Good afternoon. I'm Heather Lee Bailey, and my co-presenter and the chair of our task force is Jeff Barletta. We will be presenting Beyond the Basics Comprehensive Session on Heat Management. You will note that we have included some off-label use of medications and equipment. You don't typically hear that. So what is the global importance of heat-related emergencies? Well, it is the number one cause of environmental death worldwide. But on a local level, the importance is in the fact that this is something that you may very well encounter in your everyday life outside of the ICU and the hospital, depending on where you live, work, and play. This is a picture of row homes in Philadelphia. Notice that they're all very tightly together. They have those flat tar roofs. Very few of them have any kind of air conditioning. And so in a heat wave, they just turn into an oven. Also depending on where you work, if you work outdoors or if you don't have a place to live inside, you're at risk. And also where you play. This past summer, those heat waves, individuals who were at those large outdoor events, both attendees and performers suffered from the heat. It's also important to note that this crosses all socioeconomic boundaries. But those who have less means typically are more at risk. And the summer with the heat, there was a big problem with the people who were trying to vacation. Terrorist destinations across Europe and the Mediterranean were closed because people were collapsing of the heat. And Death Valley, the hottest place on Earth, had to post warning signs to not walk because of the risk of death. It's important to remember that it's not just during heat waves that this process can occur. This is typically during sports or during military maneuvers and practice that you can get into trouble when it's not that hot. As I mentioned, heat is the number one cause of death for environmental emergencies worldwide. Far outstrips any of the others. And death by floods is a distant second. Here you can see in the United States over the last several years, and notice it does correspond, it seems to, with COVID, the dramatic rise in heat-related deaths. And right here in Phoenix, there was, in July, you may have heard that not one day was under the high temperature of 110. But I've always heard that it's really just a dry heat. But Dr. Barletta will tell you that it doesn't matter if it's a wet or a dry heat, you still feel like you're going to spontaneously combust. This is a very interesting study, really a case series from this race in Falmouth, Massachusetts. It's been going on for 50 years. It's not very long. It's only seven miles. And typically the average temperature is about 75 degrees. And they have about 10,000 runners currently. But they have this whole case series on individuals who've suffered heat stroke during this event. Now let's see if we can get the video to play. You see how the runners are identified as they come off the finish line and during the race they're washing for it. This woman, she looks very fit. She's very excited about her time. She's giving everybody the thumbs up. She doesn't look that bad, but watch what happens as she gets on the cot. And then all of a sudden, clearly she collapses. She looks like she's in distress. And on average, they have 2 per 1,000 runners who get into trouble. And for every increase in the wet bulb globe temperature by just 2 degrees will double the number of individuals who suffer heat stroke. Just like many things, this is a spectrum. Typically the only patients you're going to be seeing in the ICU are those that have heat stroke. But the milder forms you may see in someone who's in the ICU for another reason, such as they were running and had a myocardial infarction and end up. So you do need to be aware of these. Plus you may encounter them on your daily life if you're outside doing something. So there's two types of heat stroke. There's the classic heat stroke, is what you think about during the heat wave. This is typically the very young and the very old, chronically ill individuals. And this is the hot, dry skin where they're going to not be sweating. And then there's exertional heat stroke, typically younger, more fit individuals. They're doing something, what they may do every day. And for whatever reason, they are unable to relieve the heat. And it can happen at any temperature. So common therapies are important. The thing you need to focus on is cooling methods. The sooner you identify these individuals, the sooner you cool them, the better their outcomes. So there's a wide range of things that you can use that have been shown in the literature to be successful. You have to use what you have available. Not everybody is going to have that cold ice water immersion. Your patient may or may not need large volume resuscitation. So you should use both physical exam and ultrasound to determine whether IV fluid resuscitation, how much is needed. Jeff is going to focus on medications. Do recall that skin is a big potential injury on these individuals, especially if they have any downtime. They've been collapsed outside, found on the hot pavement, or even touching a hot door. Or kids on slides can have significant burns. And then organ failure. They need to be monitored, just like every other patient we have in the ICU. Looking at cooling methods, to the left is inadequate. And these are using these types of modalities in isolation. So cooling blankets and gastric lavage by themselves will not cool the individuals fast enough. The faster you cool them, the better the neuroprotection. You can use any of these in adjunct, but anything to the left you cannot use in isolation. And ideally, those ice sheets and the cold water and ice water immersion are going to cool the individuals the fastest. You can see here, let's get the video to run, now there's a lot of people involved in this. This is that same race group. My guess is this is probably the first patient who came off the race, so there's a million people working on them. But it does take a lot of individuals and staff to cool these patients down. The most important thing, though, is there must be someone at the head, if you're going to put these people in ice water or a cold water immersion, to keep their head above water so you don't turn a heat emergency into a drowning event. Sorry. So there's a couple challenges. The two main things to think of first is, where are you? Are you in an austere environment? Are you in the middle of Death Valley? Are you in military and you're in an austere environment? Or are you in the ICU at a tertiary or quaternary hospital? And is this a mass casualty event? How many victims do you have? Is this just an isolated event, or do you have like that Taylor Swift concert where there's hundreds of people who are collapsing from the heat? And that is going to help you figure out what kind of equipment you're going to need and how much staff you're going to need. So equipment and staff can be challenging. The rate of cooling we talked about that you saw that slide. The faster you cool these individuals, the better that they are going to do. You must also think about risks, both risks to the patient. One we talked about, the integument risk. There's going to be risk of frostbite if you have ice or cold water directly on them. There's also the risk of potential electrocution if you've got them on monitors. These people are critically ill, so there is a theoretical risk of electrocution. There's also risk to staff. Think about it. When water suddenly turns cold on you in the shower, you're not very happy about it. You're taking someone who's probably already altered, dropping them into a bucket of ice. They may become combative. The other issue is that water that you're cooling them with is going to go somewhere. It typically goes on the floor, so it's not uncommon for your staff to slip and fall. And then the patients, is this someone who's had classic heat stroke or insertional heat stroke? And you're going to treat them a little bit differently, because classic heat stroke is probably going to have a lot more comorbid events. And heat stroke treatment classically is cooling them at the site of when they're found and then transporting them. Temperature monitoring can also be challenging. That woman's temperature that you saw collapse, she was 105. So it's a rectal temp. You've got to get a core temperature on these patients. And I think we have a video that'll be coming next. And you can see this is one of those off-label uses. Places will stock these inflatable pools. In Philadelphia and other places, we used to use body bags to cool these individuals down. So those are body bags. We're packing them with ice and water. And in the last picture on the right, you can see there's multiple people involved using an ultrasound to assess for volume status. You're having difficulty keeping the leads on the chest. And if you look on the right hand, they're trying to re-tape down that IV, because everything is wet. Everything slides. So these are things you have to consider when caring for these individuals. And of course, look at all that ice in that body bag and that water. As it melts, it's got to go somewhere. So you must maintain safety around the patient so that you, as a staff member, don't go down. The last thing to consider is if you don't have a heat stroke protocol, I recommend creating one. Or if you have one, go back and take a look at it. Because while we work with all these other groups, engineering, dietary, environmental, you must think about different things. You're going to need large volume of ice from the dietary. Engineering, you're going to have to convince them to attempt to alter the temperature in your unit. When was the last time engineering wanted to change the temperature of the whole unit for you? Right, never. I see lots of shaking heads. You need someone who's going to manage all that water and ice. And central supply, or wherever you get your body bags from, it's going to be like, you need what, 20 body bags? Really? What's going on? The other thing is having some type of log, or a sheet, or a checklist to say, OK, I've called environmental, I've called dietary, as difficult things to add for your protocol. And with that, I'm going to turn it over to Jeff.

heat management

heat-related emergencies

heat stroke protocols

rapid cooling

emergency response