Classic Heatstroke
Section 1: Case Summary
Scenario Title:
Keywords: Hyperthermia, Heat related illness, Classic heatstroke
83-year-old female brought in by ambulance found to be altered, febrile. The case
will progress to the diagnosis and treatment of heatstroke/ heat related illness.
Learners will be asked to manage a patient with heatstroke and review cooling
Brief Description of Case: techniques.
Goals and Objectives
Educational Goal: Diagnose and treat classical heatstroke
Objectives: 1. Perform a focused history and physical exam for a patient with
(Medical and CRM) hyperthermia and altered LOC.
2. Differentiate heat exhaustion vs heatstroke.
3. Initiate appropriate work up and monitoring for a patient presenting
with classical heatstroke.
4. Consider various cooling strategies and disposition of a heatstroke
patient.
5. Closed loop communication, role delegation, and situational
awareness
EPAs Assessed: F1: Initiating and assisting in resuscitation of critically ill patients
C1: Resuscitating and coordinating care for critically ill patients
Learners, Setting and Personnel
✘ Junior Learners ✘ Senior Learners Staff
Target Learners: ✘ Physicians ✘ Nurses RTs Inter-professional
Other Learners:
Location: ✘ Sim Lab ✘ In Situ Other:
Instructors: 1
Recommended Number
Sim Actors: 1
of Facilitators:
Sim Techs: 1
Scenario Development
Date of Development: Oct 22, 2023
Scenario Developer(s): Aneesha Thouli, Dr. Bradley Stebner
Affiliations/Institutions(s):
University of British Columbia
Contact E-mail:athouli@[Link]
[Link]@[Link]
Last Revision Date: November 10, 2023
Revised By:
Version Number:
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Classic Heatstroke
Section 2A: Initial Patient Information
A. Patient Chart
Patient Name: Helga Age: 83 Gender: F Weight: 65kg
Presenting complaint: Confusion/altered LOC
Temp: 41.3 HR: 150bpm BP: 95/65 RR: 22 O2Sat: 97% FiO2: N/A
Cap glucose: 11.2 mmol/L GCS: 12 (E3 V4 M5)
Triage note:
83 y/o F who lives independently in an apartment is brought in by EHS after being found down by healthcare aid
who checks on her once a day. She noted the patient to be very warm to touch and confused.
Allergies: none
Past Medical History: Current Medications:
HTN Metformin
DM2 Ramipril
CHF Bisoprolol
MI in 2018 Spironolactone
Furosemide
Insulin Glargine
Insulin Aspart
ASA
Section 2B: Extra Patient Information
A. Further History
Healthcare aid went to check on patient and give medications at supper time and reports that the patient said she
wasn’t feeling well with nausea, headache, and dizziness. She asked to sit down and then became progressively
confused. The co-worker thinks she may have had some convulsions or abnormal movements for 30 seconds and
remains confused. This is when she called EHS.
Healthcare aid notes the room was quite warm and there was no AC running, outside temperature is 37 degrees
Celsius during a heat wave. Patient took all her regular medications yesterday at supper time with the aid.
B. Physical Exam
List any pertinent positive and negative findings
Cardio: Tachycardia, strong central pulses but weak Neuro: AOx2 – not oriented to place, no focal neuro
peripheral. Hot, dry skin, mildly flushed. deficits but generally confused
Resp: tachypneic at rest, air entry equal bilaterally to Head & Neck:
bases. No wheeze or crackles
Abdo: soft, non-tender MSK/skin: no rashes, skin is dry and hot to touch
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Classic Heatstroke
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Classic Heatstroke
Section 3: Technical Requirements/Room Vision
A. Patient
✘ Mannequin (specify type and whether infant/child/adult)
✘ Standardized Patient (care-aid or nurse to provide further history)
Task Trainer
Hybrid
B. Special Equipment Required
Cooled IV fluids
Cooling adjuncts (avoid immersion in elderly/classic heatstroke, associated with higher mortality)
- Ice packs, cooling blanket, misting/sprays, soaked cloths
Crash Cart
C. Required Medications
IV fluids
Ice Packs
Midazolam/Lorazepam
D. Moulage
None
E. Monitors at Case Onset
Patient on monitor with vitals displayed
✘ Patient not yet on monitor
F. Patient Reactions and Exam
Patient will be slightly agitated and hard to direct to prompt use of IV Benzos.
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Classic Heatstroke
Section 4: Sim Actor and Standardized Patients
Sim Actor and Standardized Patient Roles and Scripts
Role Description of role, expected behavior, and key moments to intervene/prompt learners. Include any script
required (including conveying patient information if patient is unable)
EMS Gives background story:
83 yo F found by care-aid in warm apartment during the summer. Altered and hyperthermic.
No medication or intervention by EMS.
Nurse/ Provides further history:
Healthcare Aid
Went to check on patient at supper time and give medications and reports that the patient said
she wasn’t feeling well, nauseous, headache, dizzy. She asked to sit down and then became
progressively confused. The co-worker thinks she may have had some convulsions or abnormal
movements for 30 seconds and remains confused. This is when she called EHS.
The room was quite warm and there was no AC running, outside temperature is 37 degrees in
heat wave. Patient took all her regular medications yesterday at supper time with the aid.
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Section 5: Scenario Progression
Scenario States, Modifiers and Triggers
Patient State/Vitals Patient Status Learner Actions, Modifiers & Triggers to Move to Next State Facilitator Notes
1. Baseline State Laying in Expected Learner Actions Modifiers EHS has provided no care at this
Rhythm: sinus stretcher, Primary survey, identify Changes to patient condition based point including no IV access.
HR: 150 confused, dry skin, tachycardia and hyperthermia on learner action
BP: 95/65 complaining of Perform history and physical. - Initiate IV fluid bolus BP If missing POC glucose, can prompt
nausea improves to 110/75
RR: 22 Place patient on cardiac “isn’t she diabetic?”
O2SAT: 96% monitors. - POC glucose 11.3
T: 41.4oC Obtain POC glucose.
GCS: 12 Start crystalloid IV fluid bolus. Triggers
- Get POC glucose 2. Initial
Evaluation
2. Initial Evaluation Expected Learner Actions Modifiers Learners need to order
Rhythm: sinus Discuss hot and bothered -Patient BP and temperature investigations to r/o other potential
HR: 144 differential and initial improve with cooled IV fluids causes of altered LOC.
BP: 110/75 management plan with team.
RR: 18 Order basic labs, hepatic If team is struggling, prompt “is
O2SAT: 95% panel, coags, CK, TSH, serum tox there anything else we want to
T: 41.2oC and urinalysis consider that might be causing this?”
GCS: 12 Blood cultures
ECG Triggers
+/- Head CT - initial investigations completed
+/- Broad Spectrum Abx 3. Diagnosis
(Piptazo 3.375g IV)
3. Management Expected Learner Actions Modifiers Note: anti-pyrectics will be
Rhythm: sinus Review and interpret blood - Patient seizes if not aggressively ineffective as this is not a
HR: 126 work. cooled with temp increase back hypothalamic mediated
BP: 116/89 Identify need for cooling. to 41.8 dysregulation of temperature.
RR: 18 Initiate external cooling - If patient aggressively cooled
O2SAT: 97% (remove clothing, apply ice packs, drop temp to 39.8
T: 40.2oC misting)
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GCS: 13 Initiate core temperature Triggers
monitoring - If no aggressive cooling or
Initiate internal cooling with advanced learner 4. Seizure
refrigerated IVF. - Initiate aggressive cooling 5.
Disposition
4. +/- Seizure Patient is Expected Learner Actions Modifiers Seizure may be added if failure to
Rhythm: sinus agitated, Recognize status change - Continue seizure if no benzos recognize need for rapid cooling or if
HR: 140 shivering. Begins Progress to more advance given an advanced learner rapidly
BP: 114/79 to seize. cooling methods if not already - Stop seizure once 1-2 doses of progresses through the case.
RR: 18 done Ativan given
O2SAT: 97% IV Ativan 2-4mg repeated up - Reduce temp to 39.7 once Benzodiazepines can also be given
T: 41.2oC to 3 doses rapidly cooled for agitation to prevent excess heat
GCS: 12 generation
Triggers
- seizure treated and patient
cooled 5. Disposition
5. Disposition Patient is GCS Expected Learner Actions END CASE Patients will need ongoing
Rhythm: sinus 14, shivering, Call ICU or RAU monitoring and cooling.
HR: 114 calm Ongoing core temperature
BP: 110/78 monitoring and cooling
RR: 18 Symptom management
O2SAT: 97%
T: 39.6oC
GCS: 13
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Appendix A: Laboratory Results
CBC Cardiac/Coags
WBC 12.7 hsTroponin 235
Hgb 155 D-dimer 20
Plt 290 INR 2.5
aPTT 24
Lytes
Na 127 Biliary
K 4.8 AST 945
Cl 98 ALT 1,212
HCO3 15 GGT 465
AG 14 ALP 680
Urea 6.0 Bili 30
Cr 230 Lipase 290
Glucose 9.2
Tox (all undetectable)
Extended Lytes EtOH
Ca 2.20 ASA
Mg 0.85 Tylenol
PO4 0.95
Albumin 38 Other
TSH 4 B-HCG N/A
VBG (lactic acidosis)
pH 7.33
pCO2 40
pO2 65
HCO3 18
Lactate 5
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Appendix B: ECGs, X-rays, Ultrasounds and Pictures
Paste in any auxiliary files required for running the session. Don’t forget to include their source so you can find them later!
([Link]
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Appendix C: Facilitator Cheat Sheet & Debriefing Tips
Include key errors to watch for and common challenges with the case. List issues expected to be part of the debriefing discussion.
Supplemental information regarding any relevant pathophysiology, guidelines, or management information that may be reviewed
during debriefing should be provided for facilitators to have as a reference.
Questions for Discussions/Debrief
1. What is your differential for hot and altered patients?
2. How do you differentiate exertional heatstroke vs. classical heatstroke?
a. Classical heatstroke has a much higher mortality and several key laboratory and clinical differences
to discuss
3. What are the clinical manifestation and treatment differences between the two?
a. Ice bath submersion is not recommended in classic heatstroke and associated with higher mortality
in elderly patients
b. Evaporative and convective cooling should be primarly method of cooling
c. Vasopressors are not recommended in heatstroke, fluids are first line for hypotension
d. Benzodiazepines treat agitation, seizures, and reduce body heat generation.
4. Which patients are at highest risk for heat related illnesses?
5. Describe a few methods of rapidly cooling a patient suffering from heat illness.
6. How are these practically carried out in your Emergency Department and are there protocols in place?
References
1. Platt, MA., & Price, TG. Heat Illness. In: Walls RM, Hockberger RS, Gausche-Hill M, Erickson TB, Wilcox SR, editors.
Rosen’s Emergency Medicine: Concepts and Clinical Practice. [Internet]. 10th ed. Philadelphia (US): Elsevier; 2023.
[cited 2023 Oct 2]. Chapter 129. Available from: [Link]
C20181032357
2. Farkas, J. Hyperthermia & Heat Stroke. Internet Book of Critical Care. [Internet]. EMCrit Project; 2021. [cited
2023 Oct 2]. Available from: [Link]
3. Burns, E., & Buttner, R. Sinus Tachycardia. Life in the Fast Lane. [Internet]. 2021 [cited 2023 Oct 2]. Available
from: [Link]
4. Rodrigues, S. Heat Stroke. EM Docs. (2020) [Link]
%20characteristics%20define%20heat%20stroke,of%20other%20causes%20of%20hyperthermia.
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