nypotherm|a,

nypertherm|a and
khabdomyo|y|s
Ian|ce L. 2|mmerman, M.D.
We||| Corne|| Med|ca| Co||ege
1he Method|st nosp|ta|
nouston, 1exas
D|sc|osure
I have no con|ct of |nterest |n
re|anon to th|s presentanon.
Cb[ecnves
Cut||ne rewarm|ng techn|ques for
management of hypotherm|a
Descr|be pred|spos|ng factors, c||n|ca|
man|festanons and management of heat
stroke
D|scuss management of ma||gnant hyper-
therm|a and neuro|epnc ma||gnant syndrome
Descr|be eno|og|es and management of
rhabdomyo|ys|s
1emperature kegu|anon
Temperature-sensitive receptors
Skin Viscera
Great vessels
Anterior hypothalamus
! Sweanng
Vasod||anon
" Musc|e tone
Sh|ver|ng
Vasoconstr|cnon
! Musc|e tone
H
e
a
t

C
o
l
d

Lp|dem|o|ogy of nypotherm|a
Average of 689 deaths]yr |n U.S.
S0 of deaths >6S years o|d
Men >women
Aected |nd|v|dua|s
Urban desntute
W||derness]sports enthus|asts
Cccurs year round, any c||mate
nypotherm|a
Core temperature <3SC (9SI)
C|ass|hcanon
M||d 32-3SC (90-9SI)
Moderate 28-32C (82-90I)
Severe <28C (<82I)
1rauma c|ass|hcanon
Moderate 32-34C (90-93I)
Severe <32C (<90I)
red|spos|ng Iactors
Increased heat |oss
Lnv|ronmenta| exposure
Induced vasod||anon (drugs)
Decreased heat producnon
Lndocr|ne d|sorders
Insumc|ent fue| (hypog|ycem|a)
Impa|red thermoregu|anon
Centra| and per|phera| dysfuncnon
1. Wh|ch one of the fo||ow|ng |s ||ke|y to be
present |n a panent w|th severe
hypotherm|a (core temperature <28C)?

A. nyperg|ycem|a
8. Vo|ume over|oad
C. Low hematocr|t
D. Sh|ver|ng
L. Increased nda| vo|ume

Man|festanons of nypotherm|a
8radycard|a
nypotens|on
! System|c vascu|ar res|stance
Conducnon abnorma||nes
Atr|a| hbr|||anon
Ventr|cu|ar arrhythm|as
Asysto|e
LCG |n nypotherm|a
Man|festanons of nypotherm|a
Sh|ver|ng absent |f <30-32C
" kesp|ratory rate and nda| vo|ume

D|ures|s
Confus|on, |ethargy
I|eus
nepanc dysfuncnon
8|eed|ng
Laboratory I|nd|ngs
! nematocr|t
" |ate|ets
Norma| 1]11 |n|na||y
! 8UN, creann|ne
Var|ab|e e|ectro|ytes
nyperg|ycem|a
Ac|dem|a
No need to correct
A8G for temperature
Management of nypotherm|a
A|rway
Crotrachea| route preferred
Mon|tor L11 cu pressure
Supp|ementa| C
2

Ck
u|se|ess (check for 30-4S sec)
Nonperfus|ng rhythm
Arrhythm|as |n nypotherm|a
8radycard|a, atr|a| arrhythm|as
kewarm|ng
Ventr|cu|ar hbr|||anon
Dehbr|||anon
kewarm|ng
Avo|d drugs |f <30 C
Asysto|e, LA
Avo|d drugs |f <30 C
Management of nypotherm|a
kewarm|ng
1emperature mon|tor|ng
IV u|ds (avo|d k|nger's |actate)
Gastr|c decompress|on
Ur|nary catheter
Laboratory stud|es (no hngersncks)
1reat assoc|ated cond|nons
2. Which one of the following techniques
is the best intervention for a patient with
core temperature 30 C (86F) with pulse
50/min and BP 80/56 mm Hg?

A. Forced air warming blanket
B. Gastric lavage with heated saline
C. Peritoneal lavage
D. Cardiopulmonary bypass
E. ECMO
ass|ve Lxterna| kewarm|ng
Least |nvas|ve
Warm env|ronment
Insu|anon
anent must generate heat
So|e method on|y |n m||d
hypotherm|a
kewarm|ng rate 0.S-2C]h
www.reveresurv|va|.com
Acnve Lxterna| kewarm|ng
Lxterna| app||canon of heat
8|ankets, |amps
Immers|on
Iorced a|r
kes|snve po|ymer b|ankets
Ava||ab|e, non|nvas|ve
kewarm|ng rate 1.S-2.SC]h
Acnve Core kewarm|ng
neated, hum|d|hed C
2
(40-4S
#
C)
neated IV u|ds (40-42
#
C, short
tub|ng)
Gastr|c, b|adder, recta| |avage
er|tonea| |avage
|eura| |avage
Lndovascu|ar warm|ng
Acnve Core kewarm|ng
Lxtracorporea| techn|ques
nemod|a|ys|s
Connnuous d|a|ys|s techn|ques
Card|opu|monary bypass
LCMC
Cutcome from nypotherm|a
No re||ab|e pred|ctors of death
oor prognos|s
k
+
>10 mmo|]L
Shock, vasoacnve drug use
Connnue eorts unn| 32C (90I)
Ind|v|dua||ze term|nanon of eorts
er|operanve nypotherm|a
1emperature <3S or 36C
er|operanve comp||canons
!Morta||ty
!Infecnons
8|eed|ng
Intraoperanve]ICU measures
kewarm|ng dev|ces
Warm IV u|ds (41C)
nypertherm|a
nypertherm|a Syndromes
neat stroke
2003: 14,800 deaths |n <10
days |n Irance
Ma||gnant hypertherm|a
Neuro|epnc ma||gnant
syndrome
neat Stroke Syndromes
C|ass|c heat stroke
L|der|y w|th chron|c |||ness
Deve|ops over days
S|gn|hcant dehydranon
Lxernona| heat stroke
Ath|etes, m|||tary recru|ts
M||d dehydranon
red|spos|ng Iactors
Increased heat producnon
Lxerc|se
Drugs (sympathom|menc agents)
Lnv|ronmenta| heat
Decreased heat |oss
Lnv|ronmenta| heat, hum|d|ty
Card|ovascu|ar d|sease
Drugs (anncho||nerg|c agents)
neat Index
80 85 90 95 100 105 110
30 78 84 90 96 104 113 123
40 79 86 93 101 110 123 137
50 81 88 96 107 120 135 150
60 82 90 100 114 132 149
70 85 93 106 124 144
80 86 97 113 136
90 88 102 122
100 91 108
R
e
l
a
t
i
v
e

h
u
m
i
d
i
t
y

(
%
)

Air temperature (F)
113
136
C||n|ca| Man|festanons
! 1emperature ($40C, 104I)
CNS dysfuncnon
Cerebe||ar dysfuncnon
Se|zures, coma
1achycard|a
nypotens|on
1achypnea
Laboratory Man|festanons
kesp|ratory
a|ka|os|s
Metabo||c ac|dos|s
!Lactate
khabdomyo|ys|s

kena| |nsumc|ency
Coagu|opathy
nepanc dysfuncnon
Var|ab|e e|ectro|ytes
Ieatures of neat Stroke
Ieature C|ass|c Lxernona|
nypotens|on 20-30 Not known
khabdomyo|ys|s M||d]moderate Severe
kena| fa||ure Uncommon Common
Lacnc ac|d M||d]moderate Severe
G|ucose Increased Low
DIC M||d]moderate Severe
!!"#$%&'(' *+ ,- './ 012- 0'1, 344567789:;
3. A 75 year old with HTN and CHF was found
unresponsive outside his home in August in
Houston. Vital signs after intubation and 1.5 L
normal saline: HR 120/min, BP 80/38 mm Hg, T
106.8F. Which one of the following interventions
is most appropriate to treat the hypotension?

A. 2 L normal saline bolus
B. Norepinephrine infusion
C. Norepinephrine + dobutamine infusion
D. Evaporative cooling
E. Gastric lavage with iced saline

Coo||ng Methods
Conducnve coo||ng
Immers|on |n co|d water
Ice packs
Sk|n massage to counteract
vasoconstr|cnon
Lvaporanve]convecnve coo||ng
Warm water m|st (1S-20C)
A|r ow from fans
Cther Methods of Coo||ng
er|tonea| or gastr|c |avage
Card|opu|monary bypass
Surface coo||ng dev|ces
Lndovascu|ar coo||ng
Co|d IV u|ds (4C)
Management of neat Stroke
Coo| unn| 38-38.8C (100.4-102I)
A|rway protecnon
Supp|ementa| C
2

Intravenous u|ds
Ur|nary catheter
Mon|tor w|th therm|stor
Cutcome of neat Stroke
Corre|ates w|th duranon, |ntens|ty
Increased morta||ty
C|der age
Under|y|ng cond|nons
nypotens|on
! Lactate (c|ass|c heat stroke)
kena| fa||ure
Coma
4. Which one of the following agents is
safe to administer to a patient requiring
emergency surgery who has a family
history of malignant hyperthermia?

A. Succinylcholine and nitrous oxide
B. Succinylcholine and halothane
C. Rocuronium and nitrous oxide
D. Rocuronium and enflurane
E. Rocuronium and halothane
Ma||gnant nypertherm|a
C||n|ca| syndrome
nypertherm|a
Musc|e contracnon
Card|ovascu|ar |nstab|||ty
Genenc defect |n Ca
++
transport |n
ske|eta| musc|e
1r|ggers - ha|othane, succ|ny|cho||ne
C||n|ca| Man|festanons
Musc|e r|g|d|ty
Masseter spasm
1achycard|a
Increased aCC
2

nypertens|on
Sk|n mou||ng
C||n|ca| Man|festanons
Increased temperature
Ac|dos|s
Arrhythm|as
nypotens|on
khabdomyo|ys|s
nyperka|em|a
Management of Mn
Stop oend|ng drug
Stop surgery |f poss|b|e
Dantro|ene (2.S mg]kg qS m|n, max 10 mg]kg)
Lvaporanve coo||ng
Ma|nta|n d|ures|s
Avo|d ca|c|um channe| b|ockers
Suppornve care
www.mhaus.org, 1-800-MH-HYPER, 1-315-464-7079 (outside U.S)
Neuro|epnc Ma||gnant
Syndrome (NMS)
nypertherm|a (39.9C, 103.8I)
Musc|e r|g|d|ty (>90)
A|tered menta| status (7S)
Autonom|c dysfuncnon
khabdomyo|ys|s
oss|b|e CNS dopam|ne dep|enon
Irequent tr|gger = ha|oper|do|
C||n|ca| Course
Cnset usua||y |n 1-3 days
Drug |n|nanon
Change |n dose
Duranon 1-3 weeks
Longer w|th depot forms
Death from asp|ranon, arrhythm|as
Management of NMS
Dantro|ene (for r|g|d|ty)
Dopam|ne agon|sts
8romocr|pnne
Amantad|ne
Levodopa]carb|dopa
Suppornve therapy
www.nmsis.org, 1-888-667-8367
khabdomyo|ys|s
Musc|e |n[ury + re|ease of ce|| contents
1raumanc and nontraumanc
nyperCkem|a
Less severe form, chron|c
athogenes|s
D|rect |n[ury to sarco|emma or
dep|enon of A1
Increase |n |ntrace||u|ar Ca
+
Causes of khabdomyo|ys|s
Metabo||c
abnorma||nes
"k, C
4
, Ca
nyperosmo|a||ty
1ox|ns, drugs
Stanns
Coca|ne, hero|n
ropofo|
Genenc defects
hys|ca| |n[ury
Lxernon (exerc|se,
se|zures)
1emperature extremes
Infecnons (n1N1)
Musc|e hypox|a
8ar|atr|c surgery
C||n|ca| Man|festanons
Mya|g|as, musc|e swe|||ng and pa|n
D|sco|ored ur|ne
! Musc|e enzymes
L|ectro|yte abnorma||nes
kap|d !creann|ne, |ow ILNa (<1)
Ur|ne (+) for b|ood but no red ce||s on
m|croscop|c exam|nanon
Management
I|u|d rep|acement (ur|ne output 2-3 m|]kg]h)
Norma| sa||ne
8|carbonate-conta|n|ng u|ds
Mann|to| use controvers|a|
Mon|tor e|ectro|ytes
1reat hypoca|cem|a #<.= |f symptomanc
kena| rep|acement therapy
Mon|tor for compartment syndromes
-Bosch X, et al. NEJM 2009;361:62
Summary
kecogn|ze and account for phys|o|og|ca| changes
|n hypo- and hypertherm|a
Choose rewarm|ng techn|ques based on c||n|ca|
character|sncs and ava||ab|e resources
Conducnve or evaporanve coo||ng |s the pr|mary
|ntervennon |n heat stroke
Dantro|ene |s used to decrease heat producnon |n
ma||gnant hypertherm|a and NMS
Increas|ng ur|ne output w|th IV u|ds |s the
ma|nstay of treanng rhabdomyo|ys|s
1hank you for your
auennon