Heat related illness
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Heat-Related Illness. Mark De Carlo, PT, MHA, SCS, ATC Methodist Sports Medicine Center Indianapolis, Indiana. Introduction. Heat illness is inherent to physical activity Heat illness incidence increases with rising temperature and relative humidity

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Heat-Related Illness

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Heat related illness

Heat-Related Illness

Mark De Carlo, PT, MHA, SCS, ATC

Methodist Sports Medicine Center

Indianapolis, Indiana



  • Heat illness is inherent to physical activity

  • Heat illness incidence increases with rising temperature and relative humidity

  • Heat illness is not synonymous with hydration status

  • Heat illness deaths in football are preventable

Traditional philosophies

Traditional Philosophies

  • Not being able to “take the heat” is a sign of weakness

  • Restricting water as a disciplinary measurement

  • Drinking too much water causes cramps

  • Salt tablets prevent cramps



  • Annual Survey of Football Injury Research 1931-2003

    • Chaired by Dr. Fred Mueller

    • 106 total cases of heat stroke which resulted in death

    • 1960 to 2003 – 101 heat stroke deaths

    • 1970 – high of 8 heat stroke deaths

    • 1995 to 2001 – 15 of 21 heat stroke deaths at the high school level

    • 0 heat stroke deaths in past 2 years

Risk factors

Risk Factors

Intrinsic risk factors

History of heat illness

Poor heat acclimation

Lower fitness level

Higher % body fat



Medications (diuretics, antihistamines)

Supplements (ephedra)

Highly motivated

Reluctance to report problems

Intrinsic Risk Factors

Extrinsic risk factors

Intense and prolonged exercise

High temperature, humidity, and sun exposure

Lack of education and awareness

No shade or rest breaks

Limited access to fluids

No emergency plan

Delay in recognition of early warning signs

Extrinsic Risk Factors





  • Dehydration occurs when sweat loss exceeds fluid intake

  • Fluid-replacement should be cold and easily accessible

  • Thirst is a poor indicator of hydration



  • Prehydrate

    • Drink 16 oz 2 hours prior to activity

  • Maintain hydration

    • Drink 6-8 oz for every 15 minutes of intense activity

  • Rehydrate

    • Correct fluid loss within 2 hours after activity

Monitor weight loss

Monitor Weight Loss

  • Check weight before and after activity

  • Match fluid intake to sweat and urine loss

  • Voluntary drinking replaces only about 50% of body-fluid loss

  • Maintain less than 2% body-weight change

  • Replace weight loss with equal amount of fluid

    • Drink 16 oz for each pound lost

Electrolyte balance

Electrolyte Balance

  • Eat salty foods or add salt to meals and snacks

  • If activity > 1 hour, include carbohydrates and sodium with fluid

    • Sports drinks

  • Avoid salt tablets

    • With insufficient water, hypertonicity can make dehydration worse

Drugs and supplements

Drugs and Supplements

  • Ephedra

    • Linked to heart attacks, seizures, and heat stroke

  • Diuretics

    • Cause loss of fluids

  • Antihistamines

    • Constrict blood vessels

  • Check side effects of all medications

Heat acclimation

Heat Acclimation

  • Gradually ramp up outdoor activity

  • First 2 to 3 days of activity present greatest danger

  • Acclimatization requires 8 to 12 days for adults, 10 to 14 days for adolescents

Clothing and equipment

Clothing and Equipment

  • Wear loose fitting or moisture-wicking, light colored clothes

  • Sweat dampened clothes impede evaporation

    • Avoid cottons or bring an extra change of clothes

  • Minimize equipment and padding when indicated



  • Wet Bulb Globe Temperature (WBGT)

    • Used as an index to modify activity

    • WBGT = (.1 x Dry Bulb Temp) + (.2 x Black Globe Temp) + (.7 x Wet Bulb Temp)


Wet-Bulb Globe Temperature




  • Sling psychrometer

    • Can be used to estimate WBGT

    • Produces dry bulb temperature (DBT) and wet bulb temperature (WBT)

    • Use DBT and WBT to calculate relative humidity





  • Modify activity under high risk conditions

    • Increase length and frequency of rest breaks

    • Limit intensity and duration of activity

    • Limit the amount of clothing and equipment

    • Unlimited and accessible hydration



Heat illness

Heat Illness

  • Heat illness is traditionally divided into 4 categories

    • Heat cramps

    • Heat syncope

    • Heat exhaustion

    • Heat stroke

  • Heat illness is not sequential; there is a lack of continuum between categories

  • Early recognition of heat illness is more important than differentiating categories of heat illness

Signs and symptoms


Weakness, fatigue

Weak, rapid pulse

Dizziness, light headed, fainting

Dehydration and cramping


Cool and clammy skin

Profuse sweating


Nausea, vomiting, diarrhea

Skin hot and wet or dry

Staggering gait

Delirium, confusion

Irrational behavior, emotional instability, aggressiveness

Loss of consciousness

Signs and Symptoms

On field recognition

On-Field Recognition

  • Players

    • Taking a knee

    • Cramping

    • Vomiting

    • Slow returning to huddle or disengaged from huddle

    • Going to the wrong sideline

    • Staggering

    • Collapse

On field recognition1

On-Field Recognition

  • Officials

    • Flushed or pale face

    • Resting hands on knees

    • Altered vision

    • Confusion about rules, possession, penalties

    • Incoherent speech

    • Hyperventilation

    • Staggering

    • Collapse



Treatment guidelines

Treatment Guidelines

  • Heat loss must equal heat gain

  • Recognize that all stages of heat illness require treatment of fluid replacement and cooling

  • Take early action

  • When in doubt, assume heat stroke

Early treatment

Early Treatment

  • Remove from activity to shade or air conditioned facility

  • Begin fluid replacement

  • Remove excess clothing and equipment

  • Cool with fans, ice towels, or ice bags

  • Monitor vitals and core temperature

Severe treatment

Severe Treatment

  • Cool before transport

  • Remove excess clothing and equipment

  • Rapid, whole body cooling

    • Cold water immersion for 20 minutes in small pool or tub is best treatment

      • 100% success in 252 cases of heat stroke

    • Ice packs to axilla and groin, cover with ice towels, spray with cold water

  • Oral fluids if conscious

  • Monitor rectal temperature

Recommendations for officials

Recommendations for Officials

  • Consult with athletic training staff prior to contest

  • Utilize official’s time out for heat and humidity to allow extra rest and water breaks

    • Rule 3-5-1, ART 7 and Case 3.5.7

  • Monitor athletes for signs and symptoms

  • Practice and apply guidelines to yourselves



  • Heat illness death is preventable

  • Modify activity under high risk conditions

  • Recognize early signs of heat illness

  • All categories of heat illness require treatment of hydrating and cooling

  • Cold water immersion is the best treatment

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