Heat Related Illnesses

Erwin Mulyawan, dr, SpAn, DPBA

Case
32 year old bank employee reported
feeling unwell to his colleagues and took a
nap in the afternoon. Did not wake up.
Had traveled extensively on his bike in the
morning. No co-morbidities.
On admission GCS 5/15, HR 150/min, BP
90/60, Temp 40 C, Skin dry. No rash,
meningeal signs, localising signs.

 Diagnosed as heat stroke

Aggressive cooling measures, shifted to
ICU
Progressive severe vasodilatory shock
maximum inotropes within 4 hours
Anuric-dialyzed
DIC and bleeding product support
Progressive severe shock and lactic
acidosis-died on day 4

It does not take long either to boil

an egg or to cook neurons.
Hamilton D, Anaesthesia 32:271, 1976

Nov 2006

 Common medical catastrophe during the

summer
Failure of thermoregulatory mechanism
coupled with an exaggerated acute phase
response
Heat stroke demands urgent attention
because
High mortality
Can cause permanent neurological damage

How common is it?

Largely under diagnosed and under
reported
No reliable Indonesian data
In India, we see about 30-40 patients per
year, of which 12-15 come to the ICU
referral bias

Heat Loss
Conduction
Convection
Radiation
Evaporation
Acclimatization

Kishore P.
Critical Care Conference 2006

Heat Injury Predisposition

3 Factors Influencing Heat Production

1. Increased Internal Heat Production.
Physical Activity
Febrile illness
Pharmacologic agents

2. Increased External Heat Gain

Exposure to high ambient temperature

3. Decreased Ability to Disperse Heat

Pharmacologic agents
Humidity

Heat
Balance
H

Cooling

evaporation
of sweat

External
Heat sources
hot weather
radiant heat sources

Internal
Heat sources
muscle activity

Heat Injury Predisposition

Elderly

Labourers

Sick in our

Medications

hospital wards

Athletes, Military

Poor

Explorers

Infants

Non-Acclimated

Institutionalized

Spectrum of heat illnesses

Heat cramps

Heat syncope

Heat exhaustion

Heat stroke

Heat cramps

Cramps of most worked muscles

After exertion
Copious sweating during exertion
Copious hypotonic fluid replacement
during exertion
Hyperventilation not present in cool
environment
Treat with NS or oral salt water

Heat Syncope
Results from cumulative effect of
peripheral vasodilatation, decreased
vasomotor tone and relative volume
depletion.
Usually occurs in non acclimated pts in
early stage of exposure.
Dx includes excluding more serious
causes of syncope
Treatment includes rehydration, removal
from heat, and rest

Heat exhaustion

Vague malaise, fatigue, headache

Sensorium normal-poor judgment, vertigo
Core temperature < 40,6 C
Tachycardia, dehydration
Rule out other disease states
If in doubt, treat as heat stroke
Treat - Rest, cool environment
Hydration-IV and oral

Heat stroke-clinical diagnosis

Core temperature > 40.6 C
Severe CNS dysfunction (coma, seizures,
delirium)
During periods of sustained high ambient
temperatures
Dry hot skin common but sweating may
persist

Heat Stroke-types
Classic
Summer Heat Waves
No sweat in 84-100% of patients
More insidious onset
Elderly, poor, debilitated patients
Rhabdomyolysis and ARF rare

Heat Stroke-types
Exertional
50% sweat
Young, healthy, labourers, athletes, military
Rhabdomyolysis and ARF common
Usually have predisposing factor

Cellular level

Denaturation of all proteins

Membrane proteins become non functional
This process leads to MOSF
Endothelial damage - cytokine storm sepsis like syndrome
Gut mucosal barrier disruption
translocation of GNB contributes to
sepsis and MOSF

Heat stroke-organ dysfunction

CNS
CNS
drowsiness, coma
delirium, Irritability, bizarre behavior, seizures,
Cerebral edema with raised intracranial pressure.

Cerebellum
Highly sensitive to heat
Ataxia common

Total breakdown of thermoregulation

Any neurological disturbance can occur with
heatstroke.

CVS
Cardiogenic pulmonary edema
Myocardial hypofunction
Cooling related

Endothelial dysfunction profound

capillary leak

Hepatic
Liver injury
SGOT, SGPT > 1000 IU/L
Transaminases may not be elevated at
presentation
Jaundice
Fulminant hepatic failure

Hematological
Thrombocytopenia (aggregation)
DIC aPTT, PT prolonged, low fibrinogen
(protein denaturation)

Pulmonary
Type I respiratory failure
ARDS
Pulmonary edema

Musculoskeletal
Rhabdomyolysis

Renal
Acute renal failure
Volume depletion
Decreased cardiac output
Direct thermal tubular damage
Sepsis syndrome
Rhabdomyolysis

 Heatstroke has been reported to affect

almost every organ in the body except
for the pancreas.

Anyone with hyperpyrexia

and altered mental state is
considered heatstroke until
proven otherwise.

Differential diagnosis

Acute CNS infection

Cerebral malaria
Severe sepsis
Neuroleptic malignant syndrome
Malignant hyperthermia
Thyroid storm

Predictors of multi-organ dysfunction in

heatstroke
G M Varghese, G John, K Thomas, O C Abraham, D Mathai

28 patients over 3 years

Overall mortality 71%
85% in >2 organ failures
Elevated CPK (>1000), liver enzymes > twice
normal and metabolic acidosis were
predictors of mortality
Emerg Med J 2005;22:185187

The golden hour of heat

stroke

Nov 2006

Am J Emerg Med. 1989 Nov;7(6):616-9

Treatment-Cooling methods

Nov 2006

Evaporative
Immersion
Strategic ice packs
Ice cold IV fluids
Ice packing
Cooling blankets
Gastric lavage
Peritoneal lavage
Cardiac bypass
Endovascular cooling catheters

Ice immersion
Most effective method
Large quantities of ice
should be readily
available in a large
tub
Difficult to resuscitate
IV access difficult
Vasoconstriction may
limit heat exchange

Evaporative

Wet the body and

clothes-spray

Precautions
Wet sheets over a patient, without good air flow,
will tend to increase temperature and should be
avoided
Slow down cooling once core temperature is
less than 101F

Cold IV fluids
15 ml/kg of ice cold IV fluids reduces temp
by 1-2C
Patients need fluid resuscitation as they
are usually dehydrated
Cooling more effective in air conditioned
environment

Dangers while cooling

Pulmonary
edema
Overshoot
hypothermia

Mil Med. 2003 Aug;168(8):671-3

Resuscitation. 1991 Feb;21(1):33-9

Supportive treatment
Fluid resuscitation followed by inotrope
and vasopressor therapy
Ventilation for ARDS
Platelet, FFP and cryoprecipitate support
as indicated
Dialysis for ARF
Manage like sepsis

Treatment of early complications

Shivering
Chlorpromazine 25-50mgIV only if cooling is
not adequate because of shivering

Convulsions
Diazepam, Phenobarbitone, Mannitol to
reduce edema

Myoglobinuria
Mannitol and crystalloids

Late complications

Nosocomial sepsis
CIPN, GBS like picture
Cerebellar degeneration
Bickerstaff brainstem encephalitis

Ann Fr Anesth Reanim. 2006 Jul;25(7):780-3. Epub 2006 May 3

J Neurol Neurosurg Psychiatry. 1999 Mar;66(3):408

Heat Stroke No-Nos

Aspirin
Paracetamol
Alcohol baths
Dantrolene

Take home
Common and deadly
Recognize early
Have a high index of suspicion, even in a
hospitalised patient

Early aggressive cooling measures

Rule out differentials
Aggressive organ supportive therapy

 Copyright Texas Parks & Wildlife Department

HEAT, HATE
I hate to hate, but heat makes me hate. Therefore I hate heat, even
though, I repeat, I hate to hate.
Ramesh Gandhi