HEAT STROKE

I Made Susila Utama

Tropical & Infectious Disease Division Internal Medicine Dept, Medical Faculty Sanglah Hospital, Udayana Univ. Bali

Severe form of heat illness Heat Stroke is A MEDICAL EMERGENCY! life-threatening illness commonly fatal preventable

DEFINITION
Heat stroke is defined clinically as a core body temperature that rises above 40C and that is accompanied by hot, dry skin and central nervous system abnormalities such as delirium, convulsions, or coma.

 HYPERTHERMIA: A rise in body temperature above the hypothalamic set point when heat-dissipating mechanisms are impaired (by drugs or disease) or overwhelmed by external (environmental or induced) or internal (metabolic) heat

 HEAT EXHAUSTION: Mild-to-moderate illness due to water or salt depletion that results from exposure to high environmental heat or strenuous physical exercise; signs and symptoms include intense thirst, weakness, discomfort, anxiety, dizziness, fainting, and headache; core temperature may be normal, below normal, or slightly elevated (>37C but <40C)

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). 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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Mortality related to high temperature

Centers for Disease Control (CDC)
1999 to 2003 3442 Heat-Related Fatalities in USA. approximately 690 deaths per year The fatalities
males elderly

Predisposing factors
Increased heat production - hyperthyroidism - exercise - sepsis

Impaired heat loss -Impaired sweating Drugs - anticholinergics, anti-Parkinsonian drugs, anti-histamines, 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

 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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Pathophysiology
Balance
conduction convection radiation Evaporation
Heat Balance equation Body Heat = Metabolism + [+conduction + radiation] + convection evaporation Body Heat = M + [+ K + R + C E]
Copyright Texas Parks & Wildlife Department

Pathophysiology (cont.)
Physiologic response to heat
Anterior hypothalamus
CNS stimulation vasomotor tone, cutaneous blood flow. Increased heart rate and cardiac out put.

Parasimpatis stimulation
sweathing Dehydration

- Adaptation

Clinical Manifestation
Heatstroke
Trias
Temp > 40.50 C (104.90) Disfungsi CNS Anhidrosis

Hyperpyrexia: possibility heatstroke after exclusion the other cause. Many neurological disturbance

Clinical manifestation (cont.)

Heatstroke
Effect to system organ
CNS
Iritabilitas, Combativeness

Cerebellum
Sensitif thd panas Ataxia

Cerebral edema Anhidrosis

total failure of thermoregulation

Symptoms of heat stroke include the following: absence of sweating red or flushed skin shortness of breath rapid pulse hallucinations confusion agitation disorientation seizure coma

Core Body Temperature

Use rectal thermometer Heat exhaustion
temp < 104

Heat Stroke temp >= 104 T > 104 by itself is NOT diagnostic of heat stroke
Abnormality CNS

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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treatment
Heatstroke
Treatment
Initial ABCs, O2 high dose pulse oximetry EKG, IV access, volume replacement Temperature

treatment (cont.)
Heatstroke
Cooling Techniques
Evaporative Immersion Ice packing Strategic ice packs Gastric lavage Peritoneal lavage Cardiac bypass

Heatstroke Treatment: Cool Quickly!

Internal cooling -Intravenous fluids

External cooling
-Cold

ice packs
spraying

-Water -Fans

-Peritoneal lavage

-Cooling
-Ice

blankets

bath

Antipyretics have no role in the acute treatment of heatstroke

Complication
Heart failure, lung edema, cardiovaskulercollaps Hepatic injury (thermal) Renal injury
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Hematological insult
Micro-hemorrhages Thrombocytopenia increased thrombocyte agregation(thermal)

Fluid and electrolite imbalance

Prevention

AC non alkohol non caffein urine output monitoring

Prevention is the Best Treatment

Underestimate the seriousness of heat illness Give the victim medications to reduce fever Give the victim liquids that contain alcohol or caffeine Give anything by mouth if HEAT STROKE is suspected