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Exertional Heat Illnesses Helen M Journal of Athletic Training 2002;37(3):329±343 q by the National Athletic Trainers' Association, Inc www.journalofathletictraining.org National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses Helen M. Binkley*; Joseph Beckett²; Douglas J. Casa³; Douglas M. Kleiner§; Paul E. Plummer\ *Mesa State College, Grand Junction, CO; ²University of Charleston, Charleston, WV; ³University of Connecticut, Storrs, CT; §University of Florida, Jacksonville, FL; \Indiana State University, Terre Haute, IN Helen M. Binkley, PhD, ATC, CSCS*D, NSCA-CPT (Chair), contributed to conception and design; acquisition of the data; and drafting, critical revision, and ®nal approval of the article. Joseph Beckett, EdD, ATC, contributed to acquisition of the data and drafting, critical revision, and ®nal approval of the article. Douglas J. Casa, PhD, ATC, FACSM, contributed to conception and design; acquisition of the data; and drafting, critical revision, and ®nal approval of the article. Douglas M. Kleiner, PhD, ATC, FACSM, and Paul E. Plummer, MA, ATC, contributed to acquisition of the data and drafting, critical revision, and ®nal approval of the article. Address correspondence to National Athletic Trainers' Association, Communications Department, 2952 Stemmons Freeway, Dallas, TX 75247. Objective: To present recommendations for the prevention, Recommendations: Certi®ed athletic trainers and other al- recognition, and treatment of exertional heat illnesses and to lied health providers should use these recommendations to es- describe the relevant physiology of thermoregulation. tablish on-site emergency plans for their venues and athletes. Background: Certi®ed athletic trainers evaluate and treat The primary goal of athlete safety is addressed through the heat-related injuries during athletic activity in ``safe'' and high- prevention and recognition of heat-related illnesses and a well- risk environments. While the recognition of heat illness has im- developed plan to evaluate and treat affected athletes. Even proved, the subtle signs and symptoms associated with heat with a heat-illness prevention plan that includes medical screen- illness are often overlooked, resulting in more serious problems ing, acclimatization, conditioning, environmental monitoring, for affected athletes. The recommendations presented here and suitable practice adjustments, heat illness can and does provide athletic trainers and allied health providers with an in- occur. Athletic trainers and other allied health providers must tegrated scienti®c and practical approach to the prevention, rec- be prepared to respond in an expedient manner to alleviate ognition, and treatment of heat illnesses. These recommenda- symptoms and minimize morbidity and mortality. tions can be modi®ed based on the environmental conditions Key Words: heat cramps, heat syncope, heat exhaustion, of the site, the speci®c sport, and individual considerations to heat stroke, hyponatremia, dehydration, exercise, heat toler- maximize safety and performance. ance eat illness is inherent to physical activity and its in- letes with heat illnesses, (4) determine appropriate return-to- cidence increases with rising ambient temperature and play procedures, (5) understand thermoregulation and physi- Hrelative humidity. Athletes who begin training in the ologic responses to heat, and (6) recognize groups with special late summer (eg, football, soccer, and cross-country athletes) concerns related to heat exposure. experience exertional heat-related illness more often than ath- letes who begin training during the winter and spring.1±5 Al- ORGANIZATION though the hot conditions associated with late summer provide a simple explanation for this difference, we need to understand This position statement is organized as follows: what makes certain athletes more susceptible and how these 1. De®nitions of exertional heat illnesses, including exercise- illnesses can be prevented. associated muscle (heat) cramps, heat syncope, exercise (heat) exhaustion, exertional heat stroke, and exertional hy- PURPOSE ponatremia; 2. Recommendations for the prevention, recognition, and This position statement provides recommendations that will treatment of exertional heat illnesses; enable certi®ed athletic trainers (ATCs) and other allied health 3. Background and literature review of the diagnosis of ex- providers to (1) identify and implement preventive strategies ertional heat illnesses; risk factors; predisposing medical that can reduce heat-related illnesses in sports, (2) characterize conditions; environmental risk factors; thermoregulation, factors associated with the early detection of heat illness, (3) heat acclimatization, cumulative dehydration, and cooling provide on-site ®rst aid and emergency management of ath- therapies; Journal of Athletic Training 329 Table 1. Signs and Symptoms of Exertional Heat Illnesses Table 1. Continued Condition Condition Sign or Symptom* Sign or Symptom* Exercise-associated muscle (heat) cramps6,9±11 Extremity (hands and feet) swelling Dehydration Low blood-sodium level Thirst Progressive headache Sweating Confusion Transient muscle cramps Signi®cant mental compromise Fatigue Lethargy Heat syncope10,12 Altered consciousness Dehydration Apathy Fatigue Pulmonary edema Tunnel vision Cerebral edema Pale or sweaty skin Seizures Decreased pulse rate Coma Dizziness *Not every patient will present with all the signs and symptoms for the Lightheadedness suspected condition. Fainting Exercise (heat) exhaustion6,9,10,13 Normal or elevated body-core temperature 4. Special concerns regarding exertional heat illnesses in pre- Dehydration pubescent athletes, older athletes, and athletes with spinal- Dizziness cord injuries; Lightheadedness 5. Hospitalization and recovery from exertional heat stroke Syncope and resumption of activity after heat-related collapse; and Headache Nausea 6. Conclusions. Anorexia Diarrhea Decreased urine output DEFINITIONS OF EXERTIONAL HEAT ILLNESSES Persistent muscle cramps The traditional classi®cation of heat illness de®nes 3 cate- Pallor gories: heat cramps, heat exhaustion, and heat stroke.6±8 How- Profuse sweating Chills ever, this classi®cation scheme omits several other heat- and Cool, clammy skin activity-related illnesses, including heat syncope and exertion- Intestinal cramps al hyponatremia. The signs and symptoms of the exertional Urge to defecate heat illnesses are listed in Table 1. Weakness Heat illness is more likely in hot, humid weather but can Hyperventilation occur in the absence of hot and humid conditions. Exertional heat stroke6,9,10,14 High body-core temperature (.408C [1048F]) Central nervous system changes Exercise-Associated Muscle (Heat) Cramps Dizziness Exercise-associated muscle (heat) cramps represent a con- Drowsiness dition that presents during or after intense exercise sessions as Irrational behavior Confusion an acute, painful, involuntary muscle contraction. Proposed Irritability causes include ¯uid de®ciencies (dehydration), electrolyte im- Emotional instability balances, neuromuscular fatigue, or any combination of these Hysteria factors.6,9±11,19 Apathy Aggressiveness Delirium Heat Syncope Disorientation Heat syncope, or orthostatic dizziness, can occur when a Staggering person is exposed to high environmental temperatures.19 This Seizures condition is attributed to peripheral vasodilation, postural Loss of consciousness pooling of blood, diminished venous return, dehydration, re- Coma 10,19 Dehydration duction in cardiac output, and cerebral ischemia. Heat syn- Weakness cope usually occurs during the ®rst 5 days of acclimatization, 12 Hot and wet or dry skin before the blood volume expands, or in persons with heart 10 Tachycardia (100 to 120 beats per minute) disease or those taking diuretics. It often occurs after stand- Hypotension ing for long periods of time, immediately after cessation of Hyperventilation activity, or after rapid assumption of upright posture after rest- Vomiting ing or being seated. Diarrhea Exertional hyponatremia15±18 Body-core temperature ,408C (1048F) Exercise (Heat) Exhaustion Nausea Exercise (heat) exhaustion is the inability to continue exercise Vomiting associated with any combination of heavy sweating, dehydra- 330 Volume 37 x Number 3 x September 2002 tion, sodium loss, and energy depletion. It occurs most fre- headache, vomiting, lethargy, and swelling of the extremities quently in hot, humid conditions. At its worst, it is dif®cult to (hands and feet), pulmonary edema, cerebral edema, and sei- distinguish from exertional heat stroke without measuring rectal zures. Exertional hyponatremia can result in death if not treat- temperature. Other signs and symptoms include pallor, persis- ed properly. This condition can be prevented by matching ¯uid tent muscular cramps, urge to defecate, weakness, fainting, diz- intake with sweat and urine losses and by rehydrating with ziness, headache, hyperventilation, nausea, anorexia, diarrhea, ¯uids that contain suf®cient sodium.31,32 decreased urine output, and a body-core temperature that gen- 6,9,10,13,19 erally ranges between 368C (978F) and 408C (1048F). RECOMMENDATIONS The National Athletic Trainers' Association (NATA) advo- Exertional Heat Stroke cates the following prevention, recognition, and treatment Exertional heat stroke is an elevated core temperature (usu- strategies for exertional heat illnesses. These recommendations are presented to help ATCs and other allied health providers ally .408C [1048F]) associated with signs of organ system
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