andrews institute heat safety guidelines 2018-2019
TRANSCRIPT
Andrews Institute Heat Safety Guidelines 2018-2019
The purpose of these guidelines is to maximize the safety of all student-athletes, coaches, and spectators under the care of Andrews Institute Sports Medicine Outreach Staff by providing a comprehensive, cohesive, and consistent strategy for preventing and managing heat illnesses during practice and competition.
Table of Contents
General Guidelines ........................................................................................................................................................................... 1 Introduction ........................................................................................................................................................................................ 2 Prevention Considerations ........................................................................................................................................................... 2 Monitoring the Weather ................................................................................................................................................................. 5 Recognition & Treatment .............................................................................................................................................................. 8 Return to Play .................................................................................................................................................................................. 10 Conclusion ......................................................................................................................................................................................... 10 Supplemental Documents List .................................................................................................................................................. 11 Reference Documents .................................................................................................................................................................. 11 Document & Contact Information ........................................................................................................................................... 12
General Guidelines
The Andrews Institute shall maintain written Heat Safety Guidelines that specifically outlines the roles of the sports medicine healthcare team members and describes a unified approach to heat safety. The Andrews Institute Sports Medicine Outreach staff members’ role shall be to promote hydration and heat safety and provide medical care to victims with injuries sustained from exertion in hot or unseasonably warm environmental conditions. Andrews Institute athletic trainers will assist school representatives in monitoring weather conditions and can assist in making appropriate recommendations for activity modifications as detailed below. Heat safety guidelines shall be in keeping with the industry standards of care and in accordance with government laws and applicable established rules of governing bodies (e.g. FHSAA, NCAA, etc.). Conflicts and concerns will be forwarded to Jeremy Lowery, ATC, Director of Sports Medicine Outreach, for remediation. These guidelines will be reviewed annually and revised if needed. All sports medicine health care team members, athletic directors, event coordinators, coaches, and school district officials should be educated on these guidelines.
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Introduction As individuals exercise in the heat, the evaporation of sweat from the skin is critical as the primary method of dissipating the heat that is produced by the working muscles. The ability to dissipate heat through evaporation can be hindered by factors such as increased relative humidity, wearing athletic equipment, and hydration levels. When heat cannot dissipate as effectively the core body temperature will increase, thereby increases the risk of exertional heat illness. Exertional heat illnesses most often occur in hot weather but can occur at any time. Exertional heat stroke (EHS) is a life-threatening type of exertional heat illness and is a leading cause of preventable death in high school athletics. The implementation of heat safety guidelines however has led to a decrease in deaths from EHS. With prompt and proper treatment, exertional heat stroke is survivable and death can be prevented. Written guidelines are critical in helping to prevent, identify, and properly treat heat illnesses.
Prevention Considerations Pre-participation Physical Evaluations
All Florida High School Athletic Association (FHSAA) athletes must have the FHSAA EL-02 pre-participation physical evaluation (PPE) form on file at their school. The PPE is required by state law. These exams are important because they identify predisposing factors to heat illness and/or prior history of heat illness. Athletes and parents are encouraged to thoroughly read and complete the history portion of the PPE. It is important to note any medication or supplement use that may increase risk of heat illness. Coaches and student-athletes should also review the NFHS online educational course, “Heat Illness Prevention,” at the beginning of the season. It is encouraged that school officials, coaches, and the sports medicine healthcare team collaborate to educated parents and student-athletes on the heat safety guidelines that the school/site will follow. There are many environmental and individual risk factors that can affect an individual’s risk for experiencing heat illnesses during athletic participation.
Environmental Risk Factors Individual Risk Factors
High ambient temperature Poor physical condition; not acclimatized
High humidity Sleep loss
Direct sun exposure Dehydration
Workload severity and duration Recent illness (within 2 weeks)
Excessive clothing, uniforms, or athletic equipment Overweight/obese
High WBGT the previous practice day, followed by high WBGT on the consecutive practice day
History of gastrointestinal, diabetic, heart, or kidney problems
Lack of education, awareness, and recognition among coaches and athletes and medical staff
Prior history of heat illness
Overzealousness Use of diuretics or certain medications (i.e.,
antihistamines, anti-hypertensives, attention-deficit hyperactive disorder drugs)
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Hydration & Nutrition
It is important to start activity healthy and well hydrated. It is also recommended that athletes eat a well-balanced diet and sleep 6-8 hours a day. Special consideration should be given to athletes who are currently or have recently been ill. They may be at an increased risk due to fever, dehydration and/or medications. Intensity and duration of activities should be modified as recommended by an athletic trainer or treating physician. If an individual loses as little as two percent of their body weight, impairments in performance can begin to be noticeable and there is a risk increase that the individual may suffer an exertional heat illness. Athletes should have unlimited access to fluids at all times during practice and competition. Athletes should NEVER be denied water and there should be no fear of consequence for requesting water. In general, it is recommended that athletes consume around 6-8 ounces of fluid for every 15-20 minutes of exercise. It is also recommended that a shaded area is provided for rest breaks. A designated “cooling area” may also include cold towels, cold water immersion tubs, mist fans, etc. For sports involving equipment such as football, equipment should be removed during rest time. Per FHSAA regulations, there shall be at least a minimum 5 minute rest and hydration break for every 30 minutes of practice and rest breaks should not involve any other activity. One means of monitoring hydration status is assessing urine color. It is recommended that a urine color chart be placed in field house restrooms. A sample urine color chart is included in the attached supplemental documents. Hydration status may also be monitored through pre- and post-activity body weight measurements. Sweat rates vary but it is important for all athletes to aim to rehydrate approximately 125% of lost body weight before the next exercise session. A general rule of thumb would be to drink a 20 oz. bottle of water or sports drink for every pound lost during exercise. Equipment Considerations
Excessive clothing or athletic equipment decreases the body’s ability to thermoregulate and may cause greater absorption of radiant heat from the environment. Athletic equipment, and rubber or plastic suits used for weight loss, do not allow water vapor to pass from the skin to the environment and, as a result, inhibit evaporative, convective, and radiant heat loss. Participants who wear equipment that does not allow for heat dissipation are at an increased risk for heat illness. Wearing a helmet may also be a risk factor because a significant amount of heat is dissipated through the head. Athletes should be encouraged to wear light-colored, light-weight, non-layered shirts and apparel to facilitate evaporation and cooling.
Acclimatization
A heat acclimatization plan is critical to reducing the risk of heat illness. The acclimatization period is the initial 14 consecutive days of preseason practice. This allows the body to adapt to exercising in a warmer climate. Coaches should implement and abide by Policy 41 in the FHSAA Handbook. Possible sanctions for coaches in violation of Policy 41 can be found in the FHSAA Handbook. All student athletes should follow this plan. If an athlete misses a practice during this period, it does not count toward their acclimatization period. In addition, any training or conditioning completed before the first day of preseason practice does not count toward the acclimatization period. The following guidelines apply:
Only one practice a day is allowed during Day 1 – Day 7 A walk-through is permitted during Day 1 – Day 6, but there must be a one-hour recovery period
between the walk-through and practice or vice versa. A walk-through is a one-hour maximum teaching/learning opportunity without any protective equipment, sport-specific athletic equipment, conditioning, or weight room activities.
For Football (including spring):
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o Day 1-2: Helmets Only o Day 3-5: Helmets & Shoulder Pads w/ Shorts o Beginning Day 6: Full Pads w/ Pants & Body-to-Body Contact Can Be Initiated
Beginning Day 8: Practice must not exceed a 2-1-2-1 format. A day with 2 practices must be followed by a day with 1 practice.
Practices may not exceed 3 hours in length during two-a-days and must not exceed 5 hours total – This time includes warm-up, stretching, and cool-down. Practices must also be separated by at least 3 continuous hours.
No walk-through is permitted on days with two practices Days 8-14: Weekly practice time shall not exceed 24 hours For Cross Country: Individuals must complete at least 10 practice sessions on 10 separate days
prior to participating in first contest While heat stroke is not limited to certain sports, it is important to keep in mind that the majority of deaths in athletics resulting from heat stroke do occur during football practices and cross country events. Athletic directors, coaches, and medical staff should remain particularly vigilant during high risk participation times with these sports and ensure athletes are properly acclimatized and hydration and cooling options are readily available. Onsite Cooling
Cold water immersion (CWI) is the gold standard of care for treating exertional heat illness and heat stroke. It is important that coaches and athletic trainers ensure that teams practicing outdoors during times of heat and/or humidity have access to appropriate and effective cooling methods. This includes during any summer workouts or during training where an athletic trainer may not be present. A tub or tarp, water, and ice need to be accessible to all venues, preferably as close to the site of participation as possible. Coaches and athletic trainers should work together to assess minimum needs for ice and water. They should have the resources readily available to set up CWI tub within minutes of collapse. This may require having the tub fully or partially set up before practice. While CWI is the gold standard, other supplemental methods may be utilized along with CWI; including applying ice packs to the neck, axillae, groin and rotating ice-water soaked towels to all other areas of the body, although these methods cool at a slower rate than CWI. In the absence of onsite medical staff, the supervising coaches and staff must remain aware of the potential for heat illness and be prepared to initiate proper cooling of an athlete if the need should occur. These methods should be rehearsed annually as part of the Emergency Action Plan. At a minimum, the CWI supplies should be set up or readily available anytime that activity modifications are being made due to the heat (WBGT >87.0) and during any times of unseasonably warm weather.
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Monitoring the Weather Wet Bulb Globe Temperature
A wet bulb globe temperature (WBGT) instrument is a device that measures ambient temperature, wind, solar radiation from the sun and relative humidity to provide a value that can help monitor warm environmental conditions. WBGT guidelines are region specific. WBGT is the gold standard for determining if activity modifications are needed during athletic activity. It is important to note that WBGT is different from heat index. Heat index is a measure of how hot it feels when you factor relative humidity in with temperature. Heat index is how hot it feels to a normally dressed person not engaging in strenuous activity. Heat index may be easily acquired; however, heat index is not the most accurate gauge of heat illness risk. The WBGT provides a more accurate assessment of risk for heat illness during outdoor activities. The WBGT should be determined for the site by the most accurate method available. If a WBGT value is available for the site from a service such as WeatherSTEM or from a scientifically approved portable WBGT device then that measurement should be utilized. If a handheld device is utilized for obtaining measurements a protocol for sharing readings with all coaches should be established in advance. If a WBGT metric is not available or attainable, then the WBGT can be estimated from the temperature and relative humidity using the following chart. It is recommended to obtain the most site-specific temperature and humidity readings possible versus simply using regional data if available.
Note: This table is compiled from an approximate formula which only depends on temperature and humidity. The formula is valid for full sunshine and a light wind. Table adapted from Bureau of Meteorology.
Practice Activity Modifications Based on Wet Bulb Globe Temperature
A WBGT reading should be taken 30 minutes prior to any scheduled outdoor practice start time and then should be continually monitored at least every hour until the conclusion of practice (to monitor for any indicated modifications to practice length, rest breaks, or equipment). The appropriate frequency of readings during a practice can vary depending on the practice time, especially if the temperature is rising during the session. In cooler times and months having a WBGT reading may not be necessary to confirm the conditions are lower risk, however these guidelines are always in place even during cooler times, and any time there is uncertainty or an unseasonably warm day a measurement should be taken to ensure safety. Based upon the reading, the following chart should be utilized to make appropriate recommendations for activity and break modifications. It is recommended that when the WBGT is being actively monitored during a session that it is documented along with record of any modifications made due to the WBGT.
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If the WBGT decreases during a practice, the session can transition to the lower flag conditions and continue within those modifications, however, discretion should be used when deciding to continue a practice in higher risk situations, or when participants have already been practicing in higher risk conditions. The role of taking accurate WBGT readings and determining the appropriate modifications is a shared responsibility; the head coach, athletic director, and AT are all involved, and should collaborate effectively, to mitigate the risk of heat illness. Ultimately, if an AT is not on site, the responsibility of determining the appropriate activity and rest break guidelines lies with the supervising coach. A sample WBGT Measurement Record Sheet is included in the attached supplemental documents.
WBGT ACTIVITY AND REST BREAK GUIDELINES FOR PRACTICES
< 82.0 Good Conditions – Normal Activities
Provide at least one rest break each half hour of the session with a minimum duration of 5 minutes each. Monitor fluid intake.
82.0 – 86.9 Less Than Ideal Conditions – Use discretion for intense or prolonged exercise
Watch at-risk players carefully. Provide at least three separate rest breaks each hour with a minimum duration of 4 minutes each.
87.0 – 89.9
Moderate Risk for Heat Illness – Maximum practice time is 2 hours
For Football: Players are restricted to helmet, shoulder pads, and shorts during practice, and all protective equipment must be removed during conditioning activities. If the WBGT rises to this level during practice, players may continue to work out wearing football pants without changing to shorts.
For All Sports: Provide at least four separate rest breaks each hour with a minimum duration of 4 minutes each.
90.0 – 92.0
High Risk for Heat Illness – Maximum practice time is 1 hour
For Football: No protective equipment may be worn during practice, and there may be no conditioning activities.
For All Sports: There must be 20 minutes of rest breaks distributed throughout the hour of practice.
> 92.0 Extreme Conditions – No outdoor training
Cancel or delay practice until a cooler WBGT level is reached.
Source: This table is derived from recommendations from the NATA and the Korey Stringer Institute, using regionally-specific ranges as found in the Georgia High School Athletic Association Heat Policy for Practices and U.S. Soccer Heat Guidelines.
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 activities such as weight training, wind-sprints, timed runs for distance, etc., and may be a part of the practice time or included in voluntary workouts but should be included in time limits. Scrimmages are practices and fall under these safety guidelines. Rest breaks should not be combined with any other type of activity and there should be unlimited access to hydration. Rest breaks should occur out of direct sunlight. Football helmets should be removed during rest breaks.
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Game & Event Modifications Based on Wet Bulb Globe Temperature
Exertional heat stroke does not occur as frequently in competition, except for cross country or endurance competitions where athletes often push themselves harder than in practice bouts. Game situations usually afford participants more frequent rest and hydration breaks. Additionally, there are typically a smaller number of players on the field to actively monitor on a game field versus in practice situation; the ratio of participant to officials, coaches, medical personnel, and spectators is smaller. It is possible however that for games played earlier in a day, at an atypical time, or when athletes are in situations with other increased extrinsic or intrinsic risk factors that exertional heat illness or stroke can occur during contests. It is encouraged, in advance of a game or event, for school/event officials, head coaches, and sports medicine staff to utilize a WBGT reading to collectively determine whether conditions include extreme or severe heat and therefore merit event modifications for safety. Ultimately the final decision regarding the modification, postponement, or cancellation of a contest will lie with the game officials or event director. The following chart provides suggestions for modifications of competitions; however, it should be noted that currently there are not evidence-based modification guidelines for games.
ACTIVITY & REST BREAK SUGGESTIONS FOR COMPETITION
WBGT < 87.0 87.0-89.9 90.0-92.0 >92.0
Football & Boys Lacrosse
All contests can be conducted. Be cautious of those not acclimatized to the conditions. Add extra water breaks, when necessary.
1. The transition times following the 1st and 3rd quarters should be extended 2 minutes. 2. Water should be allowed on the field and helmets to be removed for all play stoppage (i.e., injuries, measurements, etc.). 3. Additional breaks are to be left to the discretion of the game officials, coaches, and medical staff collectively. Ice towels can be available.
1. A 5-10 minute break after the first possession change and at the halfway point of each quarter shall be utilized. 2. Timeouts and the transition times following the 1st and 3rd quarters should be extended. 3. Water should be allowed on the field and helmets to be removed for all play stoppage (i.e., injuries, measurements, etc.). Ice towels can be available.
All outside contests recommended to be postponed until conditions improve or be rescheduled.
Soccer & Girls Lacrosse
Addition of water breaks will be left to discretion of the game officials and medical staff, collectively prior to the start of the game.
A 5-10 minute water break will be between the 20-25 minute mark of each half, when there is a stoppage of play and at the discretion of the head referee. Ice towels can be available.
Non-Climate Controlled Facilities
An extended break between all games will be allowed in gym. This decision is at the discretion of the game officials and medical staff collectively.
A 5-10 minute break between all games will be allowed in a gym.
Cross Country
Water and sports drinks will be provided at the start/finish lines of the event, at least 1 hour prior to the start to the event. Cooling tubs will be available.
Water and sports drinks will be provided at the start/finish lines of the event, at least 1 hour prior to the start to the event. Cooling tubs will be available. Shaded tents and/or ability to cool in an air-conditioned facility is recommended.
Golf Golfers will be reminded to bring their own water on the course.
If water is depleted, golfers have the ability to refill water when necessary.
Tennis Addition of water breaks will be left to discretion of the game officials and medical staff collectively prior to the start of contest.
Water breaks will be extended to a minimum of 3 minutes between each set. Ice towels will be available.
Baseball & Softball
Addition of water breaks will be left to discretion of the umpires and medical staff, collectively prior to the start of the game.
Water and if available, sports drinks in each dugout. Ice towels can be available.
Outdoor Track & Field
Water and sports drinks will be provided at the event, at least 1 hour prior to the start to the event. Cooling tubs will be available.
Water and sports drinks will be provided at the event, at least 1 hour prior to the start to the event. Cooling tubs will be available. Athletic trainers should also remind track and field athletes to hydrate properly within 48 hours of anticipated event.
Any sports or activities not specifically mentioned in the contest guidelines should follow similar precautions listed under each range.
Note: Modification recommendations are not derived from evidence-based research. Source: Korey Stringer Institute
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Recognition & Treatment Exertional heat illnesses are not on a continuum and one condition does not lead to the next condition, however they are listed below in order of increasing severity and risk. Exercise-Associated Muscle Cramps
Exercise-associated muscle cramps (EAMC) may occur during or after prolonged exercise. They are defined as painful, intense, involuntary muscle contractions. Extensive sweating is common. Contributing factors may include fatigue, electrolyte imbalance, dehydration, or altered neuromuscular control. EAMC do not typically exceed 5 minutes in duration. It is important to note, that subtle muscle twitching may precede EAMC, but is not usually present in cases of rhabdomyolysis. It is recommended for athletes who repeatedly suffer from EAMC be evaluated by an appropriate physician for possible underlying conditions. EAMC can be resolved by stretching and massaging the affected area. The athlete should also be provided with water or electrolyte mixture to replace fluid lost. Heat Syncope
Heat syncope is an episode of dizziness and fainting after standing or exercising in a warm environment. Signs and symptoms include:
Tunnel vision Pale or sweaty skin Decreased pulse rate
Episodes of heat syncope are most common during the first five days of the acclimatization period. The athlete should be moved to an air conditioned or shaded area. The AT should instruct the athlete to lay supine and elevate their legs. In addition, rehydrate the athlete and cool the skin using cold towels or ice bags. Monitor the athlete’s vital signs. Exertional Heat Exhaustion
Exertional heat exhaustion can be recognized as an inability to continue exercise due to cardiovascular insufficiency and energy depletion. The following signs and symptoms may be present during heat exhaustion:
Fatigue Dizziness Headache Vomiting Nausea Fainting Low blood pressure Weakness Heavy sweating Increased core temperature (< 105⁰F)
Impaired muscle coordination
The AT should also monitor and note any central nervous system changes that occur and maintain suspicion for exertional heat stroke even at a temperature below 105⁰F.
The athlete should be moved to an air conditioned or shaded area. Any excess clothing or equipment should be removed. The AT should instruct the athlete to lay supine and elevate their legs. In addition,
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rehydrate the athlete and cool the skin using cold towels or ice bags. Monitor the athlete’s vital signs. If the athlete’s condition has not improved within 30 minutes, or if at any point the athlete’s condition declines, the EAP should be activated.
Exertional Heat Stroke
The two main criteria for recognizing and determining exertional heat stroke (EHS): central nervous system dysfunction and elevated core body temperature (>105⁰F). Signs and symptoms of EHS include:
Irrational behavior, irritability, emotional instability Altered consciousness, coma Disorientation or dizziness Headache Confusion or just look “out of it” Nausea or vomiting Diarrhea Muscle cramps, loss of muscle function/balance, inability to walk Collapse, staggering or sluggish feeling Profuse sweating Decreasing performance or weakness Dehydration, dry mouth, thirst Rapid pulse, low blood pressure, quick breathing
If exertional heat stroke is suspected, the EAP should be activated. The AT should obtain a core rectal temperature and initiate immediate cooling via CWI.
Core Rectal Temperature & Cooling
Rectal temperature is the gold standard method of obtaining a core body temperature and the only method of obtaining an immediate, accurate measurement of core body temperature in an exercising individual (ingested thermistors are accurate but are not commonly used especially in the high school setting and their use must be planned in advance of activity). Other thermometry devices, such as oral, axillary, aural, and temporal thermometers, are inaccurate methods of assessing body temperature in an exercising individual. Immediate recognition and treatment are vital in managing EHS and ruling out differential diagnoses. If rectal temperature is not available, the AT should rely on other diagnostic characteristics and treat the athlete for EHS. It is critical to ensure to always treat the most emergent condition! If needed the AT will utilize the rectal thermistor to obtain the core body temperature and will do so as discretely as possible. The rectal thermistor’s flexible probe remains in place while the individual is submerged and cooled via CWI to continually monitor the core temperature. The athlete’s trunk and limbs should be submerged in a tub of cold water. Support the athlete in the tub by looping a towel under his/her arms. The water temperature should be below 60⁰F. Excess clothing and equipment should be removed. The cold water immersion tub should be stirred constantly. The AT should continue to monitor vital signs and core temperature. If core rectal temperature monitoring is not possible, the AT may assume the cooling rate is approximately 1⁰F every three minutes. This will help provide an approximated appropriate cooling duration. To prevent critical cell damage the core body temperature needs to be lowered below 105⁰F within 30
minutes of collapse. The athlete must be cooled via CWI before being transported to a hospital – COOL FIRST, TRANSPORT SECOND! The athlete should be cooled to a core temperature below 101.5°F before being removed from the CWI tub. If the athlete is removed before sufficient cooling the core body temperature can increase and return to critical levels again.
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Return to Play Exercise-Associated Muscle Cramps
The AT should monitor the athlete until the symptoms subside. The athlete can return to play at the discretion of the athletic trainer. Heat Syncope and Heat Exhaustion
There should be no same day return to play after an episode of exertional heat illness. The AT should contact the athlete’s parent and make them aware of the situation. The AT should educate the parent/guardian on signs/symptoms that indicate additional medical care is needed. Exertional Heat Stroke
If treated appropriately, athletes suffering from EHS may return home from the hospital the same day. The American College of Sports Medicine makes five recommendations for the return to training and competition:
1. Refrain from exercise for at least 7 days following release from medical care. 2. Follow up in about 1 week for physical exam and repeat lab testing or diagnostic imaging of
affected organs that may be indicated, based on the physician's evaluation. 3. When cleared for activity, begin exercise in a cool environment and gradually increase the
duration, intensity, and heat exposure for 2 weeks to acclimatize and demonstrate heat tolerance. 4. If return to activity is difficult, consider a laboratory exercise-heat tolerance test about one month
post incident. 5. Clear the athlete for full competition if heat tolerance exists after 2-4 weeks of training.
A discharge note from the emergency department will not be accepted as return to play note. The athlete should follow up with their primary care physician or team physician and the AT. This is to ensure that all lab work has returned to normal levels and that the athlete is gradually returned to play in a safe and effective manner. Final clearance for return to full competition should be physician-directed.
Documentation
The AT should ensure that any suspected or confirmed exertional heat illness incident is documented appropriately including signs, symptoms, treatment, and home/follow up instructions. A Heat Illness Home Instruction Sheet is included in the attached supplemental documents. The head coach or athletic director should ensure that any necessary injury or incident reports required by the school or county are filed as well.
Conclusion Exertional heat illness typically occurs to individuals who are physically active in warm environments but can also occur in cooler environments. Exertional heat stroke is an emergent situation, however, it is survivable. Athletic trainers and school administrators should work to effectively identify student-athletes at greater risk for heat illness, prepare for and rehearse cooling interventions via CWI, evaluate for WBGT and modify activities as indicated, ensure acclimatization periods occur, properly recognize heat illness when it occurs, and ensure that anyone suffering from heat stroke is properly treated and cooled utilizing the principle of “Cool First, Transport Second” to prevent exertional heat illnesses and to ensure the best outcome if the situation does arise.
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Supplemental Documents List Urine Hydration Chart
Algorithm for Treatment of Exertional Heat Illness Collapse
Heat Related Illness Evaluation Form
Home Instructions for Heat Related Illness
Differential Diagnosis of a Collapsed Athlete with Heat Illness Chart
Guidelines to Treating Heat Related Illness Chart
WBGT Measurement Record Sheet
Cold Water Immersion & Treatment Guidelines
Reference Documents 1. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of
Athletic Training. 2015;50(9):986-1000.
2. Heat Illnesses & Prevention. Korey Stringer Institute website: http://ksi.uconn.edu/emergency-conditions/heat-illnesses/
3. National Athletic Trainers’ Association Consensus Statement: Preseason Heat-Acclimatization Guidelines for Secondary School Athletics. Journal of Athletic Training. 2009;44(3):332-333.
4. Consensus Statement- Prehospital Care of Exertional Heat Stroke, Prehospital Emergency Care, doi: 10.1080/10903127.2017.1392666.
5. National Athletic Trainers’ Association Position Statement: Fluid Replacement for Athletes. Journal of Athletic Training. 2000;35(2):212-224.
6. Identification and Treatment of Exertional Heat Stroke in the Prehospital Setting. Journal of Emergency Medical Services. 2017;42(5).
7. National Federation of State High School Associations’ Position Statement: Heat Acclimatization and Heat Illness Prevention. Available online at www.nfhs.org/resources/sports-medicine/
8. Gatorade Sports Science Institute Heat Illness & Hydration Documents. Available online at www.gssiweb.org
9. Florida High School Athletic Association Handbook; Policy 41; 2017-2018. Available online at www.fhsaa.org
10. Georgia High School Athletic Association Handbook; Heat Policy Information; 39. Available online at www.ghsa.net/sports-medicine
11. U.S. Soccer Heat Guidelines. Available online at http://www.ussoccerda.com/sports-medicine
Special thanks to Douglas J. Casa, PhD, ATC, FNATA, FACSM, FNAK and Samantha E. Scarneo, PhD, ATC from
the Korey Stringer Institute for their personal communications during the preparation of these guidelines.
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Andrews Institute Heat Safety Guidelines Information
Developed 2018 Planned Effective Date August 2018 Andrews Institute for Orthopaedics & Sports Medicine
James Andrews, MD David Joyner, MD Michael Milligan, MD Julie Kellen, MSPT
Jeremy Lowery, ATC Kathleen McGraw, MS, ATC Jessica Langston, MS, ATC Matt McGraw, MS, ATC
Contact Information Andrews Institute Sports Medicine Outreach 1040 Gulf Breeze Pkwy, Suite 101 Gulf Breeze, FL 32561 850.916.8700 AndrewsInstitute.com
Jeremy Lowery, ATC Director, Sports Medicine Outreach 850.916.8615 [email protected] Michael Milligan, MD Medical Director, Sports Medicine Outreach
Algorithm for Treatment of Exertional Heat Illness Collapse
Patient collapses during or after physical
activity in warm weather
Non Responsive: Assess Airway, Breathing,
Circulation & Provide appropriate emergency care
including calling 9-1-1
If ABC intact but unresponsive
If Responsive: Assess CNS function
Abnormal: Assess vital signs,
including core rectal temperature
Begin CWI if temperature is above 105°F; consider if temp below but still
suspicious of heat illness
Cease cooling & transport
when temperature is below 101.5°F
Normal: Provide care and
reassess in 5 minutes; maintain possibility of
lucid interval
Andrews Institute Sports Medicine Outreach Home Instructions for Heat Related Illness
Athlete Name: ____________________________________________________________ Date of Injury: _______________________
The individual named above has been evaluated and is suspected to have sustained a heat related illness. They were removed from practice or competition because they exhibited one or more of the following symptoms:
Blurred vision Nausea Muscle cramps Pale sweaty skin Fainting Lightheadedness Decreased pulse Heavy Sweating Vomiting
The individual’s symptoms should be monitored over the next few hours and days. If any of the following problems develop contact the nearest emergency facility or call 911. If in doubt get checked out!
Body or core temp > 105° F Inability to sweat Irregular breathing Altered consciousness Fainting or seizures Irregular pulse Decreased urine output Persistent muscle cramps Abnormal behaviors Diarrhea Vomiting Intestinal cramping
Otherwise, you can follow the instructions outlined below:
The individual should: - Rest in a cool environment - Rehydrate with water and/or sports drink and eat a good meal - Follow up with athletic trainer or appropriate medical professional prior to return to
participation as directed The individual should NOT
- Participate in any recreational or organized physical activity (including exercise, weight lifting, physical education, and work/occupational activities)
Evaluated by: _________________________________________________________ Date: ______________________________________ Cell Phone: ____________________________________________________________ Please feel free to contact me if you have any questions or concerns.
Andrews Institute Sports Medicine Outreach Heat Related Illness Evaluation Form
Patient Name: ____________________________________________ Gender: ___________ DOB: ___________________ Injury Date: ________________ Injury Time: ____________ Sport: _____________ School: ________________ Guardian Name: __________________________________________ Relation: __________ Phone: _________________ Incident occurred during: Practice Game Other: ________________________________________ Current Weather Conditions: Temperature: _________ WBGT: _____________ Heat Index: ___________ Initial treatment provided by: Athletic Trainer Physician EMT Coach Parent Other:
_______________________________________________________________________________________________________________ Vitals: Initial Onset: Pulse Rate_________ BP________/________ Temperature____________ 5 min. Post Onset: Pulse Rate_________ BP________/________ Temperature____________ 10 min. Post Onset: Pulse Rate_________ BP________/________ Temperature____________
15 min. Post Onset: Pulse Rate_________ BP________/________ Temperature____________ 30 min. Post Onset: Pulse Rate_________ BP________/________ Temperature____________ Initial Symptoms: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Activities Prior to Onset: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ On Site Treatment Provided: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ Plan: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________ _______________________________________________________________________________________________________________ AT Signature: ________________________________________ Date: ________________ ⎕ Home Instructions Provided ⎕ Guardian Contacted
Differential Diagnosis of a Collapsed Athlete with Heat Illness
Sign/Symptom Exercise-Associated
Muscle Cramps Heat
Syncope Heat
Exhaustion Heat
Stroke Exertional
Sickling
Extensive sweating
Fatigue
Dehydration
Muscle cramping
Tunnel vision
Pale, sweaty skin
Decreased pulse rate
Dizziness
Fainting
Headache
Vomiting
Nausea
Low blood pressure
Increased Core Temperature (<105° F)
Irrational Behavior
Loss of muscle function
Rapid pulse
Quick breathing
Loss of consciousness
Central Nervous System Changes
Increased Core Temperature (>105°F)
Peripheral swelling
Guide to Heat Illness Treatment
Exercise-Associated
Muscle Cramps
• Remove athlete from practice/competition
• Stretch and massage the affected area
• Provide water or electrolyte mixture
• Return to play at discretion of AT
Heat Syncope
• Remove athlete from practice/competition to a shaded or air conditioned area
• Athlete should lay on their back and elevate their legs
• Provide water or electrolyte mixture
• Cool skin using cold towels or ice bags
• Monitor vital signs
• Return to play at discretion of AT (no same day RTP)
Heat Exhaustion
• Remove athlete from practice/competition to a shaded or air conditioned area
• Remove any excesss clothing or equipment
• Athlete should lay supine and elevate their legs
• Provide water or electrolyte mixture
• Cool skin using cold towels or ice bags
• Monitor vital signs. If there is no improvement within 30 minutes or if condition declines, activate EAP
• Return to play at discretion of AT (no same day RTP)
Heat Stroke
• Activate EAP - COOL FIRST, TRANSPORT SECOND!
• Obtain rectal temperature
• If core rectal temp is >105° F, cool via cold water immersion
• Excess clothing and equipment should be removed
• Stir CWI tub constantly
• DO NOT remove athlete until temperature is below 101.5° F
• Return to play at discretion of treating physican and AT (no same day RTP)
WBGT Measurement Record Sheet
School/Site: _____________________________________
DATE TIME TEMP HUMIDITY WBGT WEATHER NOTES ACTIVITY
MODIFICATION
WBGT ACTIVITY AND REST BREAK GUIDELINES FOR PRACTICES
< 82.0 Good Conditions – Normal Activities
Provide at least one rest break each half hour of the session with a minimum duration of 5 minutes each. Monitor fluid intake.
82.0 – 86.9 Less Than Ideal Conditions – Use discretion for intense or prolonged exercise
Watch at-risk players carefully. Provide at least three separate rest breaks each hour with a minimum duration of 4 minutes each.
87.0 – 89.9
Moderate Risk for Heat Illness – Maximum practice time is 2 hours
For Football: Players are restricted to helmet, shoulder pads, and shorts during practice, and all protective equipment must be removed during conditioning activities. If the WBGT rises to this level during practice, players may continue to work out wearing football pants without changing to shorts.
For All Sports: Provide at least four separate rest breaks each hour with a minimum duration of 4 minutes each.
90.0 – 92.0
High Risk for Heat Illness – Maximum practice time is 1 hour
For Football: No protective equipment may be worn during practice, and there may be no conditioning activities.
For All Sports: There must be 20 minutes of rest breaks distributed throughout the hour of practice.
> 92.0 Extreme Conditions – No outdoor training
Cancel or delay practice until a cooler WBGT level is reached.
AT/Coach Signature: _____________________________________________ Date: ____________________________
Cold Water Immersion & Treatment Guidelines
Post Treatment
Dispose of or sterilize the thermistor probe as appropriate. Clean cold water immersion tub. Document incident appropriately.
Ensure athlete has appropriate clearance prior to return to participation.
Cooling Duration & Patient Transfer
Continue cooling until patient's temperature is below 101.5°F. If rectal temperature cannot be measured,
cool for approximately 10-15 minutes.
Remove patient only after core rectal temperature reaches 101.5°F and transfer to nearest medical facility.
Activate EMS & Monitor Athlete
Continue to monitor vital signs. Leave the thermistor probe in for duration of treatment.
Begin Cold Water Immersion
Submerge as much of the body as possible. Keep the head above water by draping a towel under patient's arms.
Place an ice towel over head/neck.
Vigorously circulate water to optimize cooling. Be prepared to manage patient if combative.
If EHS is Suspected, Evaluate Core Temperature
Drape the patient appropriately and postion patient on their side with their top knee and hip flexed forward.
Lubricate the rectal thermistor probe and insert 10 cm past the anal sphincter. If resistance is met, stop, remove the probe, and reinsert.
Initial Response to Possible Exertional Heat Illness
Check airway, breathing, pulse, and blood pressure. Assess CNS function. Activate EAP if indicated.
If possible, remove athlete from playing field and to shaded area.
Prepare for Cold Water Immersion
Fill CWI tub before event/activity or have tub half filled, with coolers of ice readily available.
Ice should cover the surface of the water at all times. Water temperature should be under 60⁰F.