WHAT IS HEAT ILLNESS?

Exercise produces heat within the body and can increase an athlete’s body temperature. Add to this a hot or humid day and any barriers to heat loss such as padding and equipment, and the temperature of the individual can become dangerously high. If left untreated, the elevation of core body temperature can cause organ systems to shut down in the body. 

HEAT RELATED ILLNESSES ARE ALL PREVENTABLE

There are several ways to prevent heat illness from occurring:

Adequate Hydration

• The athlete should arrive to practices, games, and in-between exercise sessions well-hydrated to reduce the risk of dehydration
• Water should be freely accessible and water breaks should be given in the shade if available at least every 15-20 minutes and should be long enough to allow athletes to ingest adequate volumes of fluid.  Unnecessary equipment should be removed during breaks.

Gradual Acclimatization

• Intensity and duration of exercise should be gradually increased over a period of 7-14 days to give athletes time to build fitness levels and become accustomed to practicing in the heat.
• Protective equipment should be introduced in phases.

PREVENTION

These are a few ways to help prevent the occurrence of various exertional heat illnesses.

1. Have athletes undergo a period of HEAT ACCLIMATIZATION

2. Encourage athletes to ARRIVE AT PRACTICE HYDRATED

3. Allow athletes UNLIMITED ACCESS TO HYDRATION during activity

4. MODIFY PRACTICE when environmental conditions become extreme, (allowing additional rest/hydration breaks, reducing the intensity of practice, reducing the time of practice and reducing the equipment worn during practice).

5. Practice at an INTENSITY THAT IS APPROPRIATE for the fitness level

6. Encourage athletes to SPEAK UP WHEN NOT FEELING WELL - create a culture where this is considered smart.

HEAT ACCLIMATIZATION

Use the model below to get players acclimated to the heat.

The following are important for understanding the heat acclimatization model:

1. Use good judgment. The times listed below are maximum practice times as you acclimate to the heat. Conditions may warrant shorter practice times and intensity.

2. Practice is defined as time on the football field (including warm-up, stretching, break time, cool down and any conditioning time), and it should never exceed three hours.

3. During the first five days, practices should be limited to two hours.

4. A walkthrough is defined as time dedicated to reviewing plays and field positions and should not exceed one hour.

5. Heat acclimatization days should be continuous if possible, meaning few days off. However, if your practice schedule is only a few days a week, then remember that the days between your practices (the days off) do not count toward acclimatization days. It will take longer to acclimatize in situations such as this.

Practice Days 1-2

-Practices permitted per day: 1

-Equipment: Helmets only

-Max duration of single session: 2 hours

-Contact: No contact

Practice Days 3-5

-Practices permitted per day: 1

-Equipment: Full equipment

-Max duration of single practice session: 2 hours.

-Contact: Limited.

Practice Days 6-14

-Practices permitted per day: 1

-Equipment: Full equipment

-Max duration of single practice session: 2 hours

-Contact: Full, 100% live

Additional Prevention Measures

• Provide appropriate medical coverage during exercise.
• Encourage hydration status record-keeping.  Athletes can weigh-in before and after practice, ideally in dry undergarments in check hydration status. The amount of fluid lost should be replaced by the next session of activity. An athlete should drink approximately 16 oz of fluid for each kilogram of fluid lost (1 kg = 2.2 lbs).
• Eat a well-balanced diet which aids in replacing lost electrolytes and avoid drinks containing stimulants such as ephedrine or high doses of caffeine.
• Alter practice plans in extreme environmental conditions.  Coaches should ideally be aware of the Web Bulb Globe Temperature which measures not only temperature and humidity (the "heat index") but also wind speed, sun angle, and cloud cover.  The WBGT is the most accurate measure of environmental heat stress.  For example, the higher the temperature and humidity, with minimal wind and cloud cover, and with sun directly overhead at 12 noon, the higher the WBGT and the more difficult for the body to cool itself.  Knowing the WGBT using a device, or an estimation (go to "Wet Bulb Globe Temperature Monitoring" below) will guide precautions for athletic activity.  Athletes with heat illness risk factors should be closely supervised during strenuous activities especially in hot and/or humid conditions.

IDENTIFICATION AND TREATMENT OF:

Heat Exhaustion

Heat Stroke

Heat Syncope

Exertional Hyponatremia

Heat Cramps

Exertional Heat Stroke

-How to Respond to an Exertional Heat Stroke Emergency:

1)Initial response. Once exertional heat stroke is suspected, prepare to cool the patient, and contact emergency medical services (EMS).

2)Prepare for ice water immersion. On the field or in a temporary medical tent, half-fill the tub or wading pool with water and ice (before an emergency, check the water source to see how quickly it fills the immersion tub).

a) The stock tank can be filled with ice and cold water before an event(or have tub half-filled with water and three to four coolers of ice next to tub; this prevents having to keep tub cold throughout the day.

b) Ice should always cover the surface of the water.

c) If the athlete collapses near an athletic training room, a whirlpool tub or cold shower maybe used.

3) Determine vital signs. Just before immersing the heat-stroke patient, take vital signs.

a) Assess core body temperature with a rectal thermistor(thermistor implies flexible thermometer that stays in during cooling and allows for continuous monitoring of temperature during immersion therapy).

b) Check airway, breathing, pulse, and blood pressure.

c) Assess the level of central nervous system dysfunction.

4)Begin ice water immersion. Place the athlete in the ice water immersion tub. Medical staff, volunteers, and teammates may be needed to assist with a smooth and safe entry and exit.

5)Total body coverage. Cover as much of the body as possible with ice water while cooling.

a) If full body coverage is not possible due to the container’s size, cover the torso as much as

possible.

b) To keep the athletes head and neck above water, an assistant may hold the victim under the axillae – armpits – with a towel or sheet wrapped across the chest and under the arms.

c) Place an ice/wet towel over the head and neck while body is being cooled in tub.

d) Use a water temperature under 15C(under 60-degree F).

6)Vigorously circulate water. During cooling, water should be continuously circulated or stirred to enhance the water-to-skin temperature gradient, which optimizes cooling. Have an assistant stir the water during cooling.

7)Continue medical assessment. Vital signs should be monitored at regular intervals.

a) It may be helpful for an assistant to stand nearby in case the athlete becomes combative.

b) other assistants may be needed to lift or roll the athlete if vomiting occurs.

8)Fluid administration. If a qualified medical professional is available, an intravenous fluid line can be placed for hydration and support of cardiovascular function.

a) Rest the arm to be used on the side of the water immersion tub.

9)Cooling duration. Continue cooling until the patient’s rectal temperature lowers to 39oC (102oF)

a)** If rectal temperature cannot be measured and cold-water immersion is indicated, cool for10-15 minutes and then transport to a medical facility.

b) An approximate estimate of cooling via cold water immersion is 1oC for every five minutes and 1oF every 3 minutes (if the water is aggressively stirred). This means, the cooling rate will be slower initially, and increase the longer the person is in the tub. For example, if someone is in the tub for 15 minutes, they would cool approximately 3oC or 5oF during that time.

10)Patient transfer. Remove the patient from the immersion tub only after rectal temperature reaches 39oC (102oF) and then transfer to the nearest medical facility via EMS as quickly as possible.

11)Cooling is the primary goal before transport. If appropriate medical staff is available on-site (team physician or athletic trainer); an aggressive cooling modality is readily available (i.e., Cold water immersion, ice/wet towel rotation, high flow cold water dousing); and no other emergency medical services are needed besides the rapid lowering of temperature, then always follow the “cool-first, transport second” doctrine.

-**If cold water immersion is not available or feasible given the constraints of the task being performed, then cool via the best available means. A good (although not optimal) highly portable alternative is a cooler filled with ice, water, and 12 towels. Place six ice/wet towels all over body and leave on for 2-3 minutes, then place those back in cooler and put the six others on the patient. Continue this rotation every 2-3 minutes. Another alternative when a tub is not available is cold water dousing from a locker room shower or from a hose.

When can the individual return to activity?

After an EHS episode occurs, there may be physiological changes, such as heat tolerance, that are temporarily, and occasionally, permanently compromised. Long-term complications and morbidity are directly related to the time that the core body temperature remained above the critical threshold. To safely return an athlete to full participation following an EHS, a specific return-to-play (RTP) strategy should be implemented. The following guidelines are recommended for RTP:

Physician clearance prior to return to physical activity. The athlete must be asymptomatic and lab tests must be normal.

The length of recovery time is primarily dictated by the severity of the incident.

The athlete should avoid exercise for at least one (1) week after the incident.

The athlete should begin a gradual RTP protocol in which they are under the direct supervision of an appropriate health-care professional such as an athletic trainer or physician.

The type and length of the RTP program may vary among individuals, but a general program may include:

Easy-to-moderate exercise in a climate-controlled environment for several days, followed by strenuous exercise in a climate-controlled environment for several days.

Easy-to-moderate exercise in the heat for several days, followed by strenuous exercise in the heat for several days.

If applicable to the individuals sport: easy-to-moderate exercise in the heat with equipment for several days, followed by strenuous exercise in the heat with equipment for several days.