to reduce temp to 39C (102.2F) and then stop to avoid overshoot hypothermia
 
*Antipyretics (ASA and acetaminophen) and dantrolene have no role  
 
*Antipyretics (ASA and acetaminophen) and dantrolene have no role  

Revision as of 03:30, 6 March 2016

Background

  • Severe end of heat-related illness spectrum
  • True emergency - universally fatal if left untreated

Types

  • Classic (nonexertional) - insidious development over days
    • Seen in children and elderly
  • Exertional - rapid onset during exercise or other exertion
    • Seen in otherwise young, healthy individuals

Clinical Features

  • Symptoms[1]
  • Anhidrosis is frequently present; however, its absence does NOT rule out heat stroke

Differential Diagnosis

Environmental heat diagnoses

Non-Environmental

Altered mental status and fever

Diagnosis

Workup

  • Blood glucose
  • CBC
  • Chemistry
  • Elevated LFTs sensitive for heat stroke
    • AST > 1000, poor prognosis
    • Especially in exertional heat stroke
  • Arterial blood gas or Venous blood gas
    • PaCO2 is often <20 2/2 hyperventilation
  • Lactate (often elevated in exertional heat stroke)
  • Coagulation studies
  • Creatine phosphokinase and myoglobin
  • Urine analysis
  • ECG
  • Chest x-ray
  • CT brain and/orLP as needed

Evaluation

  • Diagnosis is made by history and physical exam and exclusion of other diseases

Management

  • Address ABCs
  • Rapid cooling (see below) - mainstay of treatment
    • Reduces morbidity, should be started in prehospital setting if no other life-threats exist[1]
  • Remove from environment
  • IVF (for renal protection and avoiding rhabdomyolysis)
    • Bolus if hypotensive
    • Infusion titrated to UOP (goal 250mL/hour)

Rapid Cooling

  • Goal is to reduce temp to 39C (102.2F) and then stop to avoid overshoot hypothermia
  • Antipyretics (ASA and acetaminophen) and dantrolene have no role
  • Cooling blankets work too slowly to be employed as sole treatment
  • Ice packs to neck, axillae, groin are useful as adjunct only
  • Cold IVF is not effective
  • Techniques
    • Evaporative
      • Method of choice
      • Spray cool water (15C (59F)) on most of pt's body surface; turn on fan
      • Complications
        • Shivering (occurs when skin temp is <30C (86F): treat with short-acting benzodiazepines
        • Electrodes not sticking: place on pt's back instead
    • Ice-water immersion
      • Consider especially in young, healthy pts
      • Complications
        • Shivering
        • Inability to perform defibrillation or resuscitative procedures
    • Invasive
      • Consider if evaporative cooling or immersion is insufficient
      • Cardiopulmonary bypass
      • Cold water gastric, bladder or rectal lavage

Complications

  • Hypotension
    • BP will usually respond to small fluid bolus (500cc) and body cooling
      • If ineffective consider vasopressors (dopamine or dobutamine)
      • Avoid peripheral vasoconstriction (norepinephrine)
        • May redirect blood flow away from skin
  • 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
  • Neurologic deficit
    • Persistent in 20%, associated with high mortality

Disposition

  • All patients require admission

See Also

References

  1. 1.0 1.1 Becker JA, Stewart LK. Heat-related illness. Am Fam Physician. 2011 Jun 1;83(11):1325-30.