Table 4. .

Guidelines for Implementing Cold-Water Immersion for a Patient With Exertional Heat Stroke

1. Initial response. Once exertional heat stroke is suspected, prepare to cool the patient and contact emergency medical services.

2. Prepare for ice-water immersion. On the playing field or in close proximity, half-fill a stock tank or wading pool with water and ice (make sure there is a sufficient water source).

a. The tub can be filled with ice and water before the event begins (or have the tub half-filled with water and keep 3 to 4 coolers of ice next to the tub; this prevents having to keep the tub cold throughout the day.

b. Ice should cover the surface of the water at all times.

c. If the athlete collapses near the athletic training room, a whirlpool tub or cold shower may be used.

3. Determine vital signs. Immediately before immersing the patient, obtain vital signs.

a. Assess core body temperature with a rectal thermistor.

b. Check airway, breathing, pulse, and blood pressure.

c. Assess the level of central nervous system dysfunction.

4. Begin ice-water immersion. Place the patient in the ice-water–immersion tub. Medical staff, teammates/coaches, and volunteers may be needed to assist with entry to and exit from the tub.

5. Total-body coverage. Cover as much of the body as possible with ice water while cooling.

a. If full-body coverage is not possible due to the tub size, cover the torso as much as possible.

b. To keep the patient's head and neck from going under water, an assistant may hold him or her under the axillae with a towel or sheet wrapped across the chest and under the arms.

c. Place an ice/wet towel over the head and neck while body is being cooled in the tub.

d. Use a water temperature under 15°C (60°F).

6. Vigorously circulate the water. During cooling, water should be continuously circulated or stirred to enhance the water-to-skin temperature gradient, which optimizes cooling. Have an assistant stir the water during cooling.

7. Continue medical assessment. Vital signs should be monitored at regular intervals.

8. Fluid administration. If a qualified medical professional is available, an intravenous fluid line can be placed for hydration and support of cardiovascular function.

9. Cooling duration. Continue cooling until the patient's rectal temperature lowers to 38.9°C (102°F).

a. If rectal temperature cannot be measured and cold-water immersion is indicated, cool for 10–15 min and then transport to a medical facility.

b. An approximate estimate of cooling via cold-water immersion is 1°C for every 5 min and 1°C for every 3 min (if the water is aggressively stirred). For example, someone in the tub for 15 min would cool approximately 3°C or 5°C during that time.

10. Patient transfer. Remove the patient from the immersion tub only after rectal temperature reaches 38.9°C (102°F) and then transfer to the nearest medical facility via emergency medical services as quickly as possible.