Validity of Core Temperature Measurements at 3 Rectal Depths During Rest, Exercise, Cold-Water Immersion, and Recovery

Context: No evidence-based recommendation exists regarding how far clinicians should insert a rectal thermistor to obtain the most valid estimate of core temperature. Knowing the validity of temperatures at different rectal depths has implications for exertional heat-stroke (EHS) management. Objective: To determine whether rectal temperature (Trec) taken at 4 cm, 10 cm, or 15 cm from the anal sphincter provides the most valid estimate of core temperature (as determined by esophageal temperature [Teso]) during similar stressors an athlete with EHS may experience. Design: Cross-sectional study. Setting: Laboratory. Patients or Other Participants: Seventeen individuals (14 men, 3 women: age = 23 ± 2 years, mass = 79.7 ± 12.4 kg, height = 177.8 ± 9.8 cm, body fat = 9.4% ± 4.1%, body surface area = 1.97 ± 0.19 m2). Intervention(s): Rectal temperatures taken at 4 cm, 10 cm, and 15 cm from the anal sphincter were compared with Teso during a 10-minute rest period; exercise until the participant's Teso reached 39.5°C; cold-water immersion (∼10°C) until all temperatures were ≤38°C; and a 30-minute postimmersion recovery period. The Teso and Trec were compared every minute during rest and recovery. Because exercise and cooling times varied, we compared temperatures at 10% intervals of total exercise and cooling durations for these periods. Main Outcome Measure(s): The Teso and Trec were used to calculate bias (ie, the difference in temperatures between sites). Results: Rectal depth affected bias (F2,24 = 6.8, P = .008). Bias at 4 cm (0.85°C ± 0.78°C) was higher than at 15 cm (0.65°C ± 0.68°C, P < .05) but not higher than at 10 cm (0.75°C ± 0.76°C, P > .05). Bias varied over time (F2,34 = 79.5, P < .001). Bias during rest (0.42°C ± 0.27°C), exercise (0.23°C ± 0.53°C), and recovery (0.65°C ± 0.35°C) was less than during cooling (1.72°C ± 0.65°C, P < .05). Bias during exercise was less than during postimmersion recovery (0.65°C ± 0.35°C, P < .05). Conclusions: When EHS is suspected, clinicians should insert the flexible rectal thermistor to 15 cm (6 in) because it is the most valid depth. The low level of bias during exercise suggests Trec is valid for diagnosing hyperthermia. Rectal temperature is a better indicator of pelvic organ temperature during cold-water immersion than is Teso.

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Cold-Water Immersion and the Treatment of Hyperthermia: Using 38.6°C as a Safe Rectal Temperature Cooling Limit

Journal of Athletic Training ◽

10.4085/1062-6050-45.5.439 ◽

2010 ◽

Vol 45 (5) ◽

pp. 439-444 ◽

Cited By ~ 41

Author(s):

Daniel Gagnon ◽

Bruno B. Lemire ◽

Douglas J. Casa ◽

Glen P. Kenny

Keyword(s):

Ambient Temperature ◽

Rectal Temperature ◽

Cold Water ◽

Water Immersion ◽

Recovery Period ◽

Heat Stroke ◽

Cold Water Immersion ◽

Water Bath ◽

Fat Percentage ◽

Cold Water Bath

Abstract Context: Cold-water immersion is recommended for the immediate field treatment of exertional heat stroke. However, concerns exist over potential overcooling of hyperthermic individuals during cold-water immersion. Objective: To evaluate the recommendation that removing previously hyperthermic individuals from a cold-water bath at a rectal temperature (Tre) of 38.6°C would attenuate overcooling. Design: Controlled laboratory study. Setting: University research laboratory. Patients or Other Participants: Participants included 6 men and 4 women (age = 22 ± 3 years, height = 172 ± 10 cm, mass = 67.8 ± 10.7 kg, body fat percentage = 17.1% ± 4.5%, maximum oxygen consumption = 59.3 ± 8.7 mL·kg−1·min−1). Intervention(s): After exercising at an ambient temperature of 40.0°C for 38.5 ± 9.4 minutes, until Tre reached 39.5°C, participants were immersed in a 2.0°C circulated water bath until Tre decreased to either 37.5°C or 38.6°C. Subsequently, participants were removed from the water bath and recovered for 20 minutes at an ambient temperature of 25°C. Main Outcome Measure(s): Rectal and esophageal temperatures were measured continuously during the immersion and recovery periods. Results: Because of the experimental design, the overall time of immersion was greater during the 37.5°C trial (16.6 ± 5.7 minutes) than the 38.6°C trial (8.8 ± 2.6 minutes) (t9 = −4.740, P = .001). During the recovery period after cold-water immersion, both rectal (F1,9 = 50.540, P < .001) and esophageal (F1,6 = 20.365, P = .007) temperatures remained greater in the 38.6°C trial than in the 37.5°C trial. This was evidenced by low points of 36.47°C ± 0.70°C and 37.19°C ± 0.71°C for rectal temperature (t9 = 2.975, P = .016) and of 35.67°C ± 1.27°C and 36.72°C ± 0.95°C for esophageal temperature (t6 = 3.963, P = .007) during the recovery period of the 37.5°C and 38.6°C trials, respectively. Conclusions: Immersion for approximately 9 minutes to a rectal temperature cooling limit of 38.6°C negated any risk associated with overcooling hyperthermic individuals when they were immersed in 2°C water.

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Physiologic and Perceptual Responses to Cold-Shower Cooling After Exercise-Induced Hyperthermia

Journal of Athletic Training ◽

10.4085/1062-6050-51.4.01 ◽

2016 ◽

Vol 51 (3) ◽

pp. 252-257 ◽

Cited By ~ 11

Author(s):

Cory L. Butts ◽

Brendon P. McDermott ◽

Brian J. Buening ◽

Jeffrey A. Bonacci ◽

Matthew S. Ganio ◽

...

Keyword(s):

Heart Rate ◽

Cooling Rate ◽

Rectal Temperature ◽

Muscle Pain ◽

Cold Water ◽

Thermal Sensation ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Exercise Induced

Exercise conducted in hot, humid environments increases the risk for exertional heat stroke (EHS). The current recommended treatment of EHS is cold-water immersion; however, limitations may require the use of alternative resources such as a cold shower (CS) or dousing with a hose to cool EHS patients.Context: To investigate the cooling effectiveness of a CS after exercise-induced hyperthermia.Objective: Randomized, crossover controlled study.Design: Environmental chamber (temperature = 33.4°C ± 2.1°C; relative humidity = 27.1% ± 1.4%).Setting: Seventeen participants (10 male, 7 female; height = 1.75 ± 0.07 m, body mass = 70.4 ± 8.7 kg, body surface area = 1.85 ± 0.13 m2, age range = 19–35 years) volunteered.Patients or Other Participants: On 2 occasions, participants completed matched-intensity volitional exercise on an ergometer or treadmill to elevate rectal temperature to ≥39°C or until participant fatigue prevented continuation (reaching at least 38.5°C). They were then either treated with a CS (20.8°C ± 0.80°C) or seated in the chamber (control [CON] condition) for 15 minutes.Intervention(s): Rectal temperature, calculated cooling rate, heart rate, and perceptual measures (thermal sensation and perceived muscle pain).Main Outcome Measure(s): The rectal temperature (P = .98), heart rate (P = .85), thermal sensation (P = .69), and muscle pain (P = .31) were not different during exercise for the CS and CON trials (P > .05). Overall, the cooling rate was faster during CS (0.07°C/min ± 0.03°C/min) than during CON (0.04°C/min ± 0.03°C/min; t16 = 2.77, P = .01). Heart-rate changes were greater during CS (45 ± 20 beats per minute) compared with CON (27 ± 10 beats per minute; t16 = 3.32, P = .004). Thermal sensation was reduced to a greater extent with CS than with CON (F3,45 = 41.12, P < .001).Results: Although the CS facilitated cooling rates faster than no treatment, clinicians should continue to advocate for accepted cooling modalities and use CS only if no other validated means of cooling are available.Conclusions:

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Cooling Rates of Hyperthermic Humans Wearing American Football Uniforms When Cold-Water Immersion Is Delayed

Journal of Athletic Training ◽

10.4085/1062-6050-398-17 ◽

2018 ◽

Vol 53 (12) ◽

pp. 1200-1205 ◽

Cited By ~ 1

Author(s):

Kevin C. Miller ◽

Timothy A. Di Mango ◽

Grace E. Katt

Keyword(s):

Rectal Temperature ◽

Cold Water ◽

Thermal Sensation ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

American Football ◽

Exertional Heat Stroke ◽

Cooling Rates ◽

Treatment Delays

Context Treatment delays can be contributing factors in the deaths of American football athletes from exertional heat stroke. Ideally, clinicians begin cold-water immersion (CWI) to reduce rectal temperature (Trec) to <38.9°C within 30 minutes of collapse. If delays occur, experts recommend Trec cooling rates that exceed 0.15°C/min. Whether treatment delays affect CWI cooling rates or perceptual variables when football uniforms are worn is unknown. Objective To answer 3 questions: (1) Does wearing a football uniform and delaying CWI by 5 minutes or 30 minutes affect Trec cooling rates? (2) Do Trec cooling rates exceed 0.15°C/min when treatment delays have occurred and individuals wear football uniforms during CWI? (3) How do treatment delays affect thermal sensation and Environmental Symptoms Questionnaire responses? Design Crossover study. Setting Laboratory. Patients or Other Participants Ten physically active men (age = 22 ± 2 y, height = 183.0 ± 6.9 cm, mass = 78.9 ± 6.0 kg). Intervention(s) On 2 days, participants wore American football uniforms and exercised in the heat until Trec was 39.75°C. Then they sat in the heat, with equipment on, for either 5 or 30 minutes before undergoing CWI (10.6°C ± 0.1°C) until Trec reached 37.75°C. Main Outcome Measure(s) Rectal temperature and CWI duration were used to calculate cooling rates. Thermal sensation was measured pre-exercise, postexercise, postdelay, and post-CWI. Responses to the Environmental Symptoms Questionnaire were obtained pre-exercise, postdelay, and post-CWI. Results The Trec cooling rates exceeded recommendations and were unaffected by treatment delays (5-minute delay = 0.20°C/min ± 0.07°C/min, 30-minute delay = 0.19°C/min ± 0.05°C/min; P = .4). Thermal sensation differed between conditions only postdelay (5-minute delay = 6.5 ± 0.6, 30-minute delay = 5.5 ± 0.7; P < .05). Environmental Symptoms Questionnaire responses differed between conditions only postdelay (5-minute delay = 27 ± 15, 30-minute delay = 16 ± 12; P < .05). Conclusions Treatment delays and football equipment did not impair CWI's effectiveness. Because participants felt cooler and better after the 30-minute delay despite still having elevated Trec, clinicians should use objective measurements (eg, Trec) to guide their decision making for patients with possible exertional heat stroke.

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Assessing the Validity of Aural Thermometry for Measuring Internal Temperature in Patients With Exertional Heat Stroke

Journal of Athletic Training ◽

10.4085/1062-6050-0449.19 ◽

2021 ◽

Vol 56 (2) ◽

pp. 197-202

Author(s):

Margaret C. Morrissey ◽

Samantha E. Scarneo-Miller ◽

Gabrielle E.W. Giersch ◽

John F. Jardine ◽

Douglas J. Casa

Keyword(s):

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Accurate Method ◽

Cross Sectional Study ◽

Cold Water Immersion ◽

Internal Temperature ◽

Exertional Heat Stroke ◽

Finish Line ◽

Cross Sectional

Context The use of aural thermometry as a method for accurately measuring internal temperature has been questioned. No researchers have examined whether aural thermometry can accurately measure internal body temperature in patients with exertional heat stroke (EHS). Objective To examine the effectiveness of aural thermometry as an alternative to the criterion standard of rectal thermometry in patients with and those without EHS. Design Cross-sectional study. Setting An 11.3-km road race. Patients or Other Participants A total of 49 patients with EHS (15 men [age = 38 ± 17 years], 11 women [age = 28 ± 10 years]) and 23 individuals without EHS (10 men [age = 62 ± 17 years], 13 women [age = 45 ± 14 years]) who were triaged to the finish-line medical tent for suspected EHS. Main Outcome Measure(s) Rectal and aural temperatures were obtained on arrival at the medical tent for patients with and those without EHS and at 8.3 ± 5.2 minutes into EHS treatment (cold-water immersion) for patients with EHS. Results The mean difference between temperatures measured using rectal and aural thermometers in patients with EHS at medical tent admission was 2.4°C ± 0.96°C (4.3°F ± 1.7°F; mean rectal temperature = 41.1°C ± 0.8°C [106.1°F ± 1.4°F]; mean aural temperature = 38.8°C ± 1.1°C [101.8°F ± 2.0°F]). Rectal and aural temperatures during cold-water immersion in patients with EHS were 40.4°C ± 1.0°C (104.6°F ± 1.8°F) and 38.0°C ± 1.2°C (100.3°F ± 2.2°F), respectively. Rectal and aural temperatures for patients without EHS at medical tent admission were 38.8°C ± 0.87°C (101.9°F ± 1.6°F) and 37.2°C ± 1.0°C (99.1°F ± 1.8°F), respectively. Conclusions Aural thermometry is not an accurate method of diagnosing EHS and should not be used as an alternative to rectal thermometry. Using aural thermometry to diagnosis EHS can result in catastrophic outcomes, such as long-term sequelae or fatality.

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Recovery strategies implemented by sport support staff of elite rugby players in South Africa

South African Journal of Physiotherapy ◽

10.4102/sajp.v65i1.78 ◽

2009 ◽

Vol 65 (1) ◽

Cited By ~ 6

Author(s):

D.V. Van Wyk ◽

M.I. Lambert

Keyword(s):

Cold Water ◽

Water Immersion ◽

Total Duration ◽

Cold Water Immersion ◽

Support Staff ◽

Medical Support ◽

Cross Sectional ◽

Study Results ◽

Recovery Strategies ◽

Rugby Players

Objective: The main aim of this study was to determine strategies used toaccelerate recovery of elite rugby players after training and matches, asused by medical support staff of rugby teams in South A frica. A secondaryaim was to focus on specifics of implementing ice/cold water immersion asrecovery strategy. Design: A Questionnaire-based cross sectional descriptive survey was used.Setting and Participants: Most (n=58) of the medical support staff ofrugby teams (doctors, physiotherapists, biokineticists and fitness trainers)who attended the inaugural Rugby Medical A ssociation conference linked to the South A frican Sports MedicineA ssociation Conference in Pretoria (14-16th November, 2007) participated in the study. Results: Recovery strategies were utilized mostly after matches. Stretching and ice/cold water immersion were utilized the most (83%). More biokineticists and fitness trainers advocated the usage of stretching than their counter-parts (medical doctors and physiotherapists). Ice/Cold water immersion and A ctive Recovery were the top two ratedstrategies. A summary of the details around implementation of ice/cold water therapy is shown (mean) as utilized bythe subjects: (i) The time to immersion after matches was 12±9 min; (ii) The total duration of one immersion sessionwas 6±6 min; (iii) 3 immersion sessions per average training week was utilized by subjects; (iv) The average water temperature was 10±3 ºC.; (v) Ice cubes were used most frequently to cool water for immersion sessions, and(vi) plastic drums were mostly used as the container for water. Conclusion: In this survey the representative group of support staff provided insight to which strategies are utilizedin South A frican elite rugby teams to accelerate recovery of players after training and/or matches.

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Safety and efficacy of cold‐water immersion in the treatment of older patients with heat stroke: a case series

Acute Medicine & Surgery ◽

10.1002/ams2.635 ◽

2021 ◽

Vol 8 (1) ◽

Author(s):

Chikao Ito ◽

Isao Takahashi ◽

Miyuki Kasuya ◽

Kyoji Oe ◽

Masahito Uchino ◽

...

Keyword(s):

Older Patients ◽

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Case Series ◽

Cold Water Immersion ◽

Safety And Efficacy

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A second postcooling afterdrop: more evidence for a convective mechanism

Journal of Applied Physiology ◽

10.1152/jappl.1992.73.4.1253 ◽

1992 ◽

Vol 73 (4) ◽

pp. 1253-1258 ◽

Cited By ~ 46

Author(s):

G. G. Giesbrecht ◽

G. K. Bristow

Keyword(s):

Core Temperature ◽

Initial Rate ◽

Treadmill Exercise ◽

Cold Water ◽

Water Immersion ◽

Cold Water Immersion ◽

Probable Mechanism ◽

Warm Bath ◽

Male Subjects ◽

Shivering Thermogenesis

An attempt was made to demonstrate the importance of increased perfusion of cold tissue in core temperature afterdrop. Five male subjects were cooled twice in water (8 degrees C) for 53–80 min. They were then rewarmed by one of two methods (shivering thermogenesis or treadmill exercise) for another 40–65 min, after which they entered a warm bath (40 degrees C). Esophageal temperature (Tes) as well as thigh and calf muscle temperatures at three depths (1.5, 3.0, and 4.5 cm) were measured. Cold water immersion was terminated at Tes varying between 33.0 and 34.5 degrees C. For each subject this temperature was similar in both trials. The initial core temperature afterdrop was 58% greater during exercise (mean +/- SE, 0.65 +/- 0.10 degrees C) than shivering (0.41 +/- 0.06 degrees C) (P < 0.005). Within the first 5 min after subjects entered the warm bath the initial rate of rewarming (previously established during shivering or exercise, approximately 0.07 degrees C/min) decreased. The attenuation was 0.088 +/- 0.03 degrees C/min (P < 0.025) after shivering and 0.062 +/- 0.022 degrees C/min (P < 0.025) after exercise. In 4 of 10 trials (2 after shivering and 2 after exercise) a second afterdrop occurred during this period. We suggest that increased perfusion of cold tissue is one probable mechanism responsible for attenuation or reversal of the initial rewarming rate. These results have important implications for treatment of hypothermia victims, even when treatment commences long after removal from cold water.

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Effectiveness of Cold Water Immersion in the Treatment of Exertional Heat Stroke at the Falmouth Road Race

Medicine & Science in Sports & Exercise ◽

10.1249/mss.0000000000000409 ◽

2015 ◽

Vol 47 (2) ◽

pp. 240-245 ◽

Cited By ~ 81

Author(s):

JULIE K. DEMARTINI ◽

DOUGLAS J. CASA ◽

REBECCA STEARNS ◽

LUKE BELVAL ◽

ARTHUR CRAGO ◽

...

Keyword(s):

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Exertional Heat Stroke ◽

Road Race

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Emergency Medical Service Directors’ Protocols for Exertional Heat Stroke

Medicina ◽

10.3390/medicina56100494 ◽

2020 ◽

Vol 56 (10) ◽

pp. 494

Author(s):

Michael R. Szymanski ◽

Samantha E. Scarneo-Miller ◽

M. Seth Smith ◽

Michelle L. Bruner ◽

Douglas J. Casa

Keyword(s):

Best Practices ◽

Emergency Medical Service ◽

Best Practice ◽

Medical Service ◽

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Athletic Trainer ◽

Chi Squared

Background and Objectives: Emergency Medical Service (EMS) protocols vary widely and may not implement best practices for exertional heat stroke (EHS). EHS is 100% survivable if best practices are implemented within 30 min. The purpose of this study is to compare EMS protocols to best practices for recognizing and treating EHS. Materials and Methods: Individuals (n = 1350) serving as EMS Medical or Physician Director were invited to complete a survey. The questions related to the EHS protocols for their EMS service. 145 individuals completed the survey (response rate = 10.74%). Chi-Squared Tests of Associations (χ2) with 95% confidence intervals (CI) were calculated. Prevalence ratios (PR) with 95% CI were calculated to determine the prevalence of implementing best practices based on location, working with an athletic trainer, number of EHS cases, and years of directing. All PRs whose 95% CIs excluded 1.00 were considered statistically significant; Chi-Squared values with p values < 0.05 were considered statistically significant. Results: A majority of the respondents reported not using rectal thermometry for the diagnosis of EHS (n = 102, 77.93%) and not using cold water immersion for the treatment of EHS (n = 102, 70.34%). If working with an athletic trainer, EMS is more likely to implement best-practice treatment (i.e., cold-water immersion and cool-first transport-second) (69.6% vs. 36.9%, χ2 = 8.480, p < 0.004, PR = 3.15, 95% CI = 1.38, 7.18). Conclusions: These findings demonstrate a lack of implementation of best-practice standards for EHS by EMS. Working with an athletic trainer appears to increase the likelihood of following best practices. Efforts should be made to improve EMS providers’ implementation of best-practice standards for the diagnosis and management of EHS to optimize patient outcomes.

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Cooling Effectiveness of a Modified Cold-Water Immersion Method After Exercise-Induced Hyperthermia

Journal of Athletic Training ◽

10.4085/1062-6050-51.12.07 ◽

2016 ◽

Vol 51 (11) ◽

pp. 946-951 ◽

Cited By ~ 22

Author(s):

Katherine E. Luhring ◽

Cory L. Butts ◽

Cody R. Smith ◽

Jeffrey A. Bonacci ◽

Ramon C. Ylanan ◽

...

Keyword(s):

Heart Rate ◽

Mean Arterial Pressure ◽

Arterial Pressure ◽

Effect Size ◽

Cold Water ◽

Water Immersion ◽

Heat Stroke ◽

Cold Water Immersion ◽

Whole Body ◽

Exertional Heat Stroke

Context: Recommended treatment for exertional heat stroke includes whole-body cold-water immersion (CWI). However, remote locations or monetary or spatial restrictions can challenge the feasibility of CWI. Thus, the development of a modified, portable CWI method would allow for optimal treatment of exertional heat stroke in the presence of these challenges. Objective: To determine the cooling rate of modified CWI (tarp-assisted cooling with oscillation [TACO]) after exertional hyperthermia. Design: Randomized, crossover controlled trial. Setting: Environmental chamber (temperature = 33.4°C ± 0.8°C, relative humidity = 55.7% ± 1.9%). Patients or Other Participants: Sixteen volunteers (9 men, 7 women; age = 26 ± 4.7 years, height = 1.76 ± 0.09 m, mass = 72.5 ± 9.0 kg, body fat = 20.7% ± 7.1%) with no history of compromised thermoregulation. Intervention(s): Participants completed volitional exercise (cycling or treadmill) until they demonstrated a rectal temperature (Tre) ≥39.0°C. After exercise, participants transitioned to a semirecumbent position on a tarp until either Tre reached 38.1°C or 15 minutes had elapsed during the control (no immersion [CON]) or TACO (immersion in 151 L of 2.1°C ± 0.8°C water) treatment. Main Outcome Measure(s): The Tre, heart rate, and blood pressure (reported as mean arterial pressure) were assessed precooling and postcooling. Statistical analyses included repeated-measures analysis of variance with appropriate post hoc t tests and Bonferroni correction. Results: Before cooling, the Tre was not different between conditions (CON: 39.27°C ± 0.26°C, TACO: 39.30°C ± 0.39°C; P = .62; effect size = −0.09; 95% confidence interval [CI] = −0.2, 0.1). At postcooling, the Tre was decreased in the TACO (38.10°C ± 0.16°C) compared with the CON condition (38.74°C ± 0.38°C; P < .001; effect size = 2.27; 95% CI = 0.4, 0.9). The rate of cooling was greater during the TACO (0.14 ± 0.06°C/min) than the CON treatment (0.04°C/min ± 0.02°C/min; t15 = −8.84; P < .001; effect size = 2.21; 95% CI = −0.13, −0.08). These differences occurred despite an insignificant increase in fluid consumption during exercise preceding CON (0.26 ± 0.29 L) versus TACO (0.19 ± 0.26 L; t12 = 1.73; P = .11; effect size = 0.48; 95% CI = −0.02, 0.14) treatment. Decreases in heart rate did not differ between the TACO and CON conditions (t15 = −1.81; P = .09; effect size = 0.45; 95% CI = −22, 2). Mean arterial pressure was greater at postcooling with TACO (84.2 ± 6.6 mm Hg) than with CON (67.0 ± 9.0 mm Hg; P < .001; effect size = 2.25; 95% CI = 13, 21). Conclusions: The TACO treatment provided faster cooling than did the CON treatment. When location, monetary, or spatial restrictions are present, TACO represents an effective alternative to traditional CWI in the emergency treatment of patients with exertional hyperthermia.

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