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Comp G, Pugsley P, Sklar D, Akhter M, McElhinny M, Erickson E, Feinstein B, Enenbach M, Williams L, Pearlmutter J, Stowell JR. Heat Stroke Management Updates: A Description of the Development of a Novel in-Emergency Department Cold-Water Immersion Protocol and Guide for Implementation. Ann Emerg Med 2024:S0196-0644(24)00407-4. [PMID: 39320280 DOI: 10.1016/j.annemergmed.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 09/26/2024]
Abstract
The growing prevalence of heat stroke as a public health issue, exacerbated by climate change and increasing global temperatures, demands an immediate and strategic response to prevent weather-related morbidity and mortality. Heat stroke results from the body's inability to cope with excessive heat, leading to systemic inflammatory responses, cellular apoptosis, and potential multiorgan dysfunction or failure. However, little information explicitly outlines how to perform cold-water immersion in the emergency department (ED), including potential patient selection, how much water or ice to use, target temperatures, when to stop, and complications or challenges with the process. This narrative explores implementing a comprehensive protocol for total-body cold-water immersion developed in an ED setting, a method proven effective in rapidly reducing core body temperatures, with the goal of reducing mortality and morbidity rates associated with heat-related illnesses. The protocol involves immediate temperature assessment, followed by cold-water immersion for patients with altered mental status and core temperatures above 40 °C. Discussion about the development of the process and results from applying the protocol during the summer of 2023, including cooling rates and patient outcomes, is also included. Additionally, the article addresses challenges and lessons learned during the protocol's implementation, emphasizing the importance of multidisciplinary collaboration, staff education, and the adaptation of ED infrastructure to support this lifesaving treatment based on its use during the last 3 years. The successful resolution of the presented cases, along with the protocol's potential for widespread adoption, illustrates the critical role of cold-water immersion in enhancing ED responses to heat stroke, offering a blueprint for future research and the development of similar protocols across health care settings. This work contributes to the evolving landscape of emergency medicine and aligns with the global effort to combat the adverse health effects of climate change.
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Affiliation(s)
- Geoffrey Comp
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ.
| | - Paul Pugsley
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - David Sklar
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; Arizona State University, College of Health Solutions, Phoenix, AZ
| | - Murtaza Akhter
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; Penn State Health Milton S. Hershey Medical Center, Department of Emergency Medicine, Hershey, PA; Kendall Regional Medical Center, HCA Healthcare, Department of Emergency Medicine, Miami, FL
| | - Megan McElhinny
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - Ethan Erickson
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - Bryan Feinstein
- Tucson Medical Center, Tucson, AZ; Grand Canyon National Park Emergency Services, Grand Canyon Village, AZ
| | - Molly Enenbach
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - Lindsay Williams
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - Jacquelyn Pearlmutter
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
| | - Jeffrey R Stowell
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, AZ; Creighton University School of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ; University of Arizona College of Medicine-Phoenix, Department of Emergency Medicine, Phoenix, AZ
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Bauman J, Spano S, Storkan M. Heat-Related Illnesses. Emerg Med Clin North Am 2024; 42:485-492. [PMID: 38925769 DOI: 10.1016/j.emc.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Abstract
There is a growing incidence of heat-related illnesses due to rising global temperatures. Heat-related illnesses range from mild to severe, with heat stroke being the most critical. The wet bulb global temperature index considers humidity and solar intensity; its use is recommended to estimate heat stress on an individual and mitigate risk. Efficient cooling methods, such as cold water immersion, are essential in severe cases. Prevention is through hydration, appropriate clothing, recognition of high risk medications, and awareness of environmental conditions. Recognizing heat-related illnesses early in the clinical course and implementing rapid cooling strategies reduces morbidity and mortality.
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Affiliation(s)
- Jonathan Bauman
- Department of Emergency Medicine, University of California San Francisco, 155 N. Fresno Street, Fresno, CA 93701, USA
| | - Susanne Spano
- Department of Emergency Medicine, University of California San Francisco, 155 N. Fresno Street, Fresno, CA 93701, USA.
| | - Michelle Storkan
- Department of Emergency Medicine, University of California San Francisco, 155 N. Fresno Street, Fresno, CA 93701, USA
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Willcox MJ, Rhodehouse BB, DeGroot DW. Ice Sheet Cooling in the Field Reduces Morbidity in Exertional Heat Stroke. Curr Sports Med Rep 2024; 23:119-123. [PMID: 38578488 DOI: 10.1249/jsr.0000000000001156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2024]
Affiliation(s)
- M Justin Willcox
- Department of Family Medicine, Martin Army Community Hospital, Fort Moore, GA
| | - Blair B Rhodehouse
- Department of Family Medicine, Martin Army Community Hospital, Fort Moore, GA
| | - David W DeGroot
- The Army Heat Center, Martin Army Community Hospital, Fort Moore, GA
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Miller KC, Amaria NY. Body Bag Cooling with Two Different Water Temperatures for the Treatment of Hyperthermia. Aerosp Med Hum Perform 2024; 95:194-199. [PMID: 38486327 DOI: 10.3357/amhp.6364.2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
INTRODUCTION: Exertional heatstroke (EHS) is a life-threatening condition that requires quick recognition and cooling for survival. Experts recommend using cooling modalities that reduce rectal temperature (TREC) faster than 0.16°C/min though rates above 0.08°C/min are considered "acceptable." Hyperthermic individuals treated in body bags filled with ice water (∼3°C) have excellent cooling rates (0.28 ± 0.09°C/min). However, clinicians may not have access to large amounts of ice or ice water when treating EHS victims. The purpose of this study was to determine if using a body bag filled with water near the upper limits of expert recommendations for EHS treatment would produce acceptable (>0.08°C/min) or "ideal (>0.16°C/min)" TREC cooling rates or different nadir values.METHODS: A total of 12 individuals (9 men, 3 women; age: 21 ± 2 yr; mass: 74.6 ± 10.2 kg; height: 179.5 ± 9.6 cm) exercised in the heat until TREC was 39.5°C. They lay supine while 211.4 ± 19.5 L of 10°C (Ten) or 15°C (Fifteen) water was poured into a body bag. Subjects cooled until TREC was 38°C. They exited the body bag and rested in the heat for 10 min.RESULTS: Subjects exercised in similar conditions and for similar durations (Ten = 46.3 ± 8.6 min, Fifteen = 46.2 ± 7.8 min). TREC cooling rates were faster in Ten than Fifteen (Ten = 0.18 ± 0.07°C/min, Fifteen = 0.14 ± 0.09°C/min). TREC nadir was slightly higher in Fifteen (37.3 ± 0.2°C) than Ten (37.1 ± 0.3°C).DISCUSSION: Body bag cooling rates met expert definitions of acceptable (Fifteen) and ideal (Ten) for EHS treatment. This information is valuable for clinicians who do not have access to or the resources for ice water cooling to treat EHS.Miller KC, Amaria NY. Body bag cooling with two different water temperatures for the treatment of hyperthermia. Aerosp Med Hum Perform. 2024; 95(4):194-199.
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Pryor RR, Haboian K, Fitts T, Stooks JJ. Tarp-Assisted Cooling for Exertional Heat Stroke Treatment in Wildland Firefighting. Wilderness Environ Med 2023; 34:490-497. [PMID: 37748988 DOI: 10.1016/j.wem.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION Exertional heat stroke is a life-threatening emergency necessitating immediate treatment with rapid body cooling. A field-expedient alternative may be tarp-assisted cooling, requiring only water and a tarp. The objective of this study was to compare core temperature (Tc) cooling rates of tarp-assisted cooling using the limited resources available to a wildland firefighter and the current standard care provided in wilderness settings. METHODS This cross-over, randomized control trial of 17 healthy individuals consisted of exercise in a 42±1°C, 32±4% relative humidity environment while wearing wildland firefighter attire, followed by cooling. Body cooling consisted of either pouring 11 L of 25±1°C water over the torso while lying supine on a tarp configured to hold water close to the individual (Tarp) or dousing the water on the participant followed by lying supine with a light breeze, current standard care in the wilderness (Current Care). Cooling occurred until Tc reached 38°C. RESULTS Participants walked until a similar Tc was achieved in Tarp (39.59±0.04°C) and Current Care (39.55±0.22°C; P=0.36). Core temperature cooling rate was not different between Tarp (0.076±0.042°C·min-1) and Current Care (0.088±0.046°C·min-1; P=0.41). CONCLUSIONS In hyperthermic individuals, Tarp did not provide a faster cooling rate compared to the current exertional heat stroke care provided in the wilderness, and both provided a slower cooling rate than that provided by the traditional method of cold water immersion (>0.20°C·min-1) to treat exertional heat stroke patients.
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Affiliation(s)
- Riana R Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY.
| | - Kara Haboian
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY
| | - Triniti Fitts
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY
| | - Jocelyn J Stooks
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY
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McDermott BP, Atkins WC. Whole-body cooling effectiveness of cold intravenous saline following exercise hyperthermia: a randomized trial. Am J Emerg Med 2023; 72:188-192. [PMID: 37562177 DOI: 10.1016/j.ajem.2023.07.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 07/31/2023] [Accepted: 07/31/2023] [Indexed: 08/12/2023] Open
Abstract
INTRODUCTION In some athletic, occupational, military and emergency settings, cold intravenous (IV) fluids are used to facilitate whole-body cooling in an effort to treat heat illness. This treatment has anecdotal support, but currently lacks evidence supporting it as a whole-body cooling modality. Other modalities may offer superior cooling rates, and thus, patient outcomes following treatment. We sought to evaluate cooling rates of cold-IV normal saline immediately following exercise-induced hyperthermia. METHODS Eight healthy participants (3 females; 25 ± 2y; 72.9 ± 10.9 kg) completed 2 trials in random order. Prior to exercise, participants provided a small urine sample to confirm hydration status via urine specific gravity. Wet bulb globe temperature (WBGT) was assessed throughout trials. In both trials, participants exercised outdoors until rectal temperature (Tre) reached ∼38.9 °C, or volitional exhaustion, and then were cooled. In cooling, participants received either cold-IV (∼5 °C 0.9% NaCl fluids) or no treatment (sat in the shade; passive). Throughout exercise and treatment, Tre and heart rate (HR) were monitored. During exercise and every 10 min throughout cooling, participants were asked to assess thermal sensation. RESULTS Hydration status (P = .847) was not significantly different prior to exercise between trials. WBGT throughout was not different between trials (P = .426). Maximum Tre reached was not different between cold-IV (38.88 ± 0.30 °C) and passive cooling (38.76 ± 0.28 °C) trials (P = .184). Mean cooling rate for cold-IV (0.039 ± 0.005 °C·min-1) was significantly greater than for passive cooling (0.028 ± 0.005 °C·min-1; P = .002). Tre throughout cooling was not different between trials (P = .707), but did decrease throughout (P = .008), regardless of trial. HR was decreased over time (P < .001), but cold-IV and passive cooling were not different throughout HR recovery (P = .141). Thermal sensation decreased throughout cooling (P < .001), but was not different between trials (p = .278). CONCLUSION Emergency medical personnel should adopt treatment protocols that employ documented effective treatments for exertional heat stroke. In isolation, our data casts significant doubt for the use of cold-IV saline infusion for whole-body cooling of hyperthermic individuals.
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Affiliation(s)
- Brendon P McDermott
- Exercise Science Research Center, University of Arkansas, Fayetteville, AR, USA.
| | - Whitley C Atkins
- Exercise Science Research Center, University of Arkansas, Fayetteville, AR, USA; Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA.
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Wang G, Hurr C. Effects of cutaneous administration of an over-the-counter menthol cream during temperate-water immersion for exercise-induced hyperthermia in men. Front Physiol 2023; 14:1161240. [PMID: 37234416 PMCID: PMC10206141 DOI: 10.3389/fphys.2023.1161240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/14/2023] [Indexed: 05/28/2023] Open
Abstract
Introduction: Hyperthermia impairs various physiological functions and physical performance. We examined the effects of cutaneous administration with an over-the-counter (OTC) analgesic cream containing 20% methyl salicylate and 6% L-menthol during temperate-water immersion (TWI) for exercise-induced hyperthermia. Methods: In a randomized crossover design, twelve healthy males participated in both of two experiments. Firstly, participants underwent a 15-min TWI at 20°C with (CREAM) or without (CON) cutaneous application of an analgesic cream. Cutaneous vascular conductance (CVC) was measured using laser doppler flowmetry during TWI. In a subsequent experiment, same participants performed a 30-min strenuous interval exercise in a heated (35°C) environment to induce hyperthermia (~39°C), which was followed by 15 min of TWI. Results: Core body temperature, as measured by an ingestible telemetry sensor, and mean arterial pressure (MAP) were measured. CVC and %CVC (% baseline) were higher during TWI in CREAM than in CON (Condition effect: p = 0.0053 and p = 0.0010). An additional experiment revealed that core body heat loss during TWI was greater in CREAM than in CON (Cooling rate: CON 0.070 ± 0.020 vs. CREAM 0.084°C ± 0.026°C/min, p = 0.0039). A more attenuated MAP response was observed during TWI in CREAM than in CON (Condition effect: p = 0.0007). Conclusion: An OTC analgesic cream containing L-menthol and MS augmented cooling effects when cutaneously applied during TWI in exercise-induced hyperthermia. This was, at least in part, due to the counteractive vasodilatory effect of the analgesic cream. The cutaneous application of OTC analgesic cream may therefore provide a safe, accessible, and affordable means of enhancing the cooling effects of TWI.
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Affiliation(s)
- Gang Wang
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, Republic of Korea
- Department of Physical Education, Xinyang Normal University, Xingang, China
| | - Chansol Hurr
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, Republic of Korea
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Brearley M, Berry R, Hunt AP, Pope R. A Systematic Review of Post-Work Core Temperature Cooling Rates Conferred by Passive Rest. BIOLOGY 2023; 12:biology12050695. [PMID: 37237510 DOI: 10.3390/biology12050695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/28/2023]
Abstract
Physical work increases energy expenditure, requiring a considerable elevation of metabolic rate, which causes body heat production that can cause heat stress, heat strain, and hyperthermia in the absence of adequate cooling. Given that passive rest is often used for cooling, a systematic search of literature databases was conducted to identify studies that reported post-work core temperature cooling rates conferred by passive rest, across a range of environmental conditions. Data regarding cooling rates and environmental conditions were extracted, and the validity of key measures was assessed for each study. Forty-four eligible studies were included, providing 50 datasets. Eight datasets indicated a stable or rising core temperature in participants (range 0.000 to +0.028 °C min-1), and forty-two datasets reported reducing core temperature (-0.002 to -0.070 °C min-1) during passive rest, across a range of Wet-Bulb Globe Temperatures (WBGT). For 13 datasets where occupational or similarly insulative clothing was worn, passive rest resulted in a mean core temperature decrease of -0.004 °C min-1 (-0.032 to +0.013 °C min-1). These findings indicate passive rest does not reverse the elevated core temperatures of heat-exposed workers in a timely manner. Climate projections of higher WBGT are anticipated to further marginalise the passive rest cooling rates of heat-exposed workers, particularly when undertaken in occupational attire.
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Affiliation(s)
- Matt Brearley
- Thermal Hyperformance, Hervey Bay, QLD 4655, Australia
- National Critical Care and Trauma Response Centre, Darwin, NT 0800, Australia
- School of Allied Health, Exercise & Sports Sciences, Charles Sturt University, Albury, NSW 2640, Australia
| | - Rachel Berry
- School of Biomedical Sciences, University of New South Wales, Sydney, NSW 2052, Australia
| | - Andrew P Hunt
- School of Biomedical Sciences, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD 4059, Australia
| | - Rodney Pope
- School of Allied Health, Exercise & Sports Sciences, Charles Sturt University, Albury, NSW 2640, Australia
- Tactical Research Unit, Bond University, Robina, QLD 4229, Australia
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Young D, Everitt B, Fine B, Miramontes D. Immersive Cooling in the Prehospital Setting for Heat Stroke: A Case Report. PREHOSP EMERG CARE 2023; 27:838-840. [PMID: 37040305 DOI: 10.1080/10903127.2023.2201515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/15/2023] [Accepted: 03/23/2023] [Indexed: 04/12/2023]
Abstract
Non-exertional heat stroke is defined as exposure to high outdoor temperatures, core body temperature >40 °C, and alteration of mentation. Early identification and treatment are imperative to reduce morbidity and mortality in these patients. Cold water immersion therapy is the most efficient and efficacious modality in treating heat stroke, yet it is rarely initiated in the prehospital setting. We outline a case of an 82-year-old man found unconscious outside during a regional heat wave with a temperature >107 °F. He was treated with cold water immersion using a body bag in the back of the ambulance and cooled to 104.1 °F during transport. During the 9-minute transport, the patient regained consciousness, followed basic commands, and answered basic questions. This case highlights the novel use of body bag cold water immersion as early initiation of treatment for heat stroke patients.
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Affiliation(s)
- Douglas Young
- Department of Emergency Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | - Bryan Everitt
- Department of Emergency Medicine, University of Texas Health San Antonio, San Antonio, Texas
| | | | - David Miramontes
- Emergency Health Sciences, University of Texas Health San Antonio, San Antonio, Texas
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Miller KC, Amaria NY. Excellent Rectal Temperature Cooling Rates in the Polar Life Pod Consistent With Stationary Tubs. J Athl Train 2023; 58:244-251. [PMID: 35192711 PMCID: PMC10176839 DOI: 10.4085/1062-6050-0732.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Several tools exist to reduce rectal temperature (TREC) quickly for patients experiencing exertional heatstroke (EHS). Stationary tubs effectively treat EHS but are bulky and impractical in some situations. More portable cold-water immersion techniques, such as tarp-assisted cooling with oscillation, are gaining popularity because of their benefits (eg, less water needed, portability). The Polar Life Pod (PLP) may be another portable way to reduce TREC, but few researchers have examined its effectiveness. OBJECTIVES To determine whether the PLP and stationary tub reduced TREC at acceptable or ideal rates, whether TREC cooling rates differed by method, and how participants felt before, during, and after cooling. DESIGN Randomized crossover study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS Thirteen individuals (8 men, 5 women; age = 21 ± 2 years, mass = 73.99 ± 11.24 kg, height = 176.2 ± 11.1 cm). INTERVENTION(S) Participants exercised in the heat until TREC was 39.5°C. They immersed themselves in either the PLP (202.7 ± 23.8 L, 3.2 ± 0.6°C) or a stationary tub (567.8 ± 7.6 L, 15.0 ± 0.1°C) until TREC was 38°C. Thermal sensation and environmental symptom questionnaire (ESQ) responses were recorded before, during, and after exercise and cooling. MAIN OUTCOME MEASURE(S) Rectal temperature cooling rates, thermal sensation, and ESQ responses. RESULTS Participants had similar exercise durations (PLP = 41.6 ± 6.9 minutes, tub = 42.2 ± 9.3 minutes, t12 = 0.5, P = .31), thermal sensation scores (PLP = 7.0 ± 0.5, tub = 7.0 ± 0.5, P > .05), and ESQ scores (PLP = 25 ± 13, tub = 29 ± 14, P > .05) immediately postexercise each day. Although TREC cooling rates were excellent in both conditions, the PLP cooled faster than the stationary tub (PLP = 0.28 ± 0.09°C/min, tub = 0.20 ± 0.09°C/min, t12 = 2.5, P = .01). Thermal sensation in the PLP condition was lower than that in the tub condition halfway through cooling (PLP = 1 ± 1, tub = 2 ± 1, P < .05) and postcooling (PLP = 2 ± 1, tub = 3 ± 1, P < .05). The ESQ scores were higher for PLP than for the stationary tub postcooling (PLP = 25 ± 14, tub = 12 ± 9, P < .05). CONCLUSIONS The PLP and the stationary tub cooled individuals with hyperthermia at ideal rates for treating patients with EHS (ie, >0.16°C/min). The PLP may be an effective tool for treating EHS when limited water volumes and portability are concerns. Clinicians should have rewarming tools and strategies (eg, heating blankets) available to improve patients' comfort after PLP use.
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Affiliation(s)
- Kevin C. Miller
- Department of Health and Human Performance, Texas State University, San Marcos
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Wang G, Zhang T, Wang A, Hurr C. Topical Analgesic Containing Methyl Salicylate and L-Menthol Accelerates Heat Loss During Skin Cooling for Exercise-Induced Hyperthermia. Front Physiol 2022; 13:945969. [PMID: 35910580 PMCID: PMC9326359 DOI: 10.3389/fphys.2022.945969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 06/21/2022] [Indexed: 11/29/2022] Open
Abstract
Hyperthermia impairs physical performance and, when prolonged, results in heat stroke or other illnesses. While extensive research has investigated the effectiveness of various cooling strategies, including cold water immersion and ice-suit, there has been little work focused on overcoming the cutaneous vasoconstriction response to external cold stimulation, which can reduce the effectiveness of these treatments. Over-the-counter (OTC) topical analgesics have been utilized for the treatment of muscle pain for decades; however, to date no research has examined the possibility of taking advantage of their vasodilatory functions in the context of skin cooling. We tested whether an OTC analgesic cream containing 20% methyl salicylate and 6% L-menthol, known cutaneous vasodilators, applied to the skin during skin cooling accelerates heat loss in exercise-induced hyperthermia. Firstly, we found that cutaneous application of OTC topical analgesic cream can attenuate cold-induced vasoconstriction and enhance heat loss during local skin cooling. We also revealed that core body heat loss, as measured by an ingestible telemetry sensor, could be accelerated by cutaneous application of analgesic cream during ice-suit cooling in exercise-induced hyperthermia. A blunted blood pressure response was observed during cooling with the analgesic cream application. Given the safety profile and affordability of topical cutaneous analgesics containing vasodilatory agents, our results suggest that they can be an effective and practical tool for enhancing the cooling effects of skin cooling for hyperthermia.
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Affiliation(s)
- Gang Wang
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, South Korea
- Department of Physical Education, Xinyang Normal University, Xingang, China
| | - Tingran Zhang
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, South Korea
| | - Anjie Wang
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, South Korea
| | - Chansol Hurr
- Integrative Exercise Physiology Laboratory, Department of Physical Education, Jeonbuk National University, Jeonju, South Korea
- *Correspondence: Chansol Hurr,
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Klous L, van Diemen F, Ruijs S, Gerrett N, Daanen H, de Weerd M, Veenstra B, Levels K. Efficiency of three cooling methods for hyperthermic military personnel linked to water availability. APPLIED ERGONOMICS 2022; 102:103700. [PMID: 35231652 DOI: 10.1016/j.apergo.2022.103700] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 06/14/2023]
Abstract
PURPOSE Three feasible cooling methods for treatment of hyperthermic individuals in the military, that differed considerably in water volume needed (none to ~80 L), were evaluated. METHODS Ten male soldiers were cooled following exercise-induced hyperthermia (rectal temperature (Tre) ∼39.5 °C) using ventilation by fanning (1.7 m s-1), ventilation by fanning (1.7 m s-1) while wearing a wet t-shirt (250 mL-27 °C water) and tarp assisted cooling with oscillations (80 L of 27.2 ± 0.5 °C water; TACO). RESULTS Cooling rates were higher using TACO (0.116 ± 0.032 °C min-1) compared to ventilation (0.065 ± 0.011 °C min-1, P<0.001) and ventilation in combination with a wet t-shirt (0.074 ± 0.020 °C min-1, P=0.002). Time to cool (TTC) to Tre=38.2 °C for TACO was shorter (14 ± 4 min) compared to ventilation only (20 ± 5 min; P=0.018), but not to ventilation while wearing a wet t-shirt (18 ± 6 min; P=0.090). CONCLUSIONS TACO may be an acceptable, efficient and feasible cooling method in case of exertional heat stroke. However, in case of limited water availability, transportat should be prioritized, and cooling of any form should be implemented while waiting for and during transport.
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Affiliation(s)
- Lisa Klous
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; Netherlands Organization for Applied Scientific Research (TNO), Department of Human Performance, Unit Defence, Safety and Security, Soesterberg, The Netherlands
| | - Femke van Diemen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Silke Ruijs
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Nicola Gerrett
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands; Gentherm Inc., Michigan, USA
| | - Hein Daanen
- Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Marijne de Weerd
- Institute of Training Medicine and Training Physiology, TGTF, Royal Netherlands Army, the Netherlands
| | - Bertil Veenstra
- Institute of Training Medicine and Training Physiology, TGTF, Royal Netherlands Army, the Netherlands
| | - Koen Levels
- Institute of Training Medicine and Training Physiology, TGTF, Royal Netherlands Army, the Netherlands.
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13
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Caldwell AR, Saillant MM, Pitsas D, Johnson A, Bradbury KE, Charkoudian N. The Effectiveness of a Standardized Ice-Sheet Cooling Method Following Exertional Hyperthermia. Mil Med 2022; 187:e1017-e1023. [PMID: 35294018 DOI: 10.1093/milmed/usac047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/26/2022] [Accepted: 02/14/2022] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Exertional heat illnesses remain a major threat to military service members in the United States and around the world. Exertional heat stroke (EHS) is the most severe heat illness, characterized by core hyperthermia and central nervous system dysfunction. Per current Army regulations, iced-sheet cooling (ISC) is the recommended immediate treatment for heat casualties in the field, but concerns have been raised regarding the efficacy of this approach. Thus, the purpose of this study was to quantify the cooling rate of ISC following exertional hyperthermia. MATERIALS AND METHODS We utilized a randomized crossover design with 2 experimental trials. In both trials, exertional hyperthermia was induced by walking (3.5 mph at 5% grade) on a treadmill in an environmental chamber (40 °C, 30% RH) for up to 3 hours or until core body temperature reached 39.2 °C. After the walking portion, individuals either received ISC (experimental trial) or cooling and rested supine in the same environmental conditions for 30 minutes with no ISC (control trial). For ISC, bed sheets soaked in ice water were applied (per Army guidance) at the neck, chest, and groin with another sheet covering the body. Sheets were rotated and resoaked every 3 minutes until core temperature decreased to <38.0 °C. RESULTS By design, participants finished exercise with increased core temperature (38.8 ± 0.39 °C vs. 38.90 ± 0.34 °C, ISC and control trials, P = 1.00). The ISC trial provided significantly (P = .023) greater cooling rates, 0.068 °C/min 95% confidence interval [CI; 0.053, 0.086], compared to the control trial, 0.047 °C/min 95% CI [0.038, 0.056]. Additionally, the time to decrease to less than 38.0 °C was significantly (P = .018) faster in the ISC trial (median = 9.3 minutes) compared to the control trial (median = 26.6 minutes). CONCLUSION ISC increases the cooling rate of those recovering from exertional hyperthermia. With the observed cooling rate, we can extrapolate that ISC would reduce core temperature by ∼2 °C within 30 minutes during a case of EHS. We conclude that ISC provides a safe and effective alternative for the field where cold water immersion resources may not be readily available.
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Affiliation(s)
- Aaron R Caldwell
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA.,Oak Ridge Institute of Science and Education, Belcamp, MD 21017, USA
| | - Michelle M Saillant
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA.,Oak Ridge Institute of Science and Education, Belcamp, MD 21017, USA
| | - Dina Pitsas
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA.,Oak Ridge Institute of Science and Education, Belcamp, MD 21017, USA
| | - Audrey Johnson
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Karleigh E Bradbury
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
| | - Nisha Charkoudian
- Thermal and Mountain Medicine Division, United States Army Research Institute of Environmental Medicine, Natick, MA 01760, USA
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14
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Williams RM, Root HJ, Valovich McLeod TC. Athletic Administrators' Reporting of Emergency Preparedness Regarding Policies and Procedures in Iowa Secondary Schools. J Athl Train 2021; 56:1224-1231. [PMID: 34752627 PMCID: PMC8582625 DOI: 10.4085/1062-6050-0494.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Secondary schools that offer school-sponsored athletic events should follow best-practice guidelines to provide policies that promote student health and safety. OBJECTIVE To assess emergency preparedness from the perspective of athletic administrators (AAs) in Iowa secondary schools. DESIGN Cross-sectional study. SETTING Online survey. PATIENTS OR OTHER PARTICIPANTS Ninety-eight AAs from Iowa completed the survey (age = 45.33 ± 10.22 years, years as an AA = 9.37 ± 8.14, years in current role = 7.72 ± 7.09). MAIN OUTCOME MEASURES(S) The 6-section survey contained with questions about access to athletic trainers (ATs), emergency action plans (EAPs), cardiopulmonary resuscitation (CPR), automated external defibrillators (AEDs), concussions, heat illness, and other general policies. Descriptive statistics (percentages and frequencies) were reported. Relative risk was calculated to compare schools with and those without access to ATs (P < .05). RESULTS Most respondents (76.5%, n = 75/98) reported their school had access to a licensed AT. The majority had a written EAP (83.3%, n = 70/84), but fewer than half (39.2%, n = 31/79) reviewed it annually and fewer than 10% (n = 6/85) reported practicing it each year. All respondents (100%, N = 78/78) stated they had an AED on campus. All respondents (N = 77/77) indicated that they were familiar with the Iowa High School Athletic Association's (IHSAA's) concussion policy and had a concussion guideline in place. Many respondents (95.9%, n = 71/74) described being familiar with the IHSAA's heat illness policy, but more than half (62.1%, n = 41/66) noted they did not have a heat illness policy in place at their school. CONCLUSIONS Most respondents indicated their school had access to ATs, followed the state-mandated concussion guidelines, and had an AED. Although participants reported having written EAPs in place, levels of annual EAP review and practice were low. These results suggest that schools would benefit from educational opportunities to improve safety policies.
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Affiliation(s)
| | - Hayley J. Root
- Department of Physical Therapy and Athletic Training, Northern Arizona University, Phoenix
| | - Tamara C. Valovich McLeod
- Athletic Training Programs and School of Osteopathic Medicine in Arizona, A.T. Still University, Mesa
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15
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Scarneo-Miller SE, Lopez RM, Miller KC, Adams WM, Kerr ZY, Casa DJ. High Schools' Adoption of Evidence-Based Practices for the Management of Exertional Heat Stroke. J Athl Train 2021; 56:1142-1153. [PMID: 34662417 PMCID: PMC8530428 DOI: 10.4085/1062-6050-361-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Exertional heat stroke (EHS) deaths can be prevented by adhering to best practices. OBJECTIVE To investigate high schools' adoption of policies and procedures for recognizing and treating patients with EHS and the factors influencing the adoption of a comprehensive policy. DESIGN Cross-sectional study. SETTING Online questionnaire. PATIENTS OR OTHER PARTICIPANTS Athletic trainers (ATs) practicing in the high school (HS) setting. MAIN OUTCOME MEASURE(S) Using the National Athletic Trainers' Association position statement on exertional heat illness, we developed an online questionnaire and distributed it to ATs to ascertain their schools' current written policies for using rectal temperature and cold-water immersion. The precaution adoption process model allowed for responses to be presented across the various health behavior stages (unaware if have the policy, unaware of the need for the policy, unengaged, undecided, decided not to act, decided to act, acting, and maintaining). Additional questions addressed perceptions of facilitators and barriers. Data are presented as proportions. RESULTS A total of 531 ATs completed the questionnaire. Overall, 16.9% (n = 62) reported adoption of all components for the proper recognition and treatment of EHS. The component with the highest adoption level was "cool first, transport second"; 74.1% (n = 110) of ATs described acting on or maintaining the policy. The most variability in the precaution adoption process model responses was for a rectal temperature policy; 28.7% (n = 103) of ATs stated they decided not to act and 20.1% (n = 72) stated they maintained the policy. The most frequently cited facilitator of and barrier to obtaining rectal temperature were a mandate from the state HS athletics association (n = 274, 51.5%) and resistance to or apprehension of parents or legal guardians (n = 311, 58.5%), respectively. CONCLUSIONS Athletic trainers in the HS setting appeared to be struggling to adopt a comprehensive EHS strategy, with rectal temperature continuing as the biggest challenge. Tailored strategies based on health behavior, facilitators, and barriers may aid in changing this paradigm.
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Affiliation(s)
| | | | | | - William M. Adams
- Department of Kinesiology, University of North Carolina at Greensboro
| | | | - Douglas J. Casa
- Department of Kinesiology, University of Connecticut, Storrs
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16
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Miller KC, Casa DJ, Adams WM, Hosokawa Y, Cates J, Emrich C, Fitzpatrick T, Hopper M, Jardine JF, LaBotz M, Lopez RM, O'Connor F, Smith MS. Roundtable on Preseason Heat Safety in Secondary School Athletics: Prehospital Care of Patients With Exertional Heat Stroke. J Athl Train 2021; 56:372-382. [PMID: 33290540 PMCID: PMC8063668 DOI: 10.4085/1062-6050-0173.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE First, we will update recommendations for the prehospital management and care of patients with exertional heat stroke (EHS) in the secondary school setting. Second, we provide action items to aid clinicians in developing best-practice documents and policies for EHS. Third, we supply practical strategies clinicians can use to implement best practice for EHS in the secondary school setting. DATA SOURCES An interdisciplinary working group of scientists, physicians, and athletic trainers evaluated the current literature regarding the prehospital care of EHS patients in secondary schools and developed this narrative review. When published research was nonexistent, expert opinion and experience guided the development of recommendations for implementing life-saving strategies. The group evaluated and further refined the action-oriented recommendations using the Delphi method. CONCLUSIONS Exertional heat stroke continues to be a leading cause of sudden death in young athletes and the physically active. This may be partly due to the numerous barriers and misconceptions about the best practice for diagnosing and treating patients with EHS. Exertional heat stroke is survivable if it is recognized early and appropriate measures are taken before patients are transported to hospitals for advanced medical care. Specifically, best practice for EHS evaluation and treatment includes early recognition of athletes with potential EHS, a rectal temperature measurement to confirm EHS, and cold-water immersion before transport to a hospital. With planning, communication, and persistence, clinicians can adopt these best-practice recommendations to aid in the recognition and treatment of patients with EHS in the secondary school setting.
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Affiliation(s)
- Kevin C. Miller
- School of Rehabilitation and Medical Sciences, Central Michigan University, Mount Pleasant
| | - Douglas J. Casa
- Korey Stringer Institute, Department of Kinesiology, University of Connecticut, Storrs
| | - William M. Adams
- Department of Kinesiology, University of North Carolina at Greensboro
| | - Yuri Hosokawa
- Faculty of Sport Sciences, Waseda University, Tokorozawa, Saitama, Japan
| | | | | | | | | | - John F. Jardine
- Korey Stringer Institute, Department of Kinesiology, University of Connecticut, Storrs
| | | | - Rebecca M. Lopez
- Department of Orthopaedics and Sports Medicine, University of South Florida, Tampa
| | - Francis O'Connor
- Department of Military and Emergency Medicine, Uniformed Services University, Bethesda, MD
| | - M. Seth Smith
- Department of Orthopedics and Rehabilitation, University of Florida, Gainesville
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17
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Nedimyer AK, Chandran A, Hirschhorn RM, Adams WM, Pryor RR, Casa DJ, Register-Mihalik JK, Kerr ZY. Exertional Heat-Stroke Management Practices and Intentions Among Secondary School Football Athletic Trainers. J Athl Train 2021; 55:1081-1088. [PMID: 32966554 DOI: 10.4085/1062-6050-474-19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
CONTEXT Athletic trainers (ATs) are educated and trained in appropriate exertional heat-stroke (EHS) management strategies, yet disparities may exist between intended and actual uses in clinical practice. OBJECTIVE To examine the intended and actual uses of EHS management strategies among those who did and those who did not treat patients with suspected cases of EHS during the 2017 high school (HS) American football preseason. DESIGN Cross-sectional study. SETTING Online questionnaire. PATIENTS OR OTHER PARTICIPANTS A total of 1016 ATs who oversaw patient care during the 2017 HS American football preseason. MAIN OUTCOME MEASURE(S) Responding HS ATs recorded whether they had or had not managed patients with suspected EHS events during the 2017 HS American football preseason. Those who had managed patients with suspected cases of EHS reported the management strategies used; those who had not managed such patients described their intended management strategies. For each management strategy, z tests compared the proportions of actual use among ATs who managed patients with suspected EHS with the proportions of intended use among ATs who did not manage such patients. RESULTS Overall, 124 (12.2%) ATs treated patients with suspected EHS cases during the 2017 HS American football preseason. Generally, the proportions of intended use of management strategies among ATs who did not treat patients with suspected EHS were higher than the actual use of those strategies among ATs who did. For example, ATs who did treat patients with suspected EHS were more likely than those who did not treat such patients to intend to take rectal temperature (19.6% versus 3.2%, P < .001) and immerse the athlete in ice water (90.1% versus 51.6%, P < .001). CONCLUSIONS Inconsistencies occurred between intended and actual use of EHS management strategies. The standard of care for managing patients with suspected cases of EHS was not consistently used in clinical practice, although ATs who did not treat EHS stated they intended to use these management strategies more frequently. Future researchers should identify factors that preclude ATs from using the standard of care when treating patients with suspected cases of EHS.
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Affiliation(s)
- Aliza K Nedimyer
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.,Human Movement Science Curriculum, University of North Carolina at Chapel Hill
| | - Avinash Chandran
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.,Datalys Center for Sports Injury Research and Prevention, Inc, Indianapolis, IN
| | | | - William M Adams
- Department of Kinesiology, University of North Carolina at Greensboro
| | - Riana R Pryor
- Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, State University of New York
| | - Douglas J Casa
- Korey Stringer Institute, Department of Kinesiology, University of Connecticut, Storrs
| | | | - Zachary Y Kerr
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
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18
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Adams WM, Butke EE, Lee J, Zaplatosch ME. Cooling Capacity of Transpulmonary Cooling and Cold-Water Immersion After Exercise-Induced Hyperthermia. J Athl Train 2021; 56:383-388. [PMID: 33543267 DOI: 10.4085/1062-6050-0146.20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Cold-water immersion (CWI) may not be feasible in some remote settings, prompting the identification of alternative cooling methods as adjunct treatment modalities for exertional heat stroke (EHS). OBJECTIVE To determine the differences in cooling capacities between CWI and the inspiration of cooled air. DESIGN Randomized controlled clinical trial. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 12 recreationally active participants (7 men, 5 women; age = 26 ± 4 years, height = 170.6 ± 10.1 cm, mass = 76.0 ± 18.0 kg, body fat = 18.5% ± 9.7%, peak oxygen uptake = 42.7 ± 8.9 mL·kg-1·min-1). INTERVENTION(S) After exercise in a hot environment (40°C and 40% relative humidity), participants were randomized to 3 cooling conditions: cooling during passive rest (PASS; control), CWI, and the Polar Breeze thermal rehabilitation machine (PB) with which participants inspired cooled air (22.2°C ± 1.0°C). MAIN OUTCOME MEASURE(S) Rectal temperature (TREC) and heart rate were continuously measured throughout cooling until TREC reached 38.25°C. RESULTS Cooling rates during CWI (0.18°C·min-1 ± 0.06°C·min-1) were greater than those during PASS (mean difference [95% confidence interval] of 0.16°C·min-1 [0.13°C·min-1, 0.19°C·min-1]; P < .001) and PB (0.15°C·min-1 [0.12°C·min-1, 0.16°C·min-1]; P < .001). Elapsed time to reach a TREC of 38.25°C was also faster with CWI (9.71 ± 3.30 minutes) than PASS (-58.1 minutes [-77.1, -39.9 minutes]; P < .001) and PB (-46.8 minutes [-65.5, -28.2 minutes]; P < .001). Differences in cooling rates and time to reach a TREC of 38.25°C between PASS and PB were not different (P > .05). CONCLUSIONS Transpulmonary cooling via cooled-air inhalation did not promote an optimal cooling rate (>0.15°C·min-1) for the successful treatment of EHS. In remote settings where EHS is a risk, access and use of treatment methods via CWI or cold-water dousing are imperative to ensuring survival. TRIAL REGISTRY ClinicalTrials.gov (NCT0419026).
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Affiliation(s)
- William M Adams
- Hydration, Environment, and Thermal Stress Lab, Department of Kinesiology, University of North Carolina at Greensboro
| | - Erin E Butke
- Hydration, Environment, and Thermal Stress Lab, Department of Kinesiology, University of North Carolina at Greensboro
| | - Junyong Lee
- Hydration, Environment, and Thermal Stress Lab, Department of Kinesiology, University of North Carolina at Greensboro
| | - Mitchell E Zaplatosch
- Hydration, Environment, and Thermal Stress Lab, Department of Kinesiology, University of North Carolina at Greensboro
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19
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Filep EM, Murata Y, Endres BD, Kim G, Stearns RL, Casa DJ. Exertional Heat Stroke, Modality Cooling Rate, and Survival Outcomes: A Systematic Review. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E589. [PMID: 33167534 PMCID: PMC7694459 DOI: 10.3390/medicina56110589] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 10/15/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
Background and Objectives: The purpose of this systematic review is to synthesize the influence cooling modality has on survival with and without medical complications from exertional heat stroke (EHS) in sport and military populations. Methods and Materials: All peer-reviewed case reports or series involving EHS patients were searched in the following online databases: PubMed, Scopus, SPORTDiscus, Medline, CINAHL, Academic Search Premier, and the Cochrane Library: Central Registry of Clinical Trials. Cooling methods were subdivided into "adequate" (>0.15 °C/min) versus "insufficient" (<0.15 °C/min) based on previously published literature on EHS cooling rates. Results: 613 articles were assessed for quality and inclusion in the review. Thirty-two case reports representing 521 EHS patients met the inclusion criteria. Four hundred ninety-eight (498) patients survived EHS (95.58%) and 23 (4.41%) patients succumbed to complications. Fischer's Exact test on 2 × 2 contingency tables and relative risk ratios were calculated to determine if modality cooling rate was associated with patient outcomes. EHS patients that survived who were cooled with an insufficient cooling rate had a 4.57 times risk of medical complications compared to patients who were treated by adequate cooling methods, regardless of setting (RR = 4.57 (95%CI: 3.42, 6.28)). Conclusions: This is the largest EHS dataset yet compiled that analyzes the influence of cooling rate on patient outcomes. Zero patients died (0/521, 0.00%) when treatment included a modality with an adequate cooling rate. Conversely, 23 patients died (23/521, 4.41%) with insufficient cooling. One hundred seventeen patients (117/521, 22.46%) survived with medical complications when treatment involved an insufficient cooling rate, whereas, only four patients had complications (4/521, 0.77%) despite adequate cooling. Cooling rates >0.15 °C/min for EHS patients were significantly associated with surviving EHS without medical complications. In order to provide the best standard of care for EHS patients, an aggressive cooling rate >0.15 °C/min can maximize survival without medical complications after exercise-induced hyperthermia.
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Affiliation(s)
- Erica M. Filep
- Korey Stringer Institute, University of Connecticut, Storrs, CT 06269-1110, USA; (B.D.E.); (G.K.); (R.L.S.); (D.J.C.)
| | - Yuki Murata
- Graduate School of Education and Human Development, Nagoya University, Furo-cho, Chikusa-ku, Nagoya 464-8601, Japan;
| | - Brad D. Endres
- Korey Stringer Institute, University of Connecticut, Storrs, CT 06269-1110, USA; (B.D.E.); (G.K.); (R.L.S.); (D.J.C.)
| | - Gyujin Kim
- Korey Stringer Institute, University of Connecticut, Storrs, CT 06269-1110, USA; (B.D.E.); (G.K.); (R.L.S.); (D.J.C.)
| | - Rebecca L. Stearns
- Korey Stringer Institute, University of Connecticut, Storrs, CT 06269-1110, USA; (B.D.E.); (G.K.); (R.L.S.); (D.J.C.)
| | - Douglas J. Casa
- Korey Stringer Institute, University of Connecticut, Storrs, CT 06269-1110, USA; (B.D.E.); (G.K.); (R.L.S.); (D.J.C.)
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20
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Singletary EM, Zideman DA, Bendall JC, Berry DA, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djärv T, Douma MJ, Epstein JL, Hood NA, Markenson DS, Meyran D, Orkin A, Sakamoto T, Swain JM, Woodin JA, De Buck E, De Brier N, O D, Picard C, Goolsby C, Oliver E, Klaassen B, Poole K, Aves T, Lin S, Handley AJ, Jensen J, Allan KS, Lee CC. 2020 International Consensus on First Aid Science With Treatment Recommendations. Resuscitation 2020; 156:A240-A282. [PMID: 33098920 DOI: 10.1016/j.resuscitation.2020.09.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life- threatening bleeding through the use of tourniquets, haemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research. The 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC) Science With Treatment Recommendations (CoSTR) is the fourth in a series of annual summary publications from the International Liaison Committee on Resuscitation (ILCOR). This 2020 CoSTR for first aid includes new topics addressed by systematic reviews performed within the past 12 months. It also includes updates of the first aid treatment recommendations published from 2010 through 2019 that are based on additional evidence evaluations and updates. As a result, this 2020 CoSTR for first aid represents the most comprehensive update since 2010.
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21
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Singletary EM, Zideman DA, Bendall JC, Berry DC, Borra V, Carlson JN, Cassan P, Chang WT, Charlton NP, Djärv T, Douma MJ, Epstein JL, Hood NA, Markenson DS, Meyran D, Orkin AM, Sakamoto T, Swain JM, Woodin JA. 2020 International Consensus on First Aid Science With Treatment Recommendations. Circulation 2020; 142:S284-S334. [PMID: 33084394 DOI: 10.1161/cir.0000000000000897] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
This is the summary publication of the International Liaison Committee on Resuscitation's 2020 International Consensus on First Aid Science With Treatment Recommendations. It addresses the most recent published evidence reviewed by the First Aid Task Force science experts. This summary addresses the topics of first aid methods of glucose administration for hypoglycemia; techniques for cooling of exertional hyperthermia and heatstroke; recognition of acute stroke; the use of supplementary oxygen in acute stroke; early or first aid use of aspirin for chest pain; control of life-threatening bleeding through the use of tourniquets, hemostatic dressings, direct pressure, or pressure devices; the use of a compression wrap for closed extremity joint injuries; and temporary storage of an avulsed tooth. Additional summaries of scoping reviews are presented for the use of a recovery position, recognition of a concussion, and 6 other first aid topics. The First Aid Task Force has assessed, discussed, and debated the certainty of evidence on the basis of Grading of Recommendations, Assessment, Development, and Evaluation criteria and present their consensus treatment recommendations with evidence-to-decision highlights and identified priority knowledge gaps for future research.
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22
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Brearley MB. Are Recommended Heat Stroke Treatments Adequate for Australian Workers? Ann Work Expo Health 2020; 63:263-266. [PMID: 30908575 DOI: 10.1093/annweh/wxz001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/18/2018] [Accepted: 01/16/2019] [Indexed: 11/14/2022] Open
Abstract
Workers that combine physical exertion with exposure to hot conditions are susceptible to heat-related illnesses, including heat stroke. Despite recognition of cold water immersion as the heat stroke treatment of choice in the peer-reviewed literature, it was not included within recommended treatments of leading Australian healthcare training organizations and was omitted from Safe Work Australia's recently updated 'Managing the risks of working in heat' guidance material. On this basis, the guidance material appears an opportunity lost to assist Australian industry transition their heat stroke management to reflect the evidence. It is recommended that Australian providers of healthcare training, and those reliant on such information, review the efficacy of their heat stroke treatments.
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Affiliation(s)
- Matt B Brearley
- National Critical Care and Trauma Response Centre, Level 8 Royal Darwin Hospital, Darwin NT, Australia.,Thermal Hyperformance, Howard Springs NT, Australia
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23
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Do Alternative Cooling Methods Have Effective Cooling Rates for Hyperthermia Compared With Previously Established CWI Cooling Rates? J Sport Rehabil 2020; 29:367-372. [PMID: 31628268 DOI: 10.1123/jsr.2019-0098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/04/2019] [Accepted: 06/19/2019] [Indexed: 11/18/2022]
Abstract
Clinical Scenario: In the last few years, there have been several studies examining alternative cooling strategies in the treatment of exertional heat stroke (EHS). Morbidity and mortality with EHS are associated with how long the patient's core body temperature remains above the critical threshold of 40.5°C. Although cold-water immersion (CWI) is the gold standard of treatment when cooling a patient with EHS, more recent alternative cooling techniques have been examined for use in settings where CWI may not be feasible (ie, remote locations). Clinical Question: Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings: The authors searched for studies using alternative cooling methods to cool hyperthermic individuals. To be included, the studies needed a PEDro score ≥6 and a level of evidence ≥2. They found 9 studies related to our focused clinical question; of these, 5 studies met the inclusion criteria. The cooling rates for hand cooling, cold-water shower, and ice-sheet cooling were 0.03°C/min, 0.08°C/min, and 0.06°C/min, respectively, whereas the tarp-assisted cooling with oscillation (TACO) method was the only method that had an acceptable cooling rate (range 0.14-0.17°C/min). Clinical Bottom Line: When treating EHS, if CWI is not available, the tarp-assisted cooling method may be a reasonable alternative. Clinicians should not use cold shower, hand cooling, or ice-sheet cooling if better cooling methods are available. Clinicians should always use CWI when available. Strength of Recommendation: Five level 2 studies with PEDro scores ≥6 suggest the TACO method is the only alternative cooling method that decreases core body temperature at a similar, though slower, rate of CWI. Hand cooling, cold showering, and ice-sheet cooling do not decrease core body temperature at an appropriate rate and should not be used in EHS situations if a modality with a better cooling rate is available.
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First aid cooling techniques for heat stroke and exertional hyperthermia: A systematic review and meta-analysis. Resuscitation 2020; 148:173-190. [PMID: 31981710 DOI: 10.1016/j.resuscitation.2020.01.007] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 01/02/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Heat stroke is an emergent condition characterized by hyperthermia (>40 °C/>104 °F) and nervous system dysregulation. There are two primary etiologies: exertional which occurs during physical activity and non-exertional which occurs during extreme heat events without physical exertion. Left untreated, both may lead to significant morbidity, are considered a special circumstance for cardiac arrest, and cause of mortality. METHODS We searched Medline, Embase, CINAHL and SPORTDiscus. We used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methods and risk of bias assessments to determine the certainty and quality of evidence. We included randomized controlled trials, non-randomized trials, cohort studies and case series of five or more patients that evaluated adults and children with non-exertional or exertional heat stroke or exertional hyperthermia, and any cooling technique applicable to first aid and prehospital settings. Outcomes included: cooling rate, mortality, neurological dysfunction, adverse effects and hospital length of stay. RESULTS We included 63 studies, of which 37 were controlled studies, two were cohort studies and 24 were case series of heat stroke patients. Water immersion of adults with exertional hyperthermia [cold water (14-17 °C/57.2-62.6 °F), colder water (8-12 °C/48.2-53.6 °F) and ice water (1-5 °C/33.8-41 °F)] resulted in faster cooling rates when compared to passive cooling. No single water temperature range was found to be associated with a quicker core temperature reduction than another (cold, colder or ice). CONCLUSION Water immersion techniques (using 1-17 °C water) more effectively lowered core body temperatures when compared with passive cooling, in hyperthermic adults. The available evidence suggests water immersion can rapidly reduce core body temperature in settings where it is feasible.
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Abstract
Exertional heat stroke (EHS) remains one of the leading causes of sudden death in sport despite clear evidence showing 100% survivability with the proper standards of care in place and utilized. Of particular concern are student athletes competing at the secondary school level, where the extent of appropriate health care services remains suboptimal compared with organized athletics at the collegiate level and higher. While rapid recognition and rapid treatment of EHS ensures survival, the adoption and implementation of these lifesaving steps within secondary school athletics warrant further discussion within the sports medicine community. Establishing proper policies regarding the prevention and care of EHS coupled with utilizing an interdisciplinary care approach is essential for 1) minimizing risk and 2) guaranteeing optimal outcomes for the patient.
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Affiliation(s)
- William M Adams
- Department of Kinesiology, University of North Carolina at Greensboro, Greensboro, NC
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Affiliation(s)
- Courtney W Mangus
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD
| | - Therese L Canares
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Johns Hopkins University, School of Medicine, Baltimore, MD
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Management of exertional heat stroke. Br J Gen Pract 2018; 68:415-416. [DOI: 10.3399/bjgp18x698477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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28
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Ganesan S, Brownstein AJ, Pearce SC, Hudson MB, Gabler NK, Baumgard LH, Rhoads RP, Selsby JT. Prolonged environment-induced hyperthermia alters autophagy in oxidative skeletal muscle in Sus scrofa. J Therm Biol 2018; 74:160-169. [PMID: 29801622 DOI: 10.1016/j.jtherbio.2018.03.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 02/26/2018] [Accepted: 03/09/2018] [Indexed: 11/26/2022]
Abstract
Prolonged heat stress represents a continuing threat to human health and agricultural production. Despite the broad, negative impact of prolonged hyperthermia little is known about underlying pathological mechanisms leading to negative health outcomes, which has limited the development of etiological interventions and left clinicians and producers with only cooling and rehydration strategies. The purpose of this investigation was to determine the extent to which prolonged environment-induced hyperthermia altered autophagy in oxidative skeletal muscle in a large animal model, serving the dual purpose of accurately modeling human physiology as well as agricultural production. We hypothesized that prolonged hyperthermia would induce autophagy in skeletal muscle, independent of the accompanying caloric restriction. To test this hypothesis pigs were treated as follows: thermoneutral (20 °C), heat stress (35 °C), or were held under thermoneutral conditions but pair-fed to the heat stress group for seven days. Upon euthanasia the red portion of the semitendinosus was collected. We found that prolonged hyperthermic exposure increased oxidative stress without a corresponding change in antioxidant enzyme activities. Hyperthermia prevented initiation of autophagy despite increased markers of nucleation, elongation and autophagosome formation. However, p62 relative protein abundance, which is inversely correlated with autophagic degradation, was strongly increased suggesting suppressed degradation of autophagosomes. Markers of mitophagy and mitochondrial abundance were largely similar between groups. These data indicate that faulty autophagy plays a key role in hyperthermic muscle dysfunction.
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Affiliation(s)
- Shanthi Ganesan
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | | | - Sarah C Pearce
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | - Matthew B Hudson
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark, DE, 19716, USA
| | - Nicolas K Gabler
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | - Lance H Baumgard
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA
| | - Robert P Rhoads
- Department of Animal and Poultry Science, Virginia Tech, Blacksburg, VA, 24061, USA
| | - Joshua T Selsby
- Department of Animal Science, Iowa State University, Ames, IA 50011, USA.
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Belval LN, Casa DJ, Adams WM, Chiampas GT, Holschen JC, Hosokawa Y, Jardine J, Kane SF, Labotz M, Lemieux RS, McClaine KB, Nye NS, O'Connor FG, Prine B, Raukar NP, Smith MS, Stearns RL. Consensus Statement- Prehospital Care of Exertional Heat Stroke. PREHOSP EMERG CARE 2018; 22:392-397. [PMID: 29336710 DOI: 10.1080/10903127.2017.1392666] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Katch RK, Scarneo SE, Adams WM, Armstrong LE, Belval LN, Stamm JM, Casa DJ. Top 10 Research Questions Related to Preventing Sudden Death in Sport and Physical Activity. RESEARCH QUARTERLY FOR EXERCISE AND SPORT 2017; 88:251-268. [PMID: 28805553 DOI: 10.1080/02701367.2017.1342201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Participation in organized sport and recreational activities presents an innate risk for serious morbidity and mortality. Although death during sport or physical activity has many causes, advancements in sports medicine and evidence-based standards of care have allowed clinicians to prevent, recognize, and treat potentially fatal injuries more effectively. With the continual progress of research and technology, current standards of care are evolving to enhance patient outcomes. In this article, we provided 10 key questions related to the leading causes and treatment of sudden death in sport and physical activity, where future research will support safer participation for athletes and recreational enthusiasts. The current evidence indicates that most deaths can be avoided when proper strategies are in place to prevent occurrence or provide optimal care.
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