EMT/AEMT/PARAMEDIC STANDING ORDERS

Exertional Heat Stroke (EHS) is a unique and emergent hyperthermic condition that occurs in individuals performing intense physical activity, typically not limited to warm environments.

INDICATION:

Consider EHS in any intensely-exercising athlete, labourer, fire, police or EMS personnel with altered mental status.

PROTOCOL for EMT & AEMT/PARAMEDIC

• Perform rapid routine assessment (< 5 minutes). Assess for other causes of AMS (Altered Mental Status), including but not limited to hypoxia, hypoglycemia, inadequate perfusion, head injury or seizure.
• Consider EHS in any intensely-exercising athlete, labourer, fire, police or EMS personnel with altered mental status.
• If EHS has been confirmed and appropriate cooling has been initiated by an appropriate onsite medical team, athletic trainer, coach, or instructor, DO NOT interrupt cooling for assessment or transport.
• If care has not been initiated and EHS is suspected, immediately perform a rectal temperature (TREC).
• If rectal temperature (TREC) at or above 40 0C (104F), initiate immediate rapid cooling to a temperature less than 40 0C within 30 minutes of collapse.
  • Best practice for cooling an EHS patient is whole-body cold water immersion from the neck down.
  • Immersion in ice water-filled body bag or tarp may also yield acceptable cooling rates.
  • Ice packs, fans, cold water dousing or shower do not achieve acceptable cooling rates. Rotating ice water towels covering as much of the body surface area as possible should be considered a minimum cooling modality enroot.
• Discontinue cooling at 39 0C (102F). If a rectal temperature is not available, cooling should not be interrupted or delayed in cases of suspected EHS. Cool for a minimum of 20 minutes / clinical improvement if resources available on scene, or transport with best available active cooling method (Cold Pack or rotating ice water-soaked towels).
• Do not interrupt cooling for diarrhea, emesis, combativeness, or seizures. IV/IM medications are rarely needed.
• Transport to closest receiving facility and notify that EHS is suspected.

Notes:

• For events with medical personnel and cooling means on-site, the only appropriate standard is to cool the EHS patient in place. Transportation of an EHS patient should only be done if it is impossible to adequately cool the patient, or after adequate cooling has been verified by a rectal temperature
• The only accurate or acceptable body temperature measurement in exercising individuals is a rectal temperature.
• EMS must ensure early pre-notification to hospitals if they will be receiving an inadequately-cooled EHS patient, or suspect EHS in a scenario where treatment has not been initiated.