Case Study 11

The Answer

Assessment

  • Possible heat cramps.
  • Possible heat exhaustion.    
  • Possible hyperventilation.

The Plan

  • Move patient to shade. Use cool wet compresses to lessen heat stress. 
  • Try to rule out heat stroke.
  • Gentle stretching to try to relieve cramps.
  • Calm the patient to manage hyperventilation.
  • Hydrate and feed patient.

Anticipated Problems

  • The muscle spasms cannot be relieved.

Comments

You dismiss the notion that this is a seizure. The patient is awake and never lost responsiveness. The spasms look like isolated muscle cramps and not tonic-clonic seizures.  

You consider whether this is the life-threat of heat stroke. The patient’s mental status was normal, a strong argument against heat stroke. The temperature of 99F (37.2C) supports this assessment.  

You are not sure what exactly is happening; heat cramps, heat exhaustion, dehydration, and hyperventilation are on your problem list. But first, you wisely treat the obvious and get this patient out of the sun, onto a pad to keep him off the hot sand, and reduce the heat stress with cool wet bandannas draped on his skin. You try gentle stretching on the muscle cramps. They look like the worse case of "charley horse" muscle cramps you’ve ever seen. No wonder the patient is in pain. You also noticed the high respiratory rate and want to get this under control before you have a hyperventilation patient.

The Tale Continues

Vital Signs    
    TIME     1625 hrs    1645
    LOR    A+Ox4    A+Ox4
    HR    100, strong, regular    90, strong, regular
    RR    28, shallow, unlabored    20, shallow, unlabored
    SCTM     pink, warm, sweaty    pink, warm, sweaty
    BP    radial pulses present    radial pulses present
    Pupils    PERRL    PERRL
    T°    Not taken    99F oral

After 30 minutes of stretching, the leg cramps subside to easy “quivering” and the RR is slower. 

Then you review his recent history, especially what he has had to eat, how much he has had to drink, and what his urine looks like. The three liters of water and not eating has you suspicious of heat exhaustion and dehydration. Also, on this trip the participants can bring alcohol and you think the nausea and headache might be due to alcohol drunk last night. You decide he may be dehydrated, and may be low on salt as well so you mix up a liter of a simple electrolyte solution (1 tbsp salt/liter) and have him slowly drink this.  

Review: The terminology is changing from heat cramps to “exercise-associated muscle cramps.” "Heat cramps" is the traditional and popular term. The term "exercise-associated muscle cramps" reflects the understanding that these cramps are not directly related to an elevated body temperature. They can happen in any exercise, in warm and cold temperature, during warm-up, during the exercise, or after exercise. Their cause is not understood by the medical physiologists. They may be due to dehydration, electrolyte imbalance, central neuromuscular fatigue, or any combination of these causes.     

Exercise-associated muscle cramps are muscle spasms, twinges, or tremors that can be intense and debilitating and typically occur in the legs, arms, and abdomen. Exercise-associated muscle cramps are associated with other forms of heat illness, but they do not predispose to other forms of heat illness.     

Lack of fitness, lack of acclimatization to exercise in the heat, and profuse sweating associated with sodium loss are characteristics of people who suffer from heat cramps.      

Anecdotal reports from Grand Canyon National Park rangers and one small study support gentle stretching to interrupt muscle cramping in heat (and this is the recommendation of the National Association of Athletic Trainers). The empirical experience of most persons is that stretching and massaging helps to relieve cramps. These two interventions seem to be reasonable first-aid treatment attempts for isolated heat or exercise-related muscle cramps. It is also reasonable to use electrolyte solutions in the exercise-associated muscle cramp patient although the only available evidence is case reports.

The End Tale

Your treatment plan is to assume heat stress/exhaustion/dehydration and treat for these at the same time. You cover all these bases by camping at this spot for the night, making sure the cramps have subsided, and ensuring that George is well-fed, well-hydrated, and well-rested.  

His legs are a bit sore, but by the evening he’s walking around and says he is fine. With the lessons of this experience George pays close attention to heat stress, hydration, and diet and has no further episodes as you continue your trip down river.