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Preventing Heat IllnessHow to Beat the Heat

Catherine A. Simonson, MS, ATC, PESPUBH 8165, Environmental HealthCollege of Health SciencesWalden UniversityThe purpose of this presentation is to provide heat illness prevention education and resources to those working with high risk populations and activities.This audience of this presentation are the teachers, coaches, administrators, and resource officers for our four County High Schools. After 3 heat-related student deaths in the past school year, school administrators requested an educational seminar to provide their personnel with the right tools to identify heat illness early.

1Learning ObjectivesIdentify those at high risk for heat illnessesUtilize techniques to help prevent heat illnessRecognize signs and symptoms of heat illnessProvide basic immediate careActivate emergency responseUpon viewing this presentation, you will be able to identify those at high risk for heat illness, recognize the signs of heat illness, emergency response protocol, immediate care and techniques to help prevent serious injury and death.Who is at Risk?Identify those at high risk for heat illness

Who is at Risk?K-12 StudentsStudent Athletes Students in extra-curricular activitiesFaculty & StaffCampus visitorsSpectatorsActivity participants

Identifying who is at risk for heat related illness is our first step in prevention. We must look at our entire campus population, including faculty, staff, and visitors as well as our student population.Who is at Risk?K-12 Students are HIGH RISKSweat less than adultsPoor fitnessIllnessDehydrationCurrent or recent historyNutritional Status(Moss, 2003)As students are our number one priority, it helps to understand that K-12 Students are considered high risk. Children sweat less than adults (although we might not always think so), our students are increasingly sedentary and poor fitness levels contribute to heat illnesses. Students who are ill or have been recently ill, those currently dehydrated or recent exposure to dehydration are more likely to suffer heat illness. And last but not least, nutritional status of our students contributes to heat illness- we all know a few students here who perhaps do not have access to a well balanced meal outside of school lunches. When students are hungry or lacking nutrients, they are at higher risk for heat illness.Who is at Risk?Student AthletesIncreased muscle massEquipment intensive sportsRepeated exposure Previous historyIllnessMedications, Supplements, Drugs(Cleary,2007)Student athletes are at risk for heat illness for several reasons outside of the fact that they are performing strenuous physical activity in hot and humid weather. Students with large muscle mass produce more body heat and protective equipment can prevent normal cooling such as helmets and shoulder pads in football. They practice repeatedly in the elements, sometimes two times per day and heat illness develop as a cumulative effect. Those student athletes who are ill, have a previous history of heat illness, and take medications, supplements or drugs are more likely to suffer heat related illness. Who is at Risk?Students in extra-curricular activitiesROTCUniformsRequired gear- backpacks, weapon, suppliesBand MembersUniformsPractice timesAgriculture ClubWorking in green houses and outdoors during peak heat

Our students involved in extra curricular activites are also at risk for heat illness. Our ROTC battalion practices maneuvers in full uniforms including black boots, hats (lids in military speak) and carry up to 50 pounds of additional weight while physically active. Band members wear some serious wool and polyester uniforms that contribute to their risk of heat illness. They also practice at the times when facilities and fields are available which sometimes means they are on the field at the hottest times of the day. Our agriculture club students work in their green houses and gardens after school hours, again in the peak heat and highest risk time.Psychological FactorsStudents and Student Athletes Fear Failure-Dont want to appear weakDont want to let the team/group downDont want to miss the big game, concert, field tripDont want to let teachers and coaches downSuccess driven- need this on my college application

(Noakes, 2006)A special note about students and student athletes-Common sense should tell our students to report the signs and symptoms of heat illness but there are additional factors to consider when dealing with children and young adults.Students want to be successful and fear failure even if it is perceived failure. Help them understand that heat illness is a serious medical condition and we need their help in prevention. We cant help them if they dont tell us.Who is at Risk?Faculty and StaffOutdoor responsibilities CoachesGroundskeepersResource OfficersSpecial activitiesField TripsEnvironmental laboratories

Our faculty and staff who regularly work outside are at risk for heat illness- coaches, groundskeepers, resource officers all have job responsibilities in the outdoors. Special activities can place our faculty and staff at risk for heat illness as well- field trips and outdoor science labs are events that can place school personnel in higher risk environments- especially those who normally work in a climate controlled environment.Who is at risk?Faculty and StaffNon-climate controlled work environmentsBus DriversFood ServiceLaundry PersonnelMaintenanceCustodians

Some of our faculty and staff work in areas where climate control is minimal or not available, increasing their risk for heat related illness. The cafeteria kitchen, dish washing area and laundry facilities can reach extreme temperatures creating increased risk of heat illness. Custodians and maintenance personnel frequently work in higher risk areas such as the roof where our air conditioning units are located. Who is at Risk? Campus VisitorsSpectatorsInfants and young children People aged 65 or older Those who are physically ill, especially with heart disease or high blood pressure, obesityPeople with mental illness Participants(Carroll, 2002)Those visiting our campus can also be at risk for heat illness. Infants and young children are even more susceptible to heat illness than our K-12 students. Grandma, Grandpa, and older parents are at higher risk for heat illness, along with those who are physically or mentally ill. High blood pressure, diabetes, heart disease and obesity are illnesses that can predispose our campus visitors to heat illness.And of course those visiting our campus to participate in events such as band, ROTC, or athletic competitions.Who is Responsible?TeacherSchool NurseAdministrationBus DriverResource officerTeacher Aide

Certified athletic trainer (ATC)CoachTeam PhysicianEMSSchool DistrictStateSo who is responsible for these folks when they are on our campus? The short answer is that we all are. All of us here today have a stake in preventing heat illness on our campus.

Techniques to help prevent heat illness

There are many different techniques we can use to prevent heat illness on our campus. What can we do?Be aware- Watch for warning signsStay hydrated and encourage fluid intakeMonitor the weather- know the heat indexPrevention educationCreate an educational Heat Illness Information brochure, webpage or video clip Talk to your family, friends, colleagues about preventing heat illness(CDC, 2004)Be Aware- the best thing we can do to prevent heat illness on our campus is to be aware. Watch your students, colleagues, and visitors closely- pay close attention to those at higher risk.Stay hydrated- carry a water bottle, encourage those around you to keep regular fluid intake.Watch the weather- it is not uncommon for the heat index to reach the danger zone during the school year so be prepared with alternate activitiesEducate- let everyone know that we are serious about preventing heat illness. We cant prevent everything, but can do our part to prevent heat illness, injury and death.TeachersBe aware of temperature and humidity levels.Modify outdoor activity as needed.Number of breaks increases along with the temperature Students should have access to water during outdoor activity.

Identify students at risk and provide direct supervision. Students with chronic illness, compromised nutritional status, mental illness or obesity.

Every classroom should have an emergency action plan posted.Practice the plan in real time several times a year.

(Casa, Armstrong, Hillman, Montain, Reiff, et al 2000). Teachers- Be aware of the heat index and what activities are permissible- is there a policy on what activities are allowable in what conditions?Make sure students (and yourself) have access to water- Encourage students to carry a water bottle.Always have contact information for parents available.

Pay special attention to you high risk studentsKnow your students contact information and/or verify it is on file in the office.Show your students the emergency action plan and practice regularly.AdministratorsEnsure appropriate medical coverage at school eventsPre-participation examinations

Supervise coaching staff to ensure compliance Acclimatization, NCHSAA Regulations

Educate school community about heat illness and prevention strategies

Encourage healthy behaviorsProper nutrition, hydration, adequate sleep

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)

Be sure that all school events have appropriate medical coverage- Certified athletic trainer (ATC) - Team Physician- EMS Dont forget events such as band competitions and ROTC drilling.Verify that each student has a pre-participation physical- this includes band, agriculture and ROTC.Monitor your faculty and staff to ensure proper procedures are being followed.Provide information to the community about our prevention program and how they can help.Students, parents, coaches, teachers and the surrounding community need to be aware of heat illnessCoachesBe aware of temperature and humidity levels. Change practice length, intensity and equipment use as the levels rise.

Educate student athletes and parents about heat illness

Water should be accessible and remind student athletes to drink frequently.

Emergency Action Plan (EAP)

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002) Coaches- Know the heat index and adjust accordingly- the NCHSAA has regulations regarding acclimatization and pre-season play. Fluid breaks should be scheduled for all practices and become more frequent as the heat and humidity levels rise.Educate your athletes- help them understand that proper hydration is essential for success. Water, water, water- make sure it is available, palatable, and cool. More breaks in greater heat. Know your emergency action plan and practice with your staff regularlyAlways have contact information for parents available.Resource OfficersBe aware of temperature and humidity levels.

Collaborate with emergency services

Identify at risk populations for regular observationElderly volunteer, chronically ill parent, overweight referee

Review emergency action plan with all faculty, staff, and security personnel

(Worfolk, 2000)

Know the heat index- you are also at high risk for heat illness secondary to equipment and working environment. Notify EMS of large events Integrate emergency action planning Coordinate campus emergency response drills Crowd control Know your EMS personnel and be sure they are integrated into campus response drills; communication is a key part of the emergency action play- make sure faculty and staff can respond appropriately.Keep a look out for high risk visitors to campusHeat Safety Guidelines-NOAA National Weather Service

What is the Heat Index (HI)?The heat index (HI), sometimes called the apparent temperature, is a measurement for how hot it feels when relative humidity is added to the actual air temperature. For example, if the air temperature is 95 degrees Fahrenheit and the relative humidity is 55%, then the heat index temperature is 110 degrees Fahrenheit. Note: the heat index normal values are devised for shady, lightly windy conditions. Full sun can increase a heat index value by 15%. Heat related illnesses are most prevalent when there is a heat index of 90 degrees or higher.

Used by permission http://www.nws.noaa.gov/om/heat/index.shtml

Sedgwick County Division of Public Safety

Finding an easy to understand version of the heat index chart is essential. All students, faculty, staff and campus visitors should be able understand the heat safety guidelines.This one- from Sedgewick County EMS- is clear and easy to understand.Tips for Preventing Heat IllnessWear lightweight, light-colored, loose-fitting clothing. Drink more fluids (nonalcoholic), regardless of your activity level. Dont wait until youre thirsty to drink. Limit outdoor activity to morning and evening hours whenever possible Try to rest often in shady areas. Protect yourself from the sun by wearing a wide-brimmed hatClosely monitor those at high risk for heat illnessCDC, 2004Preventing heat illness is not difficult- but we all need to do our part. These tips may seem like common sense however we all know that is not enough. We can provide our students and campus visitors with good examples for preventing heat illness- actions speak louder than words.If I wear my sun hat when I work in the school garden, others may also.If I carry a water bottle with me at all times, others may also.If I wear appropriate clothing for the weather, monitor the heat index and those at risk others may also.Signs and Symptoms of Heat Illness& Basic Immediate CareLearning objective- Recognize the signs and symptoms of heat illnessTypes of Heat IllnessDehydrationHeat crampsHeat ExhaustionExertional Heat StrokeHyponatremiaThere are five major categories of heat illness- We will concentrate today on the first 4 and touch briefly on the 5th.Dehydration Signs and Symptoms HeadacheDry mouth Thirst Being irritable or cranky Bored or disinterested

(Casa, Armstrong, Hillman, Montain, Reiff, et al 2000).

Dizziness Cramps Excessive fatigueSkill impairments

Dehydration results when our body does not get enough fluid to sustain normal function. When we do not take in enough fluids to replace what our body utilizes we become dehydrated.DehydrationImmediate CareMove to a cool environmentProvide cool fluids as toleratedWater Sports DrinksMonitor signs and symptomsShould decrease with time and fluid intake(Casa, Armstrong, Hillman, Montain, Reiff, et al 2000). Providing fluids along with moving to a cool environment should help alleviate symptoms. If the dehydrated individual cannot take fluids because of nausea or vomiting, get medical attention.If nausea and/or vomiting is present, additional medical treatment may be necessaryHeat CrampsSigns and SymptomsIntense pain not associated with pulling or straining a muscle

Persistent muscle contractions that continue during and after exercise

Usually occur later in an activity, in conjunction with muscle fatigue and after fluid and electrolyte imbalances have reached a critical level.

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)

Muscle cramps brought on by heat exposure- or heat cramps, are an early sign of serious heat illness. The longer we ask our muscles to perform in less than optimal conditions, the more likely they are to protest. As muscles fatigue and dehydration develops, heat cramps are a possible outcome.Heat Cramps Immediate CareReestablish normal hydrationProvide Cool WaterLight stretching, relaxation and massage of the involved muscleBe proactive- especially in those with a history of heat cramps. Encourage proper nutrition and hydration.(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)Provide fluids- cool temp- dilluted sports drinks are easier on the digestive tractMassage may help acute pain of a muscle cramp along with gentle stretching. If there is a history of heat cramps, work with the individual to develop a hydration plan.27Heat Exhaustion Signs and SymptomsDifficult or impossible to keep participating Loss of coordination, dizziness or fainting Dehydration Profuse sweating or pale skin Headache, nausea, vomiting or diarrhea Stomach/intestinal cramps or persistent muscle cramps (Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)Heat exhaustion is a serious condition that can lead to heat stroke. It is essential that we identify heat exhaustion early and prevent a more serious heat illness.Additional symptoms dilated pupils, clammy skin, hyperventilation. Some or all of these symptoms may be present with heat exhaustion- the main idea is that you identify things that are not normal- is this student usually clumsy? Is my colleague profusely sweating? Heat ExhaustionImmediate CareMove to shaded or air-conditioned area. Remove excess clothing and equipment.

Have student lie comfortably with legs propped above heart level.

Activate EMS for transport to an emergency facility if rapid improvement is not noted with prescribed treatment.

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)

If condition does not improve within 30 minutes or worsens- activate EMS.If not nauseated, vomiting or altered, rehydrate orally with chilled water or sports drink. If unable to take oral fluids, implement intravenous infusion of normal saline ASAP.If trained- Monitor heart rate, blood pressure, respiratory rate, core temperature and CNS status.

29Exertional Heat StrokeSigns and SymptomsConfusion, irrational behavior, emotional instabilitySeizuresNausea, vomiting or diarrhea Headache, dizziness or weakness Hot and wet or dry skin Dehydration Combativeness

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)

Some of these signs and symptoms are similar to heat exhaustion but exertional heat stroke involves more central nervous system function- behaviors such as combativeness indicate EHS-Increased heart rate, decreased blood pressure or fast breathing This is a medical emergency- act accordingly- We must be able to recognize these signs and symptoms.30Exertional Heat StrokeImmediate CareMedical Emergency- Activate EMS!!

Aggressive and immediate whole-body cooling

Where medical coverage allows-Cool first-Transport second

Without treatment, damage to vital organ systems can be fatal. (Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)Activate EMS- This is a medical emergency- its OK to call and be wrong- no harm done. If you think it might be you are better off calling.You have the ability to save a life- know the signs and symptoms- act accordingly.Where appropriate personnel is available Prompt whole-body cooling provides the best chance for a positive outcome The use of Cold Water Immersion protocol are common where medical staff such as athletic trainer or team physician are present.

Recognition is key-Get them cool- Ice water towels, cool water shower-

31Hyponatremia (low blood-sodium levels)Too Much Water?Rare conditionUsually associated with endurance events > 4 hoursIn severe cases: altered consciousness, confusion, coma, convulsions, altered cognitive functioning, cerebral and/or pulmonary edema.(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)

This is extremely rare but it pays to be prepared. When working longer events this possibility increases- such as track & field, ROTC, band competition.Water drinking competitions or challenges are not too far fetched for the adolescent mind.Keep your ears open, drinking this amount of water will draw attention. 32Hyponatremia Signs and SymptomsIncreasing headachenausea, vomiting (often repetitive)Swelling of extremities (hands and feet) irregular diet (e.g., inadequate sodium intake) urine with low specific gravity following exerciselethargy/apathyAgitation (Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)Hyponatremia will just not match any of the other heat illnesses. You know the old saying walks like a duck, talks like a duck this is the same idea only we identify how these symptoms are not what we would expect- things that are out of the ordinary. For example, we wouldnt expect swelling in hands and feet with dehydration- and we would expect the headache to decrease with fluid.Hyponatremia Immediate Care If you suspect hyponatremia and blood sodium levels cannot be determined onsite:Hold off on rehydrating athlete as this may worsen condition Transport immediately to a medical facility.

(Binkley, Beckett, Casa, Kleiner, & Plummer, 2002)If you think there might be a possibility of hypnatremia- dont wait- activate EMS.sodium, certain diuretics or intravenous solutions may be necessary.

34Emergency ResponseEmergency PlanningIdentify stakeholdersWho is involvedWhat is their role

Identify resourcesUtilize appropriate personnelLocal collaboaration

Revisit and revise annuallyWho is involved in emergency response- dont forget the groundskeeper or custodian with the keys to everythingConcise instructions for responseIf there is a volunteer fire department or EMS, local sheriff or police- know how this works and how they will respond- what can you expectDo you have personnel that are uniquely trained? A retired doctor, nurse, medic? Other experience? Local Physician willing to donate services or oversee medical response. Revise as needed- review it each year and practice. All stakeholders need to be involved in the practice sessions.36Emergency CommunicationClear lines of communicationLogisticsRegular review of response protocol

Who, What, When, Where

Chain of command

How do we activate EMS- Land line or cell, wireless, walkie-talkie; how will we communicate with EMS. Where is the phone located. Do I need to dial 9 to get out. These are the clear instructions. Communication and Regular review of response protocolDo we call the sheriff or police- fire/rescue, who do we contact for what emergencyDo we have an emergency texting or email system- can we get a message out quickly.

37ConclusionCan you identify the signs and symptoms of heat illness?Can you identify techniques to prevent heat illness?Can you identify those at high risk for heat illnesses?Can you provide basic immediate care?Can you effectively activate emergency response?Questions?After our discussion you should be able to answer the following questions- Prevention is the key-practice is the lock.38ReferencesBinkley, H., Beckett, J., Casa, D., Kleiner, D., Plummer, P. (2002). National Athletic Trainers' Association position statement: Exertional heat illnesses.Journal of Athletic Training,37(3),329-343. Retrieved May 1st, 2009, from Research Librarydatabase. (Document ID:210650411).

Casa, D., Armstrong, L., Hillman, S., Montain, S., Reiff, R., Rich, B., Roberts, W., Stone, J. (2000). National Athletic Trainers Association position statement: Fluid Replacement for Athletes. Journal of Athletic Training 35 (2):212224.

Cleary, M. (2007). Predisposing Risk Factors on Susceptibility to Exertional Heat Illness: Clinical Decision-Making Considerations. Journal of Sport Rehabilitation, 16(3), 204-214. Retrieved May 1st, 2009, from Academic Search Premier database.

Carroll, P. (2002). The heat is on: protecting your patients from nature's silent killer. Home Healthcare Nurse, 20(6), 376-386. Retrieved May 1st, 2009, from CINAHL Plus with Full Text database.

References contCenters for Disease Control and Prevention: Tips for preventing heat related illness (2004). Retrieved May 1st, 2009 from www.bt.cdc.gov/disasters/extremeheat

Moss, R. (2003). Injury prevention & performance enhancement. Preventing heat illness: beyond the basics. Athletic Therapy Today, 8(4), 33-35. Retrieved May 1st, 2009, from CINAHL Plus with Full Text database.Noakes, T. (2006). Exercise in the heat: old ideas, new dogmas. International SportMed Journal, 7(1), 58-74. Retrieved May 1st, 2009, from CINAHL Plus with Full Text database.NOAA National Weather Service Heat Index retrieved May 1st, from: www.nws.noaa.gov/om/heat/images/CHART05.JPGSedgwick County Division of Public Safety Hot weather safety tips retrieved May 1st from: www.sedgwickcounty.org/ems/hot_weather.html

References contWexler., R. (2002). Evaluation and treatment of heat-related illnesses.American Family Physician,65(11),2307-14. Retrieved May 1st, 2009, from Research Librarydatabase. (Document ID:126427151).Worfolk, J. (2000). Heat waves: their impact on the health of elders. Geriatric Nursing, 21(2), 70-77. Retrieved May 1st, 2009, from CINAHL Plus with Full Text database.

Sources for Further ReadingFluid Replacement for Athletes Position Statement http://www.nata.org/publicinformation/files/fluidreplacement.pdf -- which presents recommendations on how to optimize fluid replacement practices of athletes. Inter-Association Task Force on Exertional Heat Illnesses Consensus Statement -- http://www.nata.org/publicinformation/files/heatillnessconsensusstatement.pdf -- which offers guidelines on how to increase safety and performance for individuals engaged in physical activities, especially in warm and hot environments. A parent and coaches guide based on the consensus statement can be found at:http://www.nata.org/publicinformation/files/parentandcoachesguide.pdf

Centers for Disease Control and Preventionhttp://www.bt.cdc.gov/disasters/extremeheat/