›First 5 minutes
›Resuscitation bay criteria
›Altered mental status
›Core temperature at or above 40 C
›Hypotension
›Monitoring
›Continuous pulse oximetry
›Cardiac monitor
›Core temperature probe
›IV access
›Two large bore IV if heat stroke or shock
›Glucose correction
›If below 3.0 mmol/L, dextrose bolus
Immediate cooling strategy
›Cooling strategy
›Goal temperature 38.0 to 39.0 C
›Stop active cooling at 38.5 to 39.0 C to avoid overshoot
›Evaporative cooling
›Remove clothing
›Spray tepid water
›High flow fan
›Ice packs
›Axilla
›Groin
›Neck
›Cold water immersion for exertional heat stroke if feasible
›Contraindications
›Hemodynamic instability requiring procedures
›Airway and breathing
›If unable to protect airway, intubation
›Avoid succinylcholine if rhabdomyolysis or hyperkalemia concern
›Ventilation target normocarbia
›Circulation and fluids
›Isotonic crystalloid bolus 10 to 20 mL/kg
›Reassess after each bolus
›If pulmonary edema risk, smaller boluses with ultrasound guidance
›If hypotension persists, norepinephrine infusion
Agitation and shivering control
›Agitation and shivering
›Benzodiazepine example
›Midazolam IV 1 to 2 mg
›Repeat every 5 to 10 minutes as needed
›Alternative
›Lorazepam IV 1 to 2 mg
›Avoid physical restraint without sedation if it impairs cooling
Exertional hyponatremia pathway
›Exertional hyponatremia pathway
›If seizures or severe symptoms with low sodium, hypertonic saline
›3 percent saline 100 mL IV bolus
›Repeat up to 2 times for ongoing severe symptoms
›Avoid large volumes of isotonic fluid if clear water intoxication
Rhabdomyolysis and renal protection
›Rhabdomyolysis and renal protection
›IV fluids to maintain urine output local protocol dependent
›Monitor potassium calcium phosphate
›Avoid nephrotoxins
Coagulopathy and hepatic injury
›Coagulopathy and hepatic injury
›If active bleeding, transfusion guided by labs
›Avoid prophylactic antipyretics for temperature control
›Reassessment loop
›Core temperature every 5 to 10 minutes during cooling
›Mental status trend every 15 minutes until stable
›Vital signs every 5 minutes in heat stroke
›Repeat electrolytes and CK every 4 to 6 hours in heat stroke
›Consultations
›ICU for heat stroke
›Nephrology for severe AKI or dialysis consideration
›Toxicology for suspected toxidrome
›Obstetrics for pregnancy