Case of the Month
June 2005

36-year-old male — sick/unknown

On a hot August day your aid car is dispatched to the home of a 36 year old man that is disoriented after working in his attic all day.

Arriving on scene the patient's wife informs you her husband is acting very tired and will not respond to her. He has been working in the attic of the house all day, running some electrical wires. When he came down for lunch a few hours ago he was fine. She was watching television inside and heard a loud thump in the hallway. She found him at the base of the attic ladder 'out of it', prompting her to call 9-1-1.

You approach the patient and see that he is slumped over, and immediately call for a medic unit based on the patients level of consciousness. When you check for a radial pulse you notice he is very warm. He has a very strong pulse of 110 and deep respirations. He does not respond to noxious stimuli and his skin is flush, hot and dry. Blood pressure is found to be 90/P. Oxygen is placed on the patient via a partial non-rebreather mask at 15 lpm and he is laid flat. A member of your team assumes head and neck stabilization while you and the other member continue to work him up. Blood pat down and head - toe exam find no obvious injuries. His blood sugar is 102. His symptoms suggest the possibility of heat related illness so you strip him down while a backboard is brought in. The patient, who is now only wearing his underwear, is rolled onto the backboard and secured with straps and a headbed.

LOC	—	Decreased LOC, not responding to noxious stimuli
RR	—	20/min
Pulse	—	110 radial, weak
BP	—	90/palp
Skin	—	Flushed, hot and dry
Chest	—	Clear lung sounds
Abd	—	Soft and unremarkable
Pulse Ox	—	98% with partial non-rebreather
Glucose	—	102 mg/dl

You give a short report to the medic unit and they suggest the use of cold packs or ice placed on the patient to promote cooling. You get ice from the home's refrigerator, make ice packs and place them near the armpits, against the sides of the patient's torso and in the groin. The cervical collar does not allow access to the neck for ice pack application.

S	—	Decreased LOC, skin is flushed hot and dry
A	—	Unknown, no medic alert tags found
M	—	Unknown
P	—	None
L	—	Lunch 2 hours ago
E	—	Patient has been working in a hot attic, wife called becasue he was "out of it"

The medic unit arrives and the patient is loaded. The medics evaluate the patient's temperature and find it to be 104.6 °F. Medics start two IVs of Lactated Ringers and consider intubation. Intubation is disregarded as the patient's level of consciousness is beginning to improve and he is starting to perspire. Transport of the patient to the local emergency department occurs without event.

The lesson learned from this case: Heat related illnesses usually occur during the warmer months in the Pacific Northwest; however they can occur anytime of year if the proper factors are present. Generally the patient has been exposed to a warm area for an extended period of time and has been exerting him or herself. Lack of adequate hydration is also a large contributing factor. Working in a hot, confined space, with poor air flow is a common setting for these emergencies, however athletes and outdoor workers can easily fall victim. Another contributing factor can be pre-existing medical conditions and/or the medications a patient takes. An example is a person who has a recent history of vomiting or diarrhea; this individual is more likely to succumb to a heat related illness than a healthy individual. Additionally, several types of blood pressure medications may leave a patient more susceptible to heat related illnesses. Age can also be a contributing factor, older individuals are more readily affected than younger ones.

Heat stroke, which was portrayed here, is one of the most severe types of heat illness. The key to aiding this person is quick recognition, rapid cooling, rehydration - if the patient will tolerate liquids by mouth - and transport. Often more severe cases will need cool IV fluid resuscitation and advanced cooling techniques only available in the emergency department. As EMTs we can go a long way in the cooling of these individuals by stripping the patient, applying ice or chemical cooling packs to areas where the major blood vessels run closer to the surface of the skin, fanning the patient, and moving them out of the hot environment into a cooler area.