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Prevention of Ensuing Heat Stroke. Karen K. O’Brien, MD, FAAFP. Overview. Magnitude of the problem Primary Prevention Secondary Prevention Tertiary Prevention- treatment by nonmedical first responders is critical How do we apply this model to return to play/duty?.

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Prevention of Ensuing Heat Stroke

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Prevention of ensuing heat stroke l.jpg

Prevention of Ensuing Heat Stroke

Karen K. O’Brien, MD, FAAFP


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Overview

  • Magnitude of the problem

  • Primary Prevention

  • Secondary Prevention

  • Tertiary Prevention- treatment by nonmedical first responders is critical

  • How do we apply this model to return to play/duty?


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Rates of Heat Stroke and Heat Exhaustion at Fort Benning

Source: AMSA/DMSS


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Prevention

  • Primary

    • Identification of individual risk factors

    • Cumulative Risk- 3rd hot day of increased temps or heat wave

    • Modification of training uniform and metabolic strain

    • Heat dumping

    • Risk management and mitigation procedures

  • Secondary

    • Sensitivity to milder forms of heat injury

    • Modification of training when mild cases occur

    • Use of buddy system to monitor meal and fluid intake

  • Tertiary

    • Use of buddy to monitor behavioral change and performance degradation

    • Aggressive cooling at first sign of mental status change


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June 06 HWI vs. Temp

Data: Fort Benning Environmental Science Division


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Risk Factors

  • Age

  • Anticholinergic medication

  • Other drugs

  • Increased body mass index

  • Illness/DM/Spinal cord injury

  • Skin disease

  • Poor acclimation and conditioning

  • Uniform/ Body Armor


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Risk Factors

  • Skin disease

    • Eczema

    • Poison ivy

    • Skin graft

      • Normothermia Heat Stress


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Medications that inhibit thermoregulation

  • Anticholinergics

  • Antihistamines

  • Tricyclics

  • Stimulants

  • Diuretics

  • Antipsychotics

  • ACE inhibitors, B-blockers


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Primary Prevention

  • Heat Injury risk management process

  • Acclimation guide for Ranger, Airborne and Elite students

  • Label high risk medications and profile at risk soldiers


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Primary Prevention

  • Air conditioning

  • Acclimatization

  • Hydration

  • Exertion

  • Modification of uniform/ training sites

    • Remove headgear when not on field

  • Increase spacing and positioning resting athletes in shade whenever possible

    • Consider tentage next to training areas


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Heat Dumping

  • Encourage cool showers and time in air conditioning between high exertion training

  • If athletes are staying in dorms for summer training- check to ensure air conditioning is functioning


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Secondary Prevention

  • Detection of milder forms of heat illness

  • Use of those sentinel cases to modify training to prevent additional cases

  • Screening for poor food and fluid intake


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Tertiary Prevention

  • Tertiary prevention efforts focus on people already affected by disease and attempt to reduce resultant disability and restore functionality

  • Rapid cooling intervention by first responders can reduce organ injury and prevent development of multi-organ dysfunction syndrome


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Return to Duty

  • How refractory was Soldier to normalizing thermoregulation?

  • Was there significant tissue injury?

  • Was the heat stroke part of a large cluster of heat injuries or an isolated event?

  • What were the risk factors and how easily can they be mitigated?


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Return to Duty

  • Primary

    • Identification of individual risk factors

    • Cumulative Risk- 3rd hot day of increased temps or heat wave

    • Modification of training uniform and metabolic strain

    • Heat dumping

    • Risk management and mitigation procedures

  • Secondary

    • Sensitivity to milder forms of heat injury

    • Modification of training when mild cases occur

    • Use of buddy system to monitor meal and fluid intake

  • Tertiary

    • Use of buddy to monitor behavioral change and performance degradation

    • Aggressive cooling at first sign of mental status change

Patient and trainer education/communication is KEY


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Risk Factors

  • Age

  • Anticholinergic medication

  • Other drugs

  • Increased body mass index

  • Illness/DM/Spinal cord injury

  • Skin disease

    • Skin graft or eczema?

    • Poison ivy, cellulilits?

  • Poor acclimation and conditioning

  • Uniform/ Body Armor

  • RECENT HEAT STROKE

  • Sickle Cell Trait

  • Environmental strain severe enough on day of injury to cause multiple injuries


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Return to Duty

  • Case 1

    • 19 yo from Alaska during 2 mi run

    • Overweight

    • Poor conditioning

    • First week in Southeast

  • Case 2

    • Paratrooper on mission in Panama

  • Case 3

    • 47 yo during minimal exertion

    • High blood pressure meds, diabetic, obese


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Summary

  • Overview of Exertional Heat Illness

  • Risk management is key

  • Heat stress is cumulative

  • Prevention1, prevention2, prevention3

    • Identify risk factors and mitigate risk

    • When early cases occur- modify training

    • When heat strokes occur- rapid first responder intervention can prevent fatal complications from developing


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