EMT Standing Order (ADULT & PEDIATRIC)

• Routine Patient Care.
• Consider exertional heat stroke in any intensely-exercising athlete, labor, fire, police or EMS personnel, etc. with altered mental status. See Exertional Heat Stroke Protocol (30 Medical).
• Move victim to a cool area and shield from the sun or any external heat source.
• Remove as much clothing as is practical and loosen any restrictive garments.
• If alert and oriented, give small sips of cool liquids.
• Monitor and record vital signs and level of consciousness. If altered mental status, check blood glucose level.
• Determine patient’s score temperature, if possible (rectal temperature preferred). If thermometer not available, assume heat stroke if altered mental status present.
• Diagnosis of hyperthermia is based on clinical signs
• If temperature is ≥ 40 0C (104F) or if altered mental status is present, begin active cooling by:
  • Whole-body cold water immersion from the neck down. Note: Elderly patients are less able to withstand sudden shocks, so begin with less aggressive cooling measures like misting or cool wet cloths. When you reassess the patient, if there is little or no improvement, use more aggressive measures.
  • Continually misting the exposed skin with tepid water while fanning patient.
  • Rotating ice water towels covering as much of the body surface area as possible.
• Discontinue active cooling if shivering occurs that cannot be managed by Paramedics (see below) or temperature is < 38.9°C (102 F).
• Call for AEMT/Paramedic intercept & Assisst them in patient care.

AEMT/Paramedic Standing Order (ADULT)

• Establish IV access.
• Administer 500 mL 0.9% NaCl room temperature or chilled IV fluid bolus for dehydration even if vital signs are normal.
• If uncontrolled shivering occurs during cooling:
  • Midazolam 2.5 mg IV/IN, may repeat once in 5 minutes OR 5 mg IM, may repeat once in 10 minutes OR
  • Diazepam 2mgIV, may repeat once in 5 minutes.

AEMT/Paramedic Standing Order (PEDIATRIC)

• Administer 20 mL/kg 0.9% NaCl room temperature or chilled IV fluid bolus for dehydration even if vital signs are normal.
• If uncontrolled shivering occurs during cooling:
  • Midazolam 0.1mg/kg IV or 0.2mg/kg IN/IM (single maximum dose 1mg)

    (Note: a 5 mg/mL concentration is recommended for administration.) OR

    • Diazepam 0.2 mg/kg IV OR 0.5 mg/kg PR (single maximum dose 2 mg/IV or 4mg PR).

Notes:

• PO (oral) and other non-core thermometers may be inaccurate when the temperature is outside the normal range.
• Elevated temperature may be due to environmental exposure, pharmacologic agents, or excited (agitated) delirium, see also Behavioral Emergencies Including Suicide Attempts (39 Medical) & Septic Shock Protocol (52/54 Medical) - Poisoning/Substance Abuse/ Overdose Protocol (20 Medical). Mortality and morbidity are directly related to the length of time the victim is subject to the heat stress.
• Sweating (or lack of sweating) is an unreliable indicator of the severity of heat illness.
• Of primary concern are the patient's vital signs and mental status.
• The patient's baseline health status and medications greatly determine the likelihood of developing and recovering from heart illness.
• The very young and very old are at greatest risk of heat illness
• For events with high risk of hyperthermia, consider having an ice bath available on scene.

Note: for Paramedics: Benzodiazepine doses for stopping shivering are lower than those for stopping seizures by approximately half.