You have been called to a 23 year old male with no previous medical history in the process of running a half marathon and has collapsed with dizziness. On arrival, the person is confused and combative with bystanders in attendance. On examination he is found to be conscious, but very confused. Pupils dilated and slow to react. Pulse rate 120, weak, thready. Blood Pressure: 87/45. Skin, pale, warm to touch and dry. Temperature 42.1 (tympanic).
Your immediate assessment of him suggests heat stroke.
Treatment commences with attempts to cool him down and rehydrate him. You get him into the Ambulance and get the air conditioning going. Your first priorities include: removing his clothing, applying cold packs to his axilla and back of his neck. Oxygen should be given to reduce his respiratory efforts and help remove any excess C02 produced secondary to metabolic acidosis. An ECG monitor should be applied, so that signs of hyperkalaemia and subsequent dysrhythmias may be monitored. IV access should be gained and fluids administered. He is currently showing signs of anhydrases (inability to sweat secondary to absolute fluid loss).
Urgent transport to hospital and early notification should be provided so that the hospital is able to organise adequate cooling devices.
Enroute he starts to have a seizure. The seizure is allowed to continue for almost 6 minutes while midazolam is drawn up and given. In this time his temperature has increased to 43.1.
Enroute to hospital, signs of hyperkalaemia occur, with tall peaked T waves, followed by a sine wave formation, and eventually, Ventricular Fibrillation occurs. Resuscitation efforts commence with immediate defibrillation and continued resuscitation in the emergency department.
The person dies in the emergency department.
Heat Stroke Lessons Learned:
Heat stroke is a life threatening emergency. In some cases, heat stroke is an irreversible life threatening emergency. Therefore the less time you spend with these people the better.
Try to cool these people down as quickly as possible. Remove clothing, apply cold packs to the neck and axilla. Get them into a cool environment (no point fiddling with ice packs if they are still outside in 40 degree heat).
Don’t try to turn the air conditioner too low. All this will do is cause the person’s peripheries to constrict and shunt the blood back to the core, further heating their core body temperature. A little air conditioning isn’t a bad thing, however.
Never let a person who has heat stroke continue fitting. A seizure will further increase this person’s body temperature and will lead to their death. Midazolam or another anti-convulsant agent should be administered immediately.
Learn more about heat stroke here.