What is the treatment for heat stroke?

Heat Stroke Treatment

Immediately initiate aggressive cooling with cold-water immersion (14-15°C) as the first-line treatment, targeting a cooling rate of ≥0.155°C/min, while simultaneously providing cardiovascular support with IV fluid resuscitation. 1, 2

Immediate Cooling Interventions

Primary Cooling Method

• Whole-body cold-water immersion (neck-down) at 14-15°C is the gold standard and should be started immediately upon recognition of heat stroke. 1, 2, 3
• Continue immersion for 15 minutes or until neurological symptoms resolve, whichever occurs first. 2, 3
• Target a cooling rate of ≥0.155°C/min to minimize morbidity and mortality. 2, 3
• This method is particularly effective for exertional heat stroke in young, fit patients. 1, 2

Alternative Cooling Methods (When Immersion Unavailable)

• Apply commercial ice packs to the neck, axilla, and groin simultaneously. 2, 3
• Use evaporative cooling: wet the entire body surface with water and apply continuous fanning. 1, 2
• Cold showers, ice sheets, and cold towels can be used as additional measures. 3
• For classic (non-exertional) heat stroke, no single cooling technique has proven superior—use whatever method is immediately available. 1

Critical Temperature Targets

• Stop cooling when core temperature reaches 38-39°C to prevent iatrogenic hypothermia. 2, 4
• Continuously monitor core temperature throughout the cooling process—rectal or esophageal probes are preferred. 3, 4
• Once target temperature is reached, dry and cover the patient to prevent overcooling. 4

Concurrent Cardiovascular Support

Fluid Resuscitation

• Establish IV access immediately and begin fluid resuscitation to address the distributive shock pattern seen in heat stroke. 1, 2, 3
• Titrate fluids to restore blood pressure and tissue perfusion—hypotension carries a 33% mortality rate versus 10% in normotensive patients. 2
• Consider invasive hemodynamic monitoring (central venous or pulmonary artery catheter) if hypotension persists after initial cooling and fluids. 1, 2
• The circulatory failure in heat stroke is primarily distributive shock with relative or absolute hypovolemia, not myocardial failure. 1

Airway and Neurological Management

Airway Protection

• Assess and maintain airway patency given the altered mental status that defines heat stroke. 2, 3
• Consider intubation if the patient cannot protect their airway during aggressive cooling or has persistent altered consciousness. 2

Seizure Monitoring

• Monitor continuously for seizures during cooling and treatment. 2
• Assess neurological status frequently to detect improvement or deterioration. 3

Critical Pitfalls to Avoid

Ineffective Medications

• Do not use antipyretics (acetaminophen, NSAIDs)—they are completely ineffective in heat stroke and may worsen coagulopathy and liver injury. 1, 2
• Do not use dantrolene—it has no role in heat stroke management despite its use in malignant hyperthermia. 1, 2
• Avoid any pharmacological interventions that affect temperature control as there is no evidence supporting their use. 1

Timing Errors

• Never delay cooling for diagnostic workup—cooling must begin immediately upon recognition. 2, 5
• Delayed cooling significantly increases mortality, as outcome is directly related to the degree and duration of hyperthermia. 1, 5, 6

Monitoring for Complications

Multi-Organ Dysfunction

• Monitor for rhabdomyolysis, acute kidney injury, liver injury, coagulopathy, and cardiac dysfunction. 2, 3
• Check for impaired liver function and renal failure as these commonly develop. 7
• Document fluid intake and output to assess hydration status and renal function. 3

Ongoing Assessment

• Continuously monitor vital signs, especially core temperature, throughout treatment. 3
• Assess for signs of organ dysfunction including coagulopathy, muscle injury, and cardiovascular collapse. 3

Clinical Context

The 2025 Society of Critical Care Medicine guidelines represent the most current evidence-based approach, emphasizing that rapid cooling is the single most important intervention to prevent irreversible organ damage and death. 1 While the 2007 systematic review found no single cooling method superior for classic heat stroke, the consensus strongly supports cold-water immersion for exertional heat stroke based on cooling rate data. 1 The key principle remains: cool first, ask questions later—every minute of delayed cooling increases mortality risk. 1, 6