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Heat stroke related to the use of topiramate. The importance of prevention
Golpe de calor relacionado con el uso de topiramato. La importancia de la prevención
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"apellidos" => "López-Menchero Oliva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Urgencias Pediátricas, Unidad de Cuidados Intensivos Pediátricos, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Pediatría, Hospital Virgen de Altagracia de Valdepeñas, Ciudad Real, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor1" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Golpe de calor relacionado con el uso de topiramato. La importancia de la prevención" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heat stroke is the most severe form of heat-related illnesses. It is a medical emergency and is potentially fatal. Heat stroke is characterised by a core body heat of more than 40<span class="elsevierStyleHsp" style=""></span>°C, accompanied by signs of neurological dysfunction caused by failure of the body's thermoregulatory mechanisms.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">It develops most commonly in the first 24–48<span class="elsevierStyleHsp" style=""></span>h following sun exposure because the body-heat regulating mechanisms fail to initiate. Heat stroke can be classified into classical heat stroke, which affects elderly or chronically illindividuals with impaired thermoregulation, and exertional heat stroke, typically found in young individuals doing strenuous activity at high temperatures whose thermoregulatory mechanisms are intact.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Since heat stroke has a high mortality rate, early diagnosis and treatment are crucial.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the other hand, topiramate, an antiepileptic drug widely prescribed due to its favourable safety profile, is being used increasingly to prevent migraines. Hypohidrosis is one of the described side effects of topiramate, and it can contribute to the development of heat stroke in patients taking this drug.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0025" class="elsevierStylePara elsevierViewall">Girl aged 11 years suffering from migraine headaches that had been receiving prophylactic topiramate treatment for 1 year. She cycles regularly and has good exercise tolerance. Following 90<span class="elsevierStyleHsp" style=""></span>min of strenuous exercise during the hottest time of day in the summer, she presented with elevated body temperature, loss of postural tone with no associated movements, and progressive loss of consciousness. Measures of external cooling were initiated in the referring hospital, including removal of clothing, application of cold pads, and hydration by intravenous administration of cooled physiological saline solution (PSS). She was admitted to the Paediatric Intensive Care Unit (PICU) of our hospital in a state of stupor and nearly unresponsive to external stimuli (Glasgow Coma Scale 12/15), with a measured core body temperature of 40.8<span class="elsevierStyleHsp" style=""></span>°C, blood pressure of 70/30<span class="elsevierStyleHsp" style=""></span>mmHg, and heart rate of 170 beats per minute. The main laboratory results were: creatinine 1.5<span class="elsevierStyleHsp" style=""></span>mg/dL, urea 45<span class="elsevierStyleHsp" style=""></span>mg/dL, creatinine kinase (CK) 116<span class="elsevierStyleHsp" style=""></span>U/L, with normal complete blood count, liver function, and levels of glucose and electrolytes. Cranial computed tomography showed no abnormalities. After the patient was diagnosed with heat stroke, external cooling measures and supportive and symptomatic treatment continued, and the patient's temperature was reduced to 38.2<span class="elsevierStyleHsp" style=""></span>°C in the first hour. She presented initially with bradypsychia, incoherent speech, lack of motor coordination, and symmetrical weakness in all 4 limbs. The patient improved progressively and her symptoms had resolved after 12<span class="elsevierStyleHsp" style=""></span>h in the PICU. She did not require inotropic therapy or respiratory support after initial stabilisation. In the first 24<span class="elsevierStyleHsp" style=""></span>h of admission she showed signs of low cardiac output and mild prerenal kidney failure that resolved completely with intravenous fluid therapy. In the second and third day, laboratory tests revealed hypertransaminasaemia and increased CK and troponin levels (maximum values: AST 928<span class="elsevierStyleHsp" style=""></span>IU/L, ALT 1236<span class="elsevierStyleHsp" style=""></span>U/L, CK 978<span class="elsevierStyleHsp" style=""></span>U/L, troponin I 0.31<span class="elsevierStyleHsp" style=""></span>ng/mL). These levels normalised in the course of 3–4 days, so the patient was discharged a week after admission with full resolution of her symptoms and after complete laboratory analysis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Heat stroke is the most severe form of illness associated to excessive heat. It is a medical emergency most prevalent in July and August. Our patient was seen during the summer after exercising during the hottest part of the day. High heat and strenuous exercise are the two main factors that cause heat stroke in young individuals, with other possible factors including low intake of fluids, the use of drugs that interfere with sweat production, or pre-existing illness.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The case we present here is one of exertional heat stroke related to the use of topiramate. The latter is a very safe drug used to treat seizures and more recently to prevent migraines. Some of its adverse effects are weight loss (15%), anorexia (8%), paresthesias (38%) orsomnolence (8%). Another side effect has been described since 2000: hypohidrosis, associated to skin dryness, facial flushing, and elevated body temperature.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> This new side effect could be attributed to inhibition by topiramate of carbonic anhydrases, enzymes located in the sweat glands that are involved in perspiration.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–9</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The characteristic signs of heat stroke are due both to the direct cytotoxic effects of hyperthermia, and to coagulopathy and the systemic inflammatory response syndrome, which can culminate in multi-organ failure and death.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main symptoms involve dysfunction of the central nervous system, and range from behavioural changes to a deep stupor or even coma. Mild symptoms can resolve gradually, as happened in the case we are presenting here.</p><p id="par0050" class="elsevierStylePara elsevierViewall">At the cardiovascular level, the hyperdynamic response of the body results in increased cardiac output, decreased peripheral resistance, and arterial hypotension, all of which were observed in our patient.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,3</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Kidney damage is one of the earliest clinical manifestations of hyperthermia, brought on by hypotension, dehydration, and rhabdomyolysis. Our patient showed a slight decrease of diuresis with a mild alteration of kidney function, which improved with administration of intravenous fluids.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Muscle injury is more severe in exertional heat stroke due to the local elevation of temperature, hypoxia, and metabolic acidosis associated with exercise. Creatinine kinase is a highly sensitive marker of skeletal muscle injury and its levels appear elevated in 100% of patients with this pathology.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">The liver is the most affected organ in the digestive system, with signs of liver necrosis and elevated AST and ALT levels that can lead to death in up to 10% of cases appearing from the second or third day of heat illness.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Other abnormalities possibly found in these patients include respiratory distress, hypoglycaemia (more common in exertional heat stroke), haematological abnormalities (leukocytosis, bleeding diathesis, anaemia, and even disseminated intravascular coagulation [DIC] in fatal forms of the disease), and electrolyte abnormalities associated to kidney disease and rhabdomyolysis (hyperkalemia, hyperphosphoraemia, and hypocalcaemia).<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,8,11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Heat stroke must be diagnosed promptly, as it is a medical emergency and a treatable cause of multi-organ failure. The diagnosis is usually suggested by the medical history, on account of environmental heat and/or performance of strenuous exercise, and by the physical examination, characterised by an elevated body temperature and dysfunction of the central nervous system.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It must be taken into account that a temperature of less than 40<span class="elsevierStyleHsp" style=""></span>°C can fulfil the temperature criterion if cooling measures have been implemented prior to assessment. The differential diagnosis includes all possible causes of hyperthermia (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">The two main therapeutic objectives are immediate cooling and support of organ–system function (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The body temperature must be reduced to less than 39<span class="elsevierStyleHsp" style=""></span>°C. This can be achieved by means of <span class="elsevierStyleItalic">external cooling methods</span> (wetting skin by application of cold pads, moving the patient to a shaded area, and removal of clothing) or of <span class="elsevierStyleItalic">internal cooling methods</span>, which are more controversial (administration of chilled intravenous solution, and in rare instances peritoneal lavage with PSS cooled to 20<span class="elsevierStyleHsp" style=""></span>°C, gastric lavage with PSS cooled to 9°, or haemodialysis or cardiopulmonary bypass with external cooling of the blood). Antipyretics are ineffective, as their action requires the proper functioning of the hypothalamic thermoregulation centre, which is abnormal in these patients.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,12,13</span></a> The efficacy of sodium dantrolene in the treatment of malignant hyperthermia or malignant neuroleptic syndrome is still under debate.</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">The prognosis depends on how early treatment is begun. A delay of just 2<span class="elsevierStyleHsp" style=""></span>h in starting treatment can raise the probability of death to up to 70%.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Prognosis is also associated to the temperature reached, and is poorer in patients with temperatures higher than 46.5<span class="elsevierStyleHsp" style=""></span>°C. It is also associated to the presence of complications, such as DIC or the persistence of severe neurological abnormalities 8<span class="elsevierStyleHsp" style=""></span>h or more after the onset of symptoms.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Most patients usually recover from kidney and liver symptoms and neurological abnormalities, which generally resolve when the body temperature returns to normal. Muscle weakness can last months in patients who have had extensive muscle damage with deleterious effects.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,14</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">To conclude, heat stroke, whether classic or exertional, is a severe condition and its prognosis depends on how early treatment starts. It has been observed that some drugs, such as topiramate, may favour its development, and only one other case similar to the one we present here has been described in the literature.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Therefore, we would underscore the importance of prevention in patients being treated with topiramate, who should be warned of their increased risk for heat stroke.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors have not conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres369689" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec348849" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres369690" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec348850" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2013-09-10" "fechaAceptado" => "2013-10-21" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec348849" "palabras" => array:3 [ 0 => "Heat stroke" 1 => "Topiramate" 2 => "Oligohydrosis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec348850" "palabras" => array:3 [ 0 => "Golpe de calor" 1 => "Topiramato" 2 => "Hipohidrosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Heat stroke is the most severe pathology related to heat. It is defined as an increase in core body temperature accompanied by signs of neurological dysfunction. In the absence of an early treatment, it has a very high mortality rate.</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Topiramate is a well-known drug widely used in epilepsy treatment and migraine prevention. Oligohydrosis has been described amongst topiramate side effects, favouring the risk of hyperthermia and heatstroke.</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">We present the case of a patient who developed heat stroke due to physical exercise while under topiramate treatment.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Entre las entidades patológicas relacionadas con el calor, el golpe de calor es el más grave. Se define como una elevación de la temperatura corporal central acompañada de signos de disfunción neurológica, presentando una elevada tasa de mortalidad si no se establece un tratamiento precoz.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El topiramato es uno de los fármacos más utilizados en el tratamiento de la epilepsia y en la prevención de las migrañas. Entre sus efectos secundarios, se ha descrito la hipohidrosis, produciendo riesgo de hipertermia y favoreciendo la aparición del golpe de calor.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Presentamos el caso de una paciente que presentó un golpe de calor por ejercicio potenciado por el uso de topiramato.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rosich del Cacho M, Pareja Grande J, Martínez Jiménez MD, Latorre Latorre JF, Bejarano Ramírez N, López-Menchero Oliva C. Golpe de calor relacionado con el uso de topiramato. La importancia de la prevención. An Pediatr (Barc). 2014;81:181–184.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Admission \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">48<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">72<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Day 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" style="border-bottom: 2px solid black">Day 7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creatinine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.7<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">46<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15<span class="elsevierStyleHsp" style=""></span>mg/dL \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AST \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unknown \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">204<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">928<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">283<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">34<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ALT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">156<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1236<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">840<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">208<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">CPK \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">116<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">643<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">978<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">685<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">243<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">67<span class="elsevierStyleHsp" style=""></span>UI/L \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Troponin <span class="elsevierStyleSmallCaps">I</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.31<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.07<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.03<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01<span class="elsevierStyleHsp" style=""></span>ng/mL \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556675.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Evolution of laboratory results.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1. <span class="elsevierStyleItalic">Hyperthermia syndromes</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Conditions caused by environmental heat: heat cramps, heat exhaustion, heat stroke \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Malignant hyperthermia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Malignant neuroleptic syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Drug-induced hyperthermia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2. <span class="elsevierStyleItalic">Infections</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Meningitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Encephalitis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3. <span class="elsevierStyleItalic">Endocrinopathies</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alterations of the CNS \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Haemorrhagic stroke \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Acute hydrocephalus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556676.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Differential diagnosis of heat stroke.</p>" ] ] 2 => array:7 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">1. ABC. Check the airways and breathing. Search for signs of shock and hypovolaemia and correct with colloids, crystalloids, or both. Assess level of consciousness</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">2. Measure rectal temperature and apply cooling methods</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">3. Rule out alternative diagnosis</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">4. Perform complementary tests</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>a. Complete blood count \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>b. Routine chemistry with glucose, kidney and liver function, ions, and muscle enzymes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>c. Venous blood gasometry \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>d. Coagulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>e. Urinalysis and examination of urinary sediment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">5. Monitor for complications</span> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab556677.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Initial management of heat stroke.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:14 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Golpe de calor" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Contreras" 1 => "Mª.A. 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| Year/Month | Html | Total | |
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| 2024 November | 10 | 14 | 24 |
| 2024 October | 119 | 41 | 160 |
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| 2023 September | 141 | 39 | 180 |
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| 2020 May | 149 | 23 | 172 |
| 2020 April | 66 | 14 | 80 |
| 2020 March | 97 | 16 | 113 |
| 2020 February | 91 | 27 | 118 |
| 2020 January | 55 | 3 | 58 |
| 2019 December | 65 | 14 | 79 |
| 2019 November | 50 | 15 | 65 |
| 2019 October | 81 | 17 | 98 |
| 2019 September | 112 | 13 | 125 |
| 2019 August | 143 | 20 | 163 |
| 2019 July | 254 | 20 | 274 |
| 2019 June | 193 | 27 | 220 |
| 2019 May | 254 | 27 | 281 |
| 2019 April | 230 | 28 | 258 |
| 2019 March | 114 | 15 | 129 |
| 2019 February | 70 | 11 | 81 |
| 2019 January | 121 | 54 | 175 |
| 2018 December | 79 | 27 | 106 |
| 2018 November | 205 | 37 | 242 |
| 2018 October | 193 | 28 | 221 |
| 2018 September | 103 | 18 | 121 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 14 | 0 | 14 |
| 2018 June | 7 | 0 | 7 |
| 2018 May | 9 | 0 | 9 |
| 2018 April | 39 | 0 | 39 |
| 2018 March | 70 | 0 | 70 |
| 2018 February | 12 | 0 | 12 |
| 2018 January | 21 | 0 | 21 |
| 2017 December | 16 | 0 | 16 |
| 2017 November | 19 | 0 | 19 |
| 2017 October | 20 | 0 | 20 |
| 2017 September | 18 | 0 | 18 |
| 2017 August | 27 | 0 | 27 |
| 2017 July | 27 | 0 | 27 |
| 2017 June | 37 | 12 | 49 |
| 2017 May | 32 | 9 | 41 |
| 2017 April | 44 | 30 | 74 |
| 2017 March | 29 | 35 | 64 |
| 2017 February | 11 | 5 | 16 |
| 2017 January | 21 | 3 | 24 |
| 2016 December | 33 | 8 | 41 |
| 2016 November | 43 | 9 | 52 |
| 2016 October | 40 | 12 | 52 |
| 2016 September | 48 | 5 | 53 |
| 2016 August | 44 | 3 | 47 |
| 2016 July | 29 | 10 | 39 |
Show all
