Galloway, R

Greenhalgh, R

Hemingway, R

Kipps, C

Leckie, T

Stacey, MJ

Woods, D

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Leeds Beckett Repository

Citation:Leckie, T and Stacey, MJ and Woods, D and Greenhalgh, R and Galloway, R and Kipps, C andHemingway, R (2023) Military standard operating procedures translated into civilian best practice:delivery of cold water immersion to treat exertional heat stroke at Brighton marathon 2023 (letter).BMJ Military Health. e002460-e002460. ISSN 2633-3767 DOI: https://doi.org/10.1136/military-2023-002460Link to Leeds Beckett Repository record:https://eprints.leedsbeckett.ac.uk/id/eprint/10083/Document Version:Article (Accepted Version)Creative Commons: Attribution-Noncommercial 4.0c© Author(s) (or their employer(s)) 2023.The aim of the Leeds Beckett Repository is to provide open access to our research, as required byfunder policies and permitted by publishers and copyright law.The Leeds Beckett repository holds a wide range of publications, each of which has beenchecked for copyright and the relevant embargo period has been applied by the Research Servicesteam.We operate on a standard take-down policy. If you are the author or publisher of an outputand you would like it removed from the repository, please contact us and we will investigate on acase-by-case basis.Each thesis in the repository has been cleared where necessary by the author for third partycopyright. If you would like a thesis to be removed from the repository or believe there is an issuewith copyright, please contact us on openaccess@leedsbeckett.ac.uk and we will investigate on acase-by-case basis. Title Military Standard Operating Procedures Translated Into Civilian Best Practice: Delivery of Cold Water Immersion to Treat Exertional Heat Stroke At Brighton Marathon 2023  Authors Leckie T,1,2 Stacey MJ,3,4 Woods DR,3,4 Greenhalgh R,2 Galloway R,2 Kipps C,5 Hemingway R.6,7  Institutions and affiliations 1. School of Sport and Health Sciences, University of Brighton, UK 2. Brighton Marathon Medical & Research Teams 3. Academic Department of Military Medicine, Research & Clinical Innovation, Defence Medical Services, Birmingham 4. Carnegie School of Sport, Leeds Beckett University 5. Institute of Sport, Exercise and Health, University College London 6. Commando Training Centre Royal Marines Medical Team 7. University of Exeter  Corresponding author Lt Col Mike Stacey, M.stacey13@imperial.ac.uk Word count 500 words (excluding references and figure legend) References 3 Tables and Figures 1  Contributorship(Authorship) MS, TL and RH devised the study; MS and DW secured material funding for the study; MS, TL and RG executed the study in the field; MS drafted the manuscript; All authors critically revised and approved the final draft and take responsibility for its contents. Funding Information Research & Clinical Innovation (Royal Centre for Defence Medicine) funded the cooling pod acquisition. University of Brighton provided funding to peripheral/ancillary materiele (e.g. warming blankets).  Military Standard Operating Procedures Translated Into Civilian Best Practice: Delivery of Cold Water Immersion to Treat Exertional Heat Stroke At Brighton Marathon 2023   Exertional Heat Stroke (EHS) poses a threat to United Kingdom (UK) Service Personnel and is a Research & Clinical Innovation (R&CI) priority in the Defence Medical Services (DMS).  Initiated promptly, body cooling may rapidly and completely reverse brain dysfunction and mitigate risk of multiple organ failure (1,2). Cold water immersion (CWI) is the preferred cooling modality in EHS guidelines (1,3) and the optimal method applicable to UK Service Personnel.  Despite adoption of CWI at the Commando Training Centre Royal Marines (CTCRM) (2), its uptake in wider UK military and civilian race medicine remains limited. Potential barriers to implementation include lack of awareness; unfamiliarity with the methods and systems available; and potential safety concerns for immersed casualties. These have been overcome at CTCRM (2), with over 50 casualties treated.  In early 2023, a collaboration was established between Brighton Marathon Medical Team (BMMT),  CTCRM Medical Team and R&CI, in order to enable CWI capability at the marathon that April. Priorities were to ensure personnel, technical and logistical requirements could be met, with the course and associated medical facilities constructed only 48 hours beforehand. The evening prior, running water was established and six portable water impermeable bags (Polar Life Pod®, Polar Products, Ohio) for delivering CWI, plus ice, were deployed at the two main medical tents.   Next morning, CWI simulation was incorporated into the BMMT pre-race moulage. Subsequently, incapacitated runners were triaged for CWI in both tents. One casualty presented at the finish line with confusion and rapidly deteriorated to Glasgow Coma Scale  10/15. Rectal temperature was 41.9 °C and CWI was initiated for EHS (Figure 1). Restoration of consciousness was observed as he cooled below 41 °C (Figure 2); with ice added sparingly to support this process (total 5 kg, water temperature 5.0 - 8.7  °C) and encapsulation up to his midriff, the exposure remained tolerable. Body core temperature of <39 °C was targeted and achieved in 21 minutes, at which point he was removed from CWI, in keeping with the experience of CTCRM (whereby active cooling to 38.6 °C, as advocated in generic guidance (3), can result in sub-normal core temperature from ‘overshoot’ associated with ongoing heat loss). He was observed for four hours, guarding against rebound hyperthermia. Biochemical abnormalities noted at point-of-care had resolved upon discharge and he was signposted to supervised recovery.  This was the first delivery of CWI  at the Brighton Marathon, despite its established status as one of the largest mass participation events in the UK. We also believe that this is the first reported domestic use of CWI with a portable water impermeable bag at an event of Brighton’s standing. CWI was achieved with an impressive cooling rate 0.14 °C.min-1 (acceptable range 0.08 - 0.15 °C.min-1) (3). The implementation of CTCRM standard operating procedures, tailored to the available conditions and resources, provides a model for wider CWI roll-out in the civilian space and in Defence. To maximise uptake and efficacy, promotion of effective planning, team management and risk mitigation is required, through training and ongoing education.   References 1. Roberts, WO, Armstrong LE, Sawka MN et al. ACSM Expert Consensus Statement on Exertional Heat Illness: Recognition, Management, and Return to Activity. Current Sports Medicine Reports 2023;22(4):p 134-149. DOI: 10.1249/JSR.0000000000001058.  2. Wood F, Roiz de Sa D, Pynn H, et al.  Outcomes of UK military personnel treated with ice cold water immersion for exertional heat stroke BMJ Mil Health 2022 Oct 6;e002133. doi: 10.1136/military-2022-002133. Online ahead of print. 3. Belval LN, Casa DJ, Adams WM, et al. Consensus Statement- Prehospital Care of Exertional Heat Stroke. Prehosp Emerg Care. 2018; 22:392-397. doi: 10.1080/10903127.2017.1392666. Epub 2018 Jan 16.   Figure 1. Casualty treatment by CWI at the Brighton Marathon, using the standard operating procedures developed at CTCRM. Note that the pod has been configured to focus cooling around the lower limbs and midriff, with upper limbs exposed for access, and the head and neck - including ears and airway - free for communication. A wetted blanket provides additional cooling around the shoulders and adjacent torso. Images with permission of D J Stotty Images.   Figure 2 Core temperature response of a marathon runner incapacitated and treated by CWI at the finish-line medical treatment tent in Brighton. Level of consciousness assessed by Glasgow Coma Scale (GCS; blue circles) increased to normal as core temperature (Tc; red squares) reduced <41 °C.    

Military standard operating procedures translated into civilian best practice: delivery of cold water immersion to treat exertional heat stroke at Brighton marathon 2023 (letter)

https://eprints.leedsbeckett.ac.uk/id/eprint/10083/1/MilitaryStandardOperatingProceduresTranslatedIntoCivilianBestPracticeDeliveryOfColdWaterImmersionToTreatExertionalHeatStrokeAtBrightonMarathon2023AM-STACEY.pdf

Military standard operating procedures translated into civilian best practice: delivery of cold water immersion to treat exertional heat stroke at Brighton marathon 2023 (letter)

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