CHAPTER I

INTRODUCTION

1.1 Issue Background

th
Traumatology and Emergency Medic is the 20 blok in the sixth
semester of Competency Based Curriculum of Medical Education Faculty of
Medicine, Muhammadiyah University of Palembang.
In this occasion already implemented tutorial with case Yantok, a boy, 4
years old, BW 16kg brought by his mother to ER RSMP at 2 pm, due to loss
of conciousness since 1 hour. Two hours ago, Yantok was suffered general
convulsion during five minutes. At 9 am, Yantok brought by his mother when
queue “sembako” at Monpera. Yantok began sweating and felt warm in
whole body at 12 pm when the weather was sweltering.

1.2 Purpose and Objectives

The purpose and objectives of this case study tutorial, namely:
1. As a report task group tutorial that is part of KBK learning system at the
Faculty of Medicine, Muhammadiyah University of Palembang.
2. Can solve the case given in the scenario with the method of analysis and
learning group discussion.
3. Achieving the objectives of the tutorial learning method.

1
 CHAPTER II

DISCUSSION

2.1 Tutorial Data

Tutor : dr. Indriyani, M.Biomed.
Moderator : Khoirunnisa Mursyidah
Secretary : M. Aditya Al Muchayat Syah
Notulis : Shabrina Ananda Heparians
Day and date : Tuesday, July 17th, 2018
(08.00 am -10.00 am)
Thursday, July 19th, 2018
(08.00 am -10.00 am)
Rule of tutorial : 1. Gadget should be nonactive or in silent mode.
2. Everyone in the group should express their opinion.
3. ask for permission if want to go outside.
4. Eating and drinking are not allowed in the room.

2.2 Case Scenario

Yantok, a boy, 4 years old, BW 16kg brought by his mother to ER RSMP
at 2 pm, due to loss of conciousness since 1 hour. Two hours ago, Yantok was
suffered general convulsion during five minutes. At 9 am, Yantok brought by
his mother when queue “sembako” at Monpera. Yantok began sweating and
felt warm in whole body at 12 pm when the weather was sweltering.
Physical examination:
Primary Survey :
- Airway : No snoring
- Breathing : RR 32x/minutes, no rales, no wheezing
- Circulation : BP 90/70 mmHg, Pulse rate 140x/minutes, hot
extremities, capillary refilled time <3 second
- Disability : Eyes opening response to pain, Best motor response move
to localized pain, best verbal response inappropriate words, normal pupil,
sight reflex (+)

2
 - Exposure : Temp 41oC, General flushing

Secondary Survey :
- Head
Eye : normal conjungtiva
Nose : Breath of the nostrils (-)
Ear : no abnormality
Mouth : dry lips
- Neck : in normal limit
- Chest : in normal limit
- Abdomen : in normal limit
Upper and lower extremities : hot and flushing

2.3 Clarification of Terms

No Terms Clarifications
1. Conciousness The state of being wake and aware of one
surrounding (Graham, 2017).
2. Convulsion A sudden, violent, irregullar movement of a limb
or of the body cause by involuntary contraction
of muscle (Adam, 2017)
3. Sight reflex Is an optical devide that allow the user to look
through a partically
4. Sweltering Hot weather can cause hyperhidrosis
5. Capillary refilled time The time taken for color to return to an external
capillary after pressure is a applied to cause
blanching.

2.4 Identification of Problem

1. Yantok, a boy, 4 years old, BW 16kg brought by his mother to ER RSMP
at 2 pm, due to loss of conciousness since 1 hour. Two hours ago, Yantok
was suffered general convulsion during five minutes.

3
 2. At 9 am, Yantok brought by his mother when queue “sembako” at
Monpera. Yantok began sweating and felt warm in whole body at 12 pm
when the weather was sweltering.
3. Physical examination:
 Circulation : BP 90/70 mmHg, Pulse rate 140x/minutes, hot
extremities, capillary refilled time <3 second
 Disability : Eyes opening response to pain, Best motor response move
to localized pain, best verbal response inappropriate words
 Exposure : Temp 41oC, General flushing
 Mouth : dry lips
 Upper and lower extremities : hot and flushing

2.5 Analysis dan Synthesis of Problem

1. Yantok, a boy, 4 years old, BW 16kg brought by his mother to ER RSMP
at 2 pm, due to loss of conciousness since 1 hour. Two hours ago, Yantok
was suffered general convulsion during five minutes.

4
a. What is the cause of loss of conciousness ?
a. Impaired blood circulation in the brain (cerebrum, cerebellum, or brainstem)
- Bleeding, thrombosis or embolism
- Given the high incidence of stroke then the suspicion of stroke in any event of
disturbance of consciousness need to be underlined.
b. Infection: encephalomeningitis (meningitis, encephalitis, cerebritis/brain
abscess)
- Given the infection (bacteria, virus, fungus) is a disease that is often
encountered in Indonesia, so in every disorder of consciousness accompanied
by elevated body temperature should be suspected of encephalomeningitis.
c. Metabolic disorders
- In Indonesia, liver disease, kidney failure, and diabetes mellitus are common.
d. Neoplasm
- Neoplasm of the brain, both primary and metastatic, often encountered in
Indonesia.
- Neoplasms are more common in adult and advanced age groups.
- Decreased awareness generally arises gradually but progressively / not
acutely.
e. Head trauma - Head trauma is most commonly caused by traffic accidents.
f. Epilepsy
- Disturbance of consciousness occurs in cases of generalized epilepsy and
status epilepticus
h. Electrolyte and endocrine disorders
- This disorder often does not show its "identity" clearly; thus requiring special
attention so as not to be forgotten in any quest for the cause of the disorder of
consciousness.
i. metabolic, nutritive and toxic
b. What is the meaning Yantok, loss of conciousness since 1 hour ago ?
Yantok have dehidration, and hot weather it cause sweating and felt warm
in whole body. After that Yantok have heat stroke from that condition.

5
c. How the mechanism of loss of conciousness in this case ?
External heat  heat stress  activation of heat defense (activation the
thermoregulator in hypotalamic)  increase cutaneus vasodilatation 
decrease of venous return and reduce ventricular filling  inadecuate brain
perfusion  hypoxia of cell brain  loss of conciousness.

d. What is the relation of convulsion 2 hours ago with loss of conciousness in

this case ?
It means sign and of loss conciousness. Failure of termoregulation and
high temperature  can’t compensation in body.
From that situation will be increase GABA (to hold inhibitor)  spending of
sitokin in hippocampus, eksitation increase although GABA decrease 
convulsion. Convulsion will cause damage in breain cells  loss of
conciousness.
(Price & Wilson, 2013)

e. What is the etiology of convulsion in this case ?

Convulsion or seizure can cause by :
Unprovoked (“natural”) seizures
Some seizures may be caused by “natural” phenomena occurring in the body,
such as a congenital defect or a chemical imbalance. One example of this is a
condition called GLUT-1 deficiency. Other examples include:
 genetic factors
 congenital (present at birth) problems or conditions
 metabolic or chemical imbalances in the body
 fever/infection
 infection
 neurological problems
 Alzheimer's disease

6
  unknown reasons

Provoked seizures
Some seizures are considered provoked if they are caused by an event that
happened to the individual. Brain injuries are often the cause of provoked
seizures. Other examples include:
 birth trauma
 alcohol or drugs
 head or brain trauma
 progressive brain disease
 stroke
 unknown reasons
 brain tumors
 hemimegalencephaly
 cortical dysplasia
 mesial temporal sclerosis
 drug withdrawal
 medications
(Hopkins, 2012)

f. What are the risk factor of convulsion to child ?

1. febrile seizures
2. infection: meningitis, encephalitis
3. metabolic disorders: hypoglycemia, hyponatremia, hypoxemia,
hypocalcemia, electrolyte disorders, pyridoxine deficiency, renal failure,
liver failure, congenital metabolic disorders
4. head trauma
5. poisoning: alcohol, theophylline
(Schweich PJ, Zempsky WT, 2009)
g. How the pathophysiology of convulsion in this case ?

7
 Failure of termoregulation and high temperature  can’t compensation
in body. Information to anterior hippotalamus  Physiology respons of heat
(thermoregulator)  increase cardiac output  From that situation will be
increase GABA HSP-70 (to hold inhibitor)  spending of sitokin in
hippocampus, eksitation increase although GABA decrease  apoptosis &
death cell  inbalance of neuron cells membrane  inbalance ion diffusion
of kalium and sodium  damaged of neurotransmitter  convulsion.

h. How the relation of age and sex, BW in this case ?

One of predisposing factors to classic heat stroke is young children and
individuals over 65 years (Morch, 2017).
Infants, children, and elderly persons have a higher incidence of heat stroke
than young, healthy adults. Infants and children are at risk for heat illness due to
inefficient sweating, a higher metabolic rate, and their inability to care for
themselves and control their environment (Helman, 2017).

2. At 9 am, Yantok brought by his mother when queue “sembako” at

Monpera. Yantok began sweating and felt warm in whole body at 12 pm
when the weather was sweltering.

a. What is possibility of illness causes by heat temperature ?

Most infectious bacteria and viruses in humans develop well if our body
temperature is at a point at 37.1 ° Celsius. When we have a fever and
increased body temperature, it means our body is defending itself and fighting
against viruses and bacteria that cause the infection. Small children can be
said to have a fever if the temperature is above 37.2 ° Celsius when measured
in the armpits, while adults are above 38 ° Celsius.
• Typhoid fever
This infection is caused by Salmonella bacteria, high fever up to 39-40 °
Celsius. The pattern of fever was up and down, in the morning our body
temperature can go down, but after that can go back up during the whole day.
• Dengue fever

8
 transmitted by Aedes mosquito bites that are infected with dengue virus. The
peak of this fever can be very high that reaches 40 ° Celsius or more ..
• Malaria
is transmitted through the bite of infected Anopheles mosquitoes. Malaria
symptoms usually take 7-18 days between infected and the appearance of
symptoms (incubation period), but there are also new symptoms come out
one year later.

b. What is the relation queue “sembako” at 9 am with convulsion sampai jam 12

?
Queuing of basic foods for 3 hours standing in hot and crowded weather
conditions will increase basal metabolism and increased oxygen demand
cause changes in the balance of neuron cell membranes resulting in diffusion
through the k + ion membrane and the Na + ion releases an electrical charge
resulting in a seizure.

c. What is the meaning of sweating and felt warm in whole body ?

A rise in the temperature of the blood by less than 1°C activates
peripheral and hypothalamic heat receptors that signal the hypothalamic
thermoregulatory center, and the efferent response from this center increases
the delivery of heated blood to the surface of the body. Active sympathetic
cutaneous vasodilation then increases blood flow in the skin by up to 8 liters
per minute. An increase in the blood temperature also initiates thermal
sweating.

d. How the pathophysiology sweating and felt warm in whole body at 12 pm ?

Failure of termoregulation and high temperature  can’t compensation
in body. Information to anterior hippotalamus  Physiology respons of heat
(thermoregulator)  increase cardiac output  increase blood flow in skin
 dilatation peripheral vein  stimulation of eccrine sweat gland 
sweating.

9
 Body change heat to environment / evaporation decrease termoregulator
 increase heat and felt warm in whole body.

e. Definition heat stroke ?

Core body temperature >40°C due to a failure of the normal
thermoregulatory mechanisms. This results in the systemic inflammatory
response syndrome and multiorgan failure in which central nervous system
dysfunction predominates. Further subclassified into exertional and non-
exertional heat stroke. (Adam & William, 2016)

f. Classification heat stroke ?

Heat stroke consists of two types, namely:

1. Exertional Heat Stroke (EHS)

Exertional heat stroke generally occurs in young individuals who are

involved in long-term heavy activity in hot environments, such as
athletes, firefighters, and military personnel.

2. Classic / Non exertional Heat Stroke (NEHS)

Classic None xertional heat stroke (NEHS) generally attacks people

who can not control their environment by fluid intake, for example in
the elderly, people with chronic illness, and in infants or children.
Classic NEHS usually occurs at very high environmental temperatures
and usually occurs in areas that have never experienced high
temperatures, but suddenly there is a high temperature change, so
many individuals who experience the failure of temperature adaptation
in the area and there was heat stroke. With rising temperatures due to
global warming, the incidence rate of heat stroke is predicted to
increase.

g. Manifestation heat stroke ?

 Throbbing headache

10
  Dizziness and light-headedness
 Lack of sweating despite the heat
 Red, hot, and dry skin
 Muscle weakness or cramps
 Nausea and vomiting
 Rapid heartbeat, which may be either strong or weak
 Rapid, shallow breathing
 Behavioral changes such as confusion, disorientation, or staggering
 Seizures
 Unconsciousness

h. Risk factor heat stroke ?

High temperature and humadity, direct sun exposure, with no breeze and wind

-heavy physically labor

- no recent exposure to hot work place

- low liquid intake

- water proof clothing

i. Epidemiology heat stroke ?

More likely in tropical climates heat stroke affects all races equally 
infants, children, and elderly persons have a higher incidence of heat stroke than
young, healthy adults. Infants and children are at risk for heat illness due to
inefficient sweating, a higher metabolic rate, and their inability to care for
themselves and control their environment. 

3. Physical examination:

11
 Circulation : BP 90/70 mmHg, Pulse rate 140x/minutes, hot
extremities, capillary refilled time <3 second
 Disability : Eyes opening response to pain, Best motor response move to
localized pain, best verbal response inappropriate words
 Exposure : Temp 41oC, General flushing
 Mouth : dry lips
 Upper and lower extremities : hot and flushing

a. How the interpretation of primary survey ?

Table 1. Interpretation of Primary Survey
Primary Survey In case Normal Value Interpretation
Airway No snoring No snoring Normal
Breathing

Respiration Rate 32x/minutes 20-50x/minutes Normal

No rales No rales Normal

No wheezing No wheezing Normal

Circulation

Blood Pressure 90/70 mmHg 99/65 mmHg Hypotension

Pulse rate 140x/minutes 105x/minutes Tachycardia

Extremities Hot extremities Normal Hipertermia

temperature
extremities
Capillary <3 second <3 second Normal
refilled time

Disability

GCS Eyes opening Eyes opening Eye 2

response to pain spontaneously
(Eye 4)
Best motor Best motor Movement 5
response move response obeys
to localized pain commands

12
 (Movement 6)
Best verbal Best verbal Verbal 3
response response
inappropriate oriented (Verbal
words 5)

GCS 10

Pupil Normal pupil Normal pupil Normal

Sight reflex Positive Normal

Exposure

Temperature 41oC 36.4°C (97.4°F) Hyperpyrexia

-
37.5°C (99.5°F)
Body General flushing No general General
flushing flushing

b. How the mechanism of primary survey ?

 External heat load → Heat stress → activation of heat defense (activation the
thermoregulator in hypotalamic → cutaneus vasodilatation ( ↑Blood flow to
cutaneus 8 L/m) → decrease of venous return reduce ventricullar filling →
ventricular muscle’s signal overrides → pump fase, but not effective →
Tachycardia & ↑ pulse rate
 External heat load → Heat stress → activation of heat defense (activation the
thermoregulator in hypotalamic → cutaneus vasodilatation ( ↑Blood flow to
cutaneus 8 L/m) → decrease of venous return reduce ventricullar filling →
ventricular muscle’s signal overides → pump fase, but not effective → cardiac
output ↓ → Hypotension

c. How does the evaluation of primary survey ?

13
 The evaluation of primary survey in this case, are:
1. Airway
In this case, the airway is normal (no snoring). We must ensure that the
airway remains normal and there is no decrease in the status of the airway
(ATLS, 2012).
2. Breathing
In this case, the breathing is normal (RR 20-50x/minutes for children).
Keep the patient’s breathing normal (ATLS, 2012).
3. Circulation
In this case, Blood Pressure is Hypotension (BP 90/70 mmHg), Pulse rate
is Tachycardia (140x/minutes), hot extremities, capillary refilled time <3
second (normal). And we have to ensure the Blood Pressure becomes
normal (99/65 mmHg), pulse rate becomes normal (105x/minutes), normal
extremities, capillary refilled time still <3 second (ATLS, 2012).
4. Disability
Eyes opening response to pain, best motor response move to localized
pain, and best verbal response inappropriate words are GCS 10. And we
have to ensure the GCS becomes better (the best is 15), keep the patient’s
pupil normal and sight reflex (+) (ATLS, 2012).
5. Exposure
In this case, the temperature is 41oC and the is general flushing. For children, a
normal temperature is actually considered to be around 36.4°C (97.4°F) -
37.5°C (99.5°F), and no general flushing anymore (ATLS, 2012).

d. How the interpretation of secondary survey ?

14
 Table 2. Interpretation of Secondary Survey
Secondary In case Normal Value Interpretation
Survey
Head
Eye Normal Normal Normal
conjungtiva conjungtiva

Nose Breath of the Negative Normal

nostrils

Ear No abnormality No abnormality Normal

Mouth Dry lips Normal lips Dry lips

Neck In normal limit In normal limit Normal

Chest In normal limit In normal limit Normal

Abdomen In normal limit In normal limit Normal

Upper and Hot and Flushing In normal limit Hot and

lower Flushing
extremities

e. How the mechanism of secondary survey ?

Heat exposure  Heat gain > heat loss  Raising of core temperature 
vasodilatation and sweating  hot and flushing  dry lips

4. How to diagnose in this case ?

First inspection to see the condition, in this case Yantok loss of his
conciousness. Anamnesis from his mother Yantok sweating and felt warm
after 3 hours queue under hot weather and dehidration from that condition. In
physical examination Yantok hypotention, takikardi, hipertemi.

5. What is different diagnosis in this case ?

15
 Heat Stroke e.c hot temperature
 Heat Syncope
 Heat Exhaustion

6. What is working diagnosis in this case ?

Heat Stroke e.c hot temperature

7. How is the treatment in this case ?

Medical Care
Heat stroke is a medical emergency and continues to be one of the leading
causes of preventable death in sports. Rapid reduction of the core body
temperature is the cornerstone of treatment because the duration of hyperthermia
is the primary determinant of outcome. Patients diagnosed with exertional heat
stroke (EHS) or nonexertional heat stroke (NEHS) should be admitted to the
hospital for at least 48 hours to monitor for complications (Helman, 2017).
Once heat stroke is suspected, cooling must begin immediately and must be
continued during the patient's resuscitation. The American College of Sports
Medicine recommends that cooling be initiated at the scene, before transporting
the patient to an emergency department for further evaluation and
treatment. Despite extensive education and training, delays are still reported due to
trepidation by athletic trainers to accurately diagnose and rapidly initiate treatment
for EHS (Helman, 2017).
Controversy still exists over what therapeutic modality is most effective in
the treatment of heat stroke. However, the basic premise of rapidly lowering the
core temperature to about 39°C (to avoid overshooting and rebound hyperthermia)
remains the primary goal (Helman, 2017).
According to one study, oral temperature assessments consistently reflected
inaccurate core body temperatures, which delayed the diagnosis and ultimate
treatment of patients with heat stroke. Rectal temperatures are still the preferred
method of accurately obtaining core body temperatures (Helman, 2017).

16
 Some studies have shown that promptly reducing the exposure time to
excessive heat can dramatically improve long-term outcomes and decrease
irreversible injury. If treatment is initiated within this so-called golden hour and is
aggressive enough to rapidly reduce the core body temperature, complications
(including multisystem organ failure) may be averted and the patient may have a
much better prognosis (Helman, 2017).
In a review of 19 clinical trials and observational studies involving 556
patients, the conduction method of cooling was found to be more efficacious in
young, active adults with EHS. Unfortunately, this review did not identify a
preferred treatment found for NEHS, or a temperature endpoint to prevent
overcooling (Helman, 2017).
Removal of restrictive clothing and spraying water on the body, covering the
patient with ice water–soaked sheets, or placing ice packs in the axillae and groin
may reduce the patient's temperature significantly. Patients who are unable to
protect their airway should be intubated. Patients who are awake and responsive
should receive supplemental oxygen (Helman, 2017).
Intravenous lines may be placed in anticipation of fluid resuscitation and for
the infusion of dextrose and thiamine if indicated. Hypoglycemia is a common
occurrence in patients with EHS and may be a manifestation of liver failure;
therefore, infusion of dextrose 50% in water solution (D50W) should be
considered in all patients with heat stroke (Helman, 2017).
Intensive care personnel must pay meticulous attention to the airway, reduce
the temperature, limit the production of heat, optimize circulation, and monitor for
and treat complications. Interventions to enable monitoring include the following
(Helman, 2017):
 Insert a thermistor probe or temperature-sensing Foley catheter to monitor
temperature continuously
 Insert a nasogastric tube to monitor for gastrointestinal bleeding and fluid
losses
 Place a Foley catheter to monitor urine output and/or monitor body
temperature

17
 The goal of treatment is to reduce the temperature by at least 0.2°C/min to
approximately 39°C. Active external cooling generally is halted at 39°C to
prevent overshooting, which can result in iatrogenic hypothermia. A flexible
indwelling thermistor rectally or an esophageal probe can be placed to monitor
core body temperature during treatment; alternatively, a more modern method is
to use a temperature-sensing Foley catheter. Because thermal instability may
persist for a few days after the onset of heat stroke, the temperature must be
monitored continuously until it is stable (Helman, 2017).

1. Methods for cooling

The optimal method of rapidly cooling patients has been a matter of debate
for some time. A 2013 guideline from the Wilderness Medical Society
recommends ice-water immersion as a superior method for rapidly lowering core
body temperature below the critical levels normally found in heat stroke
patients. However, each method has its own theoretical advantages and
disadvantages (Helman, 2017).
Ice-water immersion or an equivalent method has the advantage of rapidly
reducing core body temperature. Because of its high thermal conductivity, ice
water can reduce core body temperature to less than 39°C in approximately 20-40
minutes (Helman, 2017).
The disadvantages of ice-water immersion include the fact that it may be
extremely uncomfortable for patients who are awake. In addition, in theory it can
cause subcutaneous vasoconstriction, preventing the transfer of heat via
conduction. Ice water also increases shivering, which in turn increases internal
heat production. Other criticisms include difficulty monitoring and resuscitating
patients while using this method (Helman, 2017).
Evaporative heat loss, although perhaps less effective than immersion
techniques, poses fewer practical difficulties. Evaporative body heat loss may be
accomplished by removing all of the patient's clothes and intermittently spraying
the patient's body with tepid water while a powerful fan blows across the body,
allowing the heat to evaporate (Helman, 2017).

18
 A number of other cooling techniques have been suggested, but none has
proven superior to or equal to cold-water immersion or evaporative techniques.
These include peritoneal, thoracic, rectal, and gastric lavage with ice water; cold
intravenous fluids; cold humidified oxygen; cooling blankets; and wet towels
(Helman, 2017).
Cardiopulmonary bypass has been suggested for use in the most severe cases.
However, this requires highly trained personnel and sophisticated equipment
(Helman, 2017).

Picture 1. Sample display of equipment useful for noninvasive cooling

techniques. Clockwise from top: ice pack and water, air-cooling blanket,
Foley catheter, and intravenous fluids.
Source: Helman, 2017.

19
 Picture 2. Sample display of equipment useful for cooling via gastric
lavage. Clockwise from top: ice water, nasogastric tube, endotracheal tube,
and lavage bag.
Source: Helman, 2017.

Picture 3 . Sample display of equipment useful for cooling via peritoneal

lavage. Clockwise from top: iced water, peritoneal catheter, and saline fluid.

20
2. Pharmacologic measures
Antipyretics (eg, acetaminophen, aspirin, other nonsteroidal anti-
inflammatory drugs) have no role in the treatment of heat stroke because
antipyretics interrupt the change in the hypothalamic set point caused by
pyrogens; they are not expected to work on a healthy hypothalamus that has been
overloaded, as in the case of heat stroke. In this situation, antipyretics actually
may be harmful in patients who develop hepatic, hematologic, and renal
complications because they may aggravate bleeding tendencies (Helman, 2017).
Dantrolene has been studied as a possible pharmacologic option in the
treatment of hyperthermia and heat stroke. To date, however, it has not proved
efficacious in clinical trials (Helman, 2017).
Immediate administration of benzodiazepines is indicated in patients with
agitation and shivering, to stop excessive production of heat. In addition,
benzodiazepines are the sedatives of choice in patients with sympathomimetic-
induced delirium as well as alcohol and sedative drug withdrawals (Helman,
2017).
Neuroleptics (eg, chlorpromazine), which were the mainstays of therapy in
the past, are best avoided because of their deleterious adverse effects, including
lowering of the seizure threshold, interference with thermoregulation,
anticholinergic properties, hypotension, hepatotoxicity, and other adverse effects
(Helman, 2017).
Benzodiazepines and, if necessary, barbiturates are the recommended agents
for treatment of patients who are having convulsions. Barbiturates may be used
despite their theoretical impedance of sweat production (Helman, 2017).
Phenytoin is not effective in controlling convulsions in this situation. Patients
whose convulsions are refractory to benzodiazepines and barbiturates should be
paralyzed and provided mechanical ventilation. Electroencephalographic
monitoring is recommended in all such patients, and anticonvulsant medications
should be adjusted accordingly (Helman, 2017).

21
3. Fluid resuscitation
Recommendations on the administration of intravenous fluids for circulatory
support differ among patient populations and depend on the presence of
hypovolemia, preexisting medical conditions, and preexisting cardiovascular
disease (Helman, 2017).
While patients with heat stroke invariably are volume depleted, cooling alone
may improve hypotension and cardiac function by allowing blood to redistribute
centrally. Aggressive fluid resuscitation generally is not recommended because it
may lead to pulmonary edema. Cor pulmonale also is a common finding in
patients with heat stroke (Helman, 2017).
When pulse rate, blood pressure, and urine output do not provide adequate
hemodynamic information, fluid administration should be guided by more
invasive hemodynamic parameters, such as central venous pressure (CVP),
pulmonary capillary wedge pressure, systemic vascular resistance index (SVRI),
and cardiac index (CI) measurements. Patients who exhibit a hyperdynamic state
(ie, high CI, low SVRI) generally respond to cooling and do not require large
amounts of intravenous crystalloid infusions (Helman, 2017).
Hypotensive patients who exhibit a hypodynamic response (ie, high CVP,
low CI) traditionally have been treated with low-dose isoproterenol; however, its
arrhythmogenicity has raised questions about its continued use. Dobutamine,
which is less arrhythmogenic than isoproterenol and more cardioselective, may be
the inotrope of choice in these patients. Alpha-adrenergic drugs generally are
contraindicated because they cause vasoconstriction and may interfere with heat
loss (Helman, 2017).

4. Rhabdomyolysis
The occurrence of rhabdomyolysis may be heralded by the development of
dark, tea-colored urine and tender edematous muscles. Rhabdomyolysis releases
large amounts of myoglobin, which can precipitate in the kidneys and result
in acute kidney injury (AKI). Renal failure especially is common in patients who

22
develop hypotension or shock during the course of their disease and may occur in
as many as 25-30% of patients with EHS (Helman, 2017).
Treatment of rhabdomyolysis involves infusion of large amounts of
intravenous fluids (fluid requirements may be as high as 10 L), alkalinization of
the urine, and infusion of mannitol. Fluid administration is best guided by
invasive hemodynamic parameters, and urine output should be maintained at 3
mL/kg/h to minimize the risk of renal failure (Helman, 2017).
Alkalinization of the urine (to a pH of 7.5-8.0) prevents the precipitation of
myoglobin in the renal tubules and may control acidosis and hyperkalemia in
acute massive muscle necrosis. Mannitol may improve renal blood flow and
glomerular filtration rate, increase urine output, and prevent fluid accumulation in
the interstitial compartment (through its osmotic action). Mannitol also is a free
radical scavenger and, therefore, may reduce damage caused by free radicals.
Once renal failure occurs, dialysis is the only effective therapeutic modality for
rhabdomyolysis (Helman, 2017).

5. Metabolic support
Muscle necrosis may occur so rapidly that hyperkalemia, hypocalcemia, and
hyperphosphatemia become significant enough to cause cardiac arrhythmias and
require immediate therapy. In the presence of renal failure, hemodialysis may be
necessary (Helman, 2017).
Hypertonic dextrose and sodium bicarbonate may be used to shift potassium
into the intracellular environment while more definitive measures (eg, intestinal
potassium binding, dialysis) are prepared. Use of insulin may not be necessary in
patients who are not diabetic and may be deleterious for patients with EHS and
patients with liver failure, who commonly develop hypoglycemia (Helman, 2017).
Calcium should be used judiciously because it may precipitate in and cause
additional muscle damage. Use of calcium is reserved for patients with ventricular
ectopy, impending convulsions, or electrocardiographic evidence of hyperkalemia
(Helman, 2017).

23
 Various other electrolyte abnormalities have been reported in patients with
heat stroke and must be monitored closely and treated carefully. These
abnormalities may be related to solute-altering conditions such as vomiting,
diarrhea, and use of diuretics. For example, hypokalemia, which is common in
the early phases of heat stroke, may develop in response to respiratory
alkalosis, diarrhea, and sweating. Similarly, hyponatremia may be due to
sodium losses and/or rehydration with salt-poor solutions (eg, water), and
hypernatremia may be due to dehydration (Helman, 2017).

8. How is the complication in this case ?

The most serious complication of heat stroke is the occurrence of multiorgan
dysfunction syndrome. including encephalopathy, rhabdomyolysis, acute renal
failure, acute respiratory distress syndrome, myocardial damage,
hepatocellular damage, ischemia, or intestinal infarction, pancreatic damage,
and bleeding complications, especially intravascular disseminatory
coagulation with clear thrombocytopenia (Widjojo, B. D, 2015)

9. How the prognosis ?

Quo Ad Vitam : Dubia ad Bonam
Quo Ad Fungsionam : Dubia ad Bonam
Quo Ad Sanationam : Dubia ad Bonam

10. How does the competence of general practitioner for this case ?
3B, General practitioner be able to make a clinical diagnosis based on physical
examination and examination additional checks requested by doctors such as
lab or x-ray examination. Doctors can decide and give preliminary therapy,
and refer to a specialistrelevant (emergency case).

24
 11. What is the Islamic point of view in this case?

‫سبُنَا هّللا ُ َونِ ْع َم ا ْل َو ِكي ُل‬

ْ ‫َح‬

“Cukuplah Allah (menjadi Penolong) bagi kami dan Dia sebaik-baik

Pelindung.” (Ali Imran 173)

2.6 Conclusion
Yantok, a boy, 4 years old suffered convulsion, dehydration, hypertermi and
loss of conciousnss due to heat stroke.

2.7 Conceptual Framework

Risk Factor : High Temperature

Failure of thermoragulation

Heat stroke

Increase
Decrease venouse
neurotrasmiter GABA Temperature >41oC return

Convulsion keratocongjunctivis
Decrease blood
flow to brain

Pheriperal Increase of
evaporation Hypoksia
Vasodilatation

Loss of
Increse of sweat
Hot and flushing in conciousness
extremities 25

Dehydration