ED management of heat related illness -guideline by Miniustry Of Health, Malaysia

1. DR LEE OI WAH
KETUA PENOLONG PENGARAH
KANAN (PERUBATAN)

2. • Heat related illness is a medical emergency .
• Mortality -70% in cases of heat stroke
• If appropriate treatment is started without delay, survival
rates may approach 100%.
• Factors contributing to heat stroke:
 extrinsic factors-extreme temperature, physical effort &
environmental condition
Physiologic limitation-children, elderly, chronic illness eg
DM , heart disease, renal failure.

3. Heat related illness is a group of disorder ranging from
minor (heat oedema, pricklly heat, heat syncope, heat
cramps and heat exhaustion) to major (heat stroke).

4. • Mild swelling of feet, ankle and hands
• Appears in few days of exposure in hot environment
• Oedema usually does not progress to pretibial region
• Treatment conservatively eg elevate leg & compressive
stocking
• Resolves spontaneously

5. • Pruritic maculopapular, erythematous rash over covered
areas of body
• If prolonged or repeated heat exposure may lead to
chronic dermatitis
• Treatment with antihistamine & chlorhexidine (cream or
lotion based)

6. • Painful, involuntary , spasmodic contractions of skeletal
muscle
• Usually occurs at the calves, thighs and shoulders
• Occurs in individuals sweating profusely and only
drinking water or hypotonic solution
• Rx- fluid & salt replacement(IV or oral)
- rest in cool environment

7. • Paraesthesia of the extremities and circumoral or
carpopedal spasm
• Due to hyperventilation
• Rx- remove patient from hot environment & calm patient

8. • Postural hypotension
• Usually in elderly
• Rx- RULE OUT OTHER CAUSES FIRST
- Rest and IV drip

9. • Presented as headache, nausea, vomiting , malaise ,
dizziness and muscle cramps.
• TEMPERATURE < 40◦C OR NORMAL
• May progress to heat stroke if fails to improve with
treatment
• Rx - volume replacement
- if no response after 30 min , need to aggresively
cool the patient to core temperature < 39◦C

10. • Defined as a core temperature > 40.5◦C accompanied
by CNS dysfunction
• Types of heat stroke – classical heat stroke (CHS)
- exertional heat stroke (EHS)
- confinement hyperpyrexia

11. • Occurs slowly within few hours to days ; leading to
volume and electrolyte loss
• Population at risk - elderly
- children
- pharmacological treatment
• Occurs during severe heat wave (environmental ◦T >
39.2◦ C)

12. • Occurs in healthy young individuals after severe exertion
• May occur in normal or humid or hot environment
• Commoner in Malaysia

13. • Subtype of non-exertional hyperpyrexia
• 3 circumstances:-
 child left inside car
 human traficking- enclosed vehicle
 workers exposed to heat in enclosed space

14. • History of heat exposure and
1. Core body temperature greater than 40◦C
2. Signs of CNS dysfunction
- confusion
- delirium
- ataxia
- seizures
- coma
3. Other late findings
- anhidrosis
- coagulopathy
- multiple organ failure

15. • CNS injury
• Hyperthyroid storm
• Infection / septicemia
• Neuroleptic malignant syndrome
• Pheochromocytoma
• Anticholinergic poisoning
• Drug ingestion
• Heat exhaustion

16. 1. ABG - hypoxemia
- metabolic acidosis
2. RBS – to exclude hypoglycemia / hyperglycemia
3. Electrolytes – hypo or hypernatremia
- hypo or hyperkalemia
- hypocalcemia
4. LFT – elevated ALT
5. Coagulation studies – derangement
6. FBC - ↓ platelet , ↑ TWDC , ↑ PCV
7. Renal function test – pictures of acute kidney injury
8. Muscle enzymes - ↑ creatinine kinase
9. Urine analysis – protein , cast , myoglobin

17. 10.ECG - arrhytmia
11.CXR – to detect atelectasis , pneumonia , pulmonary
infarction etc
12.CT scan – TRO ICB if patients did not show
improvement in neurological signs

18. 1. Detect the clinical sybdrome of heat exhaustion / heat
stroke
2. To initiate effective cooling measures immediately
3. Transfer to nearest appropriate hospital for definitive
treatment

20. Aim of management:
1. To prevent further metabolic derangement
(rhabdomyolysis , coagulopathy , liver and acute kidney
injury)
2. To institute effective cooling measures

21. Initial management of the heat stroke patients is as following:
• Focused clinical assessment regarding cardiovascular,
respiratory and neurological function.
• Exclude other differential diagnoses.
• Ensure patent airway, keep patient nil by mouth.
• Provide oxygen supplementation.
• Ensure adequate respiratory effort.
• Insert intravenous cannula and initiate fluid management
• Check body core temperature
• Institute active cooling measures
• Seizure control
• Patient monitoring
• Co-management with ICU if necessary

22. • Fluid resuscitation guided based on hemodynamic status,
comorbid and ensure urine output (UO) more than 0.5
ml/kg/hr in adult.
• When HR, BP, and UO do not provide adequate
hemodynamic information, fluid administration should be
guided by other non-invasive and invasive hemodynamic
parameters

23. • Removal of body clothing
• Ice packs at groins, neck and axilla, spray cool water
• Use mist fan / air conditioned room / Stand fans.
• Ongoing tepid sponging / cooling blankets.
• Consider lavage with cold saline via nasogastric tube or 3
way urinary catheter.
• DO NOT administer Paracetamol or Aspirin or other
NSAIDS.
• Target to reduce temperature by 0.2°C per minute up to
approximately 38°C.

24. • Administer benzodiazepine in titrated doses for agitated
patient and prepare for securing the airway definitively.
• Barbiturates may be used for patients having seizures
and resistance to benzodiazepines.

25. • Core body temperature.
• Blood pressure / pulse rate / pulse oximetry.
• 12 lead ECG and continuous ECG monitoring.
• Hourly urine output (for patient with continuous bladder drainage).
• ½ hourly Glasgow Coma Scale (GCS).
• 4 hourly capillary blood sugar.
• Nasogastric tube drainage (for intubated patient)