Exertional heat illness in adolescents and adults: Management and prevention
- Francis G O'Connor, MD, MPH, FACSM
Francis G O'Connor, MD, MPH, FACSM
- Section Editor — Sports-Related Injuries; Symptom Assessment and Physical Examination; Medical Issues Related to Sports and Exercise
- Professor of Military and Emergency Medicine
- Uniformed Services University of the Health Sciences
- Douglas J Casa, PhD, ATC, FACSM, FNATA
Douglas J Casa, PhD, ATC, FACSM, FNATA
- Chief Executive Officer, Korey Stringer Institute
- Professor, Department of Kinesiology
- College of Agriculture, Health and Natural Resources, University of Connecticut
- Section Editors
- Daniel F Danzl, MD
Daniel F Danzl, MD
- Section Editor — Environmental Emergencies
- Professor of Emergency Medicine
- University of Louisville School of Medicine
- Karl B Fields, MD
Karl B Fields, MD
- Editor-in-Chief — Primary Care Sports Medicine (Adolescents and Adults)
- Section Editor — Biomechanics, Rehabilitation, and Recovery; Sports-Related Injuries; Symptom Assessment and Physical Examination
- Professor of Family Medicine and Sports Medicine
- University of North Carolina at Chapel Hill
- Deputy Editor
- Jonathan Grayzel, MD, FAAEM
Jonathan Grayzel, MD, FAAEM
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Assistant Professor of Emergency Medicine
- University of Massachusetts Medical School
Exertional heat illness (EHI) is among the leading causes of death in young athletes each year [1,2]. A report by the United States Centers for Disease Control (CDC) found that EHI occurs both during practice and competition and noted a disturbing trend of increasing incidence ; despite prevention efforts exertional heat stroke in the military continues to climb . Clinicians who care for athletes, both young and old, and for others who exert themselves in the heat (eg, firefighters, soldiers, construction workers) need to be aware of the basic physiologic principles of thermoregulation, the spectrum of heat illness, strategies for prevention and treatment, and current guidelines for determining safe return to play or work.
The management and prevention of exertional heat illness are reviewed here. Thermoregulation and the clinical presentation and diagnosis of exertional heat illness are discussed separately, as are exercise-associated hyponatremia, nonexertional heat stroke, malignant hyperthermia, and heat illness in children. (See "Exertional heat illness in adolescents and adults: Epidemiology, thermoregulation, risk factors, and diagnosis" and "Exercise-associated hyponatremia" and "Severe nonexertional hyperthermia (classic heat stroke) in adults" and "Malignant hyperthermia: Clinical diagnosis and management of acute crisis" and "Neuroleptic malignant syndrome" and "Heat stroke in children" and "Heat illness (other than heat stroke) in children".)
Two critical observations inform the management of exertional heat stroke (EHS) and all types of severe heat illness [5-7]:
●The severity of a heat illness may not be apparent during the initial presentation.
●Morbidity and mortality are directly related to the duration of core temperature elevation.
- Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009; 119:1085.
- Mueller FO, Cantu RC. Catastrophic sports injury research: 26th Annual Report Fall 1982-Spring 2008. University of North Carolina, Chapel Hill 2008. http://www.unc.edu/depts/nccsi/AllSport.pdf (Accessed on July 09, 2012).
- Centers for Disease Control and Prevention (CDC). Heat illness among high school athletes --- United States, 2005-2009. MMWR Morb Mortal Wkly Rep 2010; 59:1009.
- Update: Heat injuries, active component, U.S. Armed Forces, 2009. MSMR 2010; 17:6. http://www.afhsc.mil/viewMSMR?file=2010/v17_n03.pdf#Page=06 (Accessed on June 05, 2012).
- Bouchama A, Knochel JP. Heat stroke. N Engl J Med 2002; 346:1978.
- Gardner JW, JA K. Clinical diagnosis, management, and surveillance of exertional heat illness. In: Textbook of Military Medicine, Zajitchuk R. (Ed), Army Medical Center Borden Institute, Washington, DC 2001.
- Heled Y, Rav-Acha M, Shani Y, et al. The "golden hour" for heatstroke treatment. Mil Med 2004; 169:184.
- Stearns RL, O'Connor FG, Casa DJ, Kenny GP. Exertional heat stroke. In: Preventing Sudden Death in Sport and Physical Activity, Casa DJ. (Ed), Jones & Bartlett Learning, Sudbury 2011. p.53.
- Casa DJ, Kenny GP, Taylor NA. Immersion treatment for exertional hyperthermia: cold or temperate water? Med Sci Sports Exerc 2010; 42:1246.
- Casa DJ, McDermott BP, Lee EC, et al. Cold water immersion: the gold standard for exertional heatstroke treatment. Exerc Sport Sci Rev 2007; 35:141.
- Proulx CI, Ducharme MB, Kenny GP. Effect of water temperature on cooling efficiency during hyperthermia in humans. J Appl Physiol (1985) 2003; 94:1317.
- Sithinamsuwan P, Piyavechviratana K, Kitthaweesin T, et al. Exertional heatstroke: early recognition and outcome with aggressive combined cooling--a 12-year experience. Mil Med 2009; 174:496.
- Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic management in heatstroke: practical recommendations. Crit Care 2007; 11:R54.
- Smith JE. Cooling methods used in the treatment of exertional heat illness. Br J Sports Med 2005; 39:503.
- McDermott BP, Casa DJ, Ganio MS, et al. Acute whole-body cooling for exercise-induced hyperthermia: a systematic review. J Athl Train 2009; 44:84.
- Newport M, Grayson A. Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET 3: In patients with heatstroke is whole-body ice-water immersion the best cooling method? Emerg Med J 2012; 29:855.
- Lipman GS, Eifling KP, Ellis MA, et al. Wilderness Medical Society practice guidelines for the prevention and treatment of heat-related illness. Wilderness Environ Med 2013; 24:351.
- Atha WF. Heat-related illness. Emerg Med Clin North Am 2013; 31:1097.
- Casa DJ, Becker SM, Ganio MS, et al. Validity of devices that assess body temperature during outdoor exercise in the heat. J Athl Train 2007; 42:333.
- Ganio MS, Brown CM, Casa DJ, et al. Validity and reliability of devices that assess body temperature during indoor exercise in the heat. J Athl Train 2009; 44:124.
- Mazerolle SM, Scruggs IC, Casa DJ, et al. Current knowledge, attitudes, and practices of certified athletic trainers regarding recognition and treatment of exertional heat stroke. J Athl Train 2010; 45:170.
- Ronneberg K, Roberts WO, McBean AD, Center BA. Temporal artery temperature measurements do not detect hyperthermic marathon runners. Med Sci Sports Exerc 2008; 40:1373.
- Capacchione JF, Muldoon SM. The relationship between exertional heat illness, exertional rhabdomyolysis, and malignant hyperthermia. Anesth Analg 2009; 109:1065.
- Moran DS, Gaffin SL. Clinical management of heat-related illnesses. In: Wildnerness Medicine, Auerbach PS. (Ed), Mosby, St. Louis 2001. p.290.
- Zeller L, Novack V, Barski L, et al. Exertional heatstroke: clinical characteristics, diagnostic and therapeutic considerations. Eur J Intern Med 2011; 22:296.
- Hashim IA. Clinical biochemistry of hyperthermia. Ann Clin Biochem 2010; 47:516.
- Marom T, Itskoviz D, Lavon H, Ostfeld I. Acute care for exercise-induced hyperthermia to avoid adverse outcome from exertional heat stroke. J Sport Rehabil 2011; 20:219.
- Shahid MS, Hatle L, Mansour H, Mimish L. Echocardiographic and Doppler study of patients with heatstroke and heat exhaustion. Int J Card Imaging 1999; 15:279.
- Atar S, Rozner E, Rosenfeld T. Transient cardiac dysfunction and pulmonary edema in exertional heat stroke. Mil Med 2003; 168:671.
- Hong JY, Lai YC, Chang CY, et al. Successful treatment of severe heatstroke with therapeutic hypothermia by a noninvasive external cooling system. Ann Emerg Med 2012; 59:491.
- Varghese GM, John G, Thomas K, et al. Predictors of multi-organ dysfunction in heatstroke. Emerg Med J 2005; 22:185.
- Leon LR, Helwig BG. Heat stroke: role of the systemic inflammatory response. J Appl Physiol (1985) 2010; 109:1980.
- Costrini AM, Pitt HA, Gustafson AB, Uddin DE. Cardiovascular and metabolic manifestations of heat stroke and severe heat exhaustion. Am J Med 1979; 66:296.
- Kew MC, Tucker RB, Bersohn I, Seftel HC. The heart in heatstroke. Am Heart J 1969; 77:324.
- Wilson TE, Crandall CG. Effect of thermal stress on cardiac function. Exerc Sport Sci Rev 2011; 39:12.
- Whiticar R, Laba D, Smith S. Exertional heat stroke in a young man with a documented rise in troponin I. Emerg Med J 2008; 25:283.
- Bianchi L, Ohnacker H, Beck K, Zimmerli-Ning M. Liver damage in heatstroke and its regression. A biopsy study. Hum Pathol 1972; 3:237.
- Shibolet S, Coll R, Gilat T, Sohar E. Heatstroke: its clinical picture and mechanism in 36 cases. Q J Med 1967; 36:525.
- McDermott BP, Casa DJ, Yeargin SW, et al. Recovery and return to activity following exertional heat stroke: considerations for the sports medicine staff. J Sport Rehabil 2007; 16:163.
- Mehta AC, Baker RN. Persistent neurological deficits in heat stroke. Neurology 1970; 20:336.
- Romero JJ, Clement PF, Belden C. Neuropsychological sequelae of heat stroke: report of three cases and discussion. Mil Med 2000; 165:500.
- Wallace RF, Kriebel D, Punnett L, et al. Prior heat illness hospitalization and risk of early death. Environ Res 2007; 104:290.
- Garcin JM, Bronstein JA, Cremades S, et al. Acute liver failure is frequent during heat stroke. World J Gastroenterol 2008; 14:158.
- Maquirriain J, Merello M. The athlete with muscular cramps: clinical approach. J Am Acad Orthop Surg 2007; 15:425.
- Schwellnus MP, Drew N, Collins M. Muscle cramping in athletes--risk factors, clinical assessment, and management. Clin Sports Med 2008; 27:183.
- Bergeron MF. Exertional heat cramps: recovery and return to play. J Sport Rehabil 2007; 16:190.
- Asplund CA, O'Connor FG, Noakes TD. Exercise-associated collapse: an evidence-based review and primer for clinicians. Br J Sports Med 2011; 45:1157.
- Binkley HM, Beckett J, Casa DJ, et al. National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses. J Athl Train 2002; 37:329.
- O'Connor FG, Casa DJ, Bergeron MF, et al. American College of Sports Medicine Roundtable on exertional heat stroke--return to duty/return to play: conference proceedings. Curr Sports Med Rep 2010; 9:314.
- O'Connor FG, Williams AD, Blivin S, et al. Guidelines for return to duty (play) after heat illness: a military perspective. J Sport Rehabil 2007; 16:227.
- American College of Sports Medicine, Armstrong LE, Casa DJ, et al. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc 2007; 39:556.
- Moran DS, Erlich T, Epstein Y. The heat tolerance test: an efficient screening tool for evaluating susceptibility to heat. J Sport Rehabil 2007; 16:215.
- Moran DS, Heled Y, Still L, et al. Assessment of heat tolerance for post exertional heat stroke individuals. Med Sci Monit 2004; 10:CR252.
- Racinais S, Alonso JM, Coutts AJ, et al. Consensus recommendations on training and competing in the heat. Br J Sports Med 2015; 49:1164.
- Wegmann M, Faude O, Poppendieck W, et al. Pre-cooling and sports performance: a meta-analytical review. Sports Med 2012; 42:545.
- Tyler CJ, Sunderland C, Cheung SS. The effect of cooling prior to and during exercise on exercise performance and capacity in the heat: a meta-analysis. Br J Sports Med 2015; 49:7.
- GUIDING PRINCIPLES
- MANAGEMENT OF EXERTIONAL HEAT STROKE
- - Initial assessment
- - Cooling measures
- - Measuring temperature
- Clinical assessment at the hospital
- Laboratory and radiographic assessment
- Supportive therapy
- Pharmacologic therapy
- Disposition and admission criteria
- MANAGEMENT OF OTHER TYPES OF EXERTIONAL HEAT ILLNESS
- "Heat cramps"
- - Treatment
- - Prevention
- Heat syncope and exercise associated collapse
- Heat exhaustion
- Heat injury
- DETERMINING RETURN TO PLAY
- HEAT TOLERANCE TESTING
- PREVENTION OF EXERTIONAL HEAT ILLNESS
- COMMON MISCONCEPTIONS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS