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method but can complicate the resuscitation and pose poten- 7. Auerbach PS. Medicine for the Outdoors. Philadelphia, PA: Else-
tial risk of water aspiration. Convection cooling, the act of vier; 2016.
8
dissipating heat through evaporation, is an equally effective 8. McDermott BP, Casa DJ, Ganio MS, et al. Acute whole-body
alternative. This is accomplished by spraying the patient with cooling for exercise-induced hyperthermia: a systematic review. J
9
Athl Train 2009;44(1):84–93.
tepid water and continuous fanning. This can be performed in 9. Marx JA, Hockberger RS, Walls RM, et al. Rosen’s Emergency
a treatment facility where electric fans can be used or in the Medicine: Concepts and Clinical Practice. Philadelphia, PA: Else-
field with manual fanning. The downdraft of a helicopter has vier/Saunders; 2014.
also been used. 10 10. Poulton TJ, Walker RA. Helicopter cooling of heatstroke victims.
Aviat Space Environ Med. 1987;58(4):358–361.
Continuous core temperature and cardiac monitoring should 11. Knochel JP, Reed G. Disorders of heat regulation. In: Narins RG
be performed, if capable. Cooled intravenous fluids should (ed). Maxwell and Kleemans Clinical Disorders of Fluid and Electro-
lyte Metabolism New York, NY: McGraw-Hill;1994:1549–1590.
also be administered for hypotension and volume depletion. 12. Casa DJ, Armstrong LE, Kenny GP, et al. Exertional heatstroke:
Active cooling measures should be discontinued when the pa- new concepts regarding cause and care. Curr Sports Med Rep.
tient’s core temperature reaches 102.2°F (39°C) to avoid caus- 2012;11:115–123.
ing hypothermia. Shivering can impede cooling and responds 13. Casa DJ, Armstrong LE, Ganio MS, et al. Exertional heat stroke
well to IV benzodiazepines. Once the patient has been cooled, in competitive athletes. Curr Sports Med Rep. 2005;4:309–317.
the provider should investigate for an underlying illness (e.g., 14. Heneghan HM, Nazirawan F, Dorcaratto D, et al. Extreme heat-
stroke causing fulminant hepatic failure requiring liver transplan-
upper respiratory infection, pneumonia, supplement/stimulant tation: a case report. Transplant Proc. 2014;46:2430–2432.
use), which may have precipitated the EHI.

Acute renal failure and rhabdomyolysis are common compli-
cations of EHI. Liver function abnormalities are a common
occurrence after EHI; however, acute hepatic failure (AHF) is
relatively low at 5%. It is hypothesized that a hypoxic hepa-
11
titis ensues due to systemic hypoperfusion and intraheptatic
circulatory failure from high output cardiac failure. There
12
are several case reports of successful treatment of AHF with
nonoperative treatments. Recent case reports of AHF treated
13
with liver transplant, as with the patient in this report, have
had mixed results. In four cases reviewed by Heneghan et al,
14
three eventually died of multiorgan failure or liver rejection.
There are no clear indications for liver transplant for EHI
AHF at this time and prognosis is unpredictable.
Prevention and immediate cooling remain our best treatments
for EHI. It is imperative that military medical providers con-
tinue to remain vigilant to the signs and symptoms of EHI and
be prepared to identify and aggressively treat this potentially
fatal disease.

Disclaimer
The views expressed in this article are those of the authors and
do not necessarily reflect the official policy or position of the
Department of the Navy, Department of Defense, or the U.S.
Government.

Disclosures
The authors have nothing to disclose.

References
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2. Armed Forces Health Surveillance Center. Update: heat injuries, ac-
tive component, U.S. Armed Forces, 2016. MSMR. 2016;24:9–13.
3. Noonan B. Heat- and cold-induced injuries in athletes: evaluation
and management. J Am Acad Orthop Surg. 2012;20(12):744–754.
4. Atha WF. Heat-related illness. Emerg Med Clin North Am. 2013;
31(4):1097–1108.
5. Auerbach PS, Cushing TA, Harris NS. Auerbach’s Wilderness Med-
icine. Philadelphia, PA: Elsevier/Mosby; 2017.
6. Navy Environmental Health Center Bureau of Medicine and Sur-
gery. U.S. Navy Environmental Health Center Technical Manual
NEHC-TM-OEM 6260.6A. Prevention and treatment of heat and
cold stress injuries. Portsmouth, NH: Navy Environmental Health
Center; 2007.

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