During the fourth of July holiday, while on a family vacation in Florida, I saw a national news article from the Washington Post that stated our planet saw its hottest day on record. The average global temperature was nearly 63 degrees F. As we approach August and the dog days of summer - that record will likely be broken again very soon. The world is heating up, but even with these temperatures extremes we keep moving. The family grill outs continue, the kid still compete in recreational sports activities..etc.. So, with that said, I thought it was timely to discuss a true medical emergency that gets highly debated around this time every year. Heat Stroke vs. Heat Exhaustion. We all understand that temperature extremes greatly affect our most vulnerable populations (the young and the old), but heat stroke can bring even the healthiest individuals to their knees in short order. As pre-hospital professionals, we must be informed on the differences because while heat stroke is deadly, our quick interventions and recognition can go a long way toward deficit free patient survival.
A simple google search on the topic of heat stress will turn up thousands of results but be careful and scrutinize the images and the literature because lots of old information, not rooted in evidence is out there. It misinforms both the general public and the first responders. My trusted friend and colleague David Fifer collaborated with some other industry experts and came up with the best infographic on the matter. I have gladly shared it below - feel free to do the same with your agency:
See anything above that goes against what you have been previously taught? Two things need pointed out here -
#1 - The presence or absence of sweating on the skin is irrelevant.
[Most heat stroke victims will still continue to perspire]
#2 - Cold water immersion is the standard of care for obvious heat stroke.
[Foster an environment, that lets you complete this step before transporting]
* #2 does NOT apply to patients experiencing fever, secondary to an infectious agent and/or septicemia.
If you want a quick differentiator DO NOT focus on cessation of sweating, but rather, guide your actions on the patients' mental status and/or CNS dysfunction. As the GCS declines, it's time to start being aggressive with your care, and when you think the water bath is cold enough - you guessed it -- add more ice. Rapid and deliberate cooling is the preferential treatment + the ultimate key to recovery -- there is no harm in doing this. Historic measures of passive cooling will not work. You are cooling them quickly to prevent the bodies naturally occurring compensatory mechanisms (shivering) from kicking in. Shivering promotes heat generation and can deplete precious energy stores and we want to combat that with our treatment efforts. Don't make the shivering potential be a deterrent to making up the ice slurry -- it's still what they need, and some shivering likely won't increase their core temp enough to cause issues.
Heat stroke comes in two forms: Exertional (athletes) is much more common than non-exertional (elderly), but the treatments pathways (rapid cooling) do not change. Keep in mind, sometimes desperate times call for desperate measures. In our industry, creativity can be the name of the game. JACEP published a case study several years ago that demonstrated a novel, but successful approach to CWI. They deployed a body bag and filled it in ice -- seems easy enough to me, and it's certainly costs effective.
In closing, don't be afraid to speak up and push against older agency/industry norms. Stay centered on current, evidence-based guidelines. Know that bad information tends to travel faster than good information. Stomp out and correct misinformation quickly as it could be deadly. Lastly, when it's scorching outside, take frequent breaks and stay hydrated....water is preferred.
July 24, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.