Heatstroke

ABSTRACT

Heatstroke is a syndrome consisting of life-threatening central nervous system and multiple organ dysfunction from complications of hyperthermia. Additionally, there is an associated complex immunological and inflammatory component to the illness that resembles sepsis. Core body temperature exceeds 40°C with associated mental status changes such as delirium and coma. Generalized tonic/clonic seizures can occur. A variable degree of organ involvement is present that contributes to the severity of the medical picture. Heatstroke can be viewed as a tropical neurological disorder especially for unacclimated travelers going to warm climates. Heatstroke can be categorized into two types depending on the cause. Classic heatstroke is nonexertional, environmentally related and exertional heatstroke occurs in the setting of strenuous exercise. Heatstroke is actually the most severe of a continuum of heat-related illnesses that carries a high incidence of mortality. Treatment is directed at rapidly reducing core body temperature and the management of life-threatening systemic complications.

Heatstroke - heat illness - tropical neurology

REFERENCES

• 1 Sharma H S, Westman J, Nyberg F. Pathophysiology of brain edema and cell changes following hyperthermic brain injury.  Prog Brain Res. 1998;  115 351-412
• 2 Tan T C, Black P M. Sir Victor Horsley (1857-1916): pioneer of neurological surgery.  Neurosurgery. 2002;  50 607-611
• 3 Bouchama A, Knochel J. Medical progress: heat stroke.  N Engl J Med. 2002;  346 1978-1988
• 4 Knochel J P. Environmental heat illness: an eclectic review.  Arch Intern Med. 1974;  133 841-864
• 5 Rowell L B. Cardiovascular aspects of human thermoregulation.  Circ Res. 1983;  52 367-379
• 6 Vicario S J, Okabajue R, Haltom T. Rapid cooling in classic heatstroke: effect on mortality rates.  Am J Emerg Med. 1986;  4 394-398
• 7 Seraj M E. Heat stroke during Hajj (pilgrimage): an update.  Middle East J Anesthesiol. 1992;  11 407-441
• 8 Hart G R, Anderson R J, Crumpler C P, Shulkin A, Reed G, Knochel J P. Epidemic classical heat stroke: clinical characteristics and course of 28 patients.  Medicine. 1982;  61 189-197
• 9 Slovis C M, Anderson G F, Casolaro A. Survival in a heat stroke victim with a core temperature in excess of 46.5 C.  Ann Emerg Med. 1982;  11 269-271
• 10 Heat related deaths-four states, July-August 2001, and United States, 1979-1999.  MMWR Morb Mortal Wkly Rep. 2002;  51 567-570
• 11 Semenza J C, Rubin C H, Falter K H et al.. Heat-related deaths during the July 1995 heat wave in Chicago.  N Engl J Med. 1996;  335 84-90
• 12 Jones T S, Liang A P, Kilbourne E M et al.. Morbidity and mortality associated with the July 1980 heat wave in St. Louis and Kansas City, MO.  JAMA. 1982;  247 3327-3331
• 13 Ghaznawi H I, Ibrahim M A. Heat stroke and heat exhaustion in pilgrims performing the Haj (annual pilgrimage) in Saudi Arabia.  Ann Saudi Med. 1987;  7 323-326
• 14 Sriramachari S. Heat hyperpyrexia: time to act: editorial.  Indian J Med Res. 2004;  119 vii-x
• 15 Koppe C et al.. Heat-waves: risk and responses. Health and Global Environmental Change. Series, No. 2. World Health Organization Regional Office for Europe. 2004 51 http://Available at: www.who.dk/document/E826829.pdf
• 16 Katsouyanni K, Trichopoulos D, Zavitsanos X, Touloumi G. The 1987 Athens heat-wave.  Lancet. 1988;  2 573
• 17 Hori T, Katafuchi T. Cell biology and the functions of thermosensitive neurons in the brain.  Prog Brain Res. 1998;  115 9-23
• 18 Boulant J A. Cellular mechanisms of temperature sensitivity in hypothalamic neurons.  Prog Brain Res. 1998;  115 3-8
• 19 Nakayama T, Hardy J D. Unit responses in the rabbit's brain stem to changes in brain and cutaneous temperature.  J Appl Physiol. 1969;  27 848-857
• 20 Inoue S, Murakami N. Unit responses in the medulla oblongata of rabbit to changes in local and cutaneous temperature.  J Physiol. 1976;  259 339-356
• 21 Simon E, Iriki M. Sensory transmission of spinal heat and cold sensitivity in ascending spinal neurons.  Pflugers Arch. 1971;  328 103-120
• 22 WHO Europe .Fifth Futures Forum on rapid response decision-making tools, Section 2: heat-waves. Madrin, Spain, December 16-17. 2003
• 23 Knochel J P. Exertional heat stroke: pathophysiology of heat stroke. In: Hopkins PM, Ellis FR Hyperthermic and Hypermetabolic Disorders. Cambridge; Cambridge University Press 1996: 42-62
• 24 Passmore R, Durnin J VGA. Human energy expenditure.  Physiol Rev. 1955;  35 801-840
• 25 Knochel J P, Reed G. Disorders of heat regulation. In: Narins RG Maxwell and Kleeman's Clinical Disorders of Fluid and Electrolyte Metabolism. 5th ed. New York; McGraw-Hill 1994: 1549-1590
• 26 Nelson N, Eichna L W, Horvath S M, Shelley W B, Hatch T F. Thermal exchanges of man at high temperatures.  Am J Physiol. 1947;  151 626-652
• 27 Adams W C, Fox R H, Fry A J, MacDonald I C. Thermoregulation during marathon running in cool, moderate, and hot environments.  J Appl Physiol. 1975;  38 1030-1037
• 28 Deschamps A, Levy R D, Cosio M G, Marliss E B, Magder S. Effect of saline infusion on body temperature and endurance during heavy exercise.  J Appl Physiol. 1989;  66 2799-2804
• 29 Goldstein L S, Dewhirst M W, Repacholi M, Kheifets L. Summary, conclusions and recommendations: adverse temperature levels in the human body.  Int J Hyperthermia. 2003;  19 373-384
• 30 Westman J, Sharma H S. Heat shock protein response in the central nervous system following hyperthermia.  Prog Brain Res. 1998;  115 207-239
• 31 Ananthan J, Goldberg A L, Voellmy R. Abnormal proteins serve as eukaryotic stress signals and trigger the activation of heat shock genes.  Science. 1986;  232 522-524
• 32 Welch W J. Mammalian stress response: cell physiology, structure/function of stress proteins, and implications for medicine and diseases.  Physiol Rev. 1992;  72 1063-1081
• 33 Bardwell J C, Craig E A. Major heat shock gene of Drosophila and the heat inducible dnak gene are homologous.  Proc Natl Acad Sci USA. 1984;  81 848-849
• 34 Bouchama A, De Vol E B. Acid-base alterations in heatstroke.  Intensive Care Med. 2001;  27 680-685
• 35 Matsumura K, Cao C, Watanabe Y, Watanebe Y. Prostaglandin system in the brain: sites of biosynthesis and sites of action under normal and hyperthermic states.  Prog Brain Res. 1998;  115 275-295
• 36 Sharma H S, Westman J, Nyberg F, Cervos-Navarro J, Dey P K. Role of serotonin and prostaglandins in brain edema induced by heat stress: an experimental study in the young rat.  Acta Neurochir Suppl (Wien). 1994;  60 65-70
• 37 Sharma H S, Alm P, Westman J. Nitric oxide and carbon monoxide in the brain pathology of heat stress.  Prog Brain Res. 1998;  115 297-333
• 38 Lu K C, Lin S H, Chu P, Tsai W S, Lin Y F. Correlation of neutrophil phagocytosis and lymphocyte adhesion molecules in exertional heat stroke.  Am J Med Sci. 2004;  327 68-72
• 39 Hammami M M, Bouchama A, Al-Sedairy S et al.. Concentrations of soluble tumor necrosis factor and interleukin-6 receptors in heatstroke and heat stress.  Crit Care Med. 1997;  25 1314-1319
• 40 Bouchama A, Parhar R S, El-Yazigi A et al.. Endotoxemia and release of tumor necrosis factor and interleukin-1 alpha in acute heatstroke.  J Appl Physiol. 1991;  70 2640-2644
• 41 Bouchama A, Al Sedairy S, Siddiqui S et al.. Elevated pyrogenic cytokines in heatstroke.  Chest. 1993;  104 1498-1502
• 42 Bouchama A, Hammami M M, Haq A, Jackson J, Al-Sedairy S. Evidence for endothelial cell activation/injury in heatstroke.  Crit Care Med. 1996;  24 1173-1178
• 43 Carlson R, Sakha F. Unraveling the mysteries of heatstroke.  Crit Care Med. 1996;  24 1101-1102
• 44 Carlson R W, Besso J, Carpio M et al.. Hyperoncotic state and hypovolemia associated with heat injury.  Crit Care Med. 1981;  9 807-809
• 45 Myhre L G, Robinson S. Fluid shifts during thermal stress with and without fluid replacement.  J Appl Physiol. 1977;  42 252-256
• 46 Nylen E S, Arifi A A, Becker K L, Snider R H, Alzeer A. Effects of classic heatstroke on serum procalcitonin.  Crit Care Med. 1997;  25 1362-1365
• 47 Alzeer A H, El-Hazmi M AF, Warsy A S, Ansari Z A, Yrkendi M S. Serum enzymes in heat stroke: prognostic implication.  Clin Chem. 1997;  43 1182-1187
• 48 Lomax P, Schönbaum E. The effects of drugs on thermoregulation during exposure to hot environments.  Prog Brain Res. 1998;  115 193-204
• 49 Hopkins P M, Ellis F R, Halsall P J. Evidence for related myopathies in exertional heat stroke and malignant hyperthermia.  Lancet. 1991;  338 1491-1492
• 50 Kochling A, Wappler F, Winkler G, Schulte Am Esch J. Rhabdomyolysis following severe physical exercise in a patient with predisposition to malignant hyperthermia.  Anaesth Intensive Care. 1998;  26 315-318
• 51 Grogan H, Hopkins P M. Heat stroke: implications for critical care and anaesthesia.  Br J Anaesth. 2002;  88 700-707
• 52 Clark W G, Lipton J M. Drug related heatstroke.  Pharmacol Ther. 1984;  26 345-388
• 53 Belmin J. The consequences of the heat wave in August 2003 on the mortality of the elderly: the first overview.  Presse Med. 2003;  32 1591-1594
• 54 Heat-related deaths-Chicago, Illinois, 1996-2001, and United States, 1979-1999.  MMWR Morb Mortal Wkly Rep. 2003;  52 610-613
• 55 Kilbourne E M, Choi K, Jones S, Thacker S B. Risk factors for heat stroke: a case control study.  JAMA. 1982;  247 3332-3336
• 56 Haymes E M, Buskirk E R, Hodgson J L, Lundegren H M, Nicholas W C. Heat tolerance of exercising lean and heavy prepubertal girls.  J Appl Physiol. 1974;  36 566-571
• 57 Haymes E M, McCormick R J, Buskirk E R. Heat tolerance of exercising lean and obese prepubertal boys.  J Appl Physiol. 1975;  39 457-461
• 58 Chung N K, Pin C H. Obesity and the occurrence of heat disorders.  Mil Med. 1996;  161 739-742
• 59 O'Donnell Jr T F. Acute heat stroke: epidemiologic, biochemical, renal, and coagulation studies.  JAMA. 1975;  234 824-828
• 60 Avellini B A, Shapiro Y, Fortney S M, Wenger C B, Pandolf K B. Effects on heat tolerance of physical training in water and on land.  J Appl Physiol. 1982;  53 1291-1298
• 61 Arcas J, Ferrer T, Roche M C, Martinez-Bermejo A, Lopez-Martin V. Hypohidrosis related to the administration of topiramate to children.  Epilepsia. 2001;  42 1363-1365
• 62 Shimizu T, Yamashita Y, Satoi M et al.. Heat stroke-like episode in a child caused by zonisamide.  Brain Dev. 1997;  19 366-368
• 63 Feinberg M. The problems of anticholinergic adverse effects in older patients.  Drugs Aging. 1993;  3 335-348
• 64 Forester D. Fatal drug-induced heat stroke.  JACEP. 1978;  7 243-244
• 65 Ellis F P. Heat illness. II. Pathogenesis.  Trans R Soc Trop Med Hyg. 1977;  70 412-418
• 66 Forbes N T, Gordon E L. Heat stroke and fluphenazine therapy: report of a case.  J Forensic Sci. 1976;  21 667-670
• 67 Zelman S, Guillan R. Heat stroke in phenothiazine-treated patients: a report of three fatalities.  Am J Psychiatry. 1970;  126 1787-1790
• 68 Rosenberg J, Pentel P, Pond S, Benowitz N, Olson K. Hyperthermia associated with drug intoxication.  Crit Care Med. 1986;  14 964-969
• 69 Callaway C W, Clark R F. Hyperthermia in psychostimulant overdose.  Ann Emerg Med. 1994;  24 68-76
• 70 Watson J D, Ferguson C, Hinds C J, Skinner R, Coakley J H. Exertional heat stroke induced by amphetamine analogues: does dantrolene have a place?.  Anaesthesia. 1993;  48 1057-1060
• 71 Hantson P, Benaissa M, Clemessy J L, Baud F J. Hyperthermia complicating tricyclic antidepressant overdose.  Intensive Care Med. 1996;  22 453-455
• 72 Hund E, Wildemann B. Neuroleptic malignant syndrome following tricyclic antidepressant overdose.  Intensive Care Med. 1997;  23 480-481
• 73 Pandolf K B, Griffin T B, Munro E H, Goldman R F. Heat intolerance as a function of percent of body surface involved with miliaria rubra.  Am J Physiol. 1980;  239 R233-R240
• 74 Thami G P, Kaur S, Kanwar A J. Acquired idiopathic generalized anhidrosis: a rare cause of heat intolerance.  Clin Exp Dermatol. 2003;  28 262-264
• 75 Dann E J, Berkman N. Chronic idiopathic anhydrosis: a rare cause of heat stroke.  Postgrad Med J. 1992;  68 750-752
• 76 Fleckman P. Management of the ichthyoses.  Skin Therapy Lett. 2003;  8 3-7
• 77 Shelley E D, Shelley W B, Kurczynski T W. Painful fingers, heat intolerance, and telangiectases of the ear: easily ignored childhood signs of Fabry disease.  Pediatr Dermatol. 1995;  12 215-219
• 78 Bar-Or O, Blimkie C J, Hay J A, MacDougall J D, Ward D S, Wilson W M. Voluntary dehydration and heat intolerance in cystic fibrosis.  Lancet. 1992;  339 696-699
• 79 Mazzaferri E L. Thyrotoxicosis. Clinical syndromes and laboratory diagnosis.  Postgrad Med. 1983;  73 85-89 92-98
• 80 Tirosh I, Hoffer V, Finkelstein Y, Garty B Z. Heat stroke in familial dysautonomia.  Pediatr Neurol. 2003;  29 164-166
• 81 Fealey R D, Low P A, Thomas J E. Thermoregulatory sweating abnormalities in diabetes mellitus.  Mayo Clin Proc. 1989;  64 617-628
• 82 Katayama I, Yokozeki H, Nishioka K. Impaired sweating as an exocrine manifestation in Sjögren's syndrome.  Br J Dermatol. 1995;  133 716-720
• 83 Burch G E, Hyman A. Influence of a hot and humid environment upon cardiac output and work in normal man and in patients with chronic congestive heart failure at rest.  Am Heart J. 1957;  53 665-679
• 84 Roskind J L, Petrofsky J, Lind A R, Paletta F X. Quantitation of thermoregulatory impairment in patients with healed burns.  Ann Plast Surg. 1978;  1 172-176
• 85 Bouchama A. Heatstroke: a new look at an ancient disease.  Intensive Care Med. 1995;  21 623-625
• 86 Blum L N, Bresolin L B, Williams M A. Heat-related illness during extreme weather emergencies.  JAMA. 1998;  279 1514-1515
• 87 Royburt M, Epstein Y, Solomon Z, Shemer J. Long-term psychological and physiological effects of heat stroke.  Physiol Behav. 1993;  54 265-267
• 88 Pfeiffer G, Steffen W. Letters to the editor: Guillain-Barre syndrome after heat stroke.  J Neurol Neurosurg Psychiatry. 1999;  66 408-409
• 89 Bouges F, Vijayan G, Jaufeerally F. Peripheral neuropathy after heatstroke.  Lancet. 1987;  1 224
• 90 Pitt D C, Kriel R L, Wagner N C, Krach L E. Kluver-Bucy syndrome following heat stroke in a 12 year old girl.  Pediatr Neurol. 1995;  13 73-76
• 91 Lin J J, Chang M K, Sheu Y D, Ting K S, Sung S C, Lin T Q. Permanent neurologic deficits in heat stroke.  Zhonghua Yi Xue Za Zhi (Taipei). 1991;  47 133-138
• 92 Yaqub B A, Daif A K, Panayiotopoulos C P. Pancerebellar syndrome in heat stroke: clinical course and CT scan findings.  Neuroradiology. 1987;  29 294-296
• 93 McNamee T, Forsythe S, Wollmann R, Ndukwu I. Central pontine myelinolysis in a patient with classic heat stroke.  Arch Neurol. 1997;  54 935-936
• 94 Lin M T, Kao T Y, Su C F, Hsu S S. Interleukin-1 beta production during the onset of heat stroke in rabbits.  Neurosci Lett. 1994;  174 17-20
• 95 Chang D M. The role of cytokines in heat stroke.  Immunol Invest. 1993;  22 553-561
• 96 Dube C, Vezzani A, Behrens M, Bartfai T, Baram T Z. Interleukin-1beta contributes to the generation of experimental febrile seizures.  Ann Neurol. 2005;  57 152-155
• 97 Dematte J E, O'Mara K, Buescher J et al.. Near-fatal heat stroke during the 1995 heat wave in Chicago.  Ann Intern Med. 1998;  129 173-181
• 98 Akhtar M J, Al-Nozha M, Al-Harthi S, Nouh M S. Electrocardiographic abnormalities in patients with heat stroke.  Chest. 1993;  104 411-414
• 99 Knochel J P. Exertional heat stroke: pathophysiology of heat stroke. In: Hopkins PM, Ellis FR Hyperthermic and Hypermetabolic Disorders. Cambridge; Cambridge University Press 1996: 42-62
• 100 Keatinge W R, Coleshaw S RK, Easton J C, Cotter F, Mattock M B, Chelliah R. Increased platelet and red cell count, blood viscosity, and plasma cholesterol levels during heat stress, and mortality from coronary and cerebral thrombosis.  Am J Med. 1986;  81 795-800
• 101 Bouchama A, Bridey F, Hammami M M et al.. Activation of coagulation and fibrinolysis in heatstroke.  Thromb Haemost. 1996;  76 909-915
• 102 al-Mashhadani S A, Gader A G, Al Harthi S S, Kangav D, Shaheen F A, Bogus F. The coagulopathy of heatstroke: alterations in coagulation and fibrinolysis in heatstroke patients during the pilgrimage (Haj) to Makkah.  Blood Coagul Fibrinolysis. 1994;  5 731-736
• 103 Berger J, Hart J, Millis M, Baker A. Fulminant hepatic failure from heat stroke requiring liver transplantation.  J Clin Gastroenterol. 2000;  30 429-431
• 104 Hassanein T, Razack A, Gavaler J, Van Thiel D H. Heatstroke, its clinical and pathological presentation, with particular attention to the liver.  Am J Gastroenterol. 1992;  87 1382-1389
• 105 Kilbourne E M. Heat waves and hot environments. In: Noji EK The Public Health Consequences of Disasters. New York; Oxford University Press 1997: 245-269
• 106 Lee D H. Seventy-five years of searching for a heat index.  Environ Res. 1980;  22 331-356
• 107 Kaiser R, Rubin C H, Henderson A K et al.. Heat-related death and mental illness during the 1999 Cincinnati heat wave.  Am J Forensic Med Pathol. 2001;  22 303-307
• 108 Weiner J S, Khogali M. A physiological body-cooling unit for treatment of heat stroke.  Lancet. 1980;  1 507-509
• 109 Tek D, Olshker J S. Heat illness.  Emerg Med Clin North Am. 1992;  10 299-310
• 110 Slovis C M. Heat stroke. In: Hurst JW Medicine for the Practicing Physician. 4th ed. Stamford, CT; Appleton & Lange 1996: 1967-1972
• 111 Al-Aska A K, Abu-Aisha H, Yaqub B, Al-Harthi S S, Sallam A. Simplified cooling bed for heatstroke.  Lancet. 1987;  1 381
• 112 Graham B S. Letter to the editor.  Ann Intern Med. 1999;  130 613-614
• 113 Slovis C M. Letter to the editor.  Ann Intern Med. 1999;  130 614-615
• 114 Wyndham C H, Strydom N B, Cooke H M et al.. Methods of cooling subjects with hyperpyrexia.  J Appl Physiol. 1959;  14 771-776
• 115 Bernard G R, Vincent J L, Laterre P F et al.. Efficacy and safety of recombinant human activated protein C for severe sepsis.  N Engl J Med. 2001;  344 699-709
• 116 Bouchama A, Cafege A, Devol E B, Labdi O, el-Assil K, Seraj M. Ineffectiveness of dantrolene sodium in the treatment of heatstroke.  Crit Care Med. 1991;  19 176-180