NATA News Releases: How to Recognize, Prevent & Treat Exertional Heat Illnesses

How to Recognize, Prevent & Treat Exertional Heat Illnesses

Many cases of exertional heat illness are preventable and can be successfully treated if such conditions are properly recognized and appropriate care is given in a timely manner. The main objective of the Inter-Association Task Force on Exertional Heat Illnesses Consensus Statement is to educate athletes, coaches, parents and medical staffs alike on what can be done to avert dehydration, exertional heat stroke (EHS), heat exhaustion, heat cramps and exertional hyponatremia.

Prevention Strategies:

The Task Force committee recommends:

● Providing medical services onsite at various events ● Ensuring that preparticipation physical examinations have been completed, which include specific

questions regarding fluid intake, weight changes during activity, medication and supplement use and history of cramping/heat illnesses

● Assuring that medical staffs have authority to alter work/rest ratios, practice schedules, amounts of equipment and withdrawal of individuals from participation in sports, based on heat conditions and/or athletes’ medical conditions

Treatment Strategies for Exertional Heat Illnesses:

DEHYDRATION When athletes do not replenish lost fluids, they become dehydrated.

● Signs and Symptoms: ● Dry mouth ● Thirst ● Being irritable or cranky ● Headache ● Seeming bored or disinterested ● Dizziness ● Cramps ● Excessive fatigue ● Not able to run as fast or play as well as usual

Treatment:

● Move athlete to a cool environment and rehydrate. ● Maintain normal hydration (as indicated by baseline body weight). ● Begin exercise sessions properly hydrated. Any fluid deficits should be replaced within 1 to 2 hours

after exercise is complete. ● Hydrate with a sports drink like Gatorade, which contains carbohydrates and electrolytes (sodium and

potassium) before and during exercise is optimal to replace losses and provide energy. ● Hydrate throughout sports practice to minimize dehydration and maximize performance. ● Seek medical attention to replace fluids via an intravenous line if athlete is nauseated or vomiting.

Return-to-Play Considerations:

● If degree of dehydration is minor and the athlete is symptom free, continued participation is acceptable

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NATA News Releases: How to Recognize, Prevent & Treat Exertional Heat Illnesses

EXERTIONAL HEAT STROKE A severe illness characterized by central nervous system (CNS) abnormalities and potentially tissue damage resulting from elevated body temperatures induced by strenuous physical exercise and increased environmental heat stress.

Signs and Symptoms:

● Increase in core body temperature, usually above 104°F/40°C (rectal temperature) when athlete falls ill ● Central nervous system dysfunction, such as altered consciousness, seizures, confusion, emotional

instability, irrational behavior or decreased mental acuity ● Nausea, vomiting or diarrhea ● Headache, dizziness or weakness ● Hot and wet or dry skin ● Increased heart rate, decreased blood pressure or fast breathing ● Dehydration ● Combativeness

Treatment:

● Aggressive and immediate whole-body cooling is the key to optimizing treatment. The duration and degree of hyperthermia may determine adverse outcomes. If untreated, hyperthermia-induced physiological changes resulting in fatal consequences may occur within vital organ systems (muscle, heart, brain, etc.). Due to superior cooling rates, immediate whole-body cooling (cold water immersion), is the best treatment for EHS and should be initiated within minutes post-incident. It is recommended to cool first and transport second if onsite rapid cooling and adequate medical supervision are available.

Return-to-Play Considerations:

● The athlete’s physician should devise a careful return-to-play strategy that can be implemented with the assistance of a qualified health care professional.

HEAT EXHAUSTION Heat exhaustion is a moderate illness characterized by the inability to sustain adequate cardiac output, resulting from strenuous physical exercise and environmental heat stress.

Signs and Symptoms:

● Athlete finds it hard or impossible to keep playing ● Loss of coordination, dizziness or fainting ● Dehydration ● Profuse sweating or pale skin ● Headache, nausea, vomiting or diarrhea ● Stomach/intestinal cramps or persistent muscle cramps

Treatment:

● Remove athlete from play and immediately move to shaded or air-conditioned area. ● Remove excess clothing and equipment. ● Cool athlete until rectal temperature is approximately 101°F (38.3°C) ● Have athlete lie comfortably with legs propped above heart level. ● If athlete is not nauseated, vomiting or experiencing any CNS dysfunction, rehydrate orally with chilled

water or sports drink. If athlete is unable to take oral fluids, implement intravenous infusion of normal saline.

● Monitor heart rate, blood pressure, respiratory rate, core temperature and CNS status. ● Transport to an emergency facility if rapid improvement is not noted with prescribed treatment.

Return-to-Play Considerations:

● Athlete should be symptom free and fully hydrated; recommend physician clearance; rule out underlying condition that predisposed him/her for continue problems; and avoid intense practice in heat until at least the next day.

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NATA News Releases: How to Recognize, Prevent & Treat Exertional Heat Illnesses

HEAT CRAMPS Muscle cramps are not well understood. Heat cramps are often present in athletes who perform strenuous exercise in the heat. Conversely, cramps also occur in the absence of warm or hot conditions, which is common in ice hockey players.

Signs and Symptoms:

● Intense pain (not associated with pulling or straining a muscle) ● Persistent muscle contractions that continue during and after exercise

Treatment:

● Reestablish normal hydration status and replace some sodium losses with a sports drink or water ● Some additional sodium may be needed (especially in those with a history of heat cramps) earlier in the

activity. ● Light stretching, relaxation and massage of the involved muscle may help acute pain of a muscle

cramp.

Return-to-Play Considerations:

● Athletes should be assessed to determine if they can perform at the level needed for successful participation.

EXERTIONAL HYPONATREMIA When an athlete’s blood sodium levels decrease, either due to overhydration or inadequate sodium intake, or both, medical complications can result in cerebral and/or pulmonary edema. This tends to occur during warm/hot weather activities. Hyponatremia may be completely avoided if fluid consumption during activity does not exceed fluid losses.

Signs and Symptoms:

● Excessive fluid consumption before, during and after exercising (weight gain during activity) ● Increasing headache ● Nausea, vomiting (often repetitive) ● Swelling of extremities (hands and feet)

Treatment:

● If blood sodium levels cannot be determined onsite, hold off on rehydrating athlete (may worsen condition) and transport immediately to a medical facility.

● The delivery of sodium, certain diuretics or intravenous solutions may be necessary. All will be monitored in the emergency department to ensure no complications develop.

Return-to-Play Considerations:

● Physician clearance is strongly recommended in all cases. Prevent & Treat Heat Illnesses

Questions or comments about this web site, contact webdude@nata.org Copyright © 2003 National Athletic Trainers' Association. All Rights Reserved, Worldwide

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MSR AT Outreach Program 

Heat Illness Care Protocol 

The first step is identifying the condition. If the ATC is not present, a coach or administrator is to contact him/her immediately in order to assess the level of severity. The primary goals of any heat illness are decrease core temperature, administer fluids to aid in thermoregulation, and minimize risk of systemic shock. The following protocols will be implemented in the event of a heat illness at the time the ATC arrives.

Heat cramps

1. Assess level of illness (if thermometer is available take athlete’s temperature) 2. Move athlete to a cooler location – rest him or her in a comfortable position 3. Administer cool fluids every 15 minutes 4. Remove or loosen tight clothing or athletic equipment 5. Begin gentle stretching of affected areas 6. Monitor athlete closely for any changes in status 7. Instruct on 24 hour care

Heat Exhaustion

1. Assess level of illness (if thermometer is available take athlete’s temperature) 2. Move athlete to a cooler location – rest him or her in a comfortable position, lying

down with feet elevated if possible) 3. Administer cool fluids every 15 minutes 4. Remove or loosen tight clothing or athletic equipment and apply cool/wet towels

or sheets if fan is available or ice packs to neck, armpits, groin, wrists 5. Monitor athlete closely for any changes in status 6. Call 9-1-1 or the local emergency number if the person refuses water,

vomits or loses consciousness. 7. Based on level of severity, determine practice status in following sessions that

day 8. Instruct on 24 hour care 9. Athlete must check in with ATC the following day prior to any activity for re-

evaluation

Heat Stroke

1. Assess level of illness (if thermometer is available take athlete’s temperature) 2. Check the ABC’s

a. Airway – make sure the person’s airway is clear and not obstructed b. Breathing – make sure the person’s chest is rising and falling to indicate

breathing c. Circulation – check pulse – carotid, distal radial

3. Call 9-1-1 or your local EMS number immediately 4. Move the athlete to a cooler location – rest him or her in a supine position with

feet elevated 5. Quickly cool the body removing any athletic equipment, wrap wet sheets around

the body and fan it (box or oscillating fan if available) 6. If you have ice packs or cold packs, place them on the athlete’s wrists and

ankles, in the armpits, groin, and neck to cool the large blood vessels 7. Administer cool fluids if athlete is conscious 8. Continue to monitor ABC’s and overall status 9. Keep the person lying down and wait for EMS to arrive

 

TYPES OF SPORTS DRINKS

S Fluid Replacers

§ Examples: Water, Gatorade, 10K, Quickick, Max

§ These drinks are absorbed as quickly as water and typically are used for activities lasting less than2 hours.

S Carbohydrate loaders

§ Examples: Gatorlode, Exceed High, Carboplex

§ These drinks replace more muscle glycogen to enhance greater endurance.

§ They should be used after ultra-endurance events to increase muscle glycogen resynthesis after exercise.

S Nutrition Supplements

§ Examples: Gatorpro, Exceed Sports, Ultra Energy

§ These supplements are fortified with vitamins and minerals and they help athletes maintain a balanced diet.

§ They can be used as a meal replacement supplement for athletes who wish to skip a high fat meal,or as extra calories for athletes who wish to gain weight.

WHAT NOT TO DRINK

S Drinks with Carbohydrate (CHO) concentrations of greater than eight percent should be avoided.

S Fruit juices, CHO gels, sodas, and sports drinks that have a CHO greater than six to eight percent arenot recommended during exercise as sole beverages.

S Beverages containing caffeine, alcohol, and carbonation are not to be used because of the high risk ofdehydration associated with excess urine production, or decreased voluntary fluid intake.

RECOMMENDATIONS FOR HYDRATION

TO PREVENT HEAT ILLNESS

HYDRATION TIPS AND FLUID GUIDELINES

S Drink according to a schedule based on individual fluid needs.

S Drink before, during and after practices and games.

S Drink 17-20 ounces of water or sports drinks with six to eight percent CHO, two to three hours beforeexercise.

S Drink another 7-10 ounces of water or sport drink 10 to 20 minutes before exercise.

S Drink early — By the time you’re thirsty, you’re already dehydrated.

S In general, every 10-20 minutes drink at least 7-10 ounces of water or sports drink to maintain hydra-tion, and remember to drink beyond your thirst.

S Drink fluids based on the amount of sweat and urine loss.

S Within two hours, drink enough to replace any weight loss from exercise.

S Drink approximately 20-24 ounces of sports drink per pound of weight loss.

S Dehydration usually occurs with a weight loss of two percent of body weight ormore.

WHAT TO DRINK DURING EXERCISE

S If exercise lasts more than 45-50 minutes or is intense, a sports drink should be provided during thesession.

S The carbohydrate concentration in the ideal fluid replacement solution should be in the range of six toeight percent CHO.

S During events when a high rate of fluid intake is necessary to sustain hydration, sports drinks with lessthan seven percent CHO should be used to optimize fluid delivery. These sports drinks have a fastergastric emptying rate and thus aid in hydration.

S Sports drinks with a CHO content of 10 percent have a slow gastric emptying rate and contribute todehydration and should be avoided during exercise.

S Fluids with salt (sodium chloride) are beneficial to increasing thirst and voluntary fluid intake as wellas offsetting the amount of fluid lost with sweat.

S Salt should never be added to drinks, and salt tablets should be avoided.

S Cool beverages at temperatures between 50 to 59 degrees Fahrenheit are recommended for bestresults with fluid replacement.

DEHYDRATION, ITS EFFECTS ON PERFORMANCE,AND ITS RELATIONSHIP TO HEAT ILLNESS

S Dehydration can affect an athlete’s performance in less than an hour of exercise — sooner if the ath-lete begins the session dehydrated.

S Dehydration of just one to two percent of body weight (only 1.5-3 lb.. for a 150-pound athlete) cannegatively influence performance.

S Dehydration of greater than three percent of body weight increases an athlete’s risk of heat illness (heatcramps, heat exhaustion, heat stroke).

S High-body-fat athletes can have a harder time with exercise and can become dehydrated faster thanlower-body-fat athletes working out under the same environmental conditions.

S Poor acclimatization/fitness levels can greatly contribute to an athlete’s dehydration problems.

S Medications/fevers greatly affect an athlete’s dehydration problems.

S Environmental temperature and humidity both contribute to dehydration and heat illnesses.

S Clothing, such as dark, bulky, or rubber protective equipment can drastically increase the chance ofheat illness and dehydration.

S Wet bulb temperature measurements should be taken 10-15 minutes before practice, and the resultsshould be used with a heat index to determine if practices or contests should be started, modified orstopped.

S Even dry climates can have high humidity if sprinkler systems are scheduled to run before early morn-ing practices start. This collection of water does not evaporate until environmental temperaturesincrease and dew points lower. Dry climate areas should take wet bulb and temperature readings 10to 15 minutes before practice or contests.

S A Heat Index chart should be followed to determine if practice/contests should be held.

S A Heat Index chart should come from a reputable source like the National Oceanic and AtmosphericAssociation.

S A relative humidity of 35 percent and a temperature of 95 degrees Fahrenheit are likely to cause heatillness, with heat stroke likely.

S A relative humidity of 70 percent and a temperature of 95 degrees Fahrenheit are very likely to causeheat illness, with heat stroke very likely.

Journal of Athletic Training: 35(2): 212-224; NFHS Handbook Heat Related Illness, Sandra Shultz Phd,ATC, CSCS, Steven Zinder MS, ATC

Preseason Heat-Acclimatization Guidelines forSecondary School Athletics

Douglas J. Casa, PhD, ATC, FNATA, FACSM*; David Csillan, MS, LAT, ATC*

Inter-Association Task Force for Preseason Secondary School Athletics Participants: Lawrence E.Armstrong, PhD, FACSM�; Lindsay B. Baker, PhD`; Michael F. Bergeron, PhD, FACSM‰; Virginia M.Buchanan, JD�; Michael J. Carroll, MEd, LAT, ATCI; Michelle A. Cleary, PhD, LAT, ATCI; Edward R. Eichner,MD, FACSM�; Michael S. Ferrara, PhD, ATC, FNATAI; Tony D. Fitzpatrick, MA, LAT, ATCI; Jay R. Hoffman,PhD, FACSM, FNSCA"; Robert W. Kenefick, PhD, FACSM#; David A. Klossner, PhD, ATCI; J. Chad Knight,MSHA, MESS, ATC, OTCI; Stephanie A. Lennon, MS, NBCT, LAT, ATCI; Rebecca M. Lopez, MS, ATCI;Matthew J. Matava, MD** ; Francis G. O’Connor, MD, FACSM��; Bart C. Peterson, MSS, ATCI; Stephen G.Rice, MD, PhD, FACSM, FAAP``; Brian K. Robinson, MS, LAT, ATCI; Robert J. Shriner, MS, LAT, ATCI;Michael S. West, MS, ATCI; Susan W. Yeargin, PhD, ATCI*Co-Chairs; 3Individual Representatives; 4Gatorade Sports Science Institute; 1American College of Sports Medicine;INational Athletic Trainers’ Association; "National Strength and Conditioning Association; #United States ArmyResearch Institute of Environmental Medicine; **American Orthopaedic Society for Sports Medicine; 33AmericanMedical Society for Sports Medicine; 44American Academy of Pediatrics

Aproper heat-acclimatization plan in secondaryschool athletic programs is essential to minimizethe risk of exertional heat illness during the

preseason practice period. Gradually increasing athletes’exposure to the duration and intensity of physical activityand to the environment minimizes exertional heat-illnessrisk while improving athletic performance. Progressiveacclimatization is especially important during the initial 3to 5 days of summer practices. When an athlete undergoesa proper heat-acclimatization program, physiologic func-tion, exercise heat tolerance, and exercise performance areall enhanced.1–6 In contrast, athletes who are not exposedto a proper heat-acclimatization program face measurableincreased risks for exertional heat illness.

For these reasons, the Inter-Association Task Force forPreseason Secondary School Athletics, in conjunction withthe National Athletic Trainers’ Association’s SecondarySchool Athletic Trainers’ Committee, recommends thatthese ‘‘Preseason Heat-Acclimatization Guidelines forSecondary School Athletics’’ be implemented by all sec-ondary school athletic programs. These guidelines shouldbe used for all preseason conditioning, training, andpractice activities in a warm or hot environment, whetherthese activities are conducted indoors or outdoors. Whenathletic programs implement these guidelines, the healthand safety of the athletes are primary. However, therecommendations outlined here are only minimum stan-dards, based on the best heat-acclimatization evidenceavailable. Following these guidelines provides all second-ary school athletes an opportunity to train safely andeffectively during the preseason practice period.

DEFINITIONS

Before participating in the preseason practice period, allstudent-athletes should undergo a preparticipation medical

examination administered by a physician (MD or DO) oras required/approved by state law. The examination canidentify predisposing factors related to a number of safetyconcerns, including the identification of youths at partic-ular risk for exertional heat illness.

The heat-acclimatization period is defined as the initial 14consecutive days of preseason practice for all student-athletes. The goal of the acclimatization period is toenhance exercise heat tolerance and the ability to exercisesafely and effectively in warm to hot conditions. Thisperiod should begin on the first day of practice orconditioning before the regular season. Any practices orconditioning conducted before this time should not beconsidered a part of the heat-acclimatization period.Regardless of the conditioning program and conditioningstatus leading up to the first formal practice, all student-athletes (including those who arrive at preseason practiceafter the first day of practice) should follow the 14-dayheat-acclimatization plan. During the preseason heat-acclimatization period, if practice occurs on 6 consecutivedays, student-athletes should have 1 day of complete rest(no conditioning, walk-throughs, practices, etc).

Days on which athletes do not practice due to ascheduled rest day, injury, or illness do not count towardthe heat-acclimatization period. For example, an athletewho sits out the third and fourth days of practice duringthis time (eg, Wednesday and Thursday) will resumepractice as if on day 3 of the heat-acclimatization periodwhen returning to play on Friday.

A practice is defined as the period of time a participantengages in a coach-supervised, school-approved, sport- orconditioning-related physical activity. Each individualpractice should last no more than 3 hours. Warm-up,stretching, and cool-down activities are included as part ofthe 3-hour practice time. Regardless of ambient tempera-

Journal of Athletic Training 2009;44(3):332–333g by the National Athletic Trainers’ Association, Incwww.nata.org/jat

consensus statement

332 Volume 44 N Number 3 N June 2009

ture conditions, all conditioning and weight-room activitiesshould be considered part of practice.

A walk-through is defined as a teaching opportunity withthe athletes not wearing protective equipment (eg, helmets,shoulder pads, catcher’s gear, shin guards) or using othersport-related equipment (eg, footballs, lacrosse sticks,blocking sleds, pitching machines, soccer balls, markercones). The walk-through is not part of the 3-hour practiceperiod, can last no more than 1 hour per day, and does notinclude conditioning or weight-room activities.

A recovery period is defined as the time between the endof 1 practice or walk-through and the beginning of the nextpractice or walk-through. During this time, athletes shouldrest in a cool environment, with no sport- or conditioning-related activity permitted (eg, speed or agility drills,strength training, conditioning, or walk-through). Treat-ment with the athletic trainer is permissible.

RECOMMENDATIONS FOR THE 14-DAY HEAT-ACCLIMATIZATION PERIOD

1. Days 1 through 5 of the heat-acclimatization periodconsist of the first 5 days of formal practice. Duringthis time, athletes may not participate in more than 1practice per day.

2. If a practice is interrupted by inclement weather orheat restrictions, the practice should recommence onceconditions are deemed safe. Total practice time shouldnot exceed 3 hours in any 1 day.

3. A 1-hour maximum walk-through is permitted duringdays 1–5 of the heat-acclimatization period. However,a 3-hour recovery period should be inserted betweenthe practice and walk-through (or vice versa).

4. During days 1–2 of the heat-acclimatization period, insports requiring helmets or shoulder pads, a helmetshould be the only protective equipment permitted(goalies, as in the case of field hockey and relatedsports, should not wear full protective gear or performactivities that would require protective equipment).During days 3–5, only helmets and shoulder padsshould be worn. Beginning on day 6, all protectiveequipment may be worn and full contact may begin.

A. Football only: On days 3–5, contact withblocking sleds and tackling dummies may beinitiated.

B. Full-contact sports: 100% live contact drillsshould begin no earlier than day 6.

5. Beginning no earlier than day 6 and continuingthrough day 14, double-practice days must be followedby a single-practice day. On single-practice days, 1walk-through is permitted, separated from the practiceby at least 3 hours of continuous rest. When a double-

practice day is followed by a rest day, another double-practice day is permitted after the rest day.

6. On a double-practice day, neither practice shouldexceed 3 hours in duration, and student-athletesshould not participate in more than 5 total hours ofpractice. Warm-up, stretching, cool-down, walk-through, conditioning, and weight-room activities areincluded as part of the practice time. The 2 practicesshould be separated by at least 3 continuous hours in acool environment.

7. Because the risk of exertional heat illnesses during thepreseason heat-acclimatization period is high, westrongly recommend that an athletic trainer be on sitebefore, during, and after all practices.

REFERENCES

1. American College of Sports Medicine, Armstrong LE, Casa DJ, et al.

American College of Sports Medicine position stand: exertional heat

illnesses during training and competition. Med Sci Sports Exerc.

2007;39(3):556–572.

2. Bergeron MF, McKeag DB, Casa DJ, et al. Youth football: heat stress

and injury risk. Med Sci Sports Exerc. 2005;37(8):1421–1430.

3. Binkley HM, Beckett J, Casa DJ, Kleiner DM, Plummer PE. National

Athletic Trainers’ Association position statement: exertional heat

illnesses. J Athl Train. 2002;37(3):329–343.

4. Casa DJ, Almquist J, Anderson S, et al. Inter-Association Task Force

on Exertional Heat Illness consensus statement. NATA News. June

2003:24–29.

5. Department of the Army and Air Force. Heat Stress Control and

Casualty Management. Washington, DC: Dept of the Army and Air

Force; 2003. Technical bulletin MED 507/AFPAM 48-152 (I).

6. Wallace RF. Risk Factors and Mortality in Relation to Heat Illness

Severity. Natick, MA: United States Army Research Institute

Environmental Medicine; 2003. Technical report T-03/14.

DISCLAIMER

The National Athletic Trainers’ Association (NATA) and the Inter-

Association Task Force for Preseason Secondary School Athletics advise

individuals, schools, athletic training facilities, and institutions to

carefully and independently consider each of the recommendations.

The information contained in the statement is neither exhaustive nor

exclusive to all circumstances or individuals. Variables such as

institutional human resource guidelines, state or federal statutes, rules,

or regulations, as well as regional environmental conditions, may impact

the relevance and implementation of these recommendations. The

NATA and the Inter-Association Task Force advise their members

and others to carefully and independently consider each of the

recommendations (including the applicability of same to any particular

circumstance or individual). The foregoing statement should not be

relied upon as an independent basis for care but rather as a resource

available to NATA members or others. Moreover, no opinion is

expressed herein regarding the quality of care that adheres to or differs

from any of NATA’s other statements. The NATA and the Inter-

Association Task Force reserve the right to rescind or modify their

statements at any time.

Journal of Athletic Training 333

Heat Illness PREVENT ION AND TREATMENT

Why Kids Are at Risk: 1) Children absorb more heat from a hot environment than adults. The

smaller the child the faster they heat up.

2) Children release less heat through sweating1

.

3) Children usually don’t drink enough fluids to replenish sweat losses during prolonged exercise

2,3

.

4) Young athletes may be more easily distracted when occasions allow for them to rest and rehydrate.

Signs of Dehydration and Heat Illness 4, 5

If dehydration progresses unchecked, the risk of heat illness increases. Heat illness is best understood in three separate degrees: HEAT CRAMPS, HEAT EXHAUSTION and, the most serious and deadly form, HEAT STROKE.

| DEHYDR AT ION | Dehydration during exercise is a common problem. Some young athletes can begin to suffer the consequences of dehydration if they become dehydrated by just 2 percent of their body weight. That’s why it’s important to recognize the warning signs:

• Noticeable Thirst • Muscle Cramps• Weakness• Decreased Performance • Nausea

• Headache • Fatigue • Lightheaded feeling or dizziness • Difficulty paying attention

Treating the symptoms of dehydration is crucial in preventing more serious conditions such as heat exhaustion.

1) Rest in a cool place.

2) Consume a sports drink that contains the adequate amount of electrolytes.

3) Prevent dehydration in the future by consuming fluids before, during and after exercise.

4) Allow for ample time to rehydrate.

What Puts Youth Athletes at Risk?Heat-related illnesses are some of the most common problems for young athletes playing in the heat. These conditions can be dangerous or even fatal in some cases. Heat-induced illness is one of the most preventable sports injuries. Parents, young athletes and coaches need to understand the factors that increase the risk for heat-related illness and take steps to prevent it.

| HEAT EXHAUST ION | If dehydration goes untreated, the likelihood of heat exhaustion may increase. Common symptoms of heat exhaustion are:

• Dizziness and fatigue • Chills• Rapid pulse

Treatment of heat exhaustion is similar to that of dehydration and should take place immediately. This treatment includes:

1) Rest in a cool, shaded area and place ice cold towels on the body.

2) Drink a sports drink that contains the adequate amount of electrolytes.

3) Lie down with legs elevated to promote circulation.

4) Athlete should begin to feel better relatively soon; if not, assume heat stroke.

| HEAT ST RO KE | Heat stroke is a medical emergency! When it is not recognized promptly and treated properly, it can result in death. If rapid cooling does not occur, damage could be extreme, resulting in fatal consequences. Symptoms and results of heat stroke include:

• Very high core body temperature• Altered central nervous system function

(i.e., confusion or unconsciousness)• Otherwise healthy athlete collapses

during intense exercise in the heat

Remember that athletes get better relatively quickly with heat exhaustion, and they get worse with heat stroke. The important thing to remember is that heat stroke must be treated immediately by doing the following:

• Immediate cool-down by whatever means possible > An ice bath in a “cool pool” is preferable because of the superior

cooling rates (holding head out of bath) > Ice packs over as much of the body as possible > A cool shower > Cool, wet towels > Water spray• SEEK MEDICAL ATTENTION IMMEDIATELY (always transport a suspected

heat stroke victim to the hospital). • Do not drink fluids since nausea and vomiting are extremely common.

Hydration Game PlanYoung athletes may not think dehydration will ever happen to them, but it can — and if it does, parents, coaches and athletes had better know what to do about it.

Here are the key steps:

1. Know Your Sweat Rate Staying properly hydrated is all about maintaining the body’s fluid

balance so there’s never too much or too little. Athletes need to know how much they sweat and how much they need to drink to replace it:

• Weigh in before and after competition. • Keep track of how much fluid is consumed during a workout. • Combine the amount of weight lost after exercise with the amount of

fluid consumed in order to formulate how much the athlete should drink to stay hydrated.

DEHYDRATED HYDRATED

Also, check urine color. If it looks like lemonade, then they are likely pretty well hydrated. If urine is dark yellow like apple juice, then they are likely dehydrated. This is an easy and accurate way to assess hydration status.

2. Hydrate Before, During and After Workouts Proper hydration will help you perform at your best and protect you

from feeling dehydration’s serious side effects.

• Before gives you a head start to help you compete at your best • During gives you the energy to keep going • After helps you replace the fluids and electrolytes

3. Choose the Right Beverage While water may be good when there’s nothing else available,

research shows that a properly formulated sports drink, like Gatorade, is best when you’re working out. That’s because it has:

• Electrolytes to replace what you lose in sweat • Flavor to encourage you to drink • Carbohydrates to give energy to your working muscles

Avoid fruit juices, carbonated beverages, caffeinated beverages and energy drinks immediately before and during activity.

• Fruit juices cause upset stomach and they may also lack sodium. • Carbonated beverages, such as soft drinks, can reduce drinking because

of stomach fullness and throat burn. • Energy drinks should be avoided, because many contain caffeine and

have high carbohydrate concentrations.

4. Speak Up if You Feel Ill

Suffering in silence when feeling the early signs of dehydration can be dangerous. Instead, athletes should be encouraged to tell coaches or teammates how they’re feeling so they can get the rest, fluid and medical attention they might need.

Finally, talk to a doctor if you have additional questions about proper hydration. The health and success of your kids may depend on it.

Heat Illness Prevention Techniques| ACCL IMAT ION | • Acclimation to the heat is an important factor in preventing heat illness. The

rate of acclimation for children is slower than that of adults6

. • A child needs as many as 8 to 10 days (45 – 60 minutes/day) in a new

climate to acclimate sufficiently. • During the acclimation process, it’s important to drink adequate amounts of

fluid.• When a child becomes acclimated and his or her sweat rate increases, it’s

important to drink sufficient fluids to replace the increased sweat losses and stay hydrated.

• Medical staff, parents, players and coaches must understand that thirst is not a good indicator of a child’s fluid needs.

7

| PROPER REST |• Parents and coaches should encourage breaks in a shaded area whenever

possible, especially during tournaments, multigame and multipractice days. • It’s important to be aware of high temperatures and humidity and change

practice and game times to cooler portions in the day, such as morning and dusk.

• Practices must be modified based on conditions.

| DRESS CODE |• Children should wear clothing that is light-colored, which will absorb less

heat from the sun.• It’s best to wear lightweight, loose-fitting materials.

Environmental Conditions• Modify workouts and competition in response to the environmental

conditions.

100 72 80 91 108

90 71 79 88 102 122

80 71 78 86 97 113 136

70 70 77 85 93 106 124 144

60 70 76 82 90 100 114 132 149

50 69 75 81 88 96 107 120 135 150

40 68 74 79 86 93 101 110 123 137

30 67 73 78 84 90 96 104 113 123

20 66 72 77 82 87 93 99 105 112

10 65 70 75 80 85 90 95 100 105

0 64 69 73 78 83 87 91 95 99

70 75 80 85 90 95 100 105 110

% Humidity

AirTemp

Heat Index

80 to 89

90 to 104

105 to 129

130 or higher

Heat disorders possiblewith prolonged exposureand/or physical activity

Sunstroke, heat cramps andheat exhaustion

Sunstroke, heat cramps orheat exhaustion likely

Heatstroke/sunstrokehighly likely

Fatigue

100 72 80 91 108

90 71 79 88 102 122

80 71 78 86 97 113 136

70 70 77 85 93 106 124 144

60 70 76 82 90 100 114 132 149

50 69 75 81 88 96 107 120 135 150

40 68 74 79 86 93 101 110 123 137

30 67 73 78 84 90 96 104 113 123

20 66 72 77 82 87 93 99 105 112

10 65 70 75 80 85 90 95 100 105

0 64 69 73 78 83 87 91 95 99

70 75 80 85 90 95 100 105 110

% Humidity

AirTemp

Heat Index

80 to 89

90 to 104

105 to 129

130 or higher

Heat disorders possiblewith prolonged exposureand/or physical activity

Sunstroke, heat cramps andheat exhaustion

Sunstroke, heat cramps orheat exhaustion likely

Heatstroke/sunstrokehighly likely

Fatigue

Chart adapted from: Inter-Association task force on exertional heat llnesses consensus statement. June 2003, National Athletic Trainers’ Association.

1 Bar-Or, O. Temperature regulation during exercise in children and adolescents. In: Gisolfi C, Lamb DR, eds. Perspectives in Exercise Science and Sports Medicine, II. Youth, Exercise and Sport. Indianapolis, Ind.: Benchmark Press; 1989, 335-367.

2 Wilk B. and O. Bar-Or. J Appl Physiol. 80: 1112-1117, 1996.3 Rivera-Brown, A. et al. J Appl Phys. 86: 78-84, 1999.4 Epstein, Y. Am J Med Sports 2: 143-152, 2000.

5 Watts, S. Am J Med Sports. 3: 286-293, 2001.6 Inbar, O. Acclimatization to Dry and Hot Environment in Young Adults and Children

8-10 Years Old. New York, N.Y.: Columbia University; 1978 Dissertation.7 Yeargin S.M., Casa D.J., Decher N.R., McCaffrey M.A., Levreault M.L., Cross C.L.,

James C.T., O’Connor C.B., Psathas E. Youth’s perception of thirst is not a valid indicator of hydration status. Journal of Athletic Training. 40(2S): S20, 2005.

Production of this pamphlet made possible

by the Kendrick Fincher Memorial Foundation

and The Gatorade Company.

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Heat Stress and Athletic Participation Early fall football, cross country, soccer and field hockey practices are conducted in very hot and humid weather in many parts of the United States. Due to the equipment and uniform needed in football, most of the heat problems have been associated with football. From 1995 through the 2005 football season there have been 19 high school heat stroke deaths in football. This is not acceptable. There are no excuses for heatstroke deaths, if the proper precautions are taken. During hot weather conditions the athlete is subject to the following: HEAT CRAMPS - Painful cramps involving abdominal muscles and extremities caused by intense, prolonged exercise in the heat and depletion of salt and water due to profuse sweating. HEAT SYNCOPE - Weakness fatigue and fainting due to loss of salt and water in sweat and exercise in the heat. Predisposes to heat stroke. HEAT EXHAUSTION (WATER DEPLETION) - Excessive weight loss, reduced sweating, elevated skin and core body temperature, excessive thirst, weakness, headache and sometimes unconsciousness. HEAT EXHAUSTION (SALT DEPLETION) - Exhaustion, nausea, vomiting, muscle cramps, and dizziness due to profuse sweating and inadequate replacement of body salts. HEAT STROKE - An acute medical emergency related to thermoregulatory failure. Associated with nausea, seizures, disorientation, and possible unconsciousness or coma. It may occur suddenly without being preceded by any other clinical signs. The individual is usually unconscious with a high body temperature and a hot dry skin (heat stroke victims, contrary to popular belief, may sweat profusely). It is believed that the above-mentioned heat stress problems can be controlled provided certain precautions are taken. According to the American Academy of Pediatrics Committee on Sports Medicine, heat related illnesses are all preventable.( Sports Medicine: Health Care for Young Athletes, American Academy of Pediatrics, July 2000). The following practices and precautions are recommended:

1. Each athlete should have a physical examination with a medical history when first entering a program and an annual health history update. History of previous heat illness and type of training activities before organized practice begins should be included. State High School Associations recommendations should be followed.

2. It is clear that top physical performance can only be achieved by an athlete who is in top physical condition. Lack of physical fitness impairs the performance of an athlete who participates in high temperatures. Coaches should know the PHYSICAL CONDITION of their athletes and set practice schedules accordingly.

3. Along with physical conditioning the factor of acclimatization to heat is important. Acclimatization is the process of becoming adjusted to heat and it is essential to provide for GRADUAL ACCLIMATIZATION TO HOT WEATHER. It is necessary for an athlete to exercise in the heat if he/she is to become acclimatized to it. It is suggested that a graduated physical conditioning program be used and that 80% acclimatization can be expected to occur after the first 7-10 days. Final stages of acclimatization to heat are marked by increased sweating and reduced salt concentration in the sweat.

4. The old idea that water should be withheld from athletes during workouts has NO SCIENTIFIC FOUNDATION. The most important safeguard to the health of the athlete is the replacement of water. Water must be on the field and readily available to the athletes at all times. It is recommended that a minimum 10-minute water break be scheduled for every twenty minutes of heavy exercise in the heat. Athletes should rest in a shaded area during the break. WATER SHOULD BE AVAILABLE IN UNLIMITED QUANTITIES.

5. Check and be sure athletes are drinking the water. Replacement by thirst alone is inadequate. Test the air prior to practice or game using a wet bulb, globe, temperature index (WBGT index) which is based on the combined effects of air temperature, relative humidity, radiant heat and air movement. The following precautions are recommended when using the WBGT Index: (ACSM's Guidelines for the Team Physician, 1991)

❍ Below 65 - Unlimited activity❍ Below 65 - Unlimited activity

NFHS | Heat Stress and Athletic Participation

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NFHS | Heat Stress and Athletic Participation

❍ 65-73 - Moderate risk❍ 73-82 - High risk❍ 82 plus - Very high risk

6. An alternative method for assessing heat and humidity is the weather guide or heat index. Refer to the Sports Medicine Handbook section on heat related illness published by the NFHS. Figure I is an example of a heat-humidity index table that defines low, moderate, high, and extreme risk zones.

7. Cooling by evaporation is proportional to the area of the skin exposed. In extremely hot and humid weather reduce the amount of clothing covering the body as much as possible. NEVER USE RUBBERIZED CLOTHING.

8. Athletes should weigh each day before and after practice and WEIGHT CHARTS CHECKED. Generally a 3 percent weight loss through sweating is safe and over a 3 percent weight loss is in the danger zone. Over a 3 percent weight loss the athlete should not be allowed to practice in hot and humid conditions. Observe the athletes closely under all conditions. Do not allow athletes to practice until they have adequately replaced their weight.

9. Observe athletes carefully for signs of trouble, particularly athletes who lose significant weight and the eager athlete who constantly competes at his/her capacity. Some trouble signs are nausea, incoherence, fatigue, weakness, vomiting, cramps, weak rapid pulse, visual disturbance and unsteadiness.

10. Teams that encounter hot weather during the season through travel or following an unseasonably cool period, should be physically fit but will not be environmentally fit. Coaches in this situation should follow the above recommendations and substitute more frequently during games.

11. Know what to do in case of an emergency and have your emergency plans written with copies to all your staff. Be familiar with immediate first aid practice and prearranged procedures for obtaining medical care, including ambulance service.

12. Warn your athletes about the use of any products that contain ephedra. Ephedra has been associated with two heat stroke deaths in athletes. Ephedra speeds metabolism and increases body heat, constricts the blood vessels in the skin preventing the body from cooling itself, and by making the user feel more energetic it keeps him/her exercising longer when they should stop. Do not use ephedra or ephedra products.

HEAT STROKE - THIS IS A MEDICAL EMERGENCY - DELAY COULD BE FATAL. Immediately cool body while waiting for transfer to a hospital. Remove clothing and immerse torso in ice/cold water. Immersion therapy has the best cooling rates. A plastic baby pool can be available at all practices and games, and can always be ready for immersion procedures. If not available apply ice packs in armpits, groin and neck areas. Continue cooling efforts until EMS arrives. HEAT EXHAUSTION - OBTAIN MEDICAL CARE AT ONCE. Cool body as you would for heat stroke while waiting for transfer to hospital. Give fluids if athlete is able to swallow and is conscious. SUMMARY - The main problem associated with exercising in the hot weather is water loss through sweating. Water loss is best replaced by allowing the athlete unrestricted access to water. Water breaks two or three times every hour are better than one break an hour. Probably the best method is to have water available at all times and to allow the athlete to drink water whenever he/she needs it. Never restrict the amount of water an athlete drinks, and be sure the athletes are drinking the water. The small amount of salt lost in sweat is adequately replaced by salting food at meals. Talk to your medical personnel concerning emergency treatment plans. previous page | print this page

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NFHS Annual Summer Meeting - DC 89th NFHS Annual Summer Meeting 2008 Topic Selection Meeting

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Heat Illness: Prevention and Treatment

Perry BakerSupervisor of Athletics and Extracurricular Activities

Dangerous Conditions

Heat Index – Know Temperature and Humidity Level

Test Air with WBGT Heat Index Monitor65-73 Moderate Risk73-82 High Risk82+ Very High Risk

NOAA’s National Weather Service Heat Index

Courtesy of NOAA’s National Weather Service www.nws.noaa.gov

Signs of Dehydration

Dry mouth Thirst Irritable or cranky Headache Bored or disinterested Dizziness Cramps Excessive fatigue Not able to keep up Dark yellow urine

Other factors for Illness from Heat

Low fitness levels High body fat Sickness Previous dehydration or heat illnesses Inadequate heat acclimatization Salt deficiency Medications/Dietary supplements

Serious Health Risks

Dehydration Can Result In:1. Heat Cramps

2. Heat Exhaustion

3. Heat Stroke

Recognize Warning Signs of Heat Illness

Heat Cramps

Are a mild heat illness that can be treated easily.

Intense muscle spasms can develop after exercising and losing large amounts of fluid and salt from sweating.

Athletes who sweat a lot or have a high concentration of salt may be more likely to get heat cramps.

Heat Cramps

Signs/Symptoms Intense pain Persistent muscle contractions

Treatment Hydration (sports drink and/or water) Possibly extra sodium Stretching, relaxation, massage

Heat Cramps

When can the athlete play again?

As soon as they are symptom free. Important to continue to monitor. May need to change eating and drinking

habits, become more fit, or get better adjusted to the heat.

Heat Exhaustion

Is a moderate Heat Illness that occurs when an athlete continues to be physically active even after suffering from ill effects of the heat.

The body struggles to keep up with the demands, leading to heat exhaustion.

Heat Exhaustion Signs/Symptoms

Loss of coordination, dizziness or fainting Dehydration Profuse sweating or pale skin Headache, nausea, vomiting or diarrhea Stomach/Intestinal cramps or muscle cramps

Treatment Shade or air conditioned area Remove excess clothing and equipment Lie comfortably with feet above heart level If not nauseous, rehydrate with water or sports drink Monitor heart rate, blood pressure, CNS status and core

temperature

Heat Exhaustion

When can the athlete play again?

Should not be allowed to return until all symptoms are gone.

Avoid intense practice in heat for a few days. If received medical treatment, not until doctor

approves and gives specific return to play instructions.

Heat Stroke

Is a severe heat illness that occurs when an athlete’s body creates more heat than it can release, due to the strain of exercising in the heat.

Results in rapid increase in core body temperature.

Can lead to permanent disability or death.

Heat Stroke

Signs/Symptoms Core body temperature 104°F+ CNS dysfunction Nausea, vomiting or diarrhea Headache, dizziness or weakness Hot & wet or dry skin Increased heart rate, decreased blood pressure or fast breathing Dehydration Combativeness

Treatment 911 Aggressive whole-body cooling (cold water immersion) Fans/ice/cold towels over much of the body if immersion is not

available.

Heat Stroke

When can an athlete play again?

When the doctor approves and gives specific return to play instructions.

Parents should work with doctors to rule out or treat other conditions that may cause continued problems.

Should return very slowly under the supervision of health care professional.

Prevention

Meet with prospective players and parents to educate them.

Discuss pre-season conditioning program Avoid mid-day heat Take regular breaks in shade Slowly increase practice time and intensity Pre-participation physical Emergency action plan ATC on site if possible.

Activity GuidelinesA. 5-10 minute rest & fluid break after 25-30 minutes of activityB. 5-10 minute rest & fluid break after 25-30 minutes of activity/should

be in shorts & t-shirt with helmet & should pads.C. 5-10 minute rest & fluid break after every 15-20 minutes of

activity/shorts & t-shirt only.D. Cancel or postpone all outdoor practices. Practice in air conditioned

space.

Air Quality Index

Acclimation to Heat

Promote conditioning Usually takes 10-14 days Carefully observe athletes

Hydration Encourage athletes to drink before, during and after

exercise Take regular drink breaks in shade Helpful Beverages: water and sports drinks with

adequate electrolytes Harmful Beverages: fruit juice, CHO gels, soda,

sports drinks 8%+CHO, caffeinated drinks

Monitor Weight Loss

Athletes should weigh before and after practice Check weight charts Up to 3 percent weight loss through sweating is

normal

Use Caution

Health and safety of our athletes comes before anything else

Recognize signs and symptoms Be prepared for treatment

ResourcesHeat Stress and Athletic Participation. National Federation of State High School Associations.16 July 2008.

http:www.nfhs.org/web/2005/03/sports_medicine_heat_stress_and_athletic_participation.asp

How to Recognize, Prevent & Treat Exertional Heat Illnesses. National Athletic Trainers’ Association. 16 July 2008 http://www.nata.org/newsrelease/archives/000056.htm

Kendrick Fincher Memorial Foundation. 16 July 2008. http://www.kendrickfincher.org/index.htm

National Oceanic and Atmospheric Administration’s National Weather Service Heat Index. United States Department of Commerce. Chart. 23 July 2008. http://www.weather.gov/os/heat/index.shtml

Parents’and Coaches’ Guide to Dehydration and Other Heat Illnessess in Children. National Athletic Trainers’ Association. June 2003.http://www.nata.org/industryresources/heatillnessconcensusstatement.pdf.

Preseason Heat-Acclimatization Guidelines for Secondary School Athletics. Journal of Athletic Training Volume 44 Number 3 June 2009. National Athletic Trainers Associationhttp://www.nata.org/jat

Recommendations for Hydration to Prevent Heat Illness. National Federation of State High School Associations. 16 July 2008. http://www.nfhs.org/core/contentmanager/uploads/heatstressflyers.pdf

Heat Illness: Prevention and Treatment. Lynn Carr. August 2008.