Treatment and Prevention of Heat-Related Illness1
Treatment and Prevention of Heat-Related Illness1
Treatment and Prevention of Heat-Related Illness1
Clinical Practice
This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence
supporting various strategies is then presented, followed by a review of formal guidelines, when they exist.
The article ends with the authors’ clinical recommendations.
From the Department of Environmental A 71-year-old man with a history of coronary artery disease, congestive heart failure,
Health Sciences, Mailman School of Pub- and schizoaffective disorder presents to the emergency department with confusion.
lic Health, Columbia University (C.S.),
and the Department of Emergency Medi- On the day of presentation, he was seen walking near his apartment complex in a
cine, Columbia Irving Medical Center busy urban area and was later found collapsed outside his building. The local heat
(C.S.) — both in New York; and the De- index (accounting for temperature and relative humidity) is 105°F (40.6°C). On ar-
partment of Emergency Medicine, School
of Medicine (J.H.), the Department of rival in the emergency department, he is conscious but confused. His heart rate is 130
Environmental and Occupational Health beats per minute, blood pressure 100/70 mm Hg, respiratory rate 28 breaths per
Sciences, School of Public Health (J.H.), minute, rectal temperature 40.5°C, and oxygen saturation 90% while he is receiving
and the Department of Global Health,
Schools of Medicine and Public Health oxygen at a rate of 3 liters per minute through a nasal cannula. He opens his eyes to
(J.H.), University of Washington, Seattle. voice and can state his name. He is able to move his arms and legs and has no focal
Dr. Sorensen can be contacted at c js2282@ neurologic deficits. His skin is hot and dry to the touch. His medications include
cumc.columbia.edu or at the Columbia
University Mailman School of Public furosemide, risperidone, and carvedilol. The patient lives alone in a top-floor apart-
Health, 722 W. 168th St., New York, NY ment without air conditioning. How should this heat-related illness be treated, and
10032-3727. how could it have been prevented?
This article was published on September
28, 2022, at NEJM.org.
The Cl inic a l Probl em
C
N Engl J Med 2022;387:1404-13.
DOI: 10.1056/NEJMcp2210623 limate change is causing a global increase in average tem-
Copyright © 2022 Massachusetts Medical Society.
peratures and increasing the frequency, duration, and intensity of extreme
CME heat events,1 resulting in unprecedented levels of heat exposure. The past
at NEJM.org 7 years have been the hottest on record,1 and climate change either caused or
dramatically worsened2 recent extreme heat events in Europe (2022),3 India (2022),4
and the Pacific Northwest of the United States (2021).5 In the past 20 years, there
has been a 54% increase in heat-related mortality among persons older than 65 years
of age,6 and more than one third of all global warm-season heat-related deaths are
attributable to climate change.7 On our current global greenhouse gas emissions
trajectory, with warming of 2°C over preindustrial temperatures expected by mid-
century, most of the world is expected to encounter frequent extreme heat events
in the coming decades8; formerly once-in-10-years heat waves are projected to occur
more than 5 times as frequently and once-in-50-years events almost 14 times as
frequently.2 Elevated global temperatures and heat waves are already increasing the
global health burden and causing substantial economic loss.1
Humans thermoregulate through behavioral and autonomic mechanisms (e.g., va-
sodilation and sweating) to maintain a core internal temperature of approximately
37°C. Metabolic activity generates an internal heat load, and exogenous heat from
the environment adds to the total heat burden is the combination of central nervous system dys-
that must be managed; higher humidity levels function and a core body temperature of greater
(which are taken into account in the heat index) than 40°C.14
exacerbate the challenges of dissipating heat. Beyond traditionally recognized heat-related
Under heavy heat loads resulting from exogenous illnesses such as those that are the focus here,
heat, endogenous heat, or both, the thermoregu- many diseases are “heat sensitive,” meaning that
latory ability of the human body may become they are exacerbated or triggered by exposure to
strained or overwhelmed, which can result in a heat. Multiple studies have shown increases in the
spectrum of heat-related illnesses. These illnesses occurrence and exacerbations of a wide range of
range from non–life-threatening conditions conditions during periods of high temperature,15-17
(heat exhaustion, heat syncope, heat edema, heat including ischemic heart disease, cardiac dys-
cramps, and heat rash) to life-threatening heat rhythmias, ischemic stroke, asthma and chronic
stroke resulting from an increase in body tem- obstructive pulmonary disease, respiratory tract
perature above a dangerous threshold (Table 1). infections, hyperglycemia, kidney failure, neuro-
Heat stroke, the most serious heat-related ill- psychiatric disorders (e.g., psychosis, suicides,
ness, is subcategorized as “classic” or “exertional”; homicides, anxiety, and depression), and adverse
the former is typically observed in patients with birth outcomes, such as preterm delivery and
preexisting conditions and the latter primarily in small-for-gestational-age infants.18
healthy persons who exceed thermoregulatory The risk of heat-related illness results from a
boundaries owing to increased metabolic heat combination of individual susceptibility, endog-
generation from performing demanding physical enous and exogenous heat exposure, and socio-
tasks, often but not necessarily in conjunction cultural factors that affect the ability to adapt
with exposure to high ambient temperature. Both (Fig. 1). Older persons (>65 years of age), young
conditions lead to a similar cascade of physiologic children, infants, pregnant women, persons with
abnormalities caused by a failure to dissipate ex- preexisting medical conditions (including obesity)
cessive body heat, including a decrease in central or disabilities, outdoor workers, and athletes are
venous pressure, the onset of cellular and organ at increased risk,19 as are persons living in lower-
dysfunction, injury to the gastrointestinal tract income households and some communities of
and resulting endotoxemia, triggering of a sys- color.20
temic inflammatory response, and elevation of Individual exposure to heat-related risks var-
the core body temperature.12 ies according to geography, occupation (e.g., agri-
Heat stroke is a medical emergency that re- cultural work, construction work, delivery driv-
quires rapid recognition and treatment to prevent ing), social isolation, and time spent outdoors or
permanent complications and death; mortality in areas that amplify heat, such as urban heat
from classic heat stroke approaches 80% and, islands and areas with less green space.19 Urban
for exertional heatstroke, 33% in the absence of heat islands are areas of densely built infrastruc-
prompt treatment.10,13 The hallmark of heat stroke ture, which absorbs and then re-emits heat from
Exertional heat stroke: most often occurs among healthy persons during
extreme physical exertion, which results in excessive metabolic heat
generation, often but not always with concomitant ambient heat ex
posure
Moderate illness
Heat exhaustion Profound fatigue, weakness, nausea, headache, or dizziness (or a com- Remove patient from heat; treat with rest in supine position, evaporative cool-
bination of these symptoms) resulting from a decrease in body water ing, and intravenous or oral rehydration; monitor mental status. Delayed
content or blood volume due to water or salt depletion from heat expo- response to treatment warrants further evaluation.
sure; mild elevation (<40°C) in body temperature may be present, but
no altered mental status
Mild illness
Heat syncope Brief loss of consciousness due to vasodilation and pooling of blood in Remove patient from heat and treat with rest in supine position, passive cool-
n e w e ng l a n d j o u r na l
Heat cramps Painful muscle spasms in the abdomen, arms, or legs during or after activ- Remove patient from heat, treat with rest, oral electrolytes, and fluid repletion.
ity in the heat, which often occur when excessive amounts of salt are
lost during sweating from physical exertion
Heat rash An inflammatory disorder of the epidermis that results from blockage of Remove patient’s clothing; treat with evaporative cooling and glucocorticoid
sweat glands; may be followed by superimposed bacterial soft-tissue and antibacterial creams as needed, but avoid topical emollients; monitor
Downloaded from nejm.org on October 28, 2022. For personal use only. No other uses without permission.
infection. for cellulitis. Advise patients to avoid hot environments and to wear loose
clothing.
* CNS denotes central nervous system, and ICU intensive care unit.
Clinical Pr actice
No Yes
No Yes
Remove patient Remove patient Remove patient Remove patient Assess and manage airway, breathing,
from heat, from heat and from heat, from heat, and circulation
treat with rest elevate legs; treat with rest treat with rest
and massage, diuretics not in supine in supine
administer oral indicated position and position and
electrolyte or passive cooling, evaporative In hospital Before hospital
fluid repletion administer cooling,
intravenous or administer
oral hydration intravenous or Perform cold-water
oral hydration, immersion plus volume If insufficient Perform on-site
monitor neuro- repletion with continuous capacity to cool, cooling by
logic status monitoring of core transport cold-water
temperature immediately immersion or
to hospital other means
while using any
means necessary
Discontinue when to cool during
core temperature is transport
38°–39°C
Table 2. Medications and Drugs with Potential to Increase Risk of Heat-Related Illness.*
Agent Mechanism27
Alcohol May reduce alertness and affect judgment and perception of heat;
exacerbates dehydration and affects vasodilation and cardiac
contractility
Amphetamines May increase metabolic heat production
Anticholinergics May decrease sweat production
Antihistamines May cause peripheral vasoconstriction, limiting radiative cooling
Antipsychotics Interferes with hypothalamic thermoregulation
Benzodiazepines May reduce alertness and affect judgment and perception of heat
Beta-blockers Decreases heart rate and contractility
Calcium-channel blockers Decreases cardiac contractility and compromises vascular compensa-
tory mechanisms
Diuretics May increase risk of dehydration and hypovolemia
Illicit drugs (e.g., cocaine, heroin, phencyclidine, May increase metabolic heat production and reduce alertness and
and MDMA) judgment
Laxatives May increase risk of dehydration and hypovolemia
Lithium May reduce alertness and affect judgment and perception of heat and
lead to nephrogenic diabetes insipidus; levels may rise to danger-
ous levels and cause kidney injury in the context of dehydration
Serotonin-reuptake inhibitors May interfere with hypothalamic thermoregulation
Thyroid agonists May increase metabolic heat production
Tricyclic antidepressants May cause peripheral vasoconstriction, thereby limiting radiative
cooling, and may affect central thermoregulation
Weight-loss supplements that may increase May increase metabolic heat production
metabolic rate (e.g., carnitine and green tea
extract)
* This list of medications (based on information from Pryor et al.28) and mechanisms is not comprehensive. MDMA
denotes 3,4-methylenedioxymethamphetamine.
vided in Figure 2. Heat exhaustion exists on a immersion31; a crossover study found no differ-
continuum with heat stroke, and its treatment is ence in cooling rates between these methods.32
dictated by the severity of symptoms. Mild cases A rapid rate of cooling, ideally 0.20° to 0.35°C
can be managed with passive cooling and rehy- per minute, with continuous monitoring of the
dration, whereas moderate cases typically war- core temperature, is safe and has been associ-
rant active management with convective cooling ated with a better prognosis than slower cooling
(i.e., with the use of fans), infusion of cold fluids, in observational studies.12 In settings outside the
and close monitoring.10 hospital, where immersion is not available, a cool-
ing rate of 0.10°C per minute can be achieved by
Heat Stroke pouring copious amounts of water over the victim
For patients with heat stroke, treatment begins and fanning.33 If airway compromise, ongoing
with maintaining the airway, breathing, and cardiopulmonary resuscitation, or resource avail-
circulation, immediately followed by rapid cool- ability prevents cold-water immersion, treatment
ing. Because delays in cooling are associated involves a mixture of evaporative and conductive
with worse outcomes, initial management is fo- cooling methods, including infusion of cold fluids;
cused on rapidly reducing the core body tempera- application of ice packs to the neck, groin, and
ture to 38° to 39°C, ideally within 30 minutes axillae; and fanning.12 Intravascular cooling can
after presentation.30 The most effective cooling also be used.13 Monitoring of the core tempera-
methods are cold-water immersion and ice-water ture throughout the cooling process is imperative,
Table 3. Prevention Strategies for the General Population and for Specific Groups.*
with a goal of reaching normothermia. It is rec- interventions, particularly those targeted to sus-
ommended that cooling measures be taken before ceptible persons and their caregivers, athletes, and
and during transport to the hospital whenever outdoor workers. Table 3 outlines strategies for
possible.34 risk reduction.
Antipyretic agents should not be used; they are Expert guidelines recommend that before the
ineffective in patients with heat stroke and may warm season, clinicians should identify heat-
aggravate coagulopathy and end-organ damage.10 vulnerable patients (Fig. 1) and alert them and
Dantrolene has been associated with reduced cool- their caregivers to their potential risks, noting
ing time but not with improved rates of recovery; that a single day of extreme heat poses a threat;
it is not used to treat heat stroke in practice.35 counsel them about the identification of high-
Benzodiazepines may be used to control agitation, risk heat conditions (Fig. S1 in the Supplemen-
discomfort, and shivering. tary Appendix, available with the full text of this
Patients who are successfully cooled and sur- article at NEJM.org) and the signs and symp-
vive the hyperthermic–neurologic phase are at high toms of heat-related illness; and provide clear
risk for progression to the hematologic–enzymatic instructions about how to reduce risks and when
and late hepatic–renal phases. These patients are to seek medical attention.27,38 A randomized trial
best treated in an intensive care setting with a of a preventive-messages tool for older adults in
multidisciplinary team.13 Australia showed significant uptake of behavioral
strategies and a 63% lower risk of self-reported
Risk Reduction heat stress among those who received the inter-
Because evidence from randomized trials is lim- vention than among those who did not.36 General
ited,36 strategies to prevent heat-related illness are guidance to reduce risk includes keeping living
guided largely by clinical experience and observa- spaces cool with fans, air conditioning, or mist-
tional data. These data support the benefits of ing (with the caveat that fans are likely to be
screening for risk and of the use of behavioral ineffective at temperatures >99°F [>37.2°C] and
may be detrimental in dry conditions40), locating consensus statement on the prehospital recogni-
cooling centers or other accessible places with tion and management of exertional heat stroke.34
cooling, limiting physical activity, increasing water All guidelines stress the importance of rapid cool-
intake, wearing lightweight clothing, self-dous- ing for persons with heat stroke, recommend cold-
ing and taking cool showers, and monitoring for water immersion as first-line therapy, and advo-
symptoms, including frequent safety checks from cate for the initiation of cooling by any means
caregivers.39 available while the patient is still in the field,
Athletes and persons who manage athletic followed by transportation to a medical facility.
practices and events should be counseled that Our recommendations align with these guidelines.
heat acclimatization, which involves short periods
(1 to 2 hours) of heat-exposed exertion each day A r e a s of Uncer ta in t y
over a period of 10 to 14 days, has been shown
to increase the ability of the body to tolerate and High-quality studies to identify the temperature
dissipate heat.10 In higher-risk heat conditions, of water in which to immerse a patient are lack-
practices and events should be scheduled at cooler ing, although observational studies suggest that
times of the day and allow for more rest breaks.43 cooling rates are similar with cold water and ice
Clinicians can refer to region-specific exercise- water.32 Expert consensus supports discontinuing
modification tables for additional guidance43 and cooling when the core temperature reaches 38° to
should encourage organizers of sporting events 39°C, after which the body temperature typically
to have trained personnel on site and the capacity continues to decline to normal; however, this
to provide cold-water immersion if needed.43 recommendation has not been rigorously studied,
Preventive actions are challenging for many and isolated case reports have described favorable
workers who perform heavy labor in hot condi- outcomes with therapeutic hypothermia.49
tions.44 Outdoor workers often have little control Further study of medications to treat heat
over their work environment and activities, stroke and improvements in the identification of
which complicates normal behavioral responses persons at high risk for heat-related illness are
to heat.45 According to data from the Centers for warranted. Randomized trials involving persons
Disease Control and Prevention, crop workers die in high-risk groups are needed to evaluate the
from heat stroke at a rate nearly 20 times that of benefits of screening and of behavioral and other
U.S. civilian workers overall; most fatalities occur interventions (such as provision of air cooling in
among adults 30 to 54 years of age, with a ma- homes and congregate living settings and referral
jority of victims being foreign-born workers.46 to cooling centers). Ongoing research is evaluat-
Factors contributing to the high risk of heat-relat- ing the effects of public health measures such as
ed illness in persons who work outdoors include heat-wave alerts and heat early-warning systems
direct exposure to heat (indoor and outdoor), on the burden of heat-related disease; research
extreme physical exertion, heat-trapping protec- to date has shown inconsistent results.50
tive work clothing, and job insecurity.47 Despite
convincing evidence of the negative health ef- C onclusions a nd
fects of increased workplace heat, there is no R ec om mendat ions
dedicated U.S. standard that specifically address-
es occupational heat exposure, although there The 71-year-old man described in the vignette
are efforts under way to create one,48 and certain presents with confusion and hyperthermia in the
states (e.g., California and Washington) have context of a high ambient temperature, making
standards and regulations in place. heat stroke the likely diagnosis. Risk factors in-
clude his living alone on the top floor of a build-
ing without air conditioning and his use of
Guidel ine s
medications that can compromise thermoregu-
The Wilderness Medical Society and American lation. Treatment should involve rapid cooling
College of Sports Medicine have published guide- followed by diagnostic evaluation and manage-
lines on the prevention and treatment of heat- ment of complications such as aspiration pneu-
related illness.10,43 The National Association of monia, as well as monitoring in an intensive care
Emergency Medical Service Physicians has a unit. Subsequent preventive strategies are needed,
and, if instituted earlier, might have averted the ment. In addition to broad-based public health
current illness. These strategies should include measures aimed at reducing risks, rapid action
clinical screening before the warm season, tailored to reduce greenhouse gas emissions is needed to
recommendations that take into account the pa- prevent further increases in morbidity and mor-
tient’s coexisting conditions and medications, tality due to heat exposure.
and involvement of a multidisciplinary team to Disclosure forms provided by the authors are available with
aid in improving the safety of his home environ- the full text of this article at NEJM.org.
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Focusing on acute and preventive therapies for migraines, this video discusses pathophysiology and pro-
vides practical treatment information for this common condition.