Management of Heat Illnesses
Tod Schimelpfenig
Gates Richards Jr
Shana Tarter
INTRODUCTION
The wilderness emergency medical services (WEMS) provider will assess and treat overt heat illness, as well as underlying illness that is affected by the stress of heat, for patients in many environments. Such environments include those recreating outdoors,1 during large events such as endurance races,2 and in people working outdoors3 or serving as emergency responders for fire,4 search, rescue and EMS. In the context of a natural disaster—an event that changes the familiar urban environment into a wilderness—the WEMS provider may manage heat stress in people unable to seek shelter from heat, who have inadequate access to water, or who may be confined to residences and institutions without the electricity to power air-conditioning.5
The WEMS provider also has an important role in prevention of heat illness through education of participants, teammates and the public, and through practice of the field techniques that promote temperature homeostasis and hydration and enable response in adverse environmental conditions.
Heat-related illness is a spectrum from mild to severe; from the discomforts of exercise-associated muscle cramps, heat syncope, and heat exhaustion to the life threat of heat stroke. This chapter will review the pathophysiology and presentation of these illnesses, including the associated issues of fluid balance, dehydration and exercise-associated hyponatremia, and the range of medical care from field first aid through advanced wilderness practices and hospital-based care.
Definitions
Cramps, syncope, exhaustion, and hyperthermia have multiple causes. This chapter specifically addresses these problems, as well as hydration, dehydration, and hyponatremia, in the context of exposure to environmental heat stress.
Exercise-associated muscle cramps are muscle spasms, which can be intense and debilitating and occur typically in the legs, arms, and abdomen. Heat cramps is the traditional and popular term. The term exercise-associated muscle cramps reflects the understanding that these cramps are not directly related to an elevated body temperature.
Heat syncope is dizziness, weakness, and fainting during heat exposure and after prolonged standing or rapidly standing from a lying or sitting position.
Heat exhaustion is a generic term referring to an inability to cope with heat stress. It is characterized by minor changes in mental status, nausea, headache, fatigue and lassitude, rapid heart rate, and diaphoresis.
Heat Stroke is a life-threatening illness characterized by confusion, disorientation, impaired judgment—central nervous system dysfunction—usually accompanied by a temperature of more than 40°C (104°F).* Classic heat stroke occurs with passive exposure to heat stress. Exertional heat stroke occurs during strenuous exercise and is the presentation most often associated with wilderness activities.6
Dehydration occurs when water loss exceeds water intake and there is an overall fluid deficit. It makes us more susceptible to the effects of heat, cold, and altitude, worsens fatigue, decreases the ability to exercise efficiently, and reduces mental alertness. In extreme cases, dehydration can be a life-threatening medical problem.
Exercise-associated hyponatremia is a physiologic state where blood sodium concentration is lower than normal. In the context of
this chapter it is most often due to overhydration during exertion in the heat using fluids without supplemental electrolytes, like water. Signs and symptoms include confusion, disorientation, loss of faculties, headache, nausea, vomiting, aphasia, loss of coordination, and muscle weakness. Severe hyponatremia can lead to brain swelling and death.
this chapter it is most often due to overhydration during exertion in the heat using fluids without supplemental electrolytes, like water. Signs and symptoms include confusion, disorientation, loss of faculties, headache, nausea, vomiting, aphasia, loss of coordination, and muscle weakness. Severe hyponatremia can lead to brain swelling and death.
Scope of Discussion
Physiology of Humans in the Heat
Humans, as homeotherms, strive to maintain body temperature within acceptable limits—35° to 37°C (95° to 98.6°F) and do so in the face of wide variations in temperature, humidity, solar radiation, and other environmental parameters and with a variety of physiologic and behavioral adaptations.
There are two main avenues of heat production in the human body—basal metabolism and exercise. Basal metabolism produces an average of 65 to 85 kcal of heat per hour. This output increases 13% per degree Celsius rise in body temperature. 7 Muscular activity produces heat at a range of 300 to 1,000 kcal/h and can dramatically raise body temperature at a rate that well-conditioned athletes can sustain for hours. Even at rest, humans can produce enough heat that the excess must be dissipated. The addition of exercise, warm temperatures, humidity, solar radiation, and other environmental, physiologic (eg, underlying health, medications) and human-created (eg, excess clothing) parameters can greatly increase this challenge.
There are four main avenues of heat exchange with the environment: conduction, convection, radiation, and evaporation. These are discussed here in the context of heat illness.
Conductive heat transfer occurs when there is direct contact between two bodies of differing temperatures. Energy in the form of heat moves from the warmer to the cooler object. Human tissues are generally poor conductors of heat, especially areas with subcutaneous fat. In general, behavior limits the effect of conduction as a heat exchange mechanism; we insulate ourselves from both cold and warm surfaces.
Convective heat transfer occurs when two surfaces, in direct contact, are moving relative to each other; moving air and water are the obvious examples. Convection transfers heat within the body between blood and tissues and between blood vessels via counter current heat exchanges. This effect varies based on the temperature gradient, the thermal conductivity of the medium (air or water), surface exposure and protective clothing. In a cold environment wind chill occurs when a cool wind moves over warm skin. Moving cold water combines the increased conductivity of water with the convective mechanism to increase heat loss. In a warm environment a hot wind can theoretically add heat to the body, but its effect would be low due to the small thermal gradient. Hot wind is mostly an agent of overall heat stress.
Radiation heat transfer occurs from the emission of electromagnetic energy. The gradient of energy transfer is from a warmer to a colder object. In a cold environment humans are often the warmer objects in the environment (normal body temperature of 37°C [98.6°F]) and lose heat by emitting radiation from exposed skin. In a warm environment an increase in skin temperature facilitates heat loss from radiation as long as the surrounding environment is cooler than the skin. We receive radiation heat input from fires, from the sun or from warm objects in our surroundings such as concrete or rock walls. Bare skin is receptive to radiation heat input; clothing diminishes this response.
Evaporation is our most important means of heat dissipation. When perspiration evaporates from the skin’s surface the change in state from liquid to gas consumes energy from the surface of the skin—approximately 580 kcal/L of evaporated sweat. Evaporative heat loss accounts for 20% of the body’s total heat loss in normal conditions—much more when we are under heat stress or working hard. We use evaporation to our advantage to cool ourselves in hot environments.
For conceptual understanding the regulation of body temperature is often sketched as a negative feedback system consisting of central and peripheral sensors that signal to the anterior hypothalamus in the brain and a set of return signals that induce physiologic and behavioral responses for body temperature regulation. In homeostasis, body temperature fluctuates around a thermal set point, a homeostatic thermostat. Environmental heat exposure and exercise may raise the skin and core temperature above the set point, evoking autonomic responses (peripheral vasodilation, increased cardiac output, increased respirations, increased sweating) and behavioral responses (adjusting clothing, seeking shelter, fanning) to lower the temperature. Environmental cold exposure may lower the temperature below the set point, evoking autonomic (peripheral vasoconstriction, increased metabolic rate, cardiac output) and behavioral responses (adjusting clothing, seeking shelter, consuming food and warm fluids, exercise) to elevate the temperature back to the set point. Fever is a protective response, an increase in the set point to assist immune responses to infection, inflammation, or trauma. Protective hypothermia is used by some species to decrease metabolic demands.
Hydration
For the WEMS provider, hydration impacts personal and team homeostasis and the ability of the responder to perform. It requires constant attention while in the field. Wilderness providers care for patients whose primary medical condition may be dehydration and for patients where dehydration underlies and complicates other injuries and illnesses.
Humans are bags of water: 50% to 70% of the body mass of an average young adult male is water. We hear through a medium of water. The brain is cushioned by fluid, and the joints are lubricated by fluid. Blood is 90% water, and every biochemical
reaction takes place in a medium of water. The inability to maintain fluid balance through a lack of fluid availability or exposure to extreme environments affects health, the ability to think clearly, and to perform physical work.
reaction takes place in a medium of water. The inability to maintain fluid balance through a lack of fluid availability or exposure to extreme environments affects health, the ability to think clearly, and to perform physical work.
WATER LOSS
There is an inevitable daily turnover of water from respiratory, gastrointestinal, renal, and sweat losses and there is gain from consumption of liquid, food, and water released as a metabolic byproduct. When combined with unlimited access to food and beverages net body water balance is regulated remarkably well day-to-day as a result of thirst. In ideal environmental and physiologic conditions water gain and loss are balanced and keep total body water within 0.2% to 0.5% of baseline.8
The kidneys are a key player in the systems that regulate fluid balance. Urine output is normally 1 to 2 L/day and will fluctuate over a wide range in response to fluid consumption, activity, and total body water. Minimum outputs of approximately 20 mL/hour and maximal volumes of approximately 1,000 mL/hour are possible.8
SWEAT AND SWEAT PRODUCTION
As body temperature rises, increased skin blood flow and sweat secretion drive the evaporative heat loss process. When the air temperature is greater than or equal to skin temperature, evaporative heat loss accounts for most body cooling. Air movement and the water vapor pressure gradient between the skin and environment affect the rate of sweat evaporation; for example, in still or humid air, sweat does not evaporate readily. Thick or impermeable clothing or protective garments create high vapor pressure next to the skin and also reduce sweating. When sweat drips from the skin without the change of phase from liquid to gas it only dehydrates, it does not cool. The loss of water and electrolytes from the skin contributes to dehydration and makes less fluid available for evaporation.9
Sweat is typically one-half of plasma osmolality and is hypotonic relative to plasma. The electrolyte loss in sweat depends on the duration of sweating and the concentration of electrolytes in the sweat. Sodium is the major electrolyte in sweat and varies in concentration depending on genetic predisposition, diet, sweating rate, and heat acclimatization state. One of the benefits of acclimatization to heat is a higher and more sustained sweating rate. Heat acclimatization also improves the ability to reabsorb sodium and chloride. Heat-acclimatized individuals usually have lower sweat sodium concentrations, up to a reduction of 50% or more, for any given sweating rate.6
Table 14.1 Work, Rest and Fluid Needs in Warm-Weather | |||||||||||||||||||||||||||||||||||
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Imbalances of fluid loss and gain may occur due to illness, environmental exposure, exercise, or physical work. Illnesses, such as diarrhea and hyperglycemia, can lead to loss of large amounts of fluid and electrolytes. Physical activity in a hot environment can result in water balance deficits even with unlimited access to food and fluids.10
Fluid requirements vary based on an individual’s body size, activity level, and the environment. The range for sedentary adults is from 1.2 to 2.5 L/day. For adults performing modest physical activity in a mild environment this range expands to 3.2 L and in a hot, dry environment will reach 6.0 L or more.11 In wildland firefighting, water loss of 0.5 L/hour is common and 2 L/hour can be expected in extreme conditions.12 Females tend to have slightly lower fluid requirements than males, presumably due to lower average total body water.
To calculate water needs, an individual must predict sweat loss in a given environment and activity. There are tables available that predict fluid requirements by environmental conditions and activity (Table 14.1). These may be helpful to those supervising and providing logistic support to wilderness rescue teams. Practically, water needs are often based on the individual’s experience and self-awareness of fluid needs.
Pathophysiology of Humans in the Heat—Heat Illness, Dehydration, and Exercise-Associated Hyponatremia
Exercise-Associated Muscle Cramps
The term exercise-associated muscle cramps reflects the understanding that these cramps are not directly related to an elevated body temperature. They can happen in any exercise, in warm and cold temperature, during warm-up, during the exercise, or after exercise. The cause of exercise-associated muscle cramps remains a topic of debate. Discussions focus on exercise-associated muscle cramps as a result of local fluid and
electrolyte deficits, (eg, increased intracellular calcium stimulating muscle contraction), or as a result of central neuromuscular fatigue, or any combination of these factors.13 Exercise-associated muscle cramps are associated with other forms of heat illness, but they do not predispose a person to other forms of heat illness.
electrolyte deficits, (eg, increased intracellular calcium stimulating muscle contraction), or as a result of central neuromuscular fatigue, or any combination of these factors.13 Exercise-associated muscle cramps are associated with other forms of heat illness, but they do not predispose a person to other forms of heat illness.
Lack of fitness, lack of acclimatization to exercise in the heat, and profuse sweating associated with sodium loss are characteristics of people who suffer from exercise-associated muscle cramps.14
Heat Syncope
Syncope is a sudden, transient loss of consciousness and postural tone. Heat syncope is commonly a limited period of altered mental status or loss of consciousness in the context of heat exposure. It is similar to vasovagal syncope and results from orthostatic blood pooling, peripheral vasodilation, and the absence of a robust vascular response to positional change. There is no evidence of severe, life-threatening causes in heat syncope and either no loss of consciousness or rapid return of normal mental status once the patient is in a supine position and removed from heat stress. Dehydration, a lack of heat acclimatization, prolonged standing, and underlying cardiovascular health are presumed contributing factors. It usually resolves promptly with rest, removal from heat stress, and hydration.15
Heat-associated postural hypotension, a term that can be used interchangeably with heat syncope, often refers to syncope from inadequate hydration and alterations in lower extremity vascular tone when exercise stops. For example, when a runner stops and the leg muscles are no longer contracting in the constant rhythmic manner of running, blood may pool in the legs. The stress of dehydration and the sudden cessation of movement may cause a sudden drop in blood pressure that triggers fainting.
Heat Exhaustion
Heat exhaustion, also known as heat prostration or heat collapse, is just what the term says, fatigue from the stress of coping with a hot environment. The work of heat dissipation along with the stress from coping with sunlight and heat exhaust the patient. Heat exhaustion is not low fluid volume from dehydration, although dehydration can occur alongside heat exhaustion.
Heat exhaustion is considered to be on the mild to moderate spectrum of heat illness, although for some patients it is debilitating. It may remain an entity by itself or progress to exertional heat stroke. It may occur with or without dehydration and elevated core temperature.16
It is usually seen in the context of exercise in the heat but can occur without exercise in people with underlying medical conditions and associated heat stress (cardiovascular insufficiency limiting robust response to the heat stress, medications that predispose to dehydration or drive metabolic rate, cumulative stress over multiple days).
Exertional Heat Stroke
In the spectrum of heat illness, heat stroke is the life-threatening emergency. Patients have exaggerated heat production and an inability to cool themselves due to extreme heat challenge and underlying health issues (classic heat stroke) or heat challenge and exertion (exertional heat stroke). Core temperature is usually above 40°C (104°F).
Current understanding of the pathophysiology of heat stroke, which is still incomplete, is that the need to dissipate heat from exertion or chronic heat stress results in an increase in blood flow to the skin and a decrease in blood flow to the gut. This triggers gut ischemia, increased epithelial membrane permeability, and leakage of endotoxin into the systemic circulation causing a systemic inflammatory response. Multi-organ system failure is the ultimate cause of heat stroke death.17
Classic heat stroke occurs in an at-risk population of the very young, the elderly, and the chronically ill, often accompanied by social and economic factors such as inability to access air-conditioning or cool surroundings during periods of heat stress.
High temperature and humidity that impair heat dissipation, often for several days, can precede classic heat stroke. Infants are vulnerable due to their high surface area to body mass ratio, which can increase heat gain and dehydration, poorly developed thermoregulation mechanisms, and inadequate behavioral responses. The elderly can have comorbidities such as mental illness, use of prescription medications that influence thermoregulation (diuretics, anticholinergics, antipsychotics, tranquilizers), diabetes, and cardiovascular disease.
Exertional heat stroke is typically seen in athletes unacclimatized to exercise in the heat. During exercise, excess heat must be dissipated from the body to avoid hyperthermia. The burden of the heat load can be slow to develop and accompanied by nausea, dizziness, feeling of heat oppression, and perceived high exertion. These may be overlooked as normal side effects of exertion or ignored from motivation to train, compete, work, or rescue. The presentation may also be acute with sudden collapse and altered mental status.
Dehydration
People vary in their tolerance for dehydration. A body mass water deficit of greater than 2% is often cited as a threshold for symptomatic dehydration, although trained athletes can tolerate greater deficits during competition. Dehydration causes increased body core temperature, increased cardiovascular strain, increased glycogen utilization, and altered central nervous system function. The impact of dehydration on prolonged work efforts is magnified by hot environments, and probably worsens as the level of dehydration increases.
The 2% dehydration threshold has been reported to affect cognitive performance. Outdoor people are aware of the irritability and dullness of intellect from dehydration. Studies
of performance when dehydrated have documented reduced visual motor tracking, impaired short-term memory, reduced attention span, reduced ability to do arithmetic calculations, and higher levels of perceived effort and concentration. This has clear implications for the quality of decisions and the effect on risk management in wilderness activities.18
of performance when dehydrated have documented reduced visual motor tracking, impaired short-term memory, reduced attention span, reduced ability to do arithmetic calculations, and higher levels of perceived effort and concentration. This has clear implications for the quality of decisions and the effect on risk management in wilderness activities.18
Exercise-Associated Hyponatremia
Exercise-associated hyponatremia has been observed during marathon and ultramarathon competition, military training, and recreational activities. Hyponatremia describes a state of lower than normal blood sodium concentration, typically lower than 135 mEq/L. Exercise-associated hyponatremia tends to be more common in long-duration activities and most often occurs when individuals consume low-sodium drinks or sodium-free water in excess of sweat losses (typified by body mass gains), either during or shortly after completing exercise.
The primary cause of hyponatremia in the context of exercise in the heat is drinking fluids without electrolyte supplements in excess of fluid loss. In an effort to reduce heat stroke emergencies, Grand Canyon National Park emphasized “drink water, drink water, drink water” to its visitors. Pure water does not have electrolyte supplementation, and consequently, the incidence of hyponatremia increased. The same phenomenon was seen in marathon running where hyponatremia was virtually unknown before the modern advice to drink water to excess.
Contributing factors can include inappropriate increased antidiuretic hormone (vasopressin) secretion that causes fluid retention and a hypertonic urine. Sodium loss in sweat is not a cause of exercise-associated hyponatremia, although it may exacerbate the problem in some people. Most sports drinks are not protective as they tend to have insufficient sodium to compensate for excessive fluid intake.
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At risk is anyone consuming excessive fluids, as well as smaller people, females, those exercising for longer than 4 hours, or those taking high doses of nonsteroidal antiinflammatories (NSAIDs), which slow kidney function.19
Predisposing Factors
WEMS providers have an important role in prevention of heat illness. They should be aware of the factors which influence the incidence of heat illness in order to anticipate and prevent these problems in themselves, their teammates, and their patients.
Environmental heat is the obvious source of stress. Heat waves (three or more days of temperatures greater than 32.2°C [90°F]) are commonly associated with an increase in both direct mortality and morbidity from heat illness and with increased overall mortality.20
There are several metrics that describe and attempt to quantify environmental heat stress that may be useful to those supervising field operations. These metrics often incorporate environmental factors such as ambient temperature, humidity, wind, dew point, and cloud cover.
The U.S. National Weather Service (NWS) uses a heat index that combines ambient temperature in the shade and relative humidity with presumed clothing, body activity, and other parameters (Figure 14.1). The resulting number is expressed as “effective” or “perceived” temperature in degrees Fahrenheit.21
The wet-bulb globe temperature is used to express environmental heat load. This metric accounts for means to gain and dissipate heat by combining air temperature in the shade, effects of wind, evaporation, and sun radiation, thus accounting for the various methods by which a resting body can gain and dissipate excess heat. However, this is difficult for both the lay public and EMS to calculate or use and currently appears
to have little clinical or operational efficacy. The military has developed a flag system to communicate risk regarding activity in heat (Table 14.2).22
to have little clinical or operational efficacy. The military has developed a flag system to communicate risk regarding activity in heat (Table 14.2).22
Table 14.2 Wet Bulb Globe Temperature | ||||||||||||||||||||||||||||
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Cumulative exposure is a known risk factor in both the military and in firefighting. The risk of heat illness increases on the second and subsequent days of exposure without relief.23 Additionally, fatigue and sleep deprivation adversely affect the ability to respond to heat stress. Wildland firefighters can be deployed for multiple days of extended physical work hours. Evidence suggests that individually, physical work and sleep restriction can elicit an acute inflammatory response that may have implications for the individual’s ability to tolerate heat stress.24,25,26
Protective clothing is a significant microclimate factor in the development of heat illness. Clothing intended to protect against chemical or infectious disease exposure, search and rescue (SAR) responders with loads of protective clothing, harnesses and packs, or clothing to protect during firefighting or fire-protective flight suits insulate the skin from heat exchange and often include the head and neck in the clothing ensemble thus further reducing the ability to dissipate heat load.27,28
Exercise is another obvious source of heat stress. Core temperature rise is common in strenuous activity. In the presence of an environment unfavorable to heat dissipation, or excessive or improper clothing, or other factors that impair heat dissipation, the threat of heat illness rises. Numerous guidelines, previously noted, exist for decision-making in the context of activity in warm environments.15,29
Underlying health status influences the ability to tolerate heat stress. In studies from the Grand Canyon National Park, at least a quarter of the nonfatal cases had cardiovascular and endocrine conditions.30,31 The cardiovascular system is fully engaged in dissipating heat load as blood is shunted from the core organs to the skin. An impaired cardiovascular system may be unable to maintain cardiac output in the face of heat stress, resulting in cardiovascular collapse. The elderly may have lower sweat rates, longer time to onset of sweating, and impaired responses to vasodilation and blood pressure changes. A number of studies document the influence of cardiovascular fitness on ability to respond to heat stress and the role of cardiovascular disease on the incidence of heat illness.32,33,34
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