QUARTERLY BEAT / OCTOBER 2023 ///
/// QUARTERLY BEAT / OCTOBER 2023
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COAGULOPATHY Vasculature such as arteries, capillaries, and venous structures are widely affected by heatstroke; increased vascular permeability can result in edema and hypoalbuminemia. Trauma to the endothelium causes the release of thromboplastin and factor XII, which activate the coagulation cascade. With heatstroke, global damage causes an exaggerated release and utilization of coagulation factors; prolonged PT/PTT and thrombocytopenia are commonly seen. At this point the body will start to exhibit signs of systemic inflammatory response syndrome (SIRS) and/or disseminated intravascular coagulopathy (DIC). DIC, which may not be seen immediately, presents as microthrombi in the vasculature, but also can present as spontaneous bleeding due to the severe overstimulation of the coagulation cascade. This can be seen on the skin as petechia or ecchymosis.
increased intracranial pressure (ICP), or direct vascular damage. To support a patient’s CNS and treat cerebral edema, it is recommended to elevate the head, while avoiding compression of the jugular veins. The use of hypertonic saline or mannitol can be used to decrease ICP. Mannitol, an osmotic diuretic, may be contraindicated in patients with dehydration, hypotension, and concerns for intracranial hemorrhage.
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Melena
increased utilization of blood glucose with severely decreased production.
Hematuria
Seizures (resulting from bleeding into the CNS)
GASTROINTESTINAL TRACT (GIT) The gastrointestinal tract, which is the shock organ in our canine patients, can be severely affected with heatstroke. Mucosal damage, leading to hyperpermeability and concern for bacterial translocation out of the GIT (leading to sepsis), may occur. Supportive care for the GI tract may include anti-emetics (to prevent secondary aspiration pneumonia), anti-diarrheals, antacids (e.g., H2 blockers such as famotidine, proton pump inhibitors such as pantoprazole, etc.), and judicious antibiotics, if appropriate. Heatstroke can result in drastic injury to multiple organ systems. This critically ill population is at high risk for developing MODS (which is defined as a dysfunction of two or more organ systems). This disease process is known for having increased morbidity and mortality rates and significantly increases a patient’s ICU stay. Treatment for Heatstroke With the critically ill heat stroke patient, prompt stabilization is imperative. This may include oxygen therapy, establishing venous access with an IV catheter, checking blood glucose, treating for hypoglycemia, volume resuscitating with crystalloids, and cooling measures/thermoregulation. First, ensure that your patient has a secure, patent airway and is adequately oxygenating and ventilating. Flow-by oxygen is immediately warranted. Some patients, especially those at high risk of heat stroke (e.g., such as brachycephalic breeds, obese patients, black-furred or long-haired dogs, or patients with laryngeal paralysis) may need to be intubated or have a tracheostomy tube placed. Next, you want to rapidly gain venous access to start fluid therapy. It is ideal to collect blood while placing your intravenous catheter. A stat blood glucose, along with PCV/ TS should be immediately assessed. You will want to limit the number of times we phlebotomize these patients, especially
Once a patient is exhibiting signs of SIRS or DIC, treatment should focus on aggressive supportive care and transfusions with fresh frozen plasma (FFP) to try to replenish coagulation factors. RESPIRATORY With heat stroke, the pulmonary system may not be able to appropriately perform oxygen exchange due to pulmonary embolism (from secondary coagulopathy), alveolar hemorrhage, and pulmonary edema. Even with rapid identification and treatment, a continued decline in a patient’s respiratory status may occur. Other pulmonary complications such as aspiration pneumonia and non-cardiogenic pulmonary edema (NCPE)/acute respiratory distress syndrome (ARDS) may be seen, with the latter having a poor prognosis. It is important to provide oxygen support and ventilatory support, if needed. Patients should have respiratory rate and effort closely monitored, including pulse oximetry and blood gas monitoring. It is ideal to get baseline thoracic radiographs to monitor any changes during hospitalization. RENAL The renal system, which can be very sensitive to hypotension and acute injury, will need to be monitored closely. We often see azotemia and decreased urine production (e.g., oliguria and anuria) secondary to MODS. The secondary damage from heatstroke can send patients into acute kidney injury secondary to prolonged hypotension, SIRS, DIC, and renal tubular necrosis. Placing an indwelling urinary catheter and monitoring the ins and outs will be helpful in directing the treatment plan. LIVER The hepatic system, which normally helps produce Vitamin K-dependent factors of the clotting cascade, is unable to do so with severe heat stroke. It is common to see thermal injury from prolonged hypoperfusion and splanchnic vasodilation. Microembolisms may start to form due to coagulopathy. Hypoglycemia can also be seen with heatstroke secondary to decreased hepatic function, bacterial translocation, sepsis, or
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CARDIOVASCULAR A multitude of dysfunctions affecting the cardiovascular system can be observed, including cardiac arrhythmias (e.g., ventricular tachycardia, etc.). Appropriate monitoring with an electrocardiogram (ECG) is imperative in the critically ill heatstroke patient. Ventricular arrhythmias should be treated with an antiarrhythmic such as lidocaine if signs of altered perfusion (e.g., hypotension, pallor, etc.) or sustained tachycardia are seen (e.g., HR > 180 bpm). Secondary causes of arrhythmias, such as electrolyte abnormalities (e.g., hypokalemia, hyperkalemia, etc.), acid-base disturbances, or pain should be evaluated and treated if appropriate, to maintain cardiac function. Side effects secondary to hypoperfusion, such as myocardial ischemia, are also of concern.
Clinical signs of DIC associated with heat stroke may include: • Epistaxis • Bleeding from intravenous catheter insertion sites • Hematemesis • Hematochezia
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