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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.
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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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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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.
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.
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.
Peritoneal lavage
See the list below: