Hyperthermia and Hypothermia

Back to Basics April 2011 Dr. J. Clow, ER

Case 1:

22 y.o. female Out with friends celebrating her birthday (February 19th) Dropped off at her front door by friends Found by her parents in the morning, passed out just inside the screen door Unable to wake her call 911

Case 2:

85 y.o. male Mid-August, during heat wave Son goes to apartment and finds patient confused and lethargic Patient unable to give history

Heat Regulation

Four mechanisms of heat loss/dissipation:

Radiation Convection Conduction Evaporation

Radiation

Physical transfer of heat between the body and the environment by electromagnetic waves 65% of heat transfer under normal circumstances Modified by insulation (clothing, fat layer), cutaneous blood flow

Convection

Energy transfer between the body and a gas or liquid Affected by temperature gradient, motion at the interface, and liquid Not usually a major source for heat loss or dissipation, but this increases with wind and body motion

Conduction

Direct transfer of heat energy between two surfaces Responsible for only a small proportion of heat loss under normal circumstances Increases significantly with immersion in cold water Major cause of accidental hypothermia

Evaporation

Most important source of cooling under extreme heat stress; important for hypothermia when in wet environment 25% of heat loss in temperate/cool conditions may be increased significantly by sweating, increased respiratory rate Affected by relative humidity and clothing

Hypothermia

Definition

Core body temperature less than 35oC

Mild: 32.2 - 35oC Moderate: 28 - 32.2oC Severe: < 28oC

Causes

Decreased heat production

Endocrine, insufficient fuel, neuromuscular inactivity

Accidental/immersion hypothermia, vasodilatation, skin disorders, iatrogenic Central (metabolic, drugs, CNS) Peripheral (spinal cord injury, neuropathy, diabetes, neuromuscular disorders)

Increased heat loss

Impaired thermoregulation

Predisposing Factors
Risk Factors for Hypothermia
Age extremes Elderly Neonates Outdoor exposure Occupational Sports-related Inadequate clothing Drugs and intoxicants Ethanol Phenothiazines Barbiturates Anesthetics Neuromuscular blockers Others Endocrine-related Hypoglycemia Hypothyroidism Adrenal insufficiency Hypopituitarism Neurologic-related Stroke Hypothalamic disorders Parkinson's disease Spinal cord injury Multisystem Malnutrition Sepsis Shock Hepatic or renal failure Burns and exfoliative dermatologic disorders Immobility or debilitation

Signs and Symptoms

Clinical Manifestations of Hypothermia
System CNS Mild Hypothermia Confusion, slurred speech, impaired judgment, amnesia Moderate Hypothermia Lethargy, hallucinations, loss of pupillary reflex, EEG abnormalities Severe Hypothermia Loss of cerebrovascular regulation, decline in EEG activity, coma, loss of ocular reflex Decline in BP and cardiac output, ventricular fibrillation (< 28C) & asystole (< 20C)

CVS

Tachycardia, increased cardiac output and systemic vascular resistance

Progressive bradycardia (unresponsive to atropine), decreased cardiac output and BP, atrial and ventricular arrhythmias, J (Osborn) wave on ECG Hypoventilation (decreased rate and tidal volume), decreased oxygen consumption and CO2 production, loss of cough reflex

Respiratory

Tachypnea, bronchorrhea

Pulmonary edema, apnea

Signs and Symptoms, contd

TABLE 110-2. Clinical Manifestations of Hypothermia, contd
System Renal Mild Hypothermia Cold diuresis Moderate hypothermia Cold diuresis Severe Hypothermia Decreased renal perfusion and GFR, oliguria

Hematologic

Increased hematocrit, decreased platelet & white blood cell counts, coagulopathy, DIC Ileus, pancreatitis, gastric stress ulcers, hepatic dysfunction Increased metabolic rate, hyperglycemia Increased shivering Decreased metabolic rate, hyper- or hypoglycemia Decreased shivering (< 32C, 90F), muscle rigidity Patient appears dead, "pseudo-rigor mortis"

GI

Metabolic Musculoskeletal

History

Often from bystanders/medics Circumstances surrounding exposure

Where, submersion, ambient temperature? Length of exposure

Mental status changes Any predisposing illness acute/chronic? Alcohol/drugs?

Physical Exam

Vitals Temperature want a core temperature

Where do we take it?

Signs of other injuries? Can you find the cause of hypothermia? Any focal findings?

Esp. neurologic, cardiovascular, respiratory

Diagnositics

ECG (always), CXR (most patients) Other tests depend on the clinical scenario

Any signs of trauma? May need imaging Are you able to take a history? Past medical history?

Labs for all:

CBC, electrolytes, glucose, renal function, toxicology, coags, ABGs, LFTs, lipase/amylase, cultures

ECG Changes

May see J waves

late, terminal upright deflection of QRS complex; best seen in leads V3-V6 Heart block Atrial fibrillation Ventricular fibrillation

Multiple arrhythmias

ECG Changes, contd

Management

Interventions

Airway: need for intubation? Breathing: spontaneous respiration?

Warmed humidified oxygen either through an ETT, or via mask Large IVs warmed IV fluids Arrhythmias when do we treat? CPR?

Circulation: pulse? BP?

Interventions, contd

Disability

GCS Glucoscan, narcan, thiamine C-spine immobilization prn Undress, assess for trauma Re-cover quickly

Exposure

Rewarming
Rewarming Techniques

Passive rewarming: Removal from cold environment Insulation, Warm blankets (e.g. Bair hugger) Active external rewarming: Warm water immersion Heating blankets set at 40C Radiant heat Forced air Active core rewarming at 40C: Inhalation rewarming Heated IV fluids GI tract lavage Bladder lavage Peritoneal lavage Pleural lavage Extracorporeal rewarming

Active Rewarming

When?

Cardiovascular instability Temp less than 32oC Concominant illnesses Extremes of age Failure of passive rewarming

Active external or internal?

Rewarming - Extracorporeal
Options for Extracorporeal Rewarming
Extracorporeal Rewarming (ECR) Technique Venovenous (VV) Considerations Circuit CV catheter to CV or peripheral catheter No oxygenator/circulatory support Flow rates 150-400 mL/min ROR 2-3C/h Circuit single-or dual-vessel cannulation Stabilizes electrolyte or toxicologic abnormalities Exchange cycle volumes 200-500 mL/min ROR 2-3C/h Circuit percutaneous 8.5 Fr femoral catheters Requires BP 60 mmHg systolic No perfusionist/pump/anticoagulation Flow rates 225-375 mL/min ROR 3-4C/h

Hemodialysis (HD)

Continuous arteriovenous rewarming (CAVR)

Cardiopulmonary bypass (CPB)

Circuit full circulatory support with pump and oxygenator Perfusate-temperature gradient (5-10C) Flow rates 2-7 L/min (ave. 3-4) ROR up to 9.5C/h

Note: BP, blood pressure; CV, central venous; ROR, rate of rewarming.

Hyperthermia

Definition

Core body temperature > 38oC Caused by a failure of thermoregulation

Contrast with fever cause is cytokine activn Heat cramps Heat exhaustion Heat stroke

Spectrum of heat-related illnesses

Spectrum

Heat cramps

Cramps in big muscles spasms Normal temperature, mentation Caused by dilutional hyponatremia (hypotonic fluid replacement)

Spectrum, contd

Heat exhaustion

Weakness, dizziness, headache, syncope Nausea, vomiting Temperature 39-41.1oC Normal mentation Profuse sweating

Spectrum, contd

Heat Stroke

Temperature >41.1oC Coma, seizures, confusion No sweating Classic triad: hyperpyrexia, CNS dysfunction, anhidrosis Mortality of 10-20% with treatment Classic vs. Exertional

Spectrum, contd

Heat Stroke:

Classic (non-exertional):
Persistent environmental exposure Impaired thermoregulation

Exertional:

Heavy exercise in setting of high temperature and humidity

Causes of Hyperthermia

Increased heat load

Heat absorption from environment

Heat stroke (exertional, classic)

Metabolic heat
Obesity, anhidrosis, drugs

Diminished heat dissipation

Sepsis

Predisposing Factors
Predisposing Factors for Heat Stroke
Increased Heat Production Environmental heat stress Exertion Fever Hypothalamic dysfunction Drugs (sympathomimetics) Hyperthyroidism Decreased Heat Loss Environmental heat stress Cardiac disease Peripheral vascular disease Dehydration Anticholinergic drugs Obesity Skin disease Ethanol Blockers

Causes of Hyperthermia
Causes of Hyperthermia Syndromes
HEAT STROKE Exertional: Exercise in higher-than-normal heat and/or humidity Nonexertional: Anticholinergics, including antihistamines; antiparkinsonian drugs; diuretics; phenothiazines DRUG-INDUCED HYPERTHERMIA Amphetamines, cocaine, phencyclidine (PCP), methylenedioxymethamphetamine (MDMA; "ecstasy"), lysergic acid diethylamide (LSD), salicylates, lithium, anticholinergics, sympathomimetics NEUROLEPTIC MALIGNANT SYNDROME Phenothiazines; butyrophenones, including haloperidol and bromperidol; fluoxetine; loxapine; tricyclic dibenzodiazepines; metoclopramide; domperidone; thiothixene; molindone; withdrawal of dopaminergic agents SEROTONIN SYNDROME Selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants MALIGNANT HYPERTHERMIA Inhalational anesthetics, succinylcholine

ENDOCRINOPATHY Thyrotoxicosis, pheochromocytoma

CENTRAL NERVOUS SYSTEM DAMAGE Cerebral hemorrhage, status epilepticus, hypothalamic injury

Differential Diagnosis
Differential Diagnosis of Heatstroke
Drug toxicity: anticholinergic toxicity, stimulant toxicity (phencyclidine, cocaine, amphetamines, ephedrine), salicylate toxicity Drug withdrawal syndrome: ethanol withdrawal Serotonin syndrome Neuroleptic malignant syndrome Generalized infections: bacterial sepsis, malaria, typhoid fever, tetanus Central nervous system infections: meningitis, encephalitis, brain abscess Endocrine derangements: diabetic ketoacidosis, thyroid storm Neurologic: status epilepticus, cerebral hemorrhage

History

Circumstances (as per hypothermia) Exertion? Fluids? Past medical history any acute or chronic illnesses that may worsen situation Medications/Drugs Trauma?

Physical Examination

Temperature

Where do we take it? And how?

Vitals! Look for complications or other causes of the patients symptoms

Respiratory, cardiac, neurologic examination Signs of bleeding

Diagnostics

ECG (all), CXR (most) Imaging guided by history CBC, electrolytes, renal function, LFTs, Ca, Mg, PO4, coags, CK Urine myoglobin Pan-cultures

Poor prognostic factors

Temperature > 41.1oC AST > 1000 Coma Rhabdomyolysis Renal Failure Hypotension

Treatment

ABCs!!! Remove to cool environment! Active cooling Correct fluid and electrolyte imbalances Supportive care

Treatment
Comparison of Cooling Techniques
Technique Evaporative (i.e. wet the patients gown, sheets then use fan) Immersion (in cold/ice water) Advantages Simple, Readily available Noninvasive Easy patient access Relatively effective Noninvasive Relatively effective Disadvantages Shivering Difficult to maintain monitoring electrodes in position

Shivering, Cumbersome Poorly tolerated Logistically difficult to access Difficult to maintain monitoring Shivering Poorly tolerated Shivering Poorly tolerated Medium efficiency Invasive Labor intensive Potential for water intoxication May require airway protection Limited human experience Invasive Limited human experience

Ice packing (cover w/ ice) Strategic ice packs

Noninvasive Readily available Noninvasive Readily available Combined with other techniques Generally available

Cold gastric lavage

Cold peritoneal lavage

Theoretically beneficial

Complications of Heat Stroke

Complications of Heatstroke
Immediate Vital signs Hypotension Hypothermia overshoot Hyperthermic rebound Shivering Rhabdomyolysis Delirium Seizures Coma Heart failure Pulmonary edema Oliguria Diarrhea Hypokalemia Hypernatremia Acute respiratory distress syndrome Renal failure Hepatic necrosis Mucosal gastrointestinal hemorrhage Hyperkalemia Hypocalcemia Hyperuricemia Thrombocytopenia Disseminated intravascular coagulation Cerebral edema Delayed

Muscular Neurologic

Cardiac Pulmonary Renal Gastrointestinal Metabolic

Hematologic

Back to the cases

Case 1: Hypothermia

What do you want to know? Physical Exam? Labs? Any imaging? How are you going to treat her?

Case 2: Hyperthermia

What do you want to know? Physical Exam? Labs? Any imaging? How are you going to treat him?