Heat illness is a pervasive problem that is often encountered in patients who
present to the emergency department. During summer heat waves, large urban centers see a significant rise in hyperthermia-related fatalities. Heat illness should be thought of as a spectrum of disease from heat cramps to heatstroke. Medication-related hyperthermic conditions such as malignant hyperthermia, serotonin syndrome, and neuroleptic malignant syndrome (NMS) need to be specifically recognized, as the treatment of these diseases requires adjunctive pharmacotherapy (eg, dantrolene, cyproheptadine, bromocriptine, levodopa, amantadine) in addition to rapid cooling measures. Understanding basic principles of thermoregulation and the pathophysiology of hyperthermia is essential to treatment. [1, 2] The image below depicts items used for noninvasive cooling techniques.
Sample display of equipment
useful for various cooling techniques. Clockwise from top: ice pack and water, air-cooling blanket, Foley catheter, and intravenous fluids. View Media Gallery See Heat Illness: How To Cool Off Hyperthermic Patients, a Critical Images slideshow, for tips on treatment options for patients with heat-related illness. Also, see Football Injuries: Slideshow to help diagnose and treat injuries from a football game, including heatstroke, a major concern in college and high school football. Effective thermoregulation, controlled by the hypothalamus, is critical for proper function of the human body, with normal temperature exhibiting diurnal variation between 36-37.5C. Heat is both produced endogenously and acquired from the environment. Metabolic reactions in human bodies are exothermic, contributing 50-60 kcal/h/m2 of body surface area, or 100 kcal/h for a 70-kg person. During strenuous exercise, heat production increases 10- to 20-fold. [3] Environmental heat transfer involves the following 4 mechanisms [3] : Conduction: Direct physical contact transfers heat from a warmer object to a cooler object. Water is about 25 times more conductive (more effective at conducting heat) than air. Convection: Heat is transferred through air and water vapor molecules surrounding the body. Convective heat transfer depends on wind velocity and explains the effect of wearing loose-fitting clothing in warm climates to keep cool. Radiation: Heat is transferred by electromagnetic waves. Radiation is the major source of heat gain in hot ambient climates; up to 300 kcal/h can be gained on a hot summer day. Phase change: The conversion of a solid to a liquid (melting) or a liquid to a gas (evaporation) results in heat transfer. Evaporation of 1 L of sweat from the body results in a loss of 580 kcal of heat. Hyperthermia is defined as elevated core temperature of greater than 38.5C (101.3F). History and clinical examination can help elucidate the etiology of hyperthermia and tailor treatment. The causes of hyperthermia include the following [4] : Increased ambient heat - Heat waves, humidity Increased heat production - Overexertion, thyroid storm, malignant hyperthermia, neuroleptic malignant syndrome, pheochromocytoma, delirium tremens, hypothalamic hemorrhage, toxic ingestions (eg, sympathomimetics, anticholinergics, MDMA) Decreased heat dissipation - Humid environment, poor sweat production Sweating and peripheral vasodilation are major mechanisms of heat loss to maintain proper temperature. In the absence of these mechanisms, baseline temperature would increase 1.1C per hour from basal metabolism alone. [4]Sweat cools the body through evaporation, and peripheral vasodilation provides the blood flow and heat necessary to evaporate the sweat. During periods of high environmental heat and humidity, evaporative cooling can become insufficient, leading to heat illness. Patients at risk for heat illness include the following [5, 6] : Athletes exercising strenuously in hot climates Elderly patients (because of decreased efficacy of thermoregulation, comorbid illness or medications, lack of fans or air conditioning, inappropriate dress) Infants and small children (because of high ratio of surface area to weight, inability to control fluid intake) Patients with cardiac disease or those taking beta-blockers (because of inability to increase cardiac output sufficiently for vasodilation) Patients who are dehydrated because of poor fluid intake, gastroenteritis, and diuretic or alcohol use (Dehydration increases demand on ATPase pumps, which contribute 25-45% of basal metabolic rate.) Patients prone to higher endogenous heat production (eg, infection, thyrotoxicosis) Patients taking medications that inhibit sweat production or increase heat production (eg, anticholinergics, antidepressants, antihistamines, neuroleptics, zonisamide, sympathomimetics, alpha- and beta-blockers), especially in hot weather; deaths from cocaine are markedly increased when the ambient temperature increases [7] Recognizing the clinical signs associated with heat illness determines the appropriate therapy, from fluid replacement for heat exhaustion to rapid aggressive cooling for heatstroke. [4, 5, 6]