Heatstroke

Sun Stroke
Acute Management and Prevention

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 Heatstroke
Sun Stroke

Caused by overexposure to sun and extremely

high temperatures
occurs when the brain fails to control its own
"thermostat".
Its a life-threatening condition which can cause a
casualty to become unconscious within minutes.
As well as an unusually high temperature, a
casualty may show signs of restlessness,
headaches and hot, flushed skin.

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 Heatstroke
Sun Stroke

The underlying cause of heat stroke is

connected to the sometimes sudden inability
to dissipate (To drive away) body heat
through perspiration, especially after
strenuous physical activity

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 Heatstroke
Sun Stroke

This accounts for the excessive rise in body temperature.

It is the high fever which can cause permanent damage to internal

organs, and can result in death if not treated immediately.

Recovery depends on heat duration and intensity.

The goal of emergency treatment is to maintain circulation and lower

body temperature as quickly as possible.
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 Definition

core temperature > 41 C OR

- core temp > 40.5 C with anhidrosis
(absence or severe deficiency of sweating),
altered mental status or both

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 Classification
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).

Patients sweat normally.

- non-exertional (classic): usually affects elderly and
debilitated patients with chronic underlying disease.
Result of impaired thermoregulation combined with
high ambient temperatures. Often due to impaired 6
sweating
 Pathophysiology
Substantial fluid shift from central compartment
to periphery. Reversible on cooling
- cardiac output increased +++ (3 l/min per C
increase in rectal temperature). May fail in
patients with limited cardiac reserve
- mediators such as endotoxin and cytokines are
implicated in the pathogenesis of organ damage
in heat stroke
- intractable Disseminated Intravascular
Coagulation (DIC) is usual mode of death in
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fatal cases
 Predisposing factors

Increased heat production

- hyperthyroidism
- exercise
- sepsis

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 Impaired heat loss -Impaired sweating
Drugs
- anticholinergics, anti-Parkinsonian drugs, anti-
histamines, butyrophenones, phenothiazines,
tricyclics
Abnormal sweat glands
- sweat gland injury following acute heat stroke,
barbiturate poisoning
- cystic fibrosis
- healed thermal burn
salt and water depletion
- diuretic induced
Hypokalemia 9
 Impaired voluntary mechanisms
coma
physical disability
mental illness

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 Impaired delivery of blood to peripheral
circulation
cardiovascular disease
hypokalemia (decreased muscle blood flow)
dehydration

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 Others
- elderly
- high ambient temperature and humidity,
poor ventilation
- lack of acclimatization
- obesity
- fatigue
- DM
- malnutrition
- alcoholism
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 Clinical features
often little in the way of warning prodrome (An
early symptom indicating the onset of an attack
or a diseas) prior to development of non-
exertional heat stroke (classic heat stroke).

As thermoregulatory mechanisms fail body

temperature rises rapidly and patient can
deteriorate rapidly from apparent baseline health
to coma or an obtunded state
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 Clinical features

3 cardinal signs are:

CNS dysfunction
hyperpyrexia (core temperature >40 C)
hot dry skin. Pink or ashen depending on
circulatory state. However may be clammy and
sweat

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 CNS
Direct thermal toxicity causes cell death,
cerebral oedema and local haemorrhage
- irritability or irrational behaviour may precede
the development of either form of heatstroke
- confusion, aggressive behaviour, delirium,
convulsions and pupillary abnormalities may
progress rapidly to coma
- decorticate posturing, faecal incontinence,
flaccidity or hemiplegia (however focal signs are
unusual)
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 cerebellar signs, including ataxia and dysarthria
(Speech that is characteristically slurred, slow,
and difficult to produce (difficult to understand).
may be permanent in a few patients. Cerebellum
particularly sensitive to heat
- hypothalamic damage may exacerbate heat
stroke by further impairing sweating and heat
loss
- LP may show increased protein, xanthochromia
(is the yellow discoloration indicating the
presence of bilirubin in the cerebrospinal fluid
(CSF) and slight increase in lymphocytes
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 CVS

- tachycardia
- hypotension or normotension with wide pulse
pressure
- hyperdynamic haemodynamic profile
- myocardial pump failure. Myocardial damage
and frank infarction frequent even in patients with
normal coronaries due to the effect of heat on
myocytes and coronary hypoperfusion secondary
to hypovolaemia 17
ECG of a patient with a core temperature of 40C
dysrhythmias

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Same patient after cooling

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 RS

- extreme tachypnoea with RR up to 60/min

- crackles and cyanosis late signs of pulmonary
oedema
- direct thermal injury to pulmonary vascular
endothelium may lead to cor pulmonale or
Acute respiratory distress syndrome
(ARDS)

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 Metabolic
Dehydration leading to raised urea and
creatinine, and haemoconcentration
- sweating leading to low levels of Na, Mg, K,
early in the illness. Hypokalaemia decreases
sweat secretion and therefore exacerbates the
condition
- rhabdomyolysis resulting in hyperkalaemia,
hypocalcaemia and renal failure
- metabolic acidosis and respiratory alkalosis
common. 21
 Rhabdomyolysis
A condition in which skeletal muscle cells
break down, releasing myoglobin (the oxygen-
carrying pigment in muscle) together with
enzymes and electrolytes from inside the
muscle cells. The risks with rhabdomyolysis
include muscle breakdown and kidney failure
since myoglobin is toxic to the kidneys.

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 Hyperthermia alone can cause primary
hyperventilation and respiratory alkalosis,
while hypoperfusion, tissue hypoxia, and
anaerobic metabolism may lead to lactic
acidosis with respiratory compensation.
Former less common.

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 Renal
Some renal damage occurs in nearly all patients
as a direct result of heat
potentiated by dehydration and
Rhabdomyolysis
acute renal failure 5-6 times more common in
patients with exertional heat stroke in whom it
occurs in 30-35%

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 Splanchnic

Ischaemic intestinal ulceration common. May

lead to haemorrhage

Hepatic damage common. In 5-10% hepatic

necrosis may be severe enough to cause death

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 Haematological
Anaemia and bleeding. Result from: direct
inactivation of platelets and clotting factors by
heat
liver failure
unexplained decrease in platelets and
megakaryocytes (The source of blood platelets)
platelet aggregation due to heat
DIC. Due to activation of clotting cascade by
damaged vascular endothelium. Latter may be
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damaged as a direct result of heat
 Investigations
temperature
- electrolytes, urea, creatinine, calcium
- LFTs
- CPK
- ABG: note that Paco2 and Pao2 will be falsely
low and pH falsely elevated if results are not
corrected for temperature
- ECG and ECG monitoring
- urine output
- FBC, clotting, fibrinogen, FDP, D-dimer.
Anaemia frequent. Platelets low/normal.
Lymphocytosis
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- test urine for myoglobin
 Symptoms of Heatstroke or
Sunstroke

Headache, nausea, dizziness

Red, dry, very hot skin (sweating has ceased)
Pulse-strong & rapid
Small pupils
Very high fever
May become extremely disoriented
Unconsciousness and possible convulsions

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 If exposure to heat continues, the body temperature
rises and heatstroke may develop, causing symptoms
such as:
1.Cessation of sweating
2. Body temperature of 105 degree Fahrenheit
or higher
3. Rapid and shallow breathing
4. Rapid heartbeat
5. Elevated or lowered blood pressure
6. Confusion and disorientation
7. Seizure
8. Fainting, which may be the first sign in older
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adults
 Left untreated, heat stroke may progress to
coma. Death may result due to kidney
failure, acute heart failure, or direct heat
induced damage to the brain.

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First Aid for Heatstroke
or Sunstroke

HEATSROKE IS LIFE THREATENING!

Remove victim to cooler location, out of the sun
Loosen or remove clothing and 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
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 First Aid for Heatstroke or
Sunstroke
Seek medical attention immediately--continue first aid to lower
temp. until medical help takes over

Do NOT give any medication to lower fever--it will not be effective

and may cause further harm

Do NOT use an alcohol rub

It is not advisable to give the victim anything by mouth (even water)

until the condition has been stabilized.
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 Once in the hospital, an examination is done, and blood tests
are carried out to assess the level of salts in the blood.

Treatment of heat stroke is usually carried out

in a critical care unit.

The body temperature is lowered by sponging

the body with tepid water or loosely wrapping
the person in a wet sheet and placing him or
her near a fan.

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Intravenous fluids are given.
 Once the body temperature has been reduced
to 100 degree F(38 degree), these cooling
procedures are stopped to prevent hypothermia
(below) from developing.

Monitoring is still carried out continuously to

make sure that the body temperature returns to
normal level and that the vital organs are
functioning normally 37
 In some severe cases, mechanical
ventilation may be required to help
breathing.

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 when temperature approaches 39 active cooling
should be terminated as the body temperature
will continue to fall 1-2 C

- chlorpromazine 10-50 mg IV 6hrly may be

useful in preventing shivering

- use of dantrolene controversial. Probably

should not be used routinely at present. 39
 Dantrolene
A skeletal muscle relaxant, used as the
sodium salt in the treatment of chronic
spasticity and the treatment and prophylaxis
of malignant hyperthermia (Malignant
hyperthermia is an inherited disease that
causes a rapid rise in body temperature
(fever) and severe muscle contractions
when the affected person receives general
anesthesia 40
 Some medicines can put the patient
in danger of heatstroke.

Allergy medicines Diet pills (amphetamines)

(antihistamines) Irritable bladder and
Cough and cold medicines irritable bowel medicines
(anticholinergics) (anticholinergics)
Blood pressure and heart
medicines Laxatives
Alpha andrenergics such as
midodrine (one brand:
ProAmatine) or pseudoephedrine
(one brand: Sudafed)
Beta blockers 41
Calcium channel blockers
Some medicines can putthe patient
in danger of heatstroke.

Mental health medicines Seizure medicines

Benzodiazepines such as (anticonvulsants)
clonazepam (one brand: Thyroid pills
Klonopin), diazepam (one Water pills
brand: Valium),
chlordiazepoxide (one
brand: Librium)
Neuroleptics
Tricyclic antidepressants

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 Supportive
IV volume replacement. Note that many of these
patients only require 1-1.2 l of replacement fluid
- if inotrope required dobutamine probably drug
of choice
- urgent treatment of hyperkalaemia
- do not treat hypocalcaemia , only give calcium
if ECG changes of severe hyperkalemia occur as
calcium may exacerbate rhabdomyolysis
- small dose of mannitol may benefit patients with
rhabdomyolysis
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 Preventing heat-related
illness

Dress for the heat Wear lightweight, light-coloured clothing.

Light colours will reflect away some of the suns energy. It is also a
good idea to wear hats or to use an umbrella.
Drink water Carry water or juice with you and drink continuously
even if you do not feel thirsty. Avoid alcohol and caffeine, which
dehydrate the body.
Avoid foods that are high in protein, which increase metabolic heat.
Stay indoors when possible.
Take regular breaks when engaged in physical activity on warm
days.
Take time out to find a cool place.
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