Page 42 - JSOM Spring 2025

BOX 1 Cold Water Immersion (CWI) Setup and Procedure 1,16,33
Prepare for CWI. • On the field or in a temporary medical tent, half-fill the tub or wading pool with water and ice.
• (Before an emergency, check the water source to see how quickly it fills the immersion tub.)
• The stock tank (100–150-gallon capacity) can be filled with ice and cold water before an event
(or have the tub half filled with water and 3–4 coolers of ice next to the tub; this prevents
having to keep the tub cold through the day).
• Ice should always cover the surface of the water.
Just before immersing an EHS patient, • Assess core body temperature with a rectal thermistor.
take vital signs. • Check airway, breathing, pulse, and blood pressure.
• Assess the level of central nervous system dysfunction.
Immerse the body to the neck or half • Circulate or stir the water to increase heat transfer.
body. • Add ice during cooling, and support the head above water level.
• Continuous supervision.
Ensure total body coverage. • Cover as much of the body as possible with ice water while cooling.
• If full body coverage is not possible due to the container, cover the torso as much as possible.
• To keep the Servicemember’s head and neck above water, an assistant may hold the casualty
under the axillae with a towel or sheet wrapped across the chest and under the arms.
Circulate water. • During cooling, water should be continuously circulated to increase the water-to-skin
temperature gradient.
• Have an assistant swirl the water during cooling.
Continue medical assessment. • Vital signs should be monitored every 2–5 min.
Fluid administration. • If a qualified medical professional is available, an IV fluid line can be placed for hydration and
support of cardiovascular function.
Cooling duration. • Continue cooling until the patient’s rectal temperature lowers to 39.0–39.2°C (102.0–102.5°F).
o If rectal temperature cannot be measured and CWI is indicated, cool for 10–15 min, and then
transport to a medical facility.
• Remove the patient from the immersion tub only after the rectal temperature reaches
39°C (102°F).
• Using a bed sheet around the patient’s chest can aid in transfer.
EHS = exertional heat stroke; IV = intravenous.

in a slow back-and-forth manner to facilitate water circula- improved outcomes with their use in a prehospital setting and
tion over the patient. Continuous monitoring of the patient are generally not recommended. The treatment goal is a tem-
and the consistency of the ice water is important. Ice can perature of 39.0–39.2°C (102.0–102.5°F) within 30 minutes
quickly melt, decreasing the effectiveness of this modality. This from the time of injury. No medications have been found to
method may be resource intensive, requiring approximately 20 help achieve this goal, including antipyretics. There may be
gallons of water, 10 gallons of ice, and a two-to-three-person some uses for medications to manage patient comfort and
34
person team, making it less suitable for certain operational other symptoms, but this is more appropriate to be performed
environments. in a hospital setting.

Ice Sheets Summary
When necessitated by operational requirements, ice sheets EHI is a common medical problem across the Armed Forces,
may be the most feasible option for rapid cooling. Faster cool- including Special Operations. It requires a significant amount
ing can be achieved with this method if ice packs are added of education and planning to be prepared to manage EHI
in addition to the traditional ice sheets/towels. 5,10–12,18,19,38–40 appropriately. The primary principles of EHI management
This method utilizes sheets or towels submerged and satu- include early recognition and rapid cooling. While there is
rated within ice water and stored in a cooler ready for use. no one perfect way to manage EHI, the CPG for the Preven-
1
The sheets/towels are applied directly to the patient. Sheets/ tion, Diagnosis, and Management of Exertional Heat Illness
towels are placed over and around the head and neck, on the should be used by every military organization to guide the de-
back, chest, and each arm and leg. Additionally, a sheet/towel velopment of their management plan.
is balled up and placed in each axilla and the groin, with a
final sheet/towel draped over the body of the patient. At least About WHEC
two complete sets of sheets/towels should be available to al-
ternate between sets. Of note, ice sheets/towels can trap heat The WHEC is a multidisciplinary advisory group focused on
if left on a patient for too long without switching out, de- developing and implementing procedures to help providers,
creasing the cooling effectiveness. Therefore, exchange the ice Servicemembers, and civilians prevent and treat heat-related
sheets/towels at least every 3 minutes or when they feel warm, illnesses and injuries. WHEC works in collaboration with the
whichever is sooner; when in doubt, switch it them out. Fig- Army Heat Center at Fort Moore, GA, and CHAMP’s Multi-
ure 2 provides a step-by-step guide for performing treatment disciplinary Case Review Committee (MDCRC).
with ice sheets.
Since its inception in 2020, WHEC has been dedicated to ad-
vancing the science and the DHA’s CPGs for preventing, re-
Medications
ducing, risk-stratifying, and managing exertional injuries and
Benzodiazepines and meperidine have been used historically heat illness. The WHEC also provides information about the
for shivering during rapid cooling. No evidence supports surveillance, research, and education on heat-related injuries. 28

40 | JSOM Volume 25, Edition 1 / Spring 2025