The Tale-Tell Heart. M.Cardillo, E. Sesti, R. Squartito. Emergency Department, Ospedale G. Giglio Cefalù (Italy)

A 79 years old woman arrived in the ED in shock and altered mental status. Medical history revealed vascular dementia and psychosis in treatment with quetiapine since one month. The altered mental status started about two days before with mild confusion that rapidly progressed. 
 
The patient was promptly evaluated in the Shock Room where the continuous  monitoring revealed extreme bradycardia (junctional rhythm at 35 bpm) and severe hypotension (BP 70/50 mmHg). SpO2 was normal. Clinical examination was silent except for cold extremities.
 
  • Lung-heart-IVC sonographic evaluation showed:
  • Normal lung pattern (A lines)
  • Small IVC with normal respiratory pattern
  • Normal ejection fraction ( but take a look to Clip 1)
 
http://youtu.be/H5ZL31ZS3F0
 
 
This is the EKG stripe
 
 
 
 
 
 

After EKG and cardiac sonography what is your diagnosis?

 
 
SOLUZIONE
Corpo: 

Hypothermia secondary to quetiapine

 
Body temperature, measured through a bladder thermistor catheter, was 25.8 °C  (78.5 °F).
 
After rapid volume expansion with normal saline, the patient was rewarmed through:
  • Warm iv saline solution (40° C, 104°F)
  • Warm fluid through nasogastric tube and bladder catheter
  • External rewarming through warm air and thermal blanket 

Have a look at the clip 2

 
http://youtu.be/PI64xYhmN1E
 
 
Hypothermia was secondary to quetiapine. Anti-psycothic drugs are common cause of secondary hypothermia and mortality is about 50%, mostly due to comorbidities.
 
In this small case report ultrasound and EKG showed various effects of hypothermia on the cardiovascular system. The small IVC express the extreme hypovolemia of these patients due to “cold diuresis” (an effect of vasoconstriction) in the previous hours and days before medical contact. EKG showed the Osborn wave (a pathognomonic sign). The direct effect of hypothermia on the mechanics of the heart is little known.
 
Although ejection fraction is preserved, the systolic time is markedly prolonged. This concept, probably known in cardio-thoracic surgery, is not so defined in literature. The first ultrasonographic study was made on pigs in 2013. This study demonstrated that reducing body temperature in the laboratory animals to 33°C (91.4°F) prolonged total systolic time and reduced myocardial velocity without reducing the ejection fraction. The best way to get a normal systolic function in these patients is the rewarming. There is no clear proof in literature that inotropes (except for levosimendan) work under 31°C (87.8°F).
 
 

Clinical Case courtesy of Mauro Cardillo, Emanuele Sesti, Rosario Squartito. Emergency Department, Ospedale G. Giglio Cefalù, Palermo (Italy)

 
  • Hypothermia associated with antipsychotic drug use: a clinical case series and review of current literature. Kreuzer P J Clin Pharmacol. 2012 Jul;52(7):1090-7. 
  • Accidental Hypothermia  Douglas J.A. Brown.  New Engl J Med 2012;367:1930-8. A
  • Effects of Therapeutic Hypothermia on Left Ventricular Function Assessed by Ultrasound Imaging Andreas Espinoza; J Am Soc Echocardiogr 2013;26:1353-63. 
  • Levosimendan is superior to epinephrine in improving myocardial function after cardiopulmonary bypass with deep hypothermic circulatory arrest in rats Rungatscher A et al. J Thorac Cardiovasc Surg. 2012 Jan;143(1):209-14. 
  • Influence of hypothermia on the positive inotropic effect of levosimendan, dobutamine and milrinone AD Rieg et al. Thorac cardiovasc Surg 2009; 56 - P71