Written by Joseph Miller
Spoon Feed
In the spectrum of heat-related illness, heat stroke is a can’t miss diagnosis. Aggressive management, with rapid cooling to 38-39°C within 30 minutes of presentation at a rate of 0.20-0.35°C per minute has been shown to not only be safe but improve outcomes.
Why does this matter?
A combination of increasing global temperatures and sociocultural disparities is driving a rise in heat-related illnesses. It is crucial to understand how to treat these conditions, as we will likely see these cases with increasing frequency.
Chilled to perfection
Heat-related illness doesn’t arise in a vacuum. Individual risk factors include age, disability, medications*, and more. Sociocultural factors include poverty, housing, worker protections, and more. And heat exposure is worsened by urban heat islands, lack of access to air conditioning, rising average temperatures, and more. It is important for us to recognize susceptible patients, as heat-related illness is preventable, and we can play a role in intervention and education.
Heat-related illness is a spectrum, and most mild (heat cramps, heat syncope) to moderate (heat exhaustion) illness can be managed by removal from heat and supportive measures (evaporative cooling and hydration).
On the severe end, heat stroke consists of temperature >40°C with altered mental status, is associated with the highest mortality, and should be treated aggressively. Classic heat stroke is more common among elderly patients, whereas exertional heat stroke occurs with extreme physical exertion in healthy patients. Clinicians should obtain a core temperature while addressing the ABCs, followed by immediate cold-water immersion. If unable to immerse, chilled IV crystalloids and evaporative cooling measures may be undertaken. Further, consider bladder irrigation and ice pack application. The goal is to cool by 0.20-0.35°C per minute to a core temp of 38-39°C in 30 minutes. Ultimately, patients with heat stroke should be admitted to the ICU for further monitoring given potential for rapid deterioration. See the management algorithm.
In an ever-warmer world, heat-related illnesses are going to be more commonplace. Physicians play a vital role in recognition and management of these illnesses, especially on the severe spectrum of disease. Additionally, we need to continue to recognize at risk populations to aid in education and prevention of these illnesses.
*Medications include anticholinergics, sympathomimetics, alcohol (sort of a medication), antipsychotics, and many more.
Peer Reviewed by Dr. Ketan Patel and Clay Smith
Source
Treatment and Prevention of Heat-Related Illness. N Engl J Med. 2022 Oct 13;387(15):1404-1413. doi: 10.1056/NEJMcp2210623. Epub 2022 Sep 28.
