Heat-Related Emergencies

With Julianna Jung, MD

Learning Objectives

• After this lecture, you will be able to describe

the pathophysiology of heat-related illness.

• You will learn how to differentiate between

classic and exertional heatstroke.

• You will review an approach to the diagnosis

and management of patients with heatstroke.
Heat Homeostasis Definition

Normally, heat production = heat dissipation

Heat Homeostasis Definition

When heat production > heat dissipation  Core temperature rises

This is the physiologic basis of heatstroke and heat exhaustion.
Heat Production Definition

• Basal metabolism
• About 100 kcal/hour

• Temperature would rise 1 degree/hour

without heat dissipation mechanisms

• Skeletal muscle activity – can raise heat

production 20-fold

Wellcome Images, Yoga practice illustrated with thermography, https://www.flickr.com/photos/wellcomeimages/27710942482, no changes,

CC BY 2.0, flickr
Heat Production Definition

• Metabolic factors

• Thyroid disease

• Medications
(sympathomimetics,
anticholinergics, etc)

• Convusions

• Fever

• Environmental heat

Digitalphotolinds, CC0
Heat Dissipation Definition

Conduction Convection Radiation Evaporation

• Transfer of heat • Transfer of heat • Transfer of heat • Transfer of heat

by direct via air via electro- via conversion of
contact circulation magnetic waves liquid to gas
around body
• Minimal in air, • Bidirectional • Evaporation of 1cc
but significant in • Varies with wind sweat consumes
water velocity • Can result in 0.58 kcal
heat gain in hot
environments • Dominant
mechanism of
heat loss in hot
environments
Thermoregulation Definition

• Central heat sensors monitor core

temperature.

• Temperature inputs are monitored by the

hypothalamus.

BruceBlaus, Hypothalamus, https://commons.wikimedia.org/wiki/File:Blausen_0536_HypothalamusLocation.png, no changes, CC BY 3.0

Thermoregulation Definition

• Increases in body temperature activate

thermoregulatory effectors:
• Vasodilation

• Sweating

• Acclimatization occurs with repeated heat

exposures:
• Increased sweat volume and
decreased Na concentration

• Increased plasma volume and cardiac

stroke volume

Pexels, CC0
Heat-Related Emergencies: Case Study 1

47-year-old man found at home by family with altered mental status. H/o
schizophrenia, on haloperidol and benztropine. It’s August, and
temperatures have been 35–38 °C.

• VS: T 41.4, P 132, R 28, BP 98/40, SpO2 99 % on room air

• Skin is hot and dry, without axillary sweat

• Pupils are 6 mm and reactive

• Patient moans and opens eyes to pain, and withdraws all extremities

Josealbafotos, CC0
Classic Heatstroke
Classic Heatstroke

• Occurs during seasonal heat waves

• Affects debilitated people with limited

access to fluids and cool environments

Werni, CC0
Epidemiology and Risk Factors Epidemiology

• Advanced age or immobility

• Psychiatric disease or dementia

• Dwellings lacking climate control

• Medications that impair heat response

Medications that Impair Heat Response
Pathophysiology

• Caused by failure of normal homeostatic

mechanisms

• Allows catastrophic uncontrolled increase in

body temperature

• Tissue damage ensues, affecting all organ

systems
Pathophysiology

Hypoperfusion

• Skin vasodilates to dissipate heat

Direct heat-related cellular
• Causes compensatory central
dysfunction
vasoconstriction to maintain BP
• Severe vasoconstriction leads to ischemia of
viscera
Clinical Presentation Signs/Symptoms

CNS Cardiovascular
• Neurologic abnormalities are universal • Tachycardia

• Delirium, coma, and seizure are most common findings • Hypotension

• ANY neurologic manifestation is possible • Tachyarrhythmias

Respiratory GI symptoms Coagulopathy Skin

• Tachypnea • Nausea/vomiting • Laboratory • Absent

findings or sweating
• Alkalosis • Diarrhea
• Clinical bleeding
• Hypoxia • Transaminitis
Clinical Presentation Signs/Symptoms

CNS Cardiovascular

• Neurologic abnormalities are universal • Tachycardia

• Delirium, coma, and seizure are most common findings • Hypotension

• ANY neurologic manifestation is possible • Tachyarrhythmias

Respiratory GI symptoms Coagulopathy Skin

• Tachypnea • Nausea/vomiting • Laboratory • Absent

findings sweating
• Alkalosis • Diarrhea
• Clinical bleeding
• Hypoxia • Transaminitis
Diagnostic Criteria Diagnosis

Exposure to external heat stress

Severe CNS dysfunction

Markedly elevated core temperature, usually > 40 °C

Hot and flushed skin  usually dry

Transaminitis
Differential Diagnosis Diagnosis

• Thyroid storm • Malignant hyperthermia

• Sympathomimetic • Sepsis/septic shock

intoxication
• Meningitis/encephalitis
• Serotonin syndrome
• CNS hemorrhage
• Neuroleptic malignant
syndrome
Temperature Reduction Management

Continuous core temperature monitoring

Rapid cooling – most important aspect of management!

Tepid water mist and fans Ice water immersion Stop when core
(evaporative) (conductive) temperature reaches 39
Other Treatments Management

Volume resuscitation Avoid vasoconstrictors Antipyretics

• Be bold but • Treat dysrhythmias • Are not indicated
judicious with cooling, not drugs and may be harmful
Heat-Related Emergencies: Case Study 2

29-year-old man, collapsed during last mile of Iron Man triathlon.

Previously healthy, no PMH. It’s May, and temperature today is 27° C.

• VS: T 41.4, P 132, R 28, BP 98/40, SpO2 99 % on room air

• Skin is hot and diaphoretic

• Pupils are 6 mm and reactive

• Eyes are open, mumbles when spoken to, localizes pain

Pxhere, PD
Exertional Heatstroke
Classic vs. Exertional Heatstroke Signs/Symptoms

Finding Classic Exertional

Patient age Old Young
Health status Debilitated Healthy
Predisposing factors Medications, poor housing Athletic competition/training
Occurrence During heat waves Sporadic
Skin Anhidrosis Diaphoresis
Glucose Normal Low
Lactic acidosis Absent Often severe
Coagulopathy Mild Severe, DIC
Renal Oliguria Acute kidney injury
Rhabdomyolysis Absent or mild Often severe
Management of Exertional Heatstroke Management
Take-Home Points

Failure of normal heat homeostasis causes heat-

related illness
In the setting of heat stress, elevated temperature
and CNS dysfunction should prompt concern for
heatstroke
Heatstroke occurs in two distinct forms: classic and
exertional

The mainstay of treatment is rapid cooling

Supportive care may be needed for a variety of

physiologic derangements

Antipyretics are not indicated

Learning Outcomes

 You have learned the pathophysiology of heat-

related illness.

 You know how to differentiate between classic and

exertional heatstroke.

 You have reviewed an approach to the diagnosis

and management of patients with heatstroke.