Cold Water Immersion: The Gold Standard for Exertional Heatstroke Treatment

Douglas J. Casa; Brendon P. McDermott; Elaine C. Lee; Susan W. Yeargin; Lawrence E. Armstrong; Carl M. Maresh


Exerc Sport Sci Rev. 2007;35(3):141-149. 

In This Article

Practical Considerations of CWI

Organizations also encourage rapid cooling via CWI, including the American College of Sports Medicine,[1] National Athletic Trainers' Association,[3] and the United States Armed Forces.[13,14,28] However, these organizations realistically note that ice water and a tub may not always be available to treat an EHS victim, and that other modes of cooling (see above) can be effective if initiated promptly.[1,3,13,14,28] Procedural guidelines and considerations for the actual process of assessing, preparing, immersing, removing, transporting, and monitoring an athlete with EHS are provided in Table 2 . Research regarding EHS lead us to make the following recommendations:

  1. Measure rectal temperature and use clinical judgment regarding central nervous system dysfunction and other signs and symptoms to quickly and accurately determine the patient's condition and whether EHS is occurring.[1,3,8,9,14,28]

  2. Begin cooling individuals with EHS as rapidly as possible. The concept of "cool first, transport second" is strongly recommended, assuming that properly trained medical professionals, such as athletic trainers or physicians, are present to complete the cooling on-site via CWI (or a suitable alternative modality if CWI is not possible) and then transport to a medical facility. This method eliminates delays in treatment caused by the time constraints of arrival of care, transport, and the possibility that cooling may not be immediate or aggressive at the hospital. This protocol should be discussed with supervisors, colleagues, and adjunct medical personnel before a case of EHS occurs, so that the involved parties are in agreement during the stress of the moment.[7] Implementing these recommendations emphasizes in the strongest possible manner the importance of immediate and aggressive cooling and the critical initial 30-60 min after EHS onset.

  3. Use a cooling modality that has cooling rates sufficient to lower core temperature to less than 40°C (104°F) within 30 min.

  4. Provide fluid intravenously if dehydrated (if adequate staff is available to do so); do this immediately at hospital if not done on-site.[1,8,21]

  5. Remove from the cooling modality when the rectal temperature reaches 39°C (102°F); then immediately transport to medical facility (or continue to monitor if an adequately staffed on-site medical facility is available).

  6. Assure physician supervision after cooling is complete to monitor for sequelae, provide clearance for discharge from the hospital or medical tent, and guide (in conjunction with the athletic trainer) the return-to-participation process.[8]


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