Select ALL that apply

1. ALOC – Not Hypoglycemia or Seizure (ALOC)
2. Alcohol Intoxication (ETOH)
3. Hyperthermia (HEAT)
4. Overdose/Poisoning (ODPO)

Explanation:

• Given the history and presentation – an altered patient found on a hot day with normal blood glucose, with reported history of drinking alcohol and using methamphetamines, all of the above are possible Provider Impressions.

Since you are considering multiple Provider Impressions, with potentially different treatments, you consider ways to differentiate between these conditions and astutely decide to check her temperature. She is unable to cooperate with oral temperature checks due to her confusion; but you measure her temperature in her armpit (axilla) as 103.8 °F (39.9 °C). You and your partner conclude that the patient is experiencing hyperthermia. Her axillary temperature is 103.8 °F (39.9 °C) but having read this EmergiPress, you recognize that axillary and oral temperature checks often underestimate “core” body temperature (which is recorded by rectal or esophageal monitoring). An initial rule of thumb is that the axillary and oral temperature should be assumed to be 0.5°C (1°F) below the patient’s core temperature. You remember that Hyperthermia with a core temperature at or above 40C (104F) + Altered Mental Status = Heatstroke, a life-threatening condition.

Safety personnel from the venue confirm with their on-site medical team that there is an ice bath available in the first aid/medical area of the festival venue. After considering rapid transport or on-scene cooling, you decide to cool the patient in the on-site ice bath. The patient is immersed from the chest down, and her airway is monitored closely.

The patient’s hyperthermia was caused by multiple contributing factors including outdoor temperature,  choice of activities, and intoxication. She recently used methamphetamine—a drug classically associated with increased heat production and dysregulation. Any one of these factors may result in hyperthermia and, in this case, the excessive physical activity, hot environmental conditions, and intrinsic temperature elevation from the drug itself led to a dangerous elevation in body temperature. The circumstances allow you to differentiate this environmental hyperthermia from fever with sepsis.

When body temperature exceeds extreme levels—particularly above 104 °F (40 °C)—the body can lose the ability to regulate its own temperature, allowing it to continue rising unchecked. The body’s cellular and biochemical processes require a specific temperature range; if this range is exceeded, cellular function fails and permanent damage may occur. Heat stroke, defined as a core temperature at or above 104 °F (40 °C) with altered mental status, is associated with a mortality of up to 20% if not treated rapidly, as well as temporary and permanent damage to the brain, kidneys, and liver.

There are many methods available to cool a patient, but data suggest that the most effective technique is immersion in cold or ice water. This method provides the greatest skin surface area that is in contact with cold water, allowing for the most efficient heat transfer and fastest cooling.

Other commonly used but much less effective methods include the application of cold towels, misting with cool water and fanning, and ice pack placement. While these can be suitable for patients with heat exhaustion or heat cramps (that is, patients with elevated temperature but a normal mental status), they are not fast enough to be appropriate for those experiencing true heat stroke.

The patient’s temperature is rechecked after 10 minutes of cold water immersion and is found to be 37.8 °C. (100°F)

Question: What should your next step in treatment be?

Continue ice water immersion
Initiate transport to the MAR
Remove from ice water and reassess
Both B&C

Explanation: Once the patient’s core temperature decreases to below 38.3 °C. (101°F) the patient should be removed from cold water immersion and reassessed. She is now sufficiently cooled and out of the danger zone (> 40 °C). Rechecking vital signs and evaluating her mental status should be done at this point. Improvement in mental status would confirm the diagnosis of hyperthermia and demonstrate appropriate response to treatment. However, given her alcohol and methamphetamine intoxication, it would not be surprising for her to have continued confusion.

Other potential treatments and interventions would include administering 1L Normal Saline IV, performing a 12-lead ECG to evaluate further for arrhythmia or ischemia, and treating a dysrhythmia as appropriate.

After the patient’s temperature is rechecked and she is removed from the ice water immersion, you initiate transport to the MAR. The patient’s vital signs are improved, and her GCS is now 14 (E4V4M6). In the ED initial laboratory results indicate mild renal injury and increased CK concerning for rhabdomyolysis (a common complication of heat stroke). Additional IV fluids are continued in the hospital and she is admitted for observation and rehydration. After a brief hospital admission, her laboratory values normalize and she is discharged home with a normal neurological outcome and no permanent organ injury.

• Hyperthermia with body temperature at or above 40C (104F) + Altered Mental Status = Heatstroke, a life-threatening condition with up to 20% mortality.
• Check temperature on patients with altered mental status who are hot to touch or at risk for heat related injury. Unrecognized heatstroke is not uncommon.
• Cold water immersion results in the fastest rate of cooling in patients with heat stroke.
• For patients with heatstroke, cooling should be initiated on scene if possible – cooling significantly in the first 30 minutes of care is associated with the best outcomes.

Adnan Bukhari H. A Systematic Review on Outcomes of Patients with Heatstroke and Heat Exhaustion. Open Access Emerg Med. 2023 Sep 22;15:343-354. doi: 10.2147/OAEM.S419028. PMID: 37771523; PMCID: PMC10522494.

Craig JV, et al. Temperature measured at the axilla compared with rectum in children and young people: systematic review. BMJ. April 29, 2000;320:1174-8.

Douma MJ, Aves T, et al.; First Aid Task Force of the International Liaison Committee on Resuscitation. First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis. Resuscitation. 2020 Mar 1;148:173-190. doi: 10.1016/j.resuscitation.2020.01.007. Epub 2020 Jan 22. PMID: 31981710.

Harris M, DiCorpo JE, Merlin MA. Evaluating Temperature is Essential int eh Prehospital Setting. Journal of EMS. 2017 Nov 1. Accessed  July 18, 2025 at https://www.jems.com/patient-care/emergency-medical-care/evaluating-temperature-is-essential-in-the-prehospital-setting/

Matsumoto RR, Seminerio MJ, et al. Methamphetamine-induced toxicity: an updated review on issues related to hyperthermia. Pharmacol Ther. 2014 Oct;144(1):28-40. doi: 10.1016/j.pharmthera.2014.05.001. Epub 2014 May 14. PMID: 24836729; PMCID: PMC4700537.