Physiology Hyperthermia and Fever

Heat illnesses/ emergencies

Heat exhaustion/ heat prostration Heat cramp/ miners cramp Heat stroke/ sun stroke Malignant hyperthermia Hypothermia Case

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54-year-old man found unresponsive by emergency medical servic es presented to the emergency department with hypotension, altered mental status, respiratory failure, and a temperature of 108F. The patient had a recent history of severe burns to 50% of his body requiring skin grafting. The family reported that he had abused cocaine for the past 2 days since being discharged from an outside hospital for a skin graft infection The response exerted by the thermoregulatory center when the body is too hot Increase heat loss Decrease heat production Failing heat loss 1. Radiation Heat passes from the body by invisible infrared rays, occurs if temperature of surrounding objects (walls, furniture, etc.) is lower than body temperature In this situation, the ability to dissipate heat by radiation falls as the radiant temperature of nearby objects increases 2. Convection The air (having a lower temperature than the body) is warmed by air currents from the body by means of vasodilatation of subcutaneous blood vessels The ability to dissipate heat by convection is decreased as the temperature of external environment is increased Thanks for visiting! | http://medicalthink.blogspot.com/

3. Sweating and evaporation When temperature of external environment is increased (reaches 30 0C), sweating and evaporation becomes the only effective way for heat loss Causal factors High external temperature High external humidity Risk factors Children Elderly Obese people Medications o o o o Diuretics Neuroleptics Phenothiazines Anticholinergics Thanks for visiting! | http://medicalthink.blogspot.com/

Alcohol use Dehydration Heart Disease Sweat gland problems Too much clothing If the problem isnt addresse d, heat cramps can lead to heat exhaustion, which can progress heatstroke

Heat cramp Caused by loss of salts from heavy sweating High external temperature profuse sweating drinking much water but, loss of NaCl is not replaced!

Sign & symptoms: Profuse sweating Fatigue Painful & spasmodic muscle contraction (muscle cramps) Therapy: 0.2% NaCl in drinking water massage affected muscles gently, but firmly, until they relax. Heat exhaustion Caused by dehydration and the cardiovascular system is fault Sign & symptoms: Cool & moist skin Low blood pressure Rapid, weak, and soft pulse Headache Thanks for visiting! | http://medicalthink.blogspot.com/ Dizziness & light headedness Nausea & vomiting Weakness Therapy: Complete rest Drinking sodium water Contributing factors Old age Unfit person Failing heat loss by sweating and evaporation. When temperature of external environment is increased (reaches 30 0C), sweating and evaporation becomes the only effective way for heat loss . However, since

the rate of evaporation is inversely related with relative humidity, t he ability to dissipate heat by evaporation falls as the humidity of external environment is increased

Heat Stroke The combine reduction of heat loss by those three pathways (namely radiation, convection, and evaporation) in the prolonged exposure of h eat causes progressive hyperthermia . Rectal temperature is higher than 41 0C (1040 F) Sign & symptoms: Body t0 sharply rise Dry, hot, and red skin Irrational behavior Extreme confusion Shock Seizures Unconsciousness Thanks for visiting! | http://medicalthink.blogspot.com/ First Aid Have the person lie down in a cool place. Raise the person's feet about 12 inches. Apply cool water directly to the person's skin and use a fan to lower body temperature. Place cold compresses on the person's neck, groin, and armpits. If alert, give the person beverages (such as Ga torade), or make a salted drink by adding a teaspoon of salt per quart of water. Give a half cup every 15 minutes. Cool water will do if salt beverages are not available. DONTs DO NOT underestimate the seriousness of heat illness, especially if the perso n is a child, elderly, or injured. DO NOT give the person medications that are used to treat fever (such as aspirin or acetaminophen). They will not help, and they may be harmful. DO NOT give the person salt tablets.

 DO NOT give the person liquids that contain alcohol or caffeine. They will interfere with the body's ability to control its internal temperature. DO NOT use alcohol rubs on the person's skin. DO NOT give the person anything by mouth (not even salted drinks) if the person is vomiting or unconscious. Prevention Wear loose-fitting, lightweight clothing in hot weather. Rest frequently and seek shade when possible. Avoid exercise or strenuous physical activity outside during hot or humid weather. Drink plenty of fluids every day. Drink more fluids before, during, and after physical activity. Be especially careful to avoid overheating if you are taking drugs that impair heat regulation, or if you are overweight or elderly. Be careful of hot cars in the summer. Allow the car to cool off befor e getting in. Malignant Hyperthermia Genetic disorder of abnormal regulation of muscle contraction Sign & symptoms: Thanks for visiting! | http://medicalthink.blogspot.com/ Hyperthermia Muscular rigidity Muscular rigidity Malignant Hyperthermia Triggers: Halothane (anesthesia agent) Succinylcholine (neuromuscular blocker) Phenothiazine Haloperidol (neuroleptic neuroleptic malignant syndrome) Therapy: Dantrolene

Hypothermia in newborn baby Causes: Large surface-to-body mass ratio Limited ability to generate heat t/muscle contraction (non -shivering thermogenesis) Poor thermal insulation by adipose tissue Inability to adjust behavioral defenses (wear him/herself a warmer cloth) Hypothermia caused by exposure to extreme cold. Exposed to ice water for 20 to 30 minutes . It can occur at sub-zero temperatures or at temperatures just below freezing but with a wind (wind chill). The following events: The ability of hypothalamus to regulate temperature is lost Chemical heat production in each cell is depressed Activity of CNS is depressed; shivering is inhibited Hypothermia caused by exposure to extreme cold The following events (cont.): Cold-induced vasodilatation Thanks for visiting! | http://medicalthink.blogspot.com/ Frostbite: the freezing of bodys surface area Complication Gangrene Heart fibrillation Treatment Surgical Non-surgical: application of external heat First Aid 1. Shelter the person from the cold and move him or her to a warmer place. Remove any constricting jewelry and wet clothing. Look for signs of hypothermia (lowered body temperature) and treat accordingly.

2. If immediate medical help is available, it is us ually best to wrap the affected areas in sterile dressings (remember to separate affected fingers and toes) and transport the person to an emergency department for further care. 3. If immediate care is not available, re -warming first-aid may be given. Soak the affected areas in warm (never HOT) water -- or repeatedly apply warm cloths to affected ears, nose, or cheeks -for 20 to 30 minutes. The recommended water temperature is 104 to 108 degrees Fahrenheit. Keep circulating the water to aid the warming proce ss. Severe burning pain,swelling, and color changes may occur during warming. Warming is complete when the skin is soft and sensation returns. 4. Apply dry, sterile dressings to the frostbitten areas. Put dressings between frostbitten fingers or toes to keep them separated. 5. Move thawed areas as little as possible. 6. Re-freezing of thawed extremities can cause more severe damage. Prevent re -freezing by wrapping the thawed areas and keeping the person warm. If protection from re -freezing cannot be guaranteed, it may be better to delay the initial re -warming process until a warm, safe location is reached. 7. If the frostbite is extensive, give warm drinks to the person in order to replace lost fluids. DONTs DO NOT thaw out a frostbitten area if it cannot be kept thawe d. Refreezing may make tissue damage even worse. DO NOT use direct dry heat (such as a radiator, campfire, heating pad, or hair dryer) to thaw the frostbitten areas. Direct heat can burn the tissues that are already damaged. DO NOT rub or massage the aff ected area. DO NOT disturb blisters on frostbitten skin. DO NOT smoke or drink alcoholic beverages during recovery as both can interfere with blood circulation. Prevention Be aware of factors that can contribute to frostbite, such as extreme cold, wet c lothes, high winds, and poor circulation. Poor circulation can be caused by tight clothing or boots, cramped positions, fatigue, certain medications, smoking, alcohol use, or diseases that affect the blood vessels, such as diabetes. Wear suitable clothing in cold temperatures and protect exposed areas. In cold weather, wear mittens (not gloves); wind -proof, water-resistant, many-layered clothing; two pairs of socks Thanks for visiting! | http://medicalthink.blogspot.com/

(cotton next to skin, then wool); and a hat or scarf that covers the ears (to avoid substanti al heat loss through the scalp). If you expect to be exposed to the cold for a long period of time, don't drink alcohol or smoke, and get adequate food and rest. If caught in a severe snowstorm, find shelter early or increase physical activity to maintain body warmth. Fever A regulated elevation of core temperature due to disease. Body temperature is above 37.2 0C in the morning or above 37.8 0C in the evening. Cytokines Polypeptide which is produced and released by cells of immunity system (mainly) as the responses to antigen (microbe, virus, etc.) It functions as mediator to inflammation and immune reaction Nowadays, there is already >100 cytokines Cytokines that is responsible for development of fever TNF (Tumor Necrosis Factors) and IL -1 (Interleukin 1) Both are produced and released by macrophage and T - lymphocyte, in response to antigen TNF specifically is released as response to lipopolysaccharide (LPS) of gram negative bacteria Others cytokine are IL-6 (Interleukin 6) and INF (Interferon type I) IL-6 is similar to IL-1 INF is produced by macrophage and other cells that are infected with virus Mechanism of TNF, IL-1, IL-6, and INF to cause fever After released by macrophage and T -lymphocyte, both circulate with the blood and reach OVLT, part of brain leaked of blood-brain barrier They circulate with liquor cerebrospinal liquid (LCS) and reach hypothalamus They induce cells of the hypothalamus to release prostaglandin (PG) Mechanism of prostaglandin to cause fever Thanks for visiting! | http://medicalthink.blogspot.com/

 Prostaglandin (PG) change thermostat i n the anterior hypothalamus to a higher standard As the result, the regulatory center of body temperature: in the posterior hypothalamus, responses by increase heat production and decrease heat loss

As thermostat is set higher, posterior hypothalamus is activated The Results of Activation of Posterior Hypothalamus : Increase heat production Shivering Feeding Increased voluntary activity Increased secretion of thyroxin and norepinephrine Decrease heat loss Cutaneous vasoconstriction Curling up Horripilation (goose flesh ) Thanks for visiting! | http://medicalthink.blogspot.com/ Characteristics of febrile condition CHILLS THE CRISIS, or FLUSH The events occurred in fever In the first stage, the subject feels cold since the temperature in the skin is lower than the set point temperature in hypothalamus. The response of the body is to increase heat production (shivering, horripilation) and to decrease heat loss (cutaneous vasoconstriction, paleness), therefore body temperature increases. The metabolic rate increases (chemical heat regulation) Approximately 13% increase in metabolic rate for every degree centigrade of temperature above the normal.

 The metabolic rate increases in: Liver: increased liver transaminase & bilirubin. Skeletal muscles: increased protein breakdown, myoglobin (rhabdomiolisis) and release of K+ ion. Negative nitrogen balance as a greater excretion of nitrogen, urea, and creatinine. As metabolic rate increases, O 2 demand rises (20%) increased pulmonary ventilation, tidal volume rises (9%), and insensible perspiration through respiratory tract Cardiac parameter: cardiac output, stroke volume and pulse rate increase. Blood pressure rises in the beginning but then it returns to the normal Fluid & electrolytes disturbance Fluid depletion, dehydration, plasma becomes concentrated Influx of Na+ & Cl-, efflux K+, P and N. Hyperkalemia (causes by potasium release by skeletal muscle and efflux from body tissues), which can cause cardiac arrest. Low perfusion causes organ disturbances (especially kidneys) and tissue necrosis Damage of brain results in Cheyne-Stokes respiration, central fever, paralysis, brain edema, convulsion, coma. Thanks for visiting! | http://medicalthink.blogspot.com/ Febrile convulsion affects children who experience a rapid rise in body temperature. If the fever recedes, there is muscular relaxation and abundant sweating. Heat loss then predominates over heat production and temperature falls. Types of fever: Based on the pattern of body temperature Intermitten Remittent Relapsing Continue Intermitten fever Fever with large diurnal variation

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 Hectic/ Septic fever: if the var iation is very large Quotidian fever: if hectic fever occurs in each day Remittent fever A marked variation in temperature level each day, but the low point is still above the normal day. Relapsing fever Short febrile periods interspersed by periods of one or more days of normal temperature. Tertian: if the febrile periods occur in the 1 st & 3rd day Quartan: if the febrile periods occur in the 1 st & 4th day. Clinical causes of fever Typhoid & Paratyphoid fever Remittent fever with staircase rises for several days followed with a plateau for one to three weeks, then a step like return to normal temperature Dengue fever A saddleback curve (pelana kuda) or biphasic pattern, meant that a fever rises rapidly, then declines somewhat during the succeeding two or three days, then it rises again to peak on about the sixth day, after which it subsides quickly. Malaria Fever occurs in the 1 st & 3rd day (relapsing fever), as seen in Malaria Tertiana caused by Plasmodium vivax & P. ovale. Fever occurs in the 1 st & 3rd day (relapsing fever), as seen in Malaria Tertiana caused by plasmodium vivax & ovale. Disorder of CNS Head injury (related with prognosis) Cerebral vascular accident (high fever relates to large hemorrhage) Neurogenic hyperthermia (surgical operation of pituitary fossa & the 3 rd ventricle) Spinal cord injury (interruption of the tract to & from the hypothalamus) Neoplasma Thanks for visiting! | http://medicalthink.blogspot.com/

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 Lymphomas: the first symptom is fever Hodgkins disease: relapsing fever known as Pel-Ebstein fever 7-10 days of normal temperature alternate with equal periods of fever Drugs causing fever Sulfonamide, penicillin, iodides, bromides, barbiturates, atropine, belladona, and morphine. Dinitrophenol (weight reduction) Arsenic drug or penicillin in the thera py of Syphilis Summary Is fever physiologic or pathologic? Is fever a symptom or sign? Is fever always associated with infection?

References Baratwidjaja, KG. 2004. Imunologi Dasar. Ed.6. BP FK UI. Thanks for visiting! | http://medicalthink.blogspot.com/ Iwan Darmansyah & Suharti K. Suherman (Eds). 1981. Penatalaksanaan Demam . Isselbacher et al. (Eds). Harrisons Internal Medicines. McBryde (Ed). 1952. Signs and Symptoms: Applied pathologic physiology and clinical interpretation . Philadelphia: J.B. Lippincott. Subowo. 1993. Imunologi . Bandung: Angkasa. p187-205.

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