What are the immediate management steps for a 3-month-old infant suspected of having heat stroke?

Assessment and Immediate Management of Heat Stroke in a 3-Month-Old Infant

For a 3-month-old infant with suspected heat stroke, immediately activate emergency services, remove the infant from the hot environment, strip excess clothing, and initiate rapid whole-body cooling using cool-to-cold water immersion (neck-down) for 15 minutes or until neurological symptoms resolve, targeting a core temperature below 39°C (102.2°F). 1, 2

Recognition and Initial Assessment

Heat stroke in infants presents with three cardinal features that must be immediately recognized:

• Hot, dry skin (though infants may still have some moisture) 3
• Central nervous system disturbance (altered mental status, lethargy, irritability, seizures, or coma) 1, 3
• Hyperpyrexia (core temperature >40°C/104°F) 4, 5, 3

Infants are particularly vulnerable to heat stroke because they have a greater surface area to body mass ratio, lower sweating rates, and slower acclimatization compared to adults. 6 Unlike adults where heat stroke typically follows exertion, infant heat stroke usually results from excessive environmental temperature exposure (such as being left in a hot car) or dehydration. 3

Immediate Life-Saving Interventions

Priority Actions (First 60 Seconds)

• Activate emergency medical services immediately upon recognizing altered mental status with hyperthermia 1
• Remove the infant from the hot environment to a cool area 1, 2
• Remove all excess clothing to facilitate heat dissipation 1, 2
• Assess airway, breathing, and circulation while preparing cooling measures 2

Rapid Cooling Protocol

The 2024 American Heart Association guidelines recommend immediate active cooling for children with heat stroke using whole-body (neck-down) cool-to-cold water immersion (14-15°C/57.2-59°F) for 15 minutes or until neurological symptoms resolve, whichever occurs first. 1, 2 This is the single most important intervention, as survival from heat stroke is directly related to the speed of temperature reduction—faster cooling is associated with better survival. 1

Target cooling rate: ≥0.155°C/min to achieve optimal outcomes 2

Target core temperature: Below 39°C (102.2°F) 1, 2

Alternative Cooling Methods (When Immersion Unavailable)

If cold water immersion is not immediately available, use these alternative methods:

• Apply commercial ice packs to the neck, axillae (armpits), and groin areas where large blood vessels are superficial 1, 2
• Use cold showers, ice sheets, and towels applied to the body 1, 2
• Employ evaporative cooling with cool water spray combined with fanning 1, 7

Critical Monitoring During Cooling

Vital Sign Assessment

• Monitor core temperature continuously (rectal temperature is most accurate for infants) 2
• Assess neurological status frequently (level of consciousness, pupillary response, seizure activity) to detect improvement or deterioration 2
• Monitor vital signs including heart rate, respiratory rate, and blood pressure 2

Signs of Complications to Watch For

Heat stroke can rapidly progress to multi-organ dysfunction. Monitor for:

• Cardiovascular collapse (hypotension, arrhythmias, cardiac arrest) 1, 4
• Seizures requiring immediate management 2, 3
• Coagulopathy (bleeding, petechiae) 1
• Muscle injury/rhabdomyolysis (dark urine, decreased urine output) 1, 4
• Renal failure (oliguria, anuria) 4, 3
• Hepatic involvement (jaundice may develop later) 3
• Respiratory distress requiring airway support 2

Supportive Care Measures

Fluid Management

• Establish intravenous access for fluid resuscitation as soon as possible 2
• Do NOT give oral fluids if the infant has altered mental status or cannot swallow safely 1
• If the infant is alert and able to swallow, small amounts of cool fluids may be offered 1, 2

Positioning and Airway Management

• Position the infant appropriately to maintain airway patency (lateral recumbent position if decreased consciousness) 2
• Be prepared for intubation if respiratory compromise develops 2

Common Pitfalls to Avoid

Do not delay cooling while waiting for emergency services to arrive—begin cooling immediately on-site. 1 Early recognition and immediate treatment are imperative, as delayed cooling significantly increases mortality risk. 8, 3

Do not stop cooling prematurely—continue for the full 15 minutes or until neurological symptoms resolve, even if the infant appears to improve. 1, 2

Do not use antipyretics (acetaminophen, ibuprofen) as primary treatment—these are ineffective for heat stroke and waste precious time. 5

Do not apply ice directly to skin without a barrier, as this can cause vasoconstriction and paradoxically impair cooling. 2

Hospital-Level Care Requirements

Heat stroke is a medical emergency requiring intensive monitoring and support in a hospital setting, including:

• Intravenous fluid resuscitation with careful monitoring 2, 3
• Intensive care unit admission for continuous monitoring 2, 8
• Laboratory evaluation for organ dysfunction (complete blood count, coagulation studies, renal function, liver enzymes, creatine kinase) 3
• Management of complications such as disseminated intravascular coagulation, acute kidney injury, or cerebral edema 1, 3

Prognosis

Mortality for heat stroke in children ranges from 17% to 70% depending on severity, age, and rapidity of treatment. 6 Permanent neurological sequelae can occur if cooling is delayed. 4, 3 However, prompt initiation of aggressive cooling measures can prevent permanent brain damage and provide swift neurological recovery. 4