NATA Publishes New Exertional Heat Illnesses Position Statement

Monday, September 21, 2015

DALLAS, September 21, 2015 –The National Athletic Trainers’ Association published today its new position statement on exertional heat illnesses, an update to the original 2002 document. Created by the NATA Research & Education Foundation, the statement appears in the September issue of the Journal of Athletic Training, NATA’s scientific publication.
“We have greatly advanced the level of care we now provide to athletes who may experience exertional heat illnesses,” said position statement lead author Douglas J. Casa, PhD, ATC, FNATA, chief operating officer of the Korey Stringer Institute, director of Athletic Training Education, Department of Kinesiology at the University of Connecticut. “This is a condition that is 100 percent survivable if it is quickly and appropriately recognized and treated at the time of collapse.”
Essential steps include acclimatizing to the heat, body cooling and hydrating whether through physical activity in warm weather conditions or intense activity in cooler environments.  These recommendations are not just for athletes but for anyone exposed to warm weather such as those in the military or law enforcement or individuals whose work requires heat exposure, according to the statement authors.
Exertional heat stroke is one of the three leading causes of death in sport. The period of 2005 to 2009 had more heat stroke deaths than any other five year period in the 35 years prior. There were 18 deaths from 2005 to 2009; from 2010 to 2014 there were an estimated 20 deaths.

If individuals are particularly susceptible to heat illnesses, they should be closely monitored during stressful environmental situations and preventative steps should be taken, Casa advises.

Exertional Heat Illnesses Position Statement Highlights

Prevention of Exertional Heat Illnesses:

  • A pre-season heat acclimatization policy should be implemented to allow athletes to be acclimatized to the heat gradually over a period of 7 to 14 days. This is optimal for full heat acclimatization. The first two to three weeks of preseason present the greatest risk of exertional heat illnesses, particularly in equipment-intensive sports. All preventive measures should be taken to address this high risk period.
  • Plan rest breaks and modify the work-to-rest ratio to match environmental conditions and the intensity of the activity.

Recognition of Exertional Heat Illnesses:

  • The two main diagnostic criteria for exertional heat stroke are profound central nervous system (CNS) dysfunction and a core body temperature above 105°F. 
  • Rectal temperature is the only method of obtaining an immediate and accurate measurement of core body temperature in an exercising individual.

Treatment of Exertional Heat Illnesses:

  • The goal for any exertional heat stroke vi ctim is to lower core body temperature to less than 102.5°F within 30 minutes of collapse.
  • Cold water immersion is the most effecti ve way to treat a patient with exertional heat stroke. The water should be 35-59°F and continuously stirred to maximize cooling.

Updated findings from 2002:
Specific recommendations for pre-season heat acclimatization protocol:

  • Days 1-2: Single three hour practice OR single two hour practice and single one hour field session; only helmets may be worn
  • Days 3-4: Single three hour practice OR single two hour practice and single one hour field session; only helmets and shoulder pads may be worn
  • Day 5: Single three hour practice OR single two hour practice and single one hour field session; full equipment may be worn
  • Days 1-5: Equipment guidelines for preseason participation only impact days 1-5 of the acclimatization period 

Recommendation of assessing rectal temperature if exertional heat stroke is suspected:
Best practices strongly advise the use of rectal temperature for the assessment of body temperature in a suspected exertional heat stroke patient. It is discouraged to use inaccurate devices such as oral, tympanic, etc.

Specific protocol for the treatment of exertional heat stroke:
The new guidelines suggest a specific step-by-step protocol for cold water immersion for the clinician to implement with an exertional heat stroke patient. This protocol is backed by research exhibiting a 100 percent survival rate when initiated quickly and properly. 

Identification of approximate cooling rates for an exertional heat stroke patient:
While cooling rates may vary, the cooling rate for cold water immersion will be approximately 0.37°F/min. or about 1°F every three minutes when considering the entire immersion period for an exertional heat stroke patient. This provides an approximate treatment time for clinicians if rectal temperature monitoring is not possible during treatment.
Recommendation of “cool first, transport second”:
The current document now states that a patient suspected of having exertional heat stroke must be cooled via cold water immersion for the full treatment time prior to being transported to a hospital; and that this must be stated in the school’s emergency action plan.
A substantial revision of tables and figures have been amended to provide more clinically applicable information.
Removal of hyponatremia as an exertional heat illness:
Hyponatremia was removed from the current guidelines as this condition is not considered to be a true heat-related illness. This will now be focused on in a new fluid replacement position statement, currently in development.
“It is vital that physicians, athletic trainers and other health care professionals put these recommendations into practice as they establish on-site emergency action plans to help to ensure athlete safety,” says Casa. “Having the right programs in place is vital to the prevention and treatment of exertional heat illnesses and to ultimately stave off acute, chronic or catastrophic outcomes. In short, these recommendations can save a life.”
About NATA: National Athletic Trainers’ Association (NATA) – Health Care for Life & Sport
Athletic trainers are health care professionals who specialize in the prevention, diagnosis, treatment and rehabilitation of injuries and sport-related illnesses. They prevent and treat chronic musculoskeletal injuries from sports, physical and occupational activity, and provide immediate care for acute injuries. Athletic trainers offer a continuum of care that is unparalleled in health care. The National Athletic Trainers' Association represents and supports 39,000 members of the athletic training profession.