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Safety Alert

Exertional Heat Stroke and Emergency Issues in High School Sport

Pagnotta, Kelly D; Mazerolle, Stephanie M; Casa, Douglas J

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Journal of Strength and Conditioning Research: July 2010 - Volume 24 - Issue 7 - p 1707-1709
doi: 10.1519/JSC.0b013e3181e99d56
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Every year, recreational, high school, collegiate, and professional athletes die as a direct result from sport participation (7). The primary causes include cardiac arrest, head injuries, exertional sickling, asthma, and exertional heat stroke (EHS) (7). A recent article published in the NATA News (3) highlights the sudden deaths of young athletes, where in 2008 alone, they recount 12 high school football players died, along with 2 youth-leaguer football players and 2 soccer athletes (3,7). Although there are many causes of sudden death in sports, schools with sanctioned athletic events need to be prepared to prevent, assess, and treat these medical emergencies. The most appropriate individual to manage a medical emergency situation on a daily basis at the high school level is a certified athletic trainer.

Certified athletic trainers (ATs) are allied health care professionals specially trained in the prevention, recognition, treatment, and rehabilitation of athletic injuries within the physically active. The National Athletic Trainer's Association (NATA) encourages all secondary schools to have a comprehensive athletic health care system in place, which includes having a school physician and an on-site AT to provide appropriate medical care. Secondary schools that fail to implement the recommendations made by the NATA regarding appropriate medical care for the secondary-aged athlete places the medical care into the hands of an untrained individual and implementation of the school's emergency action plan (EAP) ultimately becomes the responsibility of the athletic director, strength and conditioning staff, and coaching staff. The EAP is a document that outlines the care an athlete should receive when a medical emergency arises and should include all personnel involved in the care of the injured athlete and include a discussion of all the potential causes of sudden death. Despite having an EAP in place, secondary schools without appropriate medical care providers on-site are at risk for common errors, such as delay in care, misdiagnosis, and improper treatment, which can lead to death, as was seen with the high-profile tragic death of Kentucky High School football player Max Gilpin in August 2008.

Exertional heat stroke is a serious medical condition and is one of the top three causes of sudden death in athletes and most likely is the leading cause of death during July/August. Exertional heat stroke is precipitated by intense physical activity that causes a rise in core body temperature (1,2,4). Although the condition is more likely to occur in hot humid conditions, it can occur in any weather condition, even cooler environments (1,2,4). Intrinsic factors are characteristics unique to that athlete, are typically caused by something in their past history, or things within their individual control, including hydration status, fitness level, acclimatization, illness, and so on (1,2,4). Extrinsic factors are external stressors, which are often out of an athlete's control, and include environmental conditions, work to rest ratio, pressures from coaches and strength and conditioning coaches, and opportunities for refueling and rehydration. Dehydration does not cause EHS, but it may be a contributing factor in exacerbating the deficit in exercise heat tolerance (1,4). These extrinsic factors can be influenced by altering practice times or increasing rest breaks. The causes of EHS are often multifactorial, and although certain factors increase an athlete's potential for EHS, any athlete, in any environment, is at risk. Because of the dynamic of a practice session, where a strength and conditioning coach's or team coach's responsibility is to get his or her athletes in the best possible shape, challenge them physically and mentally, and teach them the proper techniques of the game, the coach should never be the one who is then also expected to offer an unbiased medical opinion quickly once an emergency arises (6).

Diagnosis of EHS is challenging; though, the condition is characterized by 2 major symptoms at the time of collapse, including an elevated core body temperature (generally above 105° F at time of collapse) and central nervous system (CNS) dysfunctions, many of the other associated symptoms mimic other medical conditions (Table 1) (1,2,4). At the present time, the most accurate estimate of core body temperature is gained via a rectal temperature reading, which should be obtained by a trained medical care provider. Oral, axillary, tympa, and temporal temperature assessments are not valid measurements of core body temperature in an athlete exercising in the heat and should never be used (this includes thermometers embedded in some modern helmets). Central nervous system dysfunction often presents in several different ways but is most commonly seen in personality changes, disorientation, inability to concentrate, or altered/loss of consciousness (1,2,4). An athlete suffering from EHS may also present with a myriad of other signs and symptoms, including vomiting, diarrhea, tachycardia, hypotension, headache, dizziness, and hyperventilation (1,2,4). An athlete suffering from EHS may collapse and may be somewhat lucid and responsive (1,2,4). Despite collapse or signs of CNS dysfunction or loss of consciousness, an athlete should be evaluated for other conditions including cardiac arrest, respiratory dysfunction, hyponatremia, or a head injury, which also may cause this alteration in CNS functioning (see Table 1) (6). Because of the complexity, various differential diagnoses that should be ruled out, and variations in treatment protocols for each condition, a trained medical professional, such as an AT, should be the one assessing an athlete who collapses, not a coach or strength and conditioning coach.

Table 1:
How to prevent, recognize and treat sudden death in sport.*

When an athlete collapses during exercise, a quick and thorough assessment needs to be performed to provide the athlete with the most appropriate and timely treatment. An athlete in cardiac arrest needs immediate cardiopulmonary resuscitation and automated external defibrillator for survival, whereas an athlete suffering from EHS needs immediate and rapid cooling via cold water immersion. Differentiating among EHS, cardiac arrest, a traumatic head injury, heat exhaustion, exertional sickling, and other causes of death or illness in athletics can be challenging, even for the health care provider. A trained medical care provider, particularly an AT, needs to make an accurate diagnosis to provide the most appropriate care, which can be very different based on the clinical diagnosis to prevent death. An athlete who is suffering from EHS needs to be cooled as quickly as possible to decrease the core body temperature and reduce the risk of permanent damage or death (1,2,4). The longer an athlete's core body temperature is elevated above 105°F, the higher the risk of death or permanent damage (1,2,4). Cooling rates are key criteria in determining which cooling modality to choose because the faster you can cool a person, the greater the likelihood they will survive. Ice or cold water immersion has been proven to be the most effective method of cooling an athlete, and in cases where a cold tub has not been setup, cooling should be initiated immediately by a cold shower or rotation of cold/wet towels until the immersion tub is ready (1,2,4). There are many other means of cooling available, which have been proven ineffective and include ice bags, misting fans, cooling vests, and shade (1,2,4). Once the athlete's core body temperature has been lowered to under 102° F, transport to the closest medical facility is important (cool first, transport second if AT is on-site) (1,2,4).

It is important to remember that EHS has been 100% survivable with proper assessment and rapid treatment. Although athletes continue to die each year from EHS, it should never be the case. Our student athletes deserve the best medical treatment while participating in athletics. Trained medical professionals should be available on-site and ready to treat any medical emergency that arises to have the optimal outcome.


1. Armstrong, LE, Casa, DJ, Millard-Stafford, M, Moran, DS, Pyne, SW, and Roberts, WO. American College of Sports Medicine position stand: Exertional heat illness during training and competition. Med Sci Sports Exerc 39: 556-572, 2007.
2. Binkley, HM, Beckett, J, Casa, DJ, Kleiner, DM, and Plummer, PE. National Athletic Trainers' Association position statement: Exertional heat illnesses. J Athletic Train 37: 329-343, 2002.
3. Bostic, J and Hunt, V. Sobering season: Sports fatalities put medical care in spotlight. NATA News October: 16-17, 2008.
4. Casa, DJ, Almquist, J, Anderson, S, et al. Inter-association task force on exertional heat illness consensus statement. NATA News 329-343, 2003.
5. Casa, DJ, Csillan, D, et al. Preseason heat-acclimatization guidelines for secondary school athletics. J Athletic Train 44: 332-333, 2009.
6. Casa, DJ, Pagnotta, KD, Pinkus, DP, and Mazerolle, SM. Should coaches be in charge of care for medical emergencies in high school sport? Athletic Train Sports Health Care 1: 144-146, 2009.
7. National Center for Catastrophic Injury Research. Catastrophic Sport Injury 25th Annual Report. Available at: Accessed January 1, 2010.
© 2010 National Strength and Conditioning Association