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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  A 17-year-old boy collapsing during a football practice session « previous next »
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cleo_md
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A 17-year-old boy collapsing during a football practice session
« on: /October/ 30, 2005, 05:31:42 PM »

A 17-year-old boy was brought to the emergency department by ambulance after collapsing during a football practice session. The ambient temperature outdoors was 93?F. His teammates stated that he seemed fine during play but then went to sit down, complaining of feeling nauseated. Shortly thereafter he became confused and light-headed, and the ambulance was called. By the time the ambulance arrived several minutes later, he was incoherent and agitated. At that time, his heart rate was regular at 138 beats/min, his temperature was 104.8?F, and his skin was warm and slightly moist. His pupils were reactive, his lungs were clear, and his blood pressure was 105/50 mm Hg. The boy was doused with cool water and fanned and given intravenous (IV) fluids. By the time of his arrival at the emergency department, his temperature was 103.5?F, his blood pressure was 115/58 mm Hg, and his confusion was diminishing.

What are the signs and symptoms of heat stroke?
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3abeer
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #1 on: /November/ 01, 2005, 06:23:11 AM »

dearest cleo
salam & happy 3eed dear

good case , actually my colleague in medical school died after such an attack  wow

i will wait 4 the answers with u
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #2 on: /November/ 05, 2005, 11:15:06 AM »

3abeer.....3eed Sa3eed to you too habibti Smiley
I am so sorry to hear about your colleague...Such a tragedy

No one to answer....ok...here is the answer to the first question


The presence of a core body temperature of 104?F (40?C) or greater, anhidrosis, and mental status changes are the classic clinical findings that establish the diagnosis of heat stroke. It begins with symptoms of heat exhaustion, which can include an elevated body temperature (but less than 104?F), thirst, muscle cramping, tachycardia, nausea, vomiting, headache, malaise, syncope, confusion, and irritability. As the condition progresses, anhydrosis develops, and the core body temperature rises to 104?F or greater. Delirium, seizures, hyperventilation, and cardiac arrhythmias may be noted clinically. Pulmonary edema, shock, rhabdomyolysis, liver failure, and renal failure develop as a result of organ damage. Although the classic triad for the diagnosis includes anhidrosis, the exertional form of heat stroke can develop while the patient is still sweating.
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #3 on: /November/ 05, 2005, 11:16:35 AM »

For all those smart doctors on the forums...
 taa
Question2


What is the pathophysiologic basis of heat stroke?
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anwarica
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #4 on: /November/ 05, 2005, 12:08:35 PM »

Quote
What is the pathophysiologic basis of heat stroke?
That was the first thing I studied in medicine  wow Even before Basic medicine  Roll Eyes

I remember that article when I read, it said let's consider humans as car engines Smiley
Every engine needs water to reduce the heat, that's us .. we can produce sweat, but according to humidity, water intake, air conduction (Yes, they were factors that affects body temperature) ..

v

Dehydration

v

Well, hyperthermia will stimulate splanchnic xanthine oxidase ...

I can't remember the mechanisms  Sad

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Motaz Hatata
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #5 on: /November/ 05, 2005, 11:01:26 PM »

as u said anwar, when people like athletes excercise in warm humid environments they make profuse sweating resulting in dehydration and massive vasodilation but here is the point - they can no more sweat .
so now they are dehydrated and salt depleted - as electrolytes are secreted with water in sweating - and this dehydration leads to low blood pressure which accounts for high heart rate ( 138 beats/min in our case )
moreover, decreased blood supply to the overheatd brain causes fatigue, confusion and loss of consciousness

thanks, Dr Nuha for the discussion  clapping
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #6 on: /November/ 07, 2005, 04:04:38 PM »

Anwar and Motaz ...Well done both of you!!? You both got the base of the pathophysiology....See Anwar , we can bemore complicated than your beloved machines!! Smiley Try engineering us too

Let me share this with you both and everyone else as we can see this is a very serious condition - Dr Abeer lost a colleague to this!


Normal thermoregulation depends on dissipation of heat via vasodilation and sweating (and the generation of heat through shivering if temperature is low). These mechanisms are regulated through the hypothalamus on the basis of core body and skin temperatures. As body temperature rises, blood flow to the skin dramatically increases, with a concomitant increase in cardiac output and visceral vasoconstriction. In hyperthermia, the blood flow to the skin alone can account for up to 60% of cardiac output. The evaporation of sweat from the surface of the skin, combined with vasodilation in the skin results in heat loss, which effectively controls body temperature under normal circumstances. Any disruption in this compensatory mechanism can quickly lead to hyperthermia.

Typically, the first step in the process toward heat illness is the inability to sweat enough to dissipate the heat or a lack of air flow for sweating to be effective. This inability may be the result of inadequate fluid intake, poor conditioning, or other problems, such as being in a crowded area with little air movement to facilitate convection cooling or exercising so vigorously that heat builds up despite sweating. In environments with high humidity, sweating is not as effective because of decreased evaporation. The combination of high humidity and strenuous exercise can result in hyperthermia even when the ambient temperature is comfortable. Once the core temperature rises, the progression can be rapid as the body tries more vigorously to control the temperature elevation.

In patients with cardiac disease, the elderly, or those on medications that affect thermoregulatory mechanisms (e.g., anticholinergics, diuretics), the body may be unable to support the sustained blood flow volumes to the skin required to bring about effective cooling.

During heavy exercise, the maximum rate of oxygen (VO2max) uptake plateaus or declines as the athlete approaches fatigue. In experimental conditions evaluating blood flow and VO2max during exercise (Gonz?lez-Alonso), persons with elevated body temperature have a greater decrease in VO2max and earlier onset of fatigue than do those with normal body temperature, despite a similar initial cardiovascular response to exercise. This may contribute to the process by placing even greater demands on the heart if the person continues to exercise.

The actual damage to the tissue can occur by means of at least 3 mechanisms. Direct heat damage develops at temperatures above 106.9?F (41.6?:C) because of disruption of intracellular processes and protein denaturation. In addition, the release of inflammatory cytokines causes cell damage, and the elevated temperatures damage the vasculature directly, causing excessive vascular permeability and activation of the coagulation cascade, leading to disseminated intravascular coagulation (DIC). These tissue injury patterns explain the mental status changes, renal and liver failure, and shock seen as a result of severe hyperthermia.

In the central nervous system, vascular congestion and edema develop, resulting in increased intracranial pressure. This, combined with hypotension, can result in cerebral ischemia. Progression of the shock symptoms into DIC can then result in cerebral hemorrhages. These contribute to the neurologic symptoms associated with the illness as well as the long-term sequelae.


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3abeer
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #7 on: /November/ 14, 2005, 04:42:32 AM »

dear cleo:

i dont know what to say, it seems that i was fasting & sleeping when i read that case!!!

i didnt recognize u were talking about heat stroke , i thought u were talking about IHSS ( HOCM)

 Embarrassed
SEYAM EFFECT  wow
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #8 on: /November/ 22, 2005, 12:51:50 PM »

Dr Abeer, it's ok Smiley . Next case will be HOCM!
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #9 on: /November/ 23, 2005, 04:01:00 PM »

ome on doctors.....our patient needs help>>>>>>>>>>

What treatment should be initiated immediately?
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anwarica
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #10 on: /November/ 24, 2005, 03:29:05 AM »

I could guess the first line of treatment:
The boy was doused with cool water and fanned and given intravenous (IV) fluids.
Cold water to lower temperature, IV will be for muscle cramp and compensation of lost water + electrolytes
I remember we should avoid Cold IV solutions (or his heart will stop!  wow)..
We need to raise his BP ( Don't know how but I know how to keep it low  Cool )
That's what I know (based on 1st year info.  Huh )
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #11 on: /November/ 25, 2005, 03:16:36 PM »

Excellent Anwar...that's exactly how you treat a case of heat stroke! Wink

As was the case with this patient, the most important initial treatment is cooling by whatever means is available. Dousing the patient with water and fanning him or her is an easy way to start the cooling process. Some studies have suggested that cooling in ice water results in more rapid cooling that with cool water, even if the ice results in shivering. This is debated, however; and some suggest only using ice packs around the neck, in the axillae, and in the groin.

The second step is IV fluids. Although most patients are not significantly dehydrated, the volume repletion aids cooling and sweating, and it may help protect the kidneys from the effects of rhabdomyolysis, should it develop. Mannitol (IV) and diuretics may be useful in protecting the kidneys.

The airway should be monitored, and the patient should be intubated if needed, as the patient is at high risk for seizures and subsequent aspiration. Electrolytes, renal function, liver function, cardiac function, and vital signs should be carefully monitored.
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #12 on: /November/ 25, 2005, 03:18:19 PM »

Why are we so worried about a heat stroke...I mean for all we know it's just a "heat stroke".

We get concerned because the following complications can develop>>>
Heat stroke can progress to hepatic necrosis, liver failure, rhabdomyolysis, disseminated intravascular coagulation, seizures, and death. Up to one third of survivors of heat stroke have neurologic sequelae, such as memory loss, ataxia, and paresis, which may be permanent. The risk of death is directly related to the duration of symptoms, with nearly 100% survival if symptoms are treated promptly and nearly 100% mortality for delays in treatment. Death can occur in as little as 20 minutes in children.
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cleo_md
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #13 on: /November/ 25, 2005, 03:20:19 PM »

What can be done to prevent heat stroke?
This is basically what you need to know to advise your family/friends and patients


Prevention is critical, and it is not difficult. Patients who are at higher risk for heat stroke should be careful to avoid situations that could cause them to become overheated. Monitoring the heat index, dressing appropriately for the weather, and staying adequately hydrated with electrolyte solutions when outdoors are extremely important. The heat index is a more accurate reflection of the risk than the heat or humidity alone. At-risk patients should be encouraged to stay in a cool environment when the heat index is critically elevated.

Patients who are at increased risk include those with diabetes, cardiovascular disease, altered mental status, and advanced age. Altered vascular control in the skin in diabetic persons interferes with thermoregulation and puts them at greater risk for heat stroke and heat exhaustion. Heart disease that results in decreased cardiac output also puts a patient at higher risk because the blood flow volume to the skin is inadequate. Volume depletion as a result of poor intake or diuretic use and medications that decrease sweating (e.g., anticholinergics, tricyclic antidepressants) also increase the risk. Children are at higher risk for heat-related illnesses because of their higher metabolic rate, less adequate sweating, and smaller size.

Patients who are in good general health are still at risk if they are not adapted to the heat or are not careful to take the heat/humidity into account during activities. Heat adaptation develops over several weeks, and activities should be adapted accordingly. Adequate fluid intake during activity is essential, and electrolyte solutions in addition to water are recommended, as intake of large amounts of water alone can result in hyponatremia. If a person is out in the heat and begins to develop heat cramps, nausea, or other symptoms of heat exhaustion (as described in the answer to question 1), he or she needs to move to a cool place, drink fluids, and rest.

The use of stimulants, such as ephedra, is not uncommon among athletes, and these also increase the risk for heat-related illnesses. Risk can also be increased by the use of cocaine, which causes vasoconstriction, and alcohol, which causes a relative dehydration. The altered senses that may result from the use of cocaine and alcohol also may impair a person's ability to tell that he or she is becoming overheated.

Muscle cramping in the legs or abdomen, resulting from mild volume and/or electrolyte depletion caused by heavy sweating, is referred to as heat cramps. Heat exhaustion is characterized by more systemic symptoms, such as nausea and confusion, but the core body temperature is still below 104?F. If the illness is treated at these early stages, it is easy to reverse and control. If not treated, it can rapidly progress to heat stroke and the significant associated morbidity and mortality.
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3abeer
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Re: A 17-year-old boy collapsing during a football practice session
« Reply #14 on: /August/ 13, 2006, 05:40:41 AM »

i wanna 2 raise up this again    Tongue

what are the types of heat injury ?
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