Interesting case... T: 108.

[EM_Rebuilder]

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20 something year old male found down in some sort of barn. Unresponsive, EMS called and brought to the ED.

Noticed to be VERY warm, rectal temp...108! Pt unresponsive, GCS <8, intubated, central line started, art line started, foley with cold irrigation, NG with cold irrigation (no pill fragments found), cooling blanket and fans placed near the pt. Ended up getting about 6L of NS.

Tachy, often near 150s, but hanging in the 110-120, BP all over the place, but looked more stable once the Art line was placed (90s / 50s). (assumed cuff errors)

More history obtained, pt has mild MR (mental, not mitral), is watched 'closely' by loved ones. Stated he had been acting a bit 'weird' over the past week. Unfortunately, he takes 3 psych meds but I cannot remember them although was doubly assured that there was NO WAY an OD could have happened (family controls meds, seems reliable... no pill fragments). Family denied any other medical problems.

CT read as negative, CXR negative, LP done, slightly traumatic... awaiting those results. Rest of normal Trauma labs were unremarkable. UDS negative. Temperature was at a peak of 108, and headed south with the above interventions. Leveled off in the upper 101s. At one point, some 'possible' extensor posturing was noted. Occured in the 104 temp range.

Additional info: EKG showed slight QT prolongation, 102 temperature outside, no evidence of Rhabdo. Urine was clean. PE: Pupils 2mm, responsive, no evidence of head trauma, struggling slightly with breathing, nothing noted in OP. No response to verbal or painful stimulus. Occasionally would 'buck' and move all extremities. Some stool noted on buttocks/legs, but unsure if pts or 'manure'. No abrasions, trauma, etc noted anywhere.

Admitted to the ICU.


Thoughts?

We were thinking of some sort of heat induced pathology, but what threw that was the fact that family insisits he has acted 'different' for the past week. That prompted the LP looking for an enceph. I am anxious to get back in today and see the results of the LP.

Update: I learned that the LP was negative. We tried to electronically access the progress notes with no luck. The thyroid storm is an interesting idea. I will have to check the labs on him and see if a free T4 was done (is that a normal Trauma lab... I would not think, but really do not know..I would assume TSH would not have time to change in storm, but then again I am not sure. I have something to read about....).

 

[southerndoc]

What is kept in the barn? Tachy, altered mental status, and hyperthermia makes me wonder if he got into some anticholinergics in the barn. Then again, was the outside temperature 100 degrees and the inside of the barn 120? If so, a few hours there can raise your temperature and induce a heat stroke without any additional chemicals.

By the way, an overdose of antipsychotics is NOT required to induce neuroleptic malignant syndrome. This can occur with normal doses.

What was his EKG like? QTc? Any suggestion of rhabdo by CPK? More physical exam info? Give us a few more details here.

 

[DropkickMurphy]

What is kept in the barn? Tachy, altered mental status, and hyperthermia makes me wonder if he got into some anticholinergics in the barn. Then again, was the outside temperature 100 degrees and the inside of the barn 120? If so, a few hours there can raise your temperature and induce a heat stroke without any additional chemicals.

By the way, an overdose of antipsychotics is NOT required to induce neuroleptic malignant syndrome. This can occur with normal doses.

What was his EKG like? QTc? Any suggestion of rhabdo by CPK? More physical exam info? Give us a few more details here.

SouthernDoc, correct me if I am wrong, but I was told once that some antipsychotics tend to inhibit sweating and could contribute to the development of hyperthermia, even if NMS wasn't an issue.

 

[waterski232002]

Heat stroke is most likely if the ambient temp was very high in the barn or outside that day.

Otherwise, sounds like thyroid storm..... Hyperthermia, AMS, Tachycardia. Send a Thyroid fxn panel and treat emperically (PTU, Propranolol, Decadron, IVF)

Was there cardiomegally on CXR, any goiter, diarrhea, nausea/vomiting, weight loss, diaphoresis, hair loss, etc... Any electrolytes abronmalities?

 

[JackBauERfan]

yeah i think with that info of the medications that nms would be high on the list; read through it quick, don't think the lp will show much. also i would prob treat for thyroid storm too, I think if you go to uptodate (or other sources) they have the things you add up to clinically dx it and all those things would prob give yyou enough to treat on.

 

[basementbeastie]

serotonin syndrome?

 

[BKN]

I like the NMS and the seritonin syndrome. Was the "bucking" the muscle rigidity seen with NMS?

 

[Dimoak]

20 something year old male found down in some sort of barn. Unresponsive, EMS called and brought to the ED.

Noticed to be VERY warm, rectal temp...108! Pt unresponsive, GCS <8, intubated, central line started, art line started, foley with cold irrigation, NG with cold irrigation (no pill fragments found), cooling blanket and fans placed near the pt. Ended up getting about 6L of NS.

Tachy, often near 150s, but hanging in the 110-120, BP all over the place, but looked more stable once the Art line was placed (90s / 50s). (assumed cuff errors)

More history obtained, pt has mild MR (mental, not mitral), is watched 'closely' by loved ones. Stated he had been acting a bit 'weird' over the past week. Unfortunately, he takes 3 psych meds but I cannot remember them although was doubly assured that there was NO WAY an OD could have happened (family controls meds, seems reliable... no pill fragments). Family denied any other medical problems.

CT read as negative, CXR negative, LP done, slightly traumatic... awaiting those results. Rest of normal Trauma labs were unremarkable. UDS negative. Temperature was at a peak of 108, and headed south with the above interventions. Leveled off in the upper 101s. At one point, some 'possible' extensor posturing was noted. Occured in the 104 temp range.

Additional info: EKG showed slight QT prolongation, 102 temperature outside, no evidence of Rhabdo. Urine was clean. PE: Pupils 2mm, responsive, no evidence of head trauma, struggling slightly with breathing, nothing noted in OP. No response to verbal or painful stimulus. Occasionally would 'buck' and move all extremities. Some stool noted on buttocks/legs, but unsure if pts or 'manure'. No abrasions, trauma, etc noted anywhere.

Admitted to the ICU.


Thoughts?

We were thinking of some sort of heat induced pathology, but what threw that was the fact that family insisits he has acted 'different' for the past week. That prompted the LP looking for an enceph. I am anxious to get back in today and see the results of the LP.

Update: I learned that the LP was negative. We tried to electronically access the progress notes with no luck. The thyroid storm is an interesting idea. I will have to check the labs on him and see if a free T4 was done (is that a normal Trauma lab... I would not think, but really do not know..I would assume TSH would not have time to change in storm, but then again I am not sure. I have something to read about....).

I'm not an expert on this, but when you mentioned "found in a barn" and a rectT of 108, I immediately thought drug OD. The parents may be reliable and carefully controlled the meds, but that doesn't mean he could not have gotten them elsewhere. The acting different part just might suggest that he may have gotten mixed up with some unscrupulous people. If substances are ruled out, perhaps a serum TSH can help determine if it's indeed a thyroid condition.

 

[DrDre']

I recently admitted a 50 y o man with Hx of schzophrenia, found altered wandering around. Temp 42.7. Essentially comatose on arrival, BPs 70/p, petechial rash. Inititially treated for meningitis but neg. LP, no meningmus, neg cxs. Had stable regimen of abilify and clozaril x years. Ck hit 28k , no rigidity ever. Treated as NMS with bromocriptine. Transferred from unit comatose with trach after 2 weeks. NMS would be high on my list here. Other thoughts above are great, as well.

I'm not an expert on this, but when you mentioned "found in a barn" and a rectT of 108, I immediately thought drug OD. The parents may be reliable and carefully controlled the meds, but that doesn't mean he could not have gotten them elsewhere. The acting different part just might suggest that he may have gotten mixed up with some unscrupulous people. If substances are ruled out, perhaps a serum TSH can help determine if it's indeed a thyroid condition.

 

[whasupmd2]

same here... would go with NMS.

I recently admitted a 50 y o man with Hx of schzophrenia, found altered wandering around. Temp 42.7. Essentially comatose on arrival, BPs 70/p, petechial rash. Inititially treated for meningitis but neg. LP, no meningmus, neg cxs. Had stable regimen of abilify and clozaril x years. Ck hit 28k , no rigidity ever. Treated as NMS with bromocriptine. Transferred from unit comatose with trach after 2 weeks. NMS would be high on my list here. Other thoughts above are great, as well.

 

[Calabar]

same here... would go with NMS.

I vote NMS.

Serotnonin syndrome is a possibility as well, but the onset is usually quicker.

Regardless, if this were a hyperthermic event from a medication effect versus drug of abuse versus environmental versus infectious -- the initial approach is going to be essentially the same.

ABC's
Active cooling measures
Sedate with favorite benzo
Culture up/labs/LP
Broad-spectrum antibiotics
Admit to ICU
Followup cultures

Pretty much the course this kid got. Meticulous supportive care is usually all that is needed for most of these syndromes. Some people play around with bromocriptine, dantrolene, cyproheptadine, etc -- these should not take the place of good supportive care. One treatment that is fairly extreme is the use of long-acting paralytic agents as a way to inhibit heat generation from motor activity - I caution against this unless there is continuous EEG monitoring as paralytic agents will mask seizure activity.

There unfortunately is no diagnostic marker for NMS or SS. These are clinical diagnoses based on history and presentation. It would be nice to know exactly what medications the patient is taking. Sometimes people will send off serotonin levels from the CSF, but this is by no means standard practice.

Anyway -- just my 2 cents.

 

[FoughtFyr]

Just a thought but s/p excited delirium might also be a consideration.

 

[waterski232002]

I vote NMS.

Serotnonin syndrome is a possibility as well, but the onset is usually quicker.

Regardless, if this were a hyperthermic event from a medication effect versus drug of abuse versus environmental versus infectious -- the initial approach is going to be essentially the same.

ABC's
Active cooling measures
Sedate with favorite benzo
Culture up/labs/LP
Broad-spectrum antibiotics
Admit to ICU
Followup cultures

Pretty much the course this kid got. Meticulous supportive care is usually all that is needed for most of these syndromes. Some people play around with bromocriptine, dantrolene, cyproheptadine, etc -- these should not take the place of good supportive care. One treatment that is fairly extreme is the use of long-acting paralytic agents as a way to inhibit heat generation from motor activity - I caution against this unless there is continuous EEG monitoring as paralytic agents will mask seizure activity.

There unfortunately is no diagnostic marker for NMS or SS. These are clinical diagnoses based on history and presentation. It would be nice to know exactly what medications the patient is taking. Sometimes people will send off serotonin levels from the CSF, but this is by no means standard practice.

Anyway -- just my 2 cents.

I would suggest treating this patient for thyroid storm as well. The diagnosis needs to be made based on clinical presentation, and cannot wait for a lab result (unless you've got a lab which does in-house stat thyroid fxn panels). Similar to meningitis, when you delay treatment, you get dead patients. On the other hand, treating w/ IVF, PTU, and Steroids won't hurt the guy. NMS may be most likely, but cover your bases.

 

[Calabar]

I would suggest treating this patient for thyroid storm as well. The diagnosis needs to be made based on clinical presentation, and cannot wait for a lab result (unless you've got a lab which does in-house stat thyroid fxn panels). Similar to meningitis, when you delay treatment, you get dead patients. On the other hand, treating w/ IVF, PTU, and Steroids won't hurt the guy. NMS may be most likely, but cover your bases.

true - depends on the hospital you are at - you'd be amazed by the labs at some hospitals - one place I work I usually get the thyroid function tests back before the chemistry - I'm not sure why

definitely treating presumptive thryoid storm is the right thing to do especially if you can't obtain laboratory evidence in a timely fashion. I would argue that the initial treatment of thyroid storm is still the same with meticulous supportive care measures. skipping over active cooling and other supportive care measures in a severely hyperthermic patient can harm the patient regardless of cause. i.e. don't forget to treat the patient with other measures just because you're focused on getting the methimazole/PTU from pharmacy

I can't tell you how often I've seen people make the mistake of ignoring basic principles of supportive care just because the "cure" has been given. That's the reason early-goal directed therapy works - it emphasizes basic supportive care/resuscitative measures - not the newest broad-spectrum antibiotic/not Xigris/etc. Just because you gave the antibiotic doesn't mean you are done treating the patient.

 

[waterski232002]

definitely treating presumptive thryoid storm is the right thing to do especially if you can't obtain laboratory evidence in a timely fashion. I would argue that the initial treatment of thyroid storm is still the same with meticulous supportive care measures. skipping over active cooling and other supportive care measures in a severely hyperthermic patient can harm the patient regardless of cause. i.e. don't forget to treat the patient with other measures just because you're focused on getting the methimazole/PTU from pharmacy

I'm not arguing... If you re-read my post, I was adding to your treatment plan. I agree with all your basic supportive measures. Recognition, diagnosis, and definitive treatment should all be adressed in the ER whenever possible.

 

[Calabar]

I'm not arguing... If you re-read my post, I was adding to your treatment plan. I agree with all your basic supportive measures. Recognition, diagnosis, and definitive treatment should all be adressed in the ER whenever possible.

You wanna fight? Fine - meet me outside after gym class. 😀

I know we're saying the same thing, I just wanted to emphasize a point that is lost on many others.

 

[waterski232002]

Parking lot... 3pm... be there

 

[southerndoc]

Parking lot... 3pm... be there

Everyone, I will be taking your bets on this one. Stay tuned for the odds.

 

[WakeMedHeel]

What was the patient's glucose?

 

[EM_Rebuilder]

Well guys, I finally got word from the IM service about this guys stay. He was mildly MR and was out shoveling manure in the 102 Texas heat (in a metal building... even hotter). Evidently, he did not know when to quit and kept working until he 'passed out' thus lying there getting cooked by the Texas sun. He did well and recovered having just a bit more psychmotor slowing than he did before.


Good job, I have a nice DDx for hyperpyrexic patients now....

 

[Wahoo]

Nice save.

We recently had a similar case of environmental exposure--the guy came in with a temp of 109. He didn't make it. One of the residents did a review of the literature and couldn't find a single case report of someone surviving this type of injury with a temperature of >109 at presentation.