What is the management of unstable heat stroke?

Management of Unstable Heat Stroke

Immediate cold-water immersion is the cornerstone of treatment for unstable heat stroke, with the goal of reducing core temperature below 39°C within 30 minutes, while simultaneously addressing circulatory failure with IV fluid resuscitation and monitoring for distributive shock. 1

Initial Assessment and Stabilization

• Secure the airway if altered consciousness is present to prevent aspiration
• Continuous monitoring of vital signs, including core temperature
• Position patient safely to prevent aspiration
• Remove all clothing to facilitate cooling

Cooling Methods (in order of preference)

1. Cold-water immersion

   • Most effective method with fastest cooling rate 1
   • May be difficult with unstable patients requiring monitoring and resuscitation 2

2. Alternative active cooling methods (if immersion not feasible):

   • Ice packs to neck, axillae, and groin
   • Continuous cool water spray with fanning
   • Cooling blankets
   • Evaporative cooling techniques 1
   • Non-invasive cooling modalities like wet gauze sheets 2

3. Advanced cooling options for refractory cases:

   • Endovascular cooling devices may be considered when traditional methods fail 3
   • Recent evidence shows promising results with specialized cooling suits like CarbonCool® 4

Hemodynamic Management

• IV fluid resuscitation for hypovolemia

  • Aggressive IV rehydration should continue for 24-72 hours 5
  • Goal: maintain minimum urine output of 2 mL/kg/h 5

• Monitor for distributive shock

  • Circulatory failure occurs in 20-65% of patients 1
  • Hypotension is associated with 33% mortality vs. 10% in normotensive patients 2

• Cautious use of vasopressors

  • Use of vasoactive drugs within first 24 hours has been independently associated with increased risk of death 2

Monitoring and Management of Complications

• Continue monitoring even after cooling as patients may develop delayed complications
• Watch for multi-organ dysfunction:
  • Rhabdomyolysis and acute kidney injury
  • Disseminated intravascular coagulation
  • Hepatic injury
  • Electrolyte abnormalities 1

Important Considerations and Pitfalls

• Do not delay cooling - early recognition and immediate cooling are critical for survival 6, 7
• Avoid antipyretics (aspirin, acetaminophen) as they may aggravate coagulopathy and liver injury 2
• Avoid dantrolene sodium as it has been shown to be ineffective 2
• Do not discontinue cooling too early - target temperature should be below 39°C 1
• Be aware of patient risk factors - obesity, chronic illness, and advanced age increase risk 7

Special Considerations for Unstable Patients

• For hemodynamically unstable patients, evaporative cooling methods may be better tolerated than immersion 2
• Cooling should never be delayed for diagnostic procedures
• Intubation may be necessary for patients with Glasgow Coma Scale score ≤8 3
• Continuous core temperature monitoring is essential throughout treatment

Heat stroke is a true medical emergency with high mortality if not treated promptly. The key to successful management is rapid cooling combined with appropriate supportive care for organ dysfunction.