Recommended water immersion duration for the field treatment of exertional heat stroke when rectal temperature is unavailable

INTRODUCTION

The recommended treatment for exertional heat stroke is immediate, whole-body immersion in < 10 °C water until rectal temperature (Tre) reaches ≤ 38.6 °C. However, real-time Tre assessment is not always feasible or available in field settings or emergency situations. We defined and validated immersion durations for water temperatures of 2-26 °C for treating exertional heat stroke.

METHODS

We compiled data for 54 men and 18 women from 7 previous laboratory studies and derived immersion durations for reaching 38.6 °C Tre. The resulting immersion durations were validated against the durations of cold-water immersion used to treat 162 (98 men; 64 women) exertional heat stroke cases at the Falmouth Road Race between 1984 and 2011.

RESULTS

Age, height, weight, body surface area, body fat, fat mass, lean body mass, and peak oxygen uptake were weakly associated with the cooling time to a safe Tre of 38.6 °C during immersions to 2-26 °C water (R2 range: 0.00-0.16). Using a specificity criterion of 0.9, receiver operating characteristics curve analysis showed that exertional heat stroke patients must be immersed for 11-12 min when water temperature is ≤ 9 °C, and for 18-19 min when water temperature is 10-26 °C (Cohen's Kappa: 0.32-0.75, p < 0.001; diagnostic odds ratio: 8.63-103.27).

CONCLUSION

The reported immersion durations are effective for > 90% of exertional heat stroke patients with pre-immersion Tre of 39.5-42.8 °C. When available, real-time Tre monitoring is the standard of care to accurately diagnose and treat exertional heat stroke, avoiding adverse health outcomes associated with under- or over-cooling, and for implementing cool-first transport second exertional heat stroke policies.

A Systematic Review of Post-Work Core Temperature Cooling Rates Conferred by Passive Rest

Physical work increases energy expenditure, requiring a considerable elevation of metabolic rate, which causes body heat production that can cause heat stress, heat strain, and hyperthermia in the absence of adequate cooling. Given that passive rest is often used for cooling, a systematic search of literature databases was conducted to identify studies that reported post-work core temperature cooling rates conferred by passive rest, across a range of environmental conditions. Data regarding cooling rates and environmental conditions were extracted, and the validity of key measures was assessed for each study. Forty-four eligible studies were included, providing 50 datasets. Eight datasets indicated a stable or rising core temperature in participants (range 0.000 to +0.028 °C min^-1), and forty-two datasets reported reducing core temperature (-0.002 to -0.070 °C min^-1) during passive rest, across a range of Wet-Bulb Globe Temperatures (WBGT). For 13 datasets where occupational or similarly insulative clothing was worn, passive rest resulted in a mean core temperature decrease of -0.004 °C min^-1 (-0.032 to +0.013 °C min^-1). These findings indicate passive rest does not reverse the elevated core temperatures of heat-exposed workers in a timely manner. Climate projections of higher WBGT are anticipated to further marginalise the passive rest cooling rates of heat-exposed workers, particularly when undertaken in occupational attire.

Treating exertional heat stroke: Limited understanding of the female response to cold water immersion

According to an expansive body of research and best practice statements, whole-body cold water immersion is the gold standard treatment for exertional heat stroke. However, as this founding evidence was predominantly drawn from males, the current guidelines for treatment are being applied to women without validation. Given the recognised differences in thermal responses experienced by men and women, all-encompassing exertional heat stroke treatment advice may not effectively protect both sexes. In fact, recent evidence suggests that hyperthermic women cool faster than hyperthermic men during cold water immersion. This raises the question of whether overcooling is risked if the present guidelines are followed. The current mini-review examined the literature on women's response to cold water immersion as a treatment for exertional heat stroke and aimed to clarify whether the current guidelines have appropriately considered research investigating women. The potential implications of applying these guidelines to women were also discussed.

Meteorological Risks in Doha 2019 Athletics World Championships: Health Considerations From Organizers

The Doha 2019 IAAF World Championships represent a challenge for athletes, workforce and spectators who could compete, work or attend under likely extreme meteorological conditions. This short article summarizes the methodology used by the IAAF and the Local Organizing Committee doctors to analyze and reduce risks, while complying as much as possible with existing recommendations or policies. The main steps to be completed are identification and description of weather-related risks, description and whenever possible testing of all their possible mitigation measures during test events, revision of these risks once mitigation implemented, and finally drafting a contingency plan for remaining exceptional and impactful occurrences. Such risk management methodology could apply to other sports, ideally from the host city selection to the delivery of the competitive event.

THE EFFECT OF COLD WATER IMMERSION ON PAIN, MUSCLE RECRUITMENT AND POSTURAL CONTROL IN ATHLETES

ABSTRACT Introduction Numerous recovery strategies have been used to minimize performance loss related to delayed onset muscle soreness in athletes, and are part of prevention programs and training of most high-level sports. Objective To analyze the effects of cold-water immersion on delayed-onset muscle soreness, muscle recruitment, and postural control in soccer players. Objective The maximum load of the quadriceps femoris muscle strength was determined. After three days, the pain scale was used to measure the subject’s pain intensity. The recruitment of the quadriceps muscle was determined at the moment of the kick, and was associated with postural control. Methods Randomized, blinded clinical trial study. Two repeated series of maximum load sets at 60% MVC, performed in a knee extension chair, were used to induce quadriceps fatigue in the athletes. Participants Twenty-eight soccer players were allocated to four intervention groups: cold water immersion (CWIG, n = 7), thermoneutral water immersion (TWIG, n = 7), active recovery (ARG, n = 7), and rest (RG, n = 7), with each intervention being carried out for ten minutes. Revaluations were carried out after 24, 48, and 72 hours of the fatigue protocol. Results Pain intensity in the CWIG returned to baseline after 72 hours, while the TWIG, ARG, and RG continued to feel greater pain. For the other outcomes, no differences were found between the groups. Conclusion With regard to muscle recruitment and postural control at the time of the kick, no significant differences were found for the time periods or intervention established. Level of evidence I; High-quality randomized clinical trial with or without statistically significant difference, but with narrow confidence intervals.

Renal and segmental artery hemodynamics during whole body passive heating and cooling recovery

High environmental temperatures are associated with increased risk of acute kidney injury, which may be related to reductions in renal blood flow. The susceptibility of the kidneys may be increased because of heat stress-induced changes in renal vascular resistance (RVR) to sympathetic activation. We tested the hypotheses that, compared with normothermia, increases in RVR during the cold pressor test (CPT, a sympathoexcitatory maneuver) are attenuated during passive heating and exacerbated after cooling recovery. Twenty-four healthy adults (22 ± 2 yr; 12 women, 12 men) completed CPTs at normothermic baseline, after passive heating to a rise in core temperature of ~1.2°C, and after cooling recovery when core temperature returned to ~0.2°C above normothermic baseline. Blood velocity was measured by Doppler ultrasound in the distal segment of the right renal artery (Renal, n = 24 during thermal stress, n = 12 during CPTs) or the middle portion of a segmental artery (Segmental, n = 12). RVR was calculated as mean arterial pressure divided by renal or segmental blood velocity. RVR increased at the end of CPT during normothermic baseline in both arteries (Renal: by 1.0 ± 1.0 mmHg·cm−1·s, Segmental: by 2.2 ± 1.2 mmHg·cm−1·s, P ≤ 0.03), and these increases were abolished with passive heating ( P ≥ 0.76). At the end of cooling recovery, RVR in both arteries to the CPT was restored to that of normothermic baseline ( P ≤ 0.17). These data show that increases in RVR to sympathetic activation during passive heating are attenuated and return to that of normothermic baseline after cooling recovery.

NEW & NOTEWORTHY Our data indicate that increases in renal vascular resistance to the cold pressor test (i.e., sympathetic activation) are attenuated during passive heating, but at the end of cooling recovery this response returns to that of normothermic baseline. Importantly, hemodynamic responses were assessed in arteries going to (renal artery) and within (segmental artery) the kidney, which has not been previously examined in the same study during thermal and/or sympathetic stressors.

Heart rate variability dynamics during treatment for exertional heat strain when immediate response is not possible

NEW FINDINGS

What is the central question of this study? Does a delay in cold water immersion treatment affect the cardiac autonomic control of exertionally heat-strained individuals? What is the main finding and its importance? Cold water immersion is effective for treating exertionally heat-strained individuals even when treatment is commenced with a significant delay. However, that treatment delay leads to only partial/transient restoration of cardiac autonomic control. Therefore, we recommend that exertional heatstroke patients are continuously monitored for several hours even after core temperature has returned to normal values.

ABSTRACT

Immediate cold water immersion (CWI) is the gold-standard treatment for exertional heatstroke. In the field, however, treatment is often delayed, primarily owing to a delayed paramedic response and/or inaccurate diagnosis. We examined the effect of treatment (reduction of rectal temperature to 37.5°C) delays of 5 (short), 20 (moderate) and 40 (prolonged) min on cardiac autonomic control [as assessed via heart rate variability (HRV)] in eight exertionally heat-strained (40.0°C rectal temperature) individuals. Eleven HRV indices were computed that have been described commonly in the literature and characterize almost all known domains of the variability and complexity of the cardiopulmonary system. We found that the cardiac autonomic control (as assessed via HRV) of exertionally heat-strained individuals was significantly affected by the amount of time it took for the CWI treatment to be applied. Six out of 11 HRV indices studied, from all variability domains, displayed strong (P ≤ 0.005) time × delay interaction effects. Moreover, the number of significantly (P ≤ 0.005) abnormal (i.e. different from the short delay) HRV indices more than doubled (seven versus 15) from the moderate delay to the prolonged delay. Finally, our results demonstrated that a CWI treatment applied with delays of 20 and, primarily, 40 min did not lead to a full restoration of cardiac autonomic control of exertionally heat-strained individuals. In conclusion, this study supports CWI for treating exertionally heat-strained individuals even when applied with prolonged delay, but it highlights the importance of continued cardiac monitoring of patients who have suffered exertional heatstroke for several hours after restoration of core temperature to normal.

Cooling Rates of Hyperthermic Humans Wearing American Football Uniforms When Cold-Water Immersion Is Delayed

CONTEXT

Treatment delays can be contributing factors in the deaths of American football athletes from exertional heat stroke. Ideally, clinicians begin cold-water immersion (CWI) to reduce rectal temperature (Trec) to <38.9°C within 30 minutes of collapse. If delays occur, experts recommend Trec cooling rates that exceed 0.15°C/min. Whether treatment delays affect CWI cooling rates or perceptual variables when football uniforms are worn is unknown.

OBJECTIVE

To answer 3 questions: (1) Does wearing a football uniform and delaying CWI by 5 minutes or 30 minutes affect Trec cooling rates? (2) Do Trec cooling rates exceed 0.15°C/min when treatment delays have occurred and individuals wear football uniforms during CWI? (3) How do treatment delays affect thermal sensation and Environmental Symptoms Questionnaire responses?

DESIGN

Crossover study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Ten physically active men (age = 22 ± 2 y, height = 183.0 ± 6.9 cm, mass = 78.9 ± 6.0 kg).

INTERVENTION(S)

On 2 days, participants wore American football uniforms and exercised in the heat until Trec was 39.75°C. Then they sat in the heat, with equipment on, for either 5 or 30 minutes before undergoing CWI (10.6°C ± 0.1°C) until Trec reached 37.75°C.

MAIN OUTCOME MEASURE(S)

Rectal temperature and CWI duration were used to calculate cooling rates. Thermal sensation was measured pre-exercise, postexercise, postdelay, and post-CWI. Responses to the Environmental Symptoms Questionnaire were obtained pre-exercise, postdelay, and post-CWI.

RESULTS

The Trec cooling rates exceeded recommendations and were unaffected by treatment delays (5-minute delay = 0.20°C/min ± 0.07°C/min, 30-minute delay = 0.19°C/min ± 0.05°C/min; P = .4). Thermal sensation differed between conditions only postdelay (5-minute delay = 6.5 ± 0.6, 30-minute delay = 5.5 ± 0.7; P < .05). Environmental Symptoms Questionnaire responses differed between conditions only postdelay (5-minute delay = 27 ± 15, 30-minute delay = 16 ± 12; P < .05).

CONCLUSIONS

Treatment delays and football equipment did not impair CWI's effectiveness. Because participants felt cooler and better after the 30-minute delay despite still having elevated Trec, clinicians should use objective measurements (eg, Trec) to guide their decision making for patients with possible exertional heat stroke.

Physical characteristics cannot be used to predict cooling time using cold-water immersion as a treatment for exertional hyperthermia

We examined if physical characteristics could be used to predict cooling time during cold water immersion (CWI, 2 °C) following exertional hyperthermia (rectal temperature ≥39.5 °C) in a physically heterogeneous group of men and women (n = 62). Lean body mass was the only significant predictor of cooling time following CWI (R² = 0.137; P < 0.001); however, that prediction did not provide the precision (mean residual square error: 3.18 ± 2.28 min) required to act as a safe alternative to rectal temperature measurements.

Consensus Statement- Prehospital Care of Exertional Heat Stroke

Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to the time sensitive nature of treatment. In cases of EHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average EMS transport and ED evaluation window. The purpose of this document is to present a paradigm for prehospital healthcare systems to minimize the risk of morbidity and mortality for EHS patients. With proper planning, EHS can be managed successfully by the prehospital healthcare provider.

Restoration of thermoregulation after exercise

Performing exercise, especially in hot conditions, can heat the body, causing significant increases in internal body temperature. To offset this increase, powerful and highly developed autonomic thermoregulatory responses (i.e., skin blood flow and sweating) are activated to enhance whole body heat loss; a response mediated by temperature-sensitive receptors in both the skin and the internal core regions of the body. Independent of thermal control of heat loss, nonthermal factors can have profound consequences on the body's ability to dissipate heat during exercise. These include the activation of the body's sensory receptors (i.e., baroreceptors, metaboreceptors, mechanoreceptors, etc.) as well as phenotypic factors such as age, sex, acclimation, fitness, and chronic diseases (e.g., diabetes). The influence of these factors extends into recovery such that marked impairments in thermoregulatory function occur, leading to prolonged and sustained elevations in body core temperature. Irrespective of the level of hyperthermia, there is a time-dependent suppression of the body's physiological ability to dissipate heat. This delay in the restoration of postexercise thermoregulation has been associated with disturbances in cardiovascular function which manifest most commonly as postexercise hypotension. This review examines the current knowledge regarding the restoration of thermoregulation postexercise. In addition, the factors that are thought to accelerate or delay the return of body core temperature to resting levels are highlighted with a particular emphasis on strategies to manage heat stress in athletic and/or occupational settings.

Rapid cooling after acute hyperthermia alters intestinal morphology and increases the systemic inflammatory response in pigs

The study objective was to determine the direct effects of rapid cooling after acute hyperthermia on intestinal morphology and inflammatory response in pigs. In four repetitions, male pigs (N = 36; 88.7 ± 1.6 kg) were exposed to thermoneutrality (TN; n = 3/rep; 19.5 ± 0.1°C) for 6 h or heat stress (HS; 36.4 ± 0.1°C) for 3 h, followed by a 3-h recovery period of rapid cooling (HSRC; n = 3/rep; rapid TN exposure and ice water dousing for 1.5 h) or gradual cooling (HSGC; n = 3/rep; gradual decrease from HS to TN). Rectal (TR) and gastrointestinal tract (TGI) temperatures were obtained every 15 min for 6 h. In repetitions 1 and 2, blood was collected at 60 and 180 min during HS and 30 and 60 min during recovery, and then pigs were euthanized at 180 min of recovery and duodenum, ileum, and colon tissue were collected to evaluate intestinal morphology. HS increased (P < 0.01) maximum TR (40.7°C) and TGI (41.5°C) compared with TN treatment (38.9 and 39.3°C, respectively). Recovery reduced TR (P < 0.01; 0.4°C) in HSRC vs. HSGC pigs, but TGI was similar (40.7°C). HSRC reduced (P < 0.01) villus height-to-crypt depth ratio in the duodenum (34%) and ileum (46%) vs. HSGC pigs. Serum LPS concentration was greater in HSRC pigs (P = 0.04; 68.5% and 52.4%, respectively) compared with TN and HSGC pigs, and TNF-α concentration tended to be greater (P = 0.06; 41.2%) compared with HSGC pigs during recovery. In summary, rapid cooling reduced TR but had no effect on TGI, and this may be linked to increased intestinal damage and a systemic inflammatory response.

Water immersion for post incident cooling of firefighters; a review of practical fire ground cooling modalities

Rapidly cooling firefighters post emergency response is likely to increase the operational effectiveness of fire services during prolonged incidents. A variety of techniques have therefore been examined to return firefighters core body temperature to safe levels prior to fire scene re-entry or redeployment. The recommendation of forearm immersion (HFI) in cold water by the National Fire and Protection Association preceded implementation of this active cooling modality by a number of fire services in North America, South East Asia and Australia. The vascularity of the hands and forearms may expedite body heat removal, however, immersion of the torso, pelvis and/or lower body, otherwise known as multi-segment immersion (MSI), exposes a greater proportion of the body surface to water than HFI, potentially increasing the rates of cooling conferred. Therefore, this review sought to establish the efficacy of HFI and MSI to rapidly reduce firefighters core body temperature to safe working levels during rest periods. A total of 38 studies with 55 treatments (43 MSI, 12 HFI) were reviewed. The core body temperature cooling rates conferred by MSI were generally classified as ideal (n = 23) with a range of ~0.01 to 0.35 °C min(-1). In contrast, all HFI treatments resulted in unacceptably slow core body temperature cooling rates (~0.01 to 0.05 °C min(-1)). Based upon the extensive field of research supporting immersion of large body surface areas and comparable logistics of establishing HFI or MSI, it is recommended that fire and rescue management reassess their approach to fireground rehabilitation of responders. Specifically, we question the use of HFI to rapidly lower firefighter core body temperature during rest periods. By utilising MSI to restore firefighter Tc to safe working levels, fire and rescue services would adopt an evidence based approach to maintaining operational capability during arduous, sustained responses. While the optimal MSI protocol will be determined by the specifics of an individual response, maximising the body surface area immersed in circulated water of up to 26 °C for 15 min is likely to return firefighter Tc to safe working levels during rest periods. Utilising cooler water temperatures will expedite Tc cooling and minimise immersion duration.