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Cold water immersion for heat stroke

Started by RNOfficer, July 25, 2016, 11:39:16 PM

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RNOfficer

http://www.medscape.com/viewarticle/559753

Cold water immersion for heat stroke has long been a controversial topic in EMS. The verdict is that CWI is the preferred treatment and should be done immediately, even delaying transport if necessary.

IT was thought that cold water immersion could cause cardiac arrest but no cases have been found. A second criticism is:

"Recently (in a historical sense, i.e., 50 to 100 yrs or so ago), a widely circulated opinion has encouraged some in the medical community to avoid using cold water immersion (CWI) for the acute treatment of heatstroke.[19,30] This line of thinking has reached the medical community, including athletic trainers, team physicians, emergency department physicians, emergency medical technicians, registered nurses, first aid-trained coaches, and others. The number one criticism of CWI is that patients will actually heat up (or at least not cool down) in CWI because of peripheral vasoconstriction (PVC) and shivering. However, scientific evidence strongly refutes this criticism. Evidence from basic physiological studies looking at the effect of CWI on cooling rates in hyperthermic individuals and treatment of actual EHS victims clearly shows that CWI has cooling rates superior to any other known modality."

NB: this treatment should be applied to a normally healthy individual. For a person with underlying relevant medical conditions, seek medical advice FIRST.

Also remember that HEAT stroke has NOTHING at all to do with a "stroke" (when blood flow to an area of brain is cut off) which is one reason EMS prefer to call a stroke a "brain attack".

JayT

[quote author=RNOfficer
Also remember that HEAT stroke has NOTHING at all to do with a "stroke" (when blood flow to an area of brain is cut off) which is one reason EMS prefer to call a stroke a "brain attack".
[/quote]

Ah.....no we don't. Never seen that phrase outside of pato enter education material, and one CVA center that tried to push "brain attack."

Paramedic with a critical care certification here.
"Eagerness and thrill seeking in others' misery is psychologically corrosive, and is also rampant in EMS. It's a natural danger of the job. It will be something to keep under control, something to fight against."

Eclipse


"That Others May Zoom"

Pace

Why not dump both terms and call it by it's true name?
Lt Col, CAP

Eclipse


"That Others May Zoom"

Fubar

Quote from: Pace on July 26, 2016, 02:19:57 AM
Why not dump both terms and call it by it's true name?

Because you're not tacticool unless you can use eight words with at least five syllables each to describe a condition that already has a handy two-syllable word label.

LTC Don

See the information at the Korey Stringer Institute.  I'm inclined to go with what the recommend:  http://ksi.uconn.edu/


http://ksi.uconn.edu/emergency-conditions/heat-illnesses/exertional-heat-stroke/


It's not how high the temp goes, it's how long you are at that temp that matters.  The faster you can definitively cool the victim down, the more likely they will recover without damage.



Donald A. Beckett, Lt Col, CAP
Commander
MER-NC-143
Gill Rob Wilson #1891

RNOfficer

#7
Quote from: JayT on July 26, 2016, 02:08:18 AM
[quote author=RNOfficer
Also remember that HEAT stroke has NOTHING at all to do with a "stroke" (when blood flow to an area of brain is cut off) which is one reason EMS prefer to call a stroke a "brain attack".

Ah.....no we don't. Never seen that phrase outside of pato enter education material, and one CVA center that tried to push "brain attack
[/quote]

Thanks for raising important matter. Of course it would be more accurate to say some EMS prefer to call a stroke a brain attack".

I prefer the term "brain attack because it conveys to the lay public that a "stroke" is a very serious emergency and EMS is required immediately.

RNOfficer

Quote from: LTC Don on July 26, 2016, 04:18:36 PM
See the information at the Korey Stringer Institute.  I'm inclined to go with what the recommend:  http://ksi.uconn.edu/


http://ksi.uconn.edu/emergency-conditions/heat-illnesses/exertional-heat-stroke/


It's not how high the temp goes, it's how long you are at that temp that matters.  The faster you can definitively cool the victim down, the more likely they will recover without damage.

Yes a very good explanation of heat stroke, supporting the CWI. My only disagreement with the method presented is that it suggests the use of a rectal thermometer for signs and symptoms. Because most of us are unlikely to have a rectal thermometer, I always emphasize external signs: red, hot, dry skin, rapid breathing and heartbeat, headache, and altered mental state. Of course all these symptoms need not be present.

As the video shows COOL first TRANSPORT later. The less time the victim is overheated, the less likely will be organ damage.

My post was to dispose of counter-arguments against CWI and to empathize that advise often given: such as remove clothing, bring into an air-condition room are totally inadequate.


LSThiker

Quote from: RNOfficer on July 26, 2016, 09:29:06 PM
such as remove clothing, bring into an air-condition room are totally inadequate.

Unless that is all you can do.  Cannot really do CWI if you do not have the ability (i.e. hiking trails/backpacking).  :)

Luis R. Ramos

Squadron Safety Officer
Squadron Communication Officer
Squadron Emergency Services Officer

RNOfficer

Quote from: LSThiker on July 26, 2016, 09:46:08 PM
Quote from: RNOfficer on July 26, 2016, 09:29:06 PM
such as remove clothing, bring into an air-condition room are totally inadequate.

Unless that is all you can do.  Cannot really do CWI if you do not have the ability (i.e. hiking trails/backpacking).  :)

A good point.

The victim could be put into a stream or pond (carefully of course). If these are unavailable, you can still use the principle which is that heat dissipates ten times better from contact with water than from air. Move the victim into the shade, remove excess clothing then soak the victim's remaining clothing in water or flood his skin with a hose. Keep it up. When backpacking, prompt treatment is even more important because transport of the victim will obviously be delayed

RNOfficer

Quote from: Luis R. Ramos on July 26, 2016, 10:09:54 PM
Or working a tarmac at an airshow.

There's often a ice bucket for soft drinks. There's always a hose. Even if the victim cannot be immersed, there's plenty of water to apply.

LSThiker

Quote from: RNOfficer on July 26, 2016, 10:21:39 PM
The victim could be put into a stream or pond (carefully of course). If these are unavailable, you can still use the principle which is that heat dissipates ten times better from contact with water than from air. Move the victim into the shade, remove excess clothing then soak the victim's remaining clothing in water or flood his skin with a hose. Keep it up. When backpacking, prompt treatment is even more important because transport of the victim will obviously be delayed

I have been places where there are 10-15 miles between streams with high heat.  Or places with no water (i.e. desert in SW US).  The water you carry is vital to keep yourself from heat stroke.  I have worried about these places because you cannot really use your water for anything other than drinking yourself.  To use it on anything else will probably mean you run out of water before your next spot (assuming the water is still there). 

Luis R. Ramos

Quote

...there's plenty of water to apply.


I never said there was no water to apply. Just that there is no place to immerse. Don't put words that are not there.
Squadron Safety Officer
Squadron Communication Officer
Squadron Emergency Services Officer

RNOfficer

Quote from: LSThiker on July 26, 2016, 10:31:36 PM
Quote from: RNOfficer on July 26, 2016, 10:21:39 PM
The victim could be put into a stream or pond (carefully of course). If these are unavailable, you can still use the principle which is that heat dissipates ten times better from contact with water than from air. Move the victim into the shade, remove excess clothing then soak the victim's remaining clothing in water or flood his skin with a hose. Keep it up. When backpacking, prompt treatment is even more important because transport of the victim will obviously be delayed

I have been places where there are 10-15 miles between streams with high heat.  Or places with no water (i.e. desert in SW US).  The water you carry is vital to keep yourself from heat stroke.  I have worried about these places because you cannot really use your water for anything other than drinking yourself.  To use it on anything else will probably mean you run out of water before your next spot (assuming the water is still there).

Yes, I've hiked in similar places, mountain ridges also.

I understand that water is heavy and one is disinclined to carry more than you think is necessary. But what if you were injured between water sources? How long could you survive on the water you're carrying ? It's always best to carry much more water than you think you will need even with the weight penalty. But, of course, it's your choice.

Spam

But what if you were carried off by a twister?
... attacked by a bear?
... shot by an armed bear (we preserve the right to arm bears)?


What if,
What if,
What if,

Jeez, already. Brain attack indeed.
/Spam


Garibaldi

Quote from: Spam on July 26, 2016, 11:28:28 PM
But what if you were carried off by a twister?
... attacked by a bear?
... shot by an armed bear (we preserve the right to arm bears)?


What if,
What if,
What if,

Jeez, already. Brain attack indeed.
/Spam

Don't worry folks....I'll Gibbs-smack him at the meeting tomorrow.  :o
Still a major after all these years.
ES dude, leadership ossifer, publik affaires
Opinionated and wrong 99% of the time about all things

Spam

Quote from: Garibaldi on July 26, 2016, 11:31:39 PM
Quote from: Spam on July 26, 2016, 11:28:28 PM
But what if you were carried off by a twister?
... attacked by a bear?
... shot by an armed bear (we preserve the right to arm bears)?


What if,
What if,
What if,

Jeez, already. Brain attack indeed.
/Spam

Don't worry folks....I'll Gibbs-smack him at the meeting tomorrow.  :o

Yeah, Cletus, you gonna walk over, but limp home (grin)

Sorry, but the hypothetical hand wringing was getting to me again.

Cheers,
Spam



grunt82abn

#19
I would never delay transport even as a paramedic in CAP. Most squadrons don't carry the proper equipment to handle serious heat stroke, and CWI isn't always the correct solution. Every state, and the many medical regions with in states, have different treatment protocols to follow. If your willing to put your license on the line to start putting out treatment protocols to CAP members, that's on you, but you should at least have a caveat that you are just a MSO putting out geewiz information for knowledge base only, and not definitive care methods of treatment.

I haven't met a doctor or nurse, yet, in my 16 year career as a professional firefighter paramedic that would ever tell anybody to DELAY transport of a person having a medical emergency. Especially so that treatment can be done in the field by a layperson for someone in heat stroke or other medical emergency instead of getting the patient to the nearest emergency care facility. Your setting CAP members up for liability by putting this information out there. I know you don't like EMS first responders, but there is a reason we have 911, and that is so proper care can be provided in the pre-hospital setting and the patient can be brought to medical professionals who can fix the issues and hopefully prevent new ones from occurring. 


BTW, we call it a CVA, or Cerebrovascular Accident, and have stroke centers up here in Wisconsin and Illinois. I didn't coin the term, some big wig, supper smart brain doctor did.
Sean Riley, TSGT
US Army 1987 to 1994, WIARNG 1994 to 2008
DoD Firefighter Paramedic 2000 to Present

Luis R. Ramos

Garibaldi,

Don't smack him. Just immerse him in a pool of cold water. Or drop a bucket full of ice on him. That will fit in right with the nature of this thread.

>:D

Squadron Safety Officer
Squadron Communication Officer
Squadron Emergency Services Officer

RNOfficer

Quote from: grunt82abn on July 27, 2016, 02:19:10 AM

I haven't met a doctor or nurse, yet, in my 16 year career as a professional firefighter paramedic that would ever tell anybody to DELAY transport of a person having a medical emergency.

Apparently you did not view the video that Col Beckett linked from UConn. It clearly stated TREAT FIRST, TRANSPORT later.

My opinion is that whether to treat or transport first depends upon the circumstances. If the hospital was very close, say within 5 minutes, I would agree that transport first is correct. If EMS response time is long or the hospital is some distance, then treat first.

Also my decision would. be based upon the quality of EMS. If only EMT-Bs are the responder, then I would treat first. If paramedics (EMT-Ps) were responding and they would be there SOON (<5 minutes)., I would wait for them.

As Col Beckett and the video you did not watch state, the length of time the victim is at a critical temperature in the determinate of organ damage Waiting a long period for transport to arrive and  then a long ride to a medical facility would not be in the patient's interest.

If a patient's life were at risk I would have no problem risking the loss of my license if that was necessary for appropriate treatment.

Quote
BTW, we call it a CVA, or Cerebrovascular Accident, and have stroke centers up here in Wisconsin and Illinois. I didn't coin the term, some big wig, supper smart brain doctor did.

I know what a CVA is. However this is a board for the general CAP membership so I use non-technical
terms like "brain attack" that are more likely to stick in a layperson's memory.

DakRadz

Have I already mentioned that locally they use body bags for this immersion?

How well will that go over with parents, wing, or EMS?

The athletic trainers round here expect we will transport in the body bag, filled with ice, their charges. But that's also specifically their job.

But seriously, that is the most efficient way to do this. And to me, it's a medical treatment, not first aid.... did I mention the body bag?

Sent from my SM-N910T using Tapatalk


Luis R. Ramos

Wouldn't it be more professional for our members to know and be able to use the technical term of CVA?
Squadron Safety Officer
Squadron Communication Officer
Squadron Emergency Services Officer

LSThiker

Quote from: grunt82abn on July 27, 2016, 02:19:10 AM
BTW, we call it a CVA, or Cerebrovascular Accident, and have stroke centers up here in Wisconsin and Illinois. I didn't coin the term, some big wig, supper smart brain doctor did.

CVA was first used in 1927 after a consensus of physicians and scientists.  Unfortunately, due to the poor understanding of medicine, physiology, and pathophysiology, I do not think a single person can be credited to the term CVA.  Prior to 1927, Hippocrates described sudden deaths (such as strokes, heart attacks, etc) as apoplexia.  Over time, apoplexia meant specifically "stroke".  This term was the predominate term until 1927.  In the 1600s, it was finally discovered that a blood blockage was responsible for strokes.  The term stroke was first used to mean "CVA" somewhere between 1500 and 1970 (the journal Stroke was started in 1970).  Again, it is difficult to determine exactly simply because stroke for some time also meant seizures.

Quote from: Spam on July 26, 2016, 11:28:28 PM
(we preserve the right to arm bears)?



It was not mean to be a what if scenario.  Rather pointing out that calling something "inadequate" is not necessarily "inadequate" if it is the only thing you can do.  Stripping some person and moving them to the shade may be less effective than cooling them with water, but that does not mean it is inadequate if that is the best you can do given the current situation.  A particular scenario may mean that the actions are the most adequate for the conditions.

Anyway, sorry to sidetrack the discussion.  Moving on now.

sarmed1

The lay person information out there is Stroke:  most of the "ways to recognize" type public info lists them as signs and symptoms of a stroke. 

I have worked multiple EMS agencies in 4 different states all different parts of the country.  No one in everyday EMS uses the term brain attack.  The only exception is some "classes" for shock value.  Stroke or CVA are the common EMS terms.  the only reason Brain Attack has even surfaced is to try to draw a similarity of severity to Heart Attack, which is so common and misused its ridiculous.

back on topic, Rapid Cooling would be the best way to describe prefered Heat Stroke treatment.  Its sort of universally applicable to your resources and capabilities.  If you can immerse, immerse, if you just have AC and ice packs go with that, if you are ALS run in cool IV fluids at the same time.

MK

PS:  As a personal note based on how the last conversation went, using the word "quality" to describe the different level of EMS provider is a poor choice of wording.
Capt.  Mark "K12" Kleibscheidel

LTC Don

This is kind of a tough webinar to listen to, but give due course.  The information is very relevant, recent, and interesting.  Certainly, it is geared to EMS providers, but there are some definite takeaways for the layperson first-aiders like CAP members.  It pulls a lot of information from the Korey Stringer site, and discusses some extreme temperature cases and incidents.

https://www.youtube.com/watch?v=6YH8ZopxUdw


To note:
There has been mention in earlier posts about the 'classic' signs of:

Red flushed skin
Lack of sweating or dry skin

These are LATE signs.  If you have someone truly exhibiting these signs, you should be prepared to do CPR, or pronounce.  These victims are about to die no matter what you do.  This means IMMEDIATE CWI is their only hope of even staying alive, not necessarily without serious brain damage.

Also, the mention of not delaying transport.  The idea of the body bag filled with water and ice is great, if it can be done in conjunction with transport.  Great.  Otherwise, the goal is to AT LEAST START THE DOWNWARD trend of the temperature.  If the temp is above 102, CWI is preferred, but once the temp has trended down to 102 or under, transport should be managed without further delay, with ice and water continuously applied.

REMEMBER: It's not how high the temp, but how long at that high temp, that causes the most severe brain damage.  Get the temp down as fast as possible or start the downward trend, then transport.

ALWAYS, ALWAYS treat for the more severe condition, if unsure.  If you have members at an airshow (or other event) showing mental status changes, severe fatigue, and severe diaphoresis, and/or acting like they just can't get cooled off -- Contact CFR and get a firehose on them.  Immediately.  Since we don't carry thermometers, you have to assess the event and activity and other environmental factors.  It's  just water, and if it's a case of 'Heat Fatigue' or the more common 'Heat Exhaustion', then no harm no foul.  You still helped a fellow member avoid more serious, potentially life-threatening problems.

Heat Stroke is a HEAT problem, NOT a hydration problem.  Just drinking lots of water will not prevent the onset of heat stroke.  It helps certainly, but it's still a HEAT issue.

Oh yeah, watch the webinar.


For my fellow EMS colleagues -- Remember, we don't do CPR like we did back in the eighties.  Modalities and standards change.  Research improves.  Life goes on.
Donald A. Beckett, Lt Col, CAP
Commander
MER-NC-143
Gill Rob Wilson #1891

LSThiker

Quote from: LTC Don on July 27, 2016, 06:38:04 PM
Heat Stroke is a HEAT problem, NOT a hydration problem.  Just drinking lots of water will not prevent the onset of heat stroke.  It helps certainly, but it's still a HEAT issue.

Heat stroke is a heat issue and can be a dehydration issue.  After all, that is why there is exertional heat stroke and nonexertional heat stroke.  This is why avoiding rigorous exercise in extreme heat and/or humid conditions and avoiding dehydration is considered the best means to prevent heat stroke.  Hyperthermia over 41C and/or anhidrosis are the main causes of heat stroke.  Exertional heat stroke are those that raise the body temperatures through vigorous exercise and overwhelm their thermoregulatory mechanisms (e.g. firefighters, military, athletes).   This overwhelming can be due to poor hydration, lack of acclimatization, poor physical fitness, etc.  Nonexetional heat stroke is due to faulty cooling mechanisms such as abnormal sweating or the failure to sweat.  The main cause is dehydration. 

Therefore, while it is a heat issue, the underlying cause of that heat issue can be dehydration.     

RNOfficer

Quote from: DakRadz on July 27, 2016, 04:00:38 AM
Have I already mentioned that locally they use body bags for this immersion?

How well will that go over with parents, wing, or EMS?

The athletic trainers round here expect we will transport in the body bag, filled with ice, their charges. But that's also specifically their job.

But seriously, that is the most efficient way to do this. And to me, it's a medical treatment, not first aid.... did I mention the body bag?

Sent from my SM-N910T using Tapatalk

Body bags are an excellent idea device for cold water immersion:
relatively cheap, readily available, waterproof. Similar bags would be backpacking "bivy bags" or even large plastic trash bags.

Even if the rescuers do not have ice, the body bag would hold hosed water against the skin to speed cooling, compared to just hosing a victim down. For maximum effect the hose should be run continuously at a low rate

DakRadz

Absolutely. But as I said, we only do first aid, and I'm not sure where this stands on the scale.

And unless we do know it's first aid, the sheer shock value of putting cadets in body bags will certainly draw on scrutiny which may not end with a favorable decision.

Look, if I'm off duty, and I can't be confident I'm performing first aid, which is the only thing CAP allows, and I don't have EMS close, then I will reconsider the situation. But this seems a little farfetched for an average activity.

Sent from my SM-N910T using Tapatalk


RNOfficer

Quote from: LTC Don on July 27, 2016, 06:38:04 PM
This is kind of a tough webinar to listen to, but give due course.  The information is very relevant, recent, and interesting.  Certainly, it is geared to EMS providers, but there are some definite takeaways for the layperson first-aiders like CAP members.  It pulls a lot of information from the Korey Stringer site, and discusses some extreme temperature cases and incidents.

https://www.youtube.com/watch?v=6YH8ZopxUdw


To note:
There has been mention in earlier posts about the 'classic' signs of:

Red flushed skin
Lack of sweating or dry skin

These are LATE signs.  If you have someone truly exhibiting these signs, you should be prepared to do CPR, or pronounce.  These victims are about to die no matter what you do.  This means IMMEDIATE CWI is their only hope of even staying alive, not necessarily without serious brain damage.

Also, the mention of not delaying transport.  The idea of the body bag filled with water and ice is great, if it can be done in conjunction with transport.  Great.  Otherwise, the goal is to AT LEAST START THE DOWNWARD trend of the temperature.  If the temp is above 102, CWI is preferred, but once the temp has trended down to 102 or under, transport should be managed without further delay, with ice and water continuously applied.

REMEMBER: It's not how high the temp, but how long at that high temp, that causes the most severe brain damage.  Get the temp down as fast as possible or start the downward trend, then transport.

ALWAYS, ALWAYS treat for the more severe condition, if unsure.  If you have members at an airshow (or other event) showing mental status changes, severe fatigue, and severe diaphoresis, and/or acting like they just can't get cooled off -- Contact CFR and get a firehose on them.  Immediately.  Since we don't carry thermometers, you have to assess the event and activity and other environmental factors.  It's  just water, and if it's a case of 'Heat Fatigue' or the more common 'Heat Exhaustion', then no harm no foul.  You still helped a fellow member avoid more serious, potentially life-threatening problems.

Heat Stroke is a HEAT problem, NOT a hydration problem.  Just drinking lots of water will not prevent the onset of heat stroke.  It helps certainly, but it's still a HEAT issue.

Oh yeah, watch the webinar.


For my fellow EMS colleagues -- Remember, we don't do CPR like we did back in the eighties.  Modalities and standards change.  Research improves.  Life goes on.

Thanks for the excellent video and for reminding me that the signs like hot skin are late symptoms. In practice and teaching, I always emphasize that heat injuries are on a continuum and a victim teated for heat exhaustion should be monitored for worsening condition eg: heat stroke. But your point about early intervention is well-taken.