What is the best next step in management for a patient with heat stroke, presenting with hyperthermia, hypotension, tachycardia, and altered mental status?

Immediate Aggressive Cooling is the Best Next Step

The best next step in management for this patient with exertional heat stroke is to initiate immediate aggressive cooling, with cold-water immersion being the gold standard if available, or alternatively applying ice packs to the neck, axilla, and groin while using evaporative cooling methods. 1, 2

Why Cooling Takes Priority Over Other Options

This 16-year-old presents with classic exertional heat stroke: core temperature of 107°F (41.5°C), altered mental status (confusion, not following commands), seizure activity, and hypotension following prolonged exertion in heat. 1

The severity of tissue injury and cell death is directly proportional to both the degree and duration of hyperthermia. 1 Death from heat stroke occurs primarily from hyperthermia-induced tissue damage and cardiovascular failure, making rapid temperature reduction the single most critical intervention to prevent irreversible organ damage and death. 1

Why Not the Other Options?

• CT scan of the brain: Delays life-saving cooling. Heat stroke is a clinical diagnosis based on hyperthermia (>40°C) plus CNS dysfunction. 1 Imaging does not change immediate management and wastes precious time when every minute of hyperthermia causes progressive tissue damage. 1, 3

• Lumbar puncture and antibiotics: While meningitis is in the differential, the clinical context (outdoor football practice in summer heat, dry skin, hyperthermia) clearly points to heat stroke. 1 Cooling must begin immediately; if infection remains a concern after cooling, it can be addressed subsequently. 2

• Cool mist alone: This represents passive/evaporative cooling, which is insufficient as monotherapy for severe heat stroke with this degree of hyperthermia. 1, 2 While evaporative methods have a role, they must be combined with more aggressive techniques.

• Immediate isolation: Irrelevant to heat stroke management and delays cooling.

Optimal Cooling Protocol

First-Line Method: Cold-Water Immersion

Whole-body (neck-down) cold-water immersion at 14-15°C (57.2-59°F) is the gold standard for exertional heat stroke in young, fit patients. 2 This method has demonstrated:

• Zero fatality rates in large case series of younger patients with exertional heat stroke 4
• Cooling rates of ≥0.155°C/min, which is the target for optimal outcomes 1, 2
• Superior efficacy compared to all other methods in this population 4

Continue immersion for 15 minutes or until neurological symptoms resolve, whichever occurs first. 2

Alternative Methods When Immersion Unavailable

If cold-water immersion is not immediately available (common in ED settings):

• Apply ice packs to neck, axilla, and groin 2, 4
• Use evaporative cooling: wet the patient's skin with water and apply continuous fanning 1
• Remove all clothing to maximize heat dissipation 2
• Consider cold intravenous fluids as adjunct (though not as primary cooling method) 4

Target core temperature: below 39°C (102.2°F) 2

Critical Concurrent Management

Hemodynamic Support

This patient's hypotension (BP 98/50 mmHg) requires immediate attention alongside cooling. 1 Heat stroke causes distributive shock similar to sepsis, with relative or absolute hypovolemia. 1

• Establish IV access and begin fluid resuscitation 2
• Titrate fluids to restore blood pressure and tissue perfusion (target: adequate heart rate, urine output, blood pressure) 1
• Exercise caution with fluid volume: pulmonary edema risk is significant in heat stroke patients 1
• Consider invasive hemodynamic monitoring if hypotension persists after initial cooling and fluids 1

Hypotension in heat stroke carries a mortality rate of 33% compared to 10% in normotensive patients, making its correction crucial. 1

Seizure Management

The patient already received appropriate treatment with lorazepam for his seizure. 2 Continue monitoring for recurrent seizures during cooling.

Airway Protection

Maintain airway patency given his altered mental status. 2 Consider intubation if he cannot protect his airway during aggressive cooling, particularly if using cold-water immersion where aspiration risk increases. 1

Common Pitfalls to Avoid

Do not use antipyretics (aspirin, acetaminophen): These are ineffective in heat stroke and may worsen coagulopathy and liver injury. 1

Do not use dantrolene: Pharmacologic cooling adjuncts have proven ineffective in heat stroke. 1

Do not delay cooling for diagnostic workup: Every minute of delay increases morbidity and mortality. 1, 3 Cooling should begin in the field and continue during transport and evaluation. 5

Do not stop cooling prematurely: Continue until core temperature reaches 39°C or neurological symptoms resolve. 1, 2 Stopping too early risks rebound hyperthermia.

Do not rely on strategic ice pack placement alone (neck, axilla, groin only): These locations are insufficient as primary cooling in severe heat stroke and should only be used when better methods are unavailable. 4

Monitoring Requirements

• Continuous core temperature monitoring (rectal thermometry preferred) 1, 2
• Frequent neurological assessments to detect improvement or deterioration 2
• Monitor for multi-organ dysfunction: rhabdomyolysis, acute kidney injury, liver injury, coagulopathy, cardiac dysfunction 1, 2
• Document cooling rate, methods used, and patient response 2

Up to one-third of heat stroke survivors develop permanent neurological damage, making rapid cooling within the first hour absolutely critical to prevent irreversible injury. 1