Written by Aaron Lacy
Cold-water immersion is recognized as the fastest way to cool patients with heat stroke. Here’s how to do it in your ED.
It’s getting hot in here… dunk ‘em!
Heat-related illness kills and maims thousands of patients per year. Given climate trends, this number will continue to rise. The most effective method of lowering core body temperature is cold-water immersion – but how do you do this safely in your ED? This group developed and implemented a cold-water immersion protocol in early 2021 and has been utilizing it since.
Overview: Cool to < 39°C
- After arrival, place patient into an ice bath inside a white, front-zipped, liquid impermeable body bag, and perform a rapid primary survey. Airway management can be initiated simultaneously with initiation of cooling.
- Placement into ice mixtures is performed in parallel with placing patient on monitors (most importantly, rectal thermometer); once in place, zip patient and ice mixture up to mid chest.
- Keep the cooling coming – refresh ice often.
- Notify nutrition services of the need for additional ice. Ideally, patients should be cooled to <39°C before obtaining CT scan or moving from the resus bay.
Pearls, thoughts, and lessons learned
- Patients, staff, and family may have concerns with using a “body bag,” but this is the most cost effective and practical way to create cold-water immersion in the ED.
- With practice, staff can learn to minimize spills.
- This process requires a lot of communication, ongoing QI, and a solution-oriented team to work.
- In this study, patients with cold-water immersion cooled at a rate almost 3x as fast as non-immersion cooling.
How does this change my practice?
Heat stroke resuscitations require clear direction to the team that the priority is cooling, and distraction from that goal can be costly. We currently have to rely on evaporative cooling methods (wet + windy) and water slurry oscillation with ice packing. Our hospital will likely see heat stroke more often. I will begin discussions with our group about how we should prepare to best take care of these critically ill patients.
Source
Heat Stroke Management Updates: A Description of the Development of a Novel In-Emergency Department Cold-Water Immersion Protocol and Guide for Implementation. Ann Emerg Med. 2025 Jan;85(1):43-52. doi: 10.1016/j.annemergmed.2024.07.013. Epub 2024 Sep 24. PMID: 39320280
