Has your ED prepared for heat-related illnesses?
During the summer months, patients frequently present to the ED with heat-related illnesses, ranging from simple heat exhaustion to life-threatening heat stroke. "It's important not to miss signs and symptoms of a potentially life-threatening condition," stresses Edward Otten, MD, professor of emergency medicine at the University of Cincinnati and president of the Wilderness Medical Society, based in Indianapolis.
Here are some rapid ways to cool patients:
Use icewater baths. If a patient presents with a dangerously high temperature, immersing them in a tub filled with ice and water is the fastest way to cool them down. "With a patient with heat stroke with a temperature of 108°F who is intubated and on a monitor, within 5-6 minutes, you can get their temperature down," says Otten.
The University of Cincinnati's ED uses Aid-A-Baths to cool heat stroke patients rapidly. "This is nursing home technology that is being adapted to the ED," explains Otten. The large tub with vinyl sides flattens out like a regular stretcher, at the same height as a gurney so patients can be worked on. A hose is attached so the water can be drained into a sink.
Mist patients with cold water. If the patient's temperature is not dangerously high, you can use mist bottles while an electric fan blows onto the patient. "Keep several spray bottles in the ED for that purpose," recommends Otten. "Pouring water on them doesn't work very well, because the water has to evaporate from their skin to get the cooling effect."
Don't overlook symptoms of heat stroke. "A lot of heat stroke goes unrecognized," notes Otten. "Anybody with an elevated temperature and change of mental status should be looked at the same way as if they had a gunshot wound or acute MI. It's unacceptable to leave them waiting in the lobby for a couple of hours."
Key warning signs are a high temperature and disorientation. "If they look drowsy or like they might have symptoms of stroke or hypoglycemia, they need to be treated immediately," stresses Otten.
If a patient seems disoriented, heat stroke should be considered. "Sometimes, a patient may come in because they just don't feel right," says Otten. "If an elderly woman comes in and seems confused, be sure to take her temperature."
Heat stroke victims may come to the ED in the middle of the night, Otten says. "We tend to see exertional heat stroke during the day, with athletes riding their bikes in the heat, but you see classic heat stroke at night," he explains. "Elderly people may close their windows and lock their doors at night, and the house just heats up if there is no air conditioning."
Don't assume because patients are sweating that they do not have heat stroke. "We used to believe that if patients are sweating, it must be heat exhaustion, but that is a dangerous misconception," says Otten. "Patients can be sweating and still have heat stroke."
Hydrate patients adequately. All heat-related illnesses cause dehydration, so patients should be given IV fluids. "They are almost all dehydrated to some degree," notes Otten.
Don't assume heat illness occurs only in summer. In Cincinnati, a mini-marathon was held on a warm spring weekend. "Three patients were brought to the ED with altered mental status and high temperatures ranging from 102°F to 106°F," says Renee S. Holleran, RN, PhD, chief flight nurse and clinical nurse specialist at Cincinnati Medical Center (OH). "Patients were cooled by misting and fans, which are hard to find in the cooler months. One patient required intubation and long-term management in the ICU."
Even though the weather may not appear to be warm enough to produce heat illness, excessive exercise and inadequate fluid intake may put patients at risk of suffering a heat-related illness. "When a patient has an altered mental status, always get a temperature," Holleran emphasizes.
Monitor temperature. When using ice baths, it's essential to monitor the patient's temperature to ensure it doesn't go too low. "The best way is an esophageal probe temperature thermometer," Otten recommends. "When the temperature gets to be about 101°F, take the patient out of the ice bath. Otherwise, you may overshoot and wind up with a temperature of 92°F so the patient starts to shiver."
If patients are awake and alert, they may not be able to stand ice water. "A lot of patients are intubated and paralyzed because you don't want them to vomit and aspirate. But patients who are awake won't be able to stand being put into ice water because it's too painful. They may only be able to tolerate cold water," says Otten.
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