Cooling blankets

[slystalone]

Hi all,
I was moonlighting in a hospital I don't normally work in and a patient came in with a temp of 105. Suspected heat stroke, so we did cool IV fluids, ice packs, etc. But when I asked the nurse for a cooling blanket I was told we couldn't use it unless it was a post cardiac arrest hypothermia protocol (apparently the pads are really expensive and they won't release it for use unless certain criteria are met). Thoughts? That was new to me...

Also, anyone have any experience ever using dantrolene? I know it wouldn't be indicated in this case but just curious if anyone has ever used it.

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[Birdstrike]

I've never seen dantrolene used in heat stroke.

What about spraying the patient with water-mist and using fans?

It can be effective.

 

[Psai]

how would dantrolene help? thought heat stroke was from thermoregulation issues, not muscle contraction

 

[Daiphon]

how would dantrolene help? thought heat stroke was from thermoregulation issues, not muscle contraction

Agreed. Hyperthermia isn't from increased production of heat (with which dantrolene may help), but rather deranged ability to dissipate heat.

Could also try the "poor man's lavage" (as one of my residency attendings called it) - CBI with cooled saline.

However, I echo above: misters + fans = evaporative awesomesauce.

-d

 

[slystalone]

We did the misting too - temp came down to 101 within 30 minutes so it all worked great

To clarify it was 2 separate questions - my reading led to a different topic of dantrolene. Just wonder if anyone's used it before for NMS or for any other reason in the ER. If so how quickly does it work and was it easy to get?

 

[deleted109597]

Don't use dantrolene for this. It doesn't help. If they start shivering, give demerol or paralyze them.
Icewater and towels, or simple immersion works best. Misting or damp sheet and a fan works pretty good though.

 

[turkeyjerky]

Don't use dantrolene for this. It doesn't help. If they start shivering, give demerol or paralyze them.
Icewater and towels, or simple immersion works best. Misting or damp sheet and a fan works pretty good though.

The OP has clearly said (twice) that he knows dantrolene is not indicated for heat stroke and that he's asking about it for the treatment of other hyperthermia illnesses, such as NMS, serotonin syndrome or MH. Personally I haven't used it, and my understanding is that it's rather complex to mix up and administer and is there are better/more practical agents that I'd preferentially use in the ER, ie benzos, cyproheptadine, diphenhydramine, bromocriptine, etc.

MH is really more on an anesthesia related disease; can you get it from isolated sux exposure?

 

[Docinthetrenches]

Yeah, Dantrolene would not help - but I've never heard of some restriction on the use of the cooling blanket. It's pretty effective and safer than Ice. Misting is a good alternative along with the cool fluids and cool foley lavage. Worst case scenario would be putting in chest tubes and putting cool saline in that way and then draining it out - never done that though myself.

 

[DrDrummer]

I'd imagine you have the arctic sun system or something? Yeah, really expensive. Still, incredibly stupid that you can't use them at your discretion. I think that'd be a dealbreaker for me.

 

[deleted109597]

Yeah, Dantrolene would not help - but I've never heard of some restriction on the use of the cooling blanket. It's pretty effective and safer than Ice. Misting is a good alternative along with the cool fluids and cool foley lavage. Worst case scenario would be putting in chest tubes and putting cool saline in that way and then draining it out - never done that though myself.

Chest lavage isn't indicated for hyperthermia, it is for hypothermia. Also, curious as to your notion that a cooling blanket is safer than ice. The studies that compare them show non-inferiority, and it costs a whole hell of a lot less. Just like for therapeutic hypothermia.

 

[winkleweizen]

We did the misting too - temp came down to 101 within 30 minutes so it all worked great

To clarify it was 2 separate questions - my reading led to a different topic of dantrolene. Just wonder if anyone's used it before for NMS or for any other reason in the ER. If so how quickly does it work and was it easy to get?

I used it once.

It was a pita to get but I got it within 30 minutes. I noticed the effects within 15 minutes

 

[Daiphon]

The OP has clearly said (twice) that he knows dantrolene is not indicated for heat stroke and that he's asking about it for the treatment of other hyperthermia illnesses, such as NMS, serotonin syndrome or MH. Personally I haven't used it, and my understanding is that it's rather complex to mix up and administer and is there are better/more practical agents that I'd preferentially use in the ER, ie benzos, cyproheptadine, diphenhydramine, bromocriptine, etc.

MH is really more on an anesthesia related disease; can you get it from isolated sux exposure?

Dantrolene oughtn't be used in NMS.

MH, sure... and can get it from isolated sux exposure (esp if the patient has never had RSI before, so no knowledge if they have the mutated ryanodine receptor at the core of MH) as you may be the one making that dx.

-d

 

[WilcoWorld]

Dantrolene oughtn't be used in NMS.

MH, sure... and can get it from isolated sux exposure (esp if the patient has never had RSI before, so no knowledge if they have the mutated ryanodine receptor at the core of MH) as you may be the one making that dx.

-d

I had a patient with NMS a couple of months ago. I gave him lots of benzos in the ED, as soon as he got to the MICU they gave him dantrolene. Is there something wrong with that other than the fact that it shouldn't be necessary?

@Dr.McNinja - I know you know better, but please don't go recommending demerol (meperidine) for hyperthermic shivering patients, especially in a thread like this where indications/context has gotten so confused. If the cause happens to be serotonin toxicity one could very well kill the patient with demerol. #libbyzion

 

[arkdoc]

We had a similar last night, but we were able to get the cooling blankets without a fuss. The patient had a peak core temp measured at 107. He immediately had lines placed with cool fluids, water mist, fans, ice pack, and had a foley placed with ice water flushed.

 

[deleted109597]

@Dr.McNinja - I know you know better, but please don't go recommending demerol (meperidine) for hyperthermic shivering patients, especially in a thread like this where indications/context has gotten so confused. If the cause happens to be serotonin toxicity one could very well kill the patient with demerol. #libbyzion

Correct. I wouldn't use it at all in the undifferentiated hyperthermia patient, only the rare known environmental patient who starts shivering once doused with ice. And since that patient would most likely be intubated, I personally would just paralyze them.

 

[Daiphon]

I had a patient with NMS a couple of months ago. I gave him lots of benzos in the ED, as soon as he got to the MICU they gave him dantrolene. Is there something wrong with that other than the fact that it shouldn't be necessary?

@Dr.McNinja - I know you know better, but please don't go recommending demerol (meperidine) for hyperthermic shivering patients, especially in a thread like this where indications/context has gotten so confused. If the cause happens to be serotonin toxicity one could very well kill the patient with demerol. #libbyzion

Not wrong, per se, as it likely didn't harm... but not right either.

Dantrolene works in MH by inhibiting the overactive ryanodine receptor complex in the SR (which is releasing bookoo calcium and causing muscle hypertonicity) that is the pathophysiologic core of MH.

NMS doesn't work that way. NMS is more of a centrally-mediated state of hyperactivity involving dopaminergic dysequilibrium. You were right to benzo the bejeezus out of the parient... when those + active cooling measures fail, I typically recommend paralysis.

So, dantrolene won't fix the problem at its core, but if using it prevents an intubation, it's not entirely unreasonable (though I'd posit that your benzos probably kicked in)...

 

[TooMuchResearch]

We had a similar last night, but we were able to get the cooling blankets without a fuss. The patient had a peak core temp measured at 107. He immediately had lines placed with cool fluids, water mist, fans, ice pack, and had a foley placed with ice water flushed.

The money is getting cold water and air movement on the skin. Cooling blankets, cool IVF, cold Foley...meh. You can get them from 107 to 101 quickly with spray bottle and fan or cold wet rags and fan.

 

[RuralEDDoc]

Agreed with much of what has been said. Why spend a couple grand on some fancy blankets when water and ice are essentially free and work even better. It's one of those "pick your battle" moments.

 

[WilcoWorld]

Because when you're a resident moonlighting and someone comes in with a temp of 107 you do what you know. Sly did the best he or she could, which sounds like it was pretty damn good.

 

[TooMuchResearch]

Because when you're a resident moonlighting and someone comes in with a temp of 107 you do what you know. Sly did the best he or she could, which sounds like it was pretty damn good.

Agree.

We don't have cooling blankets in the ED at my Level 1 tertiary referral hospital. Who else uses these routinely?

 

[Dred Pirate]

We did the misting too - temp came down to 101 within 30 minutes so it all worked great

To clarify it was 2 separate questions - my reading led to a different topic of dantrolene. Just wonder if anyone's used it before for NMS or for any other reason in the ER. If so how quickly does it work and was it easy to get?

I am an ED Rph recently wrote our hospital protocol on MH and the use of Dantrolene - most ED's don't have it - ours does - most places usually just keep it in surgical areas. It is stupid expensive and rarely used (I have "heard" of it being used once in my hospital). With MH, time is more important - essentially a code, for NMS, time is not as critical. It generally is "supposed" to work fast, but like I said, I have never personally witnessed it

 

[Dred Pirate]

Agree.

We don't have cooling blankets in the ED at my Level 1 tertiary referral hospital. Who else uses these routinely?

we have them for hypothermia protocol cases post cardiac arrest.

 

[Doctor Bob]

We used to have these cheapo cooling blankets. It seems like half the time the things would tear, then the machine would pump cold water out all over the bed and floor.
Not worth the money. Ice bags + fan + cool mister = success.

As a resident I gave dantrolene to an NMS person with a risperdal overdose. Worked like a charm. Probably shouldn't have worked. So it goes.