Exertional Heat Stroke Management

Introduction to Cooling Methods

The American College of Critical Care Medicine recommends immediate aggressive cooling for exertional heat stroke, with cold-water immersion being the gold standard if available, or alternatively applying ice packs to the neck, axilla, and groin while using evaporative cooling methods 1, 2

Whole-body cold-water immersion at 14-15°C is the gold standard for exertional heat stroke in young, fit patients, with a target cooling rate of ≥0.155°C/min 1, 2
The cooling method should continue for 15 minutes or until neurological symptoms resolve, whichever occurs first 2
If cold-water immersion is not available, alternative methods include applying ice packs to the neck, axilla, and groin, and using evaporative cooling with wet skin and continuous fanning 2, 5, 6

The patient's hypotension requires immediate attention alongside cooling, with a mortality rate of 33% compared to 10% in normotensive patients 6
Establish IV access and begin fluid resuscitation, titrating fluids to restore blood pressure and tissue perfusion 2, 7, 8
Consider invasive hemodynamic monitoring if hypotension persists after initial cooling and fluids 7

The patient should be monitored for recurrent seizures during cooling, and airway patency should be maintained given his altered mental status 2, 9
Consider intubation if the patient cannot protect his airway during aggressive cooling 9

Antipyretics and dantrolene should not be used in heat stroke management, as they are ineffective and may worsen coagulopathy and liver injury 5, 6
Cooling should not be delayed for diagnostic workup, and should continue until core temperature reaches 39°C or neurological symptoms resolve 3, 5, 2

Continuous core temperature monitoring and frequent neurological assessments are necessary to detect improvement or deterioration 2, 9
Monitor for multi-organ dysfunction, including rhabdomyolysis, acute kidney injury, liver injury, coagulopathy, and cardiac dysfunction 1, 2