Sympathomimetic Hyperpyrexia

Bob Hoffman, MD

Reported temp 108oF = 42.2oC

Question 1

• Which of the following is the most common cause of death following severe hyperthermia– A. Cerebral edema– B. Myocardial dysfunction– C. Acute lung injury– D. Consumptive coagulopathy – Disseminated intravascular coagulation (DIC)

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Question SlideQuestion Slide

Question 1

• Which of the following is the most common cause of death following severe hyperthermia– A. Cerebral edema– B. Myocardial dysfunction– C. Acute lung injury– D. Consumptive coagulopathy – Disseminated intravascular coagulation (DIC)

Case Description

• A 28 year old man is brought in by police and paramedics after being found wildly agitated in an abandoned building commonly visited by drug users [crack house]

• It is summer in NYC; it has been hot for several days and the current temperature is 35.6 oC with 95% humidity

Question 2

• True or false: Ambient weather conditions impact and mortality from sympathomimetic overdose?

• A. True

• B. False

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Question 2

• True or false: Ambient weather conditions impact and mortality from sympathomimetic overdose?

• A. True

• B. False

Catravas J: J Pharmacol Exp Ther 1981;21:350-356.

Human Cocaine Fatalities and Ambient Temperature

Marzuk PM: JAMA 1998;279:1795-1800

Case (cont)

• The patient is:– Wildly agitated

– Covered in sweat

– Pupils 7-8 mm and reactive

– Disoriented, hallucinating, incoherent

Case (continued)

• Vital Signs:– BP 220/180 mm Hg

– Pulse 180/min regular

– Resp 32/min

– Temp 42.2 oC (108 oF)

– O2 Sat 100% on face mask

Question 3

• Which of the following abnormalities is MOST suggestive of a poor outcome in this patient?– A. Agitation and disorientation– B. Hypertension– C. Tachycardia– D. Hyperthermia

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Question 3

• Which of the following abnormalities is MOST suggestive of a poor outcome in this patient?– A. Agitation and disorientation– B. Hypertension– C. Tachycardia– D. Hyperthermia

Cocaine in Non-Human Primates

Treatment BP,P Sz MCD Deaths MLD

Cocaine ↑ ↑ 3/3 15 3/3 25

+Propranolol N 3/3 9.5 3/3 16

+Diazepam N 1/3 22 1/3 27

+Chlorpromzine N 2/3 27 0/3 ---

Guinn: J Toxicol Clin Toxicol 1980;16:499

Cocaine in Conscious DogsTreatment BP,P Temp pH Seizures Deaths

Cocaine ↑ ↑ ↑ ↓ + ++Propranolol N ↑ ↓ + +++Diazepam N N N - -+Chlorpromzine N N N + -

+Pancuronium ↑ N N ? -

+Bicarbonate ↑ ↑ ↑ N + +

+Cooling ↑ N N + -

Catravass J Pharm Exp Ther 1981

Question 4

• Which of the following methods would you use to cool the patient?– A. Ice packs to groin, axillae, neck, etc– B. Cooling blanket– C. Mist and fan– D. Cool water immersion– E. Ice water immersion

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Question 4

• Which of the following methods would you use to cool the patient?– A. Ice packs to groin, axillae, neck, etc– B. Cooling blanket– C. Mist and fan– D. Cool water immersion– E. Ice water immersion

Bad Things

• Pack the groin, neck and axillae in ice

• Add chlorpromazine or meperidine to prevent shivering

• Give salicylates, NSAIDs or acetaminophen

• Use a small fan

Bell 206L Longranger

3 Cases

• 50 minutes from 41.7 to 38.3 oC – With diazepam and chlorpromazine

• 35 minutes from 42.2 to 37.8 oC – With diazepam and chlorpromazine

• 18 minutes from 41.6 to 39.1 oC• Average cooling rate:

– 0.104 oC/min or– 9.66 min/oC

• Artificially induced hyperthermia

• Treatments:– Control– Water mattress– Water bath– Cold air spray– Warm air spray– 2 specialized

cooling units

• All patients sedated with a benzodiazepine

• Some paralyzed• Cooling rate

– 44.4oC = 112oF– 38.8oC = 102oF– In 20 minutes – Rate

• 0.28oC/min

• Compared with the other conditions, however, the rate of cooling (0.35 + 0.14°C/min) was significantly greater during the 2°C water immersion, in which shivering was seldom observed.

Am J Emerg Med 1996;14:355-358

• Ice water immersion (1-3oC)– Rate = 0.2 + 0.02 oC/min

• Forced air with wet towels– Rate = 0.11 + 0.2 oC/min

Question 4

• The intravascular volume status of this patient is?– A. Mild fluid overload– B. Euvolemic– C. Mild volume depletion– D. Moderate volume depletion– E. Severe volume depletion

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Question 4

• The intravascular volume status of this patient is?– A. Mild fluid overload– B. Euvolemic– C. Mild volume depletion– D. Moderate volume depletion– E. Severe volume depletion

Opportunity for Research!

Makkah Al-Mukkaramah Body Cooling Unit (MMBCU)

Volume Status

• There seems to be an assumption of hypovolemia

• You usually don’t need a Swan-Ganz to determine volume status– A study of 13 Mecca pilgrims demonstrated a

good correlation between PCWP by Swan-Ganz and CVP

• Al-Harthi et al: Ann Saudi Med 1989;9:378

Volume Status

• In 22/34 (64%) heat stroke patients CVP was > 3 cm H2O

• 12 had a CVP < 0 cm H2O

• 10 had a CVP > 10 cm H2O

• Only 3 patients required > 2L NS– Seraj et al: Resuscitation 1991;21:33

Question 5

• Which of the following drug classes would you use to sedate this patient– A. Benzodiazepine– B. Chlorpromazine– C. Meperidine– D. Haloperidol– E. Ziparasidone

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Question 5

• Which of the following drug classes would you use to sedate this patient– A. Benzodiazepine– B. Chlorpromazine– C. Meperidine– D. Haloperidol– E. Ziparasidone

Summary

• Sedate• Sometimes paralyze• Cool• Volume resuscitate• No role for paracetamol, salicylates,

dantrolene