1. Sympathomimetic Hyperpyrexia Bob Hoffman, MD

2. Reported temp 108 o F = 42.2 o C

4. 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)

5. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

6. 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)

9. 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

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

11. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

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

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

14. Human Cocaine Fatalities and Ambient Temperature Marzuk PM: JAMA 1998;279:1795-1800

15. Case (cont) The patient is: –Wildly agitated –Covered in sweat –Pupils 7-8 mm and reactive –Disoriented, hallucinating, incoherent

16. 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

17. 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

18. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

19. 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

20. 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

21. 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

22. 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

23. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

24. 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

25. 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

27. Bell 206L Longranger

28. 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

30. Artificially induced hyperthermia Treatments: –Control –Water mattress –Water bath –Cold air spray –Warm air spray –2 specialized cooling units

32. 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

33. 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.

35. Am J Emerg Med 1996;14:355-358 Ice water immersion (1-3 o C) –Rate = 0.2 + 0.02 o C/min Forced air with wet towels –Rate = 0.11 + 0.2 o C/min

37. 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

38. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

39. 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

40. Opportunity for Research!

42. Makkah Al-Mukkaramah Body Cooling Unit (MMBCU)

43. 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

44. 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

45. 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

46. Precongress Symposium Interactive Recreational Drug Toxicity Cases Question Slide

47. 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

48. Summary Sedate Sometimes paralyze Cool Volume resuscitate No role for paracetamol, salicylates, dantrolene