Page 41 - JSOM Spring 2025

While there are multiple established methods to perform rapid of the legs from ankles to the groin, and ice packs placed over
cooling in a variety of settings, two cooling methods have been major arteries of the neck, axilla, and groin. Ideally, indus-
proven to meet the established optimal cooling rate with zero trial fans are also used to assist convection. An advantage to
mortality when used promptly: cold water immersion (CWI) the Quantico method is the ease of patient transfer given the
and the Quantico method. 5,10–12,14,18,19,25 However, both CWI use of a stretcher; however, it generally requires more person-
and the Quantico method are noted to be very resource in- nel than CWI. A four-to-five-person team is required for the
tensive, which is not always feasible in an operational set- Quantico method. Responsibilities include airway manage-
ting. A single EHS patient can require approximately 75–100 ment, bilateral ice massage to legs (distal to proximal direc-
pounds of ice, 60–80 gallons of water, and a 150-gallon tub to tion, ankle to groin, and starting back at ankle), monitoring
be treated via CWI. Other highly effective interventions when core temperature, vitals, and vascular access if indicated, and
CWI and the Quantico method are not available or impracti- documentation. The senior medical provider positions them-
cal include tarp-assisted cooling with oscillation (TACO) and selves to manage the patient most appropriately, normally
the ice sheet method. Table 1 describes a series of “good, better, with airway management, or at the head of the patient.
best practices” that organizations should consider when evalu-
ating their EHI treatment plans.
Alternative Cooling Strategies
CWI The best-established treatment for rapid cooling in EHS CWI and the Quantico method are considered the standard of
is CWI. 5,10–21,31,32 The patient is submersed below the neck in treatment for EHS. This is assuming ideal conditions. However,
ice water, while ensuring that their legs and torso are fully this may not always be possible given the mission- constrained
submersed. A sheet wrapped behind the patient’s back, under environments of the Special Operations community. The
the armpits, is useful to ensure that their head does not get most important principle behind “cool first, cool fast” is that
submerged and for easier transport out of the tub. A tree-to- some cooling is better than none, which may require impro-
four-person team is required for CWI. Responsibilities include vising, adapting, and overcoming constraints and limitations
airway management, continuous ice water agitation, monitor- to provide rapid cooling to an EHI patient. When distance
ing core temperature, vitals, and vascular access if indicated, is a consideration, mobile heat treatment platforms may be
and documentation. The senior medical provider positions the solution, bringing the treatment to the patient. Treatment
themselves to manage the patient most appropriately, nor- methods that require less resources (i.e., less water or ice, no
mally with airway management or ice water agitation. Box 1 tub) may be the best or only feasible solution. Two alternative
provides a step-by-step guide for performing CWI. cooling strategies, the TACO method and ice sheets method,
are discussed below.
Quantico Method (Ice Water Dousing with
Ice Massage and Ice Packs) TACO
The Quantico method has a slightly slower cooling rate as In the TACO method, 5,10,18,1934–37 ice and water are placed to-
compared to CWI, but it is a proven alternative. 5,10,12,14,17,25 A gether with a patient in a waterproof tarp or body bag and
mesh litter/stretcher (i.e., Talon) is placed on top of a tub/pool the patient is then gently oscillated back and forth in the ice
with continuous ice water dousing to the trunk, ice massage water, in the tarp/body bag. A litter can be utilized, and moved

TABLE 1 Prehospital Exertional Heat Illness (EHI) Best Practice Assessment 1
Good Better Best
The medical team and nonmedical The medical team and nonmedical personnel The medical team and nonmedical personnel
personnel rapidly recognize the signs and rapidly recognize the signs and symptoms rapidly and accurately recognize the signs and
symptoms of EHI. of EHI. symptoms of EHI and initiate the medical
response.
All personnel have yearly body core All personnel have yearly in-person EHI All personnel have yearly EHI refresher
temperature refresher training concerning refresher training concerning the recognition training, including rigorous mock heat-casualty
the recognition and treatment of EHI. and treatment of EHI. drills.
Treatment of EHI based on signs and Intermittent use of digital rectal thermometers. Use of indwelling rectal probe for diagnosis of
symptoms. EHS, with continuous temperature monitoring.
On-site ice-sheet/towel rotation method On-site TACO method, with the ability to start On-site CWI or the Quantico method, with no
with ice packs, with the ability to start treatment within 10 minutes of EHI. more than of 10 minutes transport time from
treatment within 10 minutes of EHI. expected EHI, and initial cooling while en route
to the definitive cooling area.
Risk assessment with secondary Risk assessment with secondary prevention Risk assessment with secondary prevention and
prevention (e.g., AICS) in place. and primary management plan with logistics primary management plan with logistics for
for alternative cooling method (e.g., TACO) at definitive best-practice cooling within training
training or operational area. or operational areas.
The medical team in direct support of The medical team and nonmedical staff Both the medical team and nonmedical staff
operational or training event has the involved in operational or training event have have the knowledge and a tiered treatment plan
knowledge and a treatment plan for EHI the knowledge and a treatment plan for EHI within command SOPs for EHI in place.
in place. in place.
EHI SOP at medical team level. EHI SOP and logistical support at lower EHI SOP and logistical support throughout
command levels (e.g., platoon). all command levels (e.g., Division, Group,
Squadron, Regiment, Battalion).
AICS = Arm Immersion Cooling System; CWI = cold water immersion; SOP = standard operating procedures; TACO = tarp-assisted cooling with
oscillation.

Clinical Practice Guideline for Exertional Heat Illness | 39