Heatstroke On The Rise A Guide To Implementing.8

Advanced Emergency Nursing Journal
Vol. 45, No. 3, pp. 210–216

Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
Procedural
C O L U M N
Column Editor: Jennifer Wilbeck, DNP, RN, FNP-BC, ACNP-BC, ENP-C, FAANP,
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Heatstroke on the Rise

A Guide to Implementing Tarp-Assisted
Cooling With Oscillation (TACO) in the
Emergency Department
Lucy Tucker, DNP
Emily Evans, MSN
Abstract
Heat-related illnesses, namely, heatstroke is on the rise and is a public health concern nationally
and internationally. Heatstroke is generally considered to be a core body temperature greater than
40 °C (104 °F) with dry, hot skin, and central nervous system manifestations. Heatstroke is character-
ized by a systemic inflammatory response that leads to multiple-organ dysfunction and ultimately
death if not treated in a timely manner. Rapid recognition and cooling are imperative, as mortal-
ity is high, especially in the elderly. There are many cooling methods that have been studied that
include cold-water immersion, tarp-assisted cooling with oscillation (TACO), evaporative cooling
(misting/fanning), commercial ice packs, cooling vests and jackets, cold showers, and ice sheets.
Although cold-water immersion is the fastest method for cooling, it is not usually feasible in an
emergency department (ED). TACO is the most feasible and effective cooling method for EDs. It is
vital that EDs have a specific plan in place before implementing TACO, as it requires 30–40 gallons
of ice water, a tarp or waterproof sheet, core temperature monitoring, and an ample number of ED
staff members to oscillate the water over the patient. Further research is needed to study TACO
in the ED setting. As the incidence of heatstroke is expected to increase in the coming years, EDs
must have a plan in place to rapidly recognize and treat patients with heatstroke so that patients
will have improved outcomes and reduced mortality. Key words: cooling, heatstroke, tarp-assisted
cooling with oscillation
Author Affiliation: Department of Emergency

ticle on the journal’s website (http://www.aenjournal.
Medicine, Vanderbilt University Medical Center,
com).
Nashville, Tennessee.
Disclosure: The authors report no conflicts of interest.
The authors thank Dr. Brendon McDermott, PhD,
ATC, FACSM, for his invaluable insight and wealth of Corresponding Author: Lucy Tucker, DNP, Depart-
experience implementing TACO. ment of Emergency Medicine, Vanderbilt University
Medical Center, 1313 21st Ave South, 703 Oxford
Supplemental digital content is available for this arti-
House, Nashville, TN 37232 (lucy.e.tucker@vumc.org).
cle. Direct URL citation appears in the printed text and
is provided in the HTML and PDF versions of this ar- DOI: 10.1097/TME.0000000000000470
210
Copyright © 2023 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
July–September 2023 r Vol. 45, No. 3 Heatstroke on the Rise 211
A 25-YEAR-OLD MAN with an unknown

past medical history was brought to
the emergency department (ED) after
being found unresponsive with a core tem-
Although there is no universally accepted
definition for heatstroke in clinical set-
tings, the most commonly used definition
is a core body temperature of greater than
perature of 42.2 °C (108 °F). He was working 40 °C (104 °F), with dry, hot skin, and cen-
as a roofer on a summer day during a heat tral nervous system manifestations, includ-
wave and had been observed by coworkers ing delirium, convulsions, or coma (Hifumi,
to feel poorly. He sat down under a tree and Kondo, Shimizu, & Miyake, 2018). Exertional
was found unresponsive about 15 min later. heatstroke can occur in individuals without
Emergency medical service (EMS) was called, comorbidities, such as laborers, athletes, and
and upon their arrival, he was found to have soldiers performing strenuous physical activ-
a rectal temperature of 108 °F, with a narrow ities. In contrast, nonexertional heatstroke
complex tachycardia of 170 beats per minute. can develop with little to no physical activ-
He was intubated for airway protection, and ity, such as in the elderly and ambulatory
2 L of crystalloid fluids were administered. individuals with comorbidities including obe-
He was emergently transported to the ED. sity, diabetes, hypertension, coronary artery
No seizure activity was noted before arrival. disease, renal disease, dementia, and alco-
Upon arrival to the ED, he was unresponsive holism (Hifumi et al., 2018). In addition to
and intubated. His pupils were 2 mm reactive the elderly, children and infants lack normal
to light, he had witnessed head movement thermoregulation and are at risk for nonexer-
and blinked his eyes, but no extremity move- tional heatstroke (Douma et al., 2020).
ment was noted. His skin was hot and dry.
His heart rate was 155 beats per minute,
blood pressure 90/44 mmHg, respiratory rate
PATHOPHYSIOLOGY
20 per minute via bag mask ventilation, oxy-
gen saturations 100% on 100% FiO2 (fraction During heatstroke, there is a malfunction of
of inspired oxygen), and rectal temperature the thermoregulatory system where the body
107.8 °F. temperature exceeds the critical threshold
for cell damage (40.83 °C [105.5 °F]), lead-
ing to a cascade of events that include the
release of endotoxins resulting in multiple-
INTRODUCTION
organ dysfunction syndrome (MODS), if
Heatstroke has been a public health concern not promptly corrected (Hosokawa, Adams,
for decades. On average, there are 702 Belval, Vandermark, & Casa, 2017). There are
heat-related deaths in the United States annu- two possible pathways in heatstroke that can
ally. This figure has risen in recent decades result in MODS. The first is in the intestinal
and is projected to increase due to climate epithelial barrier. Because of an increase in
change (Centers for Disease Control and skin blood flow and a decrease in intestinal
Prevention, n.d.). Heatstroke is often fatal, blood flow, there is an elevation in intestinal
with a more than 50% mortality rate in the epithelial barrier permeability. This increase
elderly (Xia et al., 2021). Despite the elevated in intestinal epithelial barrier permeability
mortality rate, heatstroke is a condition triggers an immune response that activates
that is largely considered preventable. Early a systemic inflammatory response syndrome
recognition and initiation of treatment are (SIRS). The other pathway in heatstroke is the
crucial to reduce morbidity and mortality. development of vascular endothelial damage
It is essential that clinicians have a plan for caused by an increase in core temperature.
the recognition and treatment of heatstroke The vascular endothelial damage results in
in each individual setting (Douma et al., microvascular thrombosis and consumptive
2020). coagulation, MODS (Xia et al., 2021).
212 Advanced Emergency Nursing Journal
Organ dysfunction is common follow- are several types of cooling therapies that
ing heatstroke. Neurological dysfunction is have been studied for exertional heatstroke.
often first, with brain edema leading to These include cold-water immersion (CWI),
encephalopathy and seizures. Later organ sys- tarp-assisted cooling with oscillation (TACO),
tems affected include heart failure, acute evaporative cooling (misting/fanning), com-
kidney injury, rhabdomyolysis, disseminated mercial ice packs, cooling vests and jack-
intravascular coagulation (DIC), acute respi- ets, cold showers, and ice sheets (Douma
ratory distress syndrome (ARDS), and respi- et al., 2020). Many of the aforementioned
ratory failure. Liver failure is also common modalities use water, as water has excellent
and should be monitored for at least 4 days potential to transfer heat due to its high
(Epstein & Yanovich, 2019). specific heat capacity and thermal conduc-
Early recognition of heatstroke, followed tivity of heat, causing heat dissipation from
by the removal of the heat source and ex- the skin while the patient is submerged.
peditious cooling is essential (Douma et al., Although brief vasoconstriction occurs im-
2020). Initiation of cooling within 30 min mediately upon immersion in cold water, the
from initial collapse is paramount, as inade- effects are trivial, as the large gradient of tem-
quate treatment and improper diagnosis are perature between the patient and the water
common factors that lead to death from ex- allows for rapid cooling (Filep et al., 2020).
ertional heatstroke (Parker, Shelton, & Lopez, In the treatment of heatstroke, the mini-
2020). Although there is no specific evidence- mally accepted rate of cooling is 0.155 °C/
based temperature end point for cooling, min (0.28 °F/min) (Hosokawa et al., 2017;
a rectal temperature of 38.6 °C (101.5 °F) Parker et al., 2020). The gold standard for
(Gagnon et al., 2010; Parker et al., 2020) or rapid cooling is CWI, which is used pri-
39.4 °C (102.9 °F) has been considered safe marily on-site at races and athletic events.
(Hifumi et al., 2018). Hypothermia postcool- CWI is generally not a feasible option for
ing is a common complication that should most EDs, as it requires a tub or large con-
be avoided, which is why the body is not tainer to hold the patient and water (Luhring
cooled to a normothermic temperature of et al., 2016). Other cooling modalities include
37 °C (98.6 °F). TACO, evaporative cooling (misting/fanning),
commercial ice packs, cooling vests and jack-
ets, cold showers, and ice sheets (Douma
COMMON METHODS FOR COOLING
et al., 2020).
When considering cooling methods and their CWI cools at a rate of 0.2 °C/min (Parker
rates of cooling in the literature, it should et al., 2020). Hosokawa et al. (2017) reported
be noted that primarily exertional heatstroke a TACO cooling rate of 0.19 °C/min, whereas
with young, healthy adult participants with- Parker et al. (2020) reported a TACO cool-
out comorbidities has been studied. Clinical ing rate of 0.16 °C/min. Twenty gallons of
trials examining heatstroke in children, the cold water and 10 gallons of ice were used
elderly, or participants with comorbidities (Hosokawa et al., 2017) versus 40 gallons of
have not been studied because of ethical and ice water used (Parker et al., 2020) in the
moral considerations. There are no pharma- studies examining TACO cooling rates. Both
cological agents that will accelerate cooling. reported TACO cooling rates fall within the
Antipyretics including acetaminophen and minimally acceptable rate of cooling.
aspirin are not effective in patients with heat- Other less effective methods for cooling
stroke, as different physiological pathways with their respective cooling rates include
are utilized in fever and hyperthermia. More- cold shower at 0.078 °C/min, ice sheets at
over, some antipyretic agents may worsen 0.05 °C/min, and hand cooling at 0.033 °C/
coagulopathy and liver injury in patients with min (Parker et al., 2020). Misting and fan-
heatstroke (Epstein & Yanovich, 2019). There ning (evaporative cooling) cool at a rate of
0.01 °C/min. Commercial ice packs cool at a Parker et al., 2020). In controlled settings
rate of 0.13 °C/min. Cooling vests and jackets with healthy research participants, a mini-
and cold intravenous fluids cool at a rate of mum of three individuals were needed to
0.03 °C/min (Douma et al., 2020). Although implement TACO. However, in the ED setting
these methods fall outside of acceptable with additional variables, including hemody-
cooling rates (minimum 0.155 °C/min); they namic instability and mechanical ventilation,
should be used if other more effective meth- six or more individuals may be required to
ods are not feasible, as rapid cooling is crucial safely implement TACO. An esophageal or
in the treatment of heatstroke. rectal temperature should be used to measure
the core temperature. Individuals on each
TARP-ASSISTED COOLING WITH OSCILLATION side of the patient take turns lifting the side of
the tarp upward to oscillate the water across
A large waterproof tarp and large quantities the patient, or a towel may be used to cir-
of water and ice are required to implement culate the water around the patient. Once
TACO (see Figure 1). The patient should be the core temperature is between 38 °C and
placed on the tarp first. Next, 30–40 gal- 39 °C, the patient should be removed from
lons of ice and water are poured on top the tarp, dried, and transferred to an acute
of the patient, submerging the torso and care setting for further treatment and eval-
legs in the ice water (Luhring et al., 2016; uation. See Supplemental Digital Content
Appendix A (available at: http://links.lww.
com/AENJ/A50) for a suggested algorithm to
implement TACO.
TACO Challenges
Immediate challenges of TACO include orga-
nization and preparedness of the ED. TACO
requires at least 20 gallons of ice, which may
not be feasible to obtain from a standard
ice machine. The amount of ice required for
TACO should be considered when determin-
ing individual ED preparedness in the event
that the ED staff needs to go to a different
area of the hospital to obtain the appropriate
amount of ice (kitchen, basement, etc.).
Also, it should be noted that 30–40 gal-
lons of water weigh approximately 113–
151 kg (250–330 lb). The stretcher or table
used for TACO should be able to accommo-
date the weight of the ice, water, and the
Figure 1. TACO implementation. TACO = patient. Additional members may be required
tarp-assisted cooling with oscillation. Adapted
to trade off with initial staff members while
from “Researchers: Method Using Tarp to
Cool Person With Heat Stroke Is Effective”
implementing TACO. Also, it is common for
[Photograph], by B. McDermott, 2017, Col- staff members to become wet and cold them-
league, University of Arkansas. Retrieved from selves while implementing TACO, and cold
https://colleague.uark.edu/2017/02/researchers- hands are often stiff and may complicate
method-using-tarp-to-cool-person-with-heat- tasks requiring dexterity such as intravenous
stroke-is-effective insertion and airway management.
TACO requires vigilant care by nurses, res- young children, the elderly and individuals
piratory therapists, providers, and ancillary with chronic health problems, and those
staff to treat a critically ill patient in an ice with nonexertional heatstroke, due to eth-
bath. Although research studies report cool- ical reasons. Thus, the findings may not
ing within 30 min, patients may require a apply to individuals who have chronic health
longer duration of TACO (45 min or longer) to problems and are not recreationally active
effectively cool to a safe temperature. Other (Hosokawa et al., 2017). There is a dearth of
challenges include maintaining intravenous TACO research in the ED settings, as current
access and hemodynamic monitoring of a wet research has been primarily conducted in
patient. When electrocardiogram monitoring controlled research settings or in prehospital
is unreliable, the presence of a carotid pulse, settings. Further research must be conducted
end-tidal carbon dioxide (CO2 ) monitoring, a to determine the specific amounts of water
forehead pulse oximeter probe, and contin- and ice, as different amounts have been sug-
uous physical examination are invaluable. If gested, as well as a target water temperature
a tarp is unavailable, body bags have been for the ice bath. Hemodynamic instability dur-
used, which are readily available in most EDs. ing TACO implementation has yet to be well
Although TACO research has been mainly per- studied. For example, if a patient were to be-
formed in prehospital settings on the ground, come pulseless and require cardiopulmonary
ED providers may be more comfortable per- resuscitation (CPR) and defibrillation during
forming TACO on a stretcher or table, instead TACO, the patient would need to be rapidly
of the floor. removed from the tarp and dried prior to
The location for disposal of the ice bath defibrillation.
once the patient reaches the target temper-
ature goal must be considered. Providers
CASE CONCLUSION
should be mindful that the ice bath may be-
come contaminated with urine and/or stool Upon arrival in the ED, the patient’s airway
during TACO. Contamination is especially was confirmed with auscultation and end-
important when considering how to safely tidal carbon dioxide capnography. He was
dispose of a large quantity of ice water. transferred into the ED decontamination
Staff will become wet, cold, and experi- room and underwent TACO for 40 min until
ence stiff hands and muscle fatigue while his core temperature reached 39.5 °C (103.1
implementing TACO, which are important °F). During the cooling process, his heart rate
considerations when determining the num- remained in the 150s with a bounding pulse;
ber of staff needed for this method. After the his pulse oximetry consistently read above
patient reaches the target temperature, water 90%, although the waveform was frequently
can be poured or channeled with the tarp disrupted by movement. A liter of lactated
into large containers or buckets to reduce Ringer’s solution was initiated, and the
the chance of getting more wet and cold. patient’s blood pressure quickly improved to
As stated earlier, it is essential that individual systolic 144 mmHg. He was given fentanyl
institutions establish a detailed protocol to and midazolam intravenously for sedation
implement TACO, considering staff require- as he was observed to have spontaneous
ments and resources needed to perform this ventilatory effort and head movement. Once
effective cooling method efficiently. his temperature reached 39.5 °C (103.1 °F),
TACO was discontinued and he was dried
and transported to the medical intensive
TACO Limitations
care unit (MICU) for further management
Heatstroke research to date has been per- of heatstroke and respiratory failure. His
formed primarily on young, healthy individ- hospital course was notable for rhabdomy-
uals with exertional heatstroke, excluding olysis with acute kidney and hepatic injury,
Type 2 non-ST-segment elevation myocar- is not a feasible method for many EDs. TACO
dial infarction (NSTEMI), encephalopathy is simple, economical, and effective in rapidly
without seizure on electroencephalogram cooling individuals with heatstroke. Further
(EEG), and methicillin-sensitive Staphylo- TACO research is needed in an ED setting to
coccus aureus (MSSA) bacteremia. He was understand how to best implement this cool-
discharged from the hospital 7 days later, ing method in critically ill patients. Although
ambulatory with a normal neurological heatstroke has high morbidity and mortality,
examination. rapid cooling with TACO in EDs can improve
patient outcomes.
HEATSTROKE FOLLOW-UP AND PATIENT
EDUCATION REFERENCES
Patients who undergo treatment of heat- Centers for Disease Control and Prevention. (n.d.).
stroke must have follow-up arranged 7 days Heat & health tracker. Retrieved from https://
after hospital discharge for a physical ex- ephtracking.cdc.gov/Applications/heatTracker
Douma, M. J., Aves, T., Allan, K. S., Bendall, J. C., Berry,
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ter hospital discharge. When they are cleared atic review and meta-analysis. Resuscitation, 148,
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return or if vigorous activity is not tolerated, R. L., & Casa, D. J. (2020). Exertional heat stroke,
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heatstroke prevention. Individuals at risk for (2010). Cold-water immersion and the treatment of
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CONCLUSION
08.428
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Ylanan, R. C., Ganio, M. S., & McDermott, B. P.
of heatstroke is expected to rise. It is es-
(2016). Cooling effectiveness of a modified cold-
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McDermott, B. (2017). Researchers: Method using rates for hyperthermia compared with previously
tarp to cool person with heat stroke is effective established CWI cooling rates? Journal of Sport Re-
[photograph]. Colleague, University of Arkansas. habilitation, 29(3), 367–372. doi:10.1123/jsr.2019-
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heat-stroke-is-effective Xu, S. G. (2021). Research progress of heat stroke
Parker, K. C., Shelton, R. R., & Lopez, R. M. (2020). Do during 1989–2019: A bibliometric analysis. Military
alternative cooling methods have effective cooling Medical Research, 8(1), 5. doi:10.1186/s40779-021-
00300-z
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Advanced Emergency Nursing Journal

Vol. 45, No. 3, pp. 210–216

Heatstroke on the Rise

Author Affiliation: Department of Emergency

A 25-YEAR-OLD MAN with an unknown

For more than 135 additional nursing continuing professional de-

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