Heat Related Illness (HRI) &

Spectum
Dr. Harshal Bhitkar
 Heat Related Illnesses(HRI) and Heatwaves:
Introduction
• The HRI encompass a spectrum of disorders from heat
syncope, muscle cramps, and heat exhaustion to a life-
threatening emergency such as heatstroke.

• a disruption in regulating the body’s temperature because

heat input from the environment and body metabolism is
increased compared with output from the skin via radiation,
evaporation, and convection
• 3,775 deaths were reported during 2015-2019
• heatwave period in India, i.e., from March to July
• Heatwave: ≥ 45°C for 2 days
• Severe Heatwave: ≥47°C
• OR Temperature > 3 degree C above max temp
(40)for persistant 3 days
TEMPERATURE REGULATION
Pathophysiology
 Heat Related Illness (HRI) & Spectum
• Heat Stroke
• Heat Exhaustion
• Heat Cramps
• Heat Collapse
• Heat Rashes
• Heat Fatigue
 Predisposing factors/at risk
• Elderly, children
• Poorly nourished, obesity
• Labourers, military personnel athletes working
strenously in hot environment
• Medications- anticholinergic,
phenothiazineCCB, Beta blockers, stimulants
• Occlusive clothing,, excessive humidity
 Prickly heat (milaria rubra, lichen tropicus)

• Maculopapular, pruritic, erythematous rash commonly over

clothed areas
• Diffuse RED coloured rash
• d/t blockage of sweat ducts by debris causing inflammation
of sweat ducts
• Pruritus predominantly
• Antihistaminics, chlorhexidine, 1% salicylic acid
• Avoid activities and environments causing excess diaphoresis.
 Heat edema
• Swelling of hands, feet and ankles
• d/t peripheral vasodilatation, increased ADH and aldosterone
• Rule out systemic causes
• Resolves without treatment
• Leg elevation
• Compressive stocking
• Don’t use diuretics
 Heat cramps
• Intermittent , painful, involuntary spasmodic muscle
contractions ( Calves, thighs, shoulder)
• Unacclimated individual at rest after vigorous exercise in hot
and humid climate
• Profoundly diuretic, replacing fluid loss with water or
hypotonic fluids
• Hyponatrimia, hypochloremia, hypokalemia, fluid deficiency
at cell level
• Rehydratation with salt & water
• Rest in cooler place
 Hyperventilation tetany
• Exposure to heat can cause hyperventilation
• extremity & circumoral parasthesia, carpopedal spasm
• Little muscle pain
• Respiratory alkalosis
• Reassurance, calm the patient to reduce RR
• remove from heat
 Heat syncope
• Elderly, endurance exercises, prolonged standing in heat,
sudden standing after prolonged exposure to heat
• Postural hypotension
• d/t relative volume depletion, decreased vasomotor tone,
peripheral vasodilation
• Rule out systemic causes of syncope
• Removal from heat source, cooling and rehydration
 Heat Exhaustion
• Increased thirst
• Weakness and extreme tiredness
• Fainting
• Muscle cramps
• Nausea and vomiting
• Irritability
• Headache
• Increased sweating
• Cool, clammy skin
• Body temperature rises, but< 40 Degree C
 Heat Exhaustion
• Thermoregulatory control and CNS function maintained
• Water and salt depletion
• Orthostatic hypotension, tachycardia.
• Temp < 40 degree C
• Hepatic transaminases maybe mildly elevated, urinary sodiuma nd
chloride are low
• NO CNS involvement , may progress to heat stroke
• Remove from heat, rapid cooling and rehydrate with frequent monitoring
of electrolyte
• If no response in 30 min – aggressively cool the patient to core temp < 39
Degree C
 Heat stroke
• total loss of thermoregulatory centre
• core temp>40.5 degree C with CNS dysfunction
• Confusion , delerium, ataxia, seizures, coma
• Late – anhidrosis, coagulopathy, Multiple organ failure
• HOT FLUSHED SKIN
• Tachypnea, tachycardia, hypotension, wide pulse pressure
• Remove from heat area,
• Volume replacement
• If no response in 30 min – aggressively cool the patient to
core temp < 39 Degree C
• CLASSIC epidemic HS
• During long period of high
temp and humidity
• Elderly with comobidities
• On medications that inhibit
sweating, less access to
fluids-- skin hot and dry
• Hepatic dysfunction, renal
failure, DIC, MODS
• EXERTIONAL HS
• Young, previously heathy
• Athlete, labourer, military
recruits
• Profusely diphoretic
• acute renal failure,
rhabdomyolosis
• Elevated CK, LDH
• Thermal cardiomyopathy
– Elevated biomarkers
– elevated CVP
– Deceptive non cardiogenic pulmonary edema
– Tachyarhythmia, non specific ST- T changes, heat related
ischaemia or infarct
 INVESTIGATIONS
• There is no diagnostic test for heatstroke.

• to detect end-organ damage secondary to the metabolic

derangement

• rule out other differential diagnoses of hyperthermia and CNS

dysfunction.
 INVESTIGATIONS

• Arterial Blood Gases (ABG) – Hypoxia, Metabolic acidosis

• Random Blood Sugar
• Serum Electrolytes
• Liver Function Test (LFT)
• Coagulation Studies
• Complete Blood Count
• Renal Function Test (RFT)
• CSF examination
• Muscle Function Tests - Creatinine kinase (CK), Lactate
dehydrogenase (LDH), Aldolase, and Myoglobin
• Electrocardiography (ECG)
• CT Scan
 Management
• Confirm heatstroke
• Airway , breathing , circulation
• IV Access
• Emergency investigations
• Initiate active cooling measures
• Volume Replacement (be careful risk of pulmonary edema )
• Close monitoring
 Cooling
• Remove all clothing with maintaining dignity
• Spray cool water over exposed skin and place under direct
continuous airflow of fans
• Evaporative cooling/ mist fans
• Cold packs in axilla, groin.
• Immersion cooling
• Cooling blankets, gut and bladder irrigation, cold iv fluids
• Cold thoracic and peritoneal lavage
• Cardiopulmonary bypass
• Avoid PCM / NSAIDS
• Terminate active cooling at 38-39 degree celcius
 CLOSE MONITORING
• Temperature every 15-30 minutes (do not overcorrect to less than 38°C).
• Vital signs (BP/HR/SpO2), watch for altered cardiac rhythms (ECG), altered mental
status (GCS)
• Look out for complications of treatment: -
a. Acute pulmonary edema b. Hypothermia
• Seizure (treat with benzodiazepines)
• Prevent shivering (by paralyzing patient if intubated)
• Look for signs of coagulopathy
• Arterial Blood Gas (ABG) analysis regularly – look for metabolic acidosis
• CT brain – to look for complications or rule out intracranial pathology
• Co-management and referral to intensive care unit
• Inform / communicate with next of kin regarding patient condition & prognosis
 Preparedness
• Dedicated bed for HRI patients in cooler area of hospital,
• Thermometer, ORS packets, ice packs, BP apparatus,
• Silver sulphadiazine cream, Calamine lotion, Chlorhexidine in a
light cream or lotion base,
• Cold IV normal saline (0.9%), dextrose 50% in water solution
(D50W),
• Glucometer and testing strips,
• ECG equipment: ECG machine, Gel, electrodes, ECG paper,
• Cooling equipment: AC, cooler, fan , mist fan
• Medicines: Lorazepam, diazepam,
• Ambulance with ice packs and cold water
 Take home message
• Early diagnosis

• Prompt & early treatment by simple measures

can reduce morbidity & mortality