Heatstroke

Sun Stroke
Acute Management and Prevention
Dr. Aidah Abu El Soud Alkaissi
BSc Law, RN, BSc, MSc, PhD
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Heatstroke
Sun Stroke
Caused by overexposure to sun and extremely
high temperatures
occurs when the brain fails to control its own
"thermostat".
Its a life-threatening condition which can cause a
casualty to become unconscious within minutes.
As well as an unusually high temperature, a
casualty may show signs of restlessness,
headaches and hot, flushed skin.
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Heatstroke
Sun Stroke

The underlying cause of heat stroke is

connected to the sometimes sudden inability
to dissipate (To drive away) body heat
through perspiration, especially after
strenuous physical activity

Heatstroke
Sun Stroke

This accounts for the excessive rise in body temperature.

It is the high fever which can cause permanent damage to internal
organs, and can result in death if not treated immediately.

Recovery depends on heat duration and intensity.

The goal of emergency treatment is to maintain circulation and lower

body temperature as quickly as possible.
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Definition
core temperature > 41 C OR
- core temp > 40.5 C with anhidrosis
(absence or severe deficiency of sweating),
altered mental status or both

Classification
exertional: typically seen in healthy young adults who
overexert themselves in high ambient (Surrounding)
temperatures or in a hot environment to which they are
not acclimatized (To adapt).
Patients sweat normally.
- non-exertional (classic): usually affects elderly and
debilitated patients with chronic underlying disease.
Result of impaired thermoregulation combined with high
ambient temperatures. Often due to impaired sweating
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Pathophysiology
Substantial fluid shift from central compartment to
periphery. Reversible on cooling
- cardiac output increased +++ (3 l/min per C increase
in rectal temperature). May fail in patients with limited
cardiac reserve
- mediators such as endotoxin and cytokines are
implicated in the pathogenesis of organ damage in heat
stroke
- intractable Disseminated Intravascular Coagulation
(DIC) is usual mode of death in fatal cases
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Predisposing factors
Increased heat production
- hyperthyroidism
- exercise
- sepsis

 Impaired heat loss -Impaired sweating

Drugs
- anticholinergics, anti-Parkinsonian drugs, antihistamines, butyrophenones, phenothiazines, tricyclics
Abnormal sweat glands
- sweat gland injury following acute heat stroke,
barbiturate poisoning
- cystic fibrosis
- healed thermal burn
salt and water depletion
- diuretic induced
Hypokalemia
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Impaired voluntary mechanisms

coma
physical disability
mental illness

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 Impaired delivery of blood to peripheral

circulation
cardiovascular disease
hypokalemia (decreased muscle blood flow)
dehydration

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 Others
- elderly
- high ambient temperature and humidity,
poor ventilation
- lack of acclimatization
- obesity
- fatigue
- DM
- malnutrition
- alcoholism
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Clinical features
often little in the way of warning prodrome (An early
symptom indicating the onset of an attack or a diseas)
prior to development of non-exertional heat stroke
(classic heat stroke).
As thermoregulatory mechanisms fail body
temperature rises rapidly and patient can deteriorate
rapidly from apparent baseline health to coma or an
obtunded state
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Clinical features

3 cardinal signs are:

CNS dysfunction
hyperpyrexia (core temperature >40 C)
hot dry skin. Pink or ashen depending on
circulatory state. However may be clammy and
sweat

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CNS
Direct thermal toxicity causes cell death, cerebral
oedema and local haemorrhage
- irritability or irrational behaviour may precede the
development of either form of heatstroke
- confusion, aggressive behaviour, delirium,
convulsions and pupillary abnormalities may progress
rapidly to coma
- decorticate posturing, faecal incontinence, flaccidity
or hemiplegia (however focal signs are unusual)

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 cerebellar signs, including ataxia and dysarthria

(Speech that is characteristically slurred, slow,
and difficult to produce (difficult to understand).
may be permanent in a few patients. Cerebellum
particularly sensitive to heat
- hypothalamic damage may exacerbate heat
stroke by further impairing sweating and heat
loss
- LP may show increased protein, xanthochromia
(is the yellow discoloration indicating the
presence of bilirubin in the cerebrospinal fluid
(CSF) and slight increase in lymphocytes
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CVS
- tachycardia
- hypotension or normotension with wide pulse
pressure
- hyperdynamic haemodynamic profile
- myocardial pump failure. Myocardial damage and
frank infarction frequent even in patients with normal
coronaries due to the effect of heat on myocytes and
coronary hypoperfusion secondary to hypovolaemia
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ECG of a patient with a core temperature of 40C

dysrhythmias

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Same patient after cooling

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RS
- extreme tachypnoea with RR up to 60/min
- crackles and cyanosis late signs of pulmonary
oedema
- direct thermal injury to pulmonary vascular
endothelium may lead to cor pulmonale or
Acute respiratory distress syndrome
(ARDS)
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Metabolic
Dehydration leading to raised urea and creatinine,
and haemoconcentration
- sweating leading to low levels of Na, Mg, K,
early in the illness. Hypokalaemia decreases sweat
secretion and therefore exacerbates the condition
- rhabdomyolysis resulting in hyperkalaemia,
hypocalcaemia and renal failure
- metabolic acidosis and respiratory alkalosis
common.
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Rhabdomyolysis
A condition in which skeletal muscle cells
break down, releasing myoglobin (the oxygencarrying pigment in muscle) together with
enzymes and electrolytes from inside the
muscle cells. The risks with rhabdomyolysis
include muscle breakdown and kidney failure
since myoglobin is toxic to the kidneys.
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 Hyperthermia alone can cause primary

hyperventilation and respiratory alkalosis,
while hypoperfusion, tissue hypoxia, and
anaerobic metabolism may lead to lactic
acidosis with respiratory compensation.
Former less common.

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Renal
Some renal damage occurs in nearly all patients
as a direct result of heat
potentiated by dehydration and
Rhabdomyolysis
acute renal failure 5-6 times more common in
patients with exertional heat stroke in whom it
occurs in 30-35%
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Splanchnic
Ischaemic intestinal ulceration common. May
lead to haemorrhage
Hepatic damage common. In 5-10% hepatic
necrosis may be severe enough to cause death

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Haematological
Anaemia and bleeding. Result from: direct
inactivation of platelets and clotting factors by heat
liver failure
unexplained decrease in platelets and
megakaryocytes (The source of blood platelets)
platelet aggregation due to heat
DIC. Due to activation of clotting cascade by
damaged vascular endothelium. Latter may be
damaged as a direct result of heat
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Investigations

temperature
- electrolytes, urea, creatinine, calcium
- LFTs
- CPK
- ABG: note that Paco2 and Pao2 will be falsely low
and pH falsely elevated if results are not corrected
for temperature
- ECG and ECG monitoring
- urine output
- FBC, clotting, fibrinogen, FDP, D-dimer. Anaemia
frequent. Platelets low/normal. Lymphocytosis
- test urine for myoglobin
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Symptoms of Heatstroke or
Sunstroke

Headache, nausea, dizziness

Red, dry, very hot skin (sweating has ceased)
Pulse-strong & rapid
Small pupils
Very high fever
May become extremely disoriented
Unconsciousness and possible convulsions

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If exposure to heat continues, the body temperature

rises and heatstroke may develop, causing symptoms
such as:

1.Cessation of sweating
2.
Body temperature of 105 degree Fahrenheit or
higher
3.
Rapid and shallow breathing
4.
Rapid heartbeat
5.
Elevated or lowered blood pressure
6.
Confusion and disorientation
7.
Seizure
8.
Fainting, which may be the first sign in older adults
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 Left untreated, heat stroke may progress to

coma. Death may result due to kidney
failure, acute heart failure, or direct heat
induced damage to the brain.

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First Aid for Heatstroke

or Sunstroke

HEATSROKE IS LIFE THREATENING!

Remove victim to cooler location, out of the sun
Loosen or remove clothing and immerse victim in very cool
water if possible
If immersion isn't possible, cool victim with water, or wrap in
wet sheets and fan for quick evaporation
Use cold compresses-especially to the head & neck area, also to
armpits and groin
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First Aid for Heatstroke or

Sunstroke
Seek medical attention immediately--continue first aid to lower temp.
until medical help takes over
Do NOT give any medication to lower fever--it will not be effective
and may cause further harm
Do NOT use an alcohol rub
It is not advisable to give the victim anything by mouth (even water)
until the condition has been stabilized.
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Once in the hospital, an examination is done, and blood tests

are carried out to assess the level of salts in the blood.

Treatment of heat stroke is usually carried out in a

critical care unit.
The body temperature is lowered by sponging the
body with tepid water or loosely wrapping the person
in a wet sheet and placing him or her near a fan.
Intravenous fluids are given.
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 Once the body temperature has been reduced to 100

degree F(38 degree), these cooling procedures are
stopped to prevent hypothermia (below) from
developing.
Monitoring is still carried out continuously to make
sure that the body temperature returns to normal
level and that the vital organs are functioning
normally
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 In some severe cases, mechanical

ventilation may be required to help
breathing.

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 when temperature approaches 39 active cooling should

be terminated as the body temperature will continue to
fall 1-2 C

- chlorpromazine 10-50 mg IV 6hrly may be useful in

preventing shivering
- use of dantrolene controversial. Probably should not be
used routinely at present.
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Dantrolene
A skeletal muscle relaxant, used as the sodium
salt in the treatment of chronic spasticity and the
treatment and prophylaxis of malignant
hyperthermia (Malignant hyperthermia is an
inherited disease that causes a rapid rise in body
temperature (fever) and severe muscle
contractions when the affected person receives
general anesthesia
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Some medicines can put the patient

in danger of heatstroke.
Allergy medicines (antihistamines)
Cough and cold medicines

(anticholinergics)
Blood pressure and heart medicines
Alpha andrenergics such as
midodrine (one brand: ProAmatine)

or pseudoephedrine (one brand:

Sudafed)
Beta blockers
Calcium channel blockers

Diet pills (amphetamines)

Irritable bladder and
irritable bowel medicines
(anticholinergics)
Laxatives

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Some medicines can putthe patient

in danger of heatstroke.
Mental health medicines
Benzodiazepines such as
clonazepam (one brand:
Klonopin), diazepam (one
brand: Valium),
chlordiazepoxide (one
brand: Librium)
Neuroleptics
Tricyclic antidepressants

Seizure medicines
(anticonvulsants)
Thyroid pills
Water pills

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Supportive
IV volume replacement. Note that many of these
patients only require 1-1.2 l of replacement fluid
- if inotrope required dobutmine probably drug of
choice
- urgent treatment of hyperkalaemia
- do not treat hypocalcaemia per se; only give
calcium if ECG changes of severe hyperkalemia
occur as calcium may exacerbate rhabdomyolysis
- small dose of mannitol may benefit patients with
rhabdomyolysis
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Preventing heat-related
illness
Dress for the heat Wear lightweight, light-coloured clothing. Light
colours will reflect away some of the suns energy. It is also a good
idea to wear hats or to use an umbrella.
Drink water Carry water or juice with you and drink continuously
even if you do not feel thirsty. Avoid alcohol and caffeine, which
dehydrate the body.
Avoid foods that are high in protein, which increase metabolic heat.
Stay indoors when possible.
Take regular breaks when engaged in physical activity on warm days.
Take time out to find a cool place.
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