Exertional Heat Stroke in a Teenage Cross-Country Runner: Cool First, Transport Second
Exertional Heat Stroke in a Teenage Cross-Country Runner: Cool First, Transport Second - Sports Medicine clinical simulation case. A 16-year-old male...
Age: 16 • Gender: Male • Setting: Emergency Triage
Clinical Presentation & History
A 16-year-old male cross-country runner who collapsed at the finish line of a hot September invitational meet. He is obtunded, hot to touch, profoundly confused, and tachycardic. Ambient temperature was 34°C with 70% humidity. EMS is on scene but transport is delayed by an argument over the nearest receiving facility.
Acute Resuscitation Milestones & Priorities
Clinical phases and key interventions encountered in this emergency module:
Phase 1: On-Scene Triage & Recognition
Phase 2: Active Immersion & Core Temp Monitoring
Phase 3: Transport Decision & On-Scene Stabilization
Phase 4: Definitive Care & Anticipating End-Organ Injury
High-Yield Clinical Pearls
Exertional heat stroke is defined as core temp >40.5°C with CNS dysfunction during exertion. Rectal temperature is the only reliable field measurement.
'Cool First, Transport Second'—mortality approaches zero when cold water immersion begins within 10 minutes of collapse; transport should never interrupt cooling.
Cold water immersion achieves cooling rates of 0.15–0.35°C/min and is the only field intervention with proven mortality benefit.
Antipyretics (acetaminophen, ibuprofen) are ineffective because EHS is hyperthermia, not fever; the hypothalamic set-point is unchanged.
Dantrolene has no role in EHS; it is indicated for malignant hyperthermia and neuroleptic malignant syndrome only.
Cooling endpoint is rectal temp ≤39°C; stopping above 40°C risks rebound hyperthermia from peripheral vasoconstriction.
EHS has a biphasic course: initial recovery followed by 12–72 hours of rhabdomyolysis, transaminitis, DIC, and AKI requiring PICU admission.
Pediatric tertiary centers should receive EHS patients; community EDs lack the multi-organ support these patients require.
Rhabdomyolysis management: aggressive isotonic fluids + urinary alkalinization with sodium bicarbonate to urine pH >6.5; loop diuretics are not preventive.
Return-to-play decisions require 1–2 weeks of rest, normal labs, and heat-tolerance testing; recurrent EHS has a high mortality rate.
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