6-50
Follow-up Actions
Return Evaluation: If the patient fails to improve rapidly, assume the patient is a heat stroke casualty
and treat as such with rapid cooling and evacuation. A single episode of heat exhaustion does not imply a
predisposition to heat injury and no continuing follow up or profile evaluation is required.
Consultation Criteria: Repeated episodes of heat exhaustion require a temporary profile against heat
exposure, evacuation and referral for a thorough evaluation.
NOTES: A case of heat exhaustion or heat stroke should alert the command to instigate work/rest cycles,
increased water and electrolyte intake and reduced workload. The difference between heat exhaustion
and heat stroke is usually impossible to determine. Soldiers who do not respond dramatically to rest and
fluid/electrolyte repletion should be observed for 24 hours for delayed complications of heat stroke.
Heat-Related Illnesses: Heat Stroke
LTC Richard Kramp, MC, USAIntroduction: Heat stroke is a medical emergency, distinguished from heat exhaustion by the presence
of neurological symptoms. If heat stroke is suspected and body temperature is elevated, start cooling
immediately! Do not delay for a diagnostic evaluation. Cooling and evaluation should proceed simultaneously.
Risk Factors: A history of previous heat stroke, poor physical conditioning, dehydration, high work loads in a
hot environment, illness with fever, medications that interfere with sweating or contribute to dehydration such
as caffeine, alcohol and diuretics.
Subjective: Symptoms
Dizziness, exhaustion, weakness, nausea, possible involuntary urination, confusion, delirium and other mental
status changes.
Focused History: What have you had to eat and drink in the last 48 hours? (Water and salt intake may
be too low. If they have consumed several gallons of fluid in the past 2 hours consider hyponatremia- water
intoxication.) Do you know who you are, where you are and what day it is? (While heat exhaustion patients
may be confused, it is a common sign of heat stroke. A patient with mental status changes should be treated
as a heat stroke patient until it is proven otherwise.) How did your skin get wet? (Sweating is rare but happens
in heat stroke. Cooling liquids may have been applied.) What were you doing today? (typical exposure of
work in hot environment).
Objective: Signs
Using Basic Tools: Inspection: Sudden collapse and unconsciousness; diminished or absent sweating
with hot, red skin; markedly elevated rectal temperature to 106-110°F (not universal); convulsions; seizures;
diminished urination.
Auscultation: Elevated blood pressure; rapid, deep respirations dropping off to shallow and irregular
respirations.
Palpation: Diminished or absent sweating with hot, red skin; rapid, thready pulse.
Assessment:
Differential Diagnosis - infection (particularly meningococcemia and P. falciparum malaria), pontene or
hypothalamic hemorrhage, drug intoxication (cocaine, amphetamines, phencyclidine, theophylline, tricyclic
antidepressants), alcohol or sedative withdrawal, severe hypertonic dehydration and thyroid storm.
Plan:
Treatment
- Reduce body temperature rapidly: Use any means available. Ice water is preferred but seldom available
in the field. Field expedient baths, which will keep the water cool, can be constructed by digging plastic-lined,
shaded pits. Discontinue active cooling when the rectal temperature reaches 101°F in order to avoid