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Paediatric heat stroke secondary to vehicular entrapment

A 2-year-old previously healthy boy was transferred via aeromedical retrieval from a remote outback station to the Royal Darwin Hospital with heat stroke. He was missing for 45 min before being found unconscious in an unlocked car. The outside temperature was 35 C. On discovery, the child was unresponsive and floppy. He was immediately cooled by his parents under running water for 20 min. The aeromedical retrieval team arrived 1 h after extraction from the car. At that time, he was hemodynamically stable with a GCS of 14 and a temperature of 39 C. The team fully exposed his body and resuscitated with a 20 mL/kg bolus of 0.9% normal saline. On arrival to the hospital the child had a normal GCS, his temperature was 36.4 C and other vital signs were normal. He was euvolaemic and had a normal neurological examination. Investigations demonstrated hypernatraemia (146 mmol/L), an elevated urea (9.9 mmol/L) and normal creatinine (43 μmol/L). He had low phosphate of 0.90 mmol/L. Creatinine kinase was elevated at 279 U/L (30–150 U/L). His white cell count was raised at 37.9 10/L (6.0–11.0 10/L) with a neutrophilia of 29.4 10/L (1.5–7.0 10/L). His lactate was 3.0 mmol/L. The child was admitted to the paediatric ward and his renal function, electrolytes and white cell count normalised within 48 h. On day 2 post-hyperthermic event he developed a transaminitis with peak alanine aminotransferase of 2580 U/L (<40 U/L) and aspartate aminotransferase 2461 U/L (5–63 U/L). He had otherwise normal synthetic liver function and the transaminitis normalised after 4 weeks.