A Tale of Two Heat Strokes: A Comparative Case Study

Abstract

Overview of Presentation Exertional heat stroke (EHS) is one of the top three causes of sudden death in sports (1,9,15). Unlike other life-threatening conditions, EHS is most successfully treated on-site with cold water immersion (2–8,10,12,13,17–19). This has resulted in over 500 documented cases being successfully treated (8,9). Complications from EHS arise when effective treatment is not available and not utilized or when EHS is not recognized (14,16). Despite these observations, an ongoing controversy is the balancing treatment “on-site” with rapid cooling versus rapid transportation to definitive care. This case study provides a unique examination of two individual recoveries from EHS associated with two dichotomous treatments received while participating in the same marathon. The 2008 Marine Corps Marathon on October 26th started at 8 a.m. Two military men running the marathon collapsed in separate incidences, one around mile 24 and the other at the finish. One was immediately taken to the finish line medical tent (MT) and the other was sent directly to the hospital emergency room (ER). Both men signed a consent form approved by our institutional review board to have their data published anonymously. Both MT and ER were questioned regarding their training preparation. Neither had a history of heat illness. Fourteen days prior to the race, MT was training in California, with an average high temperature of 34.2°C (range: 28.3 to 37.8°C), and ER was training in Maryland, with an average high temperature of 20°C (range: 13.4 to 29.1°C). Both locations were warmer than during the race day (temperature at collapse = 14.4°C, 64% relative humidity). MT and ER both reported training for 4 months and had many similar demographics (25 vs 23 years, 82 vs 77 kg, and 185 vs 170 cm tall, respectively). While MT and ER’s calculated BMI are. The day of the marathon, MT and ER did not report feeling sick, did not take any supplements or ergogenic aids, had an average of 8 h of sleep per night 72 h prior, and had a goal of finishing the marathon at ∼3:30 to 3:40. MT did report having two to three cups of coffee, while ER had none. Lastly, MT had a friend pacing him during the race, while ER did not. When questioned regarding their hydration strategies for the race, MT reported that he helped a friend move the day before the race and noticed that his urine was dark so he drank a lot of water the night before to help rehydrate. ER reported drinking a mix of electrolyte drinks and water at the water stations. When asked what symptom was the strongest upon their collapse, MT replied “anger/irritability,” while ER reported “fatigue.” In terms of their memory of their collapse, MT reported, “I remember running up the final hill towards the finish … and falling over …. The last thing I remember was looking down as my buddy … helped me walk across the finish line.” ER reported, “Except for small blocks of memory, [I remember] nothing until two days later.” Diagnosis MT finished the marathon in just under 4 h and was taken directly to the MT. Other emergency medical conditions were ruled out, his rectal temperature was assessed (41.1°C), and he was diagnosed with EHS. When ER collapsed (around mile 24, but on pace to finish in 3.5 h), an ambulance was called and he was transported directly to the hospital (admitted at 11:57 a.m.). His initial rectal temperature was taken (41.2°C at 12:27 p.m.), and he was diagnosed with EHS. Treatment MT was rapidly cooled via aggressive ice water dousing, which was described previously (14). MT’s peak temperature was 42.2°C at minute 8 of cooling; however, after 30 min of cooling, MT’s rectal temperature had returned to 38.9°C, at which point cooling was ceased. MT’s peak temperature was likely recorded at 8 min of cooling because of two factors: 1) Rectal temperature reflects deep body temperature, which has an established delay in temperature response during cooling; 2) MT’s rectal thermometer was reinserted at minute 7 because of suspicious temperature readings, and this adjustment may have allowed for a deeper placement of the probe, obtaining a higher temperature. From peak rectal temperature to final rectal temperature, the resulting cooling rate was 0.15°C·min (see Fig. 1). MT was sent to the hospital for blood work but was released and returned home within 4 h.Figure 1: Cooling curves for two EHS cases occurring during the same marathon in separate incidences. MT = treated onsite at the medical tent. ER = treated at the emergency room. The overlay contains ACSM’s guidelines from the heat illness position statement regarding an early intervention cooling curve versus late intervention cooling curve (where EHS victims are exposed to more than 60°C·min above 40.5°C, where risk for morbidity and mortality is greatly elevated). ACSM early intervention = ACSM-calculated heat exposure limit (120°F under the cooling curve). ACSM late intervention = ACSM-calculated heat exposure that has an incr