Ice-water sheet coverage for rapid core temperature reduction in exertional heat stroke: A case series

Exertional heat stroke (EHS) requires immediate cooling to prevent organ injury and death. Although cold-water immersion (CWI) is the recommended first-line cooling modality, it is often difficult to implement safely in the emergency department (ED), particularly in patients requiring airway management or ongoing resuscitation. This study aimed to describe an ice-water-soaked sheet coverage protocol and preliminarily evaluate its cooling efficacy and feasibility in patients with EHS.

We conducted a retrospective study of patients with EHS admitted to the ED between May 2022 and July 2024. Patients treated with either CWI or ice-water sheet coverage were included. The ice-water sheet protocol used 2.0 × 2.5 m sheets soaked in 3-8 °C ice water, applied to the trunk and extremities, and replaced every 4-5 min. Core temperature was continuously monitored via rectal probe. Cooling performance, procedural feasibility, and adverse events were assessed descriptively.

A total of 25 male patients were included, 10 in the CWI group and 15 in the ice-water sheet coverage group. Mean age was 32.5 ± 7.4 years. The mean time from arrival in the resuscitation unit to cooling initiation was 5.2 ± 1.8 min in the ice-water sheet coverage group and 8.5 ± 1.3 min in the CWI group. All patients achieved a core temperature < 39.0 °C within 30 min of cooling initiation. The mean cooling rate was 0.09 ± 0.02 °C/min in the ice-water sheet coverage group and 0.12 ± 0.01 °C/min in the CWI group. All patients reached <38.5 °C within 45.3 ± 10.2 min. Ice-water sheet coverage did not interfere with intravenous access, endotracheal intubation, or continuous monitoring. Mild shivering occurred in 20% of patients and was controlled with low-dose sedation. No frostbite, severe arrhythmia, or hemodynamic instability was observed. All patients survived following comprehensive treatment.

Whole-body ice-water sheet coverage achieved rapid and clinically effective cooling in patients with EHS while allowing concurrent resuscitative care. This protocol may represent a practical alternative to CWI in ED settings where immersion cooling is difficult to implement.