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Heat Illness in the Emergency Department: Keeping Your Cool

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Heat Illness in the Emergency Department: Keeping Your Cool August 2014 Heat Illness In The Volume 16, Number 8 Emergency Department: Authors Jaron Santelli, MD Department of Emergency Medicine, University of Texas Keeping Your Cool Southwestern, Austin, TX Julie M. Sullivan, MD, FACEP Director of Leadership and Advocacy Education, University of Texas Abstract Southwestern, Austin, TX; Staff Physician, Department of Emergency Medicine, Guadalupe Regional Medical Center, Seguin, TX Heat illness spans a broad spectrum of disease, with outcomes Ann Czarnik, MD, FACEP Assistant Program Director, University of Texas Southwestern, Austin, ranging from benign rash to fatal heat stroke. Heat illness is broad- TX ly divided into 2 types: classic and exertional. Both types occur John Bedolla, MD as a result of exposure to elevated temperature with inadequate Assistant Director of Research Education, University of Texas thermoregulation; however, classic illness occurs without preced- Southwestern Emergency Medicine Program, Austin, TX ing physical activity. Treatment consists of rapid cooling, fluid Peer Reviewers replacement, and physiologic support. Other milder forms of heat Jarone Lee, MD, MPH illness include heat fatigue, heat syncope, heat edema, and heat Quality Director of Surgical Critical Care, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts rash. Drugs, drug combinations, drug side effects, and infections General Hospital, Harvard Medical School, Boston, MA can also cause or complicate heat illness and these manifestations Kamal Medlej, MD may not respond to standard cooling maneuvers and treatments Assistant Professor of Emergency Medicine, Director of Emergency Department Critical Care, Department of Emergency Medicine, alone; each requires specific additional therapy or antidotes to American University of Beirut Medical Center, Beirut, Lebanon reverse the cycle of heat and organ damage. This review examines the physiology, diagnosis, and treatment of exertional, classic, and Prior to beginning this activity, see “Physician CME Information” on the drug-induced hyperthermia. Field and prehospital diagnosis and back page. treatment are also reviewed, with recommendations for rehydra- tion and monitoring in rhabdomyolysis. Editor-In-Chief Michael A. Gibbs, MD, FACEP Charles V. Pollack, Jr., MA, MD, Scott Silvers, MD, FACEP Research Editor Andy Jagoda, MD, FACEP Professor and Chair, Department FACEP Chair, Department of Emergency Michael Guthrie, MD Professor and Chair, Department of of Emergency Medicine, Carolinas Professor and Chair, Department of Medicine, Mayo Clinic, Jacksonville, FL Emergency Medicine Residency, Emergency Medicine, Icahn School Medical Center, University of North Emergency Medicine, Pennsylvania Icahn School of Medicine at Mount Carolina School of Medicine, Chapel Hospital, Perelman School of Corey M. Slovis, MD, FACP, FACEP of Medicine at Mount Sinai, Medical Professor and Chair, Department Sinai, New York, NY Director, Mount Sinai Hospital, New Hill, NC Medicine, University of Pennsylvania, Philadelphia, PA of Emergency Medicine, Vanderbilt Federica Stella, MD York, NY Steven A. Godwin, MD, FACEP University Medical Center, Nashville, Emergency Medicine Residency, Professor and Chair, Department Michael S. Radeos, MD, MPH TN Giovani e Paolo Hospital in Venice, Associate Editor-In-Chief of Emergency Medicine, Assistant Assistant Professor of Emergency University of Padua, Italy Kaushal Shah, MD, FACEP Dean, Simulation Education, Medicine, Weill Medical College Stephen H. Thomas, MD, MPH George Kaiser Family Foundation Associate Professor, Department of University of Florida COM- of Cornell University, New York; International Editors Emergency Medicine, Icahn School Jacksonville, Jacksonville, FL Research Director, Department of Professor & Chair, Department of of Medicine at Mount Sinai, New Emergency Medicine, New York Emergency Medicine, University of Peter Cameron, MD Gregory L. Henry, MD, FACEP York, NY Hospital Queens, Flushing, NY Oklahoma School of Community Academic Director, The Alfred Clinical Professor, Department of Medicine, Tulsa, OK Emergency and Trauma Centre, Emergency Medicine, University Ali S. Raja, MD, MBA, MPH Editorial Board Ron M. Walls, MD Monash University, Melbourne, of Michigan Medical School; CEO, Director of Network Operations and Australia William J. Brady, MD Medical Practice Risk Assessment, Business Development, Department Professor and Chair, Department of Professor of Emergency Medicine Inc., Ann Arbor, MI of Emergency Medicine, Brigham Emergency Medicine, Brigham and Giorgio Carbone, MD and Medicine, Chair, Medical and Women’s Hospital; Assistant Women’s Hospital, Harvard Medical John M. Howell, MD, FACEP Chief, Department of Emergency Emergency Response Committee, Professor, Harvard Medical School, School, Boston, MA Medicine Ospedale Gradenigo, Medical Director, Emergency Clinical Professor of Emergency Boston, MA Scott D. Weingart, MD, FCCM Torino, Italy Management, University of Virginia Medicine, George Washington Associate Professor of Emergency Medical Center, Charlottesville, VA University, Washington, DC; Director Robert L. Rogers, MD, FACEP, Amin Antoine Kazzi, MD, FAAEM of Academic Affairs, Best Practices, FAAEM, FACP Medicine, Director, Division of Associate Professor and Vice Chair, Mark Clark, MD Inc, Inova Fairfax Hospital, Falls Assistant Professor of Emergency ED Critical Care, Icahn School of Department of Emergency Medicine, Assistant Professor of Emergency Church, VA Medicine, The University of Medicine at Mount Sinai, New University of California, Irvine; Medicine, Program Director, Maryland School of Medicine, York, NY Shkelzen Hoxhaj, MD, MPH, MBA American University, Beirut, Lebanon Emergency Medicine Residency, Baltimore, MD Chief of Emergency Medicine, Baylor Mount Sinai Saint Luke's, Mount Senior Research Editors Hugo Peralta, MD College of Medicine, Houston, TX Alfred Sacchetti, MD, FACEP Sinai Roosevelt, New York, NY Chair of Emergency Services, Assistant Clinical Professor, James Damilini, PharmD, BCPS Eric Legome, MD Hospital Italiano, Buenos Aires, Department of Emergency Medicine, Clinical Pharmacist, Emergency Peter DeBlieux, MD Chief of Emergency Medicine, Argentina Thomas Jefferson University, Room, St. Joseph’s Hospital and Professor of Clinical Medicine, King’s County Hospital; Professor of Dhanadol Rojanasarntikul, MD Philadelphia, PA Medical Center, Phoenix, AZ Interim Public Hospital Director Clinical Emergency Medicine, SUNY Attending Physician, Emergency of Emergency Medicine Services, Downstate College of Medicine, Robert Schiller, MD Joseph D. Toscano, MD Medicine, King Chulalongkorn Louisiana State University Health Brooklyn, NY Chair, Department of Family Chairman, Department of Emergency Memorial Hospital, Thai Red Cross, Science Center, New Orleans, LA Medicine, Beth Israel Medical Medicine, San Ramon Regional Thailand; Faculty of Medicine, Keith A. Marill, MD Center; Senior Faculty, Family Medical Center, San Ramon, CA Nicholas Genes, MD, PhD Research Faculty, Depatment of Chulalongkorn University, Thailand Medicine and Community Health, Assistant Professor, Department of Emergency Medicine, University of Suzanne Y.G. Peeters, MD Icahn School of Medicine at Mount Emergency Medicine, Icahn School Pittsburgh Medical Center, Pittsburgh, Emergency Medicine Residency Sinai, New York, NY of Medicine at Mount Sinai, New PA Director, Haga Teaching Hospital, York, NY The Hague, The Netherlands Case Presentations should be considered and investigated. A list of dif- ferential diagnoses is provided in Table 2, page 3. On a late summer afternoon shift, a 16-year-old adoles- Heat-related illnesses occur when the body’s cooling cent boy presents to the ED via EMS after collapsing dur- mechanisms are unable to control the natural rise in ing football practice. The medics state that he complained body temperature caused by metabolism, physical of dizziness and staggered to the edge of the field before he activity, or exposure to warm temperature. The true fell to the ground. The medics call out vital signs: blood prevalence is difficult to estimate, as many cases pressure, 102/60 mm Hg; heart rate, 120 beats/min; and go unreported. Heat-related illnesses can be multi- respiratory rate, 16 breaths/min. They did not measure a factorial, but are most commonly seen in improp- temperature, but state that he feels hot to the touch. The erly conditioned patients participating in physical patient is brought to the resuscitation room where you be- activities in environments with hot, humid weather gin your evaluation. The patient is awake, but very lethar- (exertional), and in patients unable to escape a gic and unresponsive to verbal commands. You notice he heated environment (classic). The challenge for the is flushed, his skin is hot to the touch, and he is sweating. emergency clinician is twofold: first, the severity of The rectal temperature is 40.3°C. You begin volume re- heat illness must be established and prompt cool- suscitation with normal saline, remove his athletic equip- ing therapy must be started. Second, the emergency ment and clothing, and order laboratory studies. As the clinician must be aware of toxicological substances, nurse tells you that the patient is no longer responding infectious processes, and other medical conditions to verbal or noxious stimuli, you wonder if you should that can cause symptoms that mimic heat illness. intubate him. You consider the quickest and most effec- The majority of heat illness cases are benign tive way to
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