non –exertional heatstroke and elevated troponin · non exertional heat stroke and elevated...
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Non Exertional Heat Stroke
and Elevated TroponinMaria Batool M.D
Anushree Agarwal M.D
Krishna Nagendren M.D
Aurora Health Care Internal Medicine Residency Program
51 year old female admitted to the ER
c/c: Altered mental status
HPI: Patient was living in a old house with no central air
conditioning and was reportedly doing well until the day
before
PMH:
Diabetes
Asthma
Well-controlled HTN
Bipolar disorder
Schizophrenia
Case Presentation
Social History:
No alcohol or drug use
Medications:
Valsartan
Metoprolol
Metformin
Quetiapine
Lithium
Fluphenazine
Further History
BP: 129/ 65 mmHg
PULSE: 96/min
RR: 22/min
FiO2: 60%
TEMP: 108.1 Fahrenheit !!!! (rectal)
Vital Signs
Obese female, intubated and sedated
Pupils 2 mm size and sluggishly reactive to light
No muscle rigidity
Reflexes hypoactive
Otherwise normal exam
Physical Exam
Lab Data
CBC
9.2
• BNP: 156• Myoglobin: 232 ng/ ml• CK-MB: 1.6 ng/ ml
BMP
137 105 21
5.5 22 2.00 222
• CPK: 96 units/L
• Troponin: 0.16 ng/ ml
• UDS: negative
18.6 478
29.9
Initial EKG showed sinus tachycardia with non-
specific T wave abnormality in the anterior leads
Subsequent EKG showed normal sinus rhythm
EKG
Heat Stroke
Temp > 40° C
CNS Dysfunction
Non Exertional
Cooling Measures
Hemodynamic Support
Exertional
Increased Temperature+ Thermoregulatory
Failure
Increased rate of enzymatic
reactions
Cellular denaturation/
death
Tissue ischemia
Multi-organ dysfunction
Pathophysiology
Clinical Presentation
PHYSICAL FINDINGS
Flushing (cutaneous
vasodilation)
Tachypnea
Excessive bleeding
Altered mentation or
seizures
LAB FINDINGS
Leukocytosis
Hemo concentration
Evidence of DIC
Hypokalemia/ hyperkalemia
Lactic acidosis
Elevated transaminases
Cooling blankets, infusion of cold saline and aggressive
hydration
Extubated within 48 hours
Continued to have confusion and agitation- treated with
Haldol and Lorazepam
Troponin continued to trend up in spite of overall
improvement
Back to the patient….
Troponin Level
0.16
3.39
12.38
11.15
8.79
6.28
22.4
1.8
1.40
2
4
6
8
10
12
14
19-Jul 20-Jul 21-Jul 22-Jul
cTnI - ng/ ml
Creatinine mg/ dl
108.1
102.5 101.8
96
105
95
97
99
101
103
105
107
109
19-Jul 20-Jul 21-Jul
Temp(F)
CPK - units/ L
Temperature
Increased cardiac output (cardiac output increases
about 3 L/min for each 1°C )
Severe sepsis-like syndrome
Neural mediation
Ventricular strain
Coronary endothelial dysfunction
Mechanism of Troponin
Elevation
Very few case reports about troponin elevation and it’s
significance in heat stroke, especially non exertional
heat stroke
Troponin levels significantly elevated in non-survivors
of heat stroke(1) (7.4 vs 1.1 ng.mL-1, P < 0.01)
No reports, to our knowledge, of cardiac catheterization
demonstrating normal coronary arteries in patients of
heat stroke
1. Early organ dysfunction course, cooling time and outcome in classic heatstroke..Intensive Care Med. 2009 Aug;35(8):1454-8. Epub 2009 Apr 29. Pease S, Bouadma L, Kermarrec N, Schortgen F, Régnier B, Wolff M.
Troponin and Heat stroke
Patient started on ACS protocol
Cardiology consulted
2D –ECHO - Normal
Cardiac catheterization - Clean coronaries
Patient Course
Troponin elevation is an independent adverse prognostic
factor in heat stroke(1)
Troponin elevation in heatstroke patients is rarely related
to anatomic coronary lesions
Severe increases in troponin ( > 1.5 ng /ml) indicate
severe myocardial damage(1)
Early identification of prognostic variables in the ER is
essential to determining the therapeutic priorities
1. Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave. Crit Care. 2010;14(3):R99. Epub 2010 May 27.
Conclusion
Hausfater P, Doumenc B, Chopin S, Le Manach Y, Santin A, DauthevilleS, Patzak A, Hericord P, Mégarbane B, Andronikof M, Terbaoui N, Riou B. Elevation of cardiac troponin I during non-exertional heat-related illnesses in the context of a heatwave. Crit Care. 2010;14(3):R99. Epub 2010 May 27.
Hausfater P, Megarbane B, Dautheville S, Patzak A, Andronikof M, SantinA, André S, Korchia L, Terbaoui N, Kierzek G, Doumenc B, Leroy C, Riou B.Prognostic factors in non-exertional heatstroke. Intensive Care Med. 2010 Feb;36(2):272-80. Epub 2009 Oct 20.
Hausfater P, Hurtado M, Pease S, Juillien G, Lvovschi VE, SalehabadiS, Lidove O, Wolff M, Bernard M, Chollet-Martin S, Riou B. Is procalcitonin a marker of critical illness in heatstroke? Intensive Care Med. 2008 Aug;34(8):1377-83. Epub 2008 Mar 28.
Ibrahim A Hashim. Clinical biochemistry of hyperthermia. Ann Clin Biochem2010; 47: 516–523. DOI: 10.1258/acb.2010.010186.
References