Abridged version published in Lamorinda Weekly "here"
When 19-year-old Braeden Bradforth came off the football field in visible distress after the first day of summer conditioning at Garden City Community College in Kansas last August, his coaches failed to take the appropriate actions to save the young man’s life. Precious minutes were wasted trying to decide what to do, rather than calling appropriate medical professionals, and Braeden died of exertional heat stroke later that evening. Only a few months earlier, the University of Maryland was in the news when another 19-year-old athlete, Jordan McNair, died in a very similar way after a strenuous summer workout. Tragically, had appropriate steps been taken immediately when Jordan and Braeden began displaying the classic symptoms of heat stroke, or had better preventative measures been taking before and during the workouts, both of these young men would likely still be alive today, going to class and playing football.
Both tragic stories, eerily similar, and occurring only months apart last summer, are unfortunately not uncommon. Nearly 400 people die annually in the United States from heat related illnesses, and heat stroke is the third leading cause of death in athletes. Temperature records were broken around the Bay Area recently, with many areas in the triple digits, and as the summer progresses, it is important to review some common heat related illnesses and important treatment and prevention strategies.
Athletes sustain heat stroke fatalities in football more than in any other sport, though other sports are not immune. Risk factors for heat illness include both intrinsic factors (those inherent to the athlete) and extrinsic factors (those related to the environment). Examples of intrinsic factors include obesity, dehydration, sleep deprivation, sunburn, and sickle cell trait. Extrinsic factors include ambient temperature, humidity, and clothing or equipment.
Heat illnesses range from the mild to life threatening, and a list of the different conditions and their descriptions can be found in Table 1.
|Heat Edema||Mild swelling of the hands and/or feet, more common in elderly athletes|
|Heat Rash||Also called “prickly heat”, is a prickly/itchy rash that occurs in areas of the body that have typically been occluded by clothing, and areas of friction (neck, armpit, groin, trunk)|
|Heat Fainting||Can happen when an athlete stops exercising, and their blood vessels are dilated allowing blood to pool in their legs and away from their brain, which causes them to faint. The symptoms typically resolve once they are lying flat on the ground as the blood makes it back to their brain.|
|Heat Cramps||Commonly occur when electrolytes are depleted from the body through sweat as a result of sustained exercise|
|Heat Exhaustion||Athletes will often complain of muscle cramps, fatigue, malaise, nausea, vomiting, and dizziness. Typically, these athletes are sweating profusely. If not recognized and treated immediately with attempts to decrease core temperature, the athlete can progress to Heat Stroke.|
|Heat Stroke||A life-threatening emergency with some of the same symptoms at Heat Exhaustion, except that now the athlete demonstrates signs of confusion or other signs of cognitive impairment such as incoherent speech. The core body temperature will be 104 degrees or higher, and should be measured by a rectal thermometer for the most accurate measurement.|
|Hyponatremia||Medical Emergency. Mental status changes (confusion, incoherent speech) without elevation of core body temperature. Caused by excessive water intake without adequate replenishment of electrolytes. The athlete loses sodium in sweat, and essentially dilutes their sodium levels when they drink excessive volumes of plain water. Severe problems with brain function occur.|
Likely the most important factor to prevent heat illness is the athlete’s hydration status. Athletes lose body weight from sweat losses during exercises, and pre- and post-exercise body weight is a measurable indicator of an athlete’s loss of fluid. A 1% reduction in body weight is associated with 0.25 degree increase in core body temperature. Athletes should weigh themselves before and after exercise, with a goal of replacing approximately 16 to 20 ounces of fluid per pound lost. Additionally, urine color is a valuable sign of hydration status, with a goal of pale yellow to clear urine. Finally, athletes should pay close attention to thirst, which is an important marker of dehydration; however, it is important to know that thirst does not typically develop until an athlete loses 1-2% of their body weight in fluid losses. Athletes should have an overall hydration strategy, and should hydrate throughout the day, drinking fluids and eating fruits and other foods high in water content. People who are salty sweaters should eat salty foods as well to replace salt losses. Table 3 shows some general recommendations for hydration before, during and after exercise in the heat.
|Timing||How Much Should I Drink?|
|Before Exercise||2-3 hours before: About one water bottle (16 oz.)
15 minutes before: Half a water bottle (8 oz.)
|During Exercise||4-8 oz. of fluid every 15-20 minutes (around 3 large gulps)|
|After Exercise||Around 16-20 oz. of fluid for every pound lost (1 to 1.5 water bottles per pound lost)|
(Adapted from NCAA Recommendations)
When replacing fluids, cold drinks are more effective than room temperature drinks, and increase the athlete’s consumption. Liquids with electrolytes and sugar, such as sports drinks, improve the ability for water to enter the body’s cells and hence promote rehydration. By contrast, plain water consumption during rapid sweat losses over an extended period of time causes an overall loss of salt from the body and can cause low sodium levels, a dangerous condition called “hyponatremia” and discussed in Table 1. Athletes exercising in the heat in excess of 60 minutes should consume sports drinks and water instead of just plain water.
Education also plays a critical role in prevention of heat-related illness. Athletes, coaches, parents and athletic trainers all play an important role and, if recognized early, simple measures can be taken that may prove lifesaving. Obese athletes should be monitored more closely, as their risks are greater. It is important to pay attention to clothing and equipment that can decrease the body’s ability to cool itself, such as football pads. A universally recognized stretegy to prevent heat illness is to allow athletes to build a tolerance to exercising in the heat, a process called “acclimatization.” This process can take 1-2 weeks and may take slightly longer for adolescents. The athlete should be exposed to gradually increasing levels of exertion, equipment wear, and time in the heat. As summer workouts start up for football and other sports, this need for acclimatization is a crucial, though often overlooked, strategy to minimize risk of heat illnesses. Ideally, summer football workouts should start with limited time in the heat, wearing loose fitting clothing, and without pads. Gradually, stressors should be added so that the athlete’s body can become accustomed, such as increasing the exercise intensity, or duration. Eventually, helmets might be added, and finally full pads. All athletes should be given frequent breaks, provided shade and encouraged to remove protective equipment during breaks to cool off.
Treatment once an athlete shows signs of heat illness are summarized in Table 2. The most severe form of heat illness is heat stroke and is a life-threatening medical emergency. Emergency Medical Services (9-1-1) should be called immediately. Rapid cooling of the body in an ice bath is the gold standard of treatment. Once the athlete shows signs of heat stroke, the clock is ticking, and the athlete has a much better chance of survival if these measures are taken within 30-60 minutes. For this reason, a high index of suspicion, and adequate preparation and awareness of the condition is crucial to be able to mobilize and act appropriately when the time comes.
|Heat Edema||Elevation of the swollen extremities, compression stockings, replenishment of fluid and electrolytes. Generally improves in 7-14 days.|
|Heat Rash||Reduce clothing, cool the area. Rash may take a week or more to resolve. Mild topical steroid cream can help faster resolution.|
|Heat Fainting||Lie patient flat, elevate legs to bring blood pooling in the legs toward the brain. Rehydration and electrolyte replenishment. Athlete may benefit from IV fluids.|
|Heat Cramps||Rehydration and electrolyte replenishment is important for prevention, but not very effective for treatment when cramps occur. Stretching, cooling with ice and massage of cramped muscles often helps symptoms. IV fluids for severe cases.|
|Heat Exhaustion||If mild, remove the athlete from heat and rehydrate with cool electrolyte containing fluids (sports drinks). If more significant symptoms (nausea, vomiting, abnormal vital signs) core temperature should be checked with a rectal thermometer, and the athlete may require IV fluids. Bags of ice in the armpits and groin can help to quickly reduce body temperature.|
|Heat Stroke||Call 9-1-1 immediately. Rapid cooling of the body is mandatory to the athlete’s survival. Multiple methods have been described, but gold standard is to submerge the athlete in an ice water bath. Taking these measures within 30-60 minutes of the onset of heat stroke greatly increases the athlete’s chance of survival.|
|Hyponatremia||If mild, oral sodium solutions may be sufficient. If more severe, must be done under supervision of a physician with IV fluids, as too rapid correction can also be harmful to the brain.|
In summary, heat illnesses range in severity from the inconvenient to the life threatening, and often can be prevented or mitigated by appropriate preventive strategies such as adequate hydration and the gradual increase of exposure to heat, exertion, equipment, and clothing. Awareness and preparation are crucial to be able to take appropriate action when necessary, and parents, coaches, athletes, and medical personnel must be familiar and trained in these conditions. As the days get hotter this summer, be sure to take frequent breaks, drink plenty of electrolyte rich liquids, and call for professional help when necessary. Have fun and stay safe out there!
Dr. Roth is a Board-Certified fellowship trained orthopedic surgeon specializing in Sports Medicine and injuries that occur in active people of all ages. He sees patients out of his Oakland and Dublin offices with Webster Orthopedics. He is the Head Team Physician for Contra Costa Community College and a Consultant Team Physician for Campolindo High School. Visit him at www.KevinRothMD.com or call 800-943-8099 for an appointment. Dr. Roth grew up in Moraga and currently lives in Orinda with his wife and 6-year-old twins.