From the Guidelines
Heat stroke requires immediate treatment in the emergency department, focusing on rapid cooling and supportive care, as emphasized by the 2024 American Heart Association and American Red Cross guidelines for first aid 1. The patient should be moved to a cool environment, all clothing removed, and cooling initiated immediately through methods such as ice packs to the groin, axillae, and neck, cold water immersion if available, or evaporative cooling with misting water and fans. Core body temperature should be monitored continuously with a rectal thermometer, aiming to reduce temperature to below 39°C (102.2°F) within 30 minutes, as rectal thermometry is the most accurate method for measuring body temperature 1. Intravenous access should be established for fluid resuscitation with isotonic crystalloids like normal saline, typically starting with a 1-2 liter bolus, then adjusted based on clinical response. Some key points to consider in the treatment of heat stroke include:
- Vital signs require continuous monitoring, with supplemental oxygen provided to maintain oxygen saturation above 94%
- Laboratory tests should include complete blood count, comprehensive metabolic panel, coagulation studies, and creatine kinase to assess for complications like rhabdomyolysis, electrolyte abnormalities, or organ dysfunction
- Benzodiazepines such as diazepam 5-10mg IV may be needed for shivering or seizures
- Cooling should be stopped once the target temperature is reached to prevent overcooling
- Severe cases may require intensive care for management of complications like acute kidney injury, liver failure, or disseminated intravascular coagulation Rapid cooling is critical as the mortality rate increases significantly when treatment is delayed, with cellular damage occurring above 41.6°C (107°F) due to protein denaturation, cell membrane dysfunction, and inflammatory cascade activation, highlighting the importance of prompt intervention as stated in the guidelines 1.
From the Research
Treatment for Heat Stroke in the Emergency Department (ED)
The treatment for heat stroke in the ED involves immediate cooling and support of organ-system function. The main goal is to rapidly reduce the core body temperature to prevent irreversible cellular damage and improve patient outcomes 2, 3, 4, 5, 6.
- Cooling Methods: Various cooling methods can be used, including:
- Cold water immersion: considered the fastest method for cooling, but not usually feasible in an ED setting 4, 6
- Tarp-assisted cooling with oscillation (TACO): a feasible and effective cooling method for EDs, requiring 30-40 gallons of ice water, a tarp or waterproof sheet, core temperature monitoring, and an ample number of ED staff members to oscillate the water over the patient 4
- Evaporative cooling (misting/fanning): a rapid and effective alternative to cold water immersion 5, 6
- Endovascular cooling: can be used to rapidly decrease core body temperature when external cooling methods fail 3
- Ice packs, cooling vests and jackets, cold showers, and ice sheets: other cooling methods that have been studied 4
- Support of Organ-System Function: Aggressive IV rehydration should be continued for the first 24 to 72 hours to prevent the development of rhabdomyolysis-induced acute renal failure, with the goal of maintaining a minimum urine output of 2 mL/kg/h 5
- Importance of Prompt Recognition and Action: Prompt recognition of symptoms and immediate action in the field are crucial for effective treatment of heat stroke, regardless of the cooling method used 2, 3, 4, 5, 6