eMedicine Specialties > Emergency Medicine > Environmental

Heatstroke: Follow-up

Author: Robert S Helman, MD, Director, Department of Emergency Medicine, Victory Memorial Hospital
Coauthor(s): Rania Habal, MD, Assistant Professor, Department of Emergency Medicine, New York Medical College
Contributor Information and Disclosures

Updated: Sep 18, 2009

Follow-up

Further Inpatient Care

  • Once the acute phase is stabilized, further inpatient care may be necessary to address the complications of heatstroke.

Further Outpatient Care

  • Long-term outpatient therapy may be required when chronic renal failure develops and when irreversible damage to the CNS, lungs, heart, and liver occurs.

Deterrence/Prevention

  • Heatstroke is a preventable illness, and education is the single most important tool for its prevention.
  • Recognition of host risk factors and modification of behavior (eg, limiting alcohol and drug intake, avoiding use of medications and drugs that interfere with heat dissipation) and physical activity also can prevent heatstroke.

Complications

  • Heatstroke is a multisystem insult that potentially can affect almost every organ system.
  • The CNS is especially sensitive to the damaging effects of hyperthermia. Widespread cell death occurs but is more evident in the region of the cerebellum (Purkinje cells). Heatstroke–related long-term CNS sequelae include cerebellar deficits, dementia, hemiplegia, quadriparesis, and personality changes.
  • In one study, rhabdomyolysis was observed in almost all patients with EHS and in as many as 86% of patients with NEHS. Compartment syndrome is observed most commonly in patients with severe rhabdomyolysis and in patients who are immobilized.
  • ARF may occur in as many as 25-30% of patients who have heatstroke (especially EHS).
  • Acute liver failure due to centrilobular hepatic necrosis and cholestasis generally occurs in the first 48 hours, but it can peak as long as 2 weeks after the onset of heatstroke. In rare instances, liver failure may be complicated by a fulminant course requiring liver transplantation. Patients who survive generally have a complete return of hepatic function.
  • DIC is a rare complication and caries a poor prognosis when it occurs. Electron microscopy studies have shown that direct thermal injury to the vascular endothelium is the primary trigger of platelet aggregation and, possibly, DIC.
  • ARDS may be due to direct thermal injury to the lung, or it may complicate liver failure, infection, or aspiration. When associated with liver failure, the patient prognosis is much worse.

Prognosis

  • Indicators of poor prognosis during acute episodes include the following:
    • Initial temperature measurement higher than 41°C or a temperature higher than 108°F or a temperature persisting above 102°F despite aggressive cooling measures
    • Coma duration longer than 2 hours
    • Severe pulmonary edema
    • Delayed or prolonged hypotension
    • Lactic acidosis in patients with classic heatstroke
    • ARF and hyperkalemia
    • Aminotransferase levels greater than 1000 IU/L during the first 24 hours

Patient Education

  • Education is the single most important tool for the prevention of heatstroke.
    • The media, public education, public health programs, and athlete safety programs can play a pivotal role in increasing the public's awareness of the dangers of heat during heat waves and advising the public on methods of remaining cool.
    • Similarly, drinking fluids on schedule (and not based only on thirst), frequent cooling breaks, and frequent visits to air-conditioned places are very important because even short stays in an air-conditioned environment may drastically reduce the incidence of heatstroke.
    • Recognition of host risk factors and modification of behavior (eg, limiting alcohol and drug intake and the use of medications and drugs that interfere with heat dissipation) and physical activity also will prevent heatstroke.
  • For excellent patient education resources, visit eMedicine's Environmental Exposures and Injuries Center and Exercise, Nutrition, and Weight Management Center. Also, see eMedicine's patient education articles Heat Exhaustion and Heat Stroke and Heat Cramps.

Miscellaneous

Medicolegal Pitfalls

  • Relying on the criteria listed in the classic definition for diagnosing heatstroke
  • Failure to consider the diagnosis in mildly hyperthermic patients with altered mental status: The diagnosis of heatstroke should be applied liberally to patients with altered mental status during environmental heat waves, even in the absence of severe hyperthermia.
  • Failure to measure the temperature, thereby delaying the diagnosis and therapy
  • Failure to initiate cooling measures in an expeditious manner
  • Overcooling, thus causing iatrogenic hypothermia
  • Prescribing antipyretics
 


More on Heatstroke

Overview: Heatstroke
Differential Diagnoses & Workup: Heatstroke
Treatment & Medication: Heatstroke
Follow-up: Heatstroke
References
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Further Reading

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Keywords

heatstroke, heat stroke, hyperthermia, heat-related diseases, exertional heatstroke, EHS, heat exhaustion, heat illness, heat rash, heat edema, heat cramps, nonexertional heatstroke, hyperthermia

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Contributor Information and Disclosures

Author

Robert S Helman, MD, Director, Department of Emergency Medicine, Victory Memorial Hospital
Disclosure: Nothing to disclose.

Coauthor(s)

Rania Habal, MD, Assistant Professor, Department of Emergency Medicine, New York Medical College
Disclosure: Nothing to disclose.

Medical Editor

Laurie Robin Grier, MD, Medical Director of MICU, Associate Professor of Medicine, Section of Pulmonary and Critical Care Medicine, Louisiana State University Health Science Center at Shreveport
Laurie Robin Grier, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society for Parenteral and Enteral Nutrition, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H, Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine
Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine
Disclosure: Keck School of Medicine, USC None None

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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