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Objective: To determine the clinical outcomes of an aggressive combined cooling technique for exertional heatstroke in Thailand. Methods: We analyzed patients who were diagnosed with exertional heatstroke between 1995 and 2007. Outcomes were assessed both in hospital and at 3 months follow up. Results: Twenty-eight cases of exertional heatstroke presented to Phramongkutklao Army Hospital over 12 years. All patients developed multiorgan dysfunction and encephalopathy. Twenty-four cases had acute renal failure, 7 of whom required dialysis. Disseminated intravascular coagulation (DIC) was detected in 9 patients (32.1%). In-hospital mortality was 7.1%. Most survivors recovered with nearly normal organ function. However, 9 exhibited prolonged neurologic dysfunction and 2 had chronic renal dysfunction requiring hemodialysis. At 3-month follow-up, neurologic and renal dysfunction in those patients persisted. Higher serum prothrombin time and DIC correlated to fatality. The patients whose core body temperature achieved 38°C within 3 hours revealed a significantly lower DIC and twice as low in the frequency of poor outcome than the patients cooled longer than 3 hours to reduce core body temperature to 38°C. Conclusions: Despite early recognition and aggressive combined cooling, exertional heatstroke remains associated with multiorgan dysfunction, However, our 7.1% in-hospital mortality rate was low compared to previous studies. Early diagnosis and prompt treatment are critical. [ABSTRACT FROM AUTHOR]