Sympathomimetic Hyperpyrexia Bob Hoffman, MD

Reported temp 108 o F = 42.2 o C

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)

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question 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 o C with 95% humidity

Question 2 True or false: Ambient weather conditions impact and mortality from sympathomimetic overdose? A. True B. False

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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:

Human Cocaine Fatalities and Ambient Temperature Marzuk PM: JAMA 1998;279:

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 –Pulse180/min regular –Resp32/min –Temp42.2 o C (108 o F) –O2 Sat100% 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

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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 ↑ ↑ 3/3153/325 +Propranolol N 3/39.53/316 +Diazepam N 1/3221/327 +Chlorpromzine N 2/3270/3--- Guinn: J Toxicol Clin Toxicol 1980;16:499

Cocaine in Conscious Dogs Treatment BP,P Temp pH Seizures Deaths Cocaine ↑ ↑ ↑ ↓++ +Propranolol N ↑ ↓ +++ +Diazepam N NN-- +Chlorpromzine N N N + - +Pancuronium ↑ NN?- +Bicarbonate ↑ ↑ ↑ N + + +Cooling ↑ NN +- 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

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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 o C –With diazepam and chlorpromazine 35 minutes from 42.2 to 37.8 o C –With diazepam and chlorpromazine 18 minutes from 41.6 to 39.1 o C Average cooling rate: –0.104 o C/min or –9.66 min/ o C

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 –44.4 o C = 112 o F –38.8 o C = 102 o F –In 20 minutes –Rate 0.28 o C/min

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

Am J Emerg Med 1996;14: Ice water immersion (1-3 o C) –Rate = o C/min Forced air with wet towels –Rate = o C/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

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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 H 2 O 12 had a CVP < 0 cm H 2 O 10 had a CVP > 10 cm H 2 O 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

Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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