A 76 year old female is brought to your ED by EMS on a hot summer day after she was found sitting in a wheelchair outside of her house. The patient is confused, tachycardic, hypotension with a temperature of 40.8 C (105.5˚F). As you are concerned about heat stroke, active cooling is started and with fluid boluses. If the patients blood pressure does not improve with fluids, what is the vasopressor of choice for hypotension from heat stroke refractory to fluid bolus? (scroll down for the answer)

a) Dobutamine

b) Norepinephrine

c) Epinephrine

d) Phenylephrine

The correct answer is a) Dobutamine

Both dobutamine or dopamine would be preferred agents in this scenario. The reasoning is that alpha adrenergic stimulation should be avoided as it will cause peripheral vasoconstriction and thus limit cooling by keeping the warm blood at the patients core.

Additionally, altered mental status and hyperthermia together have a broad differential. See the mnemonic TIM’S HHANDS from Dr. Cafaros post: http://emdaily.cooperhealth.org/content/back-basics-hyperthermia-and-altered-mental-status

References:

¹ Stapczynski, J. Stephan,, and Judith E. Tintinalli. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, N.Y.: McGraw-Hill Education LLC., 2011.