Wish you a safe summer! B. Pharm., M.Sc. - Clinical Research & Regulatory Affairs

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1 Wish you a safe summer! B. Pharm., M.Sc. - Clinical Research & Regulatory Affairs

2 Physiology of Sweating & Heat Stress Mechanism of Rehydration Heat Illness & First Aid Best Practices Management - Engineering Controls - Administrative Best Practices Individuals New Updates from Reputed Sources mentioning International Experiences on Oral Rehydration

3 Whether we work in cold outdoors or in Hot Outdoors

4 At 30 O C Sweat is one of the cooling mechanism Above 35 O C Sweating is the major cooling mechanism Air 30 O C Air 35 O C Sweating works even when other mechanisms fail Take Care of Sweating System. Worker should not fail to Sweat!!!

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12 Heat Loss Heat Gain

13 Heat Loss Heat Gain Sweat Wind Sun Humidity Physical Work PPE

14 Sweat Composition Waste Material & Trace Minerals Sodium Chloride Trace Minerals Waste Materials (Urea, Ammonia) Salt ( Sodium Chloride ) Water Water

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16 How much we sweat normally? 200ml -2.0 Litre of Sweat daily

17 Workers working in open sites under extreme conditions of temp. above 400C & humidity above 60% can loose upto LTR OF SWEAT PER HOUR & 3.5G of salt per hour through sweat from body.

18 (Low Body Water) Excessive Thirst Dry Mouth & thick Saliva Headache Nausea Vomiting Scanty Dark Urine Hypotension Giddiness Fainting (Heat Syncope) (Low Sodium in Blood) Muscle Cramps Lack of Concentration Fatigue & Drowsiness Irritability Mental Confusion Disorientation Seizures Cardiac failure Coma Death

19 Nervous System requires Sodium to communicate & coordinate with various parts of the body. Similarly, Proper Muscle function also requires sodium.

20 Normal sodium level in blood = meq/l. Hyponatremia = Sodium less than 135 meq/l Severe Hyponatremia = Sodium below 125 meq/l mmol/l: Mild Symptoms or Asymptomatic mmol/l: GASTROINTESTINAL: Anorexia (Loss of Appetite) Nausea Vomiting Below 120 mmol/l NEUROMUSCULAR: Muscle cramps Generalised weakness Seizures NEUROLOGIC: Confusion Disorientation Agitation Delirium Lethargy Stupor (Reduced consciousness) Below 110 mmol/l: FATAL SYMPTOMS Arrhythmia Coma

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22 The Dilutional Hyponatremia

23 Two People with same amount of Sodium in the body, but dilutes the Sodium levels below 145meq/L & produces symptoms of Hyponatremia Drinking Plain Water without replenishing electrolytes dilutes the blood further with respect to sodium concentration.

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25 Why not just plain water?

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27 Why not just plain water? 1. Water & Electrolytes, both are getting lost in sweat. 2. Even if large quantities of water is consumed, little is absorbed and a major part is soon removed as urine. (Frequent urination). 3. Sodium is the major electrolyte lost in sweat, no additional reserves of Sodium in the body. 4. Hyponatremia is a critical condition and needs urgent & immediate correction of Sodium levels in the body. 5. Heat stroke patients are given electrolytes by intravenous route.

28 Mechanism of Rehydration Rehydration has to be Fastest & Safest What is the Mechanism of Action of Oral Rehydration?

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31 Sports Drinks & Endurance Drinks Plain Water Oral Rehydration

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35 Refueling Rehydration

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37 Sod. / L Sod. / 200ml Sugar % Sugar gms / L Daily Sugar in gms W. H. O. Sp. Dr. 1 Sp. Dr. 2 Sp. Dr. 3 Endu. Dr. 1 Endu. Dr. 2 75mmol 5mmol 10mmol 15mmol 20mmol 25mmol % 5.00 % 5.00 % 6.00 % 7.00 % 7.00 % 13.5gm 50gm 50gm 60gm 70gm 70gm 5.4gms 50gm 50gm 60gm 70gm 70gm 60gms of Sugar (15 Tea Spoons full) 5.4gm Sugar (1, 1/2 Tea Spoon) 15mmol Sodium 30mmol Sodium

38 Low in Electrolytes High in Sugars Hypertonic = Delayed Absorption High Costs Frequent Urination

39 Optimum Electrolytes Low in Sugars Hypotonic + Sp. Ratios = Fast Absorption Low Cost Life Saver Less Urinations

40 Heat Illness & First Aid -Heat Rashes -Heat Syncope -Heat Cramps -Heat Exhaustion -Heat Stroke -Classic Heat Stroke -Exertional Heat Stroke -First Aid

41 Heat Illness & First Aid -Heat Rashes Sweat Pores blocked -Heat Syncope Low Blood pressure / Low body water -Heat Cramps Low Electrolytes -Heat Exhaustion Low Water + Low Electrolytes -Heat Stroke Failure of Sweating Mechanism -Classic Heat Stroke -Exertional Heat Stroke -First Aid

42 HEAT RASHES Cause Hot & Humid environment Sweat gland ducts become plugged Impervious clothing Signs & Symptoms Red, bumpy, blister like rash that is often itchy Uncomfortable, Painful Remedy Keep skin clean and dry Shower after working in hot environment Stay cool with air conditioning Fans and cool showers Wear lightweight & loose-fitting, breathable clothing

43 HEAT SYNCOPE (FAINTING) Common ill effect of heat, Mostly happens to Unacclimatized workers Cause Loss of body fluids Reduced Blood Pressure Dilation of blood vessels causes blood to get pooled in the legs Blood supply to brain reduces, brain deprieved of oxygen Lack of acclimatization Signs & Symptoms Person standing in the sun becomes pale, BP falls and collapses suddenly Practically no rise in temperature Feeling of weakness and tiredness Impaired performance of skilled tasks in heat Inability to concentrate Increased Heart Rate Treatment Made to lie down in the shade with legs raised Quick recovery usually (within 5-10min) after lying down in cool place Provide cool water & electrolyte drinks when conscious Prevention Prevent by moving around a little rather than standing still all the time Acclimatization of workers for work in the heat FAINTING

44 HEAT CRAMPS Cause Heavy Physical Work + Loss of Electrolytes = Heat Cramps Signs & Symptoms Painful muscle spasms, especially in the large voluntary muscles of the calves, thighs, and shoulders or even in abdomen or stomach area. Treatment Stop activity, move to rest in a cool place Drink water, take oral rehydration salts Massage the cramp Do not return back to same activity immediately Adequate salt intake at meals, Seek prompt medical attention if the heat cramps don t subside within an hour of resting and hydrating. Prevention Avoid over exertion or strenuous physical activity Adequate salt intake with meals Drink fluids regularly Heat Cramps are early warning sign of heat stress

45 HEAT EXHAUSTION Cause Heavy Water Loss + Heavy Electrolyte Loss = Heat Exhaustion Inadequate replacement of water and salt lost in perspiration Blood volume is decreased, electrolytes in blood are reduced Signs & Symptoms Severe Fatigue, weakness, dizziness, Nausea, headache, heavy sweating Body temp. is normal or slightly elevated (not exceed 1020F) Low to normal blood pressure Treatment Stop activity and seek treatment immediately Move person to a cool shaded area Provide cool water to drink. Fan and spray with cool water Normalising fluid and electrolyte balance by providing water & Oral Rehydration salts If vomiting Intravenous electrolytes Do not return to work unless fully recovered Prevention Drink plenty of water Take electrolyte drink intermittently Take work breaks in between If left untreated, heat exhaustion progresses to heat stroke

46 TREATMENT - HEAT RELATED ILLNESSES Remove the person to a cool shaded area. Make him lie with legs up. Put on sides if vomiting. Loosen clothes. Apply wet cloth or cool water Person should be given cool water Provide electrolyte solutions if conscious. The victim of heat syncope usually recovers rapidly in few minutes on resting Victim of heat exhaustion may need 3-4 hr rest in cool area.

47 COOLANT RESERVOIR Heat Exhaustion Point when body can no more produce sweat

48 Sweating in Engineering Language is like water cooled car. THERMOSTAT MALFUNCTION Fever Infections DAMAGED CONDUCTING SYSTEM Atherosclerosi s Diabetes LOW COOLANT LEVELS Dehydration Drugs: Diuretics Heart diseases Beta Blocker Drugs PUMP MALFUNCTION RADIATOR MALFUNCTION Skin Diseases Occlusive clothing Drugs: Anticholinergics INCREASED HEAT PRODUCTION Physical Exertion - Work - Excercise

49 HEAT STROKE Most Severe Heat Related Illness Life threatening medical emergency Cause No more sweat. Body s cooling mechanism shuts down. Body cannot get rid of excess heat. Body temperature rises sharply. Vitals organs stop working and start to get damaged. Sign & Symptoms Confusion, disorientation, dizziness, numbness, delirium, unconsciousness, convulsions, coma. Throbbing Headache Examination: Red, hot, dry Skin. Mostly, NO SWEATING. But profusely sweating also possible. Body Temperature above 102OF (can be 1040F and rising) Profound disturbance, confusion, convulsion, Altered mental state. (cannot say his name) Loss of consciousness etc. Fatal if treatment is delayed. 70% of Heat Strokes result in Death Even among those who get medical attention 40%-50% die

50 HEAT STROKE Life threatening medical emergency Treatment We have less than 30 minutes to save the life of the person. Outcomes depends on the Degree & Duration of the elevated core body temperature Start First Aid & Call for an ambulance immediately 1. Move the victim to a cool shady area. 2. Quickly remove PPE & outer clothing. Rapid Cooling is the cornerstone of therapy in the treatment of heatstroke. 3. Cool the body of the victim as rapidly as possible to prevent damage to brain & vital organs. 4. Tub of cool water / Cool shower / Douse with garden hose / Care - Water not to enter airway 5. Vigorously fan the Person manually or use an electric fan or wind blower to cool. 8. Use Ice / Ice packs or Alcohol swabs if necessary (particularly in Neck, Arms pits, Groin, Soles of Hand & Feet. 7. If the worker is unconscious make him lie on his side 8. If conscious, Give cool fluids or ORS to drink, but sip by sip, if in a position to drink. 9. Care not to choke, while drinking Fluids in Upright position. 10. Monitor & lower body temperature until professional medical help is available 11. Be prepared to give CPR or artificial respiration. 12. Intravenous saline will be administered by paramedic ambulance staff.

51 HEAT STROKE Evaporative Cooling & Immersion Cooling

52 HEAT STROKE Use of Ice Packs or Cold Packs

53 HEAT STROKE I V Fluids being administered by Paramedics

54 According to NIOSH (i.e National Institute For Occupational Safety and Health) Many accidents in the construction field are reported as accidental falls or injuries. But if you study carefully they are caused by heat stress.

55 Heat illnesses are cause of lot occupational hazards, costly errors & accidents. OSHA, NIOSH & CCOHS all agree that Awareness is the Key to Prevention

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57 Heat Stroke Heat Illness Continuum

58 New Updates from Reputed Sources mentioning International Experiences on Oral Rehydration for Exertional Heat Illness Australia Qatar Japan UK USA etc.

59 Is it High in Sodium? Can People with Blood Pressure use it? Can Diabetics use it? Is it for Treatment or Prevention?

60 Normal sodium level in blood = mmol/l. The average sodium content of sweat is 50mmols/Litre A worker loosing 4 litres of sweat in a day can loose upto 200mmol/L of Sodium One glass of Sunlyte provides 15mmol/Litre of Sodium

61 W.H.O. LYTE

62 Workers engaged in loading cargo onto aircraft at Tokyo International Airport Oral Rehydration Vs FAD (free choice Favorite Drink) Ref:

63 Compared with commercially available sports drinks, oral rehydration solutions are high in sodium, low in sugar, and have an osmotic pressure that is lower than that of plasma. One characteristic of their composition is that they contain glucose at an optimal concentration to promote sodium absorption. As a result effective water absorption by the body is possible "Oral Rehydration Solution is ideal for the intestinal absorption of water and electrolytes because of its characteristic composition" Results: People reported lower fatigue with ORS than with FAD The reason why the degree of fatigue was reduced by Oral Rehydration Solution intake in this study was assumed to be that it contains the optimal concentration of glucose for facilitating sodium absorption resulting in Sodium replacement in addition to water absorption. Ref:

64 ORS intake has been recommended in heat stroke prevention guidelines in the workplace issued by the Japanese Ministry of Health, Labor and Welfare Ref:

65 All these conditions can be prevented if some precautions are followed such as restriction and less strenuous outdoor works, light clothing, use of minimal equipment, drinking extra fluids such as oral rehydration salt (ORS) and monitoring for early symptoms of heat injury, he maintained. It is advisable for field workers and other people at high risk of dehydration to drink two-four glasses of ORS during working hours, Dr Mohamed suggested. Middle East HSE manager, explained the importance of ORS to the participants: Though ORS is attributed to treating diarrhoea, it is equally good for a rapid restoration of blood volume and stimulate the rate and completeness of rehydration. Ref: Gulf Times Page 2, Sunday, July 25,

66 Sodium during Rehydration A. 2 mmol, B 26 mmol, C52 mmol, D 100 mmol

67 Most sports drinks have a low electrolyte content, with sodium concentrations typically in the range of mmol/l. This is adequate in most situations, but may not be so when sweat losses and fluid intakes are high. Urine output was greatest with the low electrolyte drinks that were consumed in the largest volumes (the sports drink and the orange juice/lemonade mixture), and was smallest after drinking the oral rehydration solution. Confirm earlier results showing that a moderately high electrolyte content is essential if the ingested fluid is to be retained in the body. The benefits of the higher intake with the more palatable drinks were lost because of the higher urine output. Info on Swiss Forum for Sport Nutrition Website in cooperation with Swiss Olympic

68 High carbohydrate concentrations will delay gastric emptying, thus reducing the amount of fluid that is available for absorption: very high concentrations will also result in secretion of water into the intestine and thus temporarily increase the danger of dehydration (Merson et al., 2002). Conclusion In order to achieve effective rehydration following exercise in the heat or heat exposure or any type of exercise sufficient to cause sweat loss, the rehydration beverage should contain moderately high levels of sodium (at least 50 mmol l 1), plus possibly some potassium; a source of substrate is not necessary for rehydration although a small amount of carbohydrate (<2%) may improve the rate of intestinal uptake of sodium and water. Info on Swiss Forum for Sport Nutrition Website in cooperation with Swiss Olympic

69 data/assets/pdf_file/0010/146539/16complete.pdf

70 There is consistent evidence that the response of the ECF and the intracellular fluid (ICF) volumes to fluid ingestion during prolonged exercise are influenced by the content of the ingested fluid so that the plasma volume is likely to fall the most if no fluid is ingested, to fall less if either water or a dilute drink is ingested, or to expand if a concentrated ( mmol/l) drink is ingested.

71 Inclusion of sodium (<50 mmol /L) in fluid replacement drinks during exercise has not shown consistent improvements in retention of ingested fluid in the vascular compartment

72 publications/current_concepts data/asset s/pdf_file/0007/143386/currentconcepts.pdf The inclusion of sodium in beverages enhances rehydration by reducing urine output as well as by increasing intake. For modest fluid losses, sports drinks (10 25mmol/L sodium) are adequate. When fluid losses are high (greater than two litres), sodium intakes of 50 80mmol/L may be required to better replace the electrolytes lost in sweat. This can be achieved with the use of commercial oral rehydration solutions

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74 Safety in the Heat - High Impact Measures 1. Awareness Trainings & Print Materials 2. MID DAY Break Rule 3. Shaded Rest Areas 4. Unrestricted supply of cool water 5. Acclimatization 6. Oral Rehydration 7. Worker Best Practices

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