HEAT STROKE

GENERAL EMERGENCY MEDICAL TRAINNING

dr. MARIA SILVIANA

EVIDENCE BASED
MEDICINE

Epidemiology of hospitalization and deaths

from heat illness in soldiers shows that
5246 soldiers were hospitalized, and 37
died due to heat illness.
Hospitalization data were obtained from the Total Army Injury Health Outcomes Database
(TAIHOD) 1980-2002

EVIDENCE BASED
MEDICINE
Conclusion:
Exertional heat illness continues to be a
military problem during training and
operations. Whereas the hospitalization rate
of heat illness is declining, heat stroke has
markedly increased.

EVIDENCE BASED
MEDICINE
Exertional heat stroke (EHS) is one of the
leading causes of death in athletes. Certified
athletic trainers (ATs) demonstrate strong
knowledge of recommended practices with
EHS but are apprehensive in implementing 2
basic procedures: rectal temperature
assessment and cold water immersion.
This apprehension might lead to deaths from
EHS that could have been prevented.

EVIDENCE BASED
MEDICINE
Conclusions:
ATs have basic information on recognition
and treatment of EHS, but 5 themes (lack of
knowledge, comfort level, lack of initiative,
liability concerns, lack of resources) act as
barriers to implementing proper
management in the clinical setting.
Workshops or hands-on training sessions
need to be made available to improve
students' comfort levels so ATs will
implement EBP into everyday settings

HEAT STROKE
Heat stroke is a life-threatening illness
Medical emergency
A form of hyperthermia associated with a
systemic inflammatory response leading to
a syndrome of multiorgan dysfuction in
which encephalopathy predominates
Preventable

HEAT STROKE
This is distinct from afever, where there is
aphysiologicalincrease in the
temperatureset pointof the body.
The term "stroke" in "heat stroke" is a
misnomerin that it does not involve a
blockage or hemorrhage of blood flow to
the brain.

MECHANISMS OF BODY
TEMPERATURE REGULATION

P
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ENVIRONMENTAL THERMO
INJURIES

HOT EXPOSURE
Burns & Scalds Thermal burns
Chemical Burns
Electrical Burns
Sunburn
Heat Exposure
Heat Cramps
Heat Exhaustion
Heat Stroke

HEAT CRAMPS
Painful spasmodic contractions of skeletal
muscle.
Usually occur after exercise or after a
latent period.
Unconditioned, non acclimated individuals
at high risk
Pathogenesis thought to be deficiency of
Na, K+, and
H2O at cellular level.
TH/ includes rest/rehydration

HEAT EXHAUSTION
Signs and symptoms
Headache, nausea, vertigo, weakness, thirst,
myalgia, giddiness etc
May also include
Syncope
Orthostatic hypotension
ST, tachypnea
Diaphoresis
Hyperthermia
Diagnosis of exclusion
Treatment includes rest, volume and electrolyte
replacement, cooling, supine legs up

HEAT STROKE
Core body temp (rectal temp
>40.60C or 1050F
Functional disturbances of CNS
Hot dry skin (anhidrosis)
Able to exclude all other causes of
febrile illnesses

SIGNS & SYMPTOMS HEAT

STROKE

Non-Exertional (Classic) Patients sweat

normally
Elderly & debilitated patients with
chronic underlying disease
Result of impaired thermoregulation
combined with high ambient
temperatures.
Increased risk with
Lack of AC
CV disease
Older age

SIGNS & SYMPTOMS HEAT

STROKE

Exertional:
Typically seen in healthy young adults
who overexert themselves in high
ambient (Surrounding) temperatures or
In a hot environment to which they are
not acclimatized (To adapt)
Due to vigorous activity
Symptoms same as for non-exertional

MANAGEMENT HEAT
STROKE

Initial ABCs, high flow O2

The patients should be placed in a shady
area and the outer clothing should be
removed, immerse victim in very cool
water if possible
If immersion isn't possible, cool victim with
water, or wrap in wet sheets and fan for
quick evaporation
Use cold compresses-especially to the head
& neck area, also to armpits and groin

PRINCIPLES OF COOLING THE

BODY (1)
To effectively and rapidly protect the vital
organs from the heat (CNS, Heart & Lungs,
Liver, Kidneys, Blood & Coagulation
System)
It is essential to rapidly cool the core body
temperature rather than the peripheral
parts of the body

FIELD MANAGEMENT
If the core temperature is >40 oC
Lower the core temperatureto <39.4 oC
Move the patient to a cooler place
Remove his or her clothing
Promote cooling by conduction and
evaporation

INITIATE EXTERNAL
COOLING

Cold packs on the neck, axillae, and groin

Continuous fanning
Opening of the ambulance windows
Spraying of the skin with water at 25 oC to
30 oC

FIELD MANAGEMENT
Initiate high flow O2
Provide volume expansion
Give isotonic crystalloid (normal saline)

Rapid transfer the patient to an

emergency department

METHODS OF RAPID FIELD

COOLING

Mist spray and fanning

Ice in axillae, groin, neck
Ice water bath immersion

ESSENTIAL COOLING METHOD

(HOSPITAL MANAGEMENT)

Undressed the patient

Spray water at room temp over the body
Fanned warm air continuously over the body
Monitor body temperature (keep skin >30 oC,
rectal <39 oC)
If rectal temp does not decrease after 10
minutes, begin NG irrigation with cold saline
(or PD or HD using cold dialysate if indicated)
When temperature approaches 39 active
cooling should be terminated as the body
temperature will continue to fall 1-2 C

COOLING OF THE BODY

TEMPERATURE
WHAT SHOULD BE KEPT IN MIND?
No antipyretics in Exertional Heat Stroke
Cooling the body by physical method is
the only way to decrease the body
temperature

COMPLICATION OF HEAT
STROKE

Heart failure, pulmonary edema,

cardiovascular
Hepatic injury (thermal)
Renal injury

Rhabdomyolysis, myoglobinuria, and renal

failure

Hematological insult
Micro-hemorrhages
Thrombocytopenia
Increased platelet aggregation (thermal)
Fluid/Electrolyte disturbances

PREVENTION

Avoid working in high heat load

Plan work rest cycles
Avoid the sun
Calculate heat index
Sleep at least 6 hours a day
Drink (cool and flavored water)
Consider salt intake (food)
Acclimatize (>2 weeks)
Understand the cumulative effects of heat
Educate athletes, coaches

PREVENTION
Three major ways to prevent heat njuries:
1. Proper Hydration.
2. Wet-bulb monitoring, appropriate
work/rest cycles.
3. Acclimatization.

WET BULB GLOBE

TEMPERATURE (WBGT)
MONITORING
The WBGT index is a good indicator of
external
heat stress on the body.
Determines flag conditions and work/rest
cycles.
WBGT works by incorporating the effects
of air velocity and humidity (wet bulb)
and air temperature (dry) and
radiant heat (globe temperature).

FLAG WARNING
CONDITIONS
Green Flag (WBGTI of 27oC28.9oC)
Heavy exercise, for unacclimatized
personnel, will be conducted with
caution and under constant supervision.

FLAG WARNING
CONDITIONS
Yellow Flag (WBGTI 29oC 30.9oC )
Strenuous exercises, such as marching to
standard cadence, will be curtailed for
unacclimatized personnel for the first 3
weeks
Avoid outdoor classes in the sun

FLAG WARNING
CONDITIONS

Red Flag (WBGTI 31oC 31.9oC )

All PT will be curtailed for those personnel
who have not been thoroughly acclimated
by at least 12 weeks
Those personnel who are fully acclimated
may carry on limited activity not to exceed
6 hours per day.

FLAG WARNING
CONDITIONS
Black Flag (WBGTI > 32oC)
All nonessential physical activity will be
halted for all units.

RECOMMENDATION OF ACTIVITIES IN
HEAT
Brooke Army Medical Center, Fort Sam Houston,
Texas
FLAG

WBGT L/Hr

WATER
INTAKE
Mins/Mins

WORK/REST

White

< 270C

Continous

Green

270C-28.90C

50/10

Yellow

290C-30.90C

45/15

Red

310C-31.90C

30/30

Black

>320C

20/40

THANK YOU