There are a number of causes for hyperthermia that isn’t just fever and r/o sepsis. There is certainly environmental hyperthermia – particularly the elderly in poorly or non- air-conditioned buildings, the runner training for a marathon, and the lost hiker.
Today though, I want to focus on sympathomimetics and psychostimulants. In these settings, rapid cooling is often needed as there is high mortality if not cooled promptly.
Sympathomimetic/psychostimulant highlights:
hyperthermia, mydriasis, tachycardia, diaphoresis, hypertension, agitation, psychosis
cocaine, PCP, amphetamines, MDMA, LSD, bath salts, etc.
can get the phenomenon of “excited delirium” where there is excess catecholamines and/or overstimulation of dopamine and NMDA receptors
In clinical practice…
-Get a rectal temp to asses someone’s core temperature!
-High body temperatures can cause protein unraveling, severe rhabdo -> AKI ->hyperkalemia
-When agitated and hyperthemic, consider benzodiazepines or dissociating with ketamine as we are trying to stop hypermetabolism and muscle contractions that generate further heat.
-If intubation is needed, rocuronium > succylcholine to avoid hyperkalemia.
-Ways to rapidly cool somebody: remove clothing, cold IV fluids, ice packs, ice baths, and even bladder irrigation.
-With an ice or cold water bath, you can cool somebody and drop their temperature about 3°F for every 5 min in the bath.
How might we set up an ice bath here at Maimonides? Get a body bag from the charge nurse, place the patient in it, grab ice from the ice machine if it’s working (inevitably 2 out of 3 machines in the department aren’t) or go to 3-in-1 and borrow their ice (order an iced coffee with just ice, no coffee). Place the ice in the body bag with the patient, or perhaps in large biohazard bags filled with ice around the patient.
Lastly, the evidence for dantrolene when rapid cooling is needed is very limited/non-existent. It’s expensive. It’s efficacy is mostly anecdotal. That being said, some of our event medicine teams have used it in the past at music festivals for excited delirium patients.