Severe hyperthermia secondary to intravenous drug abuse

2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.

Bench-to-bedside review: mechanisms and management of hyperthermia due to toxicity

Body temperature can be severely disturbed by drugs capable of altering the balance between heat production and dissipation. If not treated aggressively, these events may become rapidly fatal. Several toxins can induce such non-infection-based temperature disturbances through different underlying mechanisms. The drugs involved in the eruption of these syndromes include sympathomimetics and monoamine oxidase inhibitors, antidopaminergic agents, anticholinergic compounds, serotonergic agents, medicaments with the capability of uncoupling oxidative phosphorylation, inhalation anesthetics, and unspecific agents causing drug fever. Besides centrally disturbed regulation disorders, hyperthermia often results as a consequence of intense skeletal muscle hypermetabolic reaction. This leads mostly to rapidly evolving muscle rigidity, extensive rhabdomyolysis, electrolyte disorders, and renal failure and may be fatal. The goal of treatment is to reduce body core temperature with both symptomatic supportive care, including active cooling, and specific treatment options.

Hyperthermic Syndromes Induced by Toxins

Normal thermogenesis requires a complex interaction between systems that generate and dissipate heat. Serving as director of thermogenesis, the hypothalamus activates the sympathetic nervous system along with the thyroid and adrenal glands to respond to changes in body temperature. Working in concert, these systems result in heat generation by uncoupling of oxidative phosphorylation, combined with impaired heat dissipation through vasoconstriction. In this article, the authors discuss serotonin and sympathomimetic syndromes, neuroleptic malignant syndrome,and malignant hyperthermia and how these syndromes affect the hypothalamic and sympathetic nervous systems, resulting at times in severe hyperthermia. Current treatment recommendations and future trends in treatment are also discussed.

Toxin-induced hyperthermic syndromes

Toxin-induced hyperthermic syndromes are important to consider in the differential diagnosis of patients presenting with fever and muscle rigidity. If untreated, toxin-induced hyperthermia may result in fatal hyperthermia with multisystem organ failure. All of these syndromes have at their center the disruption of normal thermogenic mechanisms, resulting in the activation of the hypothalamus and sympathetic nervous systems.The result of this thermogenic dysregulation is excess heat generation combined with impaired heat dissipation. Although many similarities exist among the clinical presentations and pathophysiologies of toxin-induced hyperthermic syndromes, important differences exist among their triggers and treatments. Serotonin syndrome typically occurs within hours of the addition ofa new serotonergic agent or the abuse of stimulants such as MDMA or methamphetamine. Treatment involves discontinuing the offending agent and administering either a central serotonergic antagonist, such as cyproheptadine or chlorpromazine, a benzodiazepine, or a combination of the two. NMS typically occurs over hours to days in a patient taking a neuroleptic agent; its recommended treatment is generally the combination of a central dopamine agonist, bromocriptine or L-dopa, and dantrolene. In those patients in whom it is difficult to differentiate between serotonin and neuroleptic malignant syndromes, the physical examination may be helpful:clonus and hyperreflexia are more suggestive of serotonin syndrome,whereas lead-pipe rigidity is suggestive of NMS. In patients in whom serotonin syndrome and NMS cannot be differentiated, benzodiazepines represent the safest therapeutic option. MH presents rapidly with jaw rigidity, hyperthermia, and hypercarbia. Although it almost always occurs in the setting of surgical anesthesia, cases have occurred in susceptible individuals during exertion. The treatment of MH involves the use of dantrolene. Future improvements in understanding the pathophysiology and clinical presentations of these syndromes will undoubtedly result in earlier recognition and better treatment strategies.

The role of the sympathetic nervous system and uncoupling proteins in the thermogenesis induced by 3,4-methylenedioxymethamphetamine

Body temperature regulation involves a homeostatic balance between heat production and dissipation. Sympathetic agents such as 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) can disrupt this balance and as a result produce an often life-threatening hyperthermia. The hyperthermia induced by MDMA appears to result from the activation of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-thyroid/adrenal axis. Norepinephrine release mediated by MDMA creates a double-edged sword of heat generation through activation of uncoupling protein (UCP3) along with alpha1- and beta3-adrenoreceptors and loss of heat dissipation through SNS-mediated vasoconstriction. This review examines cellular mechanisms involved in MDMA-induced thermogenesis from UCP activation to vasoconstriction and how these mechanisms are related to other thermogenic conditions and potential treatment modalities.

Cardiovascular disorders associated with cocaine use: myths and truths

Cocaine produces a pattern of cardiovascular responses that are associated with apparent myocardial ischemia, arrhythmias, and other life-threatening complications in some individuals. Despite recent efforts to better understand the causes of cocaine-induced cardiovascular dysfunction, there remain a number of unanswered questions regarding the specific mechanisms by which cocaine elicits hemodynamic responses. This review will describe the actions of cocaine on the cardiovascular system and the evidence for the mechanisms by which cocaine elicits hemodynamic and pathologic responses in humans and animals. The emphasis will be on experimental data that provide the basis for our understanding of the mechanisms of cardiovascular toxicity associated with cocaine. More importantly, this review will identify several controversies regarding the causes of cocaine-induced cardiovascular toxicity that as yet are still debated. The evidence supporting these findings will be described. Finally, this review will outline the obvious deficits in our current concepts regarding the cardiovascular actions of cocaine in hope of encouraging additional studies on this grave problem in our society.

Hyperthermia in psychostimulant overdose

Psychostimulant drugs such as amphetamines, amphetamine derivatives, and cocaine produce a variety of potentially lethal effects, and an understanding of these toxic effects is important for emergency physicians. While some effects of psychostimulant poisonings such as cardiovascular compromise and seizures have been discussed extensively, other metabolic derangements such as hyperthermia are less well characterized. In fact, hyperthermia is a common feature of severe-to-lethal poisonings and may be the primary mode of demise in some patients. Animal studies confirm that drug-induced hyperthermia alone can be lethal in some species, although other toxic effects may predominate at different drug doses or rates of administration. In non-lethal poisonings, hyperthermia can produce rhabdomyolysis, leading to further morbidity. Clinical reports and animal studies indicate that hyperthermia is a primary effect of psychostimulant drugs and can occur independently of seizures or increased motor activity. Furthermore, activation of particular dopamine receptors in the central nervous system appears to mediate psychostimulant-induced hyperthermia. The literature suggests cooling and tranquilization of psychostimulant-poisoned patients after cardiovascular stabilization. Paralysis and mechanical ventilation may be required. The involvement of dopamine receptor activation in psychostimulant toxicity suggests that dopamine-blocking neuroleptic drugs may be a useful adjunct to current treatment regimens. However, further studies are required to assess this approach. In summary, hyperthermia is a potentially lethal but treatable manifestation of severe psychostimulant poisoning.

Cocaine 'body packers'

Intracorporeal drug smuggling, particularly of cocaine, is increasing. The so-called 'body packers' present a difficult clinical problem, particularly as no coherent management policy has been formulated. The various methods of diagnosis and the treatment options available are presented and discussed.

Hyperthermia in sauna is unable to increase the plasma levels of ACTH/cortisol, beta-endorphin and prolactin in cocaine addicts

In order to establish possible different reactions between normal subjects and cocaine addicts to short term exposure to heat, thermal, cardiovascular and pituitary hormonal responses to hyperthermia in sauna were measured in 8 male cocaine addicts (studied after 14 days of abstinence) and in 8 age and weight matched normal men. Subjects sat for 30 min in a sauna room, where the temperature was 90 C and the relative humidity 10%. Physiological and hormonal parameters were measured just before and after sauna and after 30 min of rest at normal (21 C) room temperature. Significant and comparable increments in systolic and diastolic blood pressure, pulse rate and sublingual temperature were observed in the two groups at the end of sauna. All these parameters decreased to normal values after 30 min of rest at normal room temperature. Before sauna, ACTH, cortisol and beta-endorphin levels were similar in the two groups, whereas plasma prolactin concentrations were significantly higher in cocaine addicts. All examined hormones rose significantly in the normal controls at the end of sauna. All hormones, except cortisol, returned to the basal levels after 30 min at normal room temperature. In contrast, no significant hormonal responses to hyperthermia were observed at any time point in cocaine addicts. These data do not provide evidence of alterations in the cardiovascular and thermal adaptive responses to hyperthermia in cocaine abusers. On the other hand, the results show an impairment of the ACTH/cortisol, beta-endorphin and prolactin responses to hyperthermia in cocaine addicts.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of tetracaine, epinephrine, and cocaine as a topical anesthetic in the emergency department

The combination of tetracaine, epinephrine, and cocaine has gained wide acceptance as a topical anesthetic agent for use on pediatric dermal lacerations in the ED. This is despite the fact that the optimal dose and formulation have yet to be determined. TAC can be applied painlessly to wounds and is about as effective as lidocaine infiltration for anesthetizing pediatric facial and scalp lacerations. It is relatively ineffective on lacerations located elsewhere or in adults. The most commonly used TAC solution contains high concentrations of cocaine, tetracaine, and epinephrine, drugs that individually can cause serious toxicity if absorbed in sufficient amounts. In addition, the three components of TAC may interact to potentiate their intrinsic toxicities. The deliberate and inadvertent application of TAC to mucous membranes has caused status epilepticus and two pediatric deaths. The risk of toxicity from misapplication of TAC is heightened because TAC is most effective and therefore most widely used on pediatric facial and scalp lacerations. Cocaine is also absorbed after TAC is applied to dermal lacerations and may cause toxicity by this route. Until additional research is performed to establish the minimum effective dose of TAC and its potential toxicity and until FDA approval is granted, we do not think that it can be recommended as the drug of choice for pediatric facial and scalp lacerations in the ED. If TAC is administered, a maximum dose of 2 to 3 mL of the "half-strength" formula proposed by Bonadio and Wagner should be used, and application should be performed by medical personnel, using a soaked gauze or cotton ball. Care should be taken to make sure none of the solution comes in contact with mucous membranes, and TAC should not be applied to lacerations involving the vermillion border of the lip or the lip itself. Close medical monitoring of the patient is essential to detect signs of toxicity. Research on other topical agents such as tetracaine with epinephrine is also needed. Although anesthetizing wounds painlessly remains a worthy goal, exposing patients to added and unknown risks and increasing the cost of health care is unacceptable.

Clinical toxicology of cocaine

Recent widespread abuse of cocaine has resulted in an alarming increase in emergency department admissions for acute treatment of this toxic drug. Highly publicized cocaine-associated deaths of prominent athletes have awakened both the medical community and the general public to the possible devastating effects of this so-called 'champagne of drugs'. A potent central nervous system stimulant, cocaine produces symptoms that include changes in activity, mood, blood pressure, cardiac rhythm, respiration and body temperature. The adverse effects of cocaine, which may progress rapidly to death, include cerebrovascular accidents, myocardial infarction, sudden cardiac arrhythmias, pneumomediastinum, rhabdomyolysis with myoglobinuric renal failure and intestinal ischaemia. In addition, cocaine has been implicated in obstetric and neonatal complications. Because of the exceedingly rapid progression of the 'cocaine reaction' to a fatal outcome, it is imperative that clinicians know how to recognise and manage the symptoms of cocaine overdose.

Differentiation of cocaine toxicity: role of the toxicology drug screen

Fifteen cases of presumed cocaine intoxication were evaluated in the emergency room (ER) at a city hospital over a four-day period. This series is unique in that many of these patients were from a similar area of the city, in some cases had the same street address, were regular abusers of cocaine, and presented to the ER with similar symptoms of tachycardia, dilated pupils, marked confusion, bizarre and sometimes violent behavior, psychosis, and hallucinations. Many of these symptoms were present several hours after drug use. Samples of a white powder presumed by the patients to be cocaine were obtained from two patients and analyzed by gas-liquid chromatography. Neither sample contained cocaine, but rather revealed atropine, benzocaine, and procaine. The signs and symptoms of cocaine, amphetamine, and atropine intoxication are reviewed and the problems of drug analysis and differential diagnosis of drug intoxication are discussed.