Doc, I don't feel so good...

[RsovRanger]

HEAT INJURIES

It's summertime here in georgia. With summertime in the south comes something that I see all too often. You have 3 different types of heat injuries.

HEAT CRAMPS:

Symptoms: Painful cramping of muscle groups

Causes: Dehydration coupled with lack of salt content due to excessive sweating without replenishing the bodies nutrients

Treatment: Get them out of the sun. Cool them off, assist by massage/straightening limbs that cramp up. Cerasport, Issue rehydration salts, gatoraid, poweraid all will assist in equalizing the body's nutrient/water level.

Prevention: Eat your chow. Don't go without meals if possible. if you have to, try to drink gatoraid about 1/2 strength. Gatoraid is best consumed at 1/2 strength for optimum rehydration. full strength tastes better but really provides no benefit.

What I've seen: I have had them, my boys have had them. Sometimes it's just your toes or something. Sometimes it's someones quads and they happen to leg press 900 lbs on a bad day. Straightening out a limb or helping them stretch will definately increase the comfort level. Rehydration and cooling will make the chances of heat cramps lower, as well as allow the body to recover from "bonking".

HEAT EXHAUSTION

Symptoms: Heavy/excessive sweating, lightheadedness, nausea, tingling sensations. Temperature (CORE) from 99-104 F.

Cause: Dehydration, overexertion and salt deficit.

Treatment: COOL THEM OFF NOW!!!
Get this guy to the shade, loosen his clothes, chill him off. This guy is going to look like he's going to fall out, but if you let him fall out that means he's probably going to be worse than if you stopped this guys training and took care of him. Give him water, get him in the shade, let him relax generally until he feels better then make him sit there as long as it took for him to feel better so that he's not being "Hooah" and trying to drive on when he shouldn't.

What I've seen: Guess what... this stuff happens all the time, irregardless of weather. You toss on body armor and it's heat cat 5 instantly no matter what weather it is. Do a mission with full kit and if you aren't sweating, you're a freak of nature. Guys like this come in all the time to my aid station. in a clinical environment it's alot easier to control. Ice packs, rehydration via oral and IV methods, crank the superfan we have and spray him down with cold water in a mist. He'll get back to normal pretty quick. Bringing him down to about 100 or so quickly is ok, but you want to ease up so you don't DROP his core temp past his natural level.


HEAT STROKE:

Symptoms: Elevated core temperature >104 F, loss of conciousness does occur. Absence of sweating is a late finding. if someone meets the criteria for heat exhaustion, the only definitive way to discern between heat exhaustion and heat stroke is by core temperature.

Cause: same as heat exhaustion except for extended period.

Treatment: Recovery position so the patient doesn't vomit and aspirate. no more than 2 liters IV of LR preferably, NS if you don't have lactated ringers.

LOWER HIS TEMPERATURE.
Strip him, cool water in a mist with fanning works better than pouring it on them, Ice packs in the groin, armpits works great. Evac the casualty with the windows open in the vehicle unless your AC is kickin. Keep cooling until his core temperature reaches 102F.

What I've seen: 12 mile EIB practice roadmarch. I wasn't even actually doing medical coverage, I was mountain biking to root on my boys so they'd keep going. Everyone's in except one guy, and he literally burns in at the finish line. Lolling head, eyes rolled back. Generally unresponsive except to me because he's one of my good friends. I drug him to the side of the road, stripped his shit off of him, doused him with all of his water, got him to come to slightly and then took off like I was on a crotch rocket to get the truck to move him to the BAS. You can't screw around with heat stroke. If someone maintains a 105 F or higher temperature for extended periods, you can have brain damage, kidney failure, liver failure, blood clotting abnormalities. you have to cool him off NOW or else this kid can die.


What can put you at risk for these things?

Respiratory and GI illnesses, Alcohol use, Laxitives, Diuretics
Sudafed, Cocaine, antihistimines, meclazine, phenergan, anything with ephedrine, and caffeine.

Taking ripped fuel before a pt test or roadmarch is asking to fall out.

Last tips and pointers:

Don't drink more than a quart and a half of water an hour, 12 quarts a day is the max you should drink.

Acclimatization helps, but you have to be in the conditions you are in for 2 weeks in order to properly acclimitize.


Questions?

[Attila175]

Wish I knew caffeine contributed to being a heat cassualty when I was a cherry. Trying to get back to HAAF on a Sunday night/Monday morning from Florida, I was downing No-Doz followed with a Mountain Dew. Finished the Monday morning run but collapsed when we hit quick time. Heat Exhaustion.

[Bravo_One_Three]

Originally posted by TM Reich
Wish I knew caffeine contributed to being a heat cassualty when I was a cherry.

I'll second that. If it wasn't residual blood alcohol level from the previous night, it was caffeine from the night watch that made PT Formations in the PI something to remember.

[Sneaky SF Dude]

Good post P. Thanks for contributing.

[ussfpa]

The best "superfan" I ever used to help dissipate the heat off multiple casualties at once was the Blackhawk I called in to medevac them. Lined 'em up pretty as you please and let the rotors turn over top of 'em.
Just to clarify for those who read and don't understand "core"...
That puts the thermomenometer tool in your butt...yes boy's and girls, if you are a heat casualty, no ear thermometer for you :D

Primum non Nocere

[rheanna_92]

As a retired Texas sun worshipper, I have never been tagged by the Army as a heat injury, but I really fight it now.

At 43, on high blood pressure medication, even just being in the monkey suit the first few days is absolute misery.

I've learned to watch for myself a little bit simply because I don't ever really sweat freely enough to really get anyone's attention. I have always sweated mostly through my hands and feet. Being in boots the first few days, I feel like my feet will explode. I don't dare take them off for relief if there is down time, because they swell so quickly I can't get them back on. My skin get so sore I can barely touch it and my goodness, if I get a bruise it looks like someone beat me with a baseball bat.

But, an interesting tip that I learned is that it does not matter how much water you are drinking TODAY, your body if functioning on how much water you had YESTERDAY.

Switching my blood pressure medication from morning to evening is also very helpful. I don't drop liters of water at a time and it's cooler at night.

As far as the Gatorade is concerned, I find the best way to drink it is to apply the bottle directly to the back of my neck while it is still cold.

I have awful sinuses (sp), so I make a trade off on the caffeinne. I try to have a reasonable amount (half-caf if I can do it) because caffeinne is an old home remedy for bronchial problems. It will open me up a little bit until my head adjusts to the weather. I sound like I'm gonna hack up a lung, but oh well.

[SHYTE]

My own story of heat exhaustion from last year. Not a medical explanation, just a description of what happened.

It was a hot Saturday afternoon and I was in an all day outdoor basketball tournament. The weather was about 30 degrees celcius, humidity was a huge factor and it was a smog day. Later in the afternoon I began feeling tremendous pain in my right calf. Similar to the type of pain you get after using the calf machine at the gym. After toughing it out and ignoring what I knew it was, about 30 mins later I began having similar pain in my midsection. It wasn't as bad though. Then the pain moved to my lats, which I had never read about in any text. I ended up passing out and was the subject of wonderful ribbing later on that evening. The black tank top I was wearing that day, and dark boxer shorts were both a much different color. They were almost white because of the salt that I had leave my body through the sweat.

I have found that Gatorade diluted in water is a great thirst quencher. Water alone doesn't replace what your body loses and things like Gatorade are frequently regurgetated, as well as expensive. I could be wrong, and if so will gladly accept correction. My days of high school rugby showed me how bad Coke and Pepsi are for your system on a hot day.

Remember, cooling off somebody too fast can be a grave mistake. And somebody suffering from heat stroke will not be sweating. Sweat is the body's defense mechanism against overheating and when that defense gets broken there can be tremendous damage. Imagine if the cooling fan in your car's engine burns out, same thing basically. Caffeine sometimes, when take in light consumptions, is good for replenishing natural resources after you are finished in a hot environment. One can of coke can be too much ,depending on your body size and type.

the medics in our city wear poly/cotton uniforms in the summer and currently are under orders not to remove their SARS masks regardless of the incident, not even to wipe the sweat from their faces.

RsovRanger, good article.

[Doc]

Originally posted by ussfpa
The best "superfan" I ever used to help dissipate the heat off multiple casualties at once was the Blackhawk I called in to medevac them. Lined 'em up pretty as you please and let the rotors turn over top of 'em.

Nice technique Doc.

The highest temperature that I have recorded during a core check on a heat stroke casualty was 107.8 degrees Fahrenheit.

He survived too.

DOL

[RsovRanger]

Not my patient but a rippie went down with a 108.2... slowly regaining liver/kidney function.

[Doc]

Something to think about.

The hypothalamus (thermostat for the body) gets damaged during hyperthermia. One needs to be careful during the cooling process not to inadvertently cause hypothermia with the casualty.

I bring them down to about 101-2 degrees fahrenheit and then remove the cooling agent(s), dry them off if needed and provide dry cover, maintaining a constant watch on their temperature during the evacuation.

I draw some blood during the IV process and tape the tube to the litter that carries the patient to the rear.

[mbw]

What about salt pills? Don't even know if they still use/make them? My Dad used to use them back in the day and said they worked well.

How do you treat a heat casulty in a combat situation or UW/FID scenerio where and aid station/ice may not be available?

RSOVRanger: Thanks for posting this, it happens all the time around here.

Mike

[Doc]

I don't like supplements.

I believe in eating correctly, being in good shape, not drinking alcohol during training periods, and not taking or prescribing drugs that cause heat related problems.

I like Camel-backs. They allow a person to drink small amounts of water all of the time with ease.

If you don't have the high speed means to cool a patient, you do the best you can with what you got.

[Sneaky SF Dude]

Originally posted by mbw
What about salt pills?
Mike

How about 'em Mike? Do a little research and tell us the deal.

[Attila175]

They spend an awful lot of time educating us on how to avoid, identify and treat heat casualties, but how much training do the officers get on it's seriousness? I remember a company commander that was more concerned with finishing a road march with 100% and on time than the life of one of his Rangers. 8 1/2 miles into a 10 miler in the mid day Honduran sun, a Ranger collapsed as a heat casualty. Company sr medic told the C.O. over the radio we could be on time or 100% but not both. Told him we could wait for the patient to cool off enough to stabalize or we could carry his corpse in, it was up to the C.O. Listening to that conversation made humping the PRC77 worth it. The entire company was out of water and while we waited for the heat cas to cool down, we were taking voluntary preventive IV's.

[Axe]

A correlation to this thread that comes to my mind is overhydration and water intoxication. I recall reading a report in a military medical journal within the past year indicating that this is an ongoing and rather extensive problem. I can not find the report now, so I am going by memory. As I recall, one of the several cases detailed involved a female recruit consuming either 5 or 6 quarts of water within a 1-2 hour period in hot weather with fatal results.

What experiences have you all had with this?

[mbw]

Originally posted by Sneaky SF Dude
How about 'em Mike? Do a little research and tell us the deal.

SSFD:

Searched "google" and talked to a current Ranger medic. Salt pills can replace lost electrolytes, but according to The University of Buffalo Sports Medicine, not all bottles contain the labled amount of salt. Dosage also seems to create problems. Pursual of triathlon and ultra-marathon sites reveals a general trend of sports drink recomendation over salt tablets due to taste/dosage issues. Salt pills were the only game in town before Gatorade came along but given the availabilty of a better product no longer remain preferable for athletes to use. Also the avergage American gets too much salt as it is, although SOF types do not fall into this category (although MREs have a boat load of sodium).

US Army Rangers use a product called Cerasport in full strength for electrolyte replacement. The Ranger who helped with this had the following advice:

maine80bw: you got an opnion on salt tablets for replacment use?
XXXXXX: drink fuckin gatoraid.

A good diet coupled with smart fluid and electrolyte replacement (see above posts) seems to help go a long way to prevent RSOVRangers list of heat injuries.

Hope this contains enough detail. I knocked out 50 + 1.

Mike

[Sneaky SF Dude]

Originally posted by mbw
SSFD:

Searched "google" and talked to a current Ranger medic. Salt pills can replace lost electrolytes, but according to The University of Buffalo Sports Medicine, not all bottles contain the labled amount of salt. Dosage also seems to create problems. Pursual of triathlon and ultra-marathon sites reveals a general trend of sports drink recomendation over salt tablets due to taste/dosage issues. Salt pills were the only game in town before Gatorade came along but given the availabilty of a better product no longer remain preferable for athletes to use. Also the avergage American gets too much salt as it is, although SOF types do not fall into this category (although MREs have a boat load of sodium).

US Army Rangers use a product called Cerasport in full strength for electrolyte replacement. The Ranger who helped with this had the following advice:

maine80bw: you got an opnion on salt tablets for replacment use?
XXXXXX: drink fuckin gatoraid.

A good diet coupled with smart fluid and electrolyte replacement (see above posts) seems to help go a long way to prevent RSOVRangers list of heat injuries.

Hope this contains enough detail. I knocked out 50 + 1.

Mike

Good job.

[RsovRanger]

3rd Bn does medical leader development to help prevent that kinda bullshit.

[Allison]

I had heat stroke when I lived in S. Florida. I had been at the beach for about 5 hours in the summer. I wasn't feeling terribly uncomfortable, but I also remember not sweating very much at all (the ocean temp had to have been 85 degrees at the time). We got up to leave and I wanted to shower off (they had outside showers). All of a sudden everything faded into black and I smashed my chin on the railing. I came to almost immediately and stood up to get under the cold water and then passed out again. Meanwhile, blood was flowing from my face and my bikini top shifted (I probably looked like a crackhead at the time) After about 5 minutes I felt fine and went home with a raging headache and slight nausea. If anything, it scared me because nothing like that has ever happened to me. I think the most important thing about heat stroke is that you don't know you are in trouble until its too late. Had I drunk more water, I'm sure I would have been better off. Lesson learned.

[Doc]

Originally posted by Axe
A correlation to this thread that comes to my mind is overhydration and water intoxication. I recall reading a report in a military medical journal within the past year indicating that this is an ongoing and rather extensive problem. I can not find the report now, so I am going by memory. As I recall, one of the several cases detailed involved a female recruit consuming either 5 or 6 quarts of water within a 1-2 hour period in hot weather with fatal results.

What experiences have you all had with this?

I've seen quite a few heat injuries in 24 years. I've only seen one case of hyponatremia or water intoxication.

A good history was the key to catching it for me. My patient's mental faculties were only slightly compromised when I conducted the history. I almost didn't catch the correlation as I had never met the patient or seen this condition beforehand. He did state that he had drank large amounts of water prior which was the final clue.

I evacuated the patient via medevac to a hospital where they could monitor and slowly bring his sodium back up to a normal level.

Start an IV as part of patient packaging but keep it TKO for a lifeline only. Patient does not need anymore fluids.

[themadmedic]

Have seen a couple of cases of slight hypernatremia per lab surveillance, but asymptomatic...presented with heat injury Sx-I suppose that someone thought that they could replace daily fluid losses at once.

Question though, literature seems to suggest a lower threshold for administering "prophy" diazepam...thoughts here?

[Doc]

Originally posted by themadmedic
Have seen a couple of cases of slight hypernatremia per lab surveillance, but asymptomatic...presented with heat injury Sx-I suppose that someone thought that they could replace daily fluid losses at once.

Question though, literature seems to suggest a lower threshold for administering "prophy" diazepam...thoughts here?

Can you clarify your question? I'm not sure how it's directed.

[ussfpa]

Originally posted by themadmedic
Have seen a couple of cases of slight hypernatremia per lab surveillance, but asymptomatic...presented with heat injury Sx-I suppose that someone thought that they could replace daily fluid losses at once.

Question though, literature seems to suggest a lower threshold for administering "prophy" diazepam...thoughts here?
I think your thread should read HYPO natremia as the kidneys are washing OUT all the sodium. I have seen only 2 cases...1 a basic trainee at Knox (2 GALLONS of HOH pushed by her DI as punishment for whining she was thirsty (oops on the both of them)...and a NG on drill at Drum, "Pre-hydrating" for his PT Test. Again, involving GALLONS of HOH over a very condensed period of time.
Both persons appeared drunken, almost incoherantly, mildly combative, urine so dilute it was nearly drinkable (couldn't resist the relation to the SERE thread-sorry :D) Tincture of time was the prime treatment along with supplemental Na IV. BLD Na levels were monitored by the medicine Doc who came down for both of these...field treatment...protect, monitor, establish a lifeline, evacuate. Severe electrolyte imbalances do funny things to electrically functioning body parts...like the heart.

One issue with the SALT tablet / gatorade bit...
SALT tabs are rarely used in current therapies because as they enter the stomach, they create an environmet where the Sodium (Na) PULLS HOH into the gut from surrounding tissues. "Where goes Na-so goes HOH". Gatorade works on a similiar principle full strength...
It is a thirts QUENCHER for short term activity. The Na concentration helps to pull additional fluids into your tummy and give you a feeling of fullness. This additional fluid also helps to process the remaining electrolyte load contained in the sports drink, end result, short term replenishment of lost lytes. For long term activity, cutting by half with HOH is widely used, recommended and accepted.

The replacement supplements being used by various special operations elements as a test bed (for a HUGH contract) has specific concentrations of electrolytes targeting long term activity and are showing great promise.

Heat injuries in troops will end commander's carreers nowadays...there is MUCH education being given, however, the amount of compliance with the recommendations is variable (unfortunately) :rolleyes:

Never heard of administering Vailum for prevention of heat injuries...

Primum non Nocere

[themadmedic]

Correct, I meant hypoNa.

As for the Valium...wasn't a suggestion of using it to prevent heat casualties, but a low threshold in giving it to those that have become heat casualties...

[themadmedic]

The Valium can be used to prevent seizures, which can be caused by the high temp...

Which leads to my question-wondering where the individual thresholds here are on when they give it-particularly in regard to patients not currently showing any CNS changes...

[Gooch]

I was competing in a tactical sniper/rifle match in Wyoming in 1998 which was organised like a summer biathalon. I ran a stage in the morning and about did myself in. I was probably in the early stages of heat exhaustion. One of the other military guys there had some electrolyte pills (they were labled as such) that came in little packets of two pills, that appeared to be DOD issue. I took a couple and by the time I had to run my second stage in an hour I was pretty much good to go.

ANy ideas what they might be or if they were an issue deal? I know my description is pretty vague but I have tried to find these things again for years. I have some cop friends who work as snipers on a drug task force in ALabama who have asked me for advice on what to do when laying in an OP in ghillie's to keep from doing the funky chicken in the good ole ALabama heat. I advised them to eat good meals prior to going out, use a 50/50 mix of water/Gatorade in thier camel backs and take a few METREX food bars with them. Comments on that?

By the way, I think these medic threads are the most valuable threads on this site. Keep up the information spewing.

THanks.

[Fightingscottish]

I was about 3/4 of the way through a 30 mile bike ride the week before last in the DC area, it was mid-day and over 90 degress with all the good DC area humidity.

I was pretty hot, and definately had not stopped sweating when all of the sudden, I felt cold. Cold like goos bumps, etc., and this was while pedaling in the sun.

I wasn't going for any land speed records, but keeping a good pace. I had a 2 liter camel back on back that I had been drinking from for the whole ride.

I got kind of freaked out when I got the chills in the mid day sun.


Can anybody tell me what may have been happening? There was no breeze, by the way. Oh yeah, and my hands felt kind of tingly.

No cramps, nausea, I was sweating, hydrating, but just got cold for about 10 -15 minutes.

[troy2k]

Doc Keyton is the man to talk to. He told me once that he saw many cases of it in the early days of SFAS, when they were hard up for cash and even gave us baloney sandwich bag lunches. Needless to say, calories and electrolytes were much less than in MRE's, and candidates went down a lot.
If I recall, he told me that with Hyponatremia you can see patients seize up, so that would explain the Valium prophylactically.
Gooch, I did SOTIC in June on Ft Bragg and Lexington Police Sniper in July (KY). You're advice sounds right on for your buddies, Summer stalks will smoke you, and your body needs fuel as well as water.

My 2 dinar

[Doc T]

Originally posted by troy2k

If I recall, he told me that with Hyponatremia you can see patients seize up, so that would explain the Valium prophylactically.

My 2 dinar

I have seen lots of hyponatremic patients in the ICU... have never seen an algorithm that includes prophylactic valium. Typically used only after seizure activity has occurred, if it occurs.

doc t.

[troy2k]

Doc,
I understand how a joe humpin' a ruck can wash out his electrolytes, can you give other examples of what would lead to this condition?
Thanks.

Troy

[wolfhoundcowboy]

Just a quick question. Once people have a heat injury they are more likely to have more. Is this due to the damage to the hypothalamus or something else?

[Doc T]

Originally posted by wolfhoundcowboy
Just a quick question. Once people have a heat injury they are more likely to have more. Is this due to the damage to the hypothalamus or something else?

in the acute period when their hypothalamus has not really "reset" they are still at high risk for recurrence... i do not recall it increasing your lifetime risk of heat stroke... i will look into it. It may just be that having had it once shows you are at an increased risk for having poorer bodily compensation mechanisms than others in the same situation...

will f/u and let you know what i find.

[Doc T]

Originally posted by wolfhoundcowboy
Just a quick question. Once people have a heat injury they are more likely to have more. Is this due to the damage to the hypothalamus or something else?

lots of reasons i see it that you will probably never deal with like hypoadrenal response to stress, hypothyroidism, some syndromes that occur within days of head injuries, etc..., poor choices in resuscitation fluid leading to a hyponatremic state, pseudohyponatremia from diabetes and high glucoses, etc...

[troy2k]

Thanks Doc,
I'm also interested to see what you find on that hypothalamus question, as that is something the army indoctrinates us with; "Once you go down for heat injury, you're a higher risk."

[lrd]

Originally posted by Doc T
. . . some syndromes that occur within days of head injuries, etc..., Doc T,

Would you mind explaining this a bit further? Also, is this temporary or something that needs to be watched on a long-term basis?

Thank you.

[Doc T]

Originally posted by lrd
Doc T,

Would you mind explaining this a bit further? Also, is this temporary or something that needs to be watched on a long-term basis?

Thank you.

there is a syndrome called SIADH (syndrome of antidiuretic hormone) that is associated with many things, trauma to the head being one of them. Basically too much antidiuretic hormone is produced making a person's kidney think it needs to keep as much free water as it can so you end up having very concentrated urine while your blood is very diluted as far as electrolytes go. You wind up hyponatremic with very high sodium concentrations in the urine. It is not something you look for late in the course of a head injured patient...typically happens within the first few days if it is going to occur...at least that is my experience. Treatment is fluid restriction and sometimes lasix (diuretic) or mannitol. Most of the cases i have seen resolve after a few days.

the other syndrome we see is DI (diabetes insipidus) which has nothing to do with the diabetes mellitus most people know as diabetes. IT is a syndrome of too little ADH being produced by the hypothalamus. In this case we just supply it to the patient and support them with volume as they will typically be making over 500cc of urine an hour (its hard to miss this diagnosis). In this case the patient will be hypernatremic because they are losing so much free water. This can be a longer term problem...some patients wind up on nasal medications to help combat it. Most that i have seen though also resolve within a few days.

hope this helps.

doc t.

[lrd]

Originally posted by Doc T
hope this helps.

doc t. It did. Thank you.

[Doc T]

sorry should proofread before i send...SIADH is the syndrome of inappropriate secretion of antidiuretic hormone....