September 2026 ACEP Event Medicine Newsletter

Welcome to the 2026 ACEP Event Medicine electronic newsletter.

This newsletter provides an opportunity for the ACEP Event Medicine Section to share important information, updates, resources, and section activities. We also encourage you to connect with fellow section members, share your ideas, and provide feedback.

For questions, comments, ideas, or discussion, please use the Event Medicine Section engagED community. We look forward to hearing from you and continuing to build an active and collaborative Event Medicine community.

Topic Spotlight

Hyperthermia

Music festivals are increasing in popularity, with new events debuting in cities around the world each year. Although organizers do not actively promote the use of illicit substances, and harm reduction efforts continue within the music industry, the use of illicit and uncontrolled substances remains common at these events. Psychostimulant induced hyperthermia carries a high morbidity and mortality and represents a true emergency when a patient presents to an on site medical tent. Heatstroke carries a mortality rate of 40% to 64% (Pease S, Bouadma L, Kermarrec N, et al. Early organ dysfunction course, cooling time and outcome in classic heatstroke. Intensive Care Medicine. 2009;35(8):1454–1458). Hyperthermia related to drug use shares some similarities with the management of exertional and environmental hyperthermia, but there are important nuances and evolving treatment strategies that can reduce the historically high mortality rates. Evidence suggests that faster cooling is associated with improved outcomes and lower mortality (Vicario SJ, Okabajue R, Haltom T. Rapid cooling in classic heatstroke: effect on mortality rates. American Journal of Emergency Medicine. 1986;4:394–398). Severe hyperthermia is therefore a true medical emergency that requires rapid recognition and aggressive treatment by prehospital providers.

There is a published case series that includes twelve patients from a single music festival transported to an emergency department, with seven experiencing severe hyperthermia defined as 40.9 - 43˚C (105.6-109-4 ˚F ). Of the seven, one died and four survived with long term morbidity of permanent neurologic, musculoskeletal, or renal sequelae.  Guidance at that time focused on sedation, airway management and passive cooling using ice-packs and evaporation. Using these cooling methods may take several hours to cool a patient to a desirable range.  In this case series, the average time to achieve cooling was 2.7 hours. (Armenian P, Mamantov TM, Tsutaoka BT, et al. Multiple MDMA (Ecstasy) Overdoses at a Rave Event: A Case Series. Journal of Intensive Care Medicine. 2013;28(4):252-258. doi:10.1177/0885066612445982)

Best practices urge more rapid cooling of severe hyperthermic patients, treatment modalities include cooled IV fluids and ice water immersion. In a recently published case series of patients from music festivals, 21 cases of hyperthermia were identified that were treated using emergency resuscitation, cooled IV fluids, and ice-water submersion. Initial event core temperatures ranged from 41-43˚C (106.2˚-109.4˚F) with a median core temperature of 42.2˚C (107.9˚F). All patients underwent sedation, intubation, and rapid cooling.  Eighteen patients were cooled and on arrival to the ED the measured mean core temperature was 35.89˚C (96.65˚F) (SD 2.39˚C). Three patients did not complete the cooling process as they went into cardiac arrest before or during cooling, necessitating removal from the submersion tank and CPR with acute resuscitation led by the physician. The patients were transported to the closest hospital. No patients were pronounced dead at the events. (Habrat, D. A., Dukes, W. S., Neeki, M. M., & Schlesinger, S. A. (2026). Physician Directed Prehospital Treatment in Psychostimulant Induced Hyperthermia: A Case Series. Prehospital Emergency Care, 30(4), 561-569.)

Two of the three patients that arrived in cardiac arrest were pronounced dead in the emergency department without core temperature or laboratory testing performed. Of the 19 patients who survived to hospital admission, median body temperature on ED arrival was 35.89˚C (96.65 ˚F) (SD 2.39).  The most common lab abnormalities in the ED included hyperkalemia (median 5.65 mEq/L; IQR 4.15-6 mEq/L), metabolic acidosis (mean bicarbonate 17 mEq/L; SD 3.87), elevated Creatinine (mean Cr = 1.7 mg/dL; SD 0.44) and elevated Creatinine kinase (CK) (median CK =1527 U/L; IQR 344-4678 U/L). The third cardiac arrest patient obtained ROSC and was admitted to the hospital but did not survive to hospital discharge.  The remaining 18 patients were all discharged home and reported as neurologically intact. All patients in this case series received IV dantrolene during their prehospital phase of care.

The average time from initial temperature recording to ice water submersion was 10 minutes and the average time in the ice bath was 13 minutes. Goal temperature for removal from the ice bath during these cases was 38.3˚C (101˚F). The average time from ice water extraction to arrival in the ER was 23 minutes. Unfortunately, several patients arrived hypothermic to the emergency department. The goal temperature for ice bath removal was moved to 38.9˚C (102˚F), but patients still arrived hypothermic. Currently, the goal temperature for ice bath removal is 40˚C (104˚F) and now patients’ average temperatures at arrival to the ED is 37.2˚C (99˚F).

Poppers

Poppers, also known as amyl nitrite, is a recreational drug used at music festivals and in the nightlife scene for feelings of euphoria and relaxation.  Amyl nitrite is a volatile liquid meant to be inhaled to achieve the desired side effects.  When poppers are ingested by drinking the volatile liquid, the direct hemoglobin-oxidizing effects of amyl nitrite induce methemoglobinemia.  Although a rare occurrence, early identification of amyl nitrite induced methemoglobinemia and quick administration of the methylene blue can prevent fatal outcomes.  The increasing use of amyl nitrite (poppers), particularly at music events make them a drug of abuse and a potential cause of methemoglobinemia when presenting to festival medical facilities and to the ED.  

Classically, methemoglobinemia presents with shortness of breath, cyanosis, headache, tachycardia, and peripheral oxygen saturation of approximately 85% that does not improve with supplemental oxygen.  A characteristic physical finding in methemoglobinemia is chocolate-brown colored blood, which has been seen in other cases.  The antidote for methemoglobinemia is methylene blue given intravenously at a dose of 1 milligram per kilogram of a 1% solution over five to thirty minutes.  Methylene blue mechanism of action is to reduce the oxidized ferric (Fe3+) form of hemoglobin when in a state of methemoglobinemia back to the normal ferrous (Fe2+) state.  In turn, this increases the oxygen-binding capacity of hemoglobin and thus increases oxygen delivery to tissues.

Calendar of Events

The Event Medicine Section meeting will be on Monday, October 5, 2026 at 11:30 am. Location: MPCC, Level 1, W196C.