New heat illness guidelines for athletic trainers announced
New guidelines announced today in Indianapolis include an unusual policy for treating athletes with heat stroke. The National Athletic Trainers' Association (NATA) says victims of heat stroke should not be rushed to the hospital. NATA reports that cold water immersion is the most effective treatment for heat stroke.
A simple sideline ice water tub could be a life saver. Trainers say there should be one on every field when athletes are working out in the heat. When an athlete suffers from heat stroke, it's essential to get their core body temperature lowered quickly to avoid permanent organ or brain damage, or even death.
The National Athletic Trainers' Association Expo in Indianapolis released new heat and hydration guidelines for athletes. Most significant is the "cool first, transport second" policy for athletes suffering heat stroke, when core body temperature rises above 104 degrees.
"It's a complete paradigm shift in medicine," said Doug Casa, chief operation officer of the Korey Stringer Institute. "I mean what other medical condition do you say, 'I'm not going to send him to the hospital right away.' But what we understand with heat stroke is we have a very limited number of minutes to get their temperature under the critical threshold."
The Colts hit the practice fields in Anderson in less than a month. Training camp brings some of the hottest days of the summer and the danger of heat stroke.
"We report to camp July 23rd," said Colts offensive lineman Joe Reitz. "So on the 19th, the 20th, I'm really going to start pushing fluids, drinking as much water as I can, so I can be kind of 100 percent topped off in the gas tank so to speak. So that way you hit a couple hot days and you're losing some sweat, you're at your very highest level and it's not going to affect you as much."
NATA reports the best way to treat heat stroke is cold water immersion on site in the first 30 minutes after a heat stroke incident.
"You have to have cooling finish at the school before you put them in the ambulance to take them to the hospital," said Casa, "because you don't want to take him out of the tub while they're getting this great cooling and then put him in the ambulance where they can't continue that same cooling. So you want to absolutely utilize the on-site cooling modality, get them down to the 102-103 range, then you ship them to the hospital. That's your best chance of helping that person survive the heat stroke."
NATA also recommends a more gradual workload to start the football season.
"Indiana does not meet the minimum standards right now," said Casa. "One of the first things that the residents of Indiana should do is encourage the Indiana High School Athletic Association to meet the minimum standards for heat acclimatization so that there would be no two-a-days on the first five days, no successive days of two a days, phasing in the equipment over time."
But changes to the IHSAA by-laws adopted in May now require three days of non-contact drills when high school football practice starts August 4th. (By-law changes can be read below.)
"The Indiana Football Coaches Association spent countless hours in research and consultation with representatives of the football and medical communities to arrive at conditions that are appropriate for Indiana high school football players," said IHSAA commissioner Bobby Cox in an email. "It is unfortunate that individuals have made public statements without apparent research into the measures the IHSAA have implemented to promote the health and safety of our student athletes."
Heat stroke is the 3rd leading cause of sudden death in sports. But trainers say it is 100 percent preventable when it is recognized and treated correctly. Just a tub full of ice water can be the emergency response needed.
NATA Executive Summary Select Highlights: Exertional Heat Illnesses Position Statement
(full statement to be published in upcoming issue of the Journal of Athletic Training)
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.
- 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 victim is to lower core body temperature to less than 102.5°F within 30 minutes of collapse.
- Cold water immersion is the most effective way to treat a patient with exertional heat stroke. The water should be 35-59°F and continuously stirred to maximize cooling.
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.
"Death from exertional heat stroke is 100 percent preventable when proper recognition and treatment protocols are implemented," concluded Casa. "Putting the right programs into place is essential to prevent and treat exertional heat illnesses and ensure appropriate care is in place."
The IHSAA Board of Directors approved multiple changes regarding the conduct of football practices and summer activities at their annual meeting in May. Rule 15-3.3 has been totally rewritten to include the following restrictions:
A School, and players from the School's football program, may participate in Football Activities (participation in any football related activities while wearing helmets or shoulder pads) under the following standards:
- Students may not participate in any Full Contact Football Activities (any intentional football activity by a player where the goal is to take one or more competing players to the ground as the result of a collision) during the Summer.
- Schools may sponsor up to Twelve (12) Football Activity Days (a day when a School's football coaching staff coaches Two (2) or more players from the School's football team engaged in Football Activities) during the Summer.
- A School's Football Activity Days may include up to Five (5) Football Competition Days (a day when a School's football coaching staff takes Two (2) or more players from a School's football team to either practice with or compete against One (1) or more players from another School or program). The maximum time for a school's Football Activity Day held at a member-school facility will be 3.5 hours of activity over a five-hour period.
- A student's football equipment during Summer Football Activities is limited to a helmet, shoes, shoulder pads, a girdle and a mouth piece.
- A student may engage in no more than One (1) session of Football Activities during a Football Activity Day and the maximum time of the session is Two (2) hours.
- Prior to the first day of Summer, a School's football coaching staff must designate to the School's athletic director or the principal the specific Football Activity Days and the Football Competition Days in which the football program plans to participate.
Furthermore, the Board approved substantive changes regarding the first week of authorized football practice and practice protocol throughout the season. Rule 54-4 now provides the following:
All organized football practices by players or teams shall be limited to the period beginning Monday of IHSAA calendar week 5 and terminating on the date the team is eliminated from the Football Tournament Series.
Football practices must adhere to the following:
- On the first (1st) day of football practice there cannot be full contact (any intentional football activity by a player where the goal is to take one or more competing players to the ground as the result of a collision), and the player's protective equipment is limited to helmet, shoes, girdle and mouthpiece. The total time on the field cannot exceed Two and one-half (21/2) hours.
- On the second (2nd) and third (3rd) days of football practice, there cannot be full contact and the player's protective equipment is limited to helmet, shoulder pads, shoes, girdle and mouthpiece. If multiple practice sessions are held on a single day, the total time on the field cannot exceed Three (3) hours, but if there is only One (1) practice session, the total time on the field cannot exceed Two and one-half (21/2) hours.
- On the fourth (4th) day of football practice, and later, there can be full contact and players can have full pads. If multiple practices are held on a single day the total time cannot exceed Five (5) hours, but if there is only One (1) practice session, the total time on the field cannot exceed Three (3) hours.
- Beginning Monday of IHSAA calendar week 5:
(2.) There cannot be back to back calendar days having Two (2) practice sessions
on a single day.
(3.) After the third (3rd) day of practice, if there are Two (2) practice-sessions on a
single days :
ii. The break between practices must be at least Three (3) hours in duration and during the break there cannot be player physical exertion.
iii. During the break a classroom instruction session, not to exceed Forty- five (45) minutes, is permitted.
iv. During the break an indoor walkthrough session in a climate controlled environment, not to exceed Forty-five (45) minutes, is permitted.