Exertional Heat Stroke — Recognition and Cooling Protocols: A Narrative Review

Abstract

Background. Exertional heat stroke (EHS) is the most severe form of exertional heat illness and one of the leading causes of non-traumatic sudden death in athletes, soldiers and outdoor workers. It is defined by central nervous system dysfunction combined with severe hyperthermia, and its outcome depends almost entirely on how quickly the diagnosis is made and body cooling is begun. With rising global temperatures and growing participation in endurance and team sports, timely recognition and correct cooling have become increasingly relevant to clinical practice.

Aim. This narrative review synthesises the current evidence on the recognition of EHS and on cooling protocols, with a focus on medical aspects, and critically compares diagnostic tools and cooling modalities across sporting, military, occupational and community settings.

Material and methods. A thematic narrative synthesis was performed of original studies, systematic reviews, case reports and consensus-based reviews addressing the pathophysiology, recognition, cooling and prevention of EHS.

Results. EHS diagnosis rests on the combination of neurological dysfunction and elevated core temperature; rectal thermometry is the reference standard, whereas peripheral methods are unreliable and frequently unavailable. Rapid whole-body cold-water immersion is the gold-standard treatment; cooling rates above 0.15 °C·min⁻¹ and the principle of "cool first, transport second" are consistently associated with survival without complications, yet these practices remain incompletely implemented. Alternative field methods differ substantially in efficacy.

Conclusions. Recognition and aggressive cooling are the decisive, modifiable determinants of survival in EHS. Persistent gaps in temperature assessment, prehospital protocols and provider knowledge must be closed to reduce preventable morbidity and mortality.