Critical Cases - Heat Emergency!


  • 54 yo M w/ PMH of ETOH abuse, schizophrenia, seizure disorder on keppra with questionable compliance presents with seizure
  • Per EMS - patient was drinking beer, mowing the lawn (middle of day, 100 ℉, 100% humidity) and began seizing which terminated without intervention
  • On arrival patient is still postictal/unresponsive, not able to contribute to history


Physical Exam:

HR 144 BP 58/33 RR 22 O2 98% (on NRB) T 108.6 (core)

  •  Patient is completely obtunded and unresponsive
  •  Airway grossly patent but rhonchorous with equal breath sounds
  •  Skin is warm and dry with weak peripheral pulses
  •  No signs of trauma


Bedside Diagnostics:

  • Blood glucose: 93





  • ECG: Sinus tachycardia with poor baseline, peaked T waves


Differential Diagnosis:

  •  Heat stroke (exertional vs non-exertional)
  •  Neuroleptic malignant syndrome
  •  Thalamic stroke vs ICH vs SAH
  •  Intoxication/drug use
  •  Serotonin syndrome
  • Thyroid syndrome
  • Status epilepticus
  • Sepsis



  • Immediate and aggressive cooling - bags of ice in groin, axilla, neck while setting up for evaporative and convective cooling (spraying patient with tepid water with large fans blowing cool air at patient)
  • Stop cooling at 39 ℃ to prevent afterdrop
  • Benzos as needed to prevent shivering (ativan 1-2mg)
  • Fluid resuscitate (2-3L) → no change in hemodynamics
  • Anticipate and manage complications: hyperkalemia, hypoglycemia, seizures, ARDS, AKI, rhabdomyolysis, shock liver, DIC


Teaching points:

  • Heat stroke is life threatening condition (mortality estimated 21-63%) defined by core temperature >104 ℉ (40 ℃) plus neurologic deficit or altered mental status 
  • Treatment is immediate cooling: Most effective method: ice bath immersion (not usually practical in ER setting with unstable patients), Effective and practical: evaporative and convective cooling
  • Adjuncts: ice packs to neck, axilla and groin; cold IV fluids, cooling blankets


References: Bouchama A et al. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care. 2007;11(3):54. Douma M et al. First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis. Resuscitation. 2020; 148:173-190. Mehta SR and Jaswal DS. Heat stroke. Med J Armed Forces India. 2003 Apr; 59(2): 140–143.