Chapter 7: Heatstroke

What Can Happen

Hot weather has gone on for several days and nights. A care worker arrives for a morning visit and finds the woman she supports still in bed, with the curtains open and the window closed. The bedroom feels heavy and hot. The woman, who is usually chatty, does not seem to know who the care worker is. The woman's face is red, her skin feels very hot to the touch, and her words come slowly and do not make sense. The care worker feels a moment of fear. Then she remembers what she practised in her course: this could be heatstroke, and the next few minutes matter.

This chapter explains heatstroke as the emergency it is. It shows why heatstroke can develop quickly in older people, even at home. It gives the steps of first aid in order: calling the emergency number, moving the person somewhere cool and cooling the body as fast as you can with whatever you have. It then explains how to watch the person while you cool, and what to tell the paramedics when they arrive. Chapter 6 described how the body keeps cool and how to help a person with heat exhaustion; this chapter starts where heat illness becomes something more serious.

A Life-Threatening Emergency

Heatstroke happens when the body can no longer control its own temperature. The ways it normally loses heat, such as sweating and sending more blood to the skin, stop working well enough, and the temperature inside the body keeps rising. Heatstroke usually means a body temperature of about 40 °C (104 °F) or higher, together with changes in behaviour or consciousness. At that temperature the brain and other organs begin to be harmed. Without fast cooling, heatstroke can cause lasting damage or death, so it is always an emergency.

The signs that matter most are changes in how the person thinks and acts. The person may be confused, agitated, unusually drowsy or hard to wake. The person may say strange things, not know where they are, stumble or collapse, and speech may be slurred. Some people have a seizure. The skin is usually hot and may be red; it may be dry, but it can also be wet with sweat, so sweating does not mean that all is well. Breathing and the pulse are often fast, and the person may have a headache, feel sick or vomit. In a hot setting, treat any change in behaviour or consciousness as heatstroke until a professional tells you otherwise.

In young, active people, heatstroke often comes on during hard work or sport in the heat. In older people, it often develops in a different way. It can build up quietly over a day or a few days of hot weather, indoors, in a home that does not cool down at night. An older person may not feel thirsty, may not notice that the room is too hot, or may not be able to open a window, move to a cooler room or ask for help. Some health conditions and some medicines also make it harder for the body to cope with heat, as Chapter 6 explained. For these reasons, a person you support can go from looking tired to being seriously ill in a short time, and the first sign you see may be confusion.

Heatstroke is not the moment to wait and see. If the person has any sign of heatstroke, or if you are not sure whether it is heat exhaustion or heatstroke, call the emergency number and start cooling. You do not need to measure the person's temperature before you act; the changes in behaviour are enough. If your workplace uses a thermometer, a reading can help the paramedics later, but never let looking for one delay the call or the cooling. Acting early is always better than acting late, and cooling that starts at once gives the person the best chance of a full recovery.

Step by Step: First Aid for Heatstroke

Step 1. Call the emergency number at once, or ask someone nearby to call while you begin to help. Put the phone on speaker so that your hands stay free. Tell the operator that you think the person has heatstroke, describe the changes you have seen and say where you are, as Chapter 2 explains. If you are alone with the person, make the call first, then start cooling while the operator stays on the line.

Step 2. Move the person out of the heat to the coolest place you can reach safely. Indoors, this may be a room with air conditioning, a shaded room with a fan, or the coolest part of the home; outdoors, it is the nearest deep shade. Do not try to lift or carry the person on your own if that could cause a fall or hurt either of you. If the person cannot be moved safely, bring the cooling to the person instead: close the curtains, open the windows if the air outside is cooler, and turn on any fan or air conditioning.

Step 3. Remove extra clothing so that the skin can lose heat. Take off heavy layers, blankets, shoes and socks, and loosen anything tight around the neck and waist. Explain what you are doing in a calm voice, even if the person seems not to understand. Protect the person's dignity by covering the body with a thin, wet sheet or towel rather than leaving the person uncovered.

Step 4. Cool the person fast with whatever is available. Pour or spray the coolest water you have over the skin, especially on the head, neck, chest, arms and legs, and fan the wet skin at the same time, because moving air over wet skin carries heat away quickly. Wet towels or sheets laid over the body also work well if you soak them again often, before they grow warm. If you have cold packs or ice, wrap them in a cloth and place them at the neck, in the armpits and in the groin, where large blood vessels lie close to the skin. Never put ice directly on bare skin.

Step 5. Use cold water immersion only where it is available and safe, and where the courses where you live teach it. Placing the person's body in cold water up to the neck is the fastest way to cool, but it needs enough helpers to support the person, keep the head above the water and lift the person out safely. It is often not practical for a frail person or in a small bathroom. Never leave a person alone in water. When immersion is not possible, keep going with water, wet cloths and fanning; any cooling is far better than none.

Step 6. Decide carefully about drinks. If the person is confused, drowsy or cannot swallow safely, give nothing to drink, because the drink could go into the airway. Most people with heatstroke are in this state, so in most cases you will give nothing by mouth. Only if the person is fully alert and can swallow safely may you offer small sips of cool water, following any guidance in the care plan about drinks and swallowing.

Step 7. Keep cooling without stopping until the paramedics take over. Heatstroke does not get better on its own once the person is in the shade, and a person who seems a little calmer can still be dangerously hot inside. Keep the skin wet, keep the air moving, and change the cold packs and wet cloths as they warm. Tell the operator if anything changes, and follow the operator's instructions.

Step 8. Be ready for the person to become unresponsive. If the person stops responding but is breathing normally, place the person in the recovery position, as Chapter 3 explains, and go on cooling. If the person is not breathing normally, start CPR as Chapter 4 explains and tell the operator; if others are with you, one helper can give CPR while another keeps cooling where that is possible. If the person has a seizure, protect the person from injury as Chapter 13 explains, and cool again as soon as the seizure stops.

Step by Step: Watching the Person While You Cool

Step 1. Stay with the person the whole time. Heatstroke can change quickly, and the person may become more confused, restless or drowsy within minutes. If you need something, such as more water, towels or the first aid kit, ask another person to fetch it. Keep your phone close so that you can stay beside the person while you speak to the operator.

Step 2. Talk to the person in short, simple sentences and notice how the person answers. Ask easy questions, such as the person's name, or whether the person knows who you are. Notice whether the answers become clearer or more muddled. A person who begins to answer more clearly is often responding to the cooling, but the cooling must still continue until help arrives.

Step 3. Watch the breathing all the time. Look at the chest and listen. If the breathing becomes noisy, very slow or irregular, tell the operator at once. Remember from Chapter 3 that occasional gasping is not normal breathing, and that a person who is not breathing normally needs CPR.

Step 4. Watch for vomiting. A person with heatstroke may feel sick and vomit, and a drowsy person can choke on vomit. If the person begins to vomit, turn the person onto one side so that the vomit can drain from the mouth, then go on cooling in that position.

Step 5. Notice the skin and the body. Feel the skin of the forehead and chest from time to time to judge whether it is still very hot. Watch for shivering, which can happen as the skin cools, and tell the operator if it starts, because the operator can advise you on how to go on cooling. Watch also for twitching or stiffness that could be the start of a seizure.

Step 6. Keep a simple record, in your head or on paper. Note the time you found the person, the time you called and the time you started cooling. Note what you saw: the person's words, behaviour, skin and breathing, and any change. If another person is with you, ask that person to write things down so that your hands stay free. These notes will help the paramedics more than you might expect.

What to Tell the Paramedics

When the paramedics arrive, they will want to know quickly what has happened. Keep cooling while they get ready, unless they tell you to stop. Then tell them in a few clear sentences that you think the person has heatstroke, how and when you found the person, what signs you saw and, as far as you know, how long the person had been in the heat. A calm, short report helps them start the right care at once.

Tell them what you have done and when. Say when you called, when the cooling started and how you cooled: water and fanning, wet cloths, cold packs or cold water immersion. Say whether the person drank anything, vomited, had a seizure or became unresponsive, and whether you gave CPR. If you noticed that the person was getting better or worse, say so, and say when the change happened.

The paramedics also need to know about the person's health. Give them the person's care plan and the list of medicines, as your workplace keeps it, and tell them about any health conditions you know of. If the care plan records the person's wishes about treatment, tell the paramedics, following your workplace's procedures. Do not guess about things you do not know; it is better to say that you do not know and let the paramedics ask the family or the workplace.

Describe the setting, too. Tell them how hot the room or place was, whether the windows were closed, whether a fan or air conditioning was working, and whether the person had been drinking during the day. These details help the paramedics understand how the heatstroke developed. After the person has gone with the paramedics, follow your workplace's emergency procedures: tell your supervisor, contact the family as the procedures say, and write your report while the details are fresh.

Heatstroke in a care home, a day centre or a shared home is a warning for everyone in the same place. If one person has become seriously ill from the heat, other people who spent the day in the same hot rooms may be at risk too, and some of them may not be able to say so. While the first person is being cooled and handed over, ask a colleague to check on the others: how they look and act, whether they have been drinking, and how hot their rooms are. Move people to the coolest rooms, offer drinks and tell your supervisor, so that the whole team can act before anyone else becomes unwell.

Things to Check

Check that you know where the coolest room is in each home and workplace where you work. In an emergency you will not have time to search, and the coolest place may change during the day.

Check that each place has the things you would use for cooling: a fan, towels or sheets that can be soaked, a bowl or bucket, a spray bottle and, if possible, cold packs in the freezer. Knowing where they are saves time when every minute counts.

Check the room temperature and the person's state at every visit during hot weather, especially in the morning after a hot night. Look for small changes in behaviour, because confusion may be the first sign you see.

Check the care plan of each person you support for guidance on hot weather, drinks and swallowing. If the plan says nothing about heat, ask your supervisor whether it should.

Check that the emergency number of the country where you work is saved in your phone and written where your workplace keeps it. You learn it from official information, and in heatstroke the call comes first.

Check that you know your workplace's procedure for an emergency in a person's home, including whom to tell and how to report it afterwards.

Check whether your first aid course or refresher course covers heatstroke and cooling. If it does not, ask your trainer or supervisor where you can practise these steps with others, so that they come naturally when you need them.

Check before each hot season that the fans and air conditioning in the places where you work are working, and report any that are broken. A cool room only helps if it can be kept cool.