Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient’s core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14–0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.
The authors are with the Department of Orthopaedics and Sports Medicine, Morsani College of Medicine, University of South Florida, Tampa, FL.
Casa DJ, McDermott BP, Lee EC, Yeargin SW, Armstrong LE, Maresh CM. Cold water immersion: the gold standard for exertional heat stroke treatment. Exerc Sport Sci Rev. 2007;35(3):141–149. PubMed ID: 17620933
DeMartini JK, Ranalli GF, Casa DJ, et al. Comparison of body cooling methods on physiological and perceptual measures of hyperthermic athletes. J Strength Cond Res. 2011;25(8):2065–2074. PubMed ID: 21760549 doi:
DeMartiniJK, RanalliGF, CasaDJ, et al. Comparison of body cooling methods on physiological and perceptual measures of hyperthermic athletes. . 2011;25(8):2065–2074. PubMed ID: 21760549 doi:10.1519/JSC.0b013e3182259b1d21760549)| false
ProulxCI, DucharmeMB, KennyGP. Effect of water temperature on cooling efficiency during hyperthermia in humans. . 2003;94(4):1317–1323. PubMed ID: 12626467 doi:10.1152/japplphysiol.00541.200212626467)| false
Hosokawa Y, Adams WM, Belval LN, Vandermark LW, Casa DJ. Tarp-assisted cooling as a method of whole-body cooling in hyperthermic individuals. Ann Emerg Med. 2017;69(3):347–352. PubMed ID: 27865532 doi:
Adams WM, Hosokawa Y, Adams EL, Belval LN, Huggins RA, Casa DJ. Reduction in body temperature using hand cooling versus passive rest after exercise in the heat. J Sci Med Sport. 2016;19(11):936–940. PubMed ID: 27012727 doi:
AdamsWM, HosokawaY, AdamsEL, BelvalLN, HugginsRA, CasaDJ. Reduction in body temperature using hand cooling versus passive rest after exercise in the heat. . 2016;19(11):936–940. PubMed ID: 27012727 doi:10.1016/j.jsams.2016.02.00627012727)| false
DemartiniJK, CasaDJ, StearnsR, et al. Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth Road Race. . 2015;47(2):240–245. doi:10.1249/MSS.0000000000000409)| false
McDermottBP, CasaDJ, O’ConnorFG, et al. Cold-water dousing with ice massage to treat exertional heat stroke: a case series. . 2009;80(8):720–722. PubMed ID: 1965357510.3357/ASEM.2498.200919653575)| false