Exertional heat stroke (EHS) is one of the most common causes of sudden death in athletes. It also represents a unique medical challenge to the prehospital healthcare provider due to the time sensitive nature of treatment. In cases of EHS, when cooling is delayed, there is a significant increase in organ damage, morbidity, and mortality after 30 minutes, faster than the average EMS transport and ED evaluation window. The purpose of this document is to present a paradigm for prehospital healthcare systems to minimize the risk of morbidity and mortality for EHS patients. With proper planning, EHS can be managed successfully by the prehospital healthcare provider.

Personalized hydration strategies play a key role in optimizing the performance and safety of athletes during sporting activities. Clinicians should be aware of the many physiological, behavioral, logistical and psychological issues that determine both the athlete’s fluid needs during sport and his/her opportunity to address them; these are often specific to the environment, the event and the individual athlete. In this paper we address the major considerations for assessing hydration status in athletes and practical solutions to overcome obstacles of a given sport. Based on these solutions, practitioners can better advise athletes to develop practices that optimize hydration for their sports.

ObjectivesThis document aimed to summarise the key components of exertional heat stroke (EHS) prehospital management.MethodsMembers of the International Olympic Committee Adverse Weather Impact Expert Working Group for the Olympic Games Tokyo 2020 summarised the current best practice regarding the EHS prehospital management.ResultsSports competitions that are scheduled under high environmental heat stress or those that include events with high metabolic demands should implement and adopt policy and procedures for EHS prehospital management. The basic principles of EHS prehospital care are: early recognition, early diagnosis, rapid, on-site cooling and advanced clinical care. In order to achieve these principles, medical organisers must establish an area called the heat deck within or adjacent to the main medical tent that is optimised for EHS diagnosis, treatment and monitoring. Once admitted to the heat deck, the rectal temperature of the athlete with suspected EHS is assessed to confirm an elevated core body temperature. After EHS is diagnosed, the athlete must be cooled on-site until the rectal temperature is below 39°C. While cooling the athlete, medical providers are recommended to conduct a blood analysis to rule out exercise-associated hyponatraemia or hypoglycaemia, provided that this can be safely performed without interrupting cooling. The athlete is transported to advanced care for a full medical evaluation only after the treatment has been provided on-site.ConclusionsA coordination of care among all medical stakeholders at the sports venue, during transport, and at the hospital is warranted to ensure effective management is provided to the EHS athlete.

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The combination of lower exposure WBGTs and frequent extreme climatic values in milder climates during fatal EHSs indicates the need for regional activity-modification guidelines with lower, climatically appropriate weather-based thresholds. Established activity-modification guidelines, such as those from the American College of Sports Medicine, work well in the hotter climates, such as the southern United States, where hot and humid weather conditions are common.

To investigate the influence of estimated wet bulb globe temperature (WBGT) and the International Institute of Race Medicine (IIRM) activity modification guidelines on the incidence of exertional heat stroke (EHS) and heat exhaustion (HEx) and the ability of an on-site medical team to treat those afflicted. Medical records of EHS and HEx patients over a 17-year period from the New Balance Falmouth Road Race were examined. Climatologic data from nearby weather stations were obtained to calculate WBGT with the Australian Bureau of Meteorology (WBGT) and Liljegren (WBGT) models. Incidence rate (IR) of EHS, HEx, and combined total of EHS and HEx (COM) were calculated, and linear regression analyses were performed to assess the relationship between IR and WBGT or WBGT. One-way ANOVA was performed to compare differences in EHS, HEx, and COM incidence to four alert levels in the IIRM guidelines. Incidence of EHS, HEx, and COM was 2.12, 0.98, and 3.10 cases per 1000 finishers. WBGT explained 48, 4, and 46% of the variance in EHS, HEx, and COM IR; WBGT explained 63, 13, and 69% of the variance in EHS, HEx, and COM IR. Main effect of WBGT and WBGT on the alert levels were observed in EHS and COM IR (p < 0.05). The cumulative number of EHS patients treated did not exceed the number of cold water immersion tubs available to treat them. EHS IR increased as WBGT and IIRM alert level increased, indicating the need for appropriate risk mitigation strategies and on-site medical treatment.

Context Interscholastic heat policies for football have not been evidence based. Therefore, their effectiveness in mitigating exertional heat illness has not been assessed. Objective To discuss the development of the Georgia High School Association heat policy and assess the effectiveness of revised guidelines. Design Descriptive epidemiology study. Setting Georgia high schools. Patients or Other Participants Interscholastic football players in grades 9 through 12. Main Outcome Measure(s) Heat syncope and heat exhaustion (HS/HE) illness rates (IRs) were calculated per 1000 athlete-exposures (AEs), and relative risk (RR) was calculated as a ratio of postpolicy (POST) IR divided by prepolicy (PRE) IR. Results A total of 214 HS/HE cases (172 PRE, 42 POST) and 341 348 AEs (178 230 PRE, 163 118 POST) were identified. During the first 5 days of the PRE period, approximately 50% of HS/HE illnesses occurred; HS/HE IRs doubled when practice sessions increased from 2 to 2.5 hours and tripled for practices ≥3 hours. The HS/HE IRs in the PRE period increased from 0.44/1000 AEs for wet-bulb globe temperatures (WBGTs) of &lt;82°F (&lt;27.8°C) to &gt;2.0/1000 AEs for WBGTs from 87°F (30.6°C) to 89.9°F (32.2°C). The RRs comparing PRE and POST policy periods were 0.29 for WBGTs of &lt;82.0°F (&lt;27.80°C), 0.65 for WBGTs from 82.0°F (27.8°C) to 86.9°F (30.5°C), and 0.23 for WBGTs from 87.0°F (30.6°C) to 89.9°F (32.2°C). No HS/HE illnesses occurred in the POST period for WBGTs at &gt;90°F (&gt;32.3°C). Conclusions Results from the PRE period guided the Georgia High School Association to revise its heat and humidity policy to include a mandated 5-day acclimatization period when no practices may exceed 2 hours and the use of WBGT-based activity-modification categories. The new policy reduced HS/HE IRs by 35% to 100%, depending on the WBGT category. Our results may be generalizable to other states with hot and humid climates similar to that of Georgia.

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