injuries poisoning
Heatstroke
Treatment of Heatstroke
Aggressive cooling Aggressive supportive care Classic and exertional heatstroke are treated similarly. The importance of rapid recognition and effective, aggressive cooling cannot be overemphasized. The main cooling techniques are Cold water immersion Evaporative cooling Cold water immersionresults in the lowest morbidity and mortality rates and is the treatment of choice when available. Large cooling tanks are often used at outdoor activities such as football practices and endurance races. In more remote areas, patients may be immersed in a cool pond or stream. Immersion can be used in an emergency department if suitable equipment is available and the patient is stable enough (eg, no need for endotracheal intubation, absence of seizures). The rate of heat loss during cooling may be decreased by vasoconstriction and shivering; shivering can be decreased by giving a benzodiazepine (eg,diazepam5 mg orlorazepam2 to 4 mg IV, with additional doses as needed). Evaporative coolingis also very effective and works best if the patient has adequate peripheral circulation (requiring adequate cardiac output). Evaporative cooling can be accomplished quickly by spraying tepid water over the patient and using a large industrial fan (often used by the janitorial department). The use of warm or tepid water maximizes the skin-to-air vapor pressure gradient and minimizes vasoconstriction and shivering. With this technique, most patients who have heatstroke can be cooled in<60 minutes. In addition, ice or chemical cold packs can be applied to the neck, axillae, and groin or to hairless skin surfaces (ie, palms of hands, soles of feet, cheeks) that contain densely packed subcutaneous vessels to augment cooling, but are not adequate as the sole cooling method. Cooling measures should be stopped once temperature reaches approximately 39° C to avoid overcooling and causing iatrogenic hypothermia. Necessary resuscitation should proceed while cooling is done. Neuromuscular blockade with endotracheal intubation and mechanical ventilation may be needed to control shivering and prevent aspiration in obtunded patients. Supplemental oxygen is given because heatstroke increases metabolic demand. IV hydration with 0.9% saline solution should be started with 1 to 2 L of cooled 0.9% saline to help decrease core temperature. Fluid deficits range from minimal (eg, 1 to 2 L) to severe dehydration. IV fluids should be given as boluses, assessing responses and the need for additional boluses by monitoring blood pressure, urine output, and central venous pressures. Patients should be admitted to an intensive care unit and observed for multiple organ dysfunction, Disseminated Intravascular Coagulation (DIC) , and 