What is the treatment for heat stroke (not heat exhaustion)?

Treatment of Heat Stroke

Cold-water immersion is the most effective first-line treatment for heat stroke and should be initiated immediately to rapidly reduce core body temperature within 30 minutes of symptom onset. 1

Immediate Management Algorithm

1. Recognition and Assessment

   • Confirm heat stroke diagnosis: core temperature ≥40°C (104°F) WITH altered mental status 1, 2
   • Differentiate from heat exhaustion which has normal mental status 2

2. Primary Cooling Intervention

   • First choice: Cold-water immersion (1-5°C or 34-41°F) 1

     • Achieves fastest cooling rate (0.15-0.24°C/min)
     • Target reaching temperature <39°C within 30 minutes
     • Continue until core temperature reaches 39°C (102.2°F)

   • If cold-water immersion unavailable, alternative cooling methods (in order of effectiveness): 1

     • Colder water immersion (9-12°C)
     • Cold water immersion (14-17°C)
     • Tarp with cold water (approx. 25°C)
     • Cold shower (approx. 21°C)
     • Ice sheet cooling
     • Cooling vest
     • Hand cooling devices with cooling fan

3. Supportive Care

   • Move to cool environment
   • Remove excess clothing
   • Position to protect airway if altered mental status
   • Monitor core temperature continuously
   • Establish IV access for fluid resuscitation with electrolyte-containing fluids 2

Critical Considerations

• Cooling Rate Target: ≥0.155°C/min to minimize mortality and complications 1
• Time Target: Achieve temperature <39°C within 30 minutes of symptom onset 1
• Avoid Medications: Pharmacological interventions that affect temperature control are not recommended and should be avoided 1

Special Populations at Higher Risk

• Elderly individuals
• Children
• Individuals with chronic diseases
• Obese individuals
• Patients taking certain medications (diuretics, antihypertensives, psychiatric medications, SSRIs) 2

Monitoring During Treatment

• Continuous core temperature monitoring
• Mental status assessment
• Vital signs (heart rate, blood pressure, respiratory rate)
• Watch for complications: rhabdomyolysis, hepatic failure, arrhythmias, disseminated intravascular coagulation 3

Common Pitfalls to Avoid

1. Delayed cooling - The leading cause of morbidity and mortality in heat stroke 4
2. Inadequate cooling method selection - Using methods that cannot achieve target cooling rate
3. Premature termination of cooling - Continue until core temperature <39°C
4. Confusing heat exhaustion with heat stroke - Heat stroke ALWAYS has altered mental status and core temperature ≥40°C 2
5. Relying on antipyretic medications - These are ineffective for heat stroke 1

Prognosis

Mortality in patients requiring ICU care for heat stroke approaches 60%, with approximately 30% of survivors experiencing long-term cognitive or motor dysfunction. Survival is directly related to the speed of cooling, with faster cooling resulting in better outcomes 1, 2.

The central nervous system is particularly vulnerable to excessive heat, with cell death increasing exponentially as temperature exposure time increases. Recovery of CNS function during aggressive cooling is a favorable prognostic sign 1.