Heat Illness and Heat Stroke

A spectrum — but will you recognize the blurry signposts?

	Temperature (core)	Presentation	Management
Miliaria Crystallina	Normal	Salt-colored tiny papules, easily burst; not pruritic	Modify environment; light clothing; hydration

Miliaria Rubra	Normal	Discrimiate, red papules, not assocaited with follicles; pruritic	Above plus cool compresses; calamine lotion; symptomatic tx for pruritis

Miliaria Profunda	Normal	Confluent flesh-colored, “lumpy-bumpy”; burning	Same as rubra

Miliaria Pustulosa	Normal	May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis	Same as above, but may may need antibiotic if no improvement over time

Heat edema	Normal	Swelling of feet, ankles, and/or lower legs	Modify environment; elevate legs

Heat syncope	Normal	Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine	Modify environment; rehydration; monitoring

Heat cramps	May be elevated to 40°C (104°F)	Exercise-induced cramping in large muscle groups, especially legs	Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently

Heat tetany	May be elevated to 40°C (104°F)	Hyperventilation with paresthesia, carpopedal spasm	Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2

Heat exhaustion	Elevated up to 40°C (104°F)	Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities	Cool environment; hydration; consider labs with severe symptoms, or if not improved

Heat Stroke	>40 to 40.5°C (104 to 105°F)	Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC	Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission

Selected References

Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741.

Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553.

DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37.

Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992.

Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.