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 InterAssociation 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:
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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.
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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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:
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Intense pain (not associated with pulling or straining a muscle)
Persistent muscle contractions that continue during and after exercise
Treatment:
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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:
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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:
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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:
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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:
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Physician clearance is strongly recommended in all cases. Prevent & Treat Heat Illnesses
Questions or comments about this web site, contact [email protected]
Copyright © 2003 National Athletic Trainers' Association. All Rights Reserved, Worldwide
http://www.nata.org/newsrelease/archives/000056.htm (3 of 3)8/4/2008 3:48:46 PM
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.
2.
3.
4.
5.
6.
7.
Assess level of illness (if thermometer is available take athlete’s temperature)
Move athlete to a cooler location – rest him or her in a comfortable position
Administer cool fluids every 15 minutes
Remove or loosen tight clothing or athletic equipment
Begin gentle stretching of affected areas
Monitor athlete closely for any changes in status
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 reevaluation
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
RECOMMENDATIONS FOR HYDRATION
TO PREVENT HEAT ILLNESS
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 than
2 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 are
not recommended during exercise as sole beverages.
S
Beverages containing caffeine, alcohol, and carbonation are not to be used because of the high risk of
dehydration associated with excess urine production, or decreased voluntary fluid intake.
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 before
exercise.
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 hydration, and remember to drink beyond your thirst.
S
Drink fluids based on the amount of sweat and urine loss.
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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 or
more.
WHAT TO DRINK DURING EXERCISE
S
If exercise lasts more than 45-50 minutes or is intense, a sports drink should be provided during the
session.
S
The carbohydrate concentration in the ideal fluid replacement solution should be in the range of six to
eight percent CHO.
S
During events when a high rate of fluid intake is necessary to sustain hydration, sports drinks with less
than seven percent CHO should be used to optimize fluid delivery. These sports drinks have a faster
gastric 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 to
dehydration and should be avoided during exercise.
S
Fluids with salt (sodium chloride) are beneficial to increasing thirst and voluntary fluid intake as well
as 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 best
results 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 athlete 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) can
negatively influence performance.
S
Dehydration of greater than three percent of body weight increases an athlete’s risk of heat illness (heat
cramps, heat exhaustion, heat stroke).
S
High-body-fat athletes can have a harder time with exercise and can become dehydrated faster than
lower-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 of
heat illness and dehydration.
S
Wet bulb temperature measurements should be taken 10-15 minutes before practice, and the results
should be used with a heat index to determine if practices or contests should be started, modified or
stopped.
S
Even dry climates can have high humidity if sprinkler systems are scheduled to run before early morning practices start. This collection of water does not evaporate until environmental temperatures
increase and dew points lower. Dry climate areas should take wet bulb and temperature readings 10
to 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 Atmospheric
Association.
S
A relative humidity of 35 percent and a temperature of 95 degrees Fahrenheit are likely to cause heat
illness, with heat stroke likely.
S
A relative humidity of 70 percent and a temperature of 95 degrees Fahrenheit are very likely to cause
heat 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
Journal of Athletic Training
2009;44(3):332–333
g by the National Athletic Trainers’ Association, Inc
www.nata.org/jat
consensus statement
Preseason Heat-Acclimatization Guidelines for
Secondary 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 Army
Research Institute of Environmental Medicine; **American Orthopaedic Society for Sports Medicine; 33American
Medical Society for Sports Medicine; 44American Academy of Pediatrics
A
proper heat-acclimatization plan in secondary
school athletic programs is essential to minimize
the risk of exertional heat illness during the
preseason practice period. Gradually increasing athletes’
exposure to the duration and intensity of physical activity
and to the environment minimizes exertional heat-illness
risk while improving athletic performance. Progressive
acclimatization is especially important during the initial 3
to 5 days of summer practices. When an athlete undergoes
a proper heat-acclimatization program, physiologic function, exercise heat tolerance, and exercise performance are
all enhanced.1–6 In contrast, athletes who are not exposed
to a proper heat-acclimatization program face measurable
increased risks for exertional heat illness.
For these reasons, the Inter-Association Task Force for
Preseason Secondary School Athletics, in conjunction with
the National Athletic Trainers’ Association’s Secondary
School Athletic Trainers’ Committee, recommends that
these ‘‘Preseason Heat-Acclimatization Guidelines for
Secondary School Athletics’’ be implemented by all secondary school athletic programs. These guidelines should
be used for all preseason conditioning, training, and
practice activities in a warm or hot environment, whether
these activities are conducted indoors or outdoors. When
athletic programs implement these guidelines, the health
and safety of the athletes are primary. However, the
recommendations outlined here are only minimum standards, based on the best heat-acclimatization evidence
available. Following these guidelines provides all secondary school athletes an opportunity to train safely and
effectively during the preseason practice period.
DEFINITIONS
Before participating in the preseason practice period, all
student-athletes should undergo a preparticipation medical
332
Volume 44
N Number 3 N June 2009
examination administered by a physician (MD or DO) or
as required/approved by state law. The examination can
identify predisposing factors related to a number of safety
concerns, including the identification of youths at particular risk for exertional heat illness.
The heat-acclimatization period is defined as the initial 14
consecutive days of preseason practice for all studentathletes. The goal of the acclimatization period is to
enhance exercise heat tolerance and the ability to exercise
safely and effectively in warm to hot conditions. This
period should begin on the first day of practice or
conditioning before the regular season. Any practices or
conditioning conducted before this time should not be
considered a part of the heat-acclimatization period.
Regardless of the conditioning program and conditioning
status leading up to the first formal practice, all studentathletes (including those who arrive at preseason practice
after the first day of practice) should follow the 14-day
heat-acclimatization plan. During the preseason heatacclimatization period, if practice occurs on 6 consecutive
days, student-athletes should have 1 day of complete rest
(no conditioning, walk-throughs, practices, etc).
Days on which athletes do not practice due to a
scheduled rest day, injury, or illness do not count toward
the heat-acclimatization period. For example, an athlete
who sits out the third and fourth days of practice during
this time (eg, Wednesday and Thursday) will resume
practice as if on day 3 of the heat-acclimatization period
when returning to play on Friday.
A practice is defined as the period of time a participant
engages in a coach-supervised, school-approved, sport- or
conditioning-related physical activity. Each individual
practice should last no more than 3 hours. Warm-up,
stretching, and cool-down activities are included as part of
the 3-hour practice time. Regardless of ambient tempera-
ture conditions, all conditioning and weight-room activities
should be considered part of practice.
A walk-through is defined as a teaching opportunity with
the athletes not wearing protective equipment (eg, helmets,
shoulder pads, catcher’s gear, shin guards) or using other
sport-related equipment (eg, footballs, lacrosse sticks,
blocking sleds, pitching machines, soccer balls, marker
cones). The walk-through is not part of the 3-hour practice
period, can last no more than 1 hour per day, and does not
include conditioning or weight-room activities.
A recovery period is defined as the time between the end
of 1 practice or walk-through and the beginning of the next
practice or walk-through. During this time, athletes should
rest in a cool environment, with no sport- or conditioningrelated activity permitted (eg, speed or agility drills,
strength training, conditioning, or walk-through). Treatment with the athletic trainer is permissible.
RECOMMENDATIONS FOR THE 14-DAY HEATACCLIMATIZATION PERIOD
1. Days 1 through 5 of the heat-acclimatization period
consist of the first 5 days of formal practice. During
this time, athletes may not participate in more than 1
practice per day.
2. If a practice is interrupted by inclement weather or
heat restrictions, the practice should recommence once
conditions are deemed safe. Total practice time should
not exceed 3 hours in any 1 day.
3. A 1-hour maximum walk-through is permitted during
days 1–5 of the heat-acclimatization period. However,
a 3-hour recovery period should be inserted between
the practice and walk-through (or vice versa).
4. During days 1–2 of the heat-acclimatization period, in
sports requiring helmets or shoulder pads, a helmet
should be the only protective equipment permitted
(goalies, as in the case of field hockey and related
sports, should not wear full protective gear or perform
activities that would require protective equipment).
During days 3–5, only helmets and shoulder pads
should be worn. Beginning on day 6, all protective
equipment may be worn and full contact may begin.
A.
B.
5.
Football only: On days 3–5, contact with
blocking sleds and tackling dummies may be
initiated.
Full-contact sports: 100% live contact drills
should begin no earlier than day 6.
Beginning no earlier than day 6 and continuing
through day 14, double-practice days must be followed
by a single-practice day. On single-practice days, 1
walk-through is permitted, separated from the practice
by at least 3 hours of continuous rest. When a double-
6.
7.
practice day is followed by a rest day, another doublepractice day is permitted after the rest day.
On a double-practice day, neither practice should
exceed 3 hours in duration, and student-athletes
should not participate in more than 5 total hours of
practice. Warm-up, stretching, cool-down, walkthrough, conditioning, and weight-room activities are
included as part of the practice time. The 2 practices
should be separated by at least 3 continuous hours in a
cool environment.
Because the risk of exertional heat illnesses during the
preseason heat-acclimatization period is high, we
strongly recommend that an athletic trainer be on site
before, 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 InterAssociation 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 InterAssociation 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.
1
2) Children release less heat through sweating .
3)Children usually don’t drink2,3 enough fluids to replenish sweat losses
during prolonged exercise .
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.
| D E H Y D R AT I O N | 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:
•
•
•
•
•
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.
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.
| H E AT E X H A U ST I O N | If dehydration goes untreated, the likelihood
of heat exhaustion may increase. Common symptoms of heat exhaustion
are:
• Dizziness and fatigue
• Chills
• Rapid pulse
| H E AT ST R O K E | Heat stroke is a medical emergency! When it is
Treatment of heat exhaustion is similar to that of dehydration and should
take place immediately. This treatment includes:
1)
2)
3)
4)
Rest in a cool, shaded area and place ice cold towels on the body.
Drink a sports drink that contains the adequate amount of electrolytes.
Lie down with legs elevated to promote circulation.
Athlete should begin to feel better relatively soon; if not, assume heat
stroke.
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 Plan
2. Hydrate Before, During and After Workouts
Young 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.
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
• F lavor to encourage you to drink
• Carbohydrates to give energy to your working muscles
A
void fruit juices, carbonated beverages, caffeinated beverages and
energy drinks immediately before and during activity.
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.
• F ruit juices cause upset stomach and they may also lack sodium.
• C arbonated beverages, such as soft drinks, can reduce drinking because
of stomach fullness and throat burn.
• E nergy 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
| A CC L I M AT I O N |
•Acclimation to the heat is an important factor in preventing 6heat illness. The
rate of acclimation for children is slower than that of adults .
•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
7
a good indicator of a child’s fluid needs.
| P R O P E R R E ST |
•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.
| D R E SS CO D E |
•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
Heat disorders possible
• Modify workouts and competition in response to the environmental
with prolonged exposure
Heat
Index
conditions.
and/or physical activity
80 to 89
Fatigue
Heat disorders
possible
Sunstroke,
heat cramps
and
90 to 104
with prolonged exposure
Heat Index heat exhaustion
and/or physical activity
80 to 89 Sunstroke,
Fatigueheat cramps or
105 to 129
heat exhaustion likely
90 to 104
130 or higher
Sunstroke, heat cramps and
heat exhaustion
Heatstroke/sunstroke
highly likely
105 to 129
130 or higher
Sunstroke, heat cramps or
heat exhaustion likely
Heatstroke/sunstroke
highly likely
% Humidity
100 72 80 91 108
90
71 79 88 102 122
80
71 78 86 97
70
70 77 85 93 106 124 144
% Humidity
113 136
100 72 80 91 108
90 100 114
9060 71 70
79 76
88 82
102 122
132 149
88 136
96 107 120 135 150
8050 71 69
78 75
86 81
97 113
70 40 70 68
77 74
85 79
93 106
86 124
93 144
101
110 123 137
6030 70 6776 73
82 78
90 100
84 114
90 132
96 149104 113 123
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
20
10
0
20
66 72 77 82 87 93
99 105 112
65 70 75 80 85 90
95 100 105
64 69 73 78
91
104 113 123
83 87
66 72 77 82 87 93
95 99
99 105 112
Air
85 90
90 95
95 100100105105 110
Temp65 7070 75
10
75 80
80 85
Chart adapted from: Inter-Association task force on exertional heat llnesses consensus
0statement.64June 69
73 78
91 95 99
2003, National
Athletic 83
Trainers’87
Association.
Air
Temp 70 75 80 85 90 95
100 105 110
Production of this pamphlet made possible
by the Kendrick Fincher Memorial Foundation
and The Gatorade Company.
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.
NFHS | Heat Stress and Athletic Participation
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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
http://www.nfhs.org/web/2005/03/sports_medicine_heat_stress_and_athletic_participation.aspx (1 of 3)8/4/2008 3:45:00 PM
NFHS | Heat Stress and Athletic Participation
65-73 - Moderate risk
73-82 - High risk
❍
82 plus - Very high risk
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.
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.
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.
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.
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.
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.
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.
❍
❍
6.
7.
8.
9.
10.
11.
12.
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.
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NFHS Annual Summer Meeting - DC
89th NFHS Annual Summer Meeting
2008 Topic Selection Meeting
http://www.nfhs.org/web/2005/03/sports_medicine_heat_stress_and_athletic_participation.aspx (2 of 3)8/4/2008 3:45:00 PM
Heat Illness: Prevention and
Treatment
Perry Baker
Supervisor of Athletics and Extracurricular Activities
Dangerous Conditions
 Heat Index – Know Temperature and Humidity
Level
 Test Air with WBGT Heat Index Monitor
65-73 Moderate Risk
73-82 High Risk
82+
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 Guidelines
A.
B.
C.
D.
5-10 minute rest & fluid break after 25-30 minutes of activity
5-10 minute rest & fluid break after 25-30 minutes of activity/should
be in shorts & t-shirt with helmet & should pads.
5-10 minute rest & fluid break after every 15-20 minutes of
activity/shorts & t-shirt only.
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
Resources
Heat 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 Association
http://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.