From the Guidelines
The best next step in management for this 16-year-old girl is to begin rapid cooling with either ice bath immersion or evaporative cooling. This patient is presenting with heat stroke, evidenced by her elevated core temperature of 41°C (105.8°F), altered mental status, and symptoms following exertion in what was likely a hot environment during the soccer tournament. Heat stroke is a medical emergency requiring immediate cooling to prevent multi-organ damage and death. Rapid cooling should be initiated before any other interventions, as mortality increases with prolonged hyperthermia. The goal is to lower her core temperature to below 39°C (102.2°F) as quickly as possible, as recommended by the 2024 American Heart Association and American Red Cross guidelines for first aid 1.
Key Considerations
- Ice bath immersion is the most effective method, but evaporative cooling (removing clothing, spraying with tepid water, and using fans) is an acceptable alternative, as supported by the guidelines 1 and other studies 1.
- While acetaminophen may help with fever, it's ineffective for environmentally-induced hyperthermia.
- Laboratory tests and IV fluids are important but secondary to cooling.
- Intubation isn't immediately necessary unless her mental status deteriorates further.
- Once cooling has begun, supportive care including IV hydration should be initiated, and the patient should be monitored for complications such as rhabdomyolysis, electrolyte abnormalities, and coagulopathy.
Management Priorities
- Rapid cooling is the top priority to prevent further organ damage and reduce mortality.
- Activating emergency services is crucial, as recommended for people with heatstroke (heat illness with altered mental status) 1.
- The patient's vital signs and mental status should be closely monitored during the cooling process.
- The use of rectal temperature measurement to guide cooling is supported by recent guidelines and studies 1, with a target core temperature of less than 39°C (102.2°F).
From the Research
Best Next Step in Management
The patient's symptoms, such as dizziness, vomiting, fatigue, and a rectal temperature of 41 °C (105.8 °F), are indicative of heat stroke. The best next step in management would be to initiate rapid cooling to reduce the risk of mortality or morbidity.
Rapid Cooling Methods
- Ice-water immersion has been shown to be highly effective in exertional heat stroke, with a zero fatality rate in large case series of younger, fit patients 2.
- Evaporative plus convective cooling may be augmented by crushed ice or ice packs applied diffusely to the body, and is often promoted for older patients with nonexertional heat stroke 2, 3.
- Water immersion techniques, using 1-17 °C water, can rapidly reduce core body temperature in settings where it is feasible 4.
Recommended Approach
Based on the available evidence, the best next step in management would be to begin rapid cooling with either ice bath immersion or evaporative cooling 2, 3, 5, 4. This approach is supported by multiple studies, which demonstrate the effectiveness of rapid cooling in reducing the risk of mortality or morbidity in patients with heat stroke.
Other Options
- Immediate intubation for impending respiratory compromise may be necessary, but it is not the best next step in management for this patient.
- Ordering laboratory tests and placement of a central line for a crystalloid bolus of 20 cc/kg may be appropriate, but it is not the most critical step in managing heat stroke.
- Administering 450 mg acetaminophen immediately is not recommended, as it may not be effective in reducing the patient's core body temperature.