18 yo heat stroke discussion

[Tal]

21:30 not a very hot time in a day, a Company medic rushes in the clinic with a soldier that collapsed durring an ongoing walk with vest.
He came to the clinic all pale and sweaty, and very disoriented could not speak his name right.

RR: 24
HR: 150
Temp PR: 41C\ 105.8F
B.P 150\80
sat: 98%

O2 mask on and cool him down with watter 90 litters apox.
in the clinic I start an IV an at all total he got 2 litters of normal sailine.
the all cooling part took about 30 min, after that;
RR: 16
HR: 105
Temp PR: 38C\100.4F
BP: 120\70

he got to the hopital alert and oriented. no demage what so ever. after all that arose a discussion apointing that 30 minute cooling was too much time, and that durring that time we could start the transport to the hospital (40 min drive).

in my eyes, I did not agreed to trasport him unstable, same as you dont transport an VF but treat it first.

what do you think?

 

[abckidsmom]

Was it hot in the transport vehicle? Could you have packed up some cool wet towels?

I don't think that 30 minutes is all that long if you are providing definitive care. Good work, sounds like he was pretty sick to start with. Why did he get so hot do you think, if it wasn't that hot outside? What is "not that hot" there?

 

[the_negro_puppy]

Was it hot in the transport vehicle? Could you have packed up some cool wet towels?

I don't think that 30 minutes is all that long if you are providing definitive care. Good work, sounds like he was pretty sick to start with. Why did he get so hot do you think, if it wasn't that hot outside? What is "not that hot" there?

Agreed, plus his blood pressure is high, normal with a dehydrated + heat stroke type patient they will be hypotensive.

Perhaps this soldier has an infection with a fever? exacerbated by physical exercise causing almost delerium>?

I'd be hesitant to give 2 L with a BP of 150/80

 

[Tal]

Agreed, plus his blood pressure is high, normal with a dehydrated + heat stroke type patient they will be hypotensive.

Perhaps this soldier has an infection with a fever? exacerbated by physical exercise causing almost delerium>?

I'd be hesitant to give 2 L with a BP of 150/80

horses not zebras first.

second, the heat stroke durring boot-camp is very common. most of the heat strokes acurre to rookie soldiers that Experiencing the Intense training.
funny thing is that most of the heat stroke (almost 80%) happens in mild heat 20-32C.
I gave the fluids as a cooling agent (the sailine bags are in a aircondioned room and kept cool) and untill now it proved as a good agent.

 

[abckidsmom]

horses not zebras first.

second, the heat stroke durring boot-camp is very common. most of the heat strokes acurre to rookie soldiers that Experiencing the Intense training.
funny thing is that most of the heat stroke (almost 80%) happens in mild heat 20-32C.
I gave the fluids as a cooling agent (the sailine bags are in a aircondioned room and kept cool) and untill now it proved as a good agent.

When it's really hot, people are probably more cautious with the heat exposure, and force fluids more.

I would think that just about any healthy 18 yo soldier could tolerate 2 L of fluid without a blip...in your situation, I may have done the same.

Did you think that it wasn't helpful this time?

 

[Tal]

Did you think that it wasn't helpful this time?

I'm a paramedic in the Israeli army. Most of the pepole I treat are soldiers, healthy and strong. it's not you'r avrerage 03:00 AM 89 yo pulmonary edema cases.
they suck up 3 lit easy. as long as they can pee.

I belive that cool, even room temp sailine cause a decreas in core temp, and see it very well in my pt. check it out yourself, you forever feel a bit cooler with a cool bag of sailine running trough your system.
so no, I think it helps a lot.

 

[abckidsmom]

I'm a paramedic in the Israeli army. Most of the pepole I treat are soldiers, healthy and strong. it's not you'r avrerage 03:00 AM 89 yo pulmonary edema cases.
they suck up 3 lit easy. as long as they can pee.

I belive that cool, even room temp sailine cause a decreas in core temp, and see it very well in my pt. check it out yourself, you forever feel a bit cooler with a cool bag of sailine running trough your system.
so no, I think it helps a lot.

Yeah, that's what I thought, too. I guess I misunderstood your previous post. I think your treatment, including the delayed transport, was spot on.

 

[RocketMedic]

I'm in the same boat as you (US Army 68W @ Ft. Bliss, TX) and I'd have to say I agree 110% with your assessment and treatment. Regardless of why the temp anywhere was elevated, it needs to come down- the only difference an ER might have tossed in would be Tylenol, and that's not going to cool anywhere near as well as the shower. Although sepsis is a possibility, your history (pt-provided and buddy-provided) would help to rule it out, as would the lack of hypotension. I'd say you were looking at heat stroke myself here- and I fully agree, the vast majority of heat casualties/strokes I've had out here are in relatively mild temperatures with dehydrated or underacclimated soldiers. I personally believe that mild climate breeds complacency and poor preparation, which causes heat casualties.

 

[medicstudent101]

Depends.

What resources were available at the clinic as well as in the transport unit?

 

[RocketMedic]

What resources were available at the clinic as well as in the transport unit?

Generally, a military medical transport will have decent A/C, but there's really no replacement for a cool shower. I've found lots of cool/cold water to be a very, very potent tool for rapid controlled cooling.

Ice sheets, on the other hand, are too much, too fast.

 

[usafmedic45]

Could you have packed up some cool wet towels

Packing someone in wet towels isn't going to cool them very rapidly. It might actually have the opposite effect as wet towels become warm pretty rapidly and then trap the heat. Stripping the person, pouring water on them and then letting it evaporate is going to be much more effective. If there are severe symptoms, an ice pack to the back of the neck is going to be the best way to rapidly cool the brain.

Regardless of why the temp anywhere was elevated, it needs to come down- the only difference an ER might have tossed in would be Tylenol, and that's not going to cool anywhere near as well as the shower.

Maybe some Demerol or Ativan to minimize the additional heat production and metabolic strain of shivering induced by the cooling process.

 

[RocketMedic]

Packing someone in wet towels isn't going to cool them very rapidly. It might actually have the opposite effect as wet towels become warm pretty rapidly and then trap the heat. Stripping the person, pouring water on them and then letting it evaporate is going to be much more effective. If there are severe symptoms, an ice pack to the back of the neck is going to be the best way to rapidly cool the brain.



Maybe some Demerol or Ativan to minimize the additional heat production and metabolic strain of shivering induced by the cooling process.

Ativan and Demerol are generally not part of a military medic's loadout, and there's another catch- Ativan and Demerol will both sedate the patient and slow the metabolic process, but they will also lessen the effectiveness of the cooling system, and that can help cache the heat. I can see the utility to protect the airway from febrile seizures, but to me, I'd rather manage the root cause as noninvasively as possible and introduce the anticonvulsants as needed.

 

[canisdoo]

Funny, I just had a call last night involving a 63 yo female patient who's initial core temperature was 108.0 F rectal (our probes stop at 108, so who knows how hot she REALLY was):excl:.. I post the details later if you so desire

I believe your care was appropriate. Why transport a patient you can manage more effectively where you stand. Yes, I know all about the S/E and repercussions of heat stroke and comorbities of preexisting medical disorders. The point being. What did the patient need at the given time. Young male with relative no medical history. COOL THEM. Transport can vasodilate the body, increase stress, blood pressures, heart rate.....to the worlds end. You made a judgment call. stand by it. I my eyes you provided the best patient care possible. Some of my inter-facility transports take upwards of an hour just to make them "transport stable" for flight or even ground pounding.

 

[Akulahawk]

I think the OP did a fantastic job of treating the problem. If the patient wasn't in Heat Stroke, he was certainly well on his way to there. Rapid cooling without triggering shivering is what must be done and replacing lost fluids also needs to be done, if possible. While all fluid compartments contribute to the total amount of fluid lost through sweating, interstitial fluid is where the sweat glands will source their fluid for cooling purposes. If you catch the Heat Stroke early on, you won't see the hypotension because the fluid shift from the vasculature is still occurring and the body is still able to temporarily compensate for the decreasing volume in the vasculature.

Also, it is not uncommon to find heat stroke patients still sweating, if they're early into heat stroke. Pouring water on the patient and letting it evaporate works quite well.

Ice packs in the arm pits, groin, and under the neck will help cool the body, but as usalsfyre said, ice under the neck will cool the brain fastest. That would be a good way to package for transport if you don't have a means to actively cool the patient during transport otherwise.

I would imagine that what cause the heat stress problems in moderate temperatures is that the person feels that it's cool enough outside to work like it's cold out, so they don't drink as much water as necessary. Being that this patient was wearing armor, and the heat loss via sweat evaporation will be much less effective.

Excellent work!

 

[yotam]

Ah, memories...

Serving in the Jordan Valley, where temps. easily spiked to 45 c, heat strokes were part of our daily routine... Your MO is as said before me, right on the spot- rapid assesment, fluids and cooling is really the best thing to do... transport, if pt not critical, can wait. Another variable is ETA- if the ride is short, pop him in and give treatment en route. if it's more then 10 min keep him in untill he's stable. BTW did you take PR temp? how high was it?

And another little tip- on very hot days we used to keep boluses (boli?) in a freezer chest, with ice we took from the kitchen. Very handy, and you could quickly grab one to the ambulance if you know you have a heat stroke...

 

[J. Burdett]

I would have initiated transport early. Cooling can also be accomplished in the back of the ambulance on the way to the hospital.

On that note, unstable pt's should be transported as soon as reasonably possible. The pt could have been experiencing a number of medical emergencies secondary to heat exhaustion/heat stroke. Rhabdomyolysis and exertional hyponatremia come to mind with the latter being complicated by rapid infusion of NaCl which could cause Central Pontine Myelinolysis.

 

[Akulahawk]

I would have initiated transport early. Cooling can also be accomplished in the back of the ambulance on the way to the hospital.

On that note, unstable pt's should be transported as soon as reasonably possible. The pt could have been experiencing a number of medical emergencies secondary to heat exhaustion/heat stroke. Rhabdomyolysis and exertional hyponatremia come to mind with the latter being complicated by rapid infusion of NaCl which could cause Central Pontine Myelinolysis.

The problem with the Rhabdomyolysis tx is that you want to be aggressive with fluid therapy. The problem with Central Pontine Mylinolysis is that a risk factor for that is prolonged hyponatremia... that is quickly returned to normal. So if you withhold the fluids, you run risk of shoving the patient into kidney failure and and if you don't... well, I would imagine that this patient being about 19-21 years of age, who is experiencing the acute effects of Heat Stroke, probably isn't hyponatremic for very long. This patient is in need of cooling and fluids. Don't withhold the fluid... and don't give the patient hypertonic saline. Colloids like (like hespan) will draw fluid into the vascular compartment from interstitial fluid where most of the fluid loss is from... so the BP looks good, but the patient could be seriously volume deficient.

That's my take on it. If I'm wrong, so be it.

 

[J. Burdett]

The problem with the Rhabdomyolysis tx is that you want to be aggressive with fluid therapy. The problem with Central Pontine Mylinolysis is that a risk factor for that is prolonged hyponatremia... that is quickly returned to normal. So if you withhold the fluids, you run risk of shoving the patient into kidney failure and and if you don't... well, I would imagine that this patient being about 19-21 years of age, who is experiencing the acute effects of Heat Stroke, probably isn't hyponatremic for very long. This patient is in need of cooling and fluids. Don't withhold the fluid... and don't give the patient hypertonic saline. Colloids like (like hespan) will draw fluid into the vascular compartment from interstitial fluid where most of the fluid loss is from... so the BP looks good, but the patient could be seriously volume deficient.

That's my take on it. If I'm wrong, so be it.

I'm simply stating to not withhold transport. Do not attempt to "fix" the pt on scene and then transport. Everything can be done en route. If the pt had only water to drink or is a "salty sweater" hyponatremia is a real possibility. The only way to know is through labs... at a hospital. Also, without knowing CK you can't treat for rhabdo prophylactically. Unless in the setting of crush syndrome or you actually witness myoglobinuria. None of which was mentioned. I would (and have) placed the pt on the stretcher, initiate transport, direct AC vents at the pt, strategically place ice packs, place in Trendelenburg if appropriate, start a IV, administer fluids if in 250ml bolus if appropriate, and administer O2 if appropriate.

 

[jwk]

:beerchug:

I'm simply stating to not withhold transport. Do not attempt to "fix" the pt on scene and then transport. Everything can be done en route. If the pt had only water to drink or is a "salty sweater" hyponatremia is a real possibility. The only way to know is through labs... at a hospital. Also, without knowing CK you can't treat for rhabdo prophylactically. Unless in the setting of crush syndrome or you actually witness myoglobinuria. None of which was mentioned. I would (and have) placed the pt on the stretcher, initiate transport, direct AC vents at the pt, strategically place ice packs, place in Trendelenburg if appropriate, start a IV, administer fluids if in 250ml bolus if appropriate, and administer O2 if appropriate.

 

[8jimi8]

I just got back from Bonnaroo, where I personally treated over 50 patients for heat exhaustion/stroke.

Standard treatment was IV, room temp normal saline, encourage po h20.

If nauseated refractory to 1l ns and unable to tolerate sips of water 12.5mg phenergan ivp, or 4mg zofran ivp

then a 2nd bag of ns.

respite until nausea subsides, then back to the party once recovery to about 80%. (subjective 80%)