Recognition and Management of Exertional Heat Stroke:

With the summer months now upon us, there exists a possibly of athletes suffering from exertional heat stroke (EHS). Proper recognition and management of EHS is critical and can be lifesaving. The following is a summary of recommendations put forth by The American College of Sports Medicine and published in ‘Current Sports Medicine Reports’ in 2012. An article from 2011 in ‘American Family Physician’ was also referenced. Definition of EHS: A core temperature of >40 degrees Celsius, coupled with central nervous system alteration characterized by altered behaviour (not necessarily loss of consciousness). Predisposing factors: EHS is complex and varies from athlete to athlete. The following is a list of potential contributing factors:
  • Low level of physical fitness
  • Intensity of activity
  • Sleep deprivation
  • High ambient temperature
  • Intense solar radiation
  • Exercise intensity not matched to physical fitness
  • Medications that alter heat dissipation (i.e.: antihistamines, anticholinergics, calcium channel blockers, amphetamines)
  • Dehydration
Diagnosis of EHS: The paper outlines that most deaths from EHS, if diagnosed and managed within 10 minutes of collapse, are preventable. Proper diagnosis requires:
  • That temperature is taken rectally. Any other form of temperature measurement (i.e.: oral, axillary, tympanic) is not predictive and can give a false sense of security
  • Recognition of CNS dysfunction with any of the following
    • Anhydrosis
    • Mental status changes
      • Coma
      • Ataxia
      • Confusion
      • Irritability
      • Seizures
Management of EHS 
  • Reducing the temperature to <40 degrees Celsius within 30 minutes is critical
  • Initiate cooling methods immediately
  • The gold standard for cooling is cold water immersion if available
  • If a tub is available, covering as much of the athletes body as possible (except the head) should be done in very cold (1.7 to 14 degrees Celsius) or ice water
  • Remember to continually stir the water in the tub
  • If out in the field and there is not access to a tub, cooling can be initiated with covering of the athletes body with cold towels or ice and rotated every couple of minutes
  • Rapid transport to a hospital (ideally when a temperature is <40 Celsius if cold water immersion is available)
Return to play after EHS 
  • Refrain from activity for at least 7 days after EHS
  • Follow-up with medical care 1 week after incident for physical exam and possible investigations (i.e.: check lytes, CK, Cr, etc.)
  • When initiating physical activity again, begin in a cool setting, and gradually increase intensity, duration and temperature of setting over a period of 2 weeks
  • Athlete should be back to their pre EHS activity level by 4 weeks of initiating return to play
Lastly, recognize Heat Exhaustion, a milder form of exertional heat illness and manage accordingly, in order to prevent progression to EHS. Exertional heat exhaustion is characterized by:
  • A core temperature between 37-40 degrees Celcius
  • Symptoms such as headache, weakness, dizziness, goose flesh, nausea, vomiting, diarrhea, irritability, and loss of coordination
Heat Exhaustion is managed by: 
  • Moving the athlete into the shade, or a cooler environment if possible
  • Remove excess clothing
  • Rehydrate the athlete, preferably oral
  • Use cold towels to cool the athlete
  • Monitor vitals and transfer to hospital if no improvement after 30 minutes of treatment by the methods above
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