what will a temp of 108 do to a person

Chiliadedic 35 is dispatched to a local subdivision for an obese 62-year-old woman with syncope. The responding unit of measurement is a fire-based ALS unit staffed past two paramedics.

Patient Assessment

It's approximately 2:thirty p.g., with outside temperatures reaching 95 degrees F and the humidity is at 65%.The patient is lying in the grass next to a picnic blanket and paper plates with half eaten sandwiches. Her married man crouches over her. He says his wife started to mutter she felt unwell, and then passed out.

Upon evaluation, she'due south unresponsive to sternal rub. Her airway is patent. Her breaths are rapid and shallow with rales bilaterally. Her pulses are easily palpable. She'due south flushed, but her skin is hot and dry. In that location'due south no external testify of trauma.

She's placed on the monitor and vitals are as follows: respiratory rate (RR) of 24, eye rate (Hr) of 132, blood force per unit area (BP) of 94/48, and oxygen saturation of 84% on room air. The paramedic initiates delivery of 100% oxygen via a non-rebreather (NRB) mask and she'south moved into the ambulance without difficulty.

Prehospital ECG demonstrates sinus tachycardia at 136 with a right bundle branch block (RBBB) and prolonged QTc interval. A 20-judge Iv is obtained in the left forearm and 1 Fifty of normal saline is administered. The medication list provided by the husband includes sumatriptan, olanzapine and duloxetine. The patient is transported to the nearest infirmary which is x minutes away with no alter in condition.

Infirmary Course

On arrival, care is transferred to ED staff, who notes the patient has an HR of 140, a systolic BP of 95, and a pulse oximetry of 94% on NRB. She continues to exist unresponsive to pain and is emergently intubated for airway protection. Secondary survey reveals no signs of trauma and normal rectal tone. At that place's no muscular rigidity or clonus (i.east., rapid tensing and relaxing of muscles) noted.

The patient'southward ECG reveals sinus tachycardia with prolonged QRS and prolonged QTc. Labs reveal an elevated creatinine indicative of acute kidney injury. Chest X-ray reveals pulmonary edema. A CT browse of the head demonstrates no sign of bleeding or aberration.

A rectal temperature is noted to be critically loftier at 108 degrees F (42.2 degrees C). Evaporative cooling measures are undertaken, including mist spray bottle with fan along with a cooling coating.

The patient is subsequently moved to the ICU with a rectal temperature of 102 degrees F (38.9 degrees C). With continued cooling, the patient improves speedily and is extubated the post-obit 24-hour interval. Her kidney function normalizes two days after. She's discharged later six days in the infirmary with no neurological deficits and a final diagnosis of environmental hyperthermia.

Discussion

Hyperthermia is the pinnacle of core body temperature in a higher place 99.v degrees F (37.5 degrees C), which is the generally accepted upper limit of normal.¹ Environmental hyperthermia is an elevated core body temperature due to the body'due south thermoregulatory capabilities beingness overwhelmed by environmental atmospheric condition.^ii,3 Heat exhaustion is ordinarily defined every bit a core temperature between 100.iv degrees F (38.0 degrees C) and 104.0 degrees F (40 degrees C) and is accompanied by systemic symptoms including nausea, vomiting, malaise and lightheadedness.³ Physical signs include tachycardia, decreased urine output, and diaphoresis. In that location'south no associated neurologic dysfunction.^3,4 If non treated, estrus exhaustion will develop into estrus stroke, which is defined as a core temperature above 104 degrees F (forty degrees C) with associated neurologic dysfunction. The physical exam may demonstrate tachycardia, tachypnea, flushing of the pare, pulmonary crackles, altered mental status, agitation, syncope, seizures or blackout.^3—v

Hypotension may develop due to cutaneous vasodilation, diaphoresis-induced hypovolemia or cardiac dysfunction.^4,v The patient eventually develops multi-organ failure with rhabdomyolysis, renal injury, cardiovascular plummet, respiratory failure and disseminated intravascular coagulation.^iii—vii Heat stroke carries an estimated mortality of 10%—63%.^2—5,7,8 Elderly people with comorbidities such as coronary or pulmonary affliction, patients with psychiatric affliction, young children, and patients presenting with hypotension or somnolence take the highest mortality.^ii,6,7

The first step in managing environmental hyperthermia is recognizing it. This doesn't crave obtaining a core temperature, but Ems medical directors should consider protocols that include temperature checks when ambience temperatures surpass sure preset values. Rectal temperature is the most accurate,one but this isn't feasible in most prehospital settings.

Once hyperthermia is recognized, there's a mortality benefit to rapid cooling, with a goal of 100.nine degrees F (38.3 degrees C) to prevent iatrogenic hypothermia.^3,4,nine The patient should be moved out of the hot environment, preferably into an air-conditioned space, and their clothing should exist removed.^3,four There are many dissimilar treatment modalities and protocols may include infusing small-scale volumes (250 cc boluses) of cooled Iv normal saline, placing ice packs or other similar equipment in the axilla, neck and groin,^3—six or use of a commercial cooling blanket.

Partial immersion in water ice h2o has been shown to exist effective, but is poorly tolerated and not viable for general EMS operations. Evaporative cooling with convection is efficacious, well tolerated, and easy to perform by soaking a sheet in tepid sterile fluid (such as normal saline) and fanning this over the patient. Nevertheless, there isn't enough evidence to support one particular method as superior to some other. At that place'south also no demonstrated do good to antipyretics and their use isn't recommended.^3—6 Shivering can be controlled with IV fentanyl and if allowed by protocol.¹⁰

Patients may require airway management if their mental condition declines or if they develop hypoxia. Prehospital providers should follow their local airway management protocols. If hypotension or tachycardia is present, small Four crystalloid boluses should be given.^4,six Big-volume boluses should be used with caution due to business organization regarding evolution of pulmonary edema.^nine Avoid vasopressors unless absolutely necessary, as there's theoretical concern that whatsoever peripheral vasoconstriction could deadening heat loss. Prehospital ECGs should be obtained to screen for cardiac dysfunction.^3,5 Seizures should exist managed with benzodiazepines.^four

In improver to environmental hyperthermia, there's a broad differential diagnosis to consider in the patient with an elevated cadre temperature, including sepsis, intracranial drain, thyrotoxicosis, medication overdose (e.g. lithium, sympathomimetics), serotonin syndrome, neuroleptic malignant syndrome (NMS) and seizures. The prehospital provider should consider this list when presented with a patient with hyperthermia, and utilise the history and physical exam to help narrow the diagnoses. In this case, NMS and serotonin syndrome were both possibilities due to the patient'southward medications and ECG findings; all the same, both were ruled out by the patient's lack of muscular rigidity and her rapid improvement.

Despite concerns for another etiology, it'due south recommended that treatment of possible environmental hyperthermia be initiated equally early on as possible given the mortality of the disease and the minimal risks of cooling. Furthermore, prompt patient recovery with cooling measures can exist used as a diagnostic aid as it strongly suggests environmental hyperthermia.^iv

Conclusion

Environmental hyperthermia is a relatively uncommon chief complaint in the prehospital setting. Once recognized, information technology should be managed with rapid initiation of cooling according to protocol. Cardiopulmonary back up may also be required. Although there are many other underlying etiologies that cause elevated temperatures, consideration of these shouldn't filibuster treatment.

References

i. Sund-Levander M, Forsberg C, Wahren LK. Normal oral, rectal tympanic and axillary trunk temperature in developed men and women: A systematic literature review. Scand J Caring Sci . 2002;16(2):122—128.

ii. LoVecchio F, Pizon AF, Berrett C, et al. Outcomes subsequently environmental hyperthermia. Am J Emerg Med . 2007;25(four):442—444.

3. Wexler RK. Evaluation and treatment of estrus-related illness. Am Fam Medico . 2002;65(11): 2307—2314.

four. Beltran G: Heat-related illness. In Cone D, Brice J, Delbridge T, et al. (Eds.), Emergency medical services: Clinical practice and systems oversight. Second edition, Vol 1: Clinical aspects of EMS . Wiley: Due west Sussex, U.K., pp. 358—362, 2015.

5. Bouchama A, Knochel JP. Heat stroke. N Engl J Med . 2002;346(25):1978.

6. Bouchama A, Debhi M, Chaves-Carballo E. Cooling and hemodynamic management in heatstroke: Practical recommendations. Crit Intendance . 2007;11(3):R54.

7. Pease S, Bouadma L, Kermarrec N, et al. Early on organ dysfunction form, cooling time and outcome in archetype heat stroke. Intensive Care Med . 2009;35(8):1454—1458.

8. Bouchama A, Debhi G, Mohaned Chiliad, et al. Prognostic factors in oestrus wave related deaths: A meta-analysis. Arch Intern Med . 2007;167(twenty):2170.

9. Vicario SJ, Okabajue R, Haltom T. Rapid cooling in classical heat stroke: Event on bloodshed rates. Am J Emerg Med . 1986;iv:394—398.

x. Choi HA, KoSB, Presciutti One thousand, et al. Prevention of shivering during therapeutic temperature modulation: the Columbia anti-shivering protocol. Neurocrit intendance . 2011;14(3):389—394.

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