{'fraction_non_alphanumeric': 0.026018396846254926, 'fraction_numerical': 0.002102496714848883, 'mean_word_length': 5.418212478920742, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Letter in response to: “Stimulant-induced hyperthermia and ice-water submersion: practical considerations”

We appreciate Drs. Richards’ and Colby’s comments and will address each of their concerns to clarify our advocacy of a technique that has been a standard approach to hyperthermia for over 30 years at our institution. Concerns of safety and feasibility of ice-water submersion are realistic when planning to replicate this effort in a novel setting. Healthcare provider and staff safety should always be prioritized. At our institution, a number of factors make this approach both safe and readily accessible: availability of a water-impermeable bed (manufactured by Arjo Huntleigh Sweden; shower trolley model), large volume icemaker, and staff experienced in mobilizing this technique. Without these, implementation becomes more challenging, but not impossible. Without access to a water-impermeable bed or, for example, in the hypothetical case of the hyperthermic, morbidly obese patient (when patient mobilization poses an unacceptable risk to staff), we recommend using bed sheets taken up from under the patient and then tied to the bed railing, to provide a semipermeable layer for the containment of ice, with the placement of towels below to absorb excess water. Consideration of institution-specific limitations and individualized risk-benefit analyses, however, remain essential. Agitation is another factor that poses challenges to this technique. The approach to controlling psychomotor agitation in these patients is similar to any agitated patient. Parenteral (either IM or IV) benzodiazepines should be given either initially or in parallel with exposure, transfer and submersion in ice. In doing so, psychomotor effects on body temperature are mitigated, while life-sustaining efforts at cooling are facilitated. In both of our cases, efforts at chemical sedation were initiated prior to and throughout ice-water submersion; in neither case did agitation prevent effective cooling. Additional safety concerns raised by the authors include risks of drowning and electrocution. Because application of this technique requires close monitoring and multi-staff participation, patients are unlikely to suffer from complete submersion, neglect and subsequent drowning. In addition, the bed’s sidewalls are only nine inches tall, making complete submersion nearly impossible. We advise placing a roll or pillow under the patient’s head and advocate ice submersion only from the neck down. Because most monitoring leads and equipment are designed to be impermeable to body fluids, the risk for electric shock is improbable. An exception to this is if the patient develops an unstable or pulseless dysrhythmia requiring cardioversion or defibrillation. We have used remote defibrillation pads with success, but many would advocate CPR and cooling prior to defibrillation. While ice-water submersion seems ‘‘messier’’ than ice packs or mist and fan, the literature suggests it is more effective.[1,2] Benefits are that it can be performed in any ED with access to ice, does not necessitate (although benefits from) specialized equipment, is rapid and effective. We acknowledge that it requires a coordinated team, vigilant monitoring, and is resource-intensive for the duration (20–30 min) that a patient is being actively cooled. This coordination is no different than a trauma resuscitation or a cardiac arrest and becomes second nature when rehearsed or applied repeatedly in clinical practice. Although submersion may seem excessive to some, compared to the ease of applying axillary/groin ice packs and specialized cooling devices, with or without mist and fan, our risk-benefit analysis supports this approach to prevent the morbidity and mortality associated with severe hyperthermia.