Low-volume body bag cooling for severe exertional heat stroke in the emergency department: a case report

Exertional heat stroke (EHS) is a life-threatening emergency in which delayed or inadequate cooling substantially increases the risk of death and permanent neurological injury. Core temperature reduction to below 39 °C within 30 min is the therapeutic target, and cold-water immersion achieves the fastest cooling rates (0.15-0.35 °C/min) but is frequently unavailable in emergency departments (ED) due to equipment and space limitations. Body bag-based tarp-assisted cooling with oscillation (TACO) has been proposed as an alternative using universally available materials; however, clinical evidence supporting its emergency department use remains limited.

A 57-year-old immunocompromised male construction worker (acute myeloid leukemia, status post umbilical cord blood transplantation, maintained on prednisolone and tacrolimus) presented with EHS following 90 min of outdoor labor in ambient conditions of 36 °C and 65% relative humidity. On ED arrival, rectal temperature was 42.0 °C, Glasgow Coma Scale score was 4, blood pressure was 125/80 mmHg, and heart rate was 183 beats/minute. Body bag-based TACO was initiated immediately upon arrival using 15 L of tap water and 15 kg of ice. Endotracheal intubation for airway protection was performed concurrently, demonstrating patient accessibility during cooling. Target temperature (rectal temperature < 39 °C) was achieved in 39 min at a cooling rate of 0.085 °C/min. Glasgow Coma Scale score improved to 14 within 7.5 h of admission. The hospital course was complicated by bacteremia requiring prolonged antimicrobial therapy. The patient was discharged ambulatory on hospital day 42 without neurological sequelae.

Body bag-based TACO required substantially less water (15 L) than the water/ice volumes reported in TACO studies (114-151 L) using materials available in any ED. Although the cooling rate achieved (0.085 °C/min) fell below published benchmarks, the patient achieved complete neurological recovery, suggesting that immediate initiation of cooling may help offset a suboptimal rate. While a single case cannot establish equivalence to cold-water immersion, body bag-based TACO offers a practical, low-cost option for initiating cooling when standard infrastructure is unavailable, and merits further comparative evaluation.