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Some Like It Hot!

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Some Like It Hot! 2016 BRONSON SPORTS MEDICINE SYMPOSIUM: RETURN TO PLAY July 29, 2016 Stacy Majoras, DO, ATC Bronson Sports Medicine Specialists Disclosures Disclosures • I, nor my family, have any financial or other disclosures to share Objectives • Review and establish heat precautions • Review heat related illness • Discuss management of heat illness • Discuss return to play options following heat illness • Consider special populations Thermoregulation • The Players of Thermoregulation – Hypothalamus – great regulator • Monitor blood flow to brain AND thermoreceptors increased heat production or heat loss to bring the body temperature back to the “set-point” • Regulated core body temperature varies ~ 1°C (circadian rhythm, menstrual cycle, distribution) – Skin • Heat cutaneous vasodilation – Cutaneous vasodilation can increase cardiac output 60% • Exercise cutaneous vasoconstriction – Eccrine Glands (Sweating) • Sympathetic (fight) cholinergic nerve fibers • Electrolyte composition – Sodium > Calcium / Magnesium – Modified by reabsorption of sodium in sweat duct hypotonic compared to plasma – Sweat sodium concentration varies by diet, sweat rate, and degree of acclimatization • Sweat Rate is typically between 1.0-2.5L/hr (>2.5L if high temperature) Thermoregulation • Appropriate response to heat – Increase in core body temperature activate peripheral and hypothalamic heat receptors • Increase in cardiac output (increased distribution to skin) • Vasodilate skin blood vessels • Stimulate sweat gland secretion (when body temperature cannot be regulated by sensible heat loss, sweating is initiated and closely parallels body temperature (maximum sweat rates ~ 39°C)) • No heat lost from body with T 97o & > 90% humidity (well into the red) Thermoregulation • Adverse Response to Heat = Thermoregulatory Failure – Lactic Acidosis • Lactic acidosis due to energy depletion stimulation of ATP- dependent Na+-K+ pump ATP depletion / failure of ion- transport accumulation of Ca++ (+ lactic acid) cell hypoxia and necrosis – Dehydration can attenuate heat transfer and heighten cardiovascular collapse • Hypohydration increased core temp / heart rate at rest and exercise AND reduction of sweat rate (above 5% reduction in body weight) – Classical Symptom • Cease sweating in heat stroke (rare in clinical) Objectives • Review and establish heat precautions • Review heat related illness • Discuss management of heat illness • Discuss return to play options following heat illness • Consider special populations Heat Precautions First step in prevention is identifying those at risk – Intrinsic Factors • Age > 40 y/o • H/o exertional heat stroke • Inadequate acclimatization or conditioning • Low fitness level • Overweight • Fever and/or Illness • Competitive • Pre-pubescent • Medications (anticholinergics, antihistamines, stimulants, ACE-inhibitors, diuretics) • Skin disease • Chronic medical illness • Sickle cell Heat Precautions First step in prevention is identifying those at risk • Extrinsic Factors – Exercise with minimal breaks – High temperature, humidity, sun (increased WBGT) – Clothing – Equipment – Lack of education – Limited fluid access – Baseline dehydration – Medications (anticholinergics, antihistamines, stimulants, ACE-inhibitors, diuretics) – Inadequate hydration – Dietary supplements Heat Precautions Heat And Hydration l July 28, 2016 l 11 Heat Precautions WBGT Heat And Hydration l July 28, 2016 l 12 Heat Precautions WBGT Examples Wind HeatIdx Temp F Dwpt F RH % Sky % WBGT F mph F 90 65 42 05 03 92 89 WBGT=.7T90 65 w+.2T42 g+.1T05d 13 92 83 90 65 42 65 13 92 81 Tw is the wet bulb temperature, which indicates 90 70 52 10 06 96 88 humidity 90 70 52 60 06 96 86 Tg is the globe temperature, which indicates radiant90 heat70 52 60 13 96 85 100 70 39 10 13 108 90 Td is the ambient air (dry) temperature 100 70 39 10 5 108 94 100 70 39 65 05 108 91 Heat Precautions • Most effective prevention = heat acclimatization and rehydration – Heat Acclimatization • Decreased core temperature at rest • Decreased HR during exercise • Increased sweat rate (and sensitivity by decreasing “set- point” for sweating and cutaneous vasodilation) • Decreased Na loss in sweat (increased reabsorption) / urine • Increased plasma volume – Heat Acclimatization Recommendations • Begins in a few days, full adaptation by 7-14 days • Different organ systems adapt at varying rates • > 50% VO2 max x 100 minutes to maintain elevated core temperature and sweat rate critical for optimal heat acclimatization • Lost in same pattern as gained Heat Precautions NCAA / High School Acclimatization Recommendations Heat And Hydration l July 28, 2016 l 15 Heat Precautions • Rehydration – Heat acclimatization increases fluid replacement due to earlier onset of sweating – Advantages of heat acclimatization are abolished with dehydration – Choice beverage to rehydrate • Gastric Emptying : increased volume (increased energy content) increased gastric emptying • Intestinal Absorption: glucose (~ 6-7% carbohydrate) + sodium increase water absorption in small intestine due to more favorable fluid gradient • Fluid Retention in ICF/ECF compartments … Urine output inversely proportional to sodium content (Maughan et al.) Heat Precautions • Rehydration Recommendations – If sweat rate is known (next slide) • Individualized replacement based on sweat rate – If sweat rate is not known • 200 - 300 mL (7-10 oz) every 10-20 minutes for events > 30 minutes – 2% body mass loss is acceptable – 6-7% carbohydrate drink is optimal (>7% delayed gastric emptying and decreased intestinal absorption) – Multiple carbohydrate forms greater absorption due to solute transport mechanisms – Increased Na content in beverage increased Na in sweat … thus water + salty food may be more advisable than increased Na content in beverage • Water goes where the salt is Heat And Hydration l July 28, 2016 l 17 Heat Precautions Objectives • Review and establish heat precautions • Review heat related illness • Discuss management of heat illness • Discuss return to play options following heat illness • Consider special populations Heat Illness • Caused by overexertion in high temperatures and high humidity • 2 categories of heat illness – Illness without increase in core temperature – Illness with increase in core temperature Heat Illness • 2 categories of heat illness – Illness without increase in core temperature • Heat rash • Heat cramps • Heat tetany – Illness with increase in core temperature • Heat Exhaustion – normal behavior • Heat Stroke – abnormal behavior • Core temperature over 102 needs to be cooled • For every 5 min of vigorous exercise the body increases 1C Heat Rash • Definition • Treatment – Erythematous rash associated with – Cooling exercise or increased skin temperature – Showering • Mechanism – Topical steroids if – Proposed “causes” include: severe • Blocked sweat glands • Return To Play • Release of histamine with exercise – Per athlete as • Predisposing factors tolerated – Clothing • Prevention – Tropical climates – Wear appropriate • Signs and symptoms clothing – Raised, papules with erythematous base – Pruritic Heat Cramps • Definition – Painful cramping in legs , arms, abdominals with muscle contractions • Mechanism – Unknown, proposed “causes” include: • Poor hydration • Lack of adequate salt • Predisposing factors – Exercise-induced muscle fatigue – Excessive body water loss – Excessive sodium loss – Personal history – Increased running speed – Previous muscle or tendon injury • Signs and symptoms – Dehydration – Thirst – Sweating – Muscle cramps – Fatigue – Twitches aka: fasciculation Heat Cramps Heat Cramps • Treatment – Decreased activity and oral rehydration – Massage with muscle in full- length position • Return To Play – Per athlete as tolerated • Prevention – Maintain fluid / salt balance – Supplemental sodium Heat Tetany • Definition • Treatment – Muscle contraction without – Rehydrate relaxation – Do not try to stretch muscle – Severe cramp – Muscle relaxer – if severe may • Mechanism require injection – Dehydration of muscle with • Return To Play progressive work ending in failure – When full strength and ROM of • Predisposing factors limb is regained – Continuing to exercise despite • Prevention cramping – Treat muscle cramping when it • Signs and symptoms starts – Cramping of muscle off and on – Consider extensive pre – exercise hydration schedule Heat Illness • 2 categories of heat illness – Illness without increase in core temperature • Heat rash • Heat cramps • Heat tetany – Illness with increase in core temperature • Heat Exhaustion – normal behavior • Heat Stroke – abnormal behavior • Core temperature over 102 needs to be cooled • For every 5 min of vigorous exercise the body increases 1C Heat Illness • Heat exhaustion – Syndrome of hyperthermia (core temperature at time of event usually <40°C or <104°F) with physical collapse or debilitation occurring during or immediately following exertion in the heat, with no more than minor central nervous system (CNS) dysfunction (e.g., headache, dizziness). HE resolves rapidly with minimal cooling intervention • Heat injury – HE with clinical evidence of organ and/or muscle (e.g., rhabdomyolysis) damage without sufficient neurological symptoms to be diagnosed as heat stroke • Heat stroke – Syndrome of hyperthermia (core temperature at time of event >40°C or 104°F), physical collapse or debilitation, and encephalopathy as evidenced by delirium, stupor, or coma, occurring during or immediately following exertion or significant heat exposure.
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