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Cooling Techniques for Hyperthermia

Author: Erik D Schraga, MD; Chief Editor: Mark A Clark, MD more...


Updated: Apr 09, 2013

Overview

Indications
Contraindications
Anesthesia
Equipment
Positioning
Technique
Pearls
Complications
Refractory Cases
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Multimedia Library
References

Overview
Heat illness is a pervasive problem that is often encountered in patients who present to the emergency department. During summer heat waves, large
urban centers see a significant rise in hyperthermia-related fatalities. Heat illness should be thought of as a spectrum of disease from heat cramps
to heatstroke. Conditions such as malignant hyperthermia and neuroleptic malignant syndromeneed to be specifically recognized, as the treatment of
these diseases requires adjunctive pharmacotherapy (dantrolene) in addition to rapid cooling measures. Understanding basic principles of
thermoregulation and the pathophysiology of hyperthermia are essential to treatment. [1, 2]
The image below depicts items used for noninvasive cooling techniques.

Sample display of equipment useful for noninvasive cooling


techniques. Clockwise from top: ice pack and water, air-cooling blanket, Foley catheter, and intravenous fluids.

See Heat Illness: How To Cool Off Hyperthermic Patients, a Critical Images slideshow, for tips on treatment options for patients with heat-related
illness.
Also, see Football Injuries: Slideshow to help diagnose and treat injuries from a football game, including heatstroke, a major concern in college and
high school football.
Effective thermoregulation, controlled by the hypothalamus, is critical for proper function of the human body, with normal temperature exhibiting diurnal
variation between 36-37.5C. Heat is both produced endogenously and acquired from the environment. Metabolic reactions in human bodies are
exothermic, contributing 50-60 kcal/h/m 2 of body surface area, or 100 kcal/h for a 70-kg person. During strenuous exercise, heat production increases
10- to 20-fold.[3] Environmental heat transfer involves the following 4 mechanisms [3] :

Conduction: Direct physical contact transfers heat from a warmer object to a cooler object. Water is 25 times more effective than air at
conducting heat.

Convection: Heat is transferred through air and water vapor molecules surrounding the body. Convective heat transfer depends on wind
velocity and explains the effect of wearing loose-fitting clothing in warm climates to keep cool.
Radiation: Heat is transferred by electromagnetic waves. Radiation is the major source of heat gain in hot ambient climates; up to 300
kcal/h can be gained on a hot summer day.
Evaporation: The conversion of a liquid to a gas results in heat transfer. One liter of sweat from the body results in a loss of 580 kcal of
heat.
Hyperthermia is defined as elevated core temperature of greater than 38.5C. History and clinical examination can help elucidate the etiology of
hyperthermia and tailor treatment. The causes of hyperthermia include the following [4] :

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Increased ambient heat


Heat waves
Humidity
Increased heat production
Overexertion
Thyroid storm
Malignant hyperthermia
Neuroleptic malignant syndrome
Pheochromocytoma
Delirium tremens
Hypothalamic hemorrhage
Toxic ingestions (eg, sympathomimetics, anticholinergics, ecstasy)
Decreased heat dissipation
Humid environment
Poor sweat production
Sweating and peripheral vasodilation are major mechanisms of heat loss to maintain proper temperature. In the absence of these mechanisms,
baseline temperature would increase 1.1C per hour from basal metabolism alone. [4] Sweat cools the body through evaporation, and peripheral
vasodilation provides the blood flow and heat necessary to evaporate the sweat. During periods of high environmental heat and humidity, evaporative
cooling can become insufficient, leading to heat illness.
Patients at risk for heat illness include the following [5, 6] :

Athletes exercising strenuously in hot climates


Elderly patients (because of decreased efficacy of thermoregulation, comorbid illness or medications, lack of fans or air conditioning,
inappropriate dress)
Infants and small children (because of high ratio of surface area to weight, inability to control fluid intake)
Patients with cardiac disease or those taking beta-blockers (because of inability to increase cardiac output sufficiently for vasodilation)
Patients who are dehydrated because of poor fluid intake, gastroenteritis, or diuretic use (Dehydration increases demand on ATPase
pumps, which contribute 25-45% of basal metabolic rate.)
Patients prone to higher endogenous heat production
Patients taking medications that inhibit sweat production or increase heat production (eg, anticholinergics, antidepressants, antihistamines,
neuroleptics, zonisamide, sympathomimetics, lithium, alpha- and beta-blockers)
Patients taking medications that cause dehydration (eg, diuretics, alcohol)
Recognizing the clinical signs associated with heat illness determines the appropriate therapy, from fluid replacement for heat exhaustion to rapid
aggressive cooling for heatstroke.[5, 4, 6]

Symptoms of heat exhaustion include the following:

Normal to slightly elevated core temperature


Fatigue or malaise
Orthostatic hypotension, tachycardia
Clinical signs of dehydration
Nausea, vomiting, diarrhea (due to splanchnic and renal vasoconstriction)
Intact mental status
Responsive to cool environment, fluid and electrolyte replacement
Symptoms of heatstroke include the following:

Elevated core temperature, usually greater than 40.5C


Vague prodrome of weakness, nausea, vomiting, headache
CNS symptoms including confusion, ataxia, coma, seizures, delirium
Hot, dry skin
Hyperdynamic cardiovascular systems [7] (high central venous pressure [CVP], low systemic vascular resistance [SVR], tachycardia)
Elevation of hepatic transaminases, usually in the tens of thousands range
Coagulopathy
Rhabdomyolysis and renal failure
This article focuses specifically on rapid cooling techniques for hyperthermic patients, a critical action in the initial resuscitation of patients with
heatstroke. In fact, rapid cooling may be the single most important action to prevent death or permanent disability. To mitigate organ damage, the goal
should be to reduce rectal temperature to below 40C within 30 minutes of beginning cooling therapy. [6,
See the list below:

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Elevated rectal temperature greater than 40C and altered mental status
Particularly aggressive temperature reduction is necessary in the setting of hemodynamic instability.
Suspected or confirmed neuroleptic malignant syndrome and malignant hyperthermia
Cooling techniques should be administered concomitantly with administration of dantrolene. [9]
The offending drug should be discontinued.

Contraindications
See the list below:

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Treatment of hyperthermia with cooling techniques has no absolute contraindications.


Relative contraindications to specific cooling modalities include the following:
Ice water immersion - Inability to perform cardiac monitoring, limited patient supervision
Gastric lavage - Inability to protect airway unless patient is endotracheally intubated
Peritoneal lavage - Multiple previous abdominal surgeries (relatively contraindicated because of increased risk of bowel
perforation)

Anesthesia
See the list below:

Anesthesia is not typically necessary unless invasive procedures are indicated, including cardiopulmonary bypass or peritoneal lavage.
For highly invasive procedures or refractory hyperthermia, paralysis may be necessary to extinguish shivering and reduce endogenous heat
production; therefore, patients may require sedation for supportive mechanical ventilation. [10] See the Medscape Drugs & Diseases topic on Tracheal
Intubation, Rapid Sequence Intubation for more detail.

Noninvasive external cooling


See the list below:

Ice packs
Spray bottle
Tepid (15C) water
Fan
Cooling blanket
Ice bath (eg, bathtub, decontamination tub, childs wading pool)
Crystalloid intravenous fluids
Rectal thermometer probe
Noninvasive external cooling equipment is shown below.

Sample display of equipment useful for noninvasive cooling


techniques. Clockwise from top: ice pack and water, air-cooling blanket, Foley catheter, and intravenous fluids.

Gastric lavage
See the list below:

Nasogastric tube
Ice water
Endotracheal intubation equipment, if airway needs to be protected (seeTracheal Intubation, Rapid Sequence Intubation)
Y connector
Lavage bag
Gastric lavage equipment is shown below.

Sample display of equipment useful for cooling via gastric lavage.


Clockwise from top: ice water, nasogastric tube, endotracheal tube, and lavage bag.

Peritoneal lavage
See the list below:

Peritoneal catheter set


Normal saline
Ice bath
Peritoneal lavage equipment is shown below.

Sample display of equipment useful for cooling via peritoneal lavage.


Clockwise from top: iced water, peritoneal catheter, and saline fluid.