National Athletic Trainers’ Association Position Statement: Exertional Heat

Illnesses

http://natajournals.org/doi/pdf/10.4085/1062-6050-50.9.07

Objective:

To present best-practice recommendations for the prevention, recognition, and treatment of exertional heat illnesses (EHIs) and to describe the relevant physiology of thermoregulation.

Background:

Certified athletic trainers recognize and treat athletes with EHIs, often in high-risk environments. Although the proper recognition and successful treatment strategies are well documented, EHIs continue to plague athletes, and exertional heat stroke remains one of the leading causes of sudden death during sport. The recommendations presented in this document provide athletic trainers and allied health providers with an integrated scientific and clinically applicable approach to the prevention, recognition, treatment of, and return-to-activity guidelines for EHIs. These recommendations are given so that proper recognition and treatment can be accomplished in order to maximize the safety and performance of athletes.

Recommendations:

Athletic trainers and other allied health care professionals should use these recommendations to establish onsite emergency action plans for their venues and athletes. The primary goal of athlete safety is addressed through the appropriate prevention strategies, proper recognition tactics, and effective treatment plans for EHIs. Athletic trainers and other allied health care professionals must be properly educated and prepared to respond in an expedient manner to alleviate symptoms and minimize the morbidity and mortality associated with these illnesses.

Key Words:

Heat cramps, heat syncope, heat exhaustion, heat injury, heat stroke, dehydration

Summary:

  • Prevention of Exertional Heat Illnesses (EHI)
    • Thorough PPEs should be completed before the season starts to identify athletes with EHI risk factors
    • Athletes should be acclimatized to the heat gradually over a 7-14 day period
    • The first 2-3 weeks of preseason typically present the greatest risk for EHI
    • Athletes who are sick with a viral infection, other illness or fever should not participate until issue is resolved
    • Athletes should maintain their hydration and appropriately replace fluids lost through sweat after participation
    • ATs should educate relevant staff regarding recognizing EHI and in particular EHS
    • When environmental conditions warrant, a cold water immersion ice tub should be available and ready
    • The assessment of rectal temperatures is the clinical gold standard for obtaining a core body temperatures
      • Parents, administrators, coaches and athletes should be educated ahead of time that rectal temperatures will be obtained in heat illness emergencies
    • The effects of heat are cumulative
      • Athletes should be encouraged to:
        • Sleep at least 7 hours
        • Eat a balanced diet
        • Properly hydrate before, during and after participation
      • Individuals who may be at risk of EHI should be identified and closely monitored during stressful environmental conditions
      • Rest breaks should be planned and the work-to-rest ratio modified to match the environmental conditions
        • Breaks should be in the shade
        • Athletes should be allowed to remove equipment during the break
      • Exercise Associated Muscle Cramps (EAMCs)
        • EAMCs are sudden and sometimes progressively and noticeably evolving, involuntary painful muscle contractions during or after exercise
        • EAMCs S&S include:
          • Visible cramping in part or all of the muscle or muscle group
          • Localized pain
          • Dehydration
          • Thirst
          • Sweating
          • Fatigue
        • ATs must distinguish between EAMC and underlying medical conditions such as sickle cell trait
          • The latter is often preceded by subtle muscle twitching whereas the former is not
        • EAMCs tend to be short in duration (less than 5 minutes)
        • Treatment of EAMCs is rest and passive static stretching
        • Athletes with recurring EAMCs should undergo a thorough medical screening to rule out more serious conditions
        • RTP after an episode of EAMCs includes waiting until symptoms are no longer present
      • Heat Syncope
        • Heat syncope, or orthostatic dizziness, often occurs in unfit or non-heat acclimatized people who stand for a long period of time in the heat or during sudden posture changes in heat
        • Signs and symptoms of heat syncope are:
          • Brief episode of fainting
          • Dizziness
          • Tunnel vision
          • Pale or sweaty skin
          • Decreased pulse rate
          • Low rectal temp >39 degrees Celsius
        • Assess vitals to rule out a cardiac event which can mimic heat syncope
        • An exam should be performed to eliminate other medical conditions that could cause syncope
        • Move the patient to a shaded area, monitor vitals, elevate the legs above the heart and rehydrate
      • Heat Exhaustion
        • Heat exhaustion is the inability to effectively exercise in the heat, secondary to a combination of factors, including cardiovascular insufficiency, hypotension, energy depletion and central fatigue
        • It occurs most frequently in hot or humid (or both) conditions
        • An elevated core temperature of less than 105o F, red skin, heavy sweating and dehydration are often associated with it
        • Heat exhaustion may be present if the patient presents with excessive fatigue, faints, or collapses with minor cognitive changes, i.e.: headache, dizziness, confusion
        • Other S&S of exertional heat exhaustion include:
          • Fatigue
          • Weakness
          • Dizziness
          • Headache
          • Vomiting
          • Nausea
          • Lightheadedness
          • Low blood pressure
          • Impaired muscle coordination
        • It is strongly recommended that a rectal temperature be taken to exclude exertional heat stroke
        • For treatment of exertional heat exhaustion:
          • Remove patient’s excess clothing and equipment
          • Move patient to a cool shaded environment
          • Monitor vital signs
          • Place legs in an elevated position
          • If the condition worsens or does not improve after 30 minutes, EMS should be activated
        • Patients with heat exhaustion should not be returned to play in the same day
      • Heat Stroke
        • Exertional Heat Stroke (EHS) is the most severe heat illness
        • EHS is characterized by neuropsychiatric impairment and a high core body temp, higher than 105oF
        • EHS is most likely to occur in hot and humid weather
          • It can also occur with intense physical activity in the absence of extreme weather
        • CNS dysfunction is often the first sign of EHS
        • EHS is a medical emergency and can progress to a systematic inflammatory response and multi-organ system failure
        • The 2 main diagnostic criteria for EHS is CNS dysfunction and a core body temperature greater than 105oF
          • Core body temperature is only accurately obtained by using a rectal thermometer
            • If rectal thermometry is not available the AT should rely on other key diagnostic indicators
          • CNS dysfunction S&S include:
            • Disorientation
            • Confusion
            • Dizziness
            • Loss of balance
            • Staggering
            • Aggressiveness
            • Hysteria
            • Delirium
            • Collapse
            • Loss of consciousness
            • (In some cases of EHS a lucid period by be present but will deteriorate quickly)
          • Other S&S of EHS include:
            • Dehydration
            • Hot and wet skin
            • Hypotension
            • Hyperventilation
          • Treatment for patients with EHS include:
            • Lowering the core body temperature to less than 102oF within 30 minutes of collapse
              • The length of time the core body temperature is above the threshold of 105oF dictates morbidity and risk of death from EHS
            • If EHS is suspected, full body cold water immersion (CWI) should begin immediately
            • Rectal temperature and other vital signs should be monitored every 5 -10 minutes during cooling
            • CWI is the most effective cooling modality for EHS patients
              • Water should be between 35-59oF and moving
            • EHS patients should be removed from CWI when the core body temperature reaches 102oF to prevent overcooling
            • Cooling rates for CWI vary but will be approximately 1oF for every 3 minutes in the CWI
            • If full body CWI is not available ice towels or cold water dousing may be used but are not as effective
            • EHS patients should be cooled first and transported second
          • EHS patients RTP should follow the guidelines of:
            • Patient should complete a 7-21 day rest period, demonstrated normal blood work results, obtained a physician clearance note before beginning a gradual RTP under the guidance of an AT
            • Rectal temperatures and heart rate should be monitored during RTP activities
            • If the patient experiences any negative symptoms with RTP activities the progression should be slowed or stopped
  • Prevention of Exertional Heat Illnesses (EHI)
    • Thorough PPEs should be completed before the season starts to identify athletes with EHI risk factors
    • Athletes should be acclimatized to the heat gradually over a 7-14 day period
    • The first 2-3 weeks of preseason typically present the greatest risk for EHI
    • Athletes who are sick with a viral infection, other illness or fever should not participate until issue is resolved
    • Athletes should maintain their hydration and appropriately replace fluids lost through sweat after participation
    • ATs should educate relevant staff regarding recognizing EHI and in particular EHS
    • When environmental conditions warrant, a cold water immersion ice tub should be available and ready
    • The assessment of rectal temperatures is the clinical gold standard for obtaining a core body temperatures
      • Parents, administrators, coaches and athletes should be educated ahead of time that rectal temperatures will be obtained in heat illness emergencies
    • The effects of heat are cumulative
      • Athletes should be encouraged to:
        • Sleep at least 7 hours
        • Eat a balanced diet
        • Properly hydrate before, during and after participation
      • Individuals who may be at risk of EHI should be identified and closely monitored during stressful environmental conditions
      • Rest breaks should be planned and the work-to-rest ratio modified to match the environmental conditions
        • Breaks should be in the shade
        • Athletes should be allowed to remove equipment during the break
      • Exercise Associated Muscle Cramps (EAMCs)
        • EAMCs are sudden and sometimes progressively and noticeably evolving, involuntary painful muscle contractions during or after exercise
        • EAMCs S&S include:
          • Visible cramping in part or all of the muscle or muscle group
          • Localized pain
          • Dehydration
          • Thirst
          • Sweating
          • Fatigue
        • ATs must distinguish between EAMC and underlying medical conditions such as sickle cell trait
          • The latter is often preceded by subtle muscle twitching whereas the former is not
        • EAMCs tend to be short in duration (less than 5 minutes)
        • Treatment of EAMCs is rest and passive static stretching
        • Athletes with recurring EAMCs should undergo a thorough medical screening to rule out more serious conditions
        • RTP after an episode of EAMCs includes waiting until symptoms are no longer present
      • Heat Syncope
        • Heat syncope, or orthostatic dizziness, often occurs in unfit or non-heat acclimatized people who stand for a long period of time in the heat or during sudden posture changes in heat
        • Signs and symptoms of heat syncope are:
          • Brief episode of fainting
          • Dizziness
          • Tunnel vision
          • Pale or sweaty skin
          • Decreased pulse rate
          • Low rectal temp >39 degrees Celsius
        • Assess vitals to rule out a cardiac event which can mimic heat syncope
        • An exam should be performed to eliminate other medical conditions that could cause syncope
        • Move the patient to a shaded area, monitor vitals, elevate the legs above the heart and rehydrate
      • Heat Exhaustion
        • Heat exhaustion is the inability to effectively exercise in the heat, secondary to a combination of factors, including cardiovascular insufficiency, hypotension, energy depletion and central fatigue
        • It occurs most frequently in hot or humid (or both) conditions
        • An elevated core temperature of less than 105o F, red skin, heavy sweating and dehydration are often associated with it
        • Heat exhaustion may be present if the patient presents with excessive fatigue, faints, or collapses with minor cognitive changes, i.e.: headache, dizziness, confusion
        • Other S&S of exertional heat exhaustion include:
          • Fatigue
          • Weakness
          • Dizziness
          • Headache
          • Vomiting
          • Nausea
          • Lightheadedness
          • Low blood pressure
          • Impaired muscle coordination
        • It is strongly recommended that a rectal temperature be taken to exclude exertional heat stroke
        • For treatment of exertional heat exhaustion:
          • Remove patient’s excess clothing and equipment
          • Move patient to a cool shaded environment
          • Monitor vital signs
          • Place legs in an elevated position
          • If the condition worsens or does not improve after 30 minutes, EMS should be activated
        • Patients with heat exhaustion should not be returned to play in the same day
      • Heat Stroke
        • Exertional Heat Stroke (EHS) is the most severe heat illness
        • EHS is characterized by neuropsychiatric impairment and a high core body temp, higher than 105oF
        • EHS is most likely to occur in hot and humid weather
          • It can also occur with intense physical activity in the absence of extreme weather
        • CNS dysfunction is often the first sign of EHS
        • EHS is a medical emergency and can progress to a systematic inflammatory response and multi-organ system failure
        • The 2 main diagnostic criteria for EHS is CNS dysfunction and a core body temperature greater than 105oF
          • Core body temperature is only accurately obtained by using a rectal thermometer
            • If rectal thermometry is not available the AT should rely on other key diagnostic indicators
          • CNS dysfunction S&S include:
            • Disorientation
            • Confusion
            • Dizziness
            • Loss of balance
            • Staggering
            • Aggressiveness
            • Hysteria
            • Delirium
            • Collapse
            • Loss of consciousness
            • (In some cases of EHS a lucid period by be present but will deteriorate quickly)
          • Other S&S of EHS include:
            • Dehydration
            • Hot and wet skin
            • Hypotension
            • Hyperventilation
          • Treatment for patients with EHS include:
            • Lowering the core body temperature to less than 102oF within 30 minutes of collapse
              • The length of time the core body temperature is above the threshold of 105oF dictates morbidity and risk of death from EHS
            • If EHS is suspected, full body cold water immersion (CWI) should begin immediately
            • Rectal temperature and other vital signs should be monitored every 5 -10 minutes during cooling
            • CWI is the most effective cooling modality for EHS patients
              • Water should be between 35-59oF and moving
            • EHS patients should be removed from CWI when the core body temperature reaches 102oF to prevent overcooling
            • Cooling rates for CWI vary but will be approximately 1oF for every 3 minutes in the CWI
            • If full body CWI is not available ice towels or cold water dousing may be used but are not as effective
            • EHS patients should be cooled first and transported second
          • EHS patients RTP should follow the guidelines of:
            • Patient should complete a 7-21 day rest period, demonstrated normal blood work results, obtained a physician clearance note before beginning a gradual RTP under the guidance of an AT
            • Rectal temperatures and heart rate should be monitored during RTP activities
            • If the patient experiences any negative symptoms with RTP activities the progression should be slowed or stopped

 

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