Altered Mental Status in a Young Man Picked Up On the Street

Andréa B. Lese, MD, MA; Rick G. Kulkarni, MD

Disclosures

October 05, 2018

Heatstroke requires emergent treatment with active cooling measures. Ice packs should be placed on the groin and axillae, and cooled IV saline should be given. The mainstay of treatment in most centers is through the process of evaporation; tepid water is sprayed onto the patient, preferably as a mist, followed by the use of fans to evaporate the water.[10,11] If no fans are available, use of a cooling blanket can be considered, although this technique is less effective than evaporative cooling. Ice-water immersion is effective, but this technique introduces difficulties in monitoring and resuscitating patients; in addition, theoretical concerns surround peripheral vasoconstriction with this treatment; however, these are outweighed by the technique's therapeutic benefit.[11]

Other, more aggressive cooling techniques include cold lavage in the peritoneal, thoracic, rectal, and gastric cavities. This treatment has not been well studied, however, and can cause water intoxication.[11] In the most severe cases, cardiopulmonary bypass has been suggested.

Antipyretics such as acetaminophen and ibuprofen are not useful in heatstroke; however, until other causes of disease (such as infection) are ruled out, antipyretics may be used. Dantrolene has not proven to be effective in lowering body temperature.[1] Benzodiazepines are helpful in preventing the generation of additional heat by shivering, agitation, or seizures.[1] Cooling measures should be stopped when the patient's temperature reaches 102.2°F (39°C), to prevent overshoot hypothermia.[1]

In addition to cooling the patient, supportive care for other manifestations resulting from high temperatures is necessary. Hypovolemia should be treated with fluids. Rhabdomyolysis should be treated primarily with aggressive volume resuscitation. The addition of sodium bicarbonate can be considered, although no conclusive data support its use. Liver failure is usually mild or moderate and amenable to conservative therapy.[3,5] Expectant management of frank liver failure may be the best approach. Three patients with acute liver failure who met the criteria for transplantation underwent transplantation, and all had fatal outcomes. However, case reports have described patients meeting these same criteria who fully recovered after only conservative treatment.[3,5]

The patient in this case was intubated and admitted to the medical ICU. After clinicians noted continued normalization of his temperature and an improved mental status, he was successfully extubated the next day. His chest x-rays continued to show clear lungs. Treatment for his rhabdomyolysis was continued with IV fluids containing bicarbonate. His creatine kinase level continued to rise, peaking on day 2 at 130,000 units/L, then began to fall. His urine output remained adequate and, although his creatinine level peaked at 2.5 mg/dL on hospital day 4, he never required dialysis. His troponin level, within normal limits at first, peaked on hospital day 2 at 0.89 ng/mL (0.89 µg/L), then began to fall. His liver enzymes peaked on hospital day 3, with an AST level of 3870 unit/L (3870 U/L) and an ALT level of 2080 units/L (2080 U/L), then began to resolve spontaneously. He eventually stabilized by hospital day 3, and then he began to improve; at discharge, he had no evidence of any permanent neurologic damage.

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