Dr. Gaddis,

Thank you for your response (August 2017) to our review article entitled “Benzos and Chill,” from December 2016.

We believe you may have missed the point of our article. You stated that we “failed to make crucial points regarding toxin-induced hyperthermic disorders,” but then go on to agree with us and discuss a completely different topic: management of undifferentiated severe hyperthermia. We want to make clear to the readers that our submission, “Benzos and Chill,” was a review on toxin-induced hyperthermic disorders. It is not an evidence-based approach to managing patients who present with undifferentiated hyperthermia.

The majority of patients (82 percent) presenting with toxin-induced hyperthermic disorders, in fact, have mild symptoms and may be treated with benzodiazepines, cooling, withdrawal of the offending agent and supportive care alone—as we discussed in our article. It seems unreasonable and alarming that you recommend to the readers to jump to neuromuscular blockade in these situations. As we mentioned in our article, for cases of suspected toxin-induced severe hyperthermia, neuromuscular blockade is indicated for further control of muscle hyperactivity—or, as you said, putting out the fire from its source.

While we appreciate your anecdotal approach to the several patients you have managed over your 28-year career, we believe an up-to-date, evidence-based method is to be followed when managing the undifferentiated severely hyperthermic patient. In my limited three-year career as an emergency medicine resident, I have also managed several patients with toxin-induced hyperthermic disorders. In each of these patients, of whom all had mild symptoms, the offending agent was easily identified by taking a good history and physical exam.

What you have failed to mention in your anecdotal approach, which we find critical in the management of undifferentiated severely hyperthermic patients, is the importance and effectiveness of using cooling techniques such as chemical, conductive, evaporative, radiation, and core cooling methods. In addition, buried at the end of your response, you also made an incorrect statement that neuromuscular blockade “immediately stops the source of the hyperthermia, and it does not matter what mechanism is in play.” For patients with undifferentiated severe hyperthermia, the source may actually be central, caused by failure of the thermoregulatory pathways at the brainstem, as seen in stroke patients. Therefore, even with neuromuscular blockade, the fire would likely continue to burn.

Finally, we would like to stress the importance of including a consultation with a local poison center or a board-certified medical toxicologist, such as Dr. Kashani the co-author of the article, in the management of these patients.