Expanding Your Differential - Hyperthermia

[Arcan57]

The patient I referenced in the Nurse Does X thread got me thinking about the differential for severe hyperthermia. I thought it would be fun to contribute cases that illustrate the different causes of severe hyperthermia and their treatment.

I'll go first:

27 yo male brought in by police and EMS for psychotic behavior. BP 150/90 HR 146 (sinus on monitor) T-104.7. Currently in 4-points and somehow hasn't managed to dislodge the 18g in their R AC. EMS reports that he had taken a drug called 25i. 27 mg of ativan later he's starting to calm down and his temp with passive cooling is 102.3.

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[link2swim06]

When I think 'extreme hyperthermia' the following come to mind:

heat stroke/exposure
malignant hyperthermia (from paralytics)
neuroleptic malignant syndrome
serotonin syndrome
excited delirium
severe thyroid storm?

But probably most common....thermometer error or transcription error into the computer

 

[gutonc]

The patient I referenced in the Nurse Does X thread got me thinking about the differential for severe hyperthermia. I thought it would be fun to contribute cases that illustrate the different causes of severe hyperthermia and their treatment.

I'll go first:

27 yo male brought in by police and EMS for psychotic behavior. BP 150/90 HR 146 (sinus on monitor) T-104.7. Currently in 4-points and somehow hasn't managed to dislodge the 18g in their R AC. EMS reports that he had taken a drug called 25i. 27 mg of ativan later he's starting to calm down and his temp with passive cooling is 102.3.

27mg of Ativan?! Your nurses are rock stars. Most would have quit at 4.

 

[gro2001]

27mg of Ativan?! Your nurses are rock stars. Most would have quit at 4.

I think I would have quit at some number between 4 and 27 too. And by quit I mean intubate.


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[Raryn]

27mg of Ativan?! Your nurses are rock stars. Most would have quit at 4.

I've given patients >100mg in a 24 hour period without intubating them...

Then the nurse supervisor of floor X starts adding up the doses and demands an ICU consult.

*shrug*. The resident on ICU turns down the transfer anyway

 

[gutonc]

I've given patients >100mg in a 24 hour period without intubating them...

Then the nurse supervisor of floor X starts adding up the doses and demands an ICU consult.

*shrug*. The resident on ICU turns down the transfer anyway

As physicians, we know that there's nothing inherently dangerous about that amount of ativan (in the appropriate situation).

But we also know that the nurses run the joint, and that getting one of them to give that much during a (non-boarded) ED stay would be a huge "win".

 

[Raryn]

As physicians, we know that there's nothing inherently dangerous about that amount of ativan (in the appropriate situation).

But we also know that the nurses run the joint, and that getting one of them to give that much during a (non-boarded) ED stay would be a huge "win".

My favorite is the nurse that refuses to push 8mg of morphine but will push 2mg of dilaudid (~15mg morphine equivalents).

 

[alpinism]

When I think 'extreme hyperthermia' the following come to mind:

heat stroke/exposure
malignant hyperthermia (from paralytics)
neuroleptic malignant syndrome
serotonin syndrome
excited delirium
severe thyroid storm?

But probably most common....thermometer error or transcription error into the computer

Nice list. Especially serotonin syndrome.
Learned that one the hard way in med school. Super common nowadays with so many patients on antidepressants, antipsychotics, and opiates.

Others: Synthetic Marijuana, Methamphetamine, Ecstasy, and of course Anticholinergic Syndrome.
No joke we used to see K2/Spice induced severe hyperthermia almost everyday back when I was in NYC.

 

[Arcan57]

I think I would have quit at some number between 4 and 27 too. And by quit I mean intubate.


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Why?

 

[gro2001]

Why?

Pharmacokinetics and short attention span.

While onset of action is pretty rapid with lorazepam (a couple of minutes), peak effect is reached only after 15-20 minutes or so. Which is why 'stacking' happens with lorazepam but much less often with diazepam (whose time to peak effect is much closer to it's time to onset of sedation).

So if I see an wildly agitated patient, I give them say 2-4 mg of ativan, yet they are still agitated it would be difficult for me to wait a full 15 minutes before hitting them again. I am likely to just give the next dose after 2-5 minutes, and again until I see the effect. Likely by the time I am done and they are calm, the first couple of doses are just beginning to reach their peak effect, so the patient may continue to become more deeply sedated even after I stopped pushing the ativan. Which would be fine, but knowing my ER I may not be able to guarantee that someone will watch him closely for the next 20 minutes.

Except in the case of alcohol withdrawal, giving 27 mg of ativan safely (2-4 mg increments spaced out by 15 minute intervals, and closely observed for respiratory deterioration for 15-20 minutes after the last dose) is difficult to do with the resources available in most ERs I've seen. So I am either giving it unsafely, or it is taking way too long for me not to know whether this patient is bleeding in his head or has meningitis or whatevs.

I tend to either use a benzodiazepine whose peak effect I will see before I walk away from the bedside (midazolam or diazepam) or if I used lorazepam and after 2-3 rounds and they are still trying to flip the stretcher, then I need to get on with the diagnosis and treatment ASAP (for the patient's own safety). At that point the fastest way to do that is RSI. Separately, super agitated patients are often also not safe for the staff, so if there is danger of anyone getting hurt I tend to have a low threshold to get the scene under control via RSI, for everyone's safety.