550 CSF Leak or Ear Wax? Logical Thinking in Emergency Management of a Collapsed Patient with Heat Stroke

Abstract

Abstract A man in his 60s presented to RESUS by ambulance on the hottest day of the year with suspected STEMI and collapse at home. The patient was intubated and unresponsive (GCS 5), with global rigors. Hospital ECG showed sinus tachycardia. Body temperature was in excess of 41°C, confirmed on central temperature monitoring. Bilateral clear fluid was noted to be discharging from both ear canals. Query CSF leak was indication for CT head, which was unremarkable. Considering this, efforts were focused on optimising body temperature. This was done with the use of ice packs and fans as well as continuous misting of cool water over the exposed patient. Improvement was shown with temperatures decreasing to 38°C. In questioning the cause of the “clear fluid,” a swab of it placed on an icepack swiftly returned the fluid to its natural consistency of ear wax. As a result of the extraordinarily high body temperatures, ear wax had melted in both ear canals and started to leak out, giving the impression of a CSF leak. This was simply identified at the bedside to refute the idea of a CSF leak. As CSF leak was the indication for a CT head, this could have been avoided with rapid cooling initiated earlier. Unfortunately, this patient later died due to heat stroke. Whilst avoiding the delay of a CT head most likely would not have changed the prognosis for this patient, it is useful to note the importance of logical thinking in an emergency setting.