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Heat Emergencies Are Real Emergencies

The group opens by emphasizing that heat emergencies are not minor complaints. Heat stroke can rapidly become fatal, especially when altered mental status, seizures, hypotension, or loss of thermoregulation are present.

The episode highlights real-world examples from large events, including marathons, where patients presented with core temperatures of 107–108°F and required immediate cooling.

Who Is at Risk?

While anyone can suffer a heat emergency, the episode identifies several high-risk groups:

·       Infants and children

·       Older adults

·       Athletes

·       Firefighters in turnout gear

·       SWAT officers, bomb technicians, and tactical teams

·       Construction workers and landscapers

·       Patients taking medications that impair cooling or cardiovascular response

·       People using alcohol or stimulant drugs

·       Patients with poor oral intake or dehydration

·       People who have not had time to acclimate to sudden heat changesA major point of discussion was Ohio’s rapidly changing weather. When temperatures jump quickly from cool spring conditions to hot, humid summer conditions, people may not have time to acclimate.

Environmental Risk Factors

The hosts discuss how heat risk increases when temperature and humidity rise together. High humidity limits evaporation, which is the body’s primary cooling mechanism. The transcript specifically highlights the danger of environments above 90°F with humidity above 60%.

Radiant heat from pavement, roads, athletic fields, and concrete can further worsen heat exposure.

Heat Loss and Heat Gain

The episode reviews the body’s normal methods of heat regulation:

·       Evaporation: Sweating and evaporation from the skin

·       Radiation: Heat leaving the body into the surrounding environment

·       Convection: Moving air or water carrying heat away from the skin

·       Conduction: Direct transfer of heat into a cooler object or liquid

The group emphasizes that sweating is the body’s main cooling method, but sweating also causes fluid and electrolyte loss. Once the body can no longer compensate, heat illness can progress quickly.

Spectrum of Heat Illness

The hosts describe heat illness as a progression rather than a single diagnosis:

1.       Heat rash

2.       Heat edema

3.       Heat cramps

4.       Heat syncope

5.       Heat exhaustion

6.       Heat stroke

Heat stroke is the end-stage emergency where the body loses control of temperature regulation and the patient is actively dying without rapid intervention.

Heat Exhaustion vs. Heat Stroke

Heat Exhaustion

Heat exhaustion may include:

·       Weakness

·       Cramping

·       Dizziness

·       Nausea or vomiting

·       Tachycardia

·       Dehydration

·       Sweating

·       Possible mild confusion

Heat Stroke

Heat stroke should be suspected when heat exposure is combined with:

·   Altered mental status

·   Seizures

·   Bizarre behavior

·   Unconsciousness

·   Hypotension or shock

·   Very high core temperature

·   Hot skin, which may be wet or dry

A major teaching point: do not wait for the patient to stop sweating before recognizing heat stroke. If the patient is no longer sweating, the situation may already be very late.

Treat the Patient, Not the Number

The group repeatedly emphasizes that EMS should not rely solely on temperature readings. Many field thermometers, especially temporal, tympanic, oral, or axillary devices, may not accurately reflect core temperature.

Best core temperature options include:

·       Rectal temperature monitoring

·       Esophageal probe in an intubated patient

·       Foley catheter temperature probe in the hospital

·       Purpose-made continuous core temperature devices

But if those are not available, EMS should use the clinical picture.

Hot environment + altered mental status = treat as heat stroke.

The Main Treatment: Immediate Cooling

The central message of the episode is:

Cool first. Transport second.

For true heat stroke, the patient needs rapid cooling immediately. The group explains that EMS may be better prepared than many emergency departments because EMS can use field-expedient cooling methods and local resources.

Recommended cooling options include:

·       Ice-water immersion

·       Livestock troughs or water tubs

·       Commercial dunk tanks

·       Collapsible tubs

·       Tarp “taco” or “burrito” method

·       Body bag filled with ice and water

·       Cold water with ice packs if immersion is not available

·       Fans, misting, shade, and air conditioning for less severe cases

The hosts stress that ice packs alone are not enough for severe heat stroke.

Ice Bath Practical Points

For heat stroke with altered mental status, the group recommends:

·       Remove the patient from the heat source

·       Strip unnecessary clothing and gear

·       Place the patient in ice-water immersion as soon as possible

·       Submerge as much of the body as possible while keeping the head above water

·       Agitate or circulate the water continuously

·       Keep cooling until mental status improves or a target core temperature is reached

·       Do not stop cooling just because the patient shivers

       Do not interrupt cooling for vomiting, bowel movement, combativeness, or seizures unless absolutely necessary

The discussion notes that arms should ideally remain in the water because they represent additional body surface area. If IV access is needed, one arm can be removed temporarily.

Cooling Endpoint

The group discusses two practical endpoints:

·       Return of normal or near-normal mental status

·       Core temperature below approximately 102°F if reliable continuous core temperature monitoring is available

If the patient remains altered after about 20 minutes of aggressive cooling, providers should consider other causes and contact medical control.

IV Fluids: Important, But Secondary

The episode stresses that IV access and fluids are not the first priority in heat stroke.

The first priority is cooling.

Once cooling is underway, EMS should consider:

·       Blood glucose check

·       IV or IO access

·       Normal saline bolus, often 20 mL/kg

·       Chilled saline if available

·       Additional fluid resuscitation if tachycardia, hypotension, or dehydration persists

The group points out that these patients may be several liters behind, especially if they have been sweating heavily or have stopped sweating.

Seizures in Heat Stroke

The hosts discuss patients who seize from severe hyperthermia. The key message is that the seizure may be caused by the heat emergency itself.

Treatment priorities:

1.       Start aggressive cooling immediately

2.       Check glucose

3.       Support airway and breathing

4.       Give benzodiazepines when indicated

5.       Continue cooling during seizure management

Cooling is the critical intervention because treating the hyperthermia may resolve the seizure trigger.

Cardiac Arrest in the Ice Bath

The episode includes a practical discussion about defibrillation during immersion.

If a patient in an ice bath requires defibrillation:

·       Remove the patient from the water

·       Dry the chest as much as possible

·       Deliver the shock

·       Return the patient to cooling as soon as possible

The group emphasizes that the heat emergency is likely the reversible cause, so cooling must continue.

Medications and Conditions That Increase Risk

The episode discusses several medications and substances that may worsen heat emergencies or impair compensation:

·       Beta blockers

·       Diuretics

·       Anticholinergics

·       Diphenhydramine

·       Certain psychiatric medications

·       Alcohol

·       Cocaine

·       Amphetamines

·       Salicylates

These can affect sweating, hydration, cardiovascular response, or temperature regulation.

Mimics and Differential Diagnosis

The group reminds listeners not to anchor too quickly. Heat stroke may be obvious, but providers still need to think through other causes of altered mental status.

Potential mimics include:

·       Hypoglycemia

·       Stroke

·       Alcohol intoxication

·       Drug intoxication

·       Sepsis

·       Urinary tract infection

·       CNS infection

·       Thyroid storm

·       Serotonin syndrome

·       Neuroleptic malignant syndrome

·       Hyponatremia

·       Febrile seizure in children

The key teaching point: treat the immediate life threat, but continue to reassess and broaden the differential.

Fever vs. Hyperthermia

The hosts distinguish fever from hyperthermia.

A fever is the body intentionally raising its temperature as part of an immune response. Hyperthermia is a failure of thermoregulation where the body can no longer control its temperature.

That distinction matters because antipyretics like acetaminophen or ibuprofen do not fix heat stroke. Heat stroke requires physical cooling.

Pediatric Considerations

The group notes that the pediatric protocol is largely the same as the adult approach:

Move, strip, cool.

Important pediatric considerations include:

·       Children may cool faster than adults

·       Avoid overshooting into hypothermia

·       Assess hydration carefully

·       Ask about wet diapers in infants

·       Consider sunken fontanelle in younger infants

·       Differentiate febrile seizure from hyperthermic seizure

·       Do not delay cooling for fever medications if the child is hot, altered, or actively seizing from heat exposure

The team reinforces that children are not just small adults, but the core treatment for heat stroke remains aggressive cooling.

Event Medicine and Planning

A major operational theme is preparation. The group recommends that EMS, fire departments, schools, athletic programs, and event medicine teams plan before hot-weather events.

Preparation should include:

·       Identifying high-risk events

·       Pre-positioning tubs or troughs

·       Ensuring water access

·       Planning ice access

·       Knowing where fans, shade, and tents will be placed

·       Coordinating with athletic trainers

·       Practicing patient movement into and out of tubs

·       Training with sheets, MegaMovers, tarps, or other lifting devices

·       Knowing nearby departments or agencies with cooling resources

The group encourages agencies to drill this before the first real emergency.

Firefighter and Responder Rehab

The episode connects heat emergencies to responder safety. Firefighters in turnout gear, especially during summer fires or long extrications, are at major risk.

Important rehab considerations include:

·       Early rehab setup

·       Hydration

·       Cooling fans

·       Shade

·       Removing gear

·       Monitoring mental status and vital signs

·       Recognizing that bunker gear traps heat in as well as keeping heat out

·       Allowing acclimation to hot weather when possible

The group also notes that tactical teams, bomb technicians, and other responders in heavy protective gear face similar risks.

Hospital and EMS Coordination

The hosts discuss the need for EMS and hospitals to coordinate resources. Some emergency departments may not have immediate access to an ice bath, while EMS or fire departments may have tubs and ice available.

Possible system-level solutions include:

·       EMS notifying the hospital early

·       Hospitals preparing cooling resources before arrival

·       Fire departments supporting hospital cooling or decon-style operations

·       Neighboring departments sharing ice bath resources

·       Regional planning for large events or heat disasters

The group frames heat stroke care as another example of time-critical care moving into the prehospital space.

Major Clinical Pearls

·       Heat stroke is a true emergency.

·       Altered mental status is the key decision point.

·       Do not wait for dry skin or lack of sweating.

·       A bad thermometer should not delay treatment.

·       Ice-water immersion is the preferred treatment for severe heat stroke.

·       Cool first, then start IVs and secondary interventions.

·       Ice packs alone are inadequate for severe heat stroke.

·       Agitate the water to improve cooling.

·       Shivering does not mean you should stop cooling.

·       If mental status does not improve after aggressive cooling, broaden the differential.

·       EMS may be better positioned than the ED to start definitive cooling.

·       Agencies should know their resources before the hot season starts.

From The Episode