Page 38 - JSOM Spring 2025

An Update on Best Practices for the
Prehospital Management of Exertional Heat Illness

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Chad Norton, DO, CAQSM *; Yonatan Moreh, MD, MS ; Nathan Sperry, DO ;
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Francis G. O’Connor, MD, CAQSM, MPH ; David W. DeGroot, PhD, FACSM ;
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Blair Rhodehouse, DO, CAQSM, ATC ; Samuel Ivan Bartlett, DO, CAQSM 7
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ABSTRACT
Exertional heat illness (EHI) describes a spectrum of acute identified by symptoms such as confusion, disorientation, de-
medical disorders, frequently encountered in Servicemembers lirium, seizures, or coma. If EHS is not treated appropriately, it
throughout the Armed Forces, that poses a pervasive threat can result in long-term sequela or even death. Prompt recog-
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to individual and unit military readiness. In June 2024, the nition and early management of these conditions can be chal-
Consortium for Health and Military Performance Warrior lenging but are crucial to optimize patient outcomes. 1
Heat and Exertion Related Event Collaborative published a
Joint Clinical Practice Guideline for the prevention, diagnosis, EHI represents a significant threat to military readiness.
and management of exertional heat illness, which outlines best In 2023, the incidence of EHS and HE in the military were
practices in the diagnosis and management of EHI, including 31.7 and 172.7 cases per 100,000 person-years, respectively.
prevention, prehospital care, emergency department care, in- Trainees were at an increased risk of EHI with an incidence
patient hospital care, and return to duty guidelines. In the Spe- of 7803.2 cases per 100,000 person-years. The incidence was
cial Operations community, recognition and early treatment also higher in members of the Army and Marine Corps than in
via rapid cooling to a body core temperature of 39.0–39.2°C other Services. Until recently, there were no consensus guide-
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(102.0–102.5°F) within 30 minutes from the time of injury lines for the recognition or treatment of EHI in any setting
recognition are the most crucial concepts to follow to reduce including prehospital, emergency room, inpatient hospital, or
the morbidity and mortality of EHI. This article introduces intensive care for the various branches of the Armed Forces. 9
the recommended best practices from the Clinical Practice
Guideline, which are most relevant to the Special Operations In the Special Operations community, there is currently no uni-
community. formed approach for the medical management of EHI. While
some organizations have clearly defined diagnostic criteria
Keywords: heat injury; exertional heat illness; prehospital care; and published treatment algorithms, other organizations re-
exertional heat stroke; heat exhaustion port relying on nonspecific installation-mandated protocols or
individual members’ prior experiences. Special Operators are
tasked with completing missions in a broad array of settings,
Introduction
making a unified or standardized approach for treating any
Exertional heat illness (EHI) is an umbrella term that includes single problem such as EHI challenging and unrealistic. How-
a spectrum of acute clinical disorders, which are frequently ever, having clearly identified best practice treatment goals
identified in athletes as well as Servicemembers throughout the and recommendations can be a starting point leading to the
Armed Forces. EHI includes the diagnoses of heat exhaustion development of algorithms and practice guidelines that fit the
(HE), exertional heat injury (HI), and exertional heat stroke unique circumstances and limited resources that are encoun-
(EHS), which most often occur during high-intensity physical tered by each Special Operations organization and unit.
activity in hot environments. In HE, body core temperature
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typically remains below 40°C (104°F) with either minimal New EHI Clinical Practice Guideline
or no evidence of end organ damage (kidney injury, liver in-
jury, etc.). In these cases, recovery is generally rapid following In June 2024, the Consortium for Health and Military Perfor-
proper treatment (removal from heat, passive cooling, and re- mance (CHAMP) in conjunction with the Army Heat Center
hydration) and long-term effects are rare. HI is similar to HE and the Warrior Heat- and Exertion-Related Events Collabo-
with core temperature typically remaining below 40°C, but rative (WHEC) released a Clinical Practice Guideline (CPG)
patients demonstrate evidence of end organ damage. In con- for prevention, diagnosis, and management of EHI within the
trast, EHS typically involves core temperature elevated above military. This CPG uses current evidence and expert consen-
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40°C and dysfunction of the central nervous system (CNS) sus opinion to identify current best practices in the diagnosis
*Correspodence to: chad.s.norton.mil@health.mil
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1 CPT(P) Chad Norton and MAJ Samuel Ivan Bartlett are Family Medicine and Sports Medicine faculty members at the Martin Army Commu-
nity Hospital Family Medicine Residency Program at Fort Benning, GA. CPT Yonatan Moreh and CPT Nathan Sperry are Family Medicine
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residents at the Martin Army Community Hospital Family Medicine Residency Program at Fort Benning, GA. COL(Ret) Francis G. O’Connor
is a professor and the medical director at the Consortium for Health and Military Performance, Department of Military and Emergency Medi-
cine, F. Edward Herbert School of Medicine, Uniformed Services University, Bethesda, MD. LTC David W. DeGroot is the director at the Army
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Heat Center, Martin Army Community Hospital, Fort Benning, GA, and codirector at the Warrior Heat and Exertion Collaborative. MAJ Blair
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Rhodehouse is an associate program director at the Martin Army Community Hospital Family Medicine Residency Program and the medical
director at the Army Heat Center, Martin Army Community Hospital, Fort Benning, GA.
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