Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Diagnose heat stroke; start rapid cooling immediately (CWI if available).
- Support ABCs; aggressive fluids; manage shivering; monitor for arrhythmias.
- Screen and treat rhabdo, DIC, AKI, hyponatremia; admit to ICU as needed; counsel on prevention.
Clinical Synopsis & Reasoning
Core temperature ≥40°C with CNS dysfunction. Begin rapid cooling immediately—prefer cold-water immersion for exertional heat stroke or aggressive evaporative cooling with ice packs if immersion unavailable. Avoid antipyretics. Manage rhabdomyolysis, DIC, AKI, and electrolyte derangements; admit to ICU for severe cases.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| Core temp (rectal) and mental status | Diagnosis/severity | ≥40°C with CNS dysfunction | Continuous monitoring |
| CK, BMP, LFTs, coagulation panel | Complications | Rhabdo, AKI, DIC | Trend q4–6 h |
| UA and myoglobin, EKG | Complications | Myoglobinuria, dysrhythmias | Telemetry if severe |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Core temp ≥40°C with CNS dysfunction | Diagnostic emergency | Immediate cold-water immersion/evaporative cooling; ICU |
| Rhabdomyolysis, DIC, AKI | Multiorgan failure | Aggressive fluids; labs q4–6 h; nephrology/hematology consults |
| Neuroleptic malignant syndrome/serotonin syndrome mimics | Mismanagement risk | Differentiate; treat underlying toxidrome |
| Elderly or comorbid heart disease | Cooling/volume risks | Monitor closely; avoid overhydration |
| Delayed cooling (>30 min) | Worse outcomes | Maximize cooling; target <39°C |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Cold-water immersion (preferred in exertional) or evaporative cooling | Cooling modality | Immediate | Target <39°C within 30 min | Avoid antipyretics |
| IV crystalloids | Supportive | Immediate | Treat hypovolemia/rhabdo | Urine output goals ≥1–2 mL/kg/h |
| Benzodiazepines for shivering/agitation | Sedation | Minutes | Facilitate cooling | Avoid anticholinergics |
| Treat complications (e.g., DIC with blood products) | Organ support | Hours | Address coagulopathy/AKI | ICU if severe |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ACSM/NEJM reviews on heat stroke management — Link