HEAT ILLNESS - Key Concepts
■Classic heatstroke is generally diagnosed in elderly patients with co-morbidities during heat-waves while exertional heatstroke is more common in young athletic patients or military personnel.
■Patients with exertional heatstroke are commonly diaphoretic.
■ Rapid cooling of the potential heatstroke patient should be initiated before the diagnosis is firmly established.
■Antipyretics are ineffective and should not be used to control environmental hyperthermia.
■ The most effective minimally invasive cooling measure is with evaporative techniques using cool mist sprays, standing fans and strategic ice packs.
■ Heatstroke can cause right-sided cardiac dilation and elevated CVP, clinically resemble pulmonary edema, and yet require vigorous crystalloid resuscitation.
Lightning Injuries - Key Concepts
  1. Lightning strikes expose victims, who are often wet from rain, to millions of volts for an extremely short period of time (microseconds). As a result, the current may be directed superficially over the patient to the ground, resulting in no injury or only superficial burns. The shock wave associated with a lightning strike may result in physical injury.
  2. No evidence-based guidelines direct the ancillary testing of lightning strike victims. All patients should receive an ECG and that additional testing should be based on an individual patient’s signs and symptoms.
3. Lightning strike victims who present without symptoms or signs of injury, including those with minor first degree burns, do not require treatment in the ED unless their electrocardiograms show signs of ischemia or significant dysrhythmias. Patients who present with altered mentation or significant symptoms she be approached in a manner similar to that used for victims of high-voltage electrical injury.
  1. Lightning strikes can result in a spectrum of peripheral and central neurologic injuries, including pupils that are dilated and fixed in the absence of irreversible brain injury. This factor should be kept in mind when deciding when to discontinue resuscitative efforts in patients who present in cardiac arrest.
  2. Lightning strike victims are often hospitalized for care of their injuries and cardiac monitoring. However, those with a normal mental status and neurologic exam, normal ECG, and no significant injuries or complaints may be safely discharged after 6-8 hours of ED observation. All patients should be referred to ophthalmology and otolaryngology for baseline evaluation and monitoring for the development of delayed sequelae.

HIGH ALTITUDE - KEY CONCEPTS

■All forms of altitude illness can be treated with oxygen and rapid descent.
■The diagnosis of AMS requires the presence of headache in the setting of recent elevation change to greater than 8,000 feet. Additional nonspecific symptoms may include nausea, anorexia, fatigue, and insomnia.
■ Patients with AMS should not ascend further until symptoms improve. Patients with mild HAPE may be treated in place if experience providers and treatment options exist. Patients with moderate HAPE or HACE should descend immediately.
■Dyspnea at rest is an early symptom of HAPE. More advance findings of HAPE include marked rest tachypnea, cough productive of frothy sputum, and altered mentation. Immediate treatment with oxygen and descent are recommended.
■Altered consciousness and cerebellar ataxia are early signs of HACE. Failure to initiate immediate treatment with oxygen, descent, and dexamethasone can result in permanent disability or death.
■AMS may be prevented by using acetazolamide or dexamethasone. Symptoms can be controls with analgesia (ibuprofen and antiemetics). HAPE may be prevented usingnifedipine, inhaled salmetrol, and phosphodiesterase type 5 inhibitors and tadalafil. Tamazepam can safely improve sleep quality.