Sports Medicine Research: In the Lab & In the Field: Exertional Heat Stroke Management Still Has Something to be Desired (Sports Med Res)
Wednesday, February 12, 2014

Exertional Heat Stroke Management Still Has Something to be Desired

Exertional heat stroke management strategies in the United States high school football

Kerr ZY, Marshall SW, Comstock RD, Casa DJ. Am J Sport Med. 2014; 42:70.

Take Home Message: Many athletes especially football players suffer exertional heat stroke each year To reduce the prevalence of exertional heat stroke, clinicians should be well educated on, and implement active exertional heat stroke management strategies such as moving the athletes into air conditioning, cold water immersion, and monitoring body temperature.

Exertional heat stroke (EHS) is a severe condition, which if left untreated affects the central nervous system and can lead to death. Although EHS is preventable, many athletes – especially football players – are still affected each year. Because of this, many clinicians have implemented heat illness management strategies to prevent EHS. If we understood how common EHS is among football programs and how clinicians implement EHS management strategies then we could improve our management protocols. Therefore, Kerr and colleagues completed a cross-sectional survey study to examine the how athletic trainers (ATs) manage and treat EHS events in high school football. Researchers designed an anonymous, online survey and distributed it to 6,343 ATs. All ATs were identified by a National Athletic Trainers’ Association membership list and were responsible for high school sports in the 2011-2012 school year. The ATs reported their clinician experience, characteristics of the high school, number and frequency of preseason practices, as well as number and frequency of strategies used to prevent exertional heat illness and manage EHS during the 2011 football preseason. Of the 6,343 ATs contacted for participation, 1,142 (18%) agreed to participate and fully completed the survey. One third of respondents worked in a state that required implementation of heat acclimatization guidelines. The ATs treated 561 EHS events. ATs who reported treating at least 1 EHS event used an average of 6.6 management strategies, while ATs who did not treat an EHS event reported that they would have used an average of 7.9 management strategies. The most common EHS management strategies were removing the athlete’s equipment (98.2%) and moving the athlete to a shaded area (91.6%). The least common EHS management strategies were using a rectal thermometer to record body temperature (0.9%), called for EMS (29%), and cold water immersion (52%). Further, ATs reported more EHS management strategies if they worked in states that required implementation of heat acclimatization guidelines. ATs in these states also used more active management strategies than those ATs in states without mandates – such as, moving the athletes into air conditioning, cold water immersion, and monitoring body temperature.

Overall, this study provides clinicians with some interesting data regarding the prevalence and management of EHS. Perhaps the most interesting result is that ATs in states that required implementation of heat acclimatization guidelines reported the using more EHS management strategies than those in states with no such mandate. This may suggest an education bias as ATs in states with a mandate may be more aware of EHS treatment strategies to effectively implement the mandate. Furthermore, ATs in states with mandates also utilized more active EHS management strategies than ATs in states without mandates. This may indicate that clinicians in states with mandates may be more informed and better prepared to handle EHS events due to the mandated heat acclimatization guidelines. Despite the amount of education ATs received, EHS events still occurred, which suggests that EHS management is still not optimized and should be furthered studied. Currently to ensure an athlete’s safety, a clinician should be diligent in seeking continuing education opportunities on EHS and should familiarize themselves with heat acclimation guidelines regardless of if their state requires such a program.

Questions for Discussion: Do you currently implement a heat acclimation program for your athletes? If so, what does it entail? If not, would you feel confident in your EHS management strategies if faced with an EHS event?

Written by: Kyle Harris
Reviewed by:  Jeffrey Driban

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Kerr ZY, Marshall SW, Comstock RD, & Casa DJ (2014). Exertional heat stroke management strategies in United States high school football. The American Journal of Sports Medicine, 42 (1), 70-7 PMID: 24013346

3 comments:

Jake Marshall said...

It is my understanding that best practice is taking a core temp using a rectal thermometer, cold water immersion, and ambulance transport once cooled. I have always found the idea of taking a rectal temperature on the field to be asking for problems despite the fact that it is considered best practice. Too much in the way of privacy issues. It is interesting to see that it is not used much.

Kyle said...

Jake, Thanks for the comment. I think you make an excellent point. Using rectal temperature is considered best practice, however with privacy issues today this is a strategy that is often underutilized. Perhaps the solution lies in how we as clinicians deal with the issue, before it becomes a problem. Speaking with administrators, and your fellow athletic trainers, identifying best practices and how they can be implemented, may be helpful. I know that after writing this post, I have been in contact with my athletic director and team physician to compile a strategy to implement these best practices into our emergency action plan. It has also been brought up that we may want to include our Provost and other administrators at our school into the conversation. I think it is important as clinicians we encourage our administrators and other staff members to implement best practices while all the time taking into account privacy issue such. With that being said, navigating these issues is never easy. It takes a team effort even though the literature supporting these practices is widely available.

While the current study identified barriers to using some of these practices, I think the next step in the research should be to ask the question, “why aren't we using these strategies?” If privacy is the issue, perhaps we can gather on a larger scale (such as the regional or national scale) and help all of our fellow athletic trainers and clinicians identify how to best navigate this issues. What are your current guidelines at your workplace with regards to how you deal and treat exertional heat illness? Are these treatment guidelines in your policies and procedures manual and your emergency action plan? Perhaps clinicians’ uncomfortableness with this issue could be alleviated by having the strategy in writing and agreed to by all members of the sports medicine team as best practice for our athletes. Thank you again for the excellent comment. I think this is an issue that many clinicians deal and struggle with every preseason, I know that I have.

Ada Weiss said...

As a newly certified athletic trainer, I think this is great information to be aware of. In school we all learn EHS identification, assessment, and treatment techniques, but translating these facts into a protocol that can be successfully executed in an emergent situation is a larger challenge. The possible education bias was very interesting to me. It is suggestive that maybe one piece to the puzzle of preventing these deaths from EHS is to lobby for more states to adopt heat acclimatization mandates and raise awareness with athletic trainers and coaches. In my experience working with football, the coaches were very aware that if the medical staff decided to pull someone over concern for their health, there wasn't going to be an argument. I think that educating coaches to help spread this mentality could help remove athletes from risky situations before it becomes life threatening.

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