What is the initial workup and management for pediatric heat exhaustion?

Pediatric Heat Exhaustion Workup and Management

The initial workup for pediatric heat exhaustion should include immediate removal from heat, assessment of core temperature (rectal temperature preferred), vital signs, mental status evaluation, and prompt cooling with rehydration using electrolyte-containing fluids. 1, 2

Diagnosis and Assessment

Clinical Presentation

• Definition: Heat exhaustion is a moderate heat illness characterized by inability to maintain blood pressure and sustain adequate cardiac output, resulting from strenuous exercise/activity, environmental heat stress, acute dehydration, and energy depletion 1
• Core temperature: Up to 40°C (104°F) but not higher 1, 2
• Mental status: Normal (absence of significant central nervous system dysfunction distinguishes it from heat stroke) 1, 2
• Key symptoms to assess:
  • Weakness, dizziness, nausea, syncope, headache 1
  • Flushed face, hyperventilation 3
  • Possible heavy perspiration 4

Initial Assessment

1. Vital signs: Heart rate, blood pressure, respiratory rate, rectal temperature (most accurate) 1, 2
2. Mental status: Assess for orientation, confusion, or altered consciousness 2
3. Hydration status: Assess skin turgor, mucous membranes, recent urine output 5
4. Risk factors assessment:
   • Recent illness (especially with fever, vomiting, or diarrhea) 1
   • Medications (anticholinergics, SSRIs, dopamine-reuptake inhibitors, diuretics) 1, 2
   • Chronic conditions (diabetes, obesity, hyperthyroidism, cystic fibrosis) 1
   • Activity level and duration in heat 1
   • Clothing/equipment worn during activity 1

Management Algorithm

Immediate Interventions

1. Remove from heat source: Move to shade or air-conditioned environment 1, 2
2. Remove excess clothing/equipment: Immediately remove protective gear and restrictive clothing 1
3. Cooling measures:
   • For moderate cases: Apply ice packs to neck, axillae, and groin 1, 2
   • For severe cases with temperature >40°C (104°F): Cold/ice-water immersion (preferred method) 1, 2
   • Alternative: Rotating ice-water-soaked towels to all body areas 1

Rehydration

1. For alert patients able to drink:
   • Children 9-12 years: 100-250 mL (3-8 oz) every 20 minutes 1
   • Adolescents: 1.0-1.5 L (34-50 oz) per hour 1, 2
   • Use electrolyte-supplemented beverages with sodium for:
     • Exercise/activity lasting ≥1 hour
     • Repeated same-day sessions
     • Extensive sweat loss 1

Monitoring Response

1. Target temperature: Cool until rectal temperature reaches just under 39°C (102°F) 1
2. Reassess vital signs: Every 5-15 minutes until stable
3. Mental status: Continuous monitoring for changes that might indicate progression to heat stroke 2

When to Activate Emergency Medical Services

• Altered mental status (confusion, delirium, seizures, coma) 1, 2
• Core temperature >40°C (104°F) 1, 2
• Persistent symptoms despite initial cooling and rehydration 2
• Inability to maintain oral hydration 6
• Collapse or loss of consciousness 2
• Persistent vomiting 2
• Rapid heart rate that doesn't slow with rest 2

Return to Activity Considerations

• No same-day return: Anyone experiencing heat exhaustion should not return to activity for the remainder of the current day 1
• Gradual return: Wait for complete symptom resolution before gradual return to normal activities 2
• Medical clearance: May be necessary before resuming strenuous activity, especially in severe cases 2

Prevention Strategies

• Acclimatization: Gradual introduction to activity in heat over 10-14 days 1, 2
• Hydration: Proactive hydration before, during, and after heat exposure 1, 2
• Activity modification: Adjust intensity, duration, and frequency based on environmental conditions 1
• Appropriate clothing: Lightweight, loose-fitting, and minimal when possible 2
• Rest periods: Schedule frequent breaks in shade 3

Common Pitfalls to Avoid

• Delayed treatment: Do not wait for laboratory confirmation to begin cooling 1
• Inadequate temperature assessment: Rectal temperature is most accurate; other methods may underestimate core temperature 1
• Misdiagnosis: Failure to distinguish between heat exhaustion and heat stroke can be fatal 4
• Insufficient cooling: Not cooling aggressively enough or stopping too soon 1
• Inadequate fluid replacement: Water alone may be insufficient; electrolyte replacement is often necessary 2
• Premature return to activity: Allowing return to play/activity too soon increases risk of recurrence or progression to heat stroke 1, 2