Thread by @TayBurkholder

Your answers are on 🔥! These ice bath dunk tanks are for life-threatening hyperthermia at music festivals. Let’s do a little 🧵 on this *hot* topic in #festivalmedicine: 1/#eventmedicine #toxicology

https://twitter.com/TayBurkholder/status/1553048295643041792

Festival-goers can get way too hot for many reasons—high outdoor temps, dancing in crowds, & of course, recreational stimulants like MDMA, cocaine and/or amphetamines. 2/

MDMA likely causes hyperthermia by ⬆️ CNS-mediated heat generation, skin vasoconstriction (⬇️ dissipation), ⬇️ sensation of exhaustion, etc. So severe hyperthermia is really dependent on ambient temps, other drugs/meds, and activity level. 3/

People can present altered/confused, agitated, or seizing. Sustained core temps >104F (40C) can quickly lead to rhabdomyolysis, renal & failure liver failure, DIC, and deadly dysthymias. They code fast! 4/

It’s super important to get an immediate core (eg rectal) temperature. Time at elevated temps is the biggest predictor of death and poor neuro outcomes. Early recognition ⏩ early aggressive cooling measures. 5/

The highest core temp that I’ve seen survive with aggressive cooling was a >113F (45C)!!! (That’s when I found out our rectal thermometers max out at 113) Cause: ingesting 3x a typical dose of MDMA. 6/

For patients that are under 103F and have relatively normal mental status, you can consider less aggressive measures like ice packs, cool IV fluids, mist/fans and frequent temperature monitoring to ensure it’s going down. 7/

Aggressive cooling measures for severe hyperthermia go beyond that. Adequate sedation (e.g. IV or IM benzos) is key for people who are thrashing or moving a lot. Stop the exertion from generating more heat and breaking down more muscle. 8/

Cold-water immersion (dunk tank) is the mainstay for severe hyperthermia. Strongly consider it when close to or > 104F and with some combo of AMS, muscle rigidity, or hemodynamic changes. Continuously monitor vitals + core temp, take them out at 101F and then 🚑 transport! 9/

Intubation with paralysis (RSI) before cold water immersion not only controls the airway during complicated dunking process but also stops muscle tone from generating even more heat. 10/

There is limited data on the use of IV Dantrolene to reduce heat generation from muscles in MDMA toxicity, but it’s controversial. Some event med protocols use it in extreme cases, but I think of it like throwing in the kitchen sink. It’s prime time for a clinical trial! 11/

TL:DR festival hyperthermia:
1.Get a core temp 🌡 immediately for any altered, agitated or seizing patients.
2.Time is brain/survival. Delaying 🚑 transport for cold water immersion is ok.
3.Consider sedation, RSI, and ? other adjuncts like IV dantrolene (if #tox). 12/12

Thoughts or additions? @DrJLOC @hudson_kori @jtrebach @mbspyres @buchana_jab