Prognosis; well, not surprisingly, the longer you have been under water and the longer you have been dead, the more likely you are to stay dead. So if you have been underwater for a long time you don’t do so well. If it’s taken resuscitation a long time to get your heart going, you don’t do so well. If you are still apneic by the time you get to the emergency department, you don’t do so well. If you are still pulseless, despite ACLS coming into the emergency department, you don’t do so well. People who are going to do well from near drowning typically have relatively rapid neurologic improvement. Even though they got CPR at the scene, you see them six or eight hours later and they are reaching for their endotracheal tubes and trying to pull it out. In the absence of neurologic improvement over the first day, their outcome is relatively dismal. The degree of metabolic acidosis, in some studies, has been shown to be a helpful predictor in outcome.
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Okay, moving on to environmental exposures. We see environmental exposures very rarely in the ICU. The Board questions almost always have one of these topics reflected; heat stroke, smoke inhalation, or carbon monoxide poisoning.
Heat stroke; heat stroke basically refers to a very high temperature, oftentimes as high as 106 or 107 degrees, where bad things begin to happen to the enzymes in your body. How does this happen? Well, you can have increased heat generation either from pyrogens generating a fever, exercise if you go out to run a marathon across Death Valley, not surprisingly your body temperature rises. Or if you have hypothalamic disregulation problems. Some children with severe neurologic injuries don’t have good hypothalamic regulation and they don’t regulate their temperature well. So they have increased generation of heat. Usually both problems of heat generation and heat dissipation are involved with the development of heat stroke. You can impair heat dissipation with bundling. Bundling decreases both convection and conductive losses of body temperature. If you are in a very hot environment, you have decreased radiation losses to the environment if it is very humid. So if it’s very hot and humid you have decreased evaporative heat losses to the environment, and if you have a congenital difficulty with sweating, you don’t want to go live in a hot environment and get overheated.
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What’s the pathophysiology of heat stroke? Usually you end up getting dehydrated. When you get dehydrated you have hemodynamic changes. Typically what the body would do with hypovolemia is vasoconstrict. Because your temperature is high, the body is trying to unload some of the heat, and what happens is that the body vasodilates. So you have low intravascular volume and you vasodilate. You can imagine that your hemodynamics don’t stay very good and you get very hypotensive. You may have tissue damage from the hypotension, and also directly. As your body starts hitting 42 degrees or above, 106 or 107, you start having enzymatic dysfunction, direct injury to the cells in your body, and a lot of secondary injury to the body. You’ll have altered mental status, you may develop ARDS from some of the pulmonary injuries, and some of the activation of some of the mediators within your body. Myocardial ischemia as you drop your blood pressure, you are tachycardic because you are very hot and your myocardial oxygen supply is very poor so you get myocardial ischemia. You get tissue breakdown of your muscles, with rhabdomyolysis, which gives you secondary renal failure. You develop DIC, hypoglycemia, hypocalcemia, and you end up dead.
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