Management of Diarrhea in Heat Stroke
Diarrhea in heat stroke should be managed primarily through fluid and electrolyte replacement as part of the overall treatment strategy, with careful attention to maintaining adequate hydration while avoiding fluid overload. 1
Understanding Heat Stroke and Associated Diarrhea
Heat stroke is a life-threatening emergency characterized by:
- Core body temperature >40.6°C (105°F)
- Central nervous system dysfunction (altered mental status)
- Often accompanied by gastrointestinal symptoms including diarrhea 2
Diarrhea in heat stroke occurs due to several mechanisms:
- Direct thermal injury to intestinal epithelial cells
- Intestinal barrier dysfunction
- Splanchnic hypoperfusion during heat stress
- Systemic inflammatory response 3
Treatment Algorithm for Diarrhea in Heat Stroke
1. Immediate Cooling (Priority)
- Initiate rapid cooling to reduce core temperature
- For adults and children: Whole-body (neck-down) cold-water immersion for 15 minutes or until neurological symptoms resolve 1
- Alternative cooling methods if immersion not available:
- Commercial ice packs
- Cold showers
- Ice sheets and towels
- Evaporative cooling with fans 1
- Target cooling to core temperature of 39°C (102.2°F) 1
2. Fluid Resuscitation
- Provide fluid replacement sufficient to restore blood pressure and tissue perfusion 1
- Titrate fluid resuscitation to clinical endpoints:
- Optimal heart rate
- Adequate urine output
- Stable blood pressure 1
- For patients able to take oral fluids:
- Provide carbohydrate-electrolyte drinks (4-9% concentration) 1
- Avoid plain water alone as it may worsen electrolyte imbalances
3. Management of Diarrhea
- Monitor fluid losses from diarrhea and replace accordingly
- Avoid antidiarrheal medications as they may:
- Interfere with elimination of heat-damaged intestinal cells
- Mask ongoing fluid losses
- Potentially worsen intestinal injury 1
- Replace specific electrolyte losses:
- Sodium: 50-90 mEq/L in rehydration solution 1
- Potassium: Monitor and replace as needed
4. Monitoring and Supportive Care
- Assess hydration status frequently:
- Skin turgor
- Mucous membrane moisture
- Capillary refill time
- Urine output (aim for >2 mL/kg/hr) 4
- Monitor for complications:
- Acute renal failure
- Disseminated intravascular coagulation
- Rhabdomyolysis
- Electrolyte disturbances 2
- Consider invasive hemodynamic monitoring for patients who remain hypotensive despite initial fluid therapy 1
Special Considerations
Severe Cases
- Aggressive IV rehydration should be continued for 24-72 hours with goal of maintaining minimum urine output of 2 mL/kg/hr to prevent rhabdomyolysis-induced renal failure 4
- For patients with severe diarrhea and inability to maintain oral intake, IV fluid therapy is essential
Risk Factors for Persistent Diarrhea
- Severity of initial heat stroke
- Duration of hyperthermia
- Extent of intestinal damage
- Antibiotic use (may worsen diarrhea) 5
Pitfalls to Avoid
Delayed cooling: Prognosis is poorest when treatment is delayed >2 hours 2
Excessive fluid administration: Monitor for signs of pulmonary edema, which can occur during resuscitation 1
Ignoring electrolyte imbalances: Heat stroke and diarrhea can cause significant electrolyte abnormalities that require monitoring and correction
Using antipyretics: Medications like aspirin and acetaminophen should be avoided as they can worsen coagulopathy and liver injury 1
Overlooking intestinal injury: The intestine is a key target organ in heat stroke; protecting it from further damage is essential for reducing systemic inflammation 3
By following this approach, clinicians can effectively manage diarrhea as part of comprehensive heat stroke treatment, focusing on the primary goals of rapid cooling, appropriate fluid resuscitation, and prevention of complications.