This is a transcript of a Dr. Jay Show broadcast on 1560TheGame. Dr. J. Michael Bennett is a Board Certified Orthopedic Surgeon and a Fellowship Trained Sports MedicinePhysician serving patients from Katy, Fort Bend County, Metro Houston and Southeast Texas from offices in Richmond and Sugar Land, TX. Call 281-633-8600 for an appointment. Our special guest today is Dr. Terence Chang, a family practice physician Board Certified in Sports Medicine from Physicians at Sugar Creek in Sugar Land, TX. Bob Lewis, from 1560TheGame, is also participating.
Here’s the transcript of the sixth portion of the Show:
BENNETT: I think that it’s key that we break this all down for you and I want to go into each type of heat illness there is out there and what to look for and how to determine one from another and which ones are really dangerous to the point of a fatality could be a result. Heat syncope. This is what our caller, Sarah, was mentioning earlier in the show when she talked about her son getting dizzy and passing out at a game. The way I look at it is when the body does not acclimatize right and the blood vessels do not react appropriately, you pass out. And so Dr. Chang you can go ahead and give us your take on heat syncope.
CHANG: Basically what you’ve got with heat syncope is a combination of the heat and dehydration working together. Heat, what it does, is it vasodilates, it causes the blood vessels in your body to get larger in terms of their caliber. Part of it is to deliver more blood so you can also increase your circulation and because of that you get some of the blood to pool and so what happens is when these kids or adults are out there in the heat and they’re doing whatever they’re doing, all of a sudden they feel lightheaded, have a headache and feel kind of like they want to pass out. And you’ll see that these people kind of walk around and try to find some water but when they stand still they feel really, really lightheaded. The way that we teach our med students and residents to recognize the differences between heat syncope and say, cardiac arrhythmia, is that with cardiac arrhythmia, the athlete is running and doing their activity and right in the middle, in the middle of doing that activity, they hit the ground and they’re out; they don’t even protect themselves, their arms don’t go out to hold themselves and they just hit the ground. That’s because of their heart. If they are running and they’re doing their activity, playing sports, and then they stand still and walk and get some water, when they stand still is usually the time when you see them kind of sway, so they’re still with it and then slowly they start to pass out. And part of that, with heat syncope, your body is used to pumping, your muscles are working to pump the blood all the way around, so when you’re standing still the blood pools and all of a sudden you don’t have any blood flow going to the head.
BENNETT: And basically as a parent if you see this happening, the first thing you want to do is make sure of the ABCs – Airway, Breathing, Circulation. Make sure to lay them down, prop their legs up, make sure they’re getting air and getting blood flow back to the brain, and make sure that they’re cooling off; get them some water or something like that. Heat exhaustion. And this one is actually dehydration, high temperatures, high humidity, usually this means when you lose about 10 percent of your bodyweight through perspiration – so you’re losing a lot of fluid from sweating. Dr. Chang can you go ahead and discuss heat exhaustion and how serious this is?
CHANG: The hallmark sign for heat exhaustion is fatigue. So fatigue is your body’s way of protecting you from doing activity it was not meant to do in the first place. So people with heat exhaustion what they’ll have is headache, weakness, dizziness, a lot of times they’ll feel nauseous, and some kids and even adults will throw up though other kids and adults are actually a little more subtle. You’ll find that they get a little bit more irritable, their mood changes, or you’ll find that they have what you call loss of coordination, but it’s not that they’re tripping or falling all over the place but you’ll notice they’re not throwing the ball as good as they used to or you’ll notice that they’re getting more prone to injury, they’re spraining their ankles more and more. If that’s happening in the setting of being outdoors and in the heat, heat exhaustion could be one of the reasons why.
BENNETT: Vomiting is a big issue because that also speeds up dehydration, you’re losing more fluid. So heat exhaustion is primarily when you’re sweating a lot, you’re sweating a lot of volume, and you get nauseous and you start throwing up, that leads to faster dehydration and at that point an I-V is necessary. They definitely need to get either an EMS or a physician or somebody to put in an I-V to get fluids back into the system and treat them in a cool place. Heat cramps. And we talked about that briefly and I think this is very common and we see this all the time on the sidelines especially in this heat. The players get out there and they run and they fall over and they’re grabbing their leg or calf and they’re cramping. And this actually happens a lot; they have higher sweat loss and they lose more sodium so they’re basically losing a lot of their electrolytes and that puts the muscle into spasm. And that’s why I mentioned the whole pickle juice thing and the electrolyte thing. You want to make sure that the electrolytes are balanced. But nowadays you hear a lot more about the creatine aspects and some of the supplements. Dr. Chang, do you think the creatine plays a role regarding heat cramps at all?
CHANG: Absolutely. What creatine does is it makes the muscles in your body bulkier. It doesn’t make you, per se, stronger – now it can make you stronger if you’re say a powerlifter or if you’re doing a huge amount of weights – but one of the side effects of creatine is that it also draws fluid away from the circulatory system and into the muscle. And so that’s what gives you that look, that cosmetic look of making you look a little bit bigger or “swole.” So one of the things with creatine, though, is that it does lead to some aspect of dehydration and because of a larger muscle bulk, it’s harder for that muscle to dissipate heat. And the muscle is metabolically active, so it’s creating a lot of heat while it’s in use.
BENNETT: So can you elaborate a little bit on that? I know in the news, I think it was about a year ago, these football players all went to the hospital, were admitted, and they had I guess a compartment syndrome where their muscles were so tight that they actually had to have surgery to release the compartments and so they could get adequate blood flow to their legs because it was impeding the blood flow. So then I think they found the common link amongst all those kids was the fact that they all were taking creatine. Is that correct, Dr. Chang? Do you remember hearing about that story?
CHANG: I actually had a couple that were admitted into our service for that.
LEWIS: Does that do permanent damage to the muscle when that happens?
CHANG: When the muscle breaks down? Usually the muscle will heal; I mean, they do recover. But there is a point of irreversibility. There’s a point where the muscle breaks down so much that the muscle enzymes actually become toxic to the kidneys because the kidneys serve as a filter for the circulatory system. So if there are enzymes and things in the blood that are usually not there, for example a broken down muscle, it can actually be harmful to the kidneys. So on these kids, we do high amounts of I-V fluids, and luckily this kid did not have to be on dialysis.
BENNETT: There’s not a lot of orthopedic emergencies but compartment syndrome is one of them. So compartment syndrome, like we mentioned before, is basically when you go out and you can either get it through trauma, so like if you have bleeding in that muscle and that muscle continues to bleed and it gets very, very tight onto that leg and it actually closes off the blood supply to the foot or it compresses that nerve and at that point we have to take them immediately to surgery so we can release that muscle so it can breathe again and so the blood flow gets back to it. Otherwise the nerves degrade, the muscle dies and it loses its functional ability and I’ve seen a couple of very big problems where these were missed in certain athletes and they show up later and it could be a disaster if the muscle’s dead. Because then you have to do tendon transfers and things like that to get that function back in that leg. So it’s key that they see a surgeon or a doctor immediately if there’s any problems and that doctor can do what’s called a compartment measurement, where we actually take a needle, put it into that muscle, to see how much pressure is in that muscle, and determine if that needs to be released. So that’s actually a big issue in orthopedics in regards to where emergencies are concerned. And so I think it’s key. Now when Dr. Chang mentioned also the other side effect which is something called rhabdomyolosis, and basically what happens is the byproduct of the muscle breaks down and it actually destroys the kidney. It basically clogs it up.
Heat stroke. Dr. Chang, my impression of heat stroke is basically the body loses its ability to sweat, and throws everything else off, and so you don’t sweat and you’re building up all this core temperature and it can actually become something devastating and fatal if you don’t get it treated early.
CHANG: Heat stroke is everything that you see with heat exhaustion, so the fatigue, the weakness … it’s everything that you see with heat cramps, but the biggest difference is their mental status. So with heat stroke, the central nervous system, the brain, goes off. So these kids will be incoherent, they’ll be doing things, doing things that are totally irrational – rather than seeing them throw the ball you’ll see them kind of off to the side doing their own thing – and when you talk to them, they’re nonsensical, they don’t make sense. I mean, most teenage boys talk a bunch of nonsense anyway, but this is different from that. They’re actually totally out of it. And when they’re totally out of it, this is actually a true emergency.
BENNETT: It’s definitely the presentation that makes the difference like Dr. Chang mentioned, they’re hot, dry-skinned, have headaches, dizziness, nausea, confusion, a rapid pulse, they definitely look like they’re sick. And there are actually ages when you are more prone to heat stroke. And that’s kids under the age of four, and adults greater than the age of 65. Also at higher risk are patients that are overweight, or patients that are on the medications that we mentioned before. So those are all things to kind of take into consideration.
BENNETT: So in regards to treating all of these, you’ve got to make sure that you cool the patient off rapidly. And I think that there’s a misconception because a lot of people will think that you should emerge them in an icebath or something like that, but you can actually send the body into shock if you do that because it may increase your core temperature because what happens is you sit a patient in an icebath, you create vasoconstriction, which means that the body has a harder time getting rid of that heat from the core and then it also causes shivering which creates more heat so you’ve actually done more of a disfavor. What you want to do is in a controlled fashion put ice bags in areas where there’s large blood vessels like in the armpits, the neck, kind of throughout the body and make sure you wet the skin with water and use evaporative cooling, which means that you blow air around these areas of the skin. Then, if necessary, you can use some I-V fluids to cool off the body as well.
CHANG: The rapid cooling bath, you would use it in a situation where like let’s say your temperature is 106. You would use it until you bring them down to 104. But if your temperature is less than 104, let’s say you’re like 102, then you would use the ice packs. But the bath is appropriate if they’re so hot you need to bring them down quickly. If they’re sort of in the middle, in the middle range and they’re just kind of feeling the exhaustion, you could use the ice packs.
If you have questions about the prevention or treatment of heat illnesses, please call our office at 281-633-8600 for an appointment.
