heat illness/hyperthermia victor politi, m.d., facp medical director – st. johns...
TRANSCRIPT
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Heat Illness/Hyperthermia
Victor Politi, M.D., FACP
Medical Director –
St. Johns University-Physician Assistant Program
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Risk factors for heat illness
ObesityFatigueDrugsAlcoholSunburnUnacclimatizedFluid deficitPrevious history of heat injuryMany medical conditionsFebrile illnessCystic fibrosisDiabetesMalnutrition
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Heat Illness Classification
• Heat Rash
• Heat syncope
• Heat cramps
• Heat exhaustion
• Heat stroke
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Minor Heat Illness - Heat Cramps
• Brief, intermittent, often severe muscular cramps typically occurring in muscles that are fatigued by heavy work
• Usually occur after exertion• Copious hypotonic fluid replacement during
exertion
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• Related to salt deficiency
• Victims exhibit -hyponatremia, hypochloremia, low urinary sodium and chloride levels
• Usually rapidly relieved by salt solutions
Minor Heat Illness - Heat Cramps
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Minor Heat IllnessHeat Syncope
• Individuals at risk should be warned to move frequently, flex leg muscles repeatedly whenever standing
• Scintillating scotomata, tunnel vision, vertigo, nausea, diaphoresis, and weakness are prodromal symptoms of syncope
• Adequate oral volume replacement may prevent some conditions
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Minor Heat Illness - Prickly Heat AKA miliaria rubra, lichen tropicus, heat rash
• Acute phase -– Produces intensely pruritic vesicles on an
erythematous base– Rash confined to clothed areas– Effected area completely anhydrotic
• -– may persist for weeks– chronic dermatitis -frequent complication
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Heat Exhaustion - two types classically described
– Water depletion heat exhaustion• inadequate fluid replacement by persons in heat “
voluntary dehydration”
• weakness, fatigue, frontal headache, impaired judgement, vertigo, nausea/vomiting, occasional muscle cramps,sweating, body temperature near normal
• orthostatic dizziness/syncope may occur
• results in progressive hypovolemia
• Untreated can progress to heat stroke
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• Salt depletion heat exhaustion– takes longer to develop than water depletion
form– systemic symptoms occur – hyponatremia, hypochloremia, low urinary
sodium and chloride concentrations– Symptoms similar to water depletion type, body
temperature remains near normal
Heat Exhaustion - two types classically described
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Heat Exhaustion: Diagnosis
• Vague malaise, fatigue, headache• Core temperature often normal; if elevated less than
1040F• Mental function essentially intact; no coma or
seizures• Tachycardia, orthostatic hypotension, clinical
dehydration (may occur)• Other major illness ruled out
• If in doubt, --- treat as heat stroke !!
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Heat Exhaustion - Treatment
• Rest
• cool environment
• Assess volume status (orthostatic changes, BUN, hematocrit, serum sodium)
• Fluid replacement
• Consider admission if patient is elderly, has significant electolyte abnormalities or would be at risk of recurrence if d/c
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Hyperthermia
A patient presents to the ED with elevated body temperature -
1st thought ??
? Infectious etiologies/severe infection
but some patients with elevated temperature, including some with extreme pyrexia, do not have fever at all, they have hyperthermia !
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Fever versus Hyperthermia
• Body temperature can become elevated through either of two very different processes
• In fever, thermoregulation remains intact while hyperthermia represents thermoregulation failure
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Thermoregulation: Effects of EnvironmentalConditions
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Causes of Hyperthermia- Disorders of excessive heat production
– Exertional hyperthermia– Heatstroke – Malignant hyperthermia of anesthesia– Neuroleptic malignant syndrome
– Thyrotoxicosis / Pheochromocytoma– Salicylate intoxication / Delirium tremens– Cocaine, amphetamines, other drugs of abuse– Status epilepticus /Generalized tetanus
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Hyperthermia
Splanchnic vasoconstriction Rhabdomyolysis
Disseminated intravascularcoagulation
Thermal injury
Diminishedrenal blood flow
Renal Failure
Glomerulardamage
Myoglobinuria Hyperuricemia &urinary acidification
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A catastrophic life-threatening medical emergency ---
HEAT STROKE
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Heat Stroke Diagnosis
• Exposure to heat stress, endogenous or exogenous
• Signs of severe CNS dysfunction (coma, seizures, delirium
• Core temperature usually 410C (105.80F) or more,
• Dry, hot skin frequent, • Marked elevation of hepatic transaminases
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Classic Heatstroke
• Occurs primarily in epidemics during summer heat waves
• Most likely to effect the elderly and patients with serious underlying illnesses
• Infants also at risk
• Typical victim confined at home w/no fan or A/C
• Dehydration - predisposing factor
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• Other risk factors - obesity, neurologic or cardiovascular disease, use of diuretics, neuroleptics, or medications with anticholinergic properties that interfere with sweating
• Alcohol use may be a risk factor
Classic Heatstroke
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Exertional Heat Stroke
• Like classic heat stroke- occurs during hot,humid weather
• Occurs sporadically - effecting young, healthy persons engaged in strenuous physical activity
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Initial Treatment of Heat Stroke
• Immediate cooling
• Protect airway (intubate if comatose or seizing)
• IV line with 0.9% NaCl or Ringer’s lactate
• CVP or Swan Ganz catheter in hypotensive patients
• Foley catheter; monitor output
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• Rectal probe - monitor temperature• Oxygen, 5-10L/min• ABGs• Labs - CBC, electrolytes, BUN, glucose, SGOT,
LDH, CPK, calcium phosphate, lactate, PT/PTT, fibrin degradation products
• Check glucose by dextrostix method & treate- administer D50 if hypoglycemia present
Initial Treatment of Heat Stroke
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Cooling Modalities to lower body temperature in heat stroke
• Ice-water immersion• Evaporative cooling using large circulating fans and
skin wetting• Ice packs• Peritoneal lavage• Rectal lavage• Gastric lavage• Cardiopulmonary bypass• Alcohol sponge baths (caution)• Phenothiazines (caution)
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Treatment of early complications of Heat Stroke
• Shivering
• Convulsions
• Myoglobinuria
• Acidosis
• Hypokalemia
• Hypocalcemia
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Heat Illness Prevention
• A Crucial issue
• Counsel persons with any risk factors regarding symptoms of heat stroke– Elderly persons– persons with chronic diseases– those on medications predisposing them to heat
illness
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• Exertional heat stroke is most likely to strike young, healthy persons involved in strenuous physical activity – many of these people have risk factors for heat
illness -commonly obesity,diarrhea,febrile illness
– other variables to consider- hydration,salt intake, clothing, and climatic conditions
Heat Illness Prevention
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• Fluid intake is the most critical variable
Heat Illness Prevention
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Questions ?