Management of Heat-Related Illness and Injury in the ICU: A Concise Definitive Review

OBJECTIVES

The increasing frequency of extreme heat events has led to a growing number of heat-related injuries and illnesses in ICUs. The objective of this review was to summarize and critically appraise evidence for the management of heat-related illnesses and injuries for critical care multiprofessionals.

DATA SOURCES

Ovid Medline, Embase, Cochrane Clinical Trials Register, Cumulative Index to Nursing and Allied Health Literature, and ClinicalTrials.gov databases were searched from inception through August 2023 for studies reporting on heat-related injury and illness in the setting of the ICU.

STUDY SELECTION

English-language systematic reviews, narrative reviews, meta-analyses, randomized clinical trials, and observational studies were prioritized for review. Bibliographies from retrieved articles were scanned for articles that may have been missed.

DATA EXTRACTION

Data regarding study methodology, patient population, management strategy, and clinical outcomes were qualitatively assessed.

DATA SYNTHESIS

Several risk factors and prognostic indicators for patients diagnosed with heat-related illness and injury have been identified and reported in the literature. Effective management of these patients has included various cooling methods and fluid replenishment. Drug therapy is not effective. Multiple organ dysfunction, neurologic injury, and disseminated intravascular coagulation are common complications of heat stroke and must be managed accordingly. Burn injury from contact with hot surfaces or pavement can occur, requiring careful evaluation and possible excision and grafting in severe cases.

CONCLUSIONS

The prevalence of heat-related illness and injury is increasing, and rapid initiation of appropriate therapies is necessary to optimize outcomes. Additional research is needed to identify effective methods and strategies to achieve rapid cooling, the role of immunomodulators and anticoagulant medications, the use of biomarkers to identify organ failure, and the role of artificial intelligence and precision medicine.

Temperature Profiles of Sunlight-Exposed Surfaces in a Desert Climate: Determining the Risk for Pavement Burns

Plentiful sunlight and high temperatures in desert climates cause burn injuries from contact with sun-exposed surfaces. The peak temperature, times, and surfaces of greatest risk are not well described. This work recorded temperature measurements of six materials in a desert climate. Surface temperatures of asphalt, brick, concrete, sand, porous rock, and galvanized metal were measured throughout the summer, along with ambient temperature, and sunlight intensity. Samples were placed in both shade and direct sunlight for evaluation of sunlight effect. Seventy-five thousand individual measurements were obtained from March to August 2020. Maximum recorded temperatures for sunlight-exposed porous rock were 170°F, asphalt 166°F, brick 152°F, concrete 144°F, metal 144°F, and sand 143°F, measured on August 6, 2020 at 2:10 pm, when ambient temperature was 120°F and solar irradiation 940 W/m2. Sunlight-exposed materials ranged 36 to 56°F higher than shaded materials measured at the same time. The highest daily temperatures were achieved between 2:00 and 4:00 pm due to maximum solar irradiance. Contour plots of surface temperature as a function of both solar irradiation and time of day were created for all materials tested. A computational fluid dynamics model was created to validate the data and serve as a predictive model based upon temperature and sunlight inputs. This information is useful to inform the public of the risks of contact burn due to sunlight-exposed surfaces in a desert climate.

Management of Pediatric Pavement Burns

Pavement burns are common in a dry high heat climate. This study reviews the etiology, management, and outcome pavement burns in children. All patients age <18 who sustained contact burns from hot pavement from January 1, 2014 to December 31, 2019 were reviewed for mechanism, medical history, treatment course, and outcome. The high ambient temperature on each date and zip code of each injury were extracted from Weather Underground (www.wunderground.com). In this study, 45 patients met criteria and were reviewed 27 patients (60%) were male. Average age was 3.29 years (SD 0.69), made up two discrete age groups: age 3 years and under (n = 40, 89%) and older patients 14 years of age and up (n = 5, 11%). Thirty-eight patients (84%) had no known medical history. All had second-degree burns and one patient (2%) also had third-degree burns. Mean TBSA was 2.5% (SD 1.4%, range 0.75%-5.5%). Burn etiology included 31 patients (69%) who were walking barefoot on pavement, six (13%) who fell onto pavement, one (2%) seizure, and other/unknown etiology for the remaining seven patients (16%). Thirty patients (67%) had injuries on the plantar aspect of the bilateral feet, two (4%) to bilateral palms of hands, four (9%) to other parts of upper extremities, and 10 (22%) to other parts of lower extremities. Thirty-four patients (76%) were managed without any hospitalization. Those that were hospitalized had an average length of stay of 2.72 days (range 1-9 days). All burns were managed nonoperatively with topical therapy alone. Thirty-four patients (76%) were managed initially with silver sulfadiazene alone and six (13%) with bacitracin alone. Aquacel dressing was utilized in 10 patients at a follow-up visit (22%). Three patients (6.7%) were treated with collagenase enzyme therapy at some point in their care. One patient developed a superficial infection requiring oral antibiotic therapy. There were no mortalities in this group. High ambient temperature on date and location of each injury was 102.1°F (SD 5.4°F, range 89-111°F). Of the 30 patients that continued to follow up in clinic the average time to the burn being 95% healed was 10.50 days (SD 8.97 days, range 2-40 days). Pavement burns in children are partial thickness and are safely managed with topical therapy alone with good outcomes. Patients age 3 and under are at high risk.

Pavement Burns in New Mexico: Our Experiences, Treatments, and Outcomes

INTRODUCTION

This study focused on patients treated at the University of New Mexico Burn Center who sustained burn injuries from contact with environmentally heated pavement. We report on our patient demographics and outcomes as well as describe our institutional staged surgical approach to treatment. We provide a comparison of our results with other case reports as well as other findings.

METHODS

A retrospective review of patients admitted to the University of New Mexico Burn Center with injuries suffered from contact with hot pavement was performed. Patients were stratified on the presence or absence of altered mental status (AMS) and additional inciting factors. A total of 6 patients were reviewed from 2018 to 2019. We looked at patient demographics and comorbidities, time of contact with hot pavement, inciting factors, total body surface area (TBSA) burned, location of areas burned, depth of burn injury at the time of presentation and at the time of initial operative debridement, percentage of autograft take, complications, length of stay (LOS), and final disposition.

RESULTS

The patients in our study had a mean TBSA of 9.82% corresponding to pressure points of the body. All patients had nearly 100% conversion to full-thickness burns at the time of initial operative debridement. With staged excision and split-thickness autografting, our patients had nearly 100% take of their skin grafts with minimal graft loss or related complications. At the time of presentation, 100% of patients had AMS and 66% (4/6) had a drug or alcohol related inciting event. Finally, the average LOS was 19.5 days in comparison to 7-9-days for uncomplicated burns of equivalent size at our burn centre.

CONCLUSION

Despite an initial appearance of a partial-thickness burn, pavement burns had a high propensity to convert to full-thickness burns. Patients with AMS contributed to our patient population being found with pavement burns. Patients with pavement burns had a distinct anatomic pattern corresponding to pressure points of the body which were often areas at high risk for skin and wound breakdown and complications. Staged excision and split-thickness autografting in the treatment of pavement burns yielded excellent results. Finally, our data showed that providers must be prepared for an extended LOS for patients with pavement burns.