A 30 year old man present with altered mental state, severe life threatening hyperkalaemia, severe hyperthermia, hypotension and tachycardia.
He has a severe mixed HAGMA and Resp acidosis, severe hypernatraemia and elevated lactate.
Causes include:
sepsis
drugs
CNS catastrophy
renal function/ketones not given.
Complications of severe hyperthermia – rhabdo with hyperK, risk of renal failure and multi-organ failure
| Non-septic causes of hyperthermia |
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Drug Causes of Hyperthermia
Sympathimometic syndrome
- commonly found in non-prescription drugs:
- illegal street drugs (e.g. cocaine, amphetamines, methamphetamine (‘ecstasy’), mephedrone) and
- dietary supplements (e.g. ephedra alkaloids).
- cold remedies (containing ephedrine),
- Sympathomimetic agents – asthma treatment
Neuroleptic malignant syndrome (NMS)
- Neuroleptic or antipsychotic drugs. It is probably related to central dopaminergic (DA2) receptor blockade and other dopaminergic antagonists, including metoclopramide, have been implicated.
Anticholinergic syndrome
- anticholinergics (atropine, glycopyrrolate),
- antihistamines (chlorpheniramine),
- antipsychotics (olanzapine, quetiapine),
- antispasmodics (oxybutynin),
- cyclic antidepressants (amitriptyline, doxepin) and
- mydriatics (tropicamide).
Malignant hyperthermia (MH)
- MH is a life-threatening condition usually triggered by exposure to volatile anaesthetic agents or the depolarising neuromuscular blocker succinylcholine.
Causes of serotonin syndrome.
| Class | Drugs |
| Antidepressants | Monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors, serotonin-noradrenaline reuptake inhibitors, bupropion |
| Opioids | Tramadol, pethidine, fentanyl, pentazocine, buprenorphine oxycodone, hydrocodone |
| CNS stimulants | MDMA, amphetamines, sibutramine, methylphenidate, methamphetamine, cocaine |
| Psychedelics | 5-Methoxy-diisopropyltryptamine, lysergide |
| Herbs | St John’s Wort, Syrian rue, Panax ginseng, nutmeg, yohimbine |
| Others | Tryptophan, L-Dopa, valproate, buspirone, lithium, linezolid, chlorpheniramine, risperidone, olanzapine, antiemetics (ondansetron, granisetron, metoclopramide), ritonavir, sumatriptan |
Problems of extreme hyperthermia
- Cerebral or cognitive dysfunction
- Coagulopathy, liver failure and renal failure
- Rhabdomyolysis and cell damage also occur. Rhabdomyolysis may develop because of a reduction in blood flow and oxygen delivery, or by impaired ATP production or metabolism and a large number of drugs are implicated.
Treatment Priorities:
Resuscitation issues:
- Fluid resusc, aim for urine output 1ml/kg/hr
- Treat hyperkalaemia, aim for ECG improvement/ K of <6 mmol/l
- Aggressive temperature control
- Seek and treat cause
Supportive care