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.

TED Ed

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