Guidelines for transport: Cool first, transport second
Most patients suspected of suffering from heat stroke should be transported to a hospital for further evaluation because of the high morbidity and mortality rates associated with it. However, cooling techniques should be implemented while awaiting transport. The current standard is “cool first, transport second.”7 Cooling interventions should continue in the ambulance if the core body temperature is still elevated. Techniques that can be used include the use of air conditioning, convective methods, and administration of IV fluids. As previously discussed, core body temperature should be continuously monitored. Cooling measures should be discontinued only when the patient’s rectal temperature reaches 38.9° C (102° F). Overly aggressive prehospital cooling beyond this point can result in prolonged hypothermia as well as cardiac arrhythmias.6
Monitoring and further evaluation
Monitoring patients with heat-related illness can be difficult, especially when utilizing CWI, as this may limit the ability to use devices such as a cardiac monitor or to continuously monitor rectal temperature. Beyond lowering core body temperature to below 39° C (102.2° F), early evaluation and treatment of other organ systems is vital, keeping in mind that these patients may develop multisystem organ failure. The initial work-up is listed in TABLE 2.
Depending on the severity of the injury and whether you suspect another diagnosis at work, additional studies may include urine output monitoring with a Foley catheter, electrocardiogram, chest radiograph, toxicology screen, a serum lactate level, and cardiac biomarkers.
Imaging. When evaluating for heat stroke, it usually isn’t necessary to obtain head imaging initially, as there are rarely abnormal findings in the early stages. Imaging may be obtained, however, if there is concern about a head injury or if neurologic abnormalities persist into later stages of treatment.5
Pharmacologic agents have not been shown to be of benefit in the treatment of heat-related illness. While dantrolene is commonly used in the treatment of neuroleptic malignant syndrome and malignant hyperthermia, the literature has not described any benefit associated with this agent in relation to heat-related illness. The same goes for antipyretics. Researchers have hypothesized that the reason these agents are ineffective is because body temperature is raised via a different mechanism in these conditions vs heat stroke.3
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