Letters to the Editor

Suspected Heat-Related Illness Calls for Immediate Treatment


Am Fam Physician. 2012 Jan 15;85(2):92.

Original Article: Heat-Related Illness

Issue Date: June 1, 2011

Available at: https://www.aafp.org/afp/2011/0601/p1325.html

to the editor: I would like to point out an area of concern with the algorithm presented in Figure 1 of this article. The algorithm seems to suggest that patients with central nervous system symptoms who have a rectal temperature less than 104°F (40°C) do not require immediate evaluation and treatment for heat-related illness. I think this may mislead the reader to think that a lower temperature rules out heat stroke and a need for urgent treatment. Although that may be true by definition, I think the next step clinically should include much more than simply considering alternatives as suggested by the algorithm. Certainly, that would be the case in an acute exercise-related condition or any time a patient has an elevated temperature and central nervous system symptoms. Therefore, I would expect the algorithm to include at least an arrow pointing from this section to the “Treat for mild heat-related illness: Observe for symptom resolution/ Monitor core temperature” section or to the box containing more urgent care for heat stroke.

Athletic protocols1 and my understanding of the literature2 suggest immediate initiation of treatment for suspected heat-related illness (even before the temperature is obtained), and not delaying that treatment while investigating other causes.

Author disclosure: No relevant financial affiliations to disclose.


1. The National Collegiate Athletic Association. 2011–2012 Sports Medicine Handbook. http://www.ncaapublications.com/p-4203-2011-2012-sports-medicine-hand-book.aspx. Accessed December 13, 2011.

2. Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO; American College of Sports Medicine. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556–572.

in reply: Dr. Helming's point regarding Figure 1 is a valid one. For those with central nervous system symptoms, but a rectal temperature less than 104°F, the diagnosis of heat-related illness should certainly be considered. This would be especially true for a primarily healthy person engaged in physical activity. The article reviewed the management of heat-related illness in all patient populations; therefore, the primary point of that portion of the algorithm was that the presence of central nervous system symptoms, but not hyperthermia, warrants a consideration of alternative diagnoses.

Two other points in Dr. Helming's letter also warrant responses. First, the algorithm does not imply that the presence of central nervous system symptoms and the absence of a rectal temperature of 104°F should result in any less need for urgent treatment. Heat-related illness and the alternatives listed in Figure 1 are all potential medical emergencies. Second, Dr. Helming states that treatment for heat-related illness should be initiated before obtaining a rectal temperature. One of the key points of the article was that a measure of core temperature is needed to accurately diagnose the patient. This point applies to all populations, but is especially true in older patients and those with comorbidities.

Author disclosure: No relevant financial affiliations to disclose.

Send letters to afplet@aafp.org, or 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-2680. Include your complete address, e-mail address, and telephone number. Letters should be fewer than 400 words and limited to six references, one table or figure, and three authors.

Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter will be construed as granting the AAFP permission to publish the letter in any of its publications in any form. The editors may edit letters to meet style and space requirements.

This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



Copyright © 2012 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


Sep 2021

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article