Working Diagnosis:
Exertional Heat Stroke

Treatment:
Patient was intubated in the PICU to protect his airway for 48 hours and was started on Keppra for seizure prophylaxis. Patient labs were monitored closely until improvement was noticed while he was on MIVF.

Outcome:
Patient returned to school the following week.
Anti-epileptics were continued for six weeks.
Patient was not able to participate in exercise until completion of anti-epileptic course.
Patient was followed by hematology until platelets returned to baseline.

Author's Comments:
Heat Stroke is the leading cause of death in young athletes each year with the incidence increasing annually. The Highest Incidence of Heat stroke occurs in American Football players with 4.5 cases per 100,000. Morbidity and Mortality of a heat stroke is directly related to duration of the athletes temperature elevation; therefore, you want to cool the patient down as fast as possible. The best way to cool an athlete is with rapid cooling within the first 30 minutes via cold water immersion until the core temperature reaches 101 degrees. This should be done before transportation unless on site cooling is not available or the patient is having seizures. The main complications to be concerned about with patients is electrolyte abnormalities, seizures, delirium, ARDS, Rhabdomyolysis, AKI, hepatic injury, DIC (our patient), Ischemic Bowel, and Myocardial injury. The Treatment of Heat stroke besides rapid cooling is mostly supportive and correction of above abnormalities.
Prevention is key in regards to Heat related illnesses with the most important part being allowing the athletes time for acclimatization to the heat, which should take between 7-14 days. Coaches and staff should be educated about these conditions, allow frequent breaks for cooling and hydration (6 mL per kg every 2-3 hours), should avoid severe heat or humidity, pay close attention to obese athletes, and minimize equipment and clothing that hinders heat loss.

Editor's Comments:
The author identifies the key in treatment of heatstroke which are early recognition and immediate cooling on-site prior to transport. More importantly, heat stroke is a preventable disease. The following conditions increase the risk of EHS or exertional heat exhaustion: obesity, low physical
fitness level, lack of heat acclimatization, dehydration, history of EHS, sleep deprivation,
sweat gland dysfunction, sunburn, viral illness, diarrhea, or certain medications. Proper education of athletes and coaches as well as awareness of these by the medical staff are extremely important. In addition, monitoring the environmental conditions using a Wet Bulb Globe Temperature (WBGT) is useful as a WBGT over 82F places athletes at risk of developing such event. When returning athletes with significant heat illness to sports it is important to make sure that heat tolerance has returned. Gradual return to activity and possibly additional testing and management at a center specializing in heat illness should be considered.

References:
Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002; 346:1978.
Heled Y, Rav-Acha M, Shani Y, et al. The "golden hour" for heatstroke treatment. Mil Med 2004; 169:184.
Centers for Disease Control and Prevention (CDC). Heat-related deaths--United States, 1999-2003. MMWR Morb Mortal Wkly Rep 2006; 55:796.
Khosla R, Guntupalli KK. Heat-related illnesses. Crit Care Clin 1999; 15:251.
Bouchama A, Bridey F, Hammami MM, et al. Activation of coagulation and fibrinolysis in heatstroke. Thromb Haemost 1996; 76:909.
Smith JE. Cooling methods used in the treatment of exertional heat illness. Br J Sports Med 2005; 39:503.
Austin R. Krohn; Robby Sikka; David E. Olson. Heat illness in Football: Current Concepts. Curr Sports Med Rep. 2015 Nov-Dec;14(6):463-71.

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