Exertional Heat Illness and Acclimatization Policy & Procedures
Exertional Heat Illness and Acclimatization Policy & Procedures
1.Purpose of Protocol:
Exertional heat illness includes exercise-associated muscle cramps, heat syncope, heat exhaustion, and exertional heat stroke (EHS). Current best practice guidelines suggest that the risk of exertional heat injuries can be minimized with heat acclimatization and diligent attention to monitoring individuals participating in activities that place them at a higher risk for these types of injuries.1 In the event an athlete sustains a heat illness, immediate and proper treatment is needed.
National governing bodies, such as the National Collegiate Athletic Association (NCAA) and numerous state athletic/activity associations, have published guidelines for the prevention, monitoring and treatment of exertional heat illnesses. In addition, national authorities such as the National Athletic Trainers’ Association and the Korey Stringer Institute have published research to support best practices in this area. The development of the organization’s heat acclimatization guidelines will be based on the current best practice documents.
1 Casa DJ, Demartini JK, Bergeron MF, et al. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. 2015;50(9):986-1000.
2.Protocol Statement:
This policy describes the best practice procedures for the prevention, monitoring, and when necessary, the treatment of exertional heat illnesses for students/athletes and staff of the University of North Florida.
This policy will be a living, working document, that is continually reviewed and updated yearly as the organization and our community changes.
3.Definitions:
Acclimatization – The process of gradually increasing the intensity of activity in a progressive manner that improves the body’s ability to adapt to and tolerate exercise in the heat.
Wet Bulb Globe Temperature – The WBGT is a measurement tool that uses ambient temperature, relative humidity, wind, and solar radiation from the sun to get a comprehensive measure that can be used to monitor environmental conditions during exercise. WBGT is different than heat index, as it is a more comprehensive measurement of environmental heat stress on the body.
Non-Practice Activities – Activities that include meetings, injury treatment, and film study.
Practice – the period of time that a student athlete engages in coach-supervised, university approved sport or conditioning related-activity. Practice time includes from the time the players report to the field until they leave.
Walk Through – A period of time where players are reviewing positional strategy and rehearsing plays. Players do not experience contact and thus they do not wear equipment and the intensity of the activity is minimal often involving walking. This period of time shall last no more than one hour. It is not considered part of the practice time regulation. It may not involve conditioning or weight room activities. Players may not wear protective equipment during the walk through.
Recovery Time – This period of time is defined as non-activity time outside of practices or games. NO ACTIVITY, including non-practice activity, can occur during this time. Proper recovery should occur in an air-conditioned facility, when possible and usually is a minimum of 3 hours in duration.
Rest Breaks – This period of time occurs during practice and is a non-activity time that is in a ‘cool zone’ out of direct sunlight.
Exertional Heat Stroke (EHS) – Defined as having a rectal temperature over 104°F-105°F (40.5°C), and central nervous system dysfunction (e.g. irrational behavior, confusion, irritability, emotional instability, altered consciousness, collapse, coma, dizzy, etc.).
Cooling Zone - An area out of direct sunlight with adequate air flow to assist in cooling. A cold-water or ice tub and ice towels should be available to immerse or soak a patient with suspected heat illness This may be outdoors or indoors depending on proximity to field.
Qualified Health Care Professional (QHP) - As defined by the American Medical Association (AMA), “is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”
Hypohydration - (reduced hydration status) is a deficit of body water that is caused by acute or chronic dehydration.
Central Nervous System Dysfunction - includes any sign or symptom that the central nervous system is not working properly, including: dizziness, drowsiness, irrational behavior, confusion, irritability, emotional instability, hysteria, apathy, aggressiveness, delirium, disorientation, staggering, seizures, loss of consciousness, coma, etc.
4.Scope:
This protocol applies to all staff members (e.g., athletic trainers, physicians, athletic administrators, coaches and strength and conditioning staff) of University of North Florida Athletics who are associated with activities where heat illness poses a risk, including but not limited to, outdoor and indoor activities where high temperature and specifically high humidity environmental risks are present.
5.Procedures:
Prevention
Pre-participation history and physical exam
1. A thorough medical history will be gathered (history of heat illness, sickle cell trait/disease, etc.)
3. When applicable the Athletic Trainer or persons responsible will be notified of individuals with pre-existing conditions that place the individual at risk of exertional heat illness
4. As necessary, coaches are notified of individuals at higher risk
Environmental Monitoring and Activity Modification/Cancellation
1. Environmental monitoring will occur utilizing a WBGT device
2. Environmental monitoring will occur any time it is warm outside (i.e. over 70°F)
3. Environmental monitoring and activity modifications may be necessary for certain types of indoor facilities
4. Monitoring of WBGT will occur every 15 minutes beginning at the scheduled practice time
a. The Athletic Trainer/Coach or assigned personnel will monitor the WBGT
b. The Athletic Trainer will communicate with the coach so that the coach can make the modification/cancelation of activity
c. Each Athletic Trainer is responsible for determining the location of where WBGT is taken.
5. Modifications will be made in accordance with the best practice guidelines for our region. We are in Category 3 therefore we will follow the activity
guidelines for that region.
a. Based on the research document by Grundstein et al. Regional heat safety thresholds for athletes in the contiguous United States. Applied
Geography, 2015 manuscript (https://ksi.uconn.edu/wp-content/uploads/sites/1222/2018/08/RegionalWBGT_2015_AppliedGeography.pdf)
FLORIDA is CATEGORY 3
Florida is Cat 3
b. The table below shows the specific modifications that will be made for each flag zone (green, yellow, orange, red, black)
6. Modifications are meant to be fluid, meaning if the environment gets more oppressive, the modifications get stricter. However, if environmental
conditions improve, the modifications will be in line with the new environmental conditions.
Activity Guidelines
< 82.0 | Normal Activities – Provide at least three separate rest breaks each hour with a minimum duration of 3 min each during the workout.
82.2 - 86.9 | Use discretion for intense or prolonged exercise; Provide at least three separate rest breaks each hour with a minimum duration of 4 min each.
87.1 - 90.0 | Maximum practice time is 2 hours. Provide at least four separate rest breaks each hour with a minimum duration of 4 min each.
90.1 - 91.9 | Maximum practice time is 1 hour. There must be 20 min of rest breaks distributed throughout the hour of practice.
> 92.1 | No outdoor workouts. Delay practice until a cooler WBGT is reached.
Acclimatization Guidelines
1. During the first seven days of an athlete’s participation, it is required that participants not engage in more than one practice per day.
2. If a practice session is interrupted by inclement weather or heat restrictions, it is required the session be divided for the good of the student athlete’s welfare if the combined total practice time for that session does not exceed three (3) hours. The addition of a walk-through session in this situation is acceptable provided it is added because of a weather-related disruption and occurs inside an air-conditioned facility.
3. Competition is counted as three (3) hours. An official practice is not permitted on the same day of a competition.
4. A walk-through is permitted during Days 1 – 6 of the acclimatization period. However, a one-hour recovery period is required between the end of practice and the start of the walk-through or vice-versa.
5. Beginning Day 8, it is required that the practice schedule not exceed a 2-1-2-1 format. This means that a day consisting of two practices should be followed by a day with only one practice. On a day consisting of two practices, the two practices must be separated by at least three (3) hours of continuous rest. One walk-through session may be added to a day with a single practice session, with a minimum of three (3) hours of continuous rest time between the practice and walk-through. If a two-practice day were followed by a day off, a two-practice day would be permitted on the next day.
6. On days when two practices are conducted, it is required that either practice not exceed three (3) hours in length and student athletes not participate in more than five (5) total hours of practice activities on these days, Warm-up, stretching, and cooldown activities are included as part of the official practice time. Practices must be separated with at least three (3) continuous hours of recovery time between the end of the first practice and the beginning of the very next practice. A walk-though is not permitted on days that have two (2) official practices. Weekly practice time shall not exceed 20 hours
7. On days when a single practice is conducted, it is required that practices not exceed three (3) hours in length. A walkthrough is permitted after a minimum one (1) hour recovery period between the end of the first practice and the walk-through, or vice-versa.
8. It is recommended that any voluntary conditioning session is limited to three (3) hours maximum per session and these sessions should include the safeguards listed below.
Hydration
Assessing Hydration Status:
1. To ensure that athletes are hydrated prior to exercise a pre- and post-activity, measurement of bodyweight will be recorded whenever possible.
2. Athletic Trainers are highly encouraged to create a self-monitoring chart for daily weigh-ins.
4. Hypohydration is a predisposing factor for exertional sickling and those with sickle cell trait or disease will receive targeted education and hydration monitoring.
Fluid Replacement
5. Water breaks will be provided based on the policy on environmental-condition guidelines using work to rest ratios.
Treatment in the event of hypohydration (potential medical emergency if severe):
Monitoring
1. Monitoring of student athletes safety will be continuous during any physical activity.
2. Athletic trainers, coaches, administrators and other athletics personnel will be educated on the signs and symptoms of exertional heat illness (see
training/retraining in section 6).
Treatment in the event of an exertional heat stroke (medical emergency):
Recognition
1. Any athlete with signs of central nervous system dysfunction during exercise in the heat should be suspected to be suffering from EHS until a rectal temperature confirms or refutes this diagnosis.
2. Patients with suspected EHS will have a temperature obtained via rectal thermometer by a QHP.
4. Steps to obtain a rectal temperature:
Cooling
1. If rectal temperature is between 102°-104°F, initiate cooling via rotating cold wet towels.
2. If rectal temperature is at or above 104°F, initiate the exertional heat stroke treatment protocol and contact EMS services immediately.
3. The patient must be moved to a cooling zone, begin appropriate treatment and continuously monitor the patient.
Vital sign monitoring
1. The QHP will monitor vital signs including core body (rectal) temperature, heart rate, blood pressure and other vital signs.
2. Monitor vital signs every 5-7 minutes. Document results accordingly.
EMS
1. EMS must be called immediately if a patient is suspected of EHS.
2. HOWEVER, any patient with EHS must be cooled FIRST and then transported via EMS.
a. This cool first transport second EAP protocol will be communicated/shared with EMS.
Return to activity
Patients who have suffered an exertional heat illness must complete a rest period and obtain clearance from a physician before beginning a progression of physical activity under the supervision of a qualified medical professional. The following is the suggested protocol:
Training/Retraining
Athletic Trainers, team physicians and any other QHP must be trained to ensure a safe participation environment for all individuals, coaches, employees and staff mentioned in the Scope section of this document, who are engaged in activities that could put them at risk of exertional heat injuries.
Annual training includes, but is not limited to, the procedures and protocols outlined in this document, the prevention of heat illness’, identification of heat related illness’, and when to initiate treatment for those believed to be suffering from an exertional heat illness.
Qualified healthcare professional training(s):
Athletic administrators, coach, other non QHP professional(s) training(s):
(Education will be performed by the athletic trainer or other sports medicine healthcare professional)
This document is provided by the Korey Stringer Institute, an organization housed at the University of Connecticut, as a template to assist with preliminary drafting of the above policy. Using this document and any other information (text, graphics, images or other materials) from the Korey Stringer Institute is solely at your own risk. The policies described represent best practices as interpreted by the Korey Stringer Institute at the time of drafting this document. While the Korey Stringer Institute does its best to reflect current best practices, the most appropriate policies and procedures are subject to change at and may not be directly reflected in this document. Use of this document does not constitute endorsement by the Korey Stringer Institute. Modification of the policy or procedures in this document may not reflect best practices. All policy decisions should be reviewed by appropriate local administration prior to implementation. Any individual or organization utilizing this document should use discretion and consider the individual circumstances at their work setting.
This Template has been modified from the Board of Certification, Inc. (BOC) Guiding Principles for AT Policy and Procedure Development
1.Purpose of Protocol:
Exertional heat illness includes exercise-associated muscle cramps, heat syncope, heat exhaustion, and exertional heat stroke (EHS). Current best practice guidelines suggest that the risk of exertional heat injuries can be minimized with heat acclimatization and diligent attention to monitoring individuals participating in activities that place them at a higher risk for these types of injuries.1 In the event an athlete sustains a heat illness, immediate and proper treatment is needed.
National governing bodies, such as the National Collegiate Athletic Association (NCAA) and numerous state athletic/activity associations, have published guidelines for the prevention, monitoring and treatment of exertional heat illnesses. In addition, national authorities such as the National Athletic Trainers’ Association and the Korey Stringer Institute have published research to support best practices in this area. The development of the organization’s heat acclimatization guidelines will be based on the current best practice documents.
1 Casa DJ, Demartini JK, Bergeron MF, et al. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training. 2015;50(9):986-1000.
2.Protocol Statement:
This policy describes the best practice procedures for the prevention, monitoring, and when necessary, the treatment of exertional heat illnesses for students/athletes and staff of the University of North Florida.
This policy will be a living, working document, that is continually reviewed and updated yearly as the organization and our community changes.
3.Definitions:
Acclimatization – The process of gradually increasing the intensity of activity in a progressive manner that improves the body’s ability to adapt to and tolerate exercise in the heat.
Wet Bulb Globe Temperature – The WBGT is a measurement tool that uses ambient temperature, relative humidity, wind, and solar radiation from the sun to get a comprehensive measure that can be used to monitor environmental conditions during exercise. WBGT is different than heat index, as it is a more comprehensive measurement of environmental heat stress on the body.
Non-Practice Activities – Activities that include meetings, injury treatment, and film study.
Practice – the period of time that a student athlete engages in coach-supervised, university approved sport or conditioning related-activity. Practice time includes from the time the players report to the field until they leave.
Walk Through – A period of time where players are reviewing positional strategy and rehearsing plays. Players do not experience contact and thus they do not wear equipment and the intensity of the activity is minimal often involving walking. This period of time shall last no more than one hour. It is not considered part of the practice time regulation. It may not involve conditioning or weight room activities. Players may not wear protective equipment during the walk through.
Recovery Time – This period of time is defined as non-activity time outside of practices or games. NO ACTIVITY, including non-practice activity, can occur during this time. Proper recovery should occur in an air-conditioned facility, when possible and usually is a minimum of 3 hours in duration.
Rest Breaks – This period of time occurs during practice and is a non-activity time that is in a ‘cool zone’ out of direct sunlight.
Exertional Heat Stroke (EHS) – Defined as having a rectal temperature over 104°F-105°F (40.5°C), and central nervous system dysfunction (e.g. irrational behavior, confusion, irritability, emotional instability, altered consciousness, collapse, coma, dizzy, etc.).
Cooling Zone - An area out of direct sunlight with adequate air flow to assist in cooling. A cold-water or ice tub and ice towels should be available to immerse or soak a patient with suspected heat illness This may be outdoors or indoors depending on proximity to field.
Qualified Health Care Professional (QHP) - As defined by the American Medical Association (AMA), “is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”
Hypohydration - (reduced hydration status) is a deficit of body water that is caused by acute or chronic dehydration.
Central Nervous System Dysfunction - includes any sign or symptom that the central nervous system is not working properly, including: dizziness, drowsiness, irrational behavior, confusion, irritability, emotional instability, hysteria, apathy, aggressiveness, delirium, disorientation, staggering, seizures, loss of consciousness, coma, etc.
4.Scope:
This protocol applies to all staff members (e.g., athletic trainers, physicians, athletic administrators, coaches and strength and conditioning staff) of University of North Florida Athletics who are associated with activities where heat illness poses a risk, including but not limited to, outdoor and indoor activities where high temperature and specifically high humidity environmental risks are present.
5.Procedures:
Prevention
Pre-participation history and physical exam
1. A thorough medical history will be gathered (history of heat illness, sickle cell trait/disease, etc.)
- PPE are currently a requirement by UNF Athletics prior to any sport participation.
3. When applicable the Athletic Trainer or persons responsible will be notified of individuals with pre-existing conditions that place the individual at risk of exertional heat illness
4. As necessary, coaches are notified of individuals at higher risk
Environmental Monitoring and Activity Modification/Cancellation
1. Environmental monitoring will occur utilizing a WBGT device
2. Environmental monitoring will occur any time it is warm outside (i.e. over 70°F)
3. Environmental monitoring and activity modifications may be necessary for certain types of indoor facilities
4. Monitoring of WBGT will occur every 15 minutes beginning at the scheduled practice time
a. The Athletic Trainer/Coach or assigned personnel will monitor the WBGT
b. The Athletic Trainer will communicate with the coach so that the coach can make the modification/cancelation of activity
c. Each Athletic Trainer is responsible for determining the location of where WBGT is taken.
5. Modifications will be made in accordance with the best practice guidelines for our region. We are in Category 3 therefore we will follow the activity
guidelines for that region.
a. Based on the research document by Grundstein et al. Regional heat safety thresholds for athletes in the contiguous United States. Applied
Geography, 2015 manuscript (https://ksi.uconn.edu/wp-content/uploads/sites/1222/2018/08/RegionalWBGT_2015_AppliedGeography.pdf)
FLORIDA is CATEGORY 3
Florida is Cat 3
b. The table below shows the specific modifications that will be made for each flag zone (green, yellow, orange, red, black)
6. Modifications are meant to be fluid, meaning if the environment gets more oppressive, the modifications get stricter. However, if environmental
conditions improve, the modifications will be in line with the new environmental conditions.
Activity Guidelines
< 82.0 | Normal Activities – Provide at least three separate rest breaks each hour with a minimum duration of 3 min each during the workout.
82.2 - 86.9 | Use discretion for intense or prolonged exercise; Provide at least three separate rest breaks each hour with a minimum duration of 4 min each.
87.1 - 90.0 | Maximum practice time is 2 hours. Provide at least four separate rest breaks each hour with a minimum duration of 4 min each.
90.1 - 91.9 | Maximum practice time is 1 hour. There must be 20 min of rest breaks distributed throughout the hour of practice.
> 92.1 | No outdoor workouts. Delay practice until a cooler WBGT is reached.
Acclimatization Guidelines
- This acclimatization protocol applies to ALL sports.
- Because the risk of exertional heat illnesses during the preseason heat acclimatization period is high, a certified/licensed Athletic Trainer will be on site before, during, and after all practices.
- Transition periods hold particular risk but absent adherence to established standards, best practices and precautions, collegiate athletes are at risk at all points in the offseason regime
- A transitional period is defined as the first 7-10 days of any new conditioning cycle examples include but not limited to: Return in January, after spring break, return in summer and/or return after injury.
1. During the first seven days of an athlete’s participation, it is required that participants not engage in more than one practice per day.
2. If a practice session is interrupted by inclement weather or heat restrictions, it is required the session be divided for the good of the student athlete’s welfare if the combined total practice time for that session does not exceed three (3) hours. The addition of a walk-through session in this situation is acceptable provided it is added because of a weather-related disruption and occurs inside an air-conditioned facility.
3. Competition is counted as three (3) hours. An official practice is not permitted on the same day of a competition.
4. A walk-through is permitted during Days 1 – 6 of the acclimatization period. However, a one-hour recovery period is required between the end of practice and the start of the walk-through or vice-versa.
5. Beginning Day 8, it is required that the practice schedule not exceed a 2-1-2-1 format. This means that a day consisting of two practices should be followed by a day with only one practice. On a day consisting of two practices, the two practices must be separated by at least three (3) hours of continuous rest. One walk-through session may be added to a day with a single practice session, with a minimum of three (3) hours of continuous rest time between the practice and walk-through. If a two-practice day were followed by a day off, a two-practice day would be permitted on the next day.
6. On days when two practices are conducted, it is required that either practice not exceed three (3) hours in length and student athletes not participate in more than five (5) total hours of practice activities on these days, Warm-up, stretching, and cooldown activities are included as part of the official practice time. Practices must be separated with at least three (3) continuous hours of recovery time between the end of the first practice and the beginning of the very next practice. A walk-though is not permitted on days that have two (2) official practices. Weekly practice time shall not exceed 20 hours
7. On days when a single practice is conducted, it is required that practices not exceed three (3) hours in length. A walkthrough is permitted after a minimum one (1) hour recovery period between the end of the first practice and the walk-through, or vice-versa.
8. It is recommended that any voluntary conditioning session is limited to three (3) hours maximum per session and these sessions should include the safeguards listed below.
Hydration
Assessing Hydration Status:
1. To ensure that athletes are hydrated prior to exercise a pre- and post-activity, measurement of bodyweight will be recorded whenever possible.
2. Athletic Trainers are highly encouraged to create a self-monitoring chart for daily weigh-ins.
- Hydration before exercise will be maintained within + or - 1% of body mass compared to baseline values. A pre-activity hydration status of >3% body mass loss is associated with increased risk for heat illness therefore, if an individual is moderately dehydrated >3% body mass loss the individual should not be allowed to practice.
- Post exercise body mass should be <2% and athletes should not gain body mass >2%.
- Thirst
- Dark colored urine (similar to apple juice)
- Acute body weight loss >2%
4. Hypohydration is a predisposing factor for exertional sickling and those with sickle cell trait or disease will receive targeted education and hydration monitoring.
Fluid Replacement
5. Water breaks will be provided based on the policy on environmental-condition guidelines using work to rest ratios.
- Water or other palatable fluids will be easily accessible before, during and after activity. Cool and flavored beverages are often preferred by athletes and will be made available when possible for optimal rehydration.
- Environment, acclimatization state, body size, exercise duration, exercise intensity, and individual fluid preference and tolerance will be considered when calculating sweat rate.
- Sweat Rate Equation:
- Sweat loss (L) = Body mass before exercise (kg) – Body mass after exercise (kg) + (Volume of fluid consumed during exercise [L]) – (Urine volume, if any [L])
- Sweat rate (L/h) = Sweat loss (L) / Exercise duration (h)
Treatment in the event of hypohydration (potential medical emergency if severe):
- If moderate (2%-5%) or severe (greater than 5%) hypohydration is identified, oral fluids will be administered.
- If severe hypohydration is present with muscle cramping, vomiting or diarrhea, EMS will be activated
Monitoring
1. Monitoring of student athletes safety will be continuous during any physical activity.
2. Athletic trainers, coaches, administrators and other athletics personnel will be educated on the signs and symptoms of exertional heat illness (see
training/retraining in section 6).
- These signs and symptoms include (but are not limited to) the table below:
- Rectal temperature greater than 104 (40°C) at time of incident.
- Rapid pulse, low blood pressure, quick breathing
- Headache
- Dehydration, dry mouth, thirst
- Confusion or just look “out of it”
- Decreasing performance or weakness
- Disorientation or dizziness
- Profuse sweating
- Altered consciousness, coma
- Collapse, staggering or sluggish feeling
- Nausea or vomiting
- Muscle cramps, loss of muscle function/balance, inability to walk
- Diarrhea
- Irrational behavior, irritability, emotional instability
- b. Coaches and administrators will be educated annually
- See training/retraining in section 6
Treatment in the event of an exertional heat stroke (medical emergency):
Recognition
1. Any athlete with signs of central nervous system dysfunction during exercise in the heat should be suspected to be suffering from EHS until a rectal temperature confirms or refutes this diagnosis.
2. Patients with suspected EHS will have a temperature obtained via rectal thermometer by a QHP.
- Rectal thermometers may include a traditional thermometer (e.g. small, discrete), electronic thermometers with a rigid end (e.g. hand-held digital thermometer) or a thermistor (e.g. long, flexible thermistor)
- It is important to reiterate that during and following intense exercise in the heat, temporal, aural, oral, skin, axillary and tympanic temperature are not valid and should never be utilized in evaluating a potential exertional heat stroke
4. Steps to obtain a rectal temperature:
- Remove the athlete from the playing field, to a shaded area.
- Drape the patient accordingly (with towels and sheets) for privacy.
- Note: It is encouraged that the medical professional ask a coach or other adult to witness the temperature measurement.
- Position the patient on their side with their top knee and hip flexed forward.
- Make sure the thermometer is cleaned with isopropyl alcohol.
- Make sure the probe is plugged into the thermometer (when applicable).
- Turn the thermometer on.
- Insert the probe 10-15cm past the anal sphincter.
- If you meet resistance while inserting, stop and remove the probe and then try again.
- Replace the patients clothing.
- Temperature duration
- For use of a traditional thermometer or a hand-held digital thermometer, insert the probe for initial temperature. If temperature is at or above 104°F, initiate cooling protocol. See directions for continued monitoring in cooling protocol.
- For use of a flexible thermistor, leave the probe in for the duration of the treatment.
- After the treatment has ended, remove the probe gently.
Cooling
1. If rectal temperature is between 102°-104°F, initiate cooling via rotating cold wet towels.
2. If rectal temperature is at or above 104°F, initiate the exertional heat stroke treatment protocol and contact EMS services immediately.
3. The patient must be moved to a cooling zone, begin appropriate treatment and continuously monitor the patient.
- For use of a traditional thermometer or a hand-held digital thermometer (any thermometer with a rigid end), obtain initial temperature, remove device, and calculate cooling rate (approximately 1°F every 3-5 minutes when using cold water immersion). When the QHP believes the temperature is within a safe range, remove patient from tub, and re-insert probe to confirm temperature. If temperature is not within the safe range, cooling will continue. Repeat procedure until temperature is confirmed to be within the safe range.
- For use of a flexible thermistor, keep the probe in for the duration of treatment.
- If removal of clothing and/or equipment would cause delays of 5+ minutes, do not remove and initiate cooling.
- Wrap a towel across the chest and beneath both arms to prevent the athlete from sliding into the tub.
- Ice shall cover the surface of the water at all times.
- Water shall be continuously and vigorously stirred to maximize cooling.
- An ice-cold towel will be placed over the head/neck and rewet and replaced every 2 minutes.
- Cooling shall cease when body temperature reaches 102°F.
- Must be set up:
- On Site/or in Athletic Training Room
- A tub filled with water.
- Two chests filled with ice next to the tub ready for treatment.
- Available bed sheet or large towels.
- Towels for placement over the head and neck.
- Completion of set-up within 5-10 minutes prior to the practice/competition/event site.
- a. When a patient is diagnosed with EHS, the principle of Cool First, Transport Second will be used.
- Note: EMS should not transport the patient until they reach 102°F due to the inability to continue vigorous cooling in the ambulance
Vital sign monitoring
1. The QHP will monitor vital signs including core body (rectal) temperature, heart rate, blood pressure and other vital signs.
2. Monitor vital signs every 5-7 minutes. Document results accordingly.
EMS
1. EMS must be called immediately if a patient is suspected of EHS.
2. HOWEVER, any patient with EHS must be cooled FIRST and then transported via EMS.
a. This cool first transport second EAP protocol will be communicated/shared with EMS.
Return to activity
Patients who have suffered an exertional heat illness must complete a rest period and obtain clearance from a physician before beginning a progression of physical activity under the supervision of a qualified medical professional. The following is the suggested protocol:
- Activity should first begin in a cool environment
- Once patient has shown success with exercise in a cool environment, patient should then complete the heat acclimatization protocol (above) for progression back into exercise in a warm environment.
- Body temperature monitoring may be recommended during the first 1-2 weeks for those returning from EHS episode.
Training/Retraining
Athletic Trainers, team physicians and any other QHP must be trained to ensure a safe participation environment for all individuals, coaches, employees and staff mentioned in the Scope section of this document, who are engaged in activities that could put them at risk of exertional heat injuries.
Annual training includes, but is not limited to, the procedures and protocols outlined in this document, the prevention of heat illness’, identification of heat related illness’, and when to initiate treatment for those believed to be suffering from an exertional heat illness.
Qualified healthcare professional training(s):
- Environmental monitoring review (WBGT) and set up,
- Cold water immersion tub set up and management
- Rectal temperature skill development
- Cool station location evaluation
- Appropriate documentation
Athletic administrators, coach, other non QHP professional(s) training(s):
(Education will be performed by the athletic trainer or other sports medicine healthcare professional)
- Environmental monitoring review (WBGT) and set up,
- Heat acclimatization protocol review,
- Prevention strategies,
- Education on signs and symptoms of patients with exertional heat illness,
- Management of exertional heat illness’
- Agreement and understanding of activity modifications
This document is provided by the Korey Stringer Institute, an organization housed at the University of Connecticut, as a template to assist with preliminary drafting of the above policy. Using this document and any other information (text, graphics, images or other materials) from the Korey Stringer Institute is solely at your own risk. The policies described represent best practices as interpreted by the Korey Stringer Institute at the time of drafting this document. While the Korey Stringer Institute does its best to reflect current best practices, the most appropriate policies and procedures are subject to change at and may not be directly reflected in this document. Use of this document does not constitute endorsement by the Korey Stringer Institute. Modification of the policy or procedures in this document may not reflect best practices. All policy decisions should be reviewed by appropriate local administration prior to implementation. Any individual or organization utilizing this document should use discretion and consider the individual circumstances at their work setting.
This Template has been modified from the Board of Certification, Inc. (BOC) Guiding Principles for AT Policy and Procedure Development
