14 Endorsing Organizations
• 1) American College of Sports Medicine • 2) American Medical Society for Sports Medicine • 3) American Orthopaedic Society for Sports Medicine • 4) American Osteopathic Academy of Sports Medicine • 5) Canadian Athletic Therapists Association • 6) Gatorade Sports Science Institute • 7) Korey Stringer Institute (KSI) • 8) Matthew A. Gfeller Sport-Related Traumatic Brain Injury Research Center • 9) National Athletic Trainers’ Association • 10) National Center for Catastrophic Sport Injury Research • 11) National Council on Strength and Fitness • 12) National Federation of State High School Associations • 13) National Interscholastic Athletic Administrators Association • 14) National Strength and Conditioning Association
Preventing Onset of Exertional Heat Stroke &
Preventing Death if it Occurs: The Five Lifesaving Policies
Douglas J. Casa, PhD, ATC, FACSM, FNATA Chief Operating Officer, Korey Stringer Institute
Professor, Department of Kinesiology University of Connecticut
My Path
• Suffered an EHS at age 16 (28 years ago)
• Have treated 185 EHS’s • 100% survival
• Published over 160 research publications related
to heat and hydration issues • Have conducted 50 field research studies
• In addition to many lab studies
The 5 Lifesaving Heat Policies
• 1) Heat Acclimatization • 2) Work to Rest Ratios Based on Environment • 3) Accurate Core Body Temperature • 4) Cold Water Immersion • 5) Cool-First, Transport Second
Why is knowledge of heat
illnesses important?
• There are many types of heat illness, with heat cramps and heat exhaustion being the most common, but not severe.
• Exertional heat stroke (EHS) is the most severe form of exertional heat illness (EHI) with implications for potential death.
• Unlike other potentially fatal conditions, death from EHS is completely preventable if rapidly recognized and appropriately treated.
• Having appropriate medical staff, and enforcing an exercise heat acclimatization policy and wet bulb globe temperature (WBGT) policy are major strategies for preventing EHI.
American Journal of Sports Medicine, 2013
A retrospective analysis of American football hyperthermia deaths in the United States Andrew J. Grundstein et al. Int J Biometeorol (2012) 56:11–20 *58 deaths *Almost all August *Lineman (>85%) *WBGT high or extreme (better than heat index) *First few days *Equipment dramatically increases prediction of WBGT *>50% in morning
Things Are Getting Worse
Heat Stroke Fatalities, 1975-2014 Year Total 1975-1979 8 1980-1984 9 1985-1989 5 1990-1994 2 1995-1999 13 2000-2004 11 2005-2009 18 2010-2014 20 (five year average over 40 years- 11)
University of North Carolina National Center For Catastrophic Injury Research and KSI, 2010, 2014
Rav-Acha, M., Hadad, E., Epstein, Y., Heled, Y., & Moran, D. S. (2004). Fatal exertional heat stroke: a case series. The American Journal of the Medical Sciences, 328(2), 84–87.
Rav-Acha et al.
Uncompensable Heat Stress
Compensable Heat Stress Cooling
Performance Outcome
Football equipment
↑
Intermittent Cooling
Duration of Tx
High WBGT
Heat Storage ↑
Hydration
↑
↑
Theoretical Framework
12
Exercise Intensity
SA/BM
Lifesaving Heat Policy #1 Heat Acclimatization
Why is it important to…
Know what heat acclimatization is? • Heat acclimatization is a period of 7 to 14 days
where the body adapts to exercising in the heat. • This plays a large part in the body’s physical
responses to exercise under stressful conditions and its ability to cope with heat exposure.
• Heat acclimatization decreases heart rate, body temperature, and fatigue.
• Heat acclimatization decreases the risk of an athlete suffering from a heat-related illness.
EHI Injury Rate by Day (first 21 days only)
Ferrara, Casa et al. JAT, In press.
IR for 1st Week Ferrara, Casa et al. JAT, In press
IR by Week and Length of Practice for August
2.5 times increase
4.5 times increase
Ferrara, Casa et al. JAT, In press
Know what a heat acclimatization policy looks like? • It is helpful to be familiar with an example of a heat acclimatization policy in
order to develop and implement one of your own. • This is of highest importance for sports with athletes exercising outdoors in
the heat, where there is an increased risk for developing heat-related illnesses.
This heat acclimatization policy is specific to football, and is used by many organizations.
Changes to the policy may need to be addressed depending on the individual sport.
State HA Policy As of May 15, 2011
2011- NJ
2011
2011- TX
2011
2011
2012- GA
2011
2011 2012
2012- NC
2011
2011 2012
2012
2012- AR
2011
2011 2012
2012 2012
2012- AZ
2011
2011 2012
2012 2012 2012
2012- FL
2011
2011 2012
2012 2012 2012
2012
2013- CT
2011
2011 2012
2012 2012 2012
2012
2013
2013- IA
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013- MO
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013
2013- UT
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013 2013
2013- MS
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013 2013
2013
2014- AL
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013 2013
2013 2014
Meets minimum Working with KSI to attain minimum Current guidelines do not meet minimum standards
2011
2011 2012
2012 2012 2012
2012
2013 2013
2013 2013
2013 2014
Best Practice Recommendations: Heat Acclimatization
Lifesaving Heat Policy #2 Work To Rest Ratios Based on
Environment
3. Know when it is too hot to practice, and how to modify practices/games? • Exercising in a high heat stress environment can lead to heat-related illness. • Cancelling activity when it is too hot protects the health and safety of the athletes. • Making modifications to the following components will help prevent heat-related illness
• Work to rest ratios • 40 minutes of exercise followed by a 10-minute break is a good place to start
• Equipment to be worn • Remove unnecessary equipment when applicable (helmet, shoulder pads, etc.)
• Length of activity • Level in which activity is cancelled
• WBGT of 92 or above is an example, but this will depend on your geographical region
• Hydration breaks
WBGT monitor
used to measure environmental
conditions
Work to Rest Ratios
• What are these? • The amount of time spent involved in exercise versus the
amount of time spent in recovery
• When should these be modified? • Extreme environmental conditions • When athletes gain or lose fitness • Recovering from an injury • Certain genetic predispositions such as sickle cell trait • During pre-season acclimatization periods
Hydration
For every 1% body mass lost via sweat, core body temperature increases by 0.5°F(0.22°C).
RA Huggins, et al, 2013, MSSE
Work to Rest Ratios
• Wet Bulb Globe Temperature • An accurate way of measuring the heat stress an athlete
will be experiencing during exercise • Takes into account:
• Ambient temperature • Relative humidity • Radiation from the sun
WBGT = 0.7TW + 0.2Tg + 0.1Td
WBGT Data
• EHI risk was greatest when the WBGT was above 820F
Ferrara, Casa et al. JAT, In review.
Example Heat Policy Georgia High School Association
2.67 Practice Policy for Heat and Humidity • Schools must follow the statewide policy for conducting practices and voluntary
conditioning workouts (including during the summer) in all sports during times of extremely high heat and/or humidity that will be signed by each head coach at the beginning of each season and distributed to all players and their parents or guardians. The policy shall follow modified guidelines of the American College of Sports Medicine in regard to:
• A scientifically-approved instrument that measures the Wet Bulb Globe Temperature must be utilized at each practice to ensure that the written policy is being followed properly. WBGT readings should be taken every hour, beginning 30 minutes before the beginning of practice.
• Practices are defined as: the period of time that a participant engages in a coach-supervised, school-approved sport or conditioning-related activity. Practices are timed from the time the players report to the practice or workout area until players leave that area. If a practice is interrupted for a weather-related reason, the “clock” on that practice will stop and will begin again when the practice resumes.
• Conditioning activities include such things as weight training, wind-sprints, timed runs for distance, etc., and may be a part of the practice time or included in “voluntary workouts.”
• A walk-through is not a part of the practice time regulation, and may last no longer than one hour. This activity may not include conditioning activities or contact drills. No protective equipment may be worn during a walk-through, and no full-speed drills may be held.
• Rest breaks may not be combined with any other type of activity and players must be given unlimited access to hydration. These breaks must be held in a “cool zone” where players are out of direct sunlight.
Georgia High School Association WBGT policy
4. Know how to monitor environmental conditions if I do not have a WBGT device? • Monitoring environmental conditions is key to preventing heat illness, regardless of device
availability. • The next best alternative is to reference the chart below.
This is used to estimate WBGT derived from temperature and relative humidity.
Best Practice Recommendations: Extreme Weather
Lifesaving Heat Policy #3 Accurate Core Body Temperature
2 Basic Rule-In Considerations
Excessive exercise induced hyperthermia Generally greater than >105oF at time of collapse But, a temp above this does not always mean EHS
CNS dysfunction But, absence of CNS problem does not rule out EHS,
remember possible lucid interval (CNS will show itself)
Recognition
• Early warning sings include: • Headache • Dizziness • Nausea
• If these signs are detected early and individual is
allowed to bring their body temperature down, future problems may be avoided!
Recognition
• Rectal temperature is the only viable field option to assess body temperature.
• Aural, oral, tympanic, auxiliary, and forehead have all been shown to not be effective measuring devices.
• If a rectal probe is not available, any athlete showing sings of CNS dysfunction should be considered to be suffering an exertional heat stroke.
Accurate Body Temperature Assessment at Point of Care
for Collapsed Athlete
Why Do We Need An Accurate Temp
1) Determine if it is or is not EHS Is it Heat Exhaustion? Is it a Head Injury? Is it Hyponatremia? Is it a blood glucose issue? Is it something else? 2) Determine when to stop cooling 3) Determine if EHS occurred (which influences recovery
plans- if you just assume EHS w/o temp then what condition are you treating?)
Examples of Success
• Fort Benning Army Ranger Training • Falmouth Road Race • Marine Corps Marathon • University of South Florida Clinical Outreach ATC’s
Options for Assessing Core Temperature
• Axillary • Oral • Tympanic • Temporal Artery • Forehead Sticker • Ingestible Thermistor • Esophageal • Rectal
Rectal / Temporal
Casa et al, Journal of Athletic Training, 2007
Rectal / Temporal
Casa et al, Journal of Athletic Training, 2007
Ronneberg, Roberts, et al. Med Sci Sports Exerc. 2008 Aug;40(8):1373-5.
“Based on these findings, TAT measurement should not be used to assess core body temperature or make treatment decisions for marathon runners with potential exertional heat stroke.”
Mazerolle, S. M., Ganio, M. S., Casa, D. J., Vingren, J., & Klau, J. F. (2011). Is oral temperature an accurate measurement of deep body temperature? A systematic review. Journal of Athletic Training, 46(5), 566–573.
Oral Temperatures
Huggins, R., Glaviano, N., Negishi, N., Casa, D. J., & Hertel, J. (2012). Comparison of Rectal and Aural Core Body Temperature Thermometry in Hyperthermic, Exercising Individuals: A Meta-Analysis. Journal of Athletic Training, 47(3), 329–338.
Aural Temperatures
Treatment
• Cold water immersion is the gold standard for treatment of exertional heat stroke!!
• Superior cooling capability • Large surface area for cooling • Easy and cheap field modality
Casa 2007
Lifesaving Heat Policy #4 Cold Water Immersion
Treatment
• To ensure survival, cold tubs should be setup prior to an event involving exercise in the heat.
• Tub filled with water and ice nearby • Should be large enough to accommodate full immersion of
a large individual
Treatment
• Individual with heat stroke should be cooled to 102°F within 30 minutes.
• When cooling, monitor athlete’s vital signs • Core body temperature with rectal probe • Airway, breathing, pulse, and blood pressure • Level of CNS dysfunction
• Continually stir water • If not medical staff on-site, cool until EMS arrives
Know how to properly recognize/treat an athlete suffering from EHS? • Death from EHS is completely preventable with prompt recognition and treatment. • EHS has a 100% survival rate when immediate cooling via cold-water immersion or
aggressive whole body cold water dousing is initiated within 10 minutes of collapse. • To initiate emergency treatment for EHS, follow the steps in the following slides
Lifesaving Policy #5 Cool-First, Transport Second
From The Inter-Association Task-Force on Exertional Heat Illnesses Consensus
Statement, 2003
• “Provided that adequate emergency medical care is available on-site (i.e. ATC, EMT, or physician), it is recommended to cool first via cold water immersion, then transport second”
Why Is Treatment So Critical?
• The Golden Hour • The Golden Hour • The Golden Hour • The Golden Hour • The Golden Hour • The Golden ½
Hour
600 Ticks (everything riding on first 10 minutes)
5 minutes to call 10 minutes to arrive 10 minutes on-site 10 minutes to hospital 10 minutes at hospital before cooling
TOTAL = 45 minutes!!!!! Cool First (or at least while you wait)- Every minute matters
Casa et al. Medicine and Science in Sports and Exercise, 2010;42(7):1-7. (redrawn from Hubbard et al, J Applied Physiology 42: 809-816, 1977)
9.5min
17min
83min
108oF to 102oF
Core temperature diminution during three methods of post-hyperthermic cooling
40
40.5
41
41.5
42
42.5
43
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56 60 64 68 72 76 80 84 88 92 96100
Time in minutes
Core
tem
pera
ture
dec
reas
e du
ring
cool
ing
(deg
rees
Cel
sius
) Cooling rate 0.03
Cooling rate 0.10
Cooling rate 0.20
Casa et al. Cold-water immersion: The gold standard for exertional heat stroke treatment. Exercise and Sports Science Reviews. 35(3):141-149, 2007.
Consider This Premise
• Falmouth Road Race + (~10,000 runners) • Marine Corps Marathon + (30,000 runners) • Quantico + (30,000) • Peachtree Road Race + (25,000 runners) • Twin Cities Marathon + (10,500 runners) • Parris Island + (17,000) • Boston Marathon + (20,000) • Fort Benning + (140,000) • Cases I am aware of =
Your Best Option
• 100% Survival if EHS assessed via rectal temperature and aggressive cooling via cold water is begun within 10 min after collapse.
• Over 2,200 cases.
• No deaths.
• Wow.
• Fast, easy, cheap, no side-effects
DeMartini JK, Casa DJ, Stearns R, et al. (2014)
Effectiveness of CWI in the Treatment of EHS at the Falmouth Road Race. Med. Sci. Sports Exerc. 2014.
RESULTS: 274 cases of EHS were observed over the 18 years of collected data. A mean of 15.2 ± 13.0 EHS cases per year were recorded with an overall incidence of 2.13 ± 1.62 EHS cases per 1000 finishers. Average initial Tr was 41.44 ± 0.63°C and the average cooling rate for EHS patients was 0.22 ± 0.11°C · min. CWI resulted in a 100% survival rate for all EHS patients.
Falmouth Road Race
DeMartini JK, Casa DJ, Belval LN, Stearns RL, Davis RJ, Jardine JJ. Effectiveness of CWI in the Treatment of EHS at the Falmouth Road Race. Medicine and Science in Sports & Exercise, In press, 2014.
The Falmouth Model
Kerr, Z. Y., Marshall, S. W., Comstock, R. D., & Casa, D. J. (2014). Exertional heat stroke management strategies… The American Journal of Sports Medicine, 42(1), 70–77.
EHS Management Practices
Alternative Methods
• Continuous Cold Water Dousing • shower, hose, buckets
• Ice/wet towels on entire body (rotate out frequently) • Burrito and Taco Methods
• Body Bag
Treatment Steps
1. Take athlete’s rectal temperature.
2. Remove all equipment and excess clothing from the athlete, if possible (cut clothing if necessary).
3. Cool the athlete as quickly as possible via whole body ice-water immersion in a large tub that covers the athlete’s trunk and limbs. Water should be approximately 35-58°F. Continually stir the water and add ice throughout cooling process. (Note: if immersion is not possible, take athlete to cold shower or move to shaded area and use rotating ice towels to cover the body surface.
4. Wrap a towel under the athlete’s arms and hold to ensure an upright position while sitting in the tub.
5. Maintain airway, breathing, and circulation, while continuing to monitor core temperature.
6. After cooling is initiated, call 911. You must COOL BEFORE TRANSPORT. Do not transport the athlete until rectal temperature reaches 102°F.
7. Cease cooling when rectal temperature reaches 102°F.
Best Practice Recommendations: Treatment
Review The 5 Lifesaving
Heat Policies
• 1) Heat Acclimatization • 2) Work to Rest Ratios Based on Environment • 3) Accurate Core Body Temperature • 4) Cold Water Immersion • 5) Cool-First, Transport Second
• Have an athletic present to implement these
strategies
Implementation Sequence