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Heat stroke is a life-threatening medical emergency resulting from failure of the thermoregulatory mechanism Heat stroke is imminent when the core (rectal) temperature approaches 41 C It presents in one of two forms: Classic heat stroke occurs in patients with compromised homeostatic mechanisms; exertional heat stroke occurs in healthy persons undergoing strenuous exertion in a thermally stressful environment Morbidity or even death can result from cerebral, cardiovascular, hepatic, or renal damage The hallmarks of heat stroke are cerebral dysfunction with impaired consciousness, high fever, and absence of sweating Persons at greatest risk are the very young, the elderly (age > 65), chronically infirm, and patients receiving medications (eg, anticholinergics, antihistamines, phenothiazines) that interfere with heat-dissipating mechanisms Exertional heat stroke and exertion-related disorders such as rhabdomyolysis are appearing more frequently as complications of participation by unconditioned amateurs in strenuous athletic activities, such as marathon and triathlon competition, or during heat waves Heat stroke is still associated with high mortality In a study of heat stroke patients, in-hospital mortality was 626% Risk factors were identifiable within the first 24 hours of

Fluid and electrolyte depletion can result in slow, painful skeletal muscle contractions ( cramps ) and severe muscle spasms lasting 1 3 minutes, usually of the muscles most heavily used Cramping results from dilutional hyponatremia as sweat losses are replaced with water alone The skin is moist and cool, and the muscles are tender There may be muscle twitching The victim is alert, with stable vital signs, but may be agitated and complaining of pain The body temperature may be normal or slightly increased Involved muscle groups are hard and lumpy There is almost always a history of vigorous activity just preceding the onset of symptoms Laboratory evaluation may show low serum sodium, hemoconcentration, and elevated urea and creatinine

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systems as well as hemodialysis using cold dialysate (30 35 C) have been successful in reducing core temperature Other cooling alternatives include hand and forearm immersion in cold water, ice packs (groin, axillas, neck), and iced gastric lavage, although these are much less effective than evaporative cooling Treatment should be continued until the rectal temperature drops to 39 C The temperature remains stable in most cases, but it should continue to be monitored for 24 hours Antipyretics (aspirin, acetaminophen) have no effect on environmentally induced hyperthermia and are contraindicated Hypovolemic and cardiogenic shock must be carefully distinguished, since either or both may occur Central venous or pulmonary artery wedge pressure should be monitored Five percent dextrose in half-normal or normal saline should be administered for fluid replacement The patient should also be observed for renal failure due to rhabdomyolysis, hypokalemia, cardiac arrhythmias, DIC, and hepatic failure Creatine phosphokinase (CPK) > 1000 units/L, metabolic acidosis, and elevated liver enzymes are predictive of multiorgan dysfunction, the usual cause of heat stroke related death Multiorgan dysfunction and inflammation may continue after temperature is normalized Hypokalemia frequently accompanies heat stroke but may not appear until rehydration Maintenance of extracellular hydration and electrolyte balance should reduce the risk of renal failure due to rhabdomyolysis Fluid administration to ensure a high urinary output (> 50 mL/h), mannitol administration (025 mg/ kg), and alkalinizing the urine (intravenous bicarbonate administration, 250 mL of 4%) are recommended Fluid output should be monitored through the use of an indwelling urinary catheter Because sensitivity to high environmental temperature may persist for prolonged periods following an episode of heat stroke, immediate reexposure should be avoided

Glazer JL Management of heatstroke and heat exhaustion Am Fam Physician 2005 Jun 1;71(11):2133 40 [PMID: 15952443] Misset B et al Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: a national multiple-center risk-factor study Crit Care Med 2006 Apr;34(4):1087 92 [PMID: 16484920] Seto CK et al Environmental illness in athletes Clin Sports Med 2005 Jul;24(3):695 718, x [PMID: 16004926] Smith JE Cooling methods used in the treatment of exertional heat illness Br J Sports Med 2005 Aug;39(8):503 7 [PMID: 16046331] Sucholeiki R Heatstroke Semin Neurol 2005 Sep;25(3):307 14 [PMID: 16170743]

admission A high Simplified Acute Physiology Score II, high body temperature, prolonged prothrombin time, use of vasoactive drugs within the first day in the intensive care unit (ICU), and an ICU without air conditioning all were associated with increased mortality

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