Cooling as an Emergency Treatment of Heat Stroke

By : Amanda Besta Rizaldy

Heat stroke is the most serious heat stress exposure-related illness (injury).
Unfortunately, early or impending heat stroke may go unrecognized. It is defined as a
seriously elevated temperature (> 104 F or 40 C that causes CNS injury, caused by heat
stress conditions beyond the compensatory (cooling) ability of the body. It is a life-
threatening emergent medical condition. Without prompt treatment, victims will sustain
permanent injury or death. Multiple organ dysfunction syndrome has been common in some
case series.
[1]
In the United States, heat waves claim more lives each year than all other
weather-related exposures combined (hurricanes, tornadoes, floods, and earthquakes).
According to the Centers for Disease Control and Prevention, 8,015 deaths were attributed
to excessive heat exposure from 1979-2003, or an average of approximately 334 deaths per
year. Heatstroke and deaths from excessive heat exposure are more common during
summers with prolonged heat waves.
[1]
Heatstroke is uncommon in subtropical climates. The condition is recognized
increasingly in countries that experience heat waves rarely (eg, Japan), and it commonly
affects people who undertake a pilgrimage to Mecca, especially when the pilgrims arrive
from a cold environment. In 1998, one of the worst heat waves to strike India in 50 years
resulted in more than 2600 deaths in 10 weeks. Unofficial reports described the number of
deaths as almost double that figure.
[2]
Symptoms and signs of heat stroke include feeling overheated, weakness, fatigue,
irritability, bizarre behavior, combativeness, hallucinations, loss of consciousness (often with
little or no prodrome), and coma. Victims occasionally have feelings of euphoria. Sweating
may or may not be present. Heat stroke victims frequently have diarrhea and vomiting. In
exertional heat stroke, metabolic acidosis is the predominant acid-base change, especially in
victims presenting with higher temperature followed by respiratory alkalosis (astudy that may
have included both exertional and classic forms of heat stroke found similar results. 250 In
classic heat stroke, reports are inconsistent between metabolic acidosis or
respiratoryalkalosis as the predominant finding.
The hemodynamic changes in severe heat exposure reflect a hyperdynamic
circulation with tachycardia and high cardiac output. In one study, relative hypovolemia was
more pronounced in patients with heatstroke compared to patients with heat exhaustion.
Vasodilatation. Arrhythmias are common in heat stroke. Rhabdomyolysis is common in
severe heat injury, with extremely high serum and urine myoglobin and serum creatinine
kinase concentrations (for example, 100 times normal levels. Carboxyhemoglobin levels may
be elevated in heat stroke.
Heat stroke is diagnosed when there is severely elevated body temperature that
causes CNS injury. The important point are Heat stroke should be suspected in all patient
with altered mental status and elevated temperature or high levels of exertion. If other
etiology is not apparent, it should be considered heat stroke until proven otherwise. Rapid
cooling should be instituted in such cases, while further studies (such as lumbar puncture,
etc.) are pursued.
[1]
Comprehensive emergency management of heat stroke is beyond the scope of this
manual. Specific critical issues are addressed here to give the health care provider a base of
understanding from which to make clinical decisions. There are the emergency treatment for
Heat Stroke.
The goal in the treatment of heat stroke is rapid cooling to (theoretically) normal body
temperature. Clinically, to prevent over-cooling (reported to occur in 33% of heat stroke
cases, the target temperature of cooling is to 101 F (38.3 C) to 102.2 F. Cooling may be
done through three mechanisms: cooling the skin while maintaining cutaneous blood flow,
cooling internal organs directly, and cooling blood directly by removal, cooling, and re-
introduction of blood. Cooling should be started immediately on diagnosing heat stroke or
serious heat exhaustion, preferably while the victim is being transported to the hospital.
a. Clothing Removal
Unless prohibited by operational personal protection requirements (e.g., battle,
chemical or biological or radiological threat), the victims clothing should be removed
immediately.
b. Fanning
Cooling with large amounts of airflow is often the only effective cooling method
immediately available. Helicopter downdraft cooling has been used successfully on
heatstroke victims.
c. Cold or Ice Water Immersion
Immersion of the victim in cold or ice water is the most effective treatment to
rapidly decrease core temperature, and should be performed immediately. As heat
stroke victims may be shunting blood from the skin, and as cooling causes
cutaneous vasoconstriction, effort may be necessary to restore or increase
cutaneous blood flow. Cold or ice water immersion techniques are labor-intensive.
Vigorous rubbing of the skin, or intermittent warm air or warm water exposure is
done to maintain cutaneous blood flow.
d. Cold Packs, Cooling Blankets, Fanning, Mists, Cooling Units
One alternative to cold or ice water immersion is the application of cold packs or
ice packs or ice water slush to part of the body. Another alternative is the use of
cooling blankets (blankets with tubing containing a circulating coolant), which cool
the patient without wetting. However, contact area with the body is less than can be
achieved with immersion. They are unlikely to be available in a field situation.
Evaporative cooling techniques may also be used, including fanning the patient with
or without water or mist, and using a body cooling unit (a special bed spraying
water at 59 F or 15 C and blowing air at 113 F or 45 C).
[1]
Morbidity and mortality from heatstroke are related to the duration of the temperature
elevation. When therapy is delayed, the mortality rate may be as high as 80%; however, with
early diagnosis and immediate cooling, the mortality rate can be reduced to 10%.
[2]





References :
1
NEHC-TM-OEM. Prevention And Treatment Of Heat And Cold Stress Injuries. Navy
Environmental Health Center. Bureau of Medicine And Surgery.
http://www.public.navy.mil/surfor/Documents/6260_6A_NMCPHC_TM.pdf
2
Medscape. Heat Stroke.http://emedicine.medscape.com/article/166320overview#a0199