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27. Hyperthermia: “I’m Hot Blooded; Check It and See”
Keywords
HyperthermiaEnvironmental exposureHeat strokeEtiologyAlcohol intoxicationTraumaHeat illnessHeat exhaustionHeat injuryCoolingCase #1
Found altered at bus stop
Pertinent History
A 58-year-old male brought to the ED by EMS after bystanders found him at a bus stop on a 100 °F day. He smells of alcohol and is unable to supply a history due to his altered mental status. He has no visible signs of trauma. He is homeless and well known to the emergency department with multiple visits for alcohol intoxication.
PMH
Alcoholic cirrhosis, hypertension, hepatitis C
Social History
Homeless, smoker, chronic alcohol abuse, distant history of IV heroin use.
Pertinent Physical Exam
BP 103/62 mmHg, Pulse 130 beats per minute, Temp 102.4 °F (39.1 °C) axillary, RR 18 breaths/minute, SpO2 95%
Except as noted below, the findings of the complete physical exam are within normal limits.
General:
Intoxicated, minimally responsive.
HEENT:
Normocephalic, atraumatic, pupils 3 mm ERRL.
Back:
Blistering and superficial burns noted to the upper back and buttocks.
Extremities:
No deformities or edema. Burns with blistering noted over posterior calves and posterior arms.
Neuro:
Moans and opens eyes to painful stimuli, withdraws from pain, moves all extremities equally.
Pertinent Diagnostic Testing
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 16.2 ↑ | K/μL | 3.8–11.0 103 cells/mm3 |
Hgb | 12.8 ↓ | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Hematocrit | 39.2 | % | 34.9–44.3% |
Platelets | 105 ↓ | K/μL | 140–450 K/μL |
Sodium | 136 | mEq/L | 135–148 mEq/L |
Potassium | 4.8 | mEq/L | 3.5–5.5 mEq/L |
Chloride | 100 | mEq/L | 96–112 mEq/L |
Bicarbonate | 18 ↓ | mEq/L | 21–34 mEq/L |
BUN | 31 ↑ | mg/dL | 6–23 mg/dL |
Creatinine | 1.2 | mg/dL | 0.6–1.5 mg/dL |
Glucose | 120 ↑ | mg/dL | 65–99 mg/dL |
ALT | 41 ↑ | IU/L | 8–32 IU/L |
AST | 62 ↑ | IU/L | 6–21 IU/L |
Alk Phos | 121 ↑ | IU/L | 32–110 IU/L |
INR | 1.3 ↑ | – | ≤1.1 |
CK | 1340 ↑ | U/L | 30–220 U/L |
pH | 7.34 | – | 7.320–7.420 |
pCO2 | 32 | mmHg | 36.1–52.1 mmHg |
pO2 | 256 ↑ | mmHg | 46.1–71.1 mmHg |
Lactate | 2.5 ↑ | mmol/L | <2.0 mmol/L |
Alcohol | 380 ↑ | mg/dL | <10 mg/dL |
UA – specific gravity | 1.040 ↑ | – | 1.001–1.035 |
UA – Leukesterase | Negative | – | Negative |
UA – Nitrites | Negative | – | Negative |
UA – Blood | Positive | – | Negative |
UA – Ketones | Positive | – | Negative |
UA – Protein | Negative | – | Negative |
CXR
No focal opacities, no pneumothorax, stable from prior exams.
CT Head
No evidence of trauma, no intracranial hemorrhage.
CT C-Spine
No fracture or dislocation.
EKG
Sinus tachycardia, rate 132, no ectopy, normal ST segments.
Plan
Observation pending sobriety.
ED Update
The nurse obtained rectal temperature measuring 107.2 °F (41.8 °C). Active cooling measures with cold saline IV and evaporative cooling were initiated. The patient was intubated using rapid sequence intubation (RSI) and after 30 minutes of cooling had a core temperature of 39 °C. He was admitted to the ICU for further care.
Case #2 Partied Too Hard
Pertinent History
A 26-year-old male is brought to the ED by EMS at 4 a.m. after partying all night. His friends state that they had been drinking and went to a “rave.” When they were ready to leave, they went looking for their friend and found him altered and lying in the parking lot outside of the party. They immediately called EMS. They are unsure if he used any drugs but say that he “probably” did.
Social History
Nonsmoker, binge drinks, and occasionally uses party drugs per friends.
Pertinent Physical Exam
BP 115/62 mmHg, pulse 145 beats per minute, Temp 107.4 °F (41.9 °C) rectal, RR 24 breaths/minute, SpO2 98%
Except as noted below, the findings of the complete physical exam are within normal limits.
General:
Diaphoretic, minimally responsive.
HEENT:
Normocephalic, atraumatic, pupils 8 mm ERRL.
CV:
Tachycardic, regular, no murmurs appreciated. 2+ capillary refill
Neuro:
Minimal moaning to painful stimuli, does not open eyes, moves all extremities equally, withdraws from pain. Slightly increased muscle tone with six beats of clonus.
Pertinent Diagnostic Testing
Test | Result | Units | Normal range |
|---|---|---|---|
WBC | 18.3 ↑ | K/μL | 3.8–11.0 103 cells/mm3 |
Hgb | 14.2 | g/dL | (Male) 14–18 g/dL (Female) 11–16 g/dL |
Hematocrit | 44.5 ↑ | % | 34.9–44.3% |
Platelets | 284 | K/μL | 140–450 K/μL |
Sodium | 135 | mEq/L | 135–148 mEq/L |
Potassium | 4.7 | mEq/L | 3.5–5.5 mEq/L |
Chloride | 105 | mEq/L | 96–112 mEq/L |
Bicarbonate | 10 ↓ | mEq/L | 21–34 mEq/L |
BUN | 31 ↑ | mg/dL | 6–23 mg/dL |
Creatinine | 1.1 ↑ | mg/dL | 0.6–1.5 mg/dL |
Glucose | 105 ↑ | mg/dL | 65–99 mg/dL |
ALT | 29 | IU/L | 8–32 IU/L |
AST | 34 ↑ | IU/L | 6–21 IU/L |
Alk Phos | 115 ↑ | IU/L | 32–110 IU/L |
INR | 1.0 | – | ≤1.1 |
CK | 2445 ↑ | U/L | 30–220 U/L |
pH | 7.24 ↓ | – | 7.320–7.420 |
pCO2 | 25 ↓ | mmHg | 36.1–52.1 mmHg |
pO2 | 312 ↑ | mmHg | 46.1–71.1 mmHg |
Lactate | 4.1 ↑ | mmol/L | <2.0 mmol/L |
Alcohol | 80 ↑ | mg/dL | <10 mg/dL |
UA – specific gravity | 1.042 ↑ | – | 1.001–1.035 |
UA – Leukesterase | Negative | – | Negative |
UA – Nitrites | Negative | – | Negative |
UA – Blood | Positive | – | Negative |
UA – Ketones | Negative | – | Negative |
UA – Protein | Negative | – | Negative |
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