What are the immediate management steps for heat stroke?

Heat Stroke Management

Immediately initiate aggressive cooling with cold-water immersion (14-15°C) as the first-line treatment for heat stroke, targeting a core temperature below 39°C within 30 minutes, while simultaneously activating emergency services and establishing IV access for fluid resuscitation. 1

Immediate Recognition and Initial Actions

Activate emergency medical services immediately upon recognizing heat stroke, defined as core temperature >40°C with CNS dysfunction (altered mental status, confusion, seizures, or coma). 1

Remove the patient from the hot environment immediately and strip off excess clothing to facilitate heat dissipation. 1

Do not delay cooling for diagnostic workup or transport—begin cooling at the scene and continue throughout transport and into the hospital setting. 2, 3

Primary Cooling Strategy: Cold-Water Immersion

Cold-water or ice-water immersion (14-15°C/57.2-59°F) is the gold standard cooling method and should be prioritized where available, as it achieves the fastest cooling rate. 1

• Immerse the patient neck-down in cold water for 15 minutes or until neurological symptoms resolve, whichever occurs first. 1
• Target a cooling rate of ≥0.155°C/min to minimize morbidity and mortality. 2, 3
• Continue cooling until core temperature reaches 39°C (102.2°F), not normal temperature, to avoid overshooting and inducing hypothermia. 1, 2

The 2025 Society of Critical Care Medicine guidelines provide the strongest evidence, making a strong recommendation for active cooling over passive methods, with cold-water immersion achieving superior outcomes. 1

Alternative Cooling Methods When Immersion Unavailable

When cold-water immersion is not feasible (mass casualty events, lack of equipment, or patient instability requiring concurrent procedures), use these alternatives: 1

• Apply commercial ice packs to the neck, axillae, and groin (areas of large blood vessels). 1, 2
• Use cold showers, ice sheets, and wet towels applied to the skin. 1
• Implement evaporative cooling: wet the skin with water and apply continuous fanning. 1, 3
• Consider cooling vests, jackets, or novel devices like CarbonCool® that allow concurrent medical procedures and imaging. 4

Concurrent Critical Interventions

Establish IV access immediately and begin fluid resuscitation with crystalloids to address hypotension and maintain tissue perfusion. 2, 3

• Hypotension in heat stroke carries a 33% mortality rate versus 10% in normotensive patients, making aggressive fluid management essential. 3
• Titrate fluids to restore blood pressure and urine output. 2, 3
• Consider invasive hemodynamic monitoring if hypotension persists despite initial cooling and fluids. 3

Maintain airway patency in patients with altered mental status—consider intubation if the patient cannot protect their airway during aggressive cooling. 3

Monitor and manage seizures if they occur during cooling, but do not delay cooling to address seizures. 2, 3

Critical Pitfall: Avoid Pharmacological Temperature Control

Do not administer antipyretics (acetaminophen, NSAIDs) or dantrolene—there is no evidence supporting their use in heat stroke, and they may worsen coagulopathy and liver injury. 1, 3

This represents a strong recommendation from the 2025 Society of Critical Care Medicine guidelines based on lack of efficacy and potential harm. 1

Monitoring Requirements

Continuously monitor core temperature using rectal, esophageal, or bladder thermometry—oral and tympanic measurements are unreliable. 2, 3

Assess neurological status frequently (Glasgow Coma Scale, pupillary response, motor function) to detect improvement or deterioration. 2, 3

Monitor for multi-organ dysfunction, which commonly develops in heat stroke: 3, 5

• Rhabdomyolysis (elevated creatine kinase, myoglobin)
• Acute kidney injury (rising creatinine, oliguria)
• Liver injury (elevated transaminases)
• Coagulopathy (prolonged PT/PTT, thrombocytopenia, DIC)
• Cardiac dysfunction (arrhythmias, troponin elevation)
• Acute respiratory distress syndrome

Document cooling methods used, duration, and patient response to guide ongoing management. 2

Prognostic Considerations

Prognosis is optimal when cooling begins within 30 minutes and core temperature is reduced rapidly. 1, 5

Delayed treatment beyond 2 hours significantly worsens outcomes, with approximately 20% of survivors experiencing permanent neurological sequelae. 5, 6

Survival is directly related to the speed of temperature reduction—faster cooling correlates with better survival and reduced organ dysfunction. 1