We have to agree on the definition before we can discuss treatment. Many different definitions and opinions exist out there. Fort Benning has taken the lead on research and committees to help shape these opinions.
It happens all the time. You go to the field and a dude passes out. No one knows what to do. You preach hydration. But will that really help? What do you do now?
As I said, Fort Benning has been leading the way by holding annual heat conferences and bringing in speakers from all over the US and Britain, and by bringing in the Army research teams. The U.S. Army Ranger School has been testing prevention and treatment methods, and they’ve conducted a few studies themselves. As you probably know, Ranger school sees a lot of heat casualties. The stats below were collected from the Emergency Room at Fort Benning.
Heat Casualties for Fort Benning in 2019
- Heat Strokes: 74
- Heat Injuries: 23
- Exercise Associated Hyponatremia: 8
There have been several cases over the last decade of heat injuries and hyponatremia that resulted in death at Fort Benning, GA. These deaths highlight the importance of prompt recognition and treatment of heat related injuries.
I’m always amazed when I meet a leader who has never heard of ice sheets; it still happens from time to time. But did you know that there are other options. Did you know other things are being done?
One of the big issues is that various training centers and military installations have differing definitions of a “heat stroke” or a “heat injury.” We can’t even agree on apples to apples to know how extensive the problem is and if there is a trend. And we can’t decide on a standard treatment either. Below is a table of heat illnesses at different installations. But remember, they don’t all define it the same way!
Definitions As Proposed by Fort Benning
- Exercise-Induced Muscle Cramps (Heat Cramps)
- Brief, recurrent, agonizing skeletal muscle cramping of the limbs and trunk
- May be due to electrolyte loss and/or fatigue
- Not believed to pre-dispose to serious heat related illness
- Consider adding electrolytes and/or rest
- Heat Edema:
- Dependent extremity edema (hands and feet) owing to venous and interstitial fluid pooling
- Loosen clothes, elevate legs
- Self limited
- Often confusing and difficult to be certain of diagnosis as other more serious conditions can result in single limb edema. However, in the setting of heat exposure in a young individual without other medical problems, it may be easier to diagnose
- Heat rash
- Red papules, or sometimes vesicles, found in areas where sweat is often trapped.
- This heat obstructed rash cannot fully participate in sweating and evaporative cooling. The patient may be pre-disposed to heat injury until clears, due to inability to effectively dump heat
- Often responds to cooling, removing tight or occlusive clothing, limiting sweating, and sometimes use of Hydrocortisone cream (1% typically used)
- Sunburn
- Pre-disposes to heat injury for same reasons as heat rash- ineffective heat dumping
- Treat pain with Tylenol/NSAIDs. Avoid sunlight. May also use zinc cream or ointment, aloe, or cool compresses
- Heat Exhaustion
- Symptoms include fatigue, dizziness, headache, nausea, tachycardia, hyperventilation, headaches.
- No Altered mental status!
- Treatment would usually consist of cessation of activity, cooling, removal from the heat, and expeditious cooling to prevent progression to more severe heat illness
- Exertional Heat Injury
- A Heat illness of Heat Exhaustion or heat stroke that results in any end- organ damage.
- Liver enzymes may be elevated, cardiac enzymes may be elevated, creatinine may be elevated, etc. Often damages the brain, heart, gut, liver, kidneys, and skeletal muscles
- A Heat illness of Heat Exhaustion or heat stroke that results in any end- organ damage.
- Exertional Heat Stroke
- Similar symptoms to heat exhaustion, but with altered mental status
- combativeness, delirium, obtundation, or coma
- Must treat with rapid cooling and cessation of heat stress.
- Rectal temperature is often greater than 104 degrees F.
- Similar symptoms to heat exhaustion, but with altered mental status
These definitions were proposed last year at the Heat Forum at Fort Benning, by Dr. Max Bursey, DO. I have borrowed that information from the author in order to present it here, with permission. I will post the full slides on my next post.
The presenters often advised that Heat related illnesses are not well defined in the literature. They also emphasized that heat related illnesses should be thought of as a spectrum and not strict defined definitions; there is bleed over. We cannot devise too strict of definitions. Not until this is better understood with analyzed data.
The committee did develop protocols and algorithms, however. And these algorithms have been used for a few years now at Fort Benning. I believe that they are very helpful and practical. I have used them at my own FTXs. I teach this to all my medics. They seem to work well.
I cannot usurp your provider or designated medical supervision, but I do believe that this protocol should be presented to your leadership for adoption. It was developed as a committee amongst several physicians, medics, nurses, and mid-level providers. It is now the Maneuver Center of Excellence heat policy. I have some screenshots of the algorithms below, and the entire policy is in the link below for download (pdf).
Screenshot of Heat Algorithm for Untrained/CLS
Screenshot of Heat Algorithm for 68Ws
Does hydration really help? Is this the main issue? The Benning docs would argue it is not. Adequate proper hydration is important. However, over-hydration is also a problem, too. The next post will focus on more of this topic, as well as a PowerPoint that you can use to conduct your own internal hot weather/heat injury training for your unit.
CLICK HERE TO GO TO “HEAT INJURIES (CONTINUED) POST. This post includes more info, thoughts, pictures, and presentations on the topic.
All content is intended to be educational only. Medics should operate under the supervision of a medical provider and abide by all local laws while stateside. Medics should only practice at the level credentialed, and only at the level allowed. This content is not intended to treat or give a substitution for any credentialed provider. Content is intended to aid in a deployed prolonged care setting. Take guidance from your leaders. Utilize these posts as preparation and as a supplement to your provider’s direction and teaching.
This content is the author’s opinion alone and does not necessarily reflect the opinion, official position, or stance of the Department of Defense, or any other branch of the United States Military.