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Binkley*; Joseph Beckett ; Douglas J. Casa! ; Douglas M. Kleiner; Paul E. Plummera! *Mesa State College, Grand Junction, CO; University of Charleston, Charleston, WV; ! University of Connecticut, Storrs, CT; University of Florida, Jacksonville, FL; a!Indiana State University, Terre Haute, INZ/!9","} " +"B RecommendationsB  Prevention 6 ie 1. Ensure that appropriate medical care is available and that rescue personnel are familiar with exertional heat illness prevention, recognition, and treatment. Table 2 provides general guidelines that should be considered. Ensure& ( jg0 1. (continued) & that ATCs and other health care providers attending practices or events are allowed to evaluate and examine any athlete who displays signs or symptoms of heat illness and have the authority to restrict the athlete from participating if heat illness is present. ( lh 2. Conduct a thorough, physician-supervised, preparticipation medical screening before the season starts to identify athletes predisposed to heat illness on the basis of risk factors and those who have a history of exertional heat illness. ( mi 3. Adapt athletes to exercise in the heat (acclimatization) gradually over 10 to 14 days. Progressively increase the intensity and duration of work in the heat with a combination of strenuous interval training& B( (( nj 3. (continued) & and continuous exercise. Well-acclimatized athletes should train for 1 to 2 hours under the same heat conditions that will be present for their event. In a cooler environment, an athlete can wear additional clothing during training to induce& n((((P}((P\( ok  3. (continued) & or maintain heat acclimatization. Athletes should maintain proper hydration during the heat-acclimatization process. ( pl 4. Educate athletes and coaches regarding the prevention, recognition, and treatment of heat illnesses9and the risks associated with exercising in hot, humid environmental conditions. 0h((PR( 0hi qm 5. Educate athletes to match fluid intake with sweat and urine losses to maintain adequate hydration. (See the  National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes. ) Instruct athletes to drink& 0"(( rn 5. (continued) & sodium-containing fluids to keep their urine clear to light yellow to improve hydration and to replace fluids between practices on the same day and on successive days to maintain less than 2% body-weight change. These strategies will& ( so 5. (continued) & lessen the risk of acute and chronic dehydration and decrease the risk of heat-related events. ss( tp 6. Encourage athletes to sleep at least 6 to 8 hours at night in a cool environment, eat a well-balanced diet that follows the Food Guide Pyramid and United States Dietary Guidelines, and maintain proper hydration& 0V((P( uq\ 6. (continued) & status. Athletes exercising in hot conditions (especially during twice-a-day practices) require extra sodium from the diet or rehydration beverages or both.((( vr 7. Develop event and practice guidelines for hot, humid weather that anticipate potential problems encountered based on the wet-bulb globe temperature (WBGT) (Table 3) or heat and humidity as measured by a sling psychrometer (Figure 1), the number of participants,& ( ws 7. (continued) & the nature of the activity, and other predisposing risk factors. If the WBGT is greater than 28C (82F, or  very high as indicated in Table 3, Figure 1), an athletic event should be& Jq("(( " (U(  7. (continued) & delayed, rescheduled, or moved into an air-conditioned space, if possible. It is important to note that these measures are based on the risk of environmental stress for athletes wearing shorts and& ( xt 7. (continued) & a T-shirt; if an athlete is wearing additional clothing (ie, football uniform, wetsuit, helmet), a lower WBGT value could result in comparable risk of environmental heat stress (Figure 2). If the event& ( yu 7. (continued) & or practice is conducted in hot, humid conditions, then use extreme caution in monitoring the athletes and be proactive in taking preventive steps. In addition, be sure that emergency supplies and equipment are easily accessible and& ( zv 7. (continued) & in good working order. The most important factors are to limit intensity and duration of activity, limit the amount of clothing and equipment worn, increase the number and length of rest breaks, and encourage proper hydration.& ( {w 7. (continued) & Modify activity under high-risk conditions to prevent exertional heat illnesses. Identify individuals who are susceptible to heat illnesses. In some athletes, the prodromal signs and symptoms of heat illnesses are not evident before collapse, but in&   ( O |x 7. (continued) & many cases, adept medical supervision will allow early intervention. JX((?( }y 8. Check the environmental conditions before and during the activity, and adjust the practice schedule accordingly. Schedule training sessions to avoid the hottest part of the day (10 AM to 5 PM) and to avoid radiant heating from direct sunlight, especially in the& J9(;((P( ~z8. (continued) & acclimatization during the first few days of practice sessions.(Q(@( { 9. Plan rest breaks to match the environmental conditions and the intensity of the activity. Exercise intensity and environmental conditions should be the major determinants in deciding the length and frequency of rest breaks. If possible,& ( | 9. (continued) & cancel or postpone the activity or move it indoors (if air conditioned) if the conditions are  extreme or hazardous (see Table 3) or  very high (see Figure 1) or to the right of the circled line (see Figure 2). General guidelines during& ( } 9. (continued) & intense exercise would include a work:rest ratio of 1:1, 2:1, 3:1, and 4:1 for  extreme or hazardous (see Table 3) or  very high (see Figure 1),  high,  moderate, or  low environmental risk, respectively. For activities& ( ~x 9. (continued) & such as football in which equipment must be considered, please refer to Figure 2 for equipment modifications and appropriate work:rest ratios for various environmental& (  9. (continued) & conditions. Rest breaks should occur in the shade if possible, and hydration during rest breaks should be encouraged. (  10. Implement rest periods at mealtime by allowing 2 to 3 hours for food, fluids, nutrients, and electrolytes (sodium and potassium) to move into the small intestine and bloodstream before the next practice. (  11. Provide an adequate supply of proper fluids (water or sports drinks) to maintain hydration and institute a hydration protocol that allows the maintenance of hydration status. Fluids should be readily available and& (  11. (continued) & served in containers that allow adequate volumes to be ingested with ease and with minimal interruption of exercise. The goal should be to lose no more than 2% to 3% of body weight& ( p 11. (continued) & during the practice session (due to sweat and urine losses). (See the  National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes. ) (  12. Weigh high-risk athletes (in high-risk conditions, weigh all athletes) before and after practice to estimate the amount of body water lost during practice and to ensure a return to prepractice weight& (   v 12. (continued) & before the next practice. Following exercise, athletes should consume approximately 1 1.25 L (34-50 oz) of fluid for each kilogram of body water lost during exercise. (  13. Minimize the amount of equipment and clothing worn by the athlete in hot or humid (or both) conditions. For example, a full football uniform prevents sweat evaporation from more than 60% of the body. Consult Figure 2& (  13. (continued) & for possible equipment and clothing recommendations. When athletes exercise in the heat, they should wear loose-fitting, absorbent, and light-colored clothing; mesh clothing& (  13. (continued) & and new-generation cloth blends have been specially designed to allow more effective cooling. rr(  14. Minimize warm-up time when feasible, and conduct warm-up sessions in the shade when possible to minimize the radiant heat load in  high or  very high or  extreme or hazardous (see Table 3, Figure 1) conditions. ( v 15. Allow athletes to practice in shaded areas and use electric or cooling fans to circulate air whenever feasible. ww( g 16. Include the following supplies on the field, in the locker room, and at various other stations: hh(  A supply of cool water or sports drinks or both to meet the participants' needs (see the  National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes for recommendations regarding the appropriate composition& &Z=0Z( Z & of rehydration beverages based on the length and intensity of the activity) Ice for active cooling (ice bags, tub cooling) and to keep beverages cool during exercise 2S0Z[0Z$( Rectal thermometer to assess body-core temperature Telephone or 2-way radio to communicate with medical personnel and to summon emergency medical transportationL   \ 5(y( pTub, wading pool, kiddy pool, or whirlpool to cool the trunk and extremities for immersion cooling therapy(!0ZP0Zq( 17. Notify local hospital and emergency personnel before mass participation events to inform them of the event and the increased possibility of heat-related illnesses. (  18. Mandate a check of hydration status at weigh-in to ensure athletes in sports requiring weight classes (eg, wrestling, judo, rowing) are not dehydrated. Any procedures used to induce dramatic& (  18. (continued) & dehydration (eg, diuretics, rubber suits, exercising in a sauna) are strictly prohibited. Dehydrated athletes exercising at the same intensity as euhydrated athletes are at increased risk for& ( ' " 18. (continued) & thermoregulatory strain (see the  National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes ).( 75 Recognition and Treatment ,6 0 19. Exercise-associated muscle (heat) cramps: 11  An athlete showing signs or symptoms including dehydration, thirst, sweating, transient muscle cramps, and fatigue is likely experiencing exercise-associated muscle (heat) cramps. Z( To relieve muscle spasms, the athlete should stop activity, replace lost fluids with sodium-containing fluids, and begin mild stretching with massage of the muscle spasm. ( Fluid absorption is enhanced with sports drinks that contain sodium. A high-sodium sports product may be added to the rehydration beverage to prevent or relieve cramping in athletes who lose large amounts of sodium in their sweat. A simple salted fluid& "0Z(  & consists of two 10-grain salt tablets dissolved in 1 L (34 oz) of water. Intravenous fluids may be required if nausea or vomiting limits oral fluid intake; these must be ordered by a physician. $0Z( `A recumbent position may allow more rapid redistribution of blood flow to cramping leg muscles. a0Za(20. Heat syncope:  If an athlete experiences a brief episode of fainting associated with dizziness, tunnel vision, pale or sweaty skin, and a decreased pulse rate but has a normal rectal temperature (for exercise, 36C to 40C [97F to 104F]), then heat syncope is most likely the cause. Z( uMove the athlete to a shaded area, monitor vital signs, elevate the legs above the level of the head, and rehydrate. v v( 21. Exercise (heat) exhaustion: !!  Cognitive changes are usually minimal, but assess central nervous system function for bizarre behavior, hallucinations, altered mental status, confusion, disorientation, or coma (see Table 1) to rule out more serious conditions. Z( If feasible, measure body-core temperature (rectal temperature) and assess cognitive function (see Table 1) and vital signs. Rectal temperature is the most accurate method possible in the field to monitor body-core temperature. The ATC should... Z(  not rely on the oral, tympanic, or axillary temperature for athletes because these are inaccurate and ineffective measures of body-core temperature during and after exercise. Z( If the athlete's temperature is elevated, remove his or her excess clothing to increase the evaporative surface and to facilitate cooling.( Cool the athlete with fans, ice towels, or ice bags because these may help the athlete with a temperature of more than 38.8C (102F) to feel better faster. Z( ZRemove the athlete to a cool or shaded environment if possible. Start fluid replacement. [Y( kTransfer care to a physician if intravenous fluids are needed or if recovery is not rapid and uneventful. ll(22. Exertional heat stroke:   Measure the rectal temperature if feasible to differentiate between heat exhaustion and heat stroke. With heat stroke, rectal temperature is elevated (generally higher than 40C [104F]).  Z($ ^Assess cognitive function, which is markedly altered in exertional heat stroke (see Table 1). __( Lower the body-core temperature as quickly as possible. The fastest way to decrease body temperature is to remove clothes and equipment and immerse the body (trunk and extremities) into a pool or tub& ( & of cold water (approximately 1C to 15C [35F to 59F]). Aggressive cooling is the most critical factor in the treatment of exertional heat stroke. Circulation of the tub water may enhance cooling.Z( Monitor the temperature during the cooling therapy and recovery (every 5 to 10 minutes). Once the athlete's rectal temperature reaches approximately 38.3C to 38.9C (101F to 102F), he or she should be removed from the pool or tub to avoid overcooling. Z( If a physician is present to manage the athlete's medical care on site, then initial transportation to a medical facility may not be necessary so immersion can continue uninterrupted. If a physician is not present,& Z( X& aggressive first-aid cooling should be initiated on site and continued during emergency medical system transport and at the hospital until the athlete is normothermic.(w0Z60Z(  Activate the emergency medical system. Monitor the athlete's vital signs and other signs and symptoms of heat stroke (see Table 1). >(Z0ZJ0Z( During transport and when immersion is not feasible, other methods can be used to reduce body temperature: removing the clothing; sponging down the athlete with cool water and applying cold towels; applying ice& Z( .& bags to as much of the body as possible, especially the major vessels in the armpit, groin, and neck; providing shade; and fanning the body with air. 0Z( In addition to cooling therapies, first-aid emergency procedures for heat stroke may include airway management. Also a physician may decide to begin intravenous fluid replacement. Z( @Monitor for organ-system complications for at least 24 hours. $8  A(23. Exertional hyponatremia:   tAttempt to differentiate between hyponatremia and heat exhaustion. Hyponatremia is characterized by increasing headache, significant mental compromise, altered consciousness, seizures,& Z( & lethargy, and swelling in the extremities. The athlete may be dehydrated, normally hydrated, or overhydrated. 2_0Z0Zp(,c  Attempt to differentiate between hyponatremia and heat stroke. In hyponatremia, hyperthermia is likely to be less (rectal temperature less than 40C [104F]. The plasma-sodium level is less than& "(2"(  & 130 mEq/L and can be measured with a sodium analyzer on site if the device is available.[[(R If hyponatremia is suspected, immediate transfer to an emergency medical center via the emergency medical system is indicated. An intravenous line should be placed to administer medication as needed to& 0Z( X & increase sodium levels, induce diuresis, and control seizures. An athlete with suspected hyponatremia should not be administered fluids until a physician is consulted. ZBZjZZ$@($j($24. Return to activity  In cases of exercise-associated muscle (heat) cramps or heat syncope, the ATC should discuss the athlete's case with the supervising physician. The cases of athletes with heat exhaustion who& (0Z'0Z( . & were not transferred to the physician's care should also be discussed with the physician. After exertional heat stroke or exertional hyponatremia, & 0Z( * & the athlete must be cleared by a physician before returning to athletic participation. The return to full activity should be gradual and monitored. ,(8Table 1. Signs and Symptoms of Exertional Heat Illnesses99(Condition Sign or Symptom* Exercise-associated muscle (heat) cramps) Dehydration Thirst Sweating Transient muscle cramps Fatigue *Not every patient will present with all the signs and symptoms for the suspected condition. t0Z*0Z2B0Z_0Z2Z_Table 1. (continued)( Table 1. (continued)( Table 1. (continued)( Table 1. (continued)( Table 1. (continued)( Table 1. (continued)( Table 1. (continued)( @Table 2. Prevention Checklist for the Certified Athletic TrainerAA( @Table 2. Prevention Checklist for the Certified Athletic TrainerAA( Table 2. (continued)( Table 2. (continued)( Table 2. (continued)( Table 2. (continued)( Table 2. (continued)( Table 2. (continued)( .Table 3. Wet-Bulb Globe Temperature Risk Chart//( [Table 4. Physiologic Responses After Heat Acclimatization Relative to Nonacclimatized State\\$F Table 4. (continued) $ QFigure 1. Risk of heat exhaustion or heat stroke while racing in hot environments 9Figure 2. Heat stress risk temperature and humidity graph D   0` ` ̙33` 333MMM` ff3333f` f` f` 3>?" dd@,|?" dd@   " @ ` n?" dd@   @@``PR    @ ` ` p>> ~v(    6G0 P 0 T Click to edit Master title style! !  0J0  0 RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  0Q0 `  0 D* J Athl Train. 2002;37(3):329-343 #"  0W0 `  0 Z*  0<\0 `  0 f * H  0޽h ? ̙33 Default Design 0 zr (    04A6 P   6 P*    0Q6    6 R*  d  c $ ?  6  0U6  @ 6 RClick to edit Master text styles Second level Third level Fourth level Fifth level!     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̙33j  0 @(  r  S |j   H  0޽h ? ̙33j  0 P(  r  S Xv  H  0޽h ? ̙33j  0 `(  r  S   H  0޽h ? ̙33j  0 p(  r  S   H  0޽h ? ̙33j  0 (  r  S D  H  0޽h ? ̙33j  0 (  r  S (  H  0޽h ? ̙33j  0 (  r  S <  H  0޽h ? ̙33j 0 (  r  S p  H  0޽h ? ̙33j  0 (  r  S x  H  0޽h ? ̙33j  0 (  r  S   H  0޽h ? ̙33j  0 (  r  S   H  0޽h ? ̙33j  0 (  r  S p  H  0޽h ? ̙33j  0 (  r  S ̝Pp  H  0޽h ? ̙33j  0 (  r  S |؝  H  0޽h ? ̙33j  0  (  r  S   H  0޽h ? ̙33j  0 0(  r  S Pp  H  0޽h ? ̙33j  0 @(  r  S Pp  H  0޽h ? ̙33j  0 P(  r  S 4   H  0޽h ? ̙33j  0 `(  r  S h  H  0޽h ? ̙33j  0 p(  r  S   H  0޽h ? ̙33j 0 (  r  S "`0   H  0޽h ? ̙33j  0 (  r  S &  H  0޽h ? ̙33j  0 (  r  S 1p  H  0޽h ? ̙33j  0 (  r  S <  H  0޽h ? ̙33j  0 (  r  S P@  H  0޽h ? ̙33j  0 (  r  S D  H  0޽h ? ̙33j  0 (  r  S R  H  0޽h ? ̙33j 0  (   r   S ^p  H   0޽h ? ̙33j  0 $(  $r $ S Lb  H $ 0޽h ? ̙33j  0 ((  (r ( S m@`  H ( 0޽h ? ̙33j  0  0(  0r 0 S w  H 0 0޽h ? ̙33N  0 04(  4r 4 S lP    4 S   "p`PpLB 4 c $DH 4 0޽h ? ̙33 0 SK`H(  Hx H c $`   H 0r5@@ T"Condition Sign or Symptom*##LB H c $D@@ H 0` LExercise (heat) exhaustionl H 0@ Normal or body-core temperature Dehydration Dizziness Lightheadedness Syncope Headache Nausea 0a T H 0,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H H 0޽h ? ̙33} 0 -%pL(  Lx L c $`   L 0@@ T"Condition Sign or Symptom*##LB L c $D@@ L 0` X&Exercise (heat) exhaustion (continued)'': L 0\@v Anorexia Chills Diarrhea Cool, clammy skin Urine output Intestinal cramps Persistent muscle Urge to defecate cramps Weakness Pallor Hyperventilation Profuse sweating 0"q 0  24 L 0@Ϊ,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H L 0޽h ? ̙33 0 P+(  Px P c $Ҫ`   P 0 Ԫ@@ T"Condition Sign or Symptom*##LB P c $D@@ P 0٪` HExertional heat stroke P 0(ݪ XHigh body-core temperature (>40C [104F]) Central nervous system changes Dizziness Irritability Drowsiness Emotional instability Irrational behavior Hysteria Confusion Apathy t   P 0,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H P 0޽h ? ̙33 0 }T(  Tx T c $``   T 0@@ T"Condition Sign or Symptom*##LB T c $D@@ T 0` T"Exertional heat stroke (continued)## T 0p 6Central nervous system changes (continued) Aggressiveness Seizures Delirium Loss of consciousness Disorientation Coma Staggering h   T 0,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H T 0޽h ? ̙33 0 X(  Xx X c $`   X 0@@ T"Condition Sign or Symptom*##LB X c $D@@ X 0` T"Exertional heat stroke (continued)## X 0 8Dehydration Hypotension Weakness Hyperventilation Hot and wet or dry skin Vomiting Tachycardia (100-120 bpm) Diarrhea hz  {k$ X 0',0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H X 0޽h ? ̙33; 0 \{(  \x \ c $0/`   \ 0/@@ T"Condition Sign or Symptom*##LB \ c $D@@ \ 05` KExertional hyponatremia 2 \ 01 Body-core temperature Low blood-sodium level < 40C (104F) Progressive headache Nausea Confusion Vomiting Significant mental Extremity (hands and compromise feet) swelling Lethargy  7   \ 0F,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H \ 0޽h ? ̙33q 0 !`(  `x ` c $O`   ` 0O@@ T"Condition Sign or Symptom*##LB ` c $D@@ ` 0T`9  X$Exertional hyponatremia (continued) % 2%. ` 0X4 bAltered consciousness Seizures Apathy Coma Pulmonary edema Cerebral edema PS N ` 0`a,0 ]*Not every patient will present with all the signs and symptoms for the suspected condition. ^ 2^H ` 0޽h ? ̙33H 0 h(  hx h c $i`   h 0tj@@hPH@___PPT9" Pre-event preparation ___Am I challenging unsafe rules (eg, ability to receive fluids, modify game and practice times)? ___Am I encouraging athletes to drink before the onset of thirst and to be well hydrated at the start of activity? ___Am I familiar with which athletes have a history of a heat illness? ___Am I discouraging alcohol, caffeine, and drug use? ___Am I encouraging proper conditioning and acclimatization procedures? 0 @`H h 0޽h ? ̙33 0 {s (  x  c $@`  S  0@@hTLD___PPT9& Checking hydration status ___Do I know the preexercise weight of the athletes (especially those at high risk) with whom I work, particularly during hot and humid conditions? ___Are the athletes familiar with how to assess urine color? ___Do the athletes know their sweat rates and, therefore, how much to drink during exercise? ___Is a refractometer or urine color chart present to provide additional information regarding hydration status in high-risk athletes when baseline body weights are checked? 4!,,   @`H  0޽h ? ̙33 0 l((  lx l c $`  p l 0(@@ TLD___PPT9& NEnvironmental assessment ___Am I regularly checking the wet-bulb globe temperature or temperature and humidity during the day? ___Am I knowledgeable about the risk categories of a heat illness based on the environmental conditions? ___Are alternate plans made in case risky conditions force rescheduling of events or practices? 4!66 @`H l 0޽h ? ̙33 0 bZt(  tx t c $Ш`  : t 0,@@TLD___PPT9& ~Coaches and athletes responsibilities ___Are coaches and athletes educated about the signs and symptoms of heat illness? ___Am I double checking to make sure coaches are allowing ample rest and rehydration breaks? ___Are modifications being made to reduce risk in the heat (eg, intensity, change practice times, allow more frequent breaks, eliminate double sessions, or change equipment or clothing requirements, etc? ___Are rapid weight-loss practices in weight-class sports adamantly disallowed? R(!(V @`H t 0޽h ? ̙33 0 xC(  xx x c $`   x 0@@TLD___PPT9& GEvent management ___Have I checked to make sure proper amounts of fluids will be available and accessible? ___Are carbohydrate-electrolyte drinks available at events and practices (especially during twice-a-day practices and those that last longer than 50 to 60 minutes or are extremely intense in nature)? ___Am I aware of the factors that may increase the likelihood of a heat illness? ___Am I promptly rehydrating athletes to preexercise weight after an exercise session? ___Are shaded or indoor areas used for practices or breaks when possible to minimize thermal strain? 4!77  @`H x 0޽h ? ̙33  0 p`(  px p c $``   p 0x@@TLD___PPT9& Treatment considerations ___Am I familiar with the most common early signs and symptoms of heat illnesses? ___Do I have the proper field equipment and skills to assess a heat illness? ___Is an emergency plan in place in case an immediate evacuation is needed? ___Is a kiddy pool available in situations of high risk to initiate immediate cold-water immersion of heat-stroke patients? 4!nn @`H p 0޽h ? ̙335 0  |u(  |x | c $`   | 0@@TLD___PPT9& Treatment considerations (continued) ___Are ice bags available for immediate cooling when cold-water immersion is not possible? ___Have shaded, air-conditioned, and cool areas been identified to use when athletes need to cool down, recover, or receive treatment? ___Are fans available to assist evaporation when cooling? ___Am I properly equipped to assess high core temperature (ie, rectal thermometer)? 4%!w%w @`H | 0޽h ? ̙33 0 ME0(  x  c $x5` 5 %  05@@H@8___PPT9 u'Other situation-specific considerations(!( @`H  0޽h ? ̙33$  0 - @"7P(  r  S 4   t P 7 #"& n0:  <&?  zConsider rescheduling or delaying the event until safer conditions prevail; if the event must take place, be on high alert{{ @`  <&?  bExtreme or hazardous @`  <&?@  SBlack @`  <"&?P @ j >28C (82F),  & @`  <X,&?   TEveryone should be aware of injury potential; individuals at risk should not competeUU @`  <5&?   RHigh @`  <>&?@   QRed @`  <H&?P @  p23-28C (73-82F),& @`  <R&?   8Risk level increases as event progresses through the day99 @`  <[&?   VModerate   @`  <d&?@   TYellow @`   <n&?P @  q18-23C (65-73 F),& @`   <x&?   6Risk low but still exists on the basis of risk factors77 @`   <&?   QLow @`   <4s&?@   SGreen @`   <Ĕ&?P @  l<18C (<65F), & @`  <x&?   VComments   @`  <D&?   [ Level of Risk @`  <&?@  X Flag Color   @`  <ܸ&?P@  RWBGT @``B  0o ?PZB  s *1 ?P  ZB  s *1 ?P  ZB  s *1 ?P  ZB  s *1 ?P  `B  0o ?P`B  0o ?PPZB   s *1 ?@@ZB ! s *1 ?  ZB " s *1 ?  `B # 0o ?H  0޽h ? ̙33n  0 P#(  r  S &P  &  0 # #"2&@@@@@@@@0  <&?@ i W Increases   @`  <&?i@  bEvaporation of sweat @`  <h&?@ ) i aEarlier in training @`  <4&?) @ i \Onset of sweat @`  <&?@ )  W Increases   @`  <&? @ )  _Sweat output/rate @`  <'?@   W Decreases   @`   < '? @  ^Skin temperature @`   <h'?@ i   W Decreases   @`   < '?i @  cBody-core temperature @`   <*'?@ )i  W Increases   @`   <,'?)@ i  [ Stroke volume @`  <<'?@ ) W Decreases   @`  <E'?@ ) X Heart rate   @`  <G'?@ 0 XAfter Acclimatization (10-14 Days Exposure)-- @`  <Y'?0@  bPhysiologic Variable @``B  0o ?00ZB  s *1 ?ZB  s *1 ?))ZB  s *1 ?i i ZB  s *1 ?  ZB  s *1 ?  ZB  s *1 ?) ) ZB  s *1 ?ii`B  0o ?`B  0o ?0ZB  s *1 ?@ 0@ `B   0o ?0H  0޽h ? ̙33i  0 `"|(  x  c $\&  '  p  | #"6* ' > <Xq'?@   W Increases   @` = <y'? @  [ Plasma volume @` < <'?@   W Increases   @` ; <P'? @  hExtracellular fluid volume @` : <L'?@   W Decreases   @` 9 <ȝ'? @  ySyncopal response   @` 8 <'?@   W Decreases   @` 7 <'?@  `Mental disturbance @` 6 <p'?@  W Increases   @` 5 <t'?@  _Capacity for work @` 4 <'?@  W Decreases   @` 3 <'?@  UFatigue @` 2 <d'?@ p W Decreases   @` 1 <'?p@  :Subjective discomfort (rating of perceived exertion [RPE]);; @` 0 <'?@ pp W Increases   @` / <,'?p@ p Y Work output   @` . <(?@ pp W Decreases   @` - < (?p@ p [ Salt in sweat @``B A 0o ?ppZB B s *1 ?ppZB C s *1 ?ppZB D s *1 ?ZB E s *1 ?ZB F s *1 ?ZB G s *1 ?  ZB H s *1 ?  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N|~ d1Oh+'0" `h    ,8@\National Athletic Trainers Association Position Statement: Exertional Heat Illnesses annieh22Microsoft PowerPoint@0/W@`lL:+@ϦQ7 Gt!g   & WMFClxe EMFq,SF(GDICx!b $$=='% % V0xx x % % $$AA" FGDICF(GDIC lIvFGDICRp@Times New RomanhHSTimes BN`U@@Times 0  SO0O0ْ%0`U ڒ 0\!P0[0P0Hdv%    TruIAIAuLhJ Athl Train.  % ( Rp@Times New Romanh@Times 0 lO|8E8PA|H]|A, 9@E@E ڒ !P0[%0`Uڒ0 Hdv0\P^ZwP<#% @,P|O,!dv%    Tr2uIAIAuLh2002;37(3):329 % ( Rp@Times New RomanhA|H]|A, 9@E@E ڒlO|8E8PA|H]|A, :@E@Eڒ0 HdvP^ZwP<#%0`U`ے,P |O,!dv0\P^ZwP#% ,P|O,!dv%    TT3r3uIAIA3uLP- % ( Rp@Times New RomanhA|H]|A, :@E@Eڒ0 HlO|8E8PA|H]|A, ;@E@E`ے,P |O,!dvP^ZwP#%0`Uܒ,P |O,!dv0\P^ZwP#% ,P|O,!dv%    T`3r8uIAIA3uLT343 % ( F(GDIC6ljvFGDICF(GDICrlvFGDICRp@Times New RomanhHSTimes |_N`U@@Times 0 HSO0O0ْ%0`U ڒ \P0[0P0Hdv%    TTruIAIAuLP1 % ( F(GDIC +AFGDICRp@Arialhs0hOO0OQXO 0PQ%0`U ڒ  ; 0  |P|Pt0`PpPHdv%    T IAIALNational Athletic Trainers % ( Rp@ArialhO0OQlO|8E8PA|H]|A, K@E@E ڒ  ; 0  |P|P%0`UڒpP HdvP^ZwP #% ,P|O,!dv%    TT IAIALP  % ( Rp@ArialqhHSArial D5N`U@@Arial 0 SO0O0ْ%0`U ڒt [P0[0P0Hdv%    T#0IAIA.LtAssociation Position % ( Rp@ArialuhHSArial D5N`U@@Arial 0 SO0O0ْ%0`U ڒt [P0[0P0Hdv%    T<IIAIAGLxStatement: Exertional  % ( Rp@ArialNhHSArial D5N`U@@Arial 0 |SO0O0ْ%0`U ڒt [P0[0P0Hdv%    T.VucIAIA.aLhHeat Illnesses % (   x--$xx--'@Times New Roman??-. 2 uJ Athl Train. ."System-@Times New Roman??-. 2 u2002;37(3):329.-@Times New Roman??-.  2 u3-.-@Times New Roman??-.  2 u3343.-@Times New Roman??-.  2 u1.-@Arial???-. .2 National Athletic Trainers.-@Arial???-.  2 .-@Arialq??-. %2 .Association Position.-@Arialu??-. '2 GStatement: Exertional .-@ArialN??-. 2 a.Heat Illnesses.-՜.+,0-    ,On-screen Show Tt' yTimes New RomanArialArial Unicode MSSymbolDefault Design^National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses= Helen M. Binkley*; Joseph Beckett†; Douglas J. Casa‡; Douglas M. Kleiner§; Paul E. PlummerⅡ *Mesa State College, Grand Junction, CO; †University of Charleston, Charleston, WV; ‡University of Connecticut, Storrs, CT; §University of Florida, Jacksonville, FL; ⅡIndiana State University, Terre Haute, INRecommendations Prevention 1. Ensure that appropriate medical care is available and that rescue personnel are familiar with exertional heat illness prevention, recognition, and treatment. Table 2 provides general guidelines that should be considered. Ensure… 1. (continued) …that ATCs and other health care providers attending practices or events are allowed to evaluate and examine any athlete who displays signs or symptoms of heat illness and have the authority to restrict the athlete from participating if heat illness is present. 2. Conduct a thorough, physician-supervised, preparticipation medical screening before the season starts to identify athletes predisposed to heat illness on the basis of risk factors and those who have a history of exertional heat illness. 3. Adapt athletes to exercise in the heat (acclimatization) gradually over 10 to 14 days. Progressively increase the intensity and duration of work in the heat with a combination of strenuous interval training… 3. (continued) …and continuous exercise. Well-acclimatized athletes should train for 1 to 2 hours under the same heat conditions that will be present for their event. In a cooler environment, an athlete can wear additional clothing during training to induce… 3. (continued) …or maintain heat acclimatization. Athletes should maintain proper hydration during the heat-acclimatization process. 4. Educate athletes and coaches regarding the prevention, recognition, and treatment of heat illnesses9and the risks associated with exercising in hot, humid environmental conditions. 5. Educate athletes to match fluid intake with sweat and urine losses to maintain adequate hydration. (See the “National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes.”) Instruct athletes to drink… 5. (continued) …sodium-containing fluids to keep their urine clear to light yellow to improve hydration and to replace fluids between practices on the same day and on successive days to maintain less than 2% body-weight change. These strategies will…u 5. (continued) …lessen the risk of acute and chronic dehydration and decrease the risk of heat-related events. 6. Encourage athletes to sleep at least 6 to 8 hours at night in a cool environment, eat a well-balanced diet that follows the Food Guide Pyramid and United States Dietary Guidelines, and maintain proper hydration… 6. (continued) … status. Athletes exercising in hot conditions (especially during twice-a-day practices) require extra sodium from the diet or rehydration beverages or both. 7. Develop event and practice guidelines for hot, humid weather that anticipate potential problems encountered based on the wet-bulb globe temperature (WBGT) (Table 3) or heat and humidity as measured by a sling psychrometer (Figure 1), the number of participants,… 7. (continued) …the nature of the activity, and other predisposing risk factors. If the WBGT is greater than 28°C (82°F, or “very high” as indicated in Table 3, Figure 1), an athletic event should be… 7. (continued) …delayed, rescheduled, or moved into an air-conditioned space, if possible. It is important to note that these measures are based on the risk of environmental stress for athletes wearing shorts and… 7. (continued) …a T-shirt; if an athlete is wearing additional clothing (ie, football uniform, wetsuit, helmet), a lower WBGT value could result in comparable risk of environmental heat stress (Figure 2). If the event… 7. (continued) …or practice is conducted in hot, humid conditions, then use extreme caution in monitoring the athletes and be proactive in taking preventive steps. In addition, be sure that emergency supplies and equipment are easily accessible and… 7. (continued) …in good working order. The most important factors are to limit intensity and duration of activity, limit the amount of clothing and equipment worn, increase the number and length of rest breaks, and encourage proper hydration.…  7. (continued) …Modify activity under high-risk conditions to prevent exertional heat illnesses. Identify individuals who are susceptible to heat illnesses. In some athletes, the prodromal signs and symptoms of heat illnesses are not evident before collapse, but in…Z 7. (continued) … many cases, adept medical supervision will allow early intervention.  8. Check the environmental conditions before and during the activity, and adjust the practice schedule accordingly. Schedule training sessions to avoid the hottest part of the day (10 AM to 5 PM) and to avoid radiant heating from direct sunlight, especially in the… S8. (continued) … acclimatization during the first few days of practice sessions. 9. Plan rest breaks to match the environmental conditions and the intensity of the activity. Exercise intensity and environmental conditions should be the major determinants in deciding the length and frequency of rest breaks. If possible,…  9. (continued) …cancel or postpone the activity or move it indoors (if air conditioned) if the conditions are “extreme or hazardous” (see Table 3) or “very high” (see Figure 1) or to the right of the circled line (see Figure 2). General guidelines during…  9. (continued) …intense exercise would include a work:rest ratio of 1:1, 2:1, 3:1, and 4:1 for “extreme or hazardous” (see Table 3) or “very high” (see Figure 1), “high,” “moderate,” or “low” environmental risk, respectively. For activities… 9. (continued) …such as football in which equipment must be considered, please refer to Figure 2 for equipment modifications and appropriate work:rest ratios for various environmental… 9. (continued) …conditions. Rest breaks should occur in the shade if possible, and hydration during rest breaks should be encouraged. 10. Implement rest periods at mealtime by allowing 2 to 3 hours for food, fluids, nutrients, and electrolytes (sodium and potassium) to move into the small intestine and bloodstream before the next practice. 11. Provide an adequate supply of proper fluids (water or sports drinks) to maintain hydration and institute a hydration protocol that allows the maintenance of hydration status. Fluids should be readily available and… 11. (continued) …served in containers that allow adequate volumes to be ingested with ease and with minimal interruption of exercise. The goal should be to lose no more than 2% to 3% of body weight… 11. (continued) …during the practice session (due to sweat and urine losses). (See the “National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes.”) 12. Weigh high-risk athletes (in high-risk conditions, weigh all athletes) before and after practice to estimate the amount of body water lost during practice and to ensure a return to prepractice weight… 12. (continued) …before the next practice. Following exercise, athletes should consume approximately 1–1.25 L (34-50 oz) of fluid for each kilogram of body water lost during exercise. 13. Minimize the amount of equipment and clothing worn by the athlete in hot or humid (or both) conditions. For example, a full football uniform prevents sweat evaporation from more than 60% of the body. Consult Figure 2… 13. (continued) …for possible equipment and clothing recommendations. When athletes exercise in the heat, they should wear loose-fitting, absorbent, and light-colored clothing; mesh clothing… t 13. (continued) …and new-generation cloth blends have been specially designed to allow more effective cooling. 14. Minimize warm-up time when feasible, and conduct warm-up sessions in the shade when possible to minimize the radiant heat load in “high” or “very high” or “extreme or hazardous” (see Table 3, Figure 1) conditions. w 15. Allow athletes to practice in shaded areas and use electric or cooling fans to circulate air whenever feasible. h 16. Include the following supplies on the field, in the locker room, and at various other stations: Slide 44 Slide 45 Slide 46 Slide 47 17. Notify local hospital and emergency personnel before mass participation events to inform them of the event and the increased possibility of heat-related illnesses. 18. Mandate a check of hydration status at weigh-in to ensure athletes in sports requiring weight classes (eg, wrestling, judo, rowing) are not dehydrated. Any procedures used to induce dramatic… 18. (continued) …dehydration (eg, diuretics, rubber suits, exercising in a sauna) are strictly prohibited. Dehydrated athletes exercising at the same intensity as euhydrated athletes are at increased risk for… 18. (continued) …thermoregulatory strain (see the “National Athletic Trainers' Association Position Statement: Fluid Replacement in Athletes”). Recognition and Treatment 1 19. Exercise-associated muscle (heat) cramps: Slide 54 Slide 55 Slide 56 Slide 57 Slide 5820. Heat syncope: Slide 60 Slide 61!21. Exercise (heat) exhaustion: Slide 63 Slide 64 Slide 65 Slide 66 Slide 67 Slide 68 Slide 6922. Exertional heat stroke: Slide 71 Slide 72 Slide 73 Slide 74 Slide 75 Slide 76 Slide 77 Slide 78 Slide 79 Slide 80 Slide 81 Slide 8223. Exertional hyponatremia: Slide 84 Slide 85 Slide 86 Slide 87 Slide 88 Slide 8924. Return to activity Slide 91 Slide 92 Slide 939Table 1. Signs and Symptoms of Exertional Heat IllnessesTable 1. (continued)Table 1. (continued)Table 1. (continued)Table 1. (continued)Table 1. (continued)Table 1. (continued)Table 1. (continued)ATable 2. Prevention Checklist for the Certified Athletic TrainerATable 2. Prevention Checklist for the Certified Athletic TrainerTable 2. (continued)Table 2. (continued)Table 2. (continued)Table 2. (continued)Table 2. (continued)Table 2. (continued)/Table 3. Wet-Bulb Globe Temperature Risk Chart\Table 4. Physiologic Responses After Heat Acclimatization Relative to Nonacclimatized StateTable 4. (continued) RFigure 1. Risk of heat exhaustion or heat stroke while racing in hot environments Slide 114:Figure 2. Heat stress risk temperature and humidity graph Slide 116  Fonts UsedDesign Template Slide Titlest_|anniehannieh  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~Root EntrydO)PicturesCurrent UserSummaryInformation("PowerPoint Document(DocumentSummaryInformation8D-