The Journal of Emergency Medicine, Vol. -, No. -, pp.

1–10, 2015
Copyright Ó 2015 Elsevier Inc.
Printed in the USA. All rights reserved
0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.09.014

Clinical
Review

COOLING METHODS IN HEAT STROKE

Flavio G. Gaudio, MD* and Colin K. Grissom, MD†

*Division of Emergency Medicine, New York Presbyterian Hospital – Weill Cornell Medical Center, New York, New York and
†Critical Care Medicine, Intermountain Medical Center, Murray, Utah
Reprint Address: Flavio G. Gaudio, MD, Division of Emergency Medicine, New York Presbyterian Hospital – Weill Cornell Medical Center,
525 East 68th Street, New York, NY 10065

, Abstract—Background: Heat stroke is an illness with a INTRODUCTION

high risk of mortality or morbidity, which can occur in the
young and fit (exertional heat stroke) as well as the elderly
and infirm (nonexertional heat stroke). In the United States,
from 2006 to 2010, there were at least 3332 deaths attributed
to heat stroke. Objective: To summarize the available
evidence on the principal cooling methods used in the treat-
ment of heat stroke. Discussion: Although it is generally
agreed that rapid, effective cooling increases survival in
heat stroke, there continues to be debate on the optimal cool-
ing method. Large, controlled clinical trials on heat stroke
are lacking. Cooling techniques applied to healthy volun-
teers in experimental models of heat stroke have not worked
as rapidly in actual patients with heat stroke. The best avail-
able evidence has come from large case series using
ice-water immersion or evaporation plus convection to
cool heat-stroke patients. Conclusions: Ice-water immersion
has been shown to be highly effective in exertional heat
stroke, with a zero fatality rate in large case series of
younger, fit patients. In older patients with nonexertional
heat stroke, studies have more often promoted evaporative
plus convective cooling. Evaporative plus convective cooling
may be augmented by crushed ice or ice packs applied
diffusely to the body. Chilled intravenous fluids may also
supplement primary cooling. Based on current evidence,
ice packs applied strategically to the neck, axilla, and groin;
cooling blankets; and intravascular or external cooling
devices are not recommended as primary cooling methods
in heat stroke. Ó 2015 Elsevier Inc.
, Keywords—heat stroke treatment; exertional heat
stroke; nonexertional heat stroke; conductive cooling;
evaporation and convection cooling
Heat stroke is a life-threatening illness characterized by
an altered level of consciousness with an elevated core
body temperature $40 C. It may develop in persons
exerting themselves in a hot environment; or susceptible,
sedentary persons during periods of high ambient temper-
atures. Victims of advanced heat stroke require transpor-
tation to a medical facility capable of critical care
management of multiple organ failure, though treatment
of heat stroke should begin as early as possible in the pre-
hospital setting. The primary goals of treatment for heat
stroke are lowering core body temperature and supporting
organ system function. The pathophysiology and clinical
manifestations of heat stroke have been described in
detail elsewhere (1,2). The focus of this article is to
review the available evidence on the principal cooling
methods used in the treatment of heat stroke.
To this end, we conducted a PubMed search of journal
articles applicable to the cooling of human subjects with
heat stroke—using the key words ‘‘heat stroke’’ and
‘‘cooling.’’ References in these journal articles in turn
were searched for additional relevant studies. Original
studies and reviews commonly cited in the heat-stroke
literature, as well as noteworthy recent additions to this
literature, are summarized below (Tables 1–6) (3–21).
Historically, heat stroke has been divided into two
broad categories. Exertional heat stroke may develop in
able-bodied individuals such as athletes, soldiers, or
laborers performing rigorous physical activity in a hot

RECEIVED: 10 June 2015; FINAL SUBMISSION RECEIVED: 13 September 2015;

ACCEPTED: 16 September 2015

1
2 F. G. Gaudio and C. K. Grissom

Table 1. Case Series on Conductive Cooling in Exertional Heat Stroke

Study (First Author) Number of Subjects Cooling Technique Outcomes

Beller 1975 (3) 41 military recruits, mean age 21 y Ice-water immersion; cooling times 10–60 min No mortality or morbidity
Costrini 1979 (4) 41 military recruits, mean age 21 y Ice-water immersion; cooling times 10–60 min No mortality or morbidity
O’Donnell 1975 (5) 41 military recruits, mean age 21 y Ice-water immersion; cooling times 10–60 min No mortality or morbidity
Costrini 1990 (6) 252 Marine recruits Ice-water immersion No mortality
Demartini 2015 (7) 274 runners, mean age 32 y Ice-water immersion (10 C); mean cooling rate No mortality
0.22 C/minute
Shibolet 1967 (8) 36 Israeli soldiers, mean age 19 y Numerous ice-filled rubber bottles over the 22% mortality; 11%
body; cooling times 1–3 h neurological morbidity

environment. Nonexertional or classic heat stroke may
arise in elderly or infirm persons confined indoors during
protracted hot weather. Nonexertional heat stroke may
also develop with low-level physical activity in older,
ambulatory persons with associated medical or psychiat-
ric illnesses, including obesity, diabetes, hypertension,
heart disease, renal disease, dementia, and alcoholism.
Advanced age and associated illnesses may impair the
body’s ability to dissipate heat, which normally would
require a rise in cardiac output to shunt blood to dilatated
blood vessels in the skin; as well as sufficient intravascular
volume to allow for increased sweating. Medications such
as beta-blockers, diuretics, and anticholinergics may also
blunt the compensatory increase in cardiac output and
sweating needed to dissipate heat.
In both exertional and nonexertional categories, the
clinical diagnosis of heat stroke rests on findings of
hyperthermia (core body temperature $ 40 C) together
with a disturbance of consciousness in the setting of envi-
ronmental heat stress. Acute central nervous system
dysfunction may include delirium, obtundation, coma,
or seizures. Injury to the pulmonary, cardiovascular,
hepatic, renal, and coagulation systems also commonly
accompanies heat stroke. Such widespread injury arises
from heat-induced conformational changes to cellular
proteins, enzymes, and membranes. These changes
disrupt cellular function, metabolism, and barrier func-
tions, leading to the capillary leakage, severe systemic
inflammation, and multiple organ failure characteristic
of advanced heat stroke.
In addition to aggressive cooling, treatment of heat
stroke may require interventions to support airway,
breathing, blood pressure, and end-organ function. Such
interventions include supplemental oxygen and intuba-
tion, as well as intravenous volume resuscitation and
vasopressors.
Even with treatment, the risk of mortality in heat
stroke remains high, with an upward range near 30%
(9,22). A zero fatality rate has been recorded in young
heat-stroke patients treated with immediate cooling;
yet, for elderly victims during the 2003 heat wave in
France, mortality rates were catastrophic–reaching 2000
deaths on a single day; and 15,000 deaths over the month
of August (6,23). In the United States, from 2006 to
2010, there were at least 3332 deaths attributed to heat
stroke (24).
In marked contrast, heat exhaustion is a less severe
form of heat-related illness. Its clinical features may
include general weakness, fatigue, headache, nausea,
muscle aches, or cramps; as well as brief syncope or min-
imal confusion. In general, heat exhaustion responds to
the conservative treatments of resting in a cool area and
replenishing the body’s fluid and nutritional needs. Heat
stroke may progress from antecedent heat exhaustion,
but may also develop without such progression or
apparent warning.
DISCUSSION
Cooling a victim of heat stroke requires creating a
gradient for heat loss from the skin to the environment
via conduction, convection, or evaporation (Table 7).
Debate in the medical literature over the optimal cooling
method has continued for nearly 100 years without a clear
answer. Scientific studies on different methods of cooling
have used a heterogeneous range of subjects: healthy

Table 2. Case Series on Conductive Cooling in Nonexertional Heat Stroke

Study (First Author) Number of Subjects Cooling Technique Outcomes

Ferris 1938 (9) 44 hospital patients, Ice-water immersion for 25 more critically ill patients, 32% mortality
mean age 61 y cooling times 9–40 min
Hart 1982 (10) 28 ED patients, Ice-water immersion or crushed ice to body; cooling 14% mortality; 14%
mean age 71 y times generally <30 min neurological morbidity

ED = emergency department.
Cooling Methods in Heat Stroke 3

Table 3. Case Series on Evaporative + Convective Cooling in Nonexertional Heat Stroke

Study (First Author) Number of Subjects Cooling Technique Outcomes

Al-Aska 1987 (11) 25 pilgrims, mean age 58 y Water-soaked fine gauze sheets + fans; No mortality or neurological
mean cooling time 40 min morbidity
Bouchama 1991 (12) 52 pilgrims, mean age 59 y Body-cooling unit (BCU); mean cooling Mortality 2%; neurological
time 68 min morbidity 8%
Khogali 1980 (13) 18 pilgrims, mean age 54 y BCU; mean cooling time 96 min Mortality 11%
Khogali 1981 (14) 174 pilgrims, mean age 57 y BCU; mean cooling time 78 min Mortality 15%

volunteers exercising in hot, humid conditions; military
recruits or miners operating in the field; patients admitted
to hospitals during heat waves; and pilgrims traveling in
desert environments (3–5,9,13,14,17–20).
Of the studies comparing different cooling methods,
those involving randomized trials generally have been
performed on healthy volunteers and have enrolled
relatively few subjects. The remaining studies on treating
heat-stroke patients have, for the most part, been
case-series reports or nonrandomized comparisons of
treatment methods—with considerable variations in the
baseline characteristics of subjects from one study to
the next. Moreover, findings in case-series reports may
have limited applicability based on the retrospective
collection of incomplete data. For these reasons, the
historical record has not settled upon one undisputed
method for cooling heat-stroke patients. Still, despite
such limitations, this record has promoted two methods
of cooling overall: 1) in exertional heat stroke, conductive
cooling via ice-water immersion of the patient; and 2) in
nonexertional heat stroke, evaporative and convective
cooling via the application of sprayed water and forced
air currents over the body.
Ice-water Immersion in Exertional Heat Stroke
(Tables 1 and 5)
Immersion cooling, in which subjects have been partly
submerged to the upper torso or neck in baths of cold
water (Figure 1), has resulted in variable cooling rates
depending on the water temperature used. In a small study
of young, healthy volunteers who exercised to a core
temperature of 40 C, immersion in an ice-water slurry
at 2 C produced cooling rates of 0.35 C/min (18).
Immersion in water at higher temperatures of 14 –20 C
produced experimental cooling rates of 0.15 –0.19 C/
min. In comparison, simply allowing hyperthermic
subjects to rest in air-conditioned or temperature-
controlled rooms has resulted in cooling rates of only
0.03 –0.06 C/min (17,19,20).
In studies involving actual heat-stroke patients instead
of experimental volunteers, immersion in an ice-water
slurry has resulted in slower, yet still effective cooling
rates of 0.15 –22 C/min (6,7). This slower cooling of
heat-stroke patients may be explained by the preservation
of endogenous cooling mechanisms in study volunteers
who exercise to hyperthermia. In contrast, in actual
heat-stroke patients, endogenous cooling mechanisms
such as increased blood flow to the skin and sweating
may be impaired, resulting in slower cooling.
In the United States, studies on ice-water immersion in
actual patients with exertional heat stroke historically
have involved military recruits. Several case series in mil-
itary personnel treated with ice-water immersion to a
target temperature between 38.3 C and 38.8 C reported
cooling times ranging from 10–60 min (3–5). No
fatalities or adverse outcomes were reported—despite
initial mean core body temperatures of 42 C.
Additional support for immersion cooling in exertional
heat stroke has come from an internal United States
Marine Corps case series involving 252 recruits over
20 years, which demonstrated a zero fatality rate (6).
Treatment in all the military studies involved rapid
recognition of heat stroke and on-site cooling in a tub

Table 4. Case Series on Combined Methods, Nonexertional Heat Stroke

Study (First Author) Number of Subjects Cooling Technique Outcomes

Graham 1986 (15) 14 ED patients, mean age 66 y Water spray + fanned air; plus crushed 7% mortality; 0% neurological
ice to lateral aspects of trunk and morbidity
chilled IV fluids; mean cooling time
60 min
Vicario 1986 (16) 39 ED patients, mean age 63 y Cold wet sheets + fanned air; plus ice Mortality 21%
packs to axilla and groin; ice-water Majority of patients cooled <1 h
gastric lavage or cooling blanket also
used in 8 patients

ED = emergency department; IV = intravenous.

4 F. G. Gaudio and C. K. Grissom

Table 5. Comparative Trials on Cooling in Healthy Volunteers Who Exercise to Hyperthermia

Study (First Author) Number of Subjects Cooling Technique Outcomes

Kielblock 1986 (17) 25 experimental conditions Comparison of evaporative + Evaporation + convection cooled at
among 5 subjects convective cooling to ice packs 0.035 C/min; whole-body ice packs
cooled at 0.034 C/min; strategic ice
packs added 0.001 C/min to cooling
Proulx 2003 (18) 28 experimental conditions Immersion in water baths at 2 C, Water at 2 C cooled 0.35 C/min; water at
among 7 subjects 8 C, 14 C, and 20 C 8 C–20 C cooled at 0.15–0.19 C/min
Weiner 1980 (19) 38 experimental conditions Comparison of conductive vs. Body-cooling unit cooled at 0.31 C/min;
among 6 subjects evaporative + convective cooling 15 C water bath cooled at 0.11 C/min
Wyndham 1959 (20) 42 experimental conditions Comparison of immersion in water Evaporation + convection cooled at
among 6 subjects at 14 C to water spray + 0.06 C/min; immersion cooled at
compressed air 0.04 C/min

with an ice-water slurry. The excellent outcomes support
the effectiveness of ice-water immersion; but attest also
to the underlying good health of the study subjects and
to the importance of immediate cooling.
Outside the military setting, immersion cooling has
been effective as a field treatment for exertional heat
stroke at large-scale athletic events. A recent study exam-
ined 274 cases of heat stroke that occurred over 18 years
during an annual summer road race (7). Male and female
runners were treated within 2 min of collapse by immer-
sion in a tub of ice water at 10 C. Runners were cooled
from an average initial core temperature of 41.4 C to a
target temperature of 38.8 C at an average cooling rate
of 0.22 C/min. Remarkably, there were no fatalities,
and > 90% of the runners with heat stroke were
discharged home from medical tents without a need for
hospital transfer. Similar to the U.S. military research,
this study has highlighted the efficacy of immediate
immersion cooling in exertional heat stroke. Further-
more, definitive cooling at the onset of heat stroke seems
to have halted the progression to multi-systems injury
characteristic of later stages of this illness.
Indeed, such a large-scale ‘‘treat and release’’
approach to exertional heat stroke is unprecedented in
the literature. However, given the limitations of this retro-
spective study, future clarification is needed on specific
clinical criteria for the safe discharge of patients. For
example, time to collapse of athletes, a potential marker
for the severity of heat stroke, was not recorded. Simi-
larly, a detailed medical history or clinical course was
not provided for each patient, including whether point-
of-care laboratory testing was performed. Finally,
whether discharged athletes later presented to hospitals
with delayed injuries was also not known. For these
reasons, the concept of treating and releasing athletes
with exertional heat stroke after immediate, on-site im-
mersion cooling remains promising, but not yet fully
defined or established.
Ice-water Immersion in Nonexertional Heat Stroke
(Table 2)
Studies on ice-water immersion generally have involved
fit individuals with exertional hyperthermia or heat stroke
(8,25). There have been fewer studies on immersion
cooling in older patients with nonexertional stroke
(9,10). One classic study followed the hospital course
of 44 patients with nonexertional heat stroke admitted
during a heat wave in 1936. Overall mortality in this
study was high, given the older age (mean: 61 years)
and associated medical conditions of the patients—such
as hypertension, heart disease, or alcoholism. In
addition, the majority of patients presented with coma,
critically abnormal vital signs, and core body
temperature > 41.7 C.
Despite such presentations in extremis, in an era prior
to modern intensive care units, nearly 70% of the patients
who received ice-water immersion survived, suggesting a
distinct benefit for this treatment. Patients were cooled to
a target temperature < 39 C, and cooling times ranged
between 9 and 40 min (9).
Concerns with Immersion Cooling
Notwithstanding the benefits to immersion cooling,
shivering, agitation, or combativeness may occur during

Table 6. Controlled Trial on Cooling in Normothermic Subjects

Study (First Author) Number of Subjects Cooling Technique Outcomes

Moore 2008 (21) 16 healthy volunteers 30 mL/kg IV bolus over 30 min of cold Reduction of core body temperature by
(4 C) vs. room temperature (23 C) 1 C in cold saline group and 0.5 C in
saline room-temperature saline group
Cooling Methods in Heat Stroke
Table 7. Primary Methods of Heat Loss from the Body
(See Also Figure 3)
Radiation Simple loss of heat across the skin barrier
to the ambient air
Conduction Transfer of heat through contact with a
cooler object or cold water
Evaporation Transfer of heat to evaporating sweat or
water on the skin
Convection Evaporative heat loss enhanced by wind
or air currents
treatment. Pronounced shivering of study subjects has
been observed in cold-water immersions lasting longer
than 9–10 min (18–20). Theoretically, such shivering
and the accompanying reflex peripheral vasoconstriction
may hinder cooling; but immersed patients have been
effectively cooled despite any shivering. Several reasons
help explain this.
First, the total body heat generated by shivering
remains small compared to the high thermal conductivity
of a large ice-water bath. Second, several authors have
observed shivering occurring with less frequency and
severity in actual heat-stroke patients with depressed
mental status than in conscious, experimental volunteers
who have intact shivering mechanisms (9,18,20). Finally,
in modern practice, shivering of heat-stroke patients has
been pharmacologically controlled with benzodiazepines
or narcotics.
Nonetheless, shivering or agitation may become prob-
lematic. In one study involving older patients with non-
exertional heat stroke, several patients experienced such
discomfort or agitation with ice-water immersion that
they were switched to cooling by the application of
crushed ice over the body (10).
Figure 1. Conductive cooling: ice-water immersion in exer-
tional heat stroke. The collapsed runner with a core temper-
ature of nearly 41 C (106 F) is immediately cooled in a large
rubber tub containing ice water, with rescuers supporting
the head and upper body. Photograph courtesy of the Korey
Stringer Institute: ksi.uconn.edu. Used with permission,
Ó 2014.
5
Other authors have cited the additional theoretical
concern of impaired access to an elderly, immersed
patient who may require advanced cardiac monitoring
or additional resuscitative procedures (3,9,10,26). Given
the absence of large, controlled trials in heat stroke,
concerns with the potential discomfort and impaired
access of the immersed, elderly patient must be judged
clinically on an individual, patient-by-patient basis; but
weighed against a case-series record that has indicated
a benefit to immersion cooling in several score of older
patients.
Studies on Cooling by Ice Packs in Exertional Heat
Stroke (Tables 1 and 5)
Conductive cooling by the application of crushed ice or
ice packs to the body has been proposed as a reasonable
alternative to cold-water immersion, though experience
has been more limited with this method (27,28). In an
experiment of healthy volunteers who exercised to
hyperthermia, the diffuse application of ice packs over
the body cooled as well as evaporative plus convective
cooling (17). In this small study, an important distinction
was between the diffuse application of ice packs, which
cooled effectively, and the strategic application of ice
packs to the axilla, neck, and groin–which only margin-
ally contributed to cooling. Ice-filled packs may contain
more cooling capacity and remain colder longer
compared to instant, chemical cold packs (29).
On the other hand, cooling by the application of
numerous ice-filled rubber bottles over the body led to
suboptimal outcomes in an Israeli case series on exer-
tional heat stroke in military personnel. This study had
a 22% mortality rate and 11% neurological morbidity
rate. However, delays in definitive cooling (from
30 min to 2 h), rather than simply the cooling method it-
self, may have contributed to such outcomes (8).
Summary on Conductive Cooling
In summary, the available evidence indicates that
ice-water immersion is effective in younger or fit persons,
such as athletes and military personnel, with exertional
heat stroke. Immersion cooling has been studied to a
lesser extent in older patients with nonexertional heat
stroke, though case series reports have suggested a
benefit. Certain patients may not tolerate immersion
cooling and require an alternate method of treatment.
Conductive cooling via the diffuse application of crushed
ice or ice packs to the body has been reported as a reason-
able alternative to ice-water immersion—though with
less of a demonstrated track record. Strategic application
of ice packs to the axilla, neck, and groin has been shown
to contribute minimally to cooling under experimental
6 F. G. Gaudio and C. K. Grissom
conditions and would not be expected to be effective in
treating heat stroke. This last point should be emphasized,
as published articles continue to promote such treatment
despite a lack of proven effectiveness as a primary cool-
ing method (30).
Evaporative and Convective Cooling
Studies on nonexertional heat stroke (Table 3). The tech-
nique of evaporative and convective cooling involves
directing air currents while simultaneously spraying
water on study subjects (Figure 2). Experimental cooling
rates ranging from 0.034 to 0.31 C/min have been
achieved (17,19,20). This wide variation in rates may
be attributed to differences in the temperatures of the
water and air currents used in each study; the quantity
of water used; the velocity of air currents directed at
subjects; and differences in baseline characteristics of
study participants. In general, larger quantities of water
and stronger air currents directed at younger, healthier
subjects have produced faster cooling.
In a small study of young, healthy volunteers who
exercised to a core body temperature of 40 C, a specially
constructed device, termed a body-cooling unit (BCU),
produced a superior cooling rate of 0.31 C/min (19).
The BCU sprayed a standardized combination of cool
water mist (15 C) and warm, compressed air (45 C—to
help prevent shivering) at patients lying on mesh netting.
In actual heatstroke patients, however, the BCU produced
cooling rates ranging from 0.04 to 0.11 C/min—at best,
a third as effective as the experimental cooling rates (10).
Differences in health and fitness between experimental
subjects vs. actual heat-stroke patients help explain this
Figure 2. Evaporative plus convective cooling: the body-
cooling unit. Overhead pipes spray cool water mist onto the
patient. Strong air currents are created by electric fans
(pictured) or a tubular framework, which blows compressed
air. Reprinted from: Pang HN, Mong R, Lee VJ, Chua WC,
Seet (B) Treatment of exertional heat injuries with portable
body cooling unit in a mass endurance event. Lancet 2010;
28:246–8; Ó 2010; with permission from Elsevier (31).
wide variation in cooling rates. The majority of studies
on the BCU have been performed during the Muslim
summer pilgrimages to Saudi Arabia. In this context,
many patients have been older, obese, and with medical
conditions such as diabetes, high blood pressure, and
heart disease. In addition, the endogenous cooling mech-
anisms of healthy study subjects remain intact and
contribute to cooling, whereas those of heat-stroke vic-
tims may lose effectiveness. For these reasons, the BCU
has performed better in the laboratory than in actual clin-
ical practice or field conditions.
Nonetheless, despite slower cooling rates in clinical
practice, the BCU has demonstrated a useful role in treat-
ing patients with nonexertional heat stroke. In a report on
heat stroke in 192 summer pilgrims, the BCU lowered
body temperature to 38 C in a mean time of 78 min.
The mortality rate was 14.6% and there was no neurolog-
ical morbidity post-cooling among the survivors (13,14).
In another study involving 52 pilgrims, treatment with the
BCU resulted in a mean cooling time of 68 min to reach a
core temperature of 39.4 C, and only one death (12).
Other studies have used evaporative and convective
cooling without the BCU. Two case series (n = 25,
n = 14) used fans and water applied to patients with non-
exertional heat stroke. Mortality was low in both studies:
0% and 7%, respectively; short-term morbidity was 24%
and 0%, respectively (11,15).
Studies on exertional heat stroke. Large series or studies
on the use of evaporative plus convective cooling in actual
patients with exertional heat stroke are lacking. One his-
torical reference may be found during the period 1956–
1961 in the South African mines, where miners with exer-
tional heat stroke were initially treated with sprayed water
and fanned air (22). The mortality rate was 28%—consid-
erably higher than the 0% rate in the U.S. military studies.
However, fair comparison cannot be made between the
two rates. Details regarding the ages and medical condi-
tions of the miners; the specific treatment techniques
used; and the delays inherent in evacuating victims from
deep tunnels have not been published.
More recently, in a pilot study, a field-deployed BCU
was used at a half-marathon to definitively cool three run-
ners with exertional heat stroke prior to hospital transfer
(31). The runners made a full recovery after 3–10 days of
hospitalization. In a separate case report, two runners
were cooled in a striking variation of the evaporative plus
convective technique using sprayed water and the down-
drafts of a light-utility helicopter. Both runners made a
full recovery after several days of hospitalization (32).
Summary on evaporative plus convective cooling. Evapo-
rative plus convective techniques have shown an effective
role in the treatment of nonexertional heat stroke. The
Cooling Methods in Heat Stroke
higher morbidity and mortality with such techniques
compared with immersion cooling may be explained in
part by the older study population in nonexertional heat
stroke. The BCU has been used on several hundred
patients with nonexertional heat stroke. Although results
from these case-series studies have shown a beneficial
effect of the BCU, they have not demonstrated that this
device is superior to adequate wetting and fanning of the
skin in general. Studies demonstrating the effectiveness
of evaporative plus convective cooling in exertional heat
stroke have involved only a handful of patients to date.
Combined or Adjunctive Cooling Treatments
(Tables 4 and 6)
Several authors have described applying ice packs or
crushed ice to patients cooled primarily by evaporation
plus convection (Figure 3) (15,16). In one study on
nonexertional heat stroke (n = 14), applying crushed ice
along the sides of the body supplemented cooling by
sprayed water and fanned air. There was only one
death, and among the survivors, no neurological
sequelae. It is plausible that adding a conductive heat-
loss mechanism may speed cooling and improve out-
comes, but there are no controlled, comparative trials in
actual patients showing an incremental benefit. In an
experimental model of heat stroke, placing ice packs
over the whole body of hyperthermic subjects achieved
higher cooling rates than evaporative plus convective
cooling alone. On the other hand, in the same study,
placing ice packs only to the axilla, neck, and groin
increased cooling minimally (17).
Figure 3. Combined cooling methods. Removal of the pa-
tient’s clothes aids in heat loss through radiation. Cubed
ice applied by basin over and alongside the patient’s body
melts and cools through conduction. Flexible hosing directs
compressed air at the patient’s wet skin–achieving cooling
through evaporation plus convection. Spray bottles may be
used to keep the skin continuously wet during cooling; and
large room fans may be used instead of compressed air.
Photograph by Flavio Gaudio, MD, Ó 2015.
7
In patients receiving hydration, cold intravenous fluids
may supplement primary cooling. In a study of healthy
volunteers (n = 16), infusion of cold (4 C) intravenous
saline over 30 min cooled core body temperature by
1 C, compared to 0.5 C with room-temperature saline.
Cold saline, therefore, may be beneficial when added to
evaporative or conductive cooling; but would be insuffi-
cient as a primary treatment for heat stroke (21).
The U.S. military studies on ice-water immersion also
reported massaging the extremities during cooling to
limit cutaneous vasoconstriction and promote blood
flow to the skin. Whether such treatment contributed
meaningfully to cooling or outcomes has not been sepa-
rately studied and remains unknown.
Invasive techniques of body cavity lavage with cold
isotonic fluid have been reported, but have not been
adequately studied (28,33). Both intravascular cooling
devices and noninvasive external cooling systems (such
as the Arctic SunÔ; Medivance, Inc., Louisville, CO)
have provided adjunctive treatment for heat stroke in
individual case reports, but also require further study
(34,35). The use of cooling blankets in heat stroke has
not been well described or studied (16).
End Point of Cooling
Evidence is lacking for an optimal target temperature at
which to end cooling. Concern for potential cardiac dys-
rhythmias with overcooling has led to proposed end
points of cooling slightly above normal body tempera-
ture. The majority of studies on evaporative cooling
have used an end point near 38 C; studies on immersion
cooling instead have used an end point just below 39 C.
Although mortality with either cooling method has gener-
ally been low, this could not be specifically attributed to
the end-point temperature chosen. Similarly, the effect
of end-point temperature on long-term morbidity or
neurological outcome has not been established (27).
Pharmacologic Treatment of Heat Stroke
No pharmacologic agent has been shown to be helpful as
a treatment for heat stroke. Dantrolene has been used for
treatment of malignant hyperthermia and neuroleptic ma-
lignant syndrome. It acts by impairing calcium release
from the sarcoplasmic reticulum, thereby reducing the
muscular muscle rigidity and hypertonicity typical of
these conditions. A well-designed, randomized clinical
trial of dantrolene vs. placebo in 52 Muslim pilgrims
with heat stroke showed no difference in cooling rates
or outcome (12).
Commonly used antipyretic agents have not been stud-
ied for treatment of heat stroke. Theoretically, such
agents would not be expected to have benefit, because
8 F. G. Gaudio and C. K. Grissom
fever and heat stroke raise core body temperature through
different physiological pathways.
CONCLUSIONS
Current evidence supports both immersion and evapora-
tive methods for cooling of heat-stroke victims. The his-
torical record has shown that ice-water immersion until
core body temperature falls below 39 C is safe and highly
effective for young, athletic patients with exertional heat-
stroke. In this population, the water temperature most
often used has been 0 C–10 C. Among elderly study
subjects with nonexertional heat stroke, the weight of
experience has involved evaporative and convective cool-
ing to a core body temperature near 38 C. Evaporative
cooling in elderly patients may offer several theoretical
advantages, such as greater patient comfort and less agita-
tion, as well as easier access to patients who may need
advanced monitoring or resuscitation. Considerable vari-
ation in cooling rates with evaporative cooling, however,
has suggested that this method is more dependent on the
specific technique used. At a minimum, such technique
must ensure that a sufficient quantity of water and
strength of air currents be applied to the heat-stroke
patient.
Based on the evidence, we recommend that patients
with heat stroke in a medical facility be treated as soon
as possible with either conductive cooling by whole-
body ice-water immersion (preferential method in exer-
tional heat stroke); or evaporative and convective cooling
by a combination of cool water spray with continual
airflow over the body (acceptable alternative in elderly
patients with nonexertional heatstroke). Cooling should
continue until core body temperature is 38 –39 C. Either
cooling method may be augmented by the addition of
cold intravenous saline if hydration is needed. Evapora-
tive and convective cooling may be augmented with the
addition of ice packs or crushed ice over the whole
body to promote conductive cooling.
Regardless of the cooling method used, mortality and
morbidity have been higher in older patients with heat
stroke, due in part to the preexisting diseases and baseline
characteristics of this population.
There is insufficient evidence to recommend utiliza-
tion of an intravascular cooling device, noninvasive
external cooling system, body cavity lavage, or antipy-
retic agents. Dantrolene is not recommended in the treat-
ment of heat stroke. Evidence is lacking to support the use
of cooling blankets or ice packs placed strategically to the
neck, axilla, and groin as primary cooling methods.
Acknowledgments—Brief excerpts of this review article written
by the authors have appeared also in the Wilderness Medical
Society’s 2013 practice guidelines on the prevention and treat-
ment of heat-related illness. The authors acknowledge the con-
tributions of their colleagues on the practice guidelines working
group toward a better understanding of this topic.
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10 F. G. Gaudio and C. K. Grissom

ARTICLE SUMMARY
1. Why is this topic important?
In the United States, from 2006 to 2010, there were at
least 3332 deaths attributed to heat stroke. Rapid, effec-
tive cooling is fundamental to treatment.
2. What does this review attempt to show?
Although large, controlled trials are lacking, both ice-
water immersion and evaporative plus convective cooling
have a demonstrated track record in the treatment of heat
stroke.
3. What are the key findings?
Ice-water immersion has been shown to be highly
effective in exertional heat stroke, with a zero fatality
rate in large case series of younger, fit patients. In older
patients with nonexertional heat stroke, studies have
more often promoted evaporative plus convective cooling.
4. How is patient care impacted?
Heat-stroke patients should be cooled by the methods
most supported by clinical experience–namely, ice-
water immersion (preferential method in exertional heat
stroke) or evaporative plus convective cooling. Evapora-
tive plus convective cooling may be augmented by
crushed ice or ice packs applied diffusely to the body.
Chilled intravenous fluids may also supplement primary
cooling. Ice packs applied strategically to the neck, axilla,
and groin; cooling blankets; and intravascular or external
cooling devices should not be considered primary cooling
methods in heat stroke.