New Exertional Heat Stroke Guidelines: Cool First, Transport Second

By Megan Brooks

June 30, 2014

NEW YORK (Reuters Health) - An athlete suspected of suffering from exertional heat stroke should be cooled first (if possible) and then transported to the hospital, according to a new position statement from the National Athletic Trainers' Association (NATA).

The statement, released Friday at the group's annual convention in Indianapolis, updates the original 2002 statement.

In an interview with Reuters Health, Dr. Douglas J. Casa, chair of the position statement writing group, said there are a few "important changes" in the update.

"The biggest one focuses on the core concept of cool first - transport second. It's an entire paradigm shift for people in medicine to think there is a medical condition that you are better off if you don't go to the hospital right away," Dr. Casa said.

"In the world of heat stroke, we have to get people thinking that we need to cool them on site if there is appropriate medical staff like an athletic trainer before we ship them to the hospital. If you wait for the ambulance, wait till the patient gets to the hospital, you could be looking at 30-40 minutes before that patient is really aggressively cooled," Dr. Casa explained.

The goal for any exertional heat stroke victim is to lower core body temperature to less than 102.5 F (39.2 C) within 30 minutes of collapse, the guidelines say.

Dr. Casa is director of athletic training education at the University of Connecticut in Storrs and chief operating officer of the Korey Stringer Institute at UConn. Korey Stringer, an offensive lineman with the Minnesota Vikings, died of exertional heat stroke during a team practice in August 2001.

"We recommend that high schools, colleges and professional teams -- anywhere that someone is at risk for heat stroke -- have a cooling tub on site so that cooling can begin immediately. Ice water immersion has the best cooling rates of any modality," Dr. Casa told Reuters Health.

An athlete recovering from exertional heat stroke should be closely monitored by a physician or athletic trainer and return to play gradually, the guidelines say.

According to NATA, exertional heat stroke is one of the three leading causes of death in sport, and the leading cause in the summer. The period of 2005 to 2009 had more heat stroke deaths than any other five year period in the 35 years prior. There were 18 deaths from 2005-2009; from 2010-2014 (still being tracked) there are now an estimated 20 to 22 deaths.

Exertional heat illnesses are largely preventable within the confines of organized sports when appropriate protocols -- such as heat acclimatization, body cooling, hydration, and modifying exercise based on environmental conditions -- are put into place, NATA says.

And death from exertional heat stroke is 100% preventable when proper recognition and treatment protocols are implemented, NATA says.

Dr. Casa told Reuters Health the updated guidelines also reinforce the heat acclimatization guidelines (

Heat acclimatization is the gradual phasing in of practices to allow athletes to be acclimatized to the heat gradually over a period of seven to 14 days. The National Collegiate Athletic Association (NCAA) and National Football League (NFL) have heat acclimatization protocols, as do 13 states.

"At the Korey Institute, we are trying to get all states to establish heat acclimatization guidelines. In states that meet the minimum standards, there have been no heat stroke deaths in any of the summers in the last few years that they followed the guidelines," Dr. Casa said.

"Another big push," he said, "is to make sure rectal temperature is used for assessment of heat stroke. All other methods are grossly inaccurate when athletes are doing intense exercise in the heat."

Overall, the recommendations are designed to "increase safety and establish a standard of care for athletic trainers in organized sports," Dr. Brendon P. McDermott, assistant professor/clinical coordinator at the University of Arkansas' Graduate Athletic Training Education Program in Fayetteville, told Reuters Health. He wasn't part of the writing committee but has reviewed the new recommendations.

"One of the things that compromise safety is that athletic trainers aren't there to oversee and assure safety for a lot of athletic activity that is organized but is at a youth level. Most often it's claimed that an athletic trainer can't be afforded at this level. But if a coach or organization, such as little league, were to follow these recommendations, players would be safer," he added.

NATA's 2014 position statement on exertional heat illnesses will be published in an upcoming issue of the Journal of Athletic Training.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: