Dr. hamdy Ebrahim

Dr.

hamdy Ebrahim

Case presentation

• Mr. josee Louis is a 24 years old male from spain admitted to our

ICU in Imbaba Fever Hospital transferred by airplane from Aswan

after exposure to hot environmental temperature ,

• presented with high fever associated with severe agitation and

hallucination with sudden onset and progressive course

• On Examination : The patient was examined after sedation

with diazepam and halloperidol he was confused, agitated and

hallucinating

• Temp. 40.6 C B.P 90/60 mmHg , pupils : R.R.R, Respiratory rate

28/m HR: 120/m , The neck was lax , Kernig and Bruidiziniski signs

was negative

Chest and Heart : Tachycardia and Tachypnea

• The patient is managed as a case of acute confusional state due to

heat hyperpyrexia after exculsion of CNS infection by CSF

examination which revealed : No pus cells , No bacteria detected

on gram stained film , CSF glucose 106 mg/dl , CSF protein : 23 ,

• the pt. regained conscious level , temperature dropped to normal

, became oriented and discharged in a good general condition and

travelled safely without medical supervision .

Discussion

• The first step in treating a heat emergency is to have the person

lie down in a cool place , the individuals feet should be elevated

above the level of the heart , Next cool wet clothing or water

should be applied directly to the person,s skin , placing cold

compresses on the person,s head ,groin ,and arms loose heat

quickly , a fan can be used to help lower body temperature .

• Ideally the individual,s temperature should be measured rectally

every 10 minutes , fluid intake is very important , IV fluids and

observation is required .

Heat illness

• Mild : Sweat rash ,heat syncope ,heat cramps ,heat tetany (intact

thermo regulatory mechanisms ).

• Moderate : Heat exhaustion (intact thermoregulatory

mechanisms ) .

• Severe : Heat stroke (failed thermo-regulatory mechanisms )

Factors precipitating for heat illness

• Increase in the atmospheric temperature and humidity , ( about

90% of heat stroke occurs when atmospheric temperature

increases more than 30 c) .

• Lack of acclimatization .

• Fatigue .

• Physical conditions :

• (a) Extremities of age . (b) Obesity

• (c ) Alcohol consumption . (d) C.V diseases

• (e ) Strenuous exercise (f) Diabetes mellitus

• (g) Anticholinergic drugs (h )Previous history

1- Mild

• A - Sweat rash :

• An erythematous rash occurs due to excessive sweating .

• It is burning and itchy in character

• Covers the body specially the flexure points

Sweat rash

Treatment

• Taking the patient to a cold place with application of

soothing lotions like calamine lotion

B- Heat syncope

• Occurs after standing for long time in hot weather .

• It is due to failure of compensatory cardio vascular

reflexes leading to sudden drop in B.p and brain

ischemia with falling of the person on the ground .

• Treatment : Take the patient to cold place .

C- Heat cramps

• Contraction of one muscle without relaxation of the

opposite one .

• Usually affects the calf muscles and occurs mostly

during exercise in hot weather , most probably due to

salt and water depletion .

Treatment

• Putting the patient in cool place and rest

• Replacement of salt and water depletion

• 1 litre of normal saline in 1-3 hours is usually enough or

oral water and salt .

2- Moderate :Heat Exhaustion

• Due to water and salt loss

• Occurs usually to persons working for long time in

humid weather with continuous sweating .

• Rapid coarse causing predominant water loss

• Gradual coarse causing predominant salt loss

Symptoms

• Headache

• Anorexia

• Giddiness

• Excessive thirst

• Nausea and vomiting

• Cramps may occur .

Signs • Profuse sweating

• Flushing

• Temperature is normal or between 38-39 c

• Excessive thirst

• Signs of dehydration (low B.P, tachydaria ,sunken eyes,

inelastic skin )

• Mental changes which denotes that the condition is

shifted to heat stroke

Lab. analysis

• Increase hematocrite value

• Increase sodium level (relative)

• Increase creatinine kinase level

• Decrease glucose level

Treatment

• Put the patient in dry cool place

• Replace the water and salt loss according to the degree of dehydration .

• Dextrose 5% in ½ normal saline is the usual fluids needed .

• The patient may need up to 4 litres over 6-8 hours .

• In elderly the replacement should be gradual .

3- Severe Heat stroke (Heat injury)

• It is a failure of thermo-regulatory mechanisms due to

hot weather leading to increase in body temperature to a

lethal level (more than 40.6c) causing a wide spread

cellular damage .

• It is one of the causes of hyperthermia .

• Infections rarely cause hyperthermia but may initiate the condition and the environmental factors complete the picture .

• At about 32.5c degree ,sweating starts to share in the mechanisms of heat loss .

• At 35 c sweating and evaporation of the sweat becomes the main mechanisms of heat loss .

To decrease body temperature

Sweating

↓

Healthy sweat glands

↓

Intact innervation

Evaporation

↓

Dry air

↓

Air current

Predisposing factors

1- Environmental factors :

• Exposure to hot humid weather with decreased air current .

• N.B. When humidity reaches 75% evaporation of the sweat nearly ceases

Acclimatization :

• Sudden exposure of non acclimatized person to hot humid asmophere for 48 hours or more can cause heat stroke .

• .

• Wearing heavy cloths in a hot atmosphere .

• Military personnels , athletes , young people doing exercise or hard work in hot humid weather is liable to develop exertional type of heat stroke .

• 2- Age : children and elderly is the most vulnerable group .

• 3- Obesity : Fat layer work as insulator for heat loss .

• 4- Chronic illness :

• A- Cardio vascular diseases

• B- Diabetes mellitus

• Hemi quadriplegia with autonomic dysfunction

• 5- Infection : may initiate the condition only and the environment completes .

• 6- Dehydration : Affects the rate of sweating and interferes with heat loss (dehydration fever )

• Drugs : Anti-cholinergic drugs ,major tranquilizers ,and neuroleptic drugs may lead to heat stroke .

Effects of hyperthermia on the body • The lethal effects occur when the body temperature

reaches 42c but some considered the degree of 41 c is a critical level

• Denaturation of proteins ,enzymes and hormones with liquefaction of lipids including the brain tissue occuring at 42c .

• Also oxidative phosphorylation ceased at this degree with loss of energy sources to different tissues including the heat regulating center . The effects depend on the duration of hyperthermia .

Effects on the brain

• The first cell to be affected is the brain cell leading to :

1. Mental changes ,stupor,coma .

2. Convulsions or decerebrate rigidity

3. Quadriplegia,hemiplegia,or monoplegia

4. Different brain infarctions

• Paralysis of centers like heat regulating center or respiratory center leading to death .

• Degeneration then necrosis to the liver cells may lead to liver cell failure .

• Destruction of the renal cells leading to renal failure .

• Destruction of the skeletal muscle cells leading to rhabdomyolysis especially in exertional type .

• Precepitation of calcium and phosphorus on the destructed muscle cells leads to hypocalcemia and hypophosphatemia .

• Sodium inters inside the cells and potassium goes outside the cells leading to hyponatremia and hyperkalemia .

• Injury to endothelial lining of the vessels causing DIC .

• Affect the conductive system of the heart may lead to different types of arrhythmias and heart failure .

Types of heat stroke

A- Classical type :

• Occurs mainly in the extremities of age .

• Infants and young children may have undeveloped heat regulating center and sweat glands , high metabolic rate and can not care themselves .

• Old people may have low cardiac reserve ,reduced CNS reflexes ,may use medications that may affect sweating and V,D. and can not care of themselves .

• Gradual onset (more than 48 hours )

• Dehydration is more due to prolonged sweating .

• At presentation the skin is commonly dry .

B- Exertional type :

• Occurs commonly in middle aged healthy persons .

• Occurs in non acclimatized persons during exercise or hard work in hot humid atmosphere .

• Rapid onset .

• Less dehydration

Clinical picture

• A- Symptoms

• Occurs prior to coma in the form of :

• Headache - unsteadiness

• Nusea and vomiting - Light headedness

• Piloerection specially over the arms and chest

• Parathesia -Change in behaviour

• Syncope and coma

Signs • Body temperature : must be taken rectally ,usually over 41 degree

,may be cold extremities due to peripheral circulatory failure .

• Heart rate : tachycardia with weak pulse in case of dehydration .or heart failure .,in absence of dehydration pulse may be full , irregular pulse in arrhythmia ,bradycardia in heart block .

• Blood pressure : may be low due to dehydration

• Respiratory rate :

• Deep rapid respiration usually due to high temperature ,irregular respiration (chyne stoke) in the terminal stage , bubbling crepitations and frothy sputum in pulmonary edema .

• Skin : Usually dry ,may be flushed and sweaty ,sweat rash is usually present .

• Coma : with dilated fixed pupils ,convulsions ,muscle rigidity ,tremors , transient hemiplegia may be present .

Signs

Diagnostic tests

• Blood gases : reveals commonly metabolic acidosis due to lactate accumulation especially exertional type .

• Respiratory alkalosis may be present due to hypercapnia .

• Blood picture : Leucocytosis is common

• ALT,AST,LDH are markedly elevated

• The level of AST is prognostic (the level of 1000 u or more in the first 24 hours reflects a poor prognosis with serious brain ,liver ,and renal damage and the reverse .

• CK ( Creatine kinase) markedly elevated especially in exertional type

• Myoglobinuria and hyperuricemia

• Hypoglycemia especially in exertional type

• Electrolytes :

• Na ,K Ca , ph.

• ECG : ST segment and T wave abnormalities

Management

• Heat stroke is one of the medical emergencies that needs rapid interference

• The seconds are precious for the patient ,so our aim is to decrease the body temperature below the harmful level as quickly as possible to avoid irreversible cellular damage ,

• With rapid interference the mortality rate decreased from 80% to 10%

• The rapidity of interference is more valuable than the method used for cooling

The heat stroke center

Cooling room

• Enough number of air conditions insure a temperature room 25-30c

• Slated beds without matresses and opposite to each bed one fan must be fixed to wall to supply a horizontal current of air

• A number of suction fans in the upper part of the wall for renewal of air

• A source of tape water and ice must be in the cooling room

• A ll equipements ,instruments and emergency drugs needed for comatosed patient must be supplied .

Observation room

• Is a neighboring conditioned room containing normal beds for observation for 24 hours after cooling .

Technique of management

• Once the patient arrives ,his cloths must be removed quickly and then put on the special bed in the cooling room .

• Get iv line and take enough blood sample for blood picture ,blood culture ,renal and liver function tests

• Blood gases ,electrolytes ,glucose,uric acid .bleeding and coagulation time .

• Fix a urinary catheter for collection of urine

• Start iv fluids specially saline then dextrose 5% for correction of dehydration

• In exertional type ,50 % dextrose infusion is required as there may be severe hypoglycemia .

• Apply ice bag over the head only to the angle of the mandible and cover the body with blanket .

• Temperature must be taken rectally every 3 minutes , this process must be continued until temperature reaches 39c the stop cooling and take the patient to the observation room with light clothes .

• Give antipyretic like paracetamol (in case of infection ) and decardon iv to decrease brain edema and minimize the occurrence of relapse of hyperthermia that may occur .

• If ther is convulsion give valium .

• Search for any infection as a precipitating factor and if present we have to give proper therapy

• Correct acid base deficit and electrolyte disturbances (gradually in old ages )

• If there is renal or liver failure manage according to the condition

• If there is no complications and the patient regain consciousness without relapse over 24 hours and no infection you can discharge your patient .

• The patient must be informed about his illness and advised to avoid further attacks .

• Usually ,the exertional type in young patients when treated earlier ,give response without complication.

• Old people with classic type take more type to regain consciousness even with rapid interfence .

كيفية التعامل مع حالات الإجهاد الحرارى وطرق العلاج المناسب

للحالات

يحدث نتيجة ودرجة مئوية 40فوق الشخص إرتفاع درجة حرارة الإجهاد الحراري هوعند التعرض للجو الحار لمدة فقدان الجسم كمية كبيرة من السوائل والأملاح

وخاصة عند بذل مجهود شاق ممايؤدي إلى إضطراب فى وظائف الجسم طويلة الأعراض العامة

.درجة مئوية 40فوق الشخص إرتفاع درجة حرارة - .صداع وعدم إتزان وغثيان مع عرق شديد وشحوب وبرودة فى الجسم

.لام حادة بالعضلات آتقلص و - .ضعف عام مع سرعة النبض والتنفس وإضطراب فى الرؤية - .إحساس بالعطش مع إنخفاض ضغط الدم - .قد تظهر على المصاب أعراض بداية الصدمة -

طرق الوقاية

. المباشرة الشمس أشعة أو الحار للجو التعرض تجنب•

. شمسية مظلة إستخدام أو الرأس على غطاء أو قبعة وضع•

. قطنية تكون أن ويفضل فاتحة فضفاضة خفيفة ملابس إرتداء•

والفواكه الخضروات من والإكثار صحية طعام وجبات وتناول ، الماء شرب من الإكثار•

. الرطوبة وقليلة معتدلة برودة ذات التهوية جيدة أماكن فى التواجد •

الحرارة درجة إرتفاع فورتبين مستشفى أوأقرب الحميات مستشفيات إلى التوجه•

. الذكر سابقة الأخري الأعراض من أيا ظهور مع مئوية درجة 40 فوق

بروتوكول عام لعلاج الإجهاد الحراري بالمستشفيات

المستشفى إستقبال المريض دخول يتم مئوية درجة 40 فوق المريض حرارة درجة إرتفاع حالة فى•

مريض سرير أو مفرغ شبكي بسرير الغرفة بتجهيز ونوصي ، (الحراري الإحتباس غرفة) خاصة بغرفة

حرارته درجة وتثبت بالغرفة تكييف وجود مع ، المريض رأس خلف مثبتة ومروحة ، مرتبة بدون عادي

. مئوية درجة 25 على

بالغرفة المريض ويبقى ( الحنفية من) فاتر بماء مبلولة بملاءة ويلف بالكامل المريض ملابس خلع يتم•

. مئوية درجة 39 الى حرارته درجة تنخفض ىحت المكيفة

39 إلى الحرارة تنخفض حتى حرارة خافض أي ولايعطى دقائق 10 كل المريض حرارة درجة قياس يتم•

، واحدة مرة مثلج بماء معوي غسيل عمل يمكن اذوك للمريض شرجية حقنة عمل ويمكن ، مئوية درجة

اعطاء ويتم بالاستقبال الملاحظة غرفة الى المريض نقل يتم 39 إلى الحرارة درجة إنخفاض عند •

. المناسب والعلاج والمحاليل الحرارة خوافض

. لحالته طبقا مريض كل مع التعامل ويتم شاملة روتينية تحاليل وعمل دم صورة عينات سحب يتم•

يتم مادام الحميات مستشفيات الى الطبية أوالمراكز الأخري المستشفيات من الحالات لنقل لاداعي•

مع التعامل ويمكن المريض حياة على سلبا يؤثر قد الوقت عنصر ان حيث للبروتوكول طبقا التعامل

. لذلك طبقا بالمستشفيات الطوارئ اقسام بجميع الحالات