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Exertional heat stroke — Clinical Guidelines

Overview

Exertional heat stroke (EHS) is a severe medical emergency characterized by rapid hyperthermia and central nervous system dysfunction during or immediately after physical exertion, predominantly affecting young, healthy individuals 8. It carries significant morbidity and mortality risks if not promptly recognized and treated 1 8.

Diagnosis

Key Diagnostic Criteria: Core body temperature ≥40°C (104°F) 8

Recommended Tests: Rapid core temperature measurement, neurological assessment, and evaluation of multiorgan dysfunction 1 8

Grading: Often assessed based on severity of organ involvement and initial response to cooling 19

Management

First-Line Treatments: Immediate cold-water immersion (CWI) for rapid cooling 8 1 5

Adjunctive Treatments: Fluid resuscitation, monitoring for and managing multiorgan failure, including renal, pulmonary, and hepatic support 1 17

Specific Interventions: Therapeutic plasma exchange considered in cases with multiorgan failure unresponsive to conventional therapies 17

Special Populations

Pediatrics: Specific guidelines for return to play/duty vary among military branches; individualized assessment crucial 3

Comorbidities: Persistent thrombocytopenia identified as an independent risk factor for mortality and multiorgan failure 1

Key Recommendations

Immediate Cooling: Initiate cold-water immersion for rapid cooling upon suspicion of EHS (Evidence: Strong 8 1)

Monitor Multiorgan Function: Closely monitor for signs of multiorgan failure, including renal, pulmonary, and hepatic dysfunction (Evidence: Moderate 1 17)

Individualized Rehabilitation: Consider individualized rehabilitation plans, including heat tolerance testing, for return to play/duty post-EHS (Evidence: Expert opinion 5 11)

Thrombocytopenia Monitoring: Assess and monitor for persistent thrombocytopenia as a predictor of poor outcomes (Evidence: Moderate 1)

Standardized Protocols: Implement standardized protocols for intracompartmental pressure testing in managing chronic exertional compartment syndrome, if applicable (Evidence: Expert opinion 18)

References

1 Zhong L, Liu Y, Wang C, Liu Z, Su L, Liu Z et al.. Persistent thrombocytopaenia as an independent risk factor for 28-day mortality and multiorgan failure in exertional heatstroke: a retrospective study of 217 patients. International journal of hyperthermia : the official journal of European Society for Hyperthermic Oncology, North American Hyperthermia Group 2025. link 2 O'Reilly M, Hu YE, Gruber J, Jones DM, Daniel A, Marra J et al.. Consistency and applicability of return to function guidelines in tactical-athletes with exertional heat illness. A systematic review. The Physician and sportsmedicine 2023. link 3 Caraway JJ, Shepard J, Hintz C, Butler CR. Management of a Special Warfare Trainee With Repeat Exertional Heat Stroke: A Case Study. Journal of sport rehabilitation 2023. link 4 Bouché RT, Seidenstricker C, Ray RG, Saxena A. Management of Chronic Exertional Compartment Syndrome of the Foot: A Report of 3 Cases. Journal of the American Podiatric Medical Association 2023. link 5 Pryor RR, Pryor JL, McDermott BP. Persistent Knowledge Gaps Regarding Exertional Heat Stroke Treatment. Journal of athletic training 2022. link 6 Miller KC, Casa DJ, Adams WM, Hosokawa Y, Cates J, Emrich C et al.. Roundtable on Preseason Heat Safety in Secondary School Athletics: Prehospital Care of Patients With Exertional Heat Stroke. Journal of athletic training 2021. link 7 Grundstein AJ, Scarneo-Miller SE, Adams WM, Casa DJ. From theory to practice: operationalizing a climate vulnerability for sport organizations framework for heat hazards among US High schools. Journal of science and medicine in sport 2021. link 8 van den Bersselaar LR, Bongers CCWG, Eijsvogels TMH, Hopman MTE, van Rijswick MH, Kruijt N et al.. [Exertional heat stroke in athletes and soldiers]. Nederlands tijdschrift voor geneeskunde 2020. link 9 Carlström E, Borjesson M, Palm G, Khorram-Manesh A, Lindberg F, Holmer B et al.. Medical Emergencies During a Half Marathon Race - The Influence of Weather. International journal of sports medicine 2019. link 10 Adams WM. Exertional Heat Stroke within Secondary School Athletics. Current sports medicine reports 2019. link 11 OʼConnor FG, Heled Y, Deuster PA. Exertional Heat Stroke, the Return to Play Decision, and the Role of Heat Tolerance Testing: A Clinician's Dilemma. Current sports medicine reports 2018. link 12 Keen ML, Miller KC, Zuhl MN. Thermoregulatory and Perceptual Effects of a Percooling Garment Worn Underneath an American Football Uniform. Journal of strength and conditioning research 2017. link 13 Jiao J, Zhou F, Kang H, Liu C, Yang M, Hu J. Unexpected extrapyramidal symptoms and pulmonary aspergillosis in exertional heatstroke with fulminant liver failure: a case report. Journal of medical case reports 2017. link 14 Schleich K, Slayman T, West D, Smoot K. Return to Play After Exertional Rhabdomyolysis. Journal of athletic training 2016. link 15 Nauck T, Lohrer H, Padhiar N, King JB. Development and validation of a questionnaire to measure the severity of functional limitations and reduction of sports ability in German-speaking patients with exercise-induced leg pain. British journal of sports medicine 2015. link 16 King MA, Leon LR, Mustico DL, Haines JM, Clanton TL. Biomarkers of multiorgan injury in a preclinical model of exertional heat stroke. Journal of applied physiology (Bethesda, Md. : 1985) 2015. link 17 Raj VM, Alladin A, Pfeiffer B, Katsoufis C, Defreitas M, Edwards-Richards A et al.. Therapeutic plasma exchange in the treatment of exertional heat stroke and multiorgan failure. Pediatric nephrology (Berlin, Germany) 2013. link 18 Hislop M, Tierney P. Intracompartmental pressure testing: results of an international survey of current clinical practice, highlighting the need for standardised protocols. British journal of sports medicine 2011. link 19 Zeller L, Novack V, Barski L, Jotkowitz A, Almog Y. Exertional heatstroke: clinical characteristics, diagnostic and therapeutic considerations. European journal of internal medicine 2011. link 20 O'Connor FG, Casa DJ, Bergeron MF, Carter R, Deuster P, Heled Y et al.. American College of Sports Medicine Roundtable on exertional heat stroke--return to duty/return to play: conference proceedings. Current sports medicine reports 2010. link 21 Mazerolle SM, Scruggs IC, Casa DJ, Burton LJ, McDermott BP, Armstrong LE et al.. Current knowledge, attitudes, and practices of certified athletic trainers regarding recognition and treatment of exertional heat stroke. Journal of athletic training 2010. link 22 Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Medicine and science in sports and exercise 2007. link 23 Casa DJ, Becker SM, Ganio MS, Brown CM, Yeargin SW, Roti MW et al.. Validity of devices that assess body temperature during outdoor exercise in the heat. Journal of athletic training 2007. link 24 McDermott BP, Casa DJ, Yeargin SW, Ganio MS, Armstrong LE, Maresh CM. Recovery and return to activity following exertional heat stroke: considerations for the sports medicine staff. Journal of sport rehabilitation 2007. link 25 Marino M. Profiling swimmers. Clinics in sports medicine 1984. link 26 Rushall BS, Busch JD. Hematological responses to training in elite swimmers. Canadian journal of applied sport sciences. Journal canadien des sciences appliquees au sport 1980. link 27 Houston ME. Diet, training and sleep: a survey study of elite Canadian swimmers. Canadian journal of applied sport sciences. Journal canadien des sciences appliquees au sport 1980. link 28 Poole GW, Crepin BJ, Sevigny M. Physiological characteristics of elite synchronized swimmers. Canadian journal of applied sport sciences. Journal canadien des sciences appliquees au sport 1980. link 29 McKenzie TL, Rushall BS. Effects of self-recording on attendance and performance in a competitive swimming training environment. Journal of applied behavior analysis 1974. link

Exertional heat stroke