What is the management of heat stroke?

Management of Heat Stroke

Immediate aggressive cooling is the cornerstone of heat stroke management, with cold-water immersion (14-15°C) being the gold standard for exertional heat stroke in young, fit patients, while evaporative cooling combined with ice pack application is equally effective for classic heat stroke in older patients. 1

Immediate Cooling Interventions

For Exertional Heat Stroke (Young, Fit Patients)

• Whole-body cold-water immersion at 14-15°C is the definitive treatment, targeting a cooling rate of ≥0.155°C/min 1
• Continue cooling for 15 minutes or until neurological symptoms resolve, whichever occurs first 1
• This method has demonstrated zero fatality rates in large case series of younger patients 2

For Classic Heat Stroke (Elderly, Comorbid Patients)

• Apply ice packs to the neck, axilla, and groin while using evaporative cooling (wet skin with continuous fanning) 1, 3
• No single cooling technique has proven superior in classic heat stroke; evaporative and conductive methods show comparable effectiveness 3
• Augment evaporative cooling with crushed ice or ice packs applied diffusely to the body 2

Alternative Cooling Methods When Immersion Unavailable

• Chilled intravenous fluids (4°C) can supplement primary cooling 3
• Endovascular cooling devices are effective when external methods fail, achieving target temperature within 45 minutes 4
• Novel cooling suits (e.g., CarbonCool®) allow continuous cooling during transport and concurrent medical procedures 5

Critical Temperature Targets

• Cool until core temperature reaches 39°C or neurological symptoms resolve 1
• Do not delay cooling for diagnostic workup 1
• The severity of tissue injury and mortality directly correlates with the degree and duration of hyperthermia 3

Concurrent Hemodynamic Management

Circulatory Support

• Establish IV access immediately and begin fluid resuscitation to restore blood pressure and tissue perfusion 1
• Heat stroke causes distributive shock with relative or absolute hypovolemia, not primarily myocardial failure 3
• Hypotension carries a 33% mortality rate compared to 10% in normotensive patients 1
• Consider invasive hemodynamic monitoring (central venous or pulmonary artery catheters) if hypotension persists after initial cooling and fluids 1

Airway and Seizure Management

• Monitor continuously for recurrent seizures during cooling 1
• Consider intubation if the patient cannot protect their airway given altered mental status 1
• Maintain airway patency throughout aggressive cooling procedures 1

Critical Pitfalls to Avoid

Ineffective Interventions

• Do not use antipyretics (acetaminophen, NSAIDs) or dantrolene - they are ineffective in heat stroke and may worsen coagulopathy and liver injury 1
• Ice packs applied only to strategic locations (neck, axilla, groin) without diffuse application are not recommended as primary cooling 2
• Cooling blankets alone are insufficient as primary cooling methods 2

Monitoring Requirements

• Continuous core temperature monitoring (rectal or esophageal) is mandatory 1
• Frequent neurological assessments to detect improvement or deterioration 1
• Monitor for multi-organ dysfunction including rhabdomyolysis, acute kidney injury, liver injury, coagulopathy, and cardiac dysfunction 1

Pathophysiology Considerations

• Heat triggers direct cytotoxicity plus complex inflammatory and coagulation responses 3
• Cooling alone may not abrogate inflammation and coagulation activation in over one-third of patients who progress to multi-organ dysfunction 3
• Death from heat stroke occurs primarily from early hyperthermia and cardiovascular failure, with up to one-third developing irreversible organ damage 3

Special Considerations

• Hyperthermia creates a high blood flow state from cutaneous vasodilation, fundamentally different from post-cardiac arrest hypothermia protocols 3
• Do not extrapolate therapeutic hypothermia protocols from cardiac arrest management to heat stroke patients 3
• Immunomodulators (IL-1 receptor antagonists, corticosteroids, activated protein C) show promise in animal models but lack human evidence 3