Exertional heat stroke: an evidence based approach to clinical assessment and management

What is the topic of this review? The treatment of exertional heat stress, from initial field care through the return-to-activity decision. What advances does it highlight? Clinical assessment during field care using AVPU and vital signs to gauge recovery, approaches to field cooling and end of active cooling, and shared clinical decision making for return to activity recommendations.

Exertional heat stroke (EHS) is a potentially fatal condition characterized by central nervous system (CNS) dysfunction and body temperature often but not always >40°C that occurs in the context of physical work in warm or hot environments. In this paper, we review the continuum of care, from initial recognition and field care to transport and hospital care, and finally return-to-duty considerations. Morbidity and mortality can be greatly reduced if not eliminated with prompt recognition and aggressive cooling. If medical personnel are not present at point of collapse during or immediately following exercise, EHS should be the presumptive diagnosis until a formal diagnosis can be determined by qualified medical staff. EHS is a rare medical situation where initial treatment (cooling) takes precedence over transport to a medical facility, where advanced medical care may be required for severe EHS casualties. Recovery from EHS and return to activity is usually straightforward and unremarkable provided the casualty is rapidly cooled at time of collapse and adequate time is allowed for body healing. However, evidence-based data to guide return to activity following EHS are limited. Current research suggests that most individuals recover completely within a few weeks though some individuals may suffer prolonged sequalae and additional evaluation may be warranted, including heat tolerance testing (HTT). Several aspects of the care of the EHS casualty are based on best practices derived from personal experience and continued research is necessary to optimize evaluation and management.