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ELDERLY PATIENTS

Overview
Heat illness is a pervasive problem that is often encountered in patients who
present to the emergency department. During summer heat waves, large
urban centers see a significant rise in hyperthermia-related fatalities. Heat
illness should be thought of as a spectrum of disease from heat cramps
to heatstroke. Medication-related hyperthermic conditions such as malignant
hyperthermia, serotonin syndrome, and neuroleptic malignant
syndrome (NMS) need to be specifically recognized, as the treatment of these
diseases requires adjunctive pharmacotherapy (eg, dantrolene,
cyproheptadine, bromocriptine, levodopa, amantadine) in addition to rapid
cooling measures. Understanding basic principles of thermoregulation and the
pathophysiology of hyperthermia is essential to treatment. [1, 2]
The image below depicts items used for noninvasive cooling techniques.

Sample display of equipment


useful for various cooling techniques. Clockwise from top: ice pack and water,
air-cooling blanket, Foley catheter, and intravenous fluids.
View Media Gallery
See Heat Illness: How To Cool Off Hyperthermic Patients, a Critical Images
slideshow, for tips on treatment options for patients with heat-related illness.
Also, see Football Injuries: Slideshow to help diagnose and treat injuries from
a football game, including heatstroke, a major concern in college and high
school football.
Effective thermoregulation, controlled by the hypothalamus, is critical for
proper function of the human body, with normal temperature exhibiting diurnal
variation between 36-37.5C. Heat is both produced endogenously and
acquired from the environment. Metabolic reactions in human bodies are
exothermic, contributing 50-60 kcal/h/m2 of body surface area, or 100 kcal/h
for a 70-kg person. During strenuous exercise, heat production increases 10-
to 20-fold. [3] Environmental heat transfer involves the following 4
mechanisms [3] :
Conduction: Direct physical contact transfers heat from a warmer object
to a cooler object. Water is about 25 times more conductive (more
effective at conducting heat) than air.
Convection: Heat is transferred through air and water vapor molecules
surrounding the body. Convective heat transfer depends on wind velocity
and explains the effect of wearing loose-fitting clothing in warm climates
to keep cool.
Radiation: Heat is transferred by electromagnetic waves. Radiation is the
major source of heat gain in hot ambient climates; up to 300 kcal/h can
be gained on a hot summer day.
Phase change: The conversion of a solid to a liquid (melting) or a liquid to
a gas (evaporation) results in heat transfer. Evaporation of 1 L of sweat
from the body results in a loss of 580 kcal of heat.
Hyperthermia is defined as elevated core temperature of greater than
38.5C (101.3F). History and clinical examination can help elucidate the
etiology of hyperthermia and tailor treatment. The causes of hyperthermia
include the following [4] :
Increased ambient heat - Heat waves, humidity
Increased heat production - Overexertion, thyroid storm, malignant
hyperthermia, neuroleptic malignant syndrome, pheochromocytoma,
delirium tremens, hypothalamic hemorrhage, toxic ingestions (eg,
sympathomimetics, anticholinergics, MDMA)
Decreased heat dissipation - Humid environment, poor sweat production
Sweating and peripheral vasodilation are major mechanisms of heat loss to
maintain proper temperature. In the absence of these mechanisms, baseline
temperature would increase 1.1C per hour from basal metabolism
alone. [4]Sweat cools the body through evaporation, and peripheral
vasodilation provides the blood flow and heat necessary to evaporate the
sweat. During periods of high environmental heat and humidity, evaporative
cooling can become insufficient, leading to heat illness.
Patients at risk for heat illness include the following [5, 6] :
Athletes exercising strenuously in hot climates
Elderly patients (because of decreased efficacy of thermoregulation,
comorbid illness or medications, lack of fans or air conditioning,
inappropriate dress)
Infants and small children (because of high ratio of surface area to
weight, inability to control fluid intake)
Patients with cardiac disease or those taking beta-blockers (because of
inability to increase cardiac output sufficiently for vasodilation)
Patients who are dehydrated because of poor fluid intake, gastroenteritis,
and diuretic or alcohol use (Dehydration increases demand on ATPase
pumps, which contribute 25-45% of basal metabolic rate.)
Patients prone to higher endogenous heat production (eg, infection,
thyrotoxicosis)
Patients taking medications that inhibit sweat production or increase heat
production (eg, anticholinergics, antidepressants, antihistamines,
neuroleptics, zonisamide, sympathomimetics, alpha- and beta-blockers),
especially in hot weather; deaths from cocaine are markedly increased
when the ambient temperature increases [7]
Recognizing the clinical signs associated with heat illness determines the
appropriate therapy, from fluid replacement for heat exhaustion to rapid
aggressive cooling for heatstroke. [4, 5, 6]