1330 SECTION XII Pediatric Critical Care Environmental Injury and Trauma injury may lead to diarrhea The liver may be severely injured in heat stroke This is a metabolically active organ and a major s[.]
1330 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma injury may lead to diarrhea The liver may be severely injured in heat stroke This is a metabolically active organ and a major site of heat production During periods of hyperthermia, liver temperature is among the highest of any organ in the body, putting it at high risk for injury.37 Abnormal liver function tests may be seen during heat-related illnesses Elevation of aspartate aminotransferase (AST), alanine aminotransferase (ALT), g-glutamyl transpeptidase (g-GT), lactate dehydrogenase (LDH), and total bilirubin has been described.13,32,75 Patients with heat stroke demonstrate a typical rise in AST and ALT levels starting 30 minutes from onset, peaking at 48 to 72 hours following injury, with return to normal values after 10 to 14 days.37,80 Severe liver damage is more common in exertional heat stroke Fulminant liver failure is rare and usually carries a grave prognosis even with liver transplantation.81 Metabolic Early in the course of heat injury, the most common acid–base abnormality is a mixed non–anion gap metabolic acidosis and respiratory alkalosis Hypokalemia resulting from respiratory alkalosis, sweat losses, and renal wasting may change to hyperkalemia because of cellular potassium leak Several hours into the injury, the clinical picture changes into a predominantly metabolic acidosis caused by sustained tissue injury.13,32,82 Hyponatremia is the most common sodium abnormality and is typically asymptomatic Hypernatremia is rare but associated with worse outcome.83 Hematologic Anemia, thrombocytopenia, prolonged clotting time, and DIC are well documented in patients with heat stroke.7,13,32,52 Worsening coagulopathy may occur a few days after cooling Rapid drop of hematocrit in the first 24 hours following heat stroke is a common feature This is partially explained by rehydration but is most probably multifactorial The red blood cell (RBC) half-life is shortened after heat stroke; RBCs are more fragile following exposure to high temperatures, leading to early removal from the circulation.37 Hypersegmented neutrophils may be observed in peripheral blood for the first few hours following the onset of heat stroke The cause for this phenomenon is unclear These cells are thought to be undergoing changes associated with apoptosis.37 Infectious In the early phase of heat stroke, blood cultures are negative.84 In one adult study, 27% of patients had positive blood cultures and 25% had positive urine cultures 24 hours after heat stroke.13 The incidence of bacterial infections in the pediatric population with heat stroke is unknown Treatment Heat exhaustion is usually a benign clinical entity, requiring only removal of the patient from the hot environment, rest, and rehydration Referral of the more severe cases to medical attention may be necessary for intravenous fluid resuscitation and assessment of end-organ injury By contrast, heat stroke is a medical emergency, with a successful outcome depending on immediate recognition and intervention Rapid cooling and maintenance of organ perfusion and function are the major goals of treatment of heat stroke Treatment should be started promptly at the scene with removing the patient from the circumstances that led to heat stroke in order to prevent further increase in core temperature Adherence to basic resuscitative guidelines is required, with protection of the airway and management of breathing After the airway is secured, the child with heat stroke should be moved to a cool environment, clothes should be removed, intravenous access should be obtained, and a normal saline or lactated Ringer’s solution bolus should be administered Fluid resuscitation, besides ensuring organ perfusion, increases heat dissipation and lowers core temperature by improving skin blood flow.85 Cooling should be started as early as possible with readily available methods Cooling to ,39°C within 30 minutes yields survival rates of 90% to 100% in cases of exertional heat stroke and 40% to 85% in classic heat stroke.86,87 The rule of “cool first, transport second” applies This recommendation does not discount the requirement for advanced critical care at the hospital but rather prioritizes cooling in the first 30 minutes after collapse, which is critical for survival.88–90 Various cooling methods have been used to promote heat loss, but controversy remains regarding the best cooling technique Some investigators regard ice water immersion to be the most efficient cooling method.91 Indeed, ice water immersion was twice as rapid in reducing the core temperature as the evaporative spray method in patients with exertional heat stroke92 and five times faster than simply placing the patient in an air-conditioned room.93 Rapid cooling is effected through conduction of body heat across a large temperature gradient.94 Ice water is readily available and does not require special equipment It is estimated that ice water immersion cools the body at a rate of 0.15 to 0.22°C per minute.93 Some studies have indicated that cooling by ice water immersion, particularly in exertional heat stroke, is associated with 0% mortality However, it should be noted that some of these investigations applied the method to athletes and military personnel, populations who are intrinsically physically fit, immediately after onset of symptoms,93 which may account in part to its reported high success rate Others claim that there is no evidence to support the superiority of any cooling technique, especially in classic heat stroke.95,96 Critics of immersion point out that it may complicate resuscitation efforts of the comatose child who requires endotracheal intubation, mechanical ventilation, and close observation These disadvantages may be partially overcome by applying ice packs to the entire body rather than immersion in an ice cold bath, although the ice must cover the entire body; confining the application to the axilla and groin, as recommended by some, produces inferior cooling.93 Ice application is uncomfortable to the conscious child and may cause shivering and combativeness, but both may be ameliorated with benzodiazepines or narcotics Sponging the patient with ice water while massaging the body to promote cutaneous vasodilation as a fan blows air across the patient—thus employing convection and evaporation to lower body temperature—has been demonstrated to be effective, particularly in nonexertional heat stroke.97 The rapidity of lowering body heat with this technique is variable, however, likely due to differences in the temperature of the water applied to the patient and the strength of the fan.93 Evaporative/convective cooling has been made more uniform with the use of special cooling units,98 but the concept of keeping the patient “wet and windy” can be effectively achieved without specialized equipment with the application of tepid water to the skin while a commercial fan is used to keep high air flow across the patient in a cool ambient temperature.99 CHAPTER 113 Hyperthermic Injury Cooling blankets are widely used in the pediatric ICU (PICU) setting, but while the effectiveness of these devices has been evaluated in patients with fever,100 no data are available concerning their utility in heat stroke patients Invasive cooling techniques— including iced peritoneal lavage as well as bladder and gastric lavage—have been suggested Peritoneal lavage is difficult to perform and requires placement of a peritoneal catheter by trained personnel Evidence for gastric lavage comes mostly from canine models and was found to have no advantage over evaporative cooling.96 Recent reports of an intravascular cooling device to control body temperature found the system to be highly effective However, there are only case reports regarding its use on patients with heat stroke; thus, it cannot be recommended at this point.101,102 Hence, all of these techniques should be considered, at most, adjuvant to the more traditional methods for cooling.93 Antipyretics are not recommended for treatment of heat stroke.96 These drugs lower body temperature by normalizing the elevated hypothalamic set point In heat stroke, the elevated body temperature reflects failure of the cooling mechanism rather than an abnormal set point Salicylates and acetaminophen should be avoided owing to their potential to aggravate coagulopathy and hepatic injury.95,96 Dantrolene has been used successfully for malignant hyperthermia and neuroleptic malignant syndrome There are conflicting data regarding its effectiveness in heat stroke.103–105 Once a core body temperature of less than 39°C has been achieved, active cooling may be stopped This end point appears to be safe in terms of mortality, but it should be noted that a safe end point regarding long-term morbidity, particularly for neurologic outcome, has not yet been established.95 Induced hypothermia has not been evaluated for effectiveness with heat stroke A recent study looking at therapeutic hypothermia after out-of-hospital cardiac arrest in children showed no benefits in survival with good neurologic outcome.106 Hence, it is unlikely to be beneficial in pediatric patients with heat stroke All pediatric patients with heat stroke should be observed in the PICU, even if respiratory 1331 support is not required Basic laboratory evaluation should include monitoring of electrolytes, renal and liver function tests, complete blood count, creatine kinase, and coagulation studies Urine output should be followed closely, and a urine sample should be sent for myoglobin analysis Prevention is still the best approach to heat-related illness Whenever possible, people should acclimatize themselves to hot weather Physical activity should be undertaken during cooler hours, and fluid intake should be increased Children should never be left unattended in a closed car, especially during hot weather, and guidelines to prevent heat-related injuries in student athletes should be promoted and followed Physicians’ awareness and knowledge may promote diagnosis of early forms of heatrelated illness, thus, preventing progression to heat stroke On a national level, a good weather forecasting system and air-conditioned shelters for vulnerable populations may decrease heat-related morbidity and death during heat waves.107,108 Key References Bouchama A, al-Sedairy S, Siddiqui S, Shail E, Rezeig M Elevated pyrogenic cytokines in heatstroke Chest 1993;104(5):1498-1502 Casa DJ, Csillan D, Armstrong LE, et al Preseason heat-acclimatization guidelines for secondary school athletics J Athl Train 2009;44(3): 332-333 Gaudio FG, Grissom CK Cooling Methods in Heat Stroke J Emerg Med 2016;50(4):607-616 Grogan H, Hopkins PM Heat stroke: implications for critical care and anaesthesia Br J Anaesth 2002;88(5):700-707 Jardine DS Heat illness and heat stroke Pediatr Rev 2007;28(7): 249-258 Yeargin SW, Kerr ZY, Casa DJ, et al Epidemiology of exertional heat illnesses in youth, high school, and college football Med Sci Sports Exerc 2016;48(8):1523-1529 The full reference list for this chapter is available at ExpertConsult.com e1 References Kalkstein LS, Greene JS An evaluation of climate/mortality relationships in large U.S cities and the possible impacts of a climate change Environ Health Perspect 1997;105(1):84-93 O’Neill MS, Ebi KL Temperature extremes and health: impacts of climate variability and change in the United States J Occup Environ Med 2009;51(1):13-25 Centers for Disease Control and Prevention Heat-related deaths— United States, 1999-2003 MMWR Morb Mortal Wkly Rep 2006; 55(29):796-798 Centers for Disease Control and Prevention QuickStats: Number of Heat-Related Deaths, by Sex - National Vital Statistics System, United States, 1999-2010 MMWR Morb Mortal Wkly Rep 2012;61(36):729 US Dept of Commerce NWS Office of Climate, Water, and Weather Services Weather Fatalities, 2018 2019 https://www.nws.noaa.gov/ om/hazstats.shtml Voorhees AS, Fann N, Fulcher C, et al Climate change-related temperature impacts on warm season heat mortality: a proof-of-concept methodology using BenMAP Environ Sci Technol 2011;45(4):14501457 Bouchama A, Knochel JP Heat stroke N Engl J Med 2002;346(25): 1978-1988 Schwellnus MP, Drew N, Collins M Muscle cramping in athletes— risk factors, clinical assessment, and management Clin Sports Med 2008;27(1):183-194, ix-x Thacker MT, Lee R, Sabogal RI, Henderson A Overview of deaths associated with natural events, United States, 1979-2004 Disasters 2008;32(2):303-315 10 Donoghue ER, Graham MA, Jentzen JM, Lifschultz BD, Luke JL, Mirchandani HG Criteria for the diagnosis of heat-related deaths: National Association of Medical Examiners Position paper National Association of Medical Examiners Ad Hoc Committee on the Definition of Heat-Related Fatalities Am J Forensic Med Pathol 1997;18(1):11-14 11 Centers for Disease Control and Prevention Heat-related illnesses, deaths, and risk factors—Cincinnati and Dayton, Ohio, 1999, and United States, 1979-1997 MMWR Morb Mortal Wkly Rep 2000; 49(21):470-473 12 Centers for Disease Control and Prevention Heat-related deaths— Chicago, Illinois, 1996-2001, and United States, 1979-1999 MMWR Morb Mortal Wkly Rep 2003;52(26):610-613 13 Dematte JE, O’Mara K, Buescher J, et al Near-fatal heat stroke during the 1995 heat wave in Chicago Ann Intern Med 1998;129(3): 173-181 14 Choudhary E, Vaidyanathan A Heat stress illness hospitalizations— environmental public health tracking program, 20 States, 20012010 MMWR Surveill Summ 2014;63(13):1-10 15 Ghaznawi HI, Ibrahim MA Heat stroke and heat exhaustion in pilgrims performing the haj (Annual Pilgrimage) in Saudi Arabia Annals of Saudi Medicine 1987;7(4):323-326 16 How CK, Chern CH, Wang LM, Lee CH Heat stroke in a subtropical country Am J Emerg Med 2000;18(4):474-477 17 Keatinge WR, Donaldson GC, Cordioli E, et al Heat related mortality in warm and cold regions of Europe: observational study BMJ 2000;321(7262):670-673 18 Null J Heatstroke Deaths of Children in Vehicles 2018 Available at: https://www.noheatstroke.org/index.htm Accessed June 10, 2019 19 Guard A, Gallagher SS Heat related deaths to young children in parked cars: an analysis of 171 fatalities in the United States, 19952002 Inj Prev 2005;11(1):33-37 20 Yeargin SW, Kerr ZY, Casa DJ, et al Epidemiology of exertional heat illnesses in youth, high school, and college football Med Sci Sports Exerc 2016;48(8):1523-1529 21 Centers for Disease Control and Prevention Heat illness among high school athletes —- United States, 2005-2009 MMWR Morb Mortal Wkly Rep 2010;59(32):1009-1013 22 Centers for Disease Control and Prevention Nonfatal sports and recreation heat illness treated in hospital emergency departments— United States, 2001-2009 MMWR Morb Mortal Wkly Rep 2011;60(29):977-980 23 Gottschalk AW, Andrish JT Epidemiology of sports injury in pediatric athletes Sports Med Arthrosc Rev 2011;19(1):2-6 24 Casa DJ, Csillan D, Armstrong LE, et al Preseason heat-acclimatization guidelines for secondary school athletics J Athl Train 2009;44(3):332-333 25 Kerr ZY, Marshall SW, Comstock RD, Casa DJ Exertional heat stroke management strategies in United States high school football Am J Sports Med 2014;42(1):70-77 26 Kerr ZY, Register-Mihalik JK, Pryor RR, et al The association between mandated preseason heat acclimatization guidelines and exertional heat illness during preseason high school American football practices Environ Health Perspect 2019;127(4):47003 27 Clark WG, Lipton JM Drug-related heatstroke Pharmacol Ther 1984;26(3):345-388 28 Epstein Y, Albukrek D, Kalmovitc B, Moran DS, Shapiro Y Heat intolerance induced by antidepressants Ann N Y Acad Sci 1997;813: 553-558 29 Lomax P, Schonbaum E The effects of drugs on thermoregulation during exposure to hot environments Prog Brain Res 1998;115: 193-204 30 Cox B, Green MD, Lomax P Behavioral thermoregulation in the study of drugs affecting body temperature Pharmacol Biochem Behav 1975;3(6):1051-1054 31 Morrison SF, Nakamura K Central neural pathways for thermoregulation Front Biosci (Landmark Ed) 2011;16:74-104 32 Grogan H, Hopkins PM Heat stroke: implications for critical care and anaesthesia Br J Anaesth 2002;88(5):700-707 33 Rowell LB Cardiovascular aspects of human thermoregulation Circ Res 1983;52(4):367-379 34 Lepock JR Cellular effects of hyperthermia: relevance to the minimum dose for thermal damage Int J Hyperthermia 2003;19(3):252-266 35 Kultz D Molecular and evolutionary basis of the cellular stress response Annu Rev Physiol 2005;67:225-257 36 Richter K, Haslbeck M, Buchner J The heat shock response: life on the verge of death Mol Cell 2010;40(2):253-266 37 Jardine DS Heat illness and heat stroke Pediatr Rev 2007;28(7): 249-258 38 Sakaguchi Y, Stephens LC, Makino M, et al Apoptosis in tumors and normal tissues induced by whole body hyperthermia in rats Cancer Res 1995;55(22):5459-5464 39 Knochel JP Catastrophic medical events with exhaustive exercise: “white collar rhabdomyolysis” Kidney Int 1990;38(4):709-719 40 Amorim FT, Fonseca IT, Machado-Moreira CA, Magalhaes Fde C Insights into the role of heat shock protein 72 to whole-body heat acclimation in humans Temperature (Austin) 2015;2(4):499-505 41 Bouchama A, al-Sedairy S, Siddiqui S, Shail E, Rezeig M Elevated pyrogenic cytokines in heatstroke Chest 1993;104(5):1498-1502 42 Camus G, Nys M, Poortmans JR, et al Endotoxaemia, production of tumour necrosis factor alpha and polymorphonuclear neutrophil activation following strenuous exercise in humans Eur J Appl Physiol Occup Physiol 1998;79(1):62-68 43 Chang DM The role of cytokines in heat stroke Immunol Invest 1993;22(8):553-561 44 Lu KC, Wang JY, Lin SH, Chu P, Lin YF Role of circulating cytokines and chemokines in exertional heatstroke Crit Care Med 2004;32(2):399-403 45 Moldoveanu AI, Shephard RJ, Shek PN Exercise elevates plasma levels but not gene expression of IL-1beta, IL-6, and TNF-alpha in blood mononuclear cells J Appl Physiol (1985) 2000;89(4):14991504 46 Hammami MM, Bouchama A, Al-Sedairy S, Shail E, AlOhaly Y, Mohamed GE Concentrations of soluble tumor necrosis factor and interleukin-6 receptors in heatstroke and heatstress Crit Care Med 1997;25(8):1314-1319 e2 47 Heled Y, Fleischmann C, Epstein Y Cytokines and their role in hyperthermia and heat stroke J Basic Clin Physiol Pharmacol 2013;24(2):85-96 48 Hammami MM, Bouchama A, Shail E, al-Sedairy S Elevated serum level of soluble interleukin-2 receptor in heatstroke Intensive Care Med 1998;24(9):988 49 Bouchama A, Hammami MM, Haq A, Jackson J, al-Sedairy S Evidence for endothelial cell activation/injury in heatstroke Crit Care Med 1996;24(7):1173-1178 50 Ang C, Dawes J The effects of hyperthermia on human endothelial monolayers: modulation of thrombotic potential and permeability Blood Coagul Fibrinolysis 1994;5(2):193-199 51 Bouchama A, Bridey F, Hammami MM, et al Activation of coagulation and fibrinolysis in heatstroke Thromb Haemost 1996;76(6): 909-915 52 Roberts GT, Ghebeh H, Chishti MA, Al-Mohanna F, El-Sayed R, Bouchama A Microvascular injury, thrombosis, inflammation, and apoptosis in the pathogenesis of heatstroke: a study in baboon model Arterioscler Thromb Vasc Biol 2008;28(6):1130-1136 53 Sawka MN, Leon LR, Montain SJ, Sonna LA Integrated physiological mechanisms of exercise performance, adaptation, and maladaptation to heat stress Compr Physiol 2011;1(4):1883-1928 54 Eshel GM, Safar P, Stezoski W The role of the gut in the pathogenesis of death due to hyperthermia Am J Forensic Med Pathol 2001;22(1):100-104 55 Sakurada S, Hales JR A role for gastrointestinal endotoxins in enhancement of heat tolerance by physical fitness J Appl Physiol (1985) 1998;84(1):207-214 56 al-Mashhadani SA, Gader AG, al Harthi SS, Kangav D, Shaheen FA, Bogus F The coagulopathy of heat stroke: alterations in coagulation and fibrinolysis in heat stroke patients during the pilgrimage (Haj) to Makkah Blood Coagul Fibrinolysis 1994;5(5):731-736 57 Alzeer AH, Al-Arifi A, Warsy AS, Ansari Z, Zhang H, Vincent JL Nitric oxide production is enhanced in patients with heat stroke Intensive Care Med 1999;25(1):58-62 58 Hammami MM, Bouchama A, Al Sedairy S Levels of soluble L-selectin and E-selectin in heatstroke and heatstress Chest 1998;114(3): 949-950 59 Shieh SD, Shiang JC, Lin YF, Shiao WY, Wang JY Circulating angiotensin-converting enzyme, von Willebrand factor antigen and thrombomodulin in exertional heat stroke Clin Sci (Lond) 1995;89(3):261-265 60 Liu CC, Chien CH, Lin MT Glucocorticoids reduce interleukin-1 concentration and result in neuroprotective effects in rat heatstroke J Physiol 2000;527 Pt 2:333-343 61 Lin MT, Liu HH, Yang YL Involvement of interleukin-1 receptor mechanisms in development of arterial hypotension in rat heatstroke Am J Physiol 1997;273(4):H2072-H2077 62 Chen CM, Hou CC, Cheng KC, Tian RL, Chang CP, Lin MT Activated protein C therapy in a rat heat stroke model Crit Care Med 2006;34(7):1960-1966 63 Bouchama A, Kwaasi A, Dehbi M, et al Glucocorticoids not protect against the lethal effects of experimental heatstroke in baboons Shock 2007;27(5):578-583 64 Leon LR, Dineen S, Blaha MD, Rodriguez-Fernandez M, Clarke DC Attenuated thermoregulatory, metabolic, and liver acute phase protein response to heat stroke in TNF receptor knockout mice Am J Physiol Regul Integr Comp Physiol 2013;305(12):R1421-R1432 65 Hagiwara S, Iwasaka H, Goto K, et al Recombinant thrombomodulin prevents heatstroke by inhibition of high-mobility group box protein in sera of rats Shock 2010;34(4):402-406 66 Dehbi M, Baturcam E, Eldali A, et al Hsp-72, a candidate prognostic indicator of heatstroke Cell Stress Chaperones 2010;15(5): 593-603 67 Bazille C, Megarbane B, Bensimhon D, et al Brain damage after heat stroke J Neuropathol Exp Neurol 2005;64(11):970-975 68 Li J, Zhang XY, Wang B, et al Multivoxel proton magnetic resonance spectroscopy in heat stroke Clin Radiol 2015;70(1):37-41 69 Kalita J, Misra UK Neurophysiological studies in a patient with heat stroke J Neurol 2001;248(11):993-995 70 Leon LR, Bouchama A Heat stroke Compr Physiol 2015;5(2): 611-647 71 Shahid MS, Hatle L, Mansour H, Mimish L Echocardiographic and Doppler study of patients with heatstroke and heat exhaustion Int J Card Imaging 1999;15(4):279-285 72 Akhtar MJ, al-Nozha M, al-Harthi S, Nouh MS Electrocardiographic abnormalities in patients with heat stroke Chest 1993;104(2):411-414 73 Doshi HH, Giudici MC The EKG in hypothermia and hyperthermia J Electrocardiol 2015;48(2):203-209 74 el-Kassimi FA, Al-Mashhadani S, Abdullah AK, Akhtar J Adult respiratory distress syndrome and disseminated intravascular coagulation complicating heat stroke Chest 1986;90(4):571-574 75 Donoghue AM, Sinclair MJ, Bates GP Heat exhaustion in a deep underground metalliferous mine Occup Environ Med 2000;57(3): 165-174 76 Lin YF, Wang JY, Chou TC, Lin SH Vasoactive mediators and renal haemodynamics in exertional heat stroke complicated by acute renal failure QJM 2003;96(3):193-201 77 Semenza JC Acute renal failure during heat waves Am J Prev Med 1999;17(1):97 78 Yoshitake S, Noguchi T, Hoashi S, Honda N Changes in intramucosal pH and gut blood flow during whole body heating in a porcine model Int J Hyperthermia 1998;14(3):285-291 79 Lambert GP, Gisolfi CV, Berg DJ, Moseley PL, Oberley LW, Kregel KC Selected contribution: Hyperthermia-induced intestinal permeability and the role of oxidative and nitrosative stress J Appl Physiol (1985) 2002;92(4):1750-1761; discussion 1749 80 Garcin JM, Bronstein JA, Cremades S, Courbin P, Cointet F Acute liver failure is frequent during heat stroke World J Gastroenterol 2008;14(1):158-159 81 Berger J, Hart J, Millis M, Baker AL Fulminant hepatic failure from heat stroke requiring liver transplantation J Clin Gastroenterol 2000;30(4):429-431 82 Bouchama A, De Vol EB Acid-base alterations in heatstroke Intensive Care Med 2001;27(4):680-685 83 Hausfater P, Megarbane B, Fabricatore L, et al Serum sodium abnormalities during nonexertional heatstroke: incidence and prognostic values Am J Emerg Med 2012;30(5):741-748 84 Bouchama A Features and outcomes of classic heat stroke Ann Intern Med 1999;130(7):613; author reply 614-615 85 Deschamps A, Levy RD, Cosio MG, Marliss EB, Magder S Effect of saline infusion on body temperature and endurance during heavy exercise J Appl Physiol (1985) 1989;66(6):2799-2804 86 Misset B, De Jonghe B, Bastuji-Garin S, et al Mortality of patients with heatstroke admitted to intensive care units during the 2003 heat wave in France: a national multiple-center risk-factor study Crit Care Med 2006;34(4):1087-1092 87 Argaud L, Ferry T, Le QH, et al Short- and long-term outcomes of heatstroke following the 2003 heat wave in Lyon, France Arch Intern Med 2007;167(20):2177-2183 88 Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh CM Cold water immersion: the gold standard for exertional heatstroke treatment Exerc Sport Sci Rev 2007;35(3):141-149 89 Casa DJ, Armstrong LE, Kenny GP, O’Connor FG, Huggins RA Exertional heat stroke: new concepts regarding cause and care Curr Sports Med Rep 2012;11(3):115-123 90 Sloan BK, Kraft EM, Clark D, Schmeissing SW, Byrne BC, Rusyniak DE On-site treatment of exertional heat stroke Am J Sports Med 2015;43(4):823-829 91 McDermott BP, Casa DJ, Ganio MS, et al Acute whole-body cooling for exercise-induced hyperthermia: a systematic review J Athl Train 2009;44(1):84-93 92 Armstrong LE, Crago AE, Adams R, Roberts WO, Maresh CM Whole-body cooling of hyperthermic runners: comparison of two field therapies Am J Emerg Med 1996;14(4):355-358 e3 93 Gaudio FG, Grissom CK Cooling Methods in Heat Stroke J Emerg Med 2016;50(4):607-616 94 Gaffin SL, Gardner JW, Flinn SD Cooling methods for heatstroke victims Ann Intern Med 2000;132(8):678 95 Bouchama A, Dehbi M, Chaves-Carballo E Cooling and hemodynamic management in heatstroke: practical recommendations Crit Care 2007;11(3):R54 96 Hadad E, Rav-Acha M, Heled Y, Epstein Y, Moran DS Heat stroke: a review of cooling methods Sports Med 2004;34(8):501-511 97 Weiner JS, Khogali M A physiological body-cooling unit for treatment of heat stroke Lancet 1980;1(8167):507-509 98 Al-Aska AK, Abu-Aisha H, Yaqub B, Al-Harthi SS, Sallam A Simplified cooling bed for heatstroke Lancet 1987;1(8529):381 99 Slovis CM Features and outcomes of classic heat stroke Ann Intern Med 1999;130(7):614-615 100 Henker R, Rogers S, Kramer DJ, Kelso L, Kerr M, Sereika S Comparison of fever treatments in the critically ill: a pilot study Am J Crit Care 2001;10(4):276-280 101 Schmutzhard E, Engelhardt K, Beer R, et al Safety and efficacy of a novel intravascular cooling device to control body temperature in neurologic intensive care patients: a prospective pilot study Crit Care Med 2002;30(11):2481-2488 102 Hamaya H, Hifumi T, Kawakita K, et al Successful management of heat stroke associated with multiple-organ dysfunction by active intravascular cooling Am J Emerg Med 2015;33(1):124 e125-127 103 Channa AB, Seraj MA, Saddique AA, Kadiwal GH, Shaikh MH, Samarkandi AH Is dantrolene effective in heat stroke patients? Crit Care Med 1990;18(3):290-292 104 Moran D, Epstein Y, Wiener M, Horowitz M Dantrolene and recovery from heat stroke Aviat Space Environ Med 1999;70(10): 987-989 105 Bouchama A, Cafege A, Devol EB, Labdi O, el-Assil K, Seraj M Ineffectiveness of dantrolene sodium in the treatment of heatstroke Crit Care Med 1991;19(2):176-180 106 Moler FW, Silverstein FS, Holubkov R, et al Therapeutic hypothermia after out-of-hospital cardiac arrest in children N Engl J Med 2015;372(20):1898-1908 107 Changnon SA, Easterling DR Disaster management U.S policies pertaining to weather and climate extremes Science 2000; 289(5487):2053-2055 108 Kalkstein LS Saving lives during extreme weather in summer BMJ 2000;321(7262):650-651 ... case reports regarding its use on patients with heat stroke; thus, it cannot be recommended at this point.101,102 Hence, all of these techniques should be considered, at most, adjuvant to the... Once a core body temperature of less than 39°C has been achieved, active cooling may be stopped This end point appears to be safe in terms of mortality, but it should be noted that a safe end... school, and college football Med Sci Sports Exerc 2016;48(8):1523-1529 The full reference list for this chapter is available at ExpertConsult.com e1 References Kalkstein LS, Greene JS An evaluation